July 2002 • Volume 8 • Number 7 |
 D Ann Travis, M.D., of Fairburn, Ga., checks Bradly Foster's tummy during a routine physical. About 45 percent of Travis' patients, including Bradley, are on Medicaid. |
States facing budget shortfalls, for the most part, have not cut Medicaid programs or limited eligibility. Instead, they have expanded eligibility, eliminated some benefits for patients, and reduced or frozen physician reimbursement rates to cut Medicaid costs. So says a new study from the Urban Institute, a Washington-based policy analysis group.
What does that mean for you?
Most likely you're struggling to care for an increasing number of Medicaid patients, facing declining payments, and spending more and more time documenting patient care rather than treating your patients.
All of the above holds true for D Ann Travis, M.D., a Fairburn, Ga., family physician and member of the AAFP Commission on Education. If a patient visit lasts 15 minutes, she may spend up to an hour filling out diagnostic documents to make sure Medicaid reimburses her properly, she said. She now sees far fewer patients per day than she did only a few years ago.
In Fulton County, where Travis practices, 21 percent of the population receives Medicaid benefits. However, 45 percent of Travis' patients are on Medicaid. The area in which she practices has two distinct income brackets, she said. "There are the rich farmers, and then there are the poor people. There's not much middle ground here, economically." Travis fears that soon she won't have enough time to care for all her Medicaid patients.
Documentation doldrums
"Meticulous documentation slows the day considerably," Travis said. "It's very time-consuming and mentally challenging. The level of explanation required by nonmedical experts who decide the payments makes me feel as though my years of medical training are being ignored."
For example, Travis said a physician begins diagnosing patients when they walk through the door. Recently, after listening to a patient's complaints, checking her throat and confirming her fever, Travis found it obvious that the patient was suffering from strep throat.
"But you can't simply note that on the chart," she said. "You must be extremely detailed. Otherwise, it could adversely affect your reimbursement."
Medication concerns
Physicians are concerned about the future of Medicaid, Travis said, and some patients are concerned about program changes as well. She said her patients complain that Medicaid won't pay for medications they believe they need. Most are brand-name prescription drugs used to treat allergies, coughs, colds and similar conditions.
"Plus, Medicaid tends not to pay for the formulations of a medication that are easier for patients to take," she said. "And since private insurers are following the leads of Medicaid and Medicare, these changes end up affecting your entire patient population."
In Wisconsin, some Medicaid patients are assigned to an HMO for managed care, said Kevin Izard, M.D., a family physician practicing at the Capitol Drive Health Care Center in Milwaukee and a clinical professor at the Medical College of Wisconsin. The HMOs constantly change their lists of covered medications, he said, making it difficult to prescribe. More than 85 percent of Izard's patients receive Medicaid, and many are assigned to HMOs.
"These patients often wait to come in until they are really very sick," he said. "They come in sicker because they are living day to day. And this won't change. For them, medications often are a lower priority than, say, paying the rent."
Variation among states
To date, Georgia's Medicaid program reports that reimbursement rates have
remained steady even though the state's Medicaid budget is declining. Elsewhere,
Medicaid dollars are being stretched thin
to cover new programs as well as rising enrollment.
Nationwide, Medicaid enrollment is up, according to the Urban Institute's study, "Health Policy for Low-Income People: States' Responses to New Challenges." The declining economy, rising unemployment rates and decreasing family income are cited as reasons for the increase, as well as continued outreach programs designed to expand Medicaid enrollment.
Yet some states have maintained their Medicaid budgets, the study shows. If states reduce Medicaid spending, they lose federal matching funds. For each $1 spent on Medicaid, the federal government gives the state anywhere from $1 to $3.18, depending on that state's matching rate. States also find it difficult to cut elements of their Medicaid programs because of the federal minimum requirements to receive the matching funds.
Examples from three states indicate the extent of the threat to Medicaid.
Most AAFP chapters have listed Medicaid reimbursement in their top three legislative priorities for this year, reports the AAFP Government Relations Division.
Doors still open
Despite the ever-increasing financial burdens caused by compliance with federal and state health care regulations, rising practice costs and the recent decline in Medicare payment rates, Travis said she won't close her practice's doors -- yet.
"No, I'm not going to stop seeing my patients," Travis said. "But when my income stops short of paying my mortgage, then I'll have to look at doing something else."
FP Report is published by the AAFP
News Department.
Copyright © 2002 by American Academy of Family Physicians.