Medicare is bad, but Medicaid has even more problems

Now that we have an 18-month reprieve, giving us time to work on a replacement of the flawed sustainable growth rate formula for Medicare payment, let's take a look at Medicaid. As bad as the Medicare problem is, it pales in comparison with the enormous inequities for patients and physicians that come from the patchwork of Medicaid programs.

While Medicare provides health care for seniors (some of our most passionate voters in all income brackets), Medicaid is a safety net for our poorest patients. It is so complicated.

I know from direct experience that Medicaid patients in my state are clearly second-class health care citizens. Often they cannot afford transportation, parking and child care. They are frustrated by a complicated application process, more visits than other patients need for the same level of care, less access to specialty care, and the common knowledge that their insurance coverage is not attractive to their physicians. There are demeaning extra requirements of consent forms and waiting periods for sterilization. Mental health care is restricted to sometimes crowded groups or clinics that require medication-prescribing clinicians. Mental health counseling is very difficult to obtain.

You don't want to be a Massachusetts Medicaid patient who needs a dermatologist, a psychiatrist or neuropsychologist, because there are few who accept Medicaid patients. With so many newly insured patients in Massachusetts there aren't enough primary care physicians.

Physicians in Massachusetts are frustrated with Medicaid. MassHealth requires women needing gynecologic care to get a referral from a primary care physician, a burden that other women in Massachusetts don't have, and added work for both the primary care physician and the gynecologist.

If a patient comes for an annual exam in my office and reveals a serious bleeding problem, or I discover a breast mass, I may not do the endometrial biopsy or the cyst aspiration on the same day unless I am willing to forgo payment. MassHealth does not accept the CPT modifier 25. So either I make a sacrifice or my patient must.

A study by AthenaHealth showed MassHealth has more denials than any other insurer in the state. MassHealth has its own claim forms and rules for electronic billing that make it more difficult to file a clean claim.

Explanations for denials are all coded and must be searched for among about 1,000 different codes in a complicated, constantly changing provider manual, about 4 inches thick. Many services that are electronically billed require paper evidence, so it is a combined system with delays. And, of course, MassHealth pays less than every other insurer.

On top of the problems already associated with MassHealth is a mandatory revenue-neutral physician pay-for-performance program. It is not likely to change behavior, but surely will make the payment system more complicated for physicians. For some, it may be the last straw.

Here are some points cited by the American College of Obstetricians and Gynecologists:

• Medicaid provides essential health care to more than 20 million women, 69% of adult beneficiaries.
• Most nonelderly women in Medicaid are in their reproductive years (69%), have incomes below the poverty level (56%) and are raising children younger than 18 (60%).
• Women in Medicaid report poorer health status than do women with private insurance or the uninsured.
• Medicaid provides essential well-woman care, including maternity care, family planning, and treatment for breast and cervical cancers. It also provides care for women with disabilities. One barrier faced in nearly every state is poor reimbursement for obstetric services, which limits the number of physicians accepting Medicaid patients. With reimbursement often 15% below the Medicare benchmark and half that of private insurance rates, ob-gyns accepting a significant number of Medicaid patients have difficulty breaking even.
• More than half of Arkansas' births are paid for by Medicaid, making many ob-gyns dependent on the program. But, in 2003, reimbursement was only 78% of Medicare's rates.
• California doctors were recently hit with a 10% Medicaid cut, threatening access for 7 million people.
• Low provider participation makes it more difficult for pregnant patients to find a health care professional and schedule an appointment.
• Patients often face complicated enrollment procedures and documentation requirements that delay access to early prenatal care. Only 30 states expedited enrollment for pregnant women.

Stuart Cohen, MD, of the American Academy of Pediatrics, shared pediatric goals for Medicaid. The federal share of Medicaid spending, known as the Federal Medical Assistance Percentage, varies by state and ranges from 50% to 77%, with an average of 57% of funding coming from the federal government. Dr. Cohen says the pediatricians want a change, so as not to disadvantage large states with huge numbers of very poor residents.

They want parity with Medicare payment (an irony, when you consider our troubles there). In most cases, as bad as Medicare payment has been, Medicaid is worse.

While we work on Medicare, professional liability, and access, we cannot forget that Medicaid reform is an absolute necessity. The AMA supports uniform Medicaid eligibility, standardization of the Medicaid benefit package, and improved payment for participating physicians. The AMA also wants patient-centered efforts, such as a streamlined enrollment process and referral options that promote continuity of care.

The American Medical Association, the Practicing Physicians Advisory Council to the Centers for Medicare & Medicaid Services, and the AAP all have recommended federal legislation to establish a Medicaid Physician Advisory Commission to advise CMS and Congress on policies impacting physicians and patients related to state Medicaid programs.

Medicaid may have a robust coverage policy, but because of its hassles and inadequate payments, Medicaid patients have the least access to health care. Because it is a shared state-federal program, it is much harder to change and monitor.

Federal law requires Medicaid payments to be sufficient to ensure equal access with private insurance. It just isn't happening!