Stanley Feld M.D.,FACP,MACE
There are always problems with federally funded programs. They are bureaucratic, inefficient, and always seem to contain loopholes that can be taken advantage of by stakeholders.
Most states are desperate for additional funding this budget year. They have large budget deficits despite increasing state tax rate. States raising taxes do not seem to be the solution. People move out of the state as in California. President Obama providing an additional 100 billion dollars to the states for Medicaid bailout is not the solution to Medicaid’s problems or the uninsured problem. .
“The federal and state governments are equally culpable for the program’s troubles. The federal government matches state Medicaid spending, paying an average of 57% of costs. States expand enrollment in order to qualify for more federal aid.
The barriers to medical care listed in Part 1 have resulted in extreme shortfalls in physician coverage for Medicaid patients.
a. A government survey in 2002 for the Medicare Payment Advisory Committee found that "approximately 40% of physicians restricted access for Medicaid patients" because reimbursement rates are so low.
b. Only about half of U.S. physicians accept new Medicaid patients, compared with more than 70% who accept new Medicare patients.
c. Several recent studies trace the difficulty in getting Medicaid patients seen by specialists to low fees and payment delays.
d. Technologies are also restricted. Many expensive but important drugs aren’t paid for under various state drug formularies.
Newspaper headlines continue to point out Medicaid fraud by various stakeholders.
“ James Mehmet, New York’s former chief Medicaid investigator, was quoted in the New York Times as believing that at least 10% of state Medicaid dollars were spent on fraudulent claims, while 20% or 30% more was siphoned off by what he termed "abuse."”
Think about this. The implication is that physicians are at fault but the states are the entities siphoning off large amounts of money for “other uses” and not for medical care.
40% of physicians did not accept Medicaid patients in their practices in 2002. I am sure the percentage is higher today. 50% of the 60% remaining physicians who have Medicaid patients in their practices do not take new patients. Medicaid patients do not have the choice of their physicians. Their choice is limited to the remaining 35% of the physician workforce. This workforce is overburdened with Medicaid patients.
Some of these physicians see many patients a day or restrict access to care. A small percentage of these physicians have figured out how to leverage their practice. They see an unserviceable number of patients a day. Many call these practices are called Medicaid mills by healthcare policy wonks. In some locations they are the only practices available to service Medicaid patients.
Newt Gingrich has complained about these physicians. He has called them fraudulent. My guess is that less than 10% of the 35% (3.5%) might be fraudulent. Newt’s solution is force all physicians have an EMR so the government can capture “fraud” instantaneously.
“ Even if the federal government wanted to hold states more accountable for peoples’ health, Medicaid claims data is poorly gathered in most states, making meaningful oversight hard.”
I would suggest that the states get better electronic data systems. I believe EMR’s are essential in physicians’ practices but not for the punitive reason expressed by Mr. Gingrich.
“Barack Obama’s team and Democratic leaders plan to change the federal matching rate to reduce the amount of state funding that is required for maintaining a given level of federal Medicaid spending.”
The issue of states receiving increased funding for Medicaid is very complicated. Some states are trying to change the definition of poverty to include people earning up to 63,000 dollars a year. The rationale is the states need to encourage low paid workers to stay in their state. Other states are keeping the 1955 definition of poverty and siphoning money that should be spent on Medicaid care for “other uses”.
If someone had the desire to do it right, the government would change the criteria for the definition of poverty. President Bush was uninterested. He wanted to eliminate Medicaid as a federal entitlement and put the burden on the states.
“ Mr. Obama would give Medicaid tens of billions more in federal dollars as part of the fiscal stimulus bill. And he wants to extend Medicaid to some unemployed workers, with the federal government paying the entire cost — a watershed expansion of the program.”
President Obama,s healthcare advisors do not understand that throwing money at the Medicaid system will not fix the system. It will reduce the number of uninsured. It will increase the number of people who have inadequate healthcare insurance..
The “stimulus” will not increase the quality of medical care delivered. I fear the biggest accomplishment will be to increase the incentive for the misuse of more taxpayers’ dollars. Medicaid’s open ended funding must stop.
a. The states must be held accountable for their healthcare subsidy spending .
b. The states must be held accountable for providing incentives for patients to sign up for this healthcare insurance.
c. The states must be accountable for providing incentives for patients to become responsible for their own healthcare.
d. The states must be accountable for decreasing environmental risks to their citizens (stop developing coal burning plants).
e. The states must be accountable for giving physicians incentives to participate in the system.
The ideal medical savings account in the Medicaid system would be effective. It would put patients in charge of their healthcare dollar and their health care. The states and federal government would be responsible for helping patients be responsible purchasers of their medical care.