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NC Medicaid: “A Modest Proposal for Medicaid Reform”

Medicaid recipients in North Carolina are not getting the same, quality health care that citizens with private insurance receive.

Health care providers refuse to accept Medicaid due to low, Medicaid reimbursement rates.  There are not enough Medicaid providers for all the Medicaid recipients.  Medicaid recipients have difficulty finding health care providers, especially dentists and other specialists. Many Medicaid recipients are forced to go to the emergency departments (EDs) for medical issues that could have been conducted in a primary care doctor’s office, thereby creating excessively long, waiting periods at EDs.  Medicaid recipients, who understand they need mental health services, are left to the whim of an employee at a managed care organization (MCO) as to whether the recipient meets medical necessity for a behavioral health care service.

I’ve blogged before that the disparity between the health care a Medicaid recipient receives and the health care a citizen with private insurance receives reminds me of the “separate, but equal” doctrine during the Civil Rights Movement. 

Medicaid recipients in North Carolina are not getting the same, quality health care that citizens with private insurance receive.

Separate is not equal!

As a nod to the great author, Jonathan Swift, I have “A Modest Proposal for Medicaid Reform.”  Jonathan Swift is probably more well-known for “Gulliver’s Travels,” but, by far, my favorite Swift work is “A Modest Proposal.”  With “A Modest Proposal,” Swift defined satirical writing, but about 300 hundred years ago. 

“It is a melancholy object to those who walk through this great town or travel in the country, when they see the streets, the roads, and cabin doors, crowded with beggars of the female sex, followed by three, four, or six children, all in rags and importuning every passenger for an alms. These mothers, instead of being able to work for their honest livelihood, are forced to employ all their time in strolling to beg sustenance for their helpless infants: who as they grow up either turn thieves for want of work, or leave their dear native country to fight for the Pretender in Spain, or sell themselves to the Barbadoes.”

Interestingly, Swift published “A Modest Proposal” anonymously in a newspaper.  At the time Swift wrote it, Ireland was in an impoverished state with an over-population problem.  Some lawmakers had suggested a number of population-control methods that, apparently, insulted Swift to his core.  One person suggested running the poor through a joint-stock company, presumably for the “rich, educated” people to control the “poor.”  Others suggested population-control, such as preventing childbirth for certain demographics.

Similarly, today I was listening to CNN when the newscaster explained that a mother of an autistic child received a hateful letter from a neighbor about her autistic child.   

Here are some statements found in the letter: (Please understand that these words are not mine.  In fact, when I heard this story, I was torn between crying for this mother and child or becoming infuriated at the ignorance and narcissistic hubris of the author).

The letter goes on to criticize Begley for allowing Max to play outside and says: “That noise he makes when he is outside is DREADFUL!!!!!!!!!! It scares the hell out of my normal children!!!!!!!”

The letter also tells Karla that she has a “retarded kid” and “should deal with it properly”.

“What right do you have to do this to hard working people!!!!!!!! I HATE people like you who believe, just because you have a special needs kid, you are entitled to special treatment!!! GOD!!!!!!”

The writer finishes by demanding the family “go live in a trailer in the woods or something with your wild animal kid!!!” and asks the family to do the right thing and move or “euthanize him. Either way, we are ALL better off!!!”

I hope that the above words impacted you as they did me.  I simply cannot believe that a person…any person….would THINK those words, much less write those words.  Has our society become so callous to people with special needs that the people with special needs have become (in the author’s view) burdensome or annoying?  To the author of that hateful letter, I say, “Shame on you!” 

I also say, “If there were laws against being heartless, you would be sentenced for life!”

In “A Modest Proposal,” Swift suggests (satirically) that the impoverished Irish might ease their troubles by selling their children as food for rich gentlemen and ladies. “This satirical hyperbole mocks heartless attitudes towards the poor, as well as Irish policy in general.”  See Wikipedia . (It amazes me that the authors of Wikipedia draft better English essays than I did in college).

According to DMA, in 1999-2000 more than 1.22 million individuals were covered under North Carolina’s Medicaid program.  By 2009, that number had grown to more than 1.81 million individuals, an increase of approximately 50%.  That means that 1.81 million people in North Carolina depend on Medicaid.  These are our neighbors; these are our children; this may even be us.

I have my own “A Modest Proposal.”  My “A Modest Proposal” is:

A Modest Proposal for Medicaid Reform.”

Our Medicaid budget  is approximately $14 billion.  According to Kaiser, our Medicaid expenditures were $10,546,984,914 in fiscal year (FY) 2011.  However, Kaiser also notes that “expenditures do not include administrative costs, accounting adjustments, or the U.S. Territories. Total Medicaid [federal and state…as in, nationwide] spending including these additional items was $427.4 billion in FFY 2011.”

We spent $10.5 billion (estimated) on Medicaid services for Medicaid recipients in FY 2011.  According to the January 2013 State Audit of DHHS, in fiscal year 2011, North Carolina Medicaid incurred administrative expenses of approximately $648.8 million.  Now, here in 2013, with the MCOs in place statewide, I wager that the administrative costs for Medicaid for fiscal year 2013 will, at least, double due to the salaries and benefits awarded to MCO employees. 

67.4% of our $10.5 expenditure went to acute care (hospitals).  No shock there. Medicaid recipients generally do not receive continuity of care through a primary physician.  Therefore, many Medicaid recipients end up in the ED for an ear ache (ever wonder why the waiting period at the ED is so long?). 

Plus, North Carolina is, sadly, floundering as to providing mental health services, so it is no wonder that  “almost one-third of ED visits by those with underlying mental health disorders resulted in hospital admission, more than twice as many as those without underlying mental health disorders,” according to a new study released by North Carolina School of Medicine researchers.  For the study, click here.

28.8% of our Medicaid expenditure went to long-term care.  Again, not surprising with the rise of more aged, NC citizens.  Kaiser Family Foundation data for FY 2009 show that approximately 27% of those enrolled in the North Carolina Medicaid program were categorized as aged or disabled, and that the cost of services for those 2 categories of recipients made up approximately 63% of the program’s total costs that year.

3.9% of our Medicaid expenditures for 2011 went to DSH payments.  Disproportionate Share Hospital (DSH) adjustment payments provide additional money to hospitals that serve a significantly disproportionate number of Medicaid recipients.

3.9 + 28.8 + 67.4 = 100%

North Carolina’s total Medicaid spending including these additional items was approximately $11.149 million in FY 2011. ($10.5 billion + $648.8 million administrative costs). According to Beth Wood’s January 2013 Performance Audit, private contractor payments represent about $120 million (46.7%) of DMA’s $257 million in administration expenditures for FY 2012.  Almost half of the administrative costs for Medicaid, in 2012, went to contracted companies, such as Piedmont, Carolinas Center for Medical Excellence (CCME), Public Consulting Group (PCG), etc…

So…here is my “A Modest Proposal:”

If you take the total Medicaid budget (currently, over $14 billion) for the fiscal year ended June 30, 2012, and divide the budgeted amount by 1.8 million (the approximate number of North Carolinians on Medicaid), you get: $7,777.78.

$7,777.78/year for each Medicaid recipient.

My health care premiums for a “Cadillac health care” with my husband costs $9000/year.  And it is great health care.  All copays are $10 for generics, $15 for non-generic.  Doctor visits are $10, a specialist is $25.  The beauty of my health care, though, is the deductible is only $500.  I hit $500, and everything is covered.

Now, mind you, the $9000 ($750/month) includes my husband.  If I wanted individual insurance  it would only have cost $228/month or $2,736/year.  Why the addition of my husband increases the premium from $228 to $750, I have no idea, but it does. (He does not even have pre-existing conditions!!! In fact, he flatly refuses to visit a doctor unless pending death.  In my mind, he should have been cheaper than I).

As an individual, in order to pay for this “Cadillac” policy, you would have to pay $2,736/year.  Add in the $500 deductible and the total cost (barring unexpected and individual costs) would  be $3236. 

Our Medicaid budget allows each Medicaid recipient approximately $7,777.78/year. 

First, I propose North Carolina downsize 80-90% of the Division of Medical Assistance (DMA) and keep running a much smaller DMA for the sole purpose of determining yearly Medicaid eligibility, thereby cutting almost all administrative costs.  I also propose hiring ZERO contracted companies for Medicaid.  There is no reason for any contracted companies under my “A Modest Proposal for Medicaid Reform.”

17,000+ people are currently employed by Health and Human Services.  But employment of citizens is not a reason to maintain an agency.  Therefore, if we can manage Medicaid without 16,500 employees (which my “A Modest Proposal for Medicaid Reform” purports to do), then we are paying unnecessary administrative costs.

Secondly, taking the Medicaid funds, and, instead of paying administrative costs to DHHS, DMA, PCG, CCME, all the MCOs, we purchase excellent, quality private insurance for each Medicaid recipient.  We pre-pay the deductible for all Medicaid recipients.  We hand the Medicaid recipients a private insurance card that is “pre-paid” with no deductible.

A pre-paid, private insurance card!  With no deductible! (Because the deductible is paid).

No more doctors refusing Medicaid!  Think about it….all doctors would take the new “Medicaid,” because the recipients would have private insurors paying the full price for medical services. 

No more placing the burden of whether a recipient meets medical necessity for a medical service in the hands of DMA or a contracted company.  The private insuror would take on that burden and use the same standard of medical necessity as it does for all its consumers.  And why not? The insurance company is getting paid the same…

Medicaid recipients would get quality care just as if they were not Medicaid-eligible.  And isn’t that our goal? For the Medicaid recipients to be cared for just as well as if they were not Medicaid-eligible?

No more difficulty finding health care providers that accept Medicaid. Medicaid recipients would have the “Cadillac” Blue Cross Blue Shield just like I do.

No more excessively long, waiting periods at the ED! Medicaid recipients would benefit from continuity of care just like I do.  No need to go to the ED for an ear ache.  The primary care physician can tend to the ear ache.

No one would worry about Medicaid fraud anymore because, as to health care, everyone would be the same.  (So, we could also eliminate the need for Program Integrity).

No more Medicaid provider contracts, as all health care providers would accept the new “Medicaid.”

No more Medicaid recoupments.

I profess, in the sincerity of my heart, that I have not the least personal interest in endeavoring to promote this [Medicaid reform], having no other motive than the public good of my [state], by advancing our trade, providing for [Medicaid recipients], and giving some pleasure to the rich.

Think what an impact North Carolina would have on the nation if we were to implement my “A Modest Proposal for Medicaid Reform!!”

NC Medicaid Providers: Does Your Insurance Cover Legal Fees for Regulatory Audits??

I must confess…I do not know much about health care providers’ liability insurance.  I just haven’t had to deal with liability insurance many times.

But, a client has recently informed me that their liability insurance will compensate them for 100% of my attorney fees that pertain to my representation germane to their regulatory audit. If this is true, then I have many clients that need to have a chat with their insurance companies.

Please understand…I have NOT read the small print with this insurance coverage. I do NOT know the ins and the outs of this insurance, or, even, whether it will actually, truly cover 100% of attorneys fees.

But, IF there is a possibility of your insurance company covering attorneys fees, what is there to lose?

This is all I know:

Alleged insurance that covers legal fees for regulatory audits? “APA Plus.”

From what I understand, if you pay an extra $15/month, the insurance will cover legal fees associated with regulatory audits, up to $50,000.

Again, please understand, this is hearsay, and I have read no insurance contract.  The ONLY reason I am blogging about an issue that I do not have verification of its veracity is because if, and only if, there is even a 1% chance that your insurance company will cover legal fees, this could be such a burden off your shoulders during such a stressful time anyway.

What does it hurt to try?

What the Heck are the NC MCOs’ Jurisdictions?

Since the new MCO (managed care organization) system is SO new to the Medicaid system in North Carolina (as in since February 1, 2013), I though it would be prudent to explain what the in the heck is the MCO jurisdiction system.

An MCO is defined, generally, as:  a health care provider or a group or organization of medical service providers who offers managed care health plans. It is a health organization that contracts with insurers or self-insured employers and finances and delivers health care using a specific provider network and specific services and products.

In NC, the MCOs are the messengers to the Division of Medical Assistance (DMA)…the middlemen…the ears of DMA.  Instead of 100 separate LMEs, the 11 or so MCOs are supposed to create more of a state-wide, uniform Medicaid criteria.  Now, I am not sure if the below image correctly depicts the jurisdictions of all the MCOs.  It seems as though the MCOs’ jurisdictions change quite often, but the image below is the most current jurisdiction map I could find. Please, if someone else has a more current map, please share.

Image

 

A Personal Account of a Medicaid Audit

Readers: I did not write the following blog.  A gentleman emailed me his personal account of a health care provider undergoing a Medicaid audit.  I asked for his permission to publish it and it was granted. (I apologize for any formatting issues.)

NOTE:  The following is somewhat long but is a reflection of the recent topsy-turvy, sinusoidal, and duplicitous events in the NC Outpatient Mental Health setting…….

During the summer of 2012, while I was standing outside of a clinic where I contract waiting for my next client, a car rapidly pulled up and out jumped 4 stony faced people with briefcases and a purpose in their steps as they entered the clinic

It was an unannounced Medicaid audit.

Many clinicians and agencies knew these were occurring so it was not completely unexpected.  At this particular free-standing private clinic which accepted Medicaid there was some anxiety (as any audit would produce) but we were pretty confident about our work – electronic medical records had fail safes for compliance, supervision occurred regularly, and the Clinical Coverage Policies for Medicaid were followed.

Over the next few months as the audit progressed a surrealistic Russian style bureaucratic nightmare occurred.  Medical records were requested by the auditors and submitted by the clinic.  CCME (Carolina Center for Medicaid Excellence) who was doing the audit would say ‘we didn’t get the records’ and be elusive and dodgy.  Medical records were re-submitted – hand delivered.  Feedback from CCME was that the Treatment Plans did not meet standards.  The Treatment Plans were being developed in line with the posted Clinical Coverage Policy and they were also in line with the recommendations of one of the LME/MCO’s right over the county border but after much back and forth CCME continued to say they were not in compliance.  CCME did not provide a clear indication of what compliance was nor did they provide a clear template for the Treatment Plans.  (NOTE: The LME/MCO from the nearby county said the clinic’s Medical Records per their site review were at a 92.5% accuracy!!!)

Staff at the clinic worked diligently to cooperate with CCME but every attempt at cooperation was met with a shift of the carrot on the stick.  Conference calls were scheduled, emails were written, repetitive requests for clarification were pursued without any success or resolve.

The clinic was then put on a “pre-payment review” meaning claims for services rendered were not paid until the records were reviewed and approved.  ‘Pre-payment review’ is an unguided process that could take 30 days – the approval of records is based on unclear standards so any clinical services rendered were like the lottery – maybe they’ll get reimbursed if someone somewhere says documents meet some kind of unknown standards….or maybe they won’t get reimbursed at all.

Eventually, so much unproductive hoop jumping occurred and time was wasted that a deadline for acceptance by the local LME/MCO came due.  Because of the delays by the CCME, the LME/MCO which went live on 2/1/13 said to the clinic ‘we can’t enroll you’ due to the ‘pre-payment’ status.

With only 3 days of lead time, over 100 clients – some of which were children in foster care or with PTSD or within the Juvenile Justice System – had to suddenly be terminated from treatment and referred to other agencies.  Fortunately, the clinic will continue – contracted with the other county LME/MCO and accepting private insurance.

Was this top-down inefficient State bureaucracy?  Was this effective Public Mental Health policy?  Was there any consideration for how this would impact service provision and the clients? Was this purposeful – intended sabotaging of a clinic in order to reduce the number of providers within a community and save Medicaid dollars?  Is this the CCME’s way of insuring ‘Excellence?’

I, and my colleagues who provide Public Mental Health services and who have weathered many pressures and changes, are not naive about accountability – we are ready to stand accountable and provide appropriate services with appropriate billing and documentation. I understand there are economic pressures at hand here but the current zeitgeist of audits, regulations and site reviews seems like a witch hunt and feels like a displacement for the past sins of others (http://www.inthepublicinterest.org/article/reform-wastes-millions-fails-mentally-ill).  With the laser beam aimed at service providers – purposely geared to finding the smallest of errors in an effort to go ‘GOTCHA’ the zeitgeist is a culture of fear in order to insure accountability to DMA, CCME, DHHS, CMS, EDS, and the LME/MCO.  Well what about accountability to our clients?  Have policy makers forgotten about the clients in an effort to weed out the service provider playing field?

As a side note, it was rumored –  and it may just be urban legend – that Medicaid auditors were paid based upon how much money they generated from the audit. If anyone has more information on this I would love to hear it – but at the community level it is understood that the contracted auditors were paid based upon how much money they were able to save Medicaid – how many claim denials they could find and how much money they were able to claw-back.

Wouldn’t this contractual arrangement be considered a kickback?….’the more money you save or make us the more you will get from us?’  Aren’t kickbacks considered illegal within the Medicaid and Medicare system?

Clinicians, Clinics and Agencies believe that there has been an INTENDED consequence with the tightening of regulations (such as CABHA and Medicaid Waiver) – the intention is the eventual reduction of the number of private agencies that provide outpatient Mental Healthcare. Both, agencies that do enhanced services as well as core services, are being purposely circuitously and indirectly liquidated.  When looking at lists of agencies that accept Medicaid over time, there was a 50% reduction of agencies after CABHA.  With the implementation of the Medicaid Waiver the list has dwindled even further.  Initially LME/MCO’s have been accepting virtually all agencies that apply but it is anticipated that over the next year the bonsai tree will be trimmed even further with reviews of ‘outcome measures.’  More and more agencies will not be able to sustain.  It is presumed that the final goal is to have a few large agencies contracted across the state.

Now, be advised that I have seen with my own eyes heinous service and billing improprieties in 2005 and 2006 and received backlash from profiteers when I called out inappropriate activities….so, I agree that it is necessary to set clear standards and hold providers accountable…HOWEVER, the zeitgeist is an over-rotation.

Let’s see how the pendulum swing, tightening of the noose and reduction of reimbursements is working….

One of the larger agencies that has satellite offices in 15 counties in the central NC area just closed two of it’s offices in 2 counties.  In a different county where this large agency still has an office the pay for clinicians was cut, then cut again, then cut again, and a colleague of mine who works at this agency said that there were sweeping layoffis in her office.  What is interesting is that many community clinicians believed this big multi county agency was one of the golden children that would sustain and still be standing while all the other ‘mom and pop’ or ‘pop up’ agencies were dissolved.  Well, it seems like no one is immune anymore.

Another colleague of mine described how his multi county agency had radical re-structuring recently, specific Medicaid services were cut and the providers of those services were laid off, and there were across the board pay cuts.

Clinicians have no recourse either – ‘if you don’t like the pay cut then you can always try to find another job…wait…there are no other jobs since everyone else is closing so I guess you are stuck.’

On another side note, I recently head about a survey of private Psychologists who had been accepting Medicaid.  The survey showed that over 40% of them intended to stop taking Medicaid clients due to the increase of regulations and requirements and reduction of reimbursements (all of which makes service provision cost and time prohibitive).  Many of these surveyed Psychologists had over 8 years of experience – the intended consequence of reducing providers ALSO reduces your qualified and experienced professional base – these are the providers who know the clients and know the community and know the collateral resources.

I am aware of several private multi-county/multi-provider agencies that used to accept Medicaid clients but have stopped due to the cuts in rates and arduous regulations.  What is interesting is that these private non-CABHA agencies provide excellent care, are preferred by clients, and ironically they bill a FRACTION of what CABHA agencies bill.

On February 1st a therapist from NC had an ‘opinion’ published in the Washington Post called:

“The risk of skimping on mental health funding”

 Below is the link to this article which describes his frustrations with the Medicaid cuts in Southern Pines:

http://www.washingtonpost.com/opinions/the-risk-of-skimping-on-mental-health-funding/2013/02/01/5cdf8ad4-6ba6-11e2-ada0-5ca5fa7ebe79_story.html

Since you may have to do a free ‘Register’ with the Washington Post online to see the article, here is an excerpt:

For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3 billionhas been slashed from state mental health budgets nationwide since 2009, according to theNational Association of State Mental Health Program DirectorsSouth Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.

The director of our clinic in Southern Pines, N.C., in the center of the state, has told me that this year’s cuts are likely to force us to close. Our facility offers mental-health and substance-abuse counseling to 75 to 100 clients a week, half of whom are 18 years old or younger. Typically, they are referred to us from child protective services, doctor’s offices or the local domestic violence/sexual assault agency.

When the events at the service delivery level are brought to policy makers’ attention, I deeply resent their disregarding platitude of “oh well….we know change is hard.”  Well, it has been change (2001 divestiture and privatization), and change (2005 slashing community support), and change (2006 ValueOptions authorization policy changes) and change (2010 CABHA), and change (2012 Medicaid Waiver) and change (new billing and authorization systems such as Alpha and Provider Direct) and change (2013 Medicaid rates rates slashed 40% effective 1/1/13 then returned to prior rate on 1/23/13 with delays of payment for 1/13) and change (2013 CPT code changes and Medicaid rate and service time reductions)….You don’t know how many times I have had to say to clients “….I am sorry but there are NEW Medicaid regulations which will effect you in the following way…”  You don’t know how many of my colleagues have said to me “….the agency where I was working closed….do you know who is hiring….”).

Furthermore, I resent the proverbial ‘pot calling the kettle black’ when Community Agencies, Individual Clinicians, and Private Practices accepting Medicaid are being scrutinized and audited to the point of being inoperable ALL THE WHILE there is waste and mismanagement at the top – DMA mismanagement (http://pulse.ncpolicywatch.org/2013/02/01/problems-identified-by-medicaid-audit-largely-result-of-nc-republicans-own-budget/), cost over runs with Computer Sciences Corporation (http://www.newsobserver.com/2012/06/17/2142627/state-contract-for-updating-computer.html), “structural flaws,” and more (http://www.wral.com/audit-mismanagement-costs-nc-medicaid-system-millions/12048026/).

I hope McCrory means what he says ( “We want to make sure that the money that’s supposed to help people is going to them, not to the administrative cost.”) and that ‘Medicaid Reform’ will have a positive result.  I hate to be a ‘Negative Nick,’ but my fear (based on experience) is that if you squeeze on one side of the tube of toothpaste it gets smooshed (yes…a real word) to the other side….in other words, the ATTEMPT to reduce administrative waste may actually make its way down to the community level in the form of service and provider cuts.   We shall see…..

I continue to provide services to Medicaid clients and IPRS clients through contracts with agencies, but it is unclear if I will be regulated out of the field.  The Waiver continues….

Feel free to write back with your experiences, thoughts, and or comments.

Geoffrey Zeger, ACSW, LCSW

 

 

A Comparative Study: Nursing Homes With or Without Medicaid Clients

Today, I had a fascinating discussion with a gentleman (who will remain unnamed.  I will call him Joe). (BTW: The veracity of the information in this blog is not based on my first-hand knowledge, it is based on Joe’s).  For years,  Joe owned a nursing home ( he recently sold it).  He explained that he never accepted over 20% Medicaid clients. His friend, Bill (also unnamed) also owned a nursing home. Bill accepted 100% Medicaid clients. So let’s explore the differences between the two nursing homes.

Joe’s: The nursing home was brand new. Joe had the building built with state-of-the-art medical access (pre-wired for medical equipment, etc.). The staff was exceptional. The beds were the kind that you can lay down or sit up; the beds also vibrated at certain times of the day to prevent bed sores. Each room had a television. The cafeteria provided an array of healthy foods.

Bill’s: The nursing home was located in an old concrete building. The nursing home met all the minimal requirements in which to meet the criteria to receive its Certificate of Need (CON). There was staff.  There were beds, but not the movable type, just basic single beds. There was food.  Residents and family of residents complained often about the living conditions, but the nursing home met the state’s minimum requirements.

Joe’s: The nursing home was profitable as long as it kept the number of Medicaid recipients to a minimum. Many times Medicaid recipients were turned away.

Bill’s: The nursing home was profitable as long as he kept his staff to a minimum and quality of food, beds, cafeteria meeting the minimum requirements.

What I extracted from Joe’s comparison between the two nursing homes, was that Medicaid recipients, for the most part, were receiving less quality care than those with private insurance. Fair?

You have to ask yourself why was Bill’s nursing home profitable with all Medicaid clients? Because the Medicaid clients were housed in a nursing home that only met minimum standards.  Bill’s nursing home was a concrete block building.  There were neither TVs nor upgraded medical equipment.  By keeping his overhead at a minimum, Bill was able to make a profit off Medicaid clients.

On the other hand, Joe’s state-of-the-art nursing home had to limit the number of Medicaid recipients in order to maintain a profit.

Why does Medicaid pay so little to health care providers? With all the money going into Medicaid budgets/funds, why can’t more be allocated to paying higher reimbursements to health care providers?  It seems to me that, if you agree that Medicaid is a needed program, you would agree that the Medicaid recipients should also receive quality health care. Personally, I would much rather end up in Joe’s nursing home rather than Bill’s.

 

The NC Medicaid System is Broken: FIX IT!!

People covered by Medicaid receive worse medical service than people with private insurance.  This is a fact.  It is a sad fact, but a fact nonetheless.  Hundreds of studies have shown this fact.  Here are a few:

A recent study published in the New England Journal of Medicine examined pediatric access to specialty clinics in Cook County, Illinois.  The study sent out research assistants posing as mothers and making phone calls to a random sample of specialty clinics, the study found a significant disparity between access to specialty care for privately insured children and children on Medicaid as well as the publicly funded Children’s Health Insurance Program (CHIP). Specifically, the researchers noted more denials of appointments as well as longer waiting times for Medicaid and CHIP patients than for privately insured patients.

A very scary study conducted on North Carolina‘s Medicaid in 2010 published in the State Center for Health Statistics, found that the North Carolina Medicaid population experiences a much higher rate of overdose deaths than the North Carolina population. This study suggests that fatal overdose among the Medicaid population are associated with claims for mental health disorders, substance abuse, and routine medical care for pain management.

A 2000 study published in the American Journal of Public Health that examines colorectal cancer treatments and outcomes found that Medicaid patients not only had higher mortality rates, but were also less likely to receive cancer-directed surgery, than patients using commercial fee-for-service insurance.

A 2010 study in the Journal of Hospital Medicine found similar results for non-cancer-related illness. In this study, the authors examine the relationship between insurance status and health outcomes for myocardial infarction, stroke, and pneumonia patients.  The authors statistically analyzed a nationally representative hospital database and noticed, even after adjusting for factors such as age, gender, income, other illnesses, and severity, higher in-hospital mortality rates for Medicaid patients than for privately insured patients. Additionally, even after adjusting for these factors, the study found that Medicaid patients hospitalized for strokes and pneumonia also ran up higher costs than the privately insured, as well as the uninsured.

A 2012 study in Health Affairs examined physicians’ willingness to accept new patients. Using survey data from a nationally representative sample, the study found that nearly one-third of physicians nationwide will not accept new Medicaid patients. Doctors in smaller practices, as well as doctors in metropolitan areas, are among the least inclined to accept new Medicaid patients.

So, with the understanding that  the Medicaid system  is failing those very people it is designed to protect, why are our political leaders ignoring the broken system and merely dumping more people into the failing Medicaid system????

With Obamacare‘s Medicaid expansion, hundreds of thousands of people will be dumped into this broken Medicaid system with zero political effort to FIX the system. In NC alone, if we expand our Medicaid, approximately 720,000 more North Carolinians will be Medicaid eligible.

Obama proponents would, most likely, argue that Obama raised the Medicaid reimbursement amount to physicians to meet the Medicare reimbursement rate. Raising the Medicaid reimbursement rate tempts more physicians to accept Medicaid.

I agree with the last sentence of the above paragraph. Raising the Medicaid reimbursement rate WOULD cause more physicians to accept Medicaid. But that is not what Obamacare does.  Obamacare does not raise the Medicaid rate to all physicians, only primary care physicians, and only temporarily.  And even the raised rate for primary physicians is nominal, at best. Because, during the 2012 election,  while Obama was standing on his platform of higher Medicaid reimbursement to physicians…up to the Medicare rate….Obama was slashing the Medicare reimbursements. It’s the old bait and switch. GOTCHA!

Again I ask: Why are our political leaders ignoring the broken system and merely dumping more people into the failing Medicaid system????

Medicaid expansion will cause more people to be declined medical treatment by providers, cause people to receive sub-par health services, and to the extreme, cause deaths when those deaths should not have happened.

Unintentional overdosed (UO) deaths have become the second leading cause of unintentional injury deaths in the United States, exceeded only by motor vehicle injuries. (1)  North Carolina UO death rates exceed the national average.  The Medicaid population represented approximately 20 percent of the overall state population in 2007, but it experienced one-third of the unintentional overdose deaths.  (2)

Instead of expanding Medicaid to more people,  our leaders need to fix the Medicaid system first. Fixing the Medicaid system should be the number one top priority.  Not exasperating the problem by dumping 720,000 more North Carolinians into the Medicaid system. FIX IT!! 

Make sure that if I hold a Medicaid card that (1) I am able to get an appointment with the proper physician; (2) that the physician I visit does the very best he or she can to ameliorate my problem (as if I were on private insurance); (3) provide me with any needed test to determine the cause of my problem; (4) allow me to have follow up appointments.

In essence, those with Medicaid should receive the same care as those on Blue Cross (not saying Blue Cross in the bee’s knees).

FIX IT!!!

 

NC Medicaid Expansion: BAD for the Poor

Seems odd, right? How can providing more health care coverage to more people in need actually be BAD for the poor? Let me explain:

Essential to Medicaid is physician participation. Yet, Medicaid only pays approximately 60% of the total charge to a health care provider providing Medicaid services. For example, if a doctor charges $100/office visit, Medicaid would pay the physician $60. Therefore, most physicians refuse to accept Medicaid. In fact, in rural areas of North Carolina, where the percentage of Medicaid recipients is greatest, there can be a ratio of 200:1 Medicaid recipient to physicians accepting Medicaid. For some rural North Carolinians, the Medicaid card in their hand is worthless; people cannot find physicians accepting Medicaid. This scarcity of Medicaid providers becomes even more of an issue when it comes to dentists. A recent nationwide study indicated that over 60% of dentists refuse to accept Medicaid. The percentage grows if the dentist is a specialist.

What will happen if North Carolina accepts federal dollars to expand Medicaid? Approximately 720,000 more North Carolinians will be covered by Medicaid. But the laws do not require additional doctors to accept Medicaid. 720,000 more North Carolinians covered by medicaid means: many people holding Medicaid cards will have no doctor/dentist willing to treat them.

Obamacare does increase the amount paid to physicians accepting Medicaid in 2013 and 2014. But the increase is nominal (20%) and Obama has not explained from where the additional funds will come.

So how does “too many Medicaid recipients and not enough physicians accepting Medicaid” affect the real world? Let me tell you a story:

It is 2007 in Maryland. A 12 year old boy named Deamonte Driver complained to his mom that he had a toothache. Deamonte’s family depended on Medicaid for health insurance. Deamonte was eligible; he held a Medicaid card. Deamonte’s mom called and called and searched and searched for a dentist willing to accept Medicaid. Unsuccessfully. Sadly, unbeknownst to Deamonte’s mom, Deamonte suffered a tooth abscess.  Unable to find a Medicaid-accepting dentist, weeks later, Deamonte was admitted into the ER.  Deamonte’s bacteria from the tooth abscess, the tooth which could have been extracted for approximately $80, spread into Deamonte’s brain. After 2 operations and a 6 week hospital stay (for approximately $250,000), Deamonte died. All because Deamonte’s mom could not find a dentist willing to accept Medicaid.

Giving people Medicaid cards does not equal providing Medicaid recipients quality health care services…or even adequate health care services. Basically, this sham of of expanding Medicaid is just that…a sham. On paper, it appears that more people will be helped. And it is a GREAT marketing tool for politicians. Who would vote for the politician who said….we just cannot cover everyone with Medicaid? But, in reality, expanding Medicaid will make it harder for Medicaid recipients to receive good health service.

The disparity between the quality of health service to those people with private insurance versus those people with Medicaid reminds me of a sad part of U.S. history…when U.S. implemented “separate but equal” for blacks during the Civil Rights movement. In the pivotal case of Plessy v. Ferguson in 1896, the U.S. Supreme Court ruled that racially separate facilities, if equal, did not violate the Constitution.  Much later, Chief Justice Earl Warren, following the decision of Brown v. Board of Education of Topeka, stated that “separate but equal is inherently unequal.”  The general implications of the Warren Court opinion, however, are applicable to a great variety of separations, such as the separation of quality medical care for those people with private insurance and the sub-par health care for those people who depend on Medicaid for insurance. Separate is not equal. Giving more people a Medicaid card does not provide health service.

People with Medicaid deserve the same quality health care that people with private health insurance receive. But expanding Medicaid will do the exact opposite. More people will depend on Medicaid, and more people with receive sub-par health services…or worse, no health care at all.