nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Monday, July 12, 2010

Doctors Who Are Leaving Medicaid And Why

Some journalists have pooh-pooh'ed the rising number of doctors who are not participating in Medicare and Medicaid.  It's not an avalanche, granted.  But it is a trend.

It's also just my observation--as one doctor--that the number of doctors who are "officially" restricting their practices is smaller than the number who are "unofficially" doing it.  If you're a Medicare or Medicaid patient, a common experience is to find a nearby physician who participates in (i.e., signed up for) Medicare, but when you call to become a new patient, as soon as they find out your insurance status, "I'm sorry, we're not taking any new patients now."  (This happened to me)

This happens because practices are at the limit of what they think they can shoulder in government-funded care, but want to preserve their options.  Maybe later in the year, if they lose some patients, they can "re-open" the practice (like a faucet...turn it on for a bit, then turn it off).  Participation in Medicare and Medicaid is a decision that is made on an annual basis.

So, the practical difficulty of finding a doctor if you're in this category--Medicare/Medicaid--is actually greater than the statistics suggest, which include only the "official" data.

I've written about why doctors are participating less and less here, and here.  While the situation is not an avalanche as the medical societies would have you believe, neither is the assessment by reform supporters like Maggie Mahar at Health Beat, who suggest the growth in physicians who are opting-out is temporary or illusory.  Just talking to colleagues and looking at the rising numbers, I think it's more of a trend of increasing dissatisfaction with attempts to lower reimbursement rates even further, and uncertainty every year over whether Congress will effect permanent payment reform, or let the axe fall.

The latest from the Dallas Morning News (July 12), describes doctors' responding to the state's decision to lower Medicaid reimbursement by another 1% (to help deal with the budget shortfall).  While one percent may seem small, Medicaid already has the lowest (of the below-cost) reimbursement rates.  I'm not an economist, but some studies say that Medicaid pays only about 80% of what it costs to deliver the care, and about 70% of what other insurance pays.   The state's experience with Medicaid reflects the trend toward fewer doctors taking Medicaid:
Medicaid, which covers about 3.3 million poor and disabled Texans, has steadily lost doctors over the past two decades. (Participation improved slightly after 2007, when the Legislature approved fee hikes, mainly for pediatric services as part of a settlement to a long-running class-action lawsuit.)
Although more than 800 doctors and group practices in Dallas County are listed on the Medicaid program's website as taking patients in Star, the main Medicaid HMO, that's not necessarily so. Of 30 offices randomly selected and queried last week by The Dallas Morning News, only 14 said they were taking new Medicaid patients, and some had waiting lists or other restrictions.

Supporters of the new HCR law think they can force payment rates for private insurance down to the level paid by the government.  This would give doctors no choice but to accept low rates--or see no patients.  But this effort is running into problems in several states, as the insurance companies justify and are given premium rate increases.

The whole exercise is one of trying to put a lid on cost, by forcing price controls on premiums and payment rates, and by denying allegedly "less effective" treatment.  Controls of this type have enjoyed little historical success.  Those who believe health care can be regulated in this way need to re-look at Europe's recent experience of centralized regulatory failure.

And they need to dig out their college textbook on Keynesian economics and read it again in greater depth.

Doc D

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