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Sunday, April 18, 2010

Wednesdays With Medicaid

Just a little anecdote about the likely future of Obamacare:

I was speaking with a doctor friend earlier today, and the topic turned to Medicaid, Medicare and private insurance reimbursement rates. He told me that Medicare pays him about half what private insurance pays, and Medicaid pays even less.

He takes Medicaid patients, but does so only out of a sense of community service. The reimbursement rates on their own make no sense.

Now the anecdote. In the small city in which he lives, the OBGYN's only book Medicaid patients on Wednesdays, and they triple book compared to how they book other days of the week.

The reason for triple-booking on Wednesdays? Two-thirds of the Medicaid patients don't show up for their appointments.

Why should they? They don't pay for coverage or for missed appointments. When something is totally free there is no downside to treating it casually.

Now that there will be 15 million more people on Medicaid, the situation will get worse. The question is whether doctors will continue to take Medicaid, and if not, what will be the reaction of the administration.

Just as I predict coercion as to private pay medical care, so too there will be coercion as to physicians who refuse to accept Medicaid. Can anyone say "single payer"?

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  1. Of course. That was the point all along. The new health care reform law is designed to push the country towards single payer by making the private medical system untenable. It isn't a bug, it's a feature...

  2. In a recent edition of the Houston Physician's Journal, it stated that 52% of all Texas doctors refuse to accept M/M patients. Why? Compensation.

    My own doctor stopped taking M/M patients five years ago unless you were already a patient of record. He told me that when Obamacare is implemented, he will no longer accept insurance assignments, and although his office will fill out the insurance paper work, the patient will have to pay, up front, and be reimbursed by the insurance provider.

    This is sad because my doctor is in a small town that, like so many small communities, suffered a doctor shortage. Seniors are now moving to small communities in Texas only to learn that they have to drive 60 miles to Austin for medical care.

    This is not going to change. And what will change is that students, who were once willing to pay $200-250K for a medical degree, will figure out it just ain't worth it. Or they will go into a medical field that doesn't deal with patients, like research or pathology.

    We are going to dump 15 million more patients on an existing number of primary care physicians. And physicians will react by either not taking insurance assignments, reserving the right to drop you as a patient if you miss a designated number of appointments, or simply go out of business.

    If Congress thinks the health care situation is bad now, they ain't seen nothin' yet.

  3. Mark is spot on. I am surprised not very many people understand this basic point about Obamacare (at least I haven't read this point very often). Insurance companies will not be able to stay in business profitably once Obamacare is fully implemented. A single payer is all we'll have left.

  4. We're still repealing this thing, right? I refuse to believe Americans will put up with this. We are the exception, and it needs to stay that way. What an exhausting next 3 years this is turning out to be.

  5. Prof. Jacobson:

    I don't buy your assertion that Medicaid patients miss their OBGYN appointments because they don't pay for missing an appointment.

    Try this. First, calculate the average amount of money it takes for one person to get to the appointment. Then calculate the amount it takes for an adult and two children, because if the woman has children and can't get childcare she has to bring them, too, if she can't get childcare, so add that. Then, work out an alternative figure of transportation for one person plus the cost of childcare.

    Then, find out this year's monthly SSI payment. Work out the fraction of the monthly payment that the cost of each of the three scenarios would be.

    Now, to get an idea of how much money that is in terms that will be meaningful to YOU, apply those fractions to your own monthly income.

    That may help you understand the proportion of the cost, but it still doesn't tell you that the patient is paying rent and food and clothes from that SSI payment -- even when living in Section 8 housing and getting the maximum allowance for food stamps.

    By the way, the government viciously punishes making extra cash or receiving gifts -- like busfare -- to make up for shortfalls -- on a dollar for dollar basis.

    The bottom line is that the most likely explanation for Medicaid patients not showing up for appointments is that they didn't have the money for public transportation to make the round trip. And their Cadillacs are, how you say -- in the shop.

  6. If we talk HUD Sec 8 recipients, the lack of money for a bus trip is less likely to cause a missed appointments than a Meth binge.

    For common folks, however, a free doctor still has a huge penalty for no-show: impossible to get an appointment. I am on the pre-Obamacare insurance and I have to schedule months in advance today. Heck, back in the day I lived in a country with fully socialized medicine, and I used to fight to the death for the appointment coupons, figuratively speaking. So, outside of Secion 8 bums, even if doctors are paid by the government, nobody dares to miss.