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A 5% commitment for Medicaid?

Professionalism and Caring for Medicaid Patients — The 5% Commitment?

By Lawrence P. Casalino, M.D., Ph.D.
The New England Journal of Medicine, November 7, 2013

Medicaid is an important federal–state partnership that provides health insurance for more than one fifth of the U.S. population — 73 million low-income people in 2012. The Affordable Care Act will expand Medicaid coverage to millions more. But 30% of office-based physicians do not accept new Medicaid patients, and in some specialties, the rate of nonacceptance is much higher — for example, 40% in orthopedics, 44% in general internal medicine, 45% in dermatology, and 56% in psychiatry. Physicians practicing in higher-income areas are less likely to accept new Medicaid patients. Physicians who do accept new Medicaid patients may use various techniques to severely limit their number — for example, one study of 289 pediatric specialty clinics showed that in the 34% of these clinics that accepted new Medicaid patients, the average waiting time for an appointment was 22 days longer for children on Medicaid than for privately insured children.

Physicians have good reasons for not accepting Medicaid patients, as I learned from direct experience as a member of a nine-physician primary care practice in California. We accepted Medicaid patients, but it was difficult. Medicaid's payment rate was very low — we lost money on each Medicaid visit. When referrals were necessary, we often had to personally ask specialists to accept our patient. Administratively, it was not simple to obtain payment from Medicaid for our services, in part because some patients frequently moved between eligibility and ineligibility for the program. In addition, it was time-consuming for our physicians and staff to deal with the Medicaid pharmaceutical formulary and to obtain prior authorization for Medicaid patients to see specialists and obtain imaging studies.

There are additional reasons — beyond low payment rates, administrative complexity, and problems obtaining specialist care — why physicians may be reluctant to see Medicaid patients. Medicaid patients often have complicated behavioral health, transportation, and social service needs that require physician and staff time.

Nevertheless, there is a fundamental reason why physicians should strongly consider providing care for at least a reasonable number of Medicaid patients. It is a core professional principle that physicians should put the patient's interest first; refusing to care for vulnerable, socioeconomically disadvantaged Medicaid patients seems incompatible with this principle. Many medical schools ask their students to accept the World Health Organization's Declaration of Geneva (a modified version of the Hippocratic Oath), which states in part that “I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.”

Physicians who are reluctant to provide care for Medicaid patients can argue, with justice, that policymakers are trying to make medicine as market-driven as possible, that physicians are increasingly expected to respond to market incentives and market constraints, and that no business in other sectors of the economy is asked to provide a service that loses money year after year. Many physicians, however, earn very high incomes, and some of the highest-paid specialties are the least willing to care for Medicaid patients. Would it be reasonable to ask all physicians to commit to providing care for enough Medicaid enrollees so that at least 5% of each physician's practice consisted of Medicaid patients (assuming sufficient demand)?

We live in an era in which, for better or for worse, market-based solutions are dominant and policymakers tend to view physicians as self-interested actors. Little or no attention is paid to physician professionalism or to the possible effects of policies on professionalism. Policies that are based on this view may be justifiable if many physicians are indeed seeking to maximize their incomes and refusing to accept even a slight reduction in income as the price for helping to provide care to the most vulnerable patients in our society. A 5%-commitment campaign would be a meaningful, highly visible demonstration of physician professionalism — of putting patients first.

http://www.nejm.org/doi/full/10.1056/NEJMp1310974

Comment:

By Don McCanne, M.D.

The expansion of Medicaid for low-income patients is one of the more troublesome features of the Affordable Care Act. Because of low payment rates, many physicians, especially high-income specialists, already refuse to accept Medicaid patients. Increasing the burden on those physicians who do accept Medicaid is apt to result in a pushback wherein access may be further impaired.

What can be done? Lawrence Cassalino has provided us with an excellent description of the dilemma, but I’m afraid that his 5% solution - physicians devoting 5% of their practices to Medicaid - will fail since it depends on physician professionalism, of putting patients first. After a career of trying to obtain specialized care for Medicaid patients, it was quite clear that that level of professionalism was not ubiquitous in my community, and I doubt that it is in most other communities. Relying on the pure goodness of physicians will not work because there are not enough so oriented to meet the need.

One important measure in ACA is the expansion of funding for federally qualified health centers. These centers improve access for vulnerable populations, though they still have difficulties obtaining adequate support of specialists. Today, the government announced a $150 million grant to assist these community health centers. $150 million? Unless the government becomes serious about community center funding, and unless something is done to attract specialists to support these centers, we cannot expect them to fill the void either.

There is a clear solution. We could establish a single payer national health program in which everyone has the same coverage and access to care. That may or may not renew the commitment of today’s physicians to professionalism, but at least it would create the appearance that patients would be placed first. For individuals considering a future career in medicine, professionalism would be a given.