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But They Said This Key Would Work: Coverage, Access and the Meaning of Insurance, Part 2

by Emily Friedman

First published in Hospitals & Health Networks OnLine, December 6, 2010

The Patient Protection and Affordable Care Act (the health care "reform" law) has been trumpeted as potentially raising the number of Americans with health insurance to 90 percent of the population by 2014. Unfortunately, having some types of coverage—through Medicaid, Medicare, other public programs and some managed care plans—is no guarantee of access to even basic care.

Emily Friedman
Emily Friedman

His name was Deamonte Driver. He was a low-income child in Maryland whose tooth hurt. His mother Alyce had recently worked three low-paying jobs, none of which offered health insurance, let alone dental coverage. The family did have Medicaid, or so they thought. When, in 2006, his younger brother DaShawn was found to have several abscessed teeth, finding a dentist to care for him was extremely difficult, although they finally were successful. But his treatment had to be suspended when the family's Medicaid coverage lapsed; they had gone through a period of homelessness, and Mrs. Driver suspects that the paperwork they needed to confirm their eligibility was sent to an old address or the shelter where they had stayed.

Meanwhile, Deamonte didn't complain much about his tooth—at least, not until he came home in January 2007 and said he had a headache. A local hospital treated him for the headache as well as sinusitis and his tooth problem, which was now an abscess. That didn't help; by the next day he was in bad shape. Surgeons at Children's Hospital in Baltimore performed an emergency brain procedure. He started having seizures. A second surgery was performed and, finally, the tooth was extracted. He received care for two weeks at Children's, then six weeks' treatment at another hospital. He seemed to be getting better, albeit slowly.

He died of a massive brain infection caused by the abscessed tooth on Feb. 25, 2007. He was 12 years old.

The cost of the frantic efforts to save him at Children's Hospital was estimated to be at least $200,000. The cost of a tooth extraction? The Washington Post reporter, in telling his story ("For Want of a Dentist," by Mary Otto, Feb. 28, 2007), estimated that it would have been around $80.

Deamonte and his four brothers "all had a primary care doctor—a medical home," says Laurie Norris, an attorney with Maryland's Public Justice Center, "but the Driver boys never had a regular primary care dentist—a dental home."

The Problem with Medicaid

The Driver children were fortunate to have medical homes; many Medicaid beneficiaries do not. The figures speak for themselves: In 2008, according to the Center for Studying Health System Change ("A Snapshot of U.S. Physicians: Key Findings from the 2008 Health Tracking Study Physician Survey," by Ellyn Boukus et al., Data Bulletin No. 35, Sept. 2009), only 40.2 percent of physicians accepted all new Medicaid patients, and only 12.4 percent accepted most of them; 28.2 percent of physicians accepted none. A full 40 percent of internists and 46 percent of psychiatrists accepted none. AmeriMed Consulting, in a 2009 poll, found that only 50 percent of physicians were accepting new Medicaid patients.

A 2006 study by the Center for Studying Health System Change found that "care of Medicaid patients … is becoming increasingly concentrated among physicians who practice in large groups, hospitals, academic medical centers, and community health centers as fewer small practices accept new Medicaid patients" ("Medicaid Patients Increasingly Concentrated Among Physicians," news release, Aug. 17, 2006). In September 2010, the Robert Wood Johnson Foundation reported that although 85 percent of physicians said they saw at least some Medicaid patients during the course of a year, only 50 percent said they accepted all new such patients.

The situation with dentistry is even direr. No wonder the Drivers had problems finding a dentist. In Maryland, less than 20 percent of dentists accepted Medicaid patients in 2007—the year Deamonte died—and the percentage for dental specialists was even lower. That same year, it was estimated that only 30 percent of nearly 30 million Medicaid-eligible children had ever received dental care.

What's the problem? Most physicians and dentists say it's simple: Medicaid does not pay enough to cover the cost of care, let alone produce any revenue. The New York Times, on March 15, profiled an obstetrician in Michigan who receives $29.42 from Medicaid for care that Blue Cross Blue Shield would pay $69.63. In 2009 alone, Michigan Medicaid cut physicians' pay by 8 percent and eliminated dental, vision, podiatric, hearing and chiropractic services from the benefit package. Physicians in Texas are protesting a 1 percent cut in Medicaid reimbursement that threatens to lower the already skimpy 32 percent of primary care doctors who accept beneficiaries of the program. The same situation prevails across the country, as states facing desperate economic times trim the program as much as they can. And that's if the provider can even get reimbursed, as states slow payments to a crawl; I've heard of some situations in which reimbursement lags by nearly a year.

This would not be good news at any time, but if the Patient Protection and Affordable Care Act is implemented as planned, by the end of 2014, another 16 million people may have Medicaid coverage as eligibility for the program is greatly expanded.

But is the problem only economic? When times get better, couldn't states and the feds raise Medicaid reimbursement and make everything rosy?

A Dirty Little Secret?

It couldn't hurt. When states have increased Medicaid rates, access for at least some Medicaid beneficiaries has become easier, but not always. There is a body of research going back at least 20 years that suggests there are other reasons many physicians avoid Medicaid patients. The key issues in this uncomfortable situation are race, poverty and economic class.

Study after study has shown that physicians are more likely to participate in Medicaid if the beneficiaries are white. Furthermore, physicians are less likely to accept most or all Medicaid patients if they are practicing in racially segregated areas. Also, physicians in areas where average income is lower are less likely to accept Medicaid beneficiaries.

Before anyone thinks I am accusing the medical and dental professions of gross racism, let me make it clear that the interaction of race, income and class is one of the most studied and least understood phenomena in American society. On one hand, many researchers historically have used race as a proxy for poverty, which some of us think is an outdated idea, but we'll leave detailed discussion of research methodologies for another time. On the other hand, median income among minority groups is, in fact, lower than that of whites.

And class distinctions, although more subtle in the United States than in many other countries, are still alive and well among us. For example, there is currently a huge push to get McDonald's and other fast-food purveyors to make their food healthier and to stop trying to lure children with toys or other incentives. I have not heard a word (at least since C. Everett Koop left the post of U.S. surgeon general) about gigantic steaks and three-pound lobster and butter dinners in our more upscale eateries. Indeed, former NFL coach Don Shula's steak house chain offers a 48-ounce (that's three pounds) porterhouse steak; if you eat it in one sitting, you get your name displayed on the restaurant's "wall of fame." As of this writing, nearly 36,000 people have accomplished the task, including one man who has consumed 100 of the oversized steaks and was accompanied by Shula, who cheered him on as he finished his 100th. Gosh, a Big Mac sort of pales in comparison. But then, there generally aren't a lot of low-income people noshing at Shula's.

And there was former U.S. Attorney General Janet Reno's failed attempt to equalize judicial penalties for use of powder cocaine and crack; although the difference between doing lines and smoking crack is lost on me (as it was on Reno), crack users historically receive much longer sentences. The Obama administration has quietly succeeded in reducing the disparity in federal cases, but several states, notably California, tack on extra time if the cocaine was in crack form. The conclusion in this instance is unavoidable.

We are often uncomfortable with people who are of a different class, regardless of income or station in life. Languages and dialects differ. Social behaviors differ. Ability to communicate differs. Topics of conversation can be a bit strained. So it is not surprising if most physicians, who are highly educated, disproportionately white and generally graced with good incomes, might be antsy about having a large percentage of their patients be Medicaid beneficiaries who, by law, must be poor—sometimes incredibly poor, depending on the state—and are disproportionately members of minority groups.

And there are more practical considerations. A physician practicing in a middle-class suburb almost always will treat the occasional Medicaid patient, especially if that person is a formerly insured patient who has lost his or her job and coverage. A physician practicing in a low-income community who does not receive government financial assistance (which most community health centers do) can go broke in a hurry if all he or she accepts are Medicaid and/or uninsured patients. That may not have anything at all to do with race or class.

So it's a stew of obvious financial risks associated with Medicaid patients, and social factors that can be very slippery to pin down. The fact remains that having Medicaid is no guarantee of access to care. As former American Medical Association President Donald Palmisano, M.D., told an audience in September, "Medicaid is a failed system, and putting millions of additional people on Medicaid will not fix the failure. I believe it's a cruel hoax on Americans to claim that having Medicaid gives you access to medical care."

Medicare Is No Longer a Guarantee, Either

And it isn't just Medicaid. Medicare, often celebrated as the closest thing to universal coverage this country has (at least for those 65 and older and a few other groups), is starting to run into access constraints as well.

Historically, access to care for Medicare beneficiaries has been pretty good. In 2008, about 75 percent of physicians accepted all new Medicare patients, according to the Robert Wood Johnson Foundation. The same year, the Government Accountability Office found that less than 3 percent of beneficiaries reported having major problems trying to get physician services.

But that may be changing, due to an unusual—and, frankly, partially avoidable—coalescence of forces. The most powerful is that, due to a glitch in federal law that Congress has managed to avoid fixing, U.S. physicians are facing a nearly 23 percent cut in Medicare reimbursement. It's a long and boring health policy saga, but the bottom line is that (as of now) although the decrease has not yet been implemented, physicians have had to limp along with periodic postponements, never knowing when the axe will fall. It certainly plays havoc with your planning.

Although there is a general myth that physicians are all rich as Croesus, their expenses have been going up like everyone else's, and recent studies have suggested that many people, newly uninsured and unable to pay medical bills, are staying away from the doctor's office. Physician income is at risk. And if you are an internist or geriatrician with a practice that consists largely of Medicare patients, this cut could be catastrophic.

Furthermore, with the boomers beginning to pound on Medicare's door, physicians must anticipate that more of their future patients will be beneficiaries of the program, and fewer will have better-paying private insurance.

And these issues collide with the fact that the nation is exceedingly short of primary care physicians of all kinds, about which I have written in this space before ("Surf, Turf and the Future of Primary Care," June 3, 2008). Perhaps the most notable example of what happens when coverage is greatly expanded, but there are not enough primary care providers, occurred in Massachusetts in 2006 and afterward, when the state made insurance coverage almost universal—and waiting lists immediately cropped up as newly enfranchised patients tried to find physicians to accept them.

For these reasons and others, more physicians are opting out of Medicare. A 2009 study by the American Academy of Family Physicians found that 13 percent of its members did not participate in the program. The same year, the American Osteopathic Association reported that neither did 15 percent of its members. And the AMA found that 17 percent of its members limited the number of Medicare patients they accepted; 31 percent of primary care AMA members did the same. Similar results have been reported in several states.

It was not a total shock, but still a bombshell, when on Dec. 31, 2009, the Mayo Clinic—in many people's eyes, the gold standard of care and the type of integrated health system praised by President Obama and others—announced that one of its primary care clinics in Arizona no longer would accept Medicare patients. If those patients want to stay with the clinic, they will have to pony up $1,500 a year. Mayo says it's a two-year "pilot program" designed to determine if it should terminate Medicare at its other facilities in Arizona, Florida and Minnesota.

This came on the heels of Mayo's announcement in October last year that its Rochester, Minn., clinic and hospitals will no longer accept Medicaid patients except from Minnesota and the four states that border it. The reason given: low reimbursement rates that don't cover costs or produce enough revenue.

Let's Go to the Boutique

Another response to Medicare rates deemed unacceptably low is for physicians to go "boutique" or "concierge"—to either drop out of the program entirely or charge a "retainer" to patients for access and for services supposedly not covered by Medicare. That's essentially what the Mayo experiment in Arizona is.

Boutique Medicare medicine comes in two forms: One is that the physician or practice still will take Medicare, but the patient pays a stiff fee—up to $2,000—to be accepted by the practice. The other more expensive version requires that Medicare patients pay a fee of up to $15,000 to physicians who opt out of the program; this covers physician office visits, referrals and some other services. One concierge physician advocate of my acquaintance proudly told me that he gives his patients his personal cell phone number. Golly gee.

There are at least 500 boutique Medicare (or formerly Medicare) practices nationally, and the number is growing.

Of course, what happens to Medicare beneficiaries who don't have the money to go boutique doesn't seem to be much of a concern.

Assessing this complex landscape, the great Princeton economist Uwe Reinhardt summed up the situation nicely in a letter to the British Medical Journal: "I consider the boutique medicine now emerging for the upper income classes a harmless, almost playful fringe phenomenon practiced by but a handful of physicians who, I believe, do hide behind the shield of 'quality' basically to protect their incomes. Let them. Not much harm done. The boutique medicine implicit in the Medicaid program for the poor strikes me as far more harmful, and, indeed, inherently fraudulent. When federal and state legislators pay physicians and hospitals a pittance for hard work under the Medicaid program for the poor and then pretend to God and country that they have looked after the poor, that strikes me as fraud. After all, what is a state legislator really saying to a pediatrician when, through the legislator's own insurance, he or she is willing to pay the physician $80 for a patient visit, all the while paying the physician only $20 or $30 for the same visit accorded the child of a poor family. Economists believe that the relative prices buyers offer signal relative values. The state legislators' relative valuation of the treatment of their own children and that of poor children is crystal clear."

Just ask the Driver family. And by the way, in some states, $30 for a Medicaid pediatric visit would be a pipe dream for physicians.

Can Anything Be Done?

The new health care law seeks to address some of these issues. It has established yet another national health care workforce commission, charged with assessing future needs for various clinical and other health professions. There is also money for increasing the primary care workforce. I must cynically observe that we have been trying these tactics for years, with little to show for it.

Congress, currently in lame-duck status, is considering yet another postponement of the Medicare physician-payment reduction, but it is still death by a thousand cuts for physicians until a permanent solution is found.

There are also calls to require physicians to accept Medicare and Medicaid patients as a condition of state licensure, but such a mandate is impossible to enforce. The physicians can simply tell inquiring supplicants that they aren't accepting new patients of any kind at that time. Indeed, a while back, Massachusetts tried to mandate Medicaid participation and found it a very difficult path to tread.

However, if you are a provider receiving federal subsidies to care for the poor, then you should care for the poor. Although most community health centers (CHCs) and most community mental health centers, albeit fewer of them, do an impressive—indeed, often heroic—job of caring for patients who are often very sick and almost always very poor, some of these clinics have been known to pick and choose, despite hefty federal subsidies and grants. That's not acceptable.

And we can debate the morality of providers refusing to participate in Medicaid or Medicare and of boutique medicine, and so forth, but that's not going to powder the doughnut. The fact is that in this country we generally do not tell physicians where to practice or which patients to accept. We don't force physicians to accept patients they don't want to treat, and one would have to wonder what kind of care those patients would get if we did. It's a free country.

The fact is that federally funded CHCs and hospitals are, as always, the last line of defense for those who are rejected by the rest of the system. Medicaid doesn't pay much but, then again, it pays something, which is more than the dead loss of caring for the uninsured.

I think the lessons of this tangled web are many, but I will confine myself to three. First, coverage isn't access. As I often say in my presentations, coverage is a promise; access is a fact. And the fact is that in many cases, we aren't keeping the promise.

Second, everyone should have a medical home. Everyone should have someone he or she can call when the husband has a fever, when that cut seems to be infected, when that child's tooth has been hurting for a while and now he has a headache and seems tired. Yes, this model saves money, but that's not the point; it saves lives.

Third, we must be aware of the consequences when coverage does not mean access, and we should do something about it. In the wake of Deamonte Driver's death, two African-American dentists in Maryland, Hazel J. Harper and Belinda Carver-Taylor, founded the Deamonte Driver Dental Project. It began by establishing relationships with nine elementary schools in Prince George's County, where Deamonte lived and died, so that principals, school nurses, teachers and parents can refer kids who need dental care. Services are provided in a mobile dental clinic that comes to each school. Kids who need referrals are given a "dental report card" to take home. During a four-day period at one school last year, project staff found 32 children who needed emergency dental care, some of whom had abscesses like the one that killed Deamonte, and "teeth rotted down to the nerve centers," according to a press release.

The state of Maryland provided $288,000 to the project for a more sophisticated, fully equipped dental office on wheels. That's just about what it cost to try to save Deamonte. The new mobile clinic was dedicated on Capitol Hill in May at a ribbon-cutting ceremony.

You could say that this effort is just a drop in the bucket. But until we come to our senses in terms of our health care priorities, at least these folks are trying to make a difference. Mother Teresa once said that although her efforts were but a drop of water in the ocean, the ocean would be less without that one drop.

So here's to every physician, dentist, nurse, hospital, clinic and other provider who, despite the low reimbursement, the ridiculous paperwork hassles, the sometimes-difficult patients, and policymakers and a society who look the other way, care for patients who have Medicare or Medicaid or no coverage at all. We may attain universal coverage and access someday but, in the meantime, I salute you for refusing to give up on those who need you—or on the rest of us, hardhearted fools that we so often are.

Editor's note: Part 1 of this article published in H&HN Weekly on October 5, 2010.

Copyright ©2010 by Emily Friedman. All rights reserved.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Weekly and a member of the Center for Healthcare Governance's Speakers Express service.

First published in Hospitals & Health Networks OnLine, December 6, 2010


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