Why No One on Medicaid Can Find a Doctor

New research shows that the Affordable Care Act (ACA) has helped close the gap between whites and other ethnic groups when it comes to health insurance coverage.

It sounds like great news, but many of the newly insured will have trouble finding a doctor. Those who do may have difficulty getting quick appointments. Many have gained or will gain coverage under the expansion of Medicaid. Medicaid is the U.S. government’s insurance plan for low-income Americans.

A study by the Urban Institute shows that the number of uninsured American Indian and Alaskan natives will plunge from 25.7 percent to 13 percent under the ACA. The study even breaks down disparities by tribe. The percentage of uninsured Latinos has improved from 31 percent to 19 percent.

Study author Lisa Clemans-Cope said the color gap nationwide will shrink even more dramatically if Florida, Georgia, Texas, North Carolina, and Louisiana decide to expand their Medicaid programs. An interactive map by the Urban Institute shows coverage statistics by state with and without Medicaid expansion.

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A big problem, even for those who do live in Medicaid expansion states, is that there are not enough primary care physicians to treat people on the government insurance plan. This was a problem even before the expansion.

A recent report by the U.S. Department of Health and Human Services shows the problem is even worse than previously feared. The report revealed that half of doctors listed on health insurance websites as serving Medicaid patients aren’t actually available to do so.

A Happy New Year?

And the situation could get worse beginning Jan. 1. Primary care doctors will ring in 2015 by receiving even less in Medicaid payments. Temporary federal funding bumped the Medicaid dollars doctors receive up to the level of reimbursements for services to patients on Medicare. Medicare is the health insurance program for seniors.

This “reimbursement gap,” as doctors call it, is what caused the shortage of primary care providers for Medicaid patients in the first place. A provision under the ACA included funding to increase Medicaid payments by 73 percent, but it is set to expire on Dec. 31. The Urban Institute estimates it will result in an average 42.8 percent decrease in fees to doctors.

I’m a physician with insurance and I can’t find a primary care doctor.
Dr. Leigh Vinocur

Sara Rosenbaum of the George Washington University School of Public Health shone a spotlight on a little known federal statute in a perspective this week in the New England Journal of Medicine. An equal access provision states that Medicaid provider payments must be “sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available in the general populations in the geographic area.”

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Those Who Can’t Find a Doctor Head to the ER

Meanwhile, a new study shows that Americans are visiting emergency rooms in record numbers. Americans made 136 million trips in 2011, the most recent year for which data are available. The American College of Emergency Physicians polled its members in April and said that nearly half reported ER traffic had gone up since Medicaid expansion began.

ER

Almost all of their members expected the numbers to only go up during the next three years. Three-quarters are saying their ERs are not prepared to handle this influx of patients.

Dr. Leigh Vinocur is an emergency room physician in Baltimore, Maryland. She also works in urgent care. She put the severe shortage of primary care physicians bluntly in an interview with Healthline. “I’m a physician with insurance and I can’t find a primary care doctor,” she said.

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So where are patients supposed to go? In practice, the emergency room. “Medicaid reimbursement always has been an issue, and the American College of Emergency Physicians said there could be an influx (with the expansion) and we are starting to see that,” she said.

Vinocur said young doctors don’t want to go into primary care when they are saddled with $200,000 or more in student loans. “They want to become specialists,” she said.

Medicare Providers Get More as Medicaid Pay Dwindles

There is one bright spot in the gray skies looming over primary care doctors, at least when it comes to Medicare reimbursement. As the Congressional stop-gap funding for Medicaid sunsets Jan. 1, a new Medicare system will launch.

Doctors with patients who have “two or more chronic conditions that are expected to last at least 12 months and that confer a significant risk of death, decompensation, or functional decline” can receive $40 per month per patient under the new policy. That category of patients includes more than two-thirds of Medicare beneficiaries. A doctor caring for 200 qualifying patients would get an extra $100,000 per year.

The new Medicare plan is based on the idea that it’s cheaper to give patients with several chronic medical conditions well-coordinated care. It’s causing some critics to wonder why directing resources toward coordinated primary care is a government priority for Medicare but not Medicaid.

The new Medicare reform has its own red tape. Doctors will have to bill using a certified electronic health record that their staff can access around the clock. They must designate a practitioner to coordinate care for each patient. They will also have to create a comprehensive care plan. The plan must include everything from medication-management instructions to records of social and community services involved in the patient’s care.

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The exact details still need to be worked out, but some of the regulations may be onerous to smaller practices, Drs. Samuel Edwards and Bruce Landon argue in a perspective published last month in the New England Journal of Medicine. They also argued that the coming compensation increase is not high enough.

They wrote that Medicare’s new payment program for chronic care management is “poorly designed to support the core activities of primary care, which involve substantial time outside office visits for tasks such as care coordination, patient communication, medication refills, and care provided electronically or by telephone.”

Medicare patients without supplemental insurance will also have to pay co-insurance for chronic care management to the tune of about $100 per year “out of pocket, and poor patients may not be able to afford the extra expense,” the doctors wrote.

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