Hello ladies,

I read the following article about a study done in Cook County, Illinois comparing comparing the time children on medicaid/CHIP must wait to get an appointment with a specialist, versus children on private insurance.

Here's the article:
http://www.nytimes.com/2011/06/16/health/policy/16care.html?hp

and here's the paper the article cites:
http://www.nejm.org/doi/full/10.1056/NEJMsa1013285

The main conclusion was that in clinics that accept both medicaid and private insurance, children on medicaid/ CHIP have to wait longer (42 days vs 20 days), to be seen for urgent, but non-emergent conditions like diabetes, seizures, uncontrolled asthma, broken bone, or severe depression.

I found this worrisome but not surprising. Given lower reimbursements, I imagine that many practices that accept Medicaid try to keep Medicaid patients below a certain percentage of their patient load to maintain revenues. This problem will only worsen when the federal boost to Medicaid ends at the end of this month. Also states are likely to keep cutting medicaid, not to mention the Republican plan to turn Medicaid into a block grant, drastically reducing federal funding for the program. Medicaid, like all means-tested programs, is politically just way more vulnerable than entitlements like Medicare and Social Security...

Thoughts, anyone? For those of you who are in practice, how do your practices handle Medicaid patients (pediatric and adult)? Do you accept them at all? If so, is there a limit on how many you will accept in a given time period or as a percentage of all your appointments?

Can't wait to see the responses to this thread although I can probably already guess how this "discussion" is gonna go down.

Yes, Medicaid reimbursements in Illinois are abysmal. They used to pay me 10 bucks and change to admit a normal newborn, make rounds on him/her, and discharge to home, including discharge instructions to the mom. Even if mom had a c-section and I had to see the kid three times, they still only paid about 10 bucks. Since I frequently only had one baby at a time in the hospital, the 10 bucks barely covered the gas and mileage to and from the hospital.
Since a large percentage of kids in Illinois are now on Medicaid or KidCare, thanks to our ex-governor who raised the income guidelines, it becomes extremely difficult for pediatricians and pediatric specialists to make a living. They have a choice: Limit the number of appointment slots for medicaid patients or go out of business. It's reality, and it is only going to get worse when ObamaCare dumps several million more patients onto medicaid.

A couple of problems I see with the article: The secret shoppers posed as parents calling on their own. If asked, they said they were referred by a doctor or ER. Most specialists want a direct call from another doc's office for the referral, and if I thought a kid needed a particular specialist, I could just pick up the phone myself and get the kid seen.
Some of the diagnoses they called about (broken bone, uncontrolled asthma, seizures, severe depression) sound like stuff that should be seen in the ER (and frequently is).
I have NO idea where she got the figure of 99+ bucks reimbursement for a moderate complexity problem as payment from Illinois Medicaid. That is pure fantasy. A 99213 used to pay something like 30 bucks, if memory serves.

What will an EM doc do about depression? Depression does not seem like an issue that should be seen/treated in an ER.

I'm not sure how many children and adults who are currently privately insured will be end up on Medicaid/ CHIP due to the Affordable Care Act. The expansion of Medicaid will include individuals and families with income levels up to 135% of the poverty level, and Illinois already covers children whose family incomes are up to at least 200% of the federal poverty level (maybe higher? I can't seem to find the exact number....) So I think few if any children will be on Medicaid who weren't before, except for those whose family incomes have suffered; this will be due to the economy and not the ACA. As for adults, I think the bulk of the new enrollees in Medicaid will be those who are currently uninsured, because (a) few people will want to give up private insurance for Medicaid and (b) employers of over 50 employees will be required to provide insurance to full-time employees. It is possible that some small employers of low-income (135% FPL) individuals will use the expanded Medicaid eligibility as a reason to stop providing private health insurance for their employees, but I just don't think this will account for the bulk of the new Medicaid recipients. I think the people you say will be 'dumped' on Medicaid are those who are currently uninsured, and who are 'dumped' at emergency rooms, particularly at public or charity hospitals and ultimately, at great expense to the public. I'll look to see if there is a study that has looked at this rigorously.
Of course, increasing Medicaid eligibility doesn't solve the problem of Medicaid reimbursements being too low. Only increased funding per recipient will do that.

As an aside, average annual Medicaid spending per child in Illinois is $2600.

For the reimbursement figure, the paper cites Illinois Department of Healthcare and Family Services, Physician fee schedule key revised 7-01-09.

From the fee schedule as of 4/11:

99213-$28.35
99214-$42.50
99215-$48.00

There are add-on reimbursements for a few codes (99213, 99214, and the well-child codes) that a doc could qualify for if they became a registered Maternal-Child Health Primary Care Provider. I was on one of the local committees that explored the problem of low reimbursements for maternal-child stuff, back in the day, which eventually led to somewhat enhanced rates for pregnancy care. The state government was pretty much forced to raise some of the reimbursements because NO ONE would see kids or pregnant women on Public aid. If I remember correctly, medicaid was paying less for a full 9 months of maternity care than the federal government was paying for the toilet seats on military transport aircraft. I kid you not.

Currently, for a new patient at the highest level (99205), the state reimburses $70.85, plus a whopping extra $3.25 to a registered MCH provider. 99205, for those who don't have any training in coding, would be a new kid who you've never seen before who comes to your office with insulin-dependent type I diabetes out of control, with an acute infection on top of that, or a new patient who comes to your office acutely suicidal, or with new-onset psychosis.

The enhanced reimbursements are not available to specialists, of course, because it is left up to the PCP to spend her limited precious time on the phone trying to find a specialist to see a kid for 30 bucks.

Think about this the next time you get the bill from your plumber or your auto mechanic.

Re: depression: to me, "severe depression" in a child would be a kid who is overtly suicidal. That would be treated in the ER, because there is no way I could get a psychiatrist to see the kid on an emergent basis from the office.

My office does not take medicaid currently. My prior office did, and I can tell you for a fact that many specialists have 2 waiting lists- one for private pay patients, and one for medicaid. Yes, if I call someone I know personally and say its an emergency, I might get my patient in... but then again I might not. Consider that medicaid in most states pays less than it actually costs to see the patients, and it is essentially charity care. We would all go out of business if that was our only payor. In AnnaM's scenario above, you are being paid $48 to see a visit that is presumed to take a minimum of 25 minutes face to face, when billed based on time... so you can see 2 of those an hour, for the whopping payment of $96. That would not even cover the staff salaries for that hour at my office, much less mine, the power, the supplies, etc. Medicaid is a travesty for its patients, in virually all aspects, and I don't think loading even more unsuspecting patients into it will help.