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    Treating Medicaid patients

    Medicaid is a difficult payer to work with, but growing patient numbers means physicians must consider how to overcome the obstacles

    The provider that accepts a large number of Medicaid patients and makes it work for his or her practice is much like the fabled unicorn: there are rumors that they exist, but no one has actually seen them.

    But with more states expanding Medicaid through the Affordable Care Act (ACA), the number of patients covered by the program is growing, and not all these new patients will find it easy to get to a provider.

    Medicaid is a well-known irritant of physicians, and many providers won’t even accept it as a payer. A 2014 study by Merritt Hawkins looked at Medicaid acceptance by physicians in 15 major metropolitan areas called 1,400 offices across five specialties: family medicine, cardiology, dermatology, obstetrics and gynecology and orthopedic surgery.

    They found that the average overall rate of Medicaid acceptance by physicians was 45.7% in 2014, down from 55.4% in 2009. Cardiologists averaged the highest rate of acceptance at 63%; primary care providers averaged 50%. The lowest acceptance rate was among dermatologists at 27%.

    The trend of Medicaid non-acceptance by physicians may only worsen given the expiration of the Medicaid pay boost tied to the ACA at the end of 2014. A study by the Urban Institute estimates that primary care physicians could see their Medicaid reimbursements cut by an average of 43%.

    At groups such as Salud Family Health Centers, a system of community health clinics in northeastern Colorado, Medicaid expansion was welcome. The federally qualified health centers saw a jump from 30% percent of its patient population with Medicaid coverage prior to expansion to 57% post-expansion.

    Jennifer Morse, development director for Salud, admits there can be challenges to accepting Medicaid, including access issues and greater complexity among patients. But for them, moving 27% of patients from self-pay to insured represented a significant improvement.

    Healthcare is a business. If the money is there to make taking a patient worthwhile, doctors will take them, Morse said. If the reimbursement doesn’t warrant the administrative burdens, they won’t be as motivated. Much of the issue of Medicaid is perspective, she said.

    Related: Medicaid provider figures don't reflect reality of patient care

    “It is a good payer for us, so we don’t experience a lot of challenges,” she said. “We have a really unique perspective–we would rather a patient have Medicaid than no insurance at all.”

    An increasing number of patients will be enrolling in Medicaid and will be seeking care as states continue to expand the program. Accepting such patients may pose challenges, but making Medicaid a larger part of a practice–or just accepting any Medicaid patients–may be a viable option with some tweaks to a practice.

    Addressing the issues

    The most frequently cited reason for not accepting Medicaid? Low reimbursements. Payments vary from state to state, but, on average, Medicaid pays about 66% of what Medicare reimburses, according to the Kaiser Family Foundation.

    But that clearly isn’t the only challenge. Medicaid acceptance is down across the country even as provisions in the ACA increased reimbursements (primary care fees were increased to Medicare rates in 2013 and 2014).

    “Reimbursement is the number one factor (physicians provide for not taking Medicaid), but we have seen in states that have increased rates, it doesn’t cause physicians to take more patients,” said Catherine Sreckovich, M.S., managing director in Navigant’s Healthcare practice. “It motivates physicians that are already taking it to take more patients, but not make others add it.”

    Sreckovich said it can be a challenge for physicians because patients often don’t have child care, so their whole family comes to the waiting room. Physicians tell her that their Medicaid claims are rejected more than other payers. It is more challenging to verify eligibility and deal with prior authorization than with other insurers.

    Referring to specialists can also be difficult because “there aren’t an overabundance of specialists taking Medicaid, particularly in pediatric subspecialties,” she says. Physicians also cite high turnover rates and long wait times for reimbursements as challenges to accepting Medicaid patients.

    Related: Medical societies seek extension of Medicaid/Medicare parity 

    A study published in Health Affairs found that Medicaid reimbursement times vary considerably from state to state. The shortest wait time was in Kansas, at 36.9 days (compared with 29 days for commercial insurers) and the longest was 114.6 days in Pennsylvania (compared with 26.8 percent for commercial payers).

    Not surprisingly, physicians in states with faster reimbursements were more likely to accept Medicaid patients.

    NEXT: Minding the gaps


    Minding the gaps

    From a provider standpoint, there is little that can be done regarding reimbursements. However, there are options for overcoming problems such as no-shows and patient noncompliance.

    In recent years, the American Dental Association has been pushing for more dentists to take Medicaid patients. The association has recommendations on its website for meeting the challenge of no-shows.

    One option is booking Medicaid patients for times during the day when it would be less inconvenient for the patient not to keep the appointment, such as right before or after lunch or at the end of the day.

    All a practice’s Medicaid patients should be scheduled on specific days, if possible. Another option is to overbook, particularly if you have Medicaid patients grouped into one particular day.

    Morse says that as with all practices, the Salud centers have a problem with no-shows. In response, they have instigated a policy whereby such patients have three strikes “then they are out.” They have also attempted pilot programs that include calling patients the day before to remind them of their appointments.

    Medicaid expansion

    NEXT PAGE: Expanding resources

    Expanding resources

    According to Morse, many no-shows among the Medicaid patient population are the result of obstacles such as lack of child care, inadequate transportation or jobs that don’t allow for time off. This is one reason Medicaid patients are sometimes considered noncompliant. But there are steps providers can take to help remedy these situations.

    Teresa Koenig, MD, MBA, senior vice president of the Camden Group, says physicians will benefit from helping patients overcome some of these problems because healthcare is moving toward dealing with population health, which includes psychosocial, as well as biological, care.

    “They can always look at elements of the patient-centered medical home and bring the kind of care model into an office that assists the patients with transitions of care, resources, transportation or clothing or medication needs,” she says. “We want to make sure they remain part of the solution but are being rewarded for those changes to deliver care along a continuum.”

    One way to do this is to work with outside groups such as churches and community agencies to help patients get needed transportation, medications or other assistance. This doesn’t need to be something put upon the shoulders of physicians, either. Sreckovich notes that physician extenders and administrators can connect with resources patients might need.

    Physician extenders, such as nurse practitioners and physician assistants can also be used to their greatest ability when dealing with Medicaid patients. These providers can perform checkups or non-emergent visits in states that allow this with provider oversight.

    “If they aren’t going to have a care model like this in their office, it may be cost- prohibitive or overwhelming to take care of this population,” Sreckovich says. “The workflow needs to be more patient-centered using the staff to the fullest extent of their licenses.”

    Sreckovich says she does know physicians near her Chicago office making Medicaid work in their practices. It just takes getting used to the payer and patients.

    “If you are able to deal with the administrative hassles, it becomes a matter of treating a patient just like any other,” she says.

    Tammy Worth
    The author is a freelance writer based in Blue Springs, MO.


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