If a child needs a pediatric neurologist in Chicago, he‘d better hope that he isn‘t on Medicaid. An alarming “secret shopper” style study published in the June 16 New England Journal of Medicine found that children with Medicaid were far more likely to be declined an appointment with a pediatric neurologist (as well as eight other types of specialists) than those with private insurance.
The researchers called 273 specialty practices in the Chicago area, posing as parents of children with urgent — but not emergency — medical problems. For the pediatric neurology practices, the child described was an eight-year-old with an initial onset of afebrile seizures, and a referral from both a primary care doctor and the emergency department.
The “patient” on Medicaid was nine times more likely to be denied an appointment with a pediatric neurologist than one with private insurance. The Medicaid callers who did get an appointment would have had to wait two weeks longer for their appointments than those with private insurance. (Pediatric neurologists actually did better than most other specialties in the study at accepting Medicaid patients — Medicaid callers seeking appointments with asthma specialists, otolaryngologists, dermatologists, and orthopedists were 34 to 44 times more likely to be denied a slot.)
“There‘s never been a study this comprehensive or this rigorous that actually measured access to specialty care, let alone children‘s access,” Karin V. Rhodes, MD, an author of the study and director of emergency care policy research in the department of emergency medicine at the University of Pennsylvania, told the New York Times in a June 15 report on the study.
“We‘ve known this is the case for a long time, but I was really struck by this research and the incredible differences between Medicaid-insured children and privately insured children in their access to neurology specialty care,” said Rachel Nardin, MD, assistant professor of neurology at Harvard Medical School and a practicing neurologist at the Cambridge Health Alliance. “It‘s one of the most dramatic things I‘ve ever seen,” added Dr. Nardin, who was not involved with the study.
MORE THAN A PEDIATRIC PROBLEM
The barriers to neurology care for people on Medicaid aren‘t limited to pediatric neurology. “These disparities aren‘t just for children; they‘re there for adults as well,” Dr. Nardin noted. In the April 13, 2010 issue of Neurology, she and colleagues reported that the uninsured and those with Medicaid receive substandard migraine care, at least in part because they receive more care in emergency departments and less in physicians‘ offices.
But, Dr. Nardin pointed out, the New England Journal study pinpoints the problem precisely, by separating out insurance factors from factors having to do with the patients themselves — such as lack of access to transportation and low health literacy. “That‘s why it‘s so important,” said Dr. Nardin. “It controlled for all the other variables and showed that simply being on Medicaid was responsible for dramatically reduced access to care.”
That finding doesn‘t surprise Robert Friedland, MD, the Mason C. and Mary D. Rudd Chair of Neurology at the University of Louisville. “Rates of Medicaid reimbursement are falling, while expenses are not. It‘s basically impossible for a neurologist to make a living seeing only Medicaid patients. I‘m not talking about making a good living, I‘m talking about making any living at all.”
In Illinois, for example, Dr. Rhodes reported that Medicaid pays $99.86 for an office visit for a problem of “moderate severity,” while private insurers pay $160. “At an AAN practice management class, I learned that for one neurologist in private practice to break even, they need to generate over $240,000 of income in order to cover all expenses. You can‘t do that if you see Medicaid patients,” Dr. Friedland said.
“Through my contacts through the Florida Society of Neurology, I have heard from many private neurologists who have had to either stop taking Medicaid entirely, or limit the percentage of patients that they take, simply because they lose money every time they see a Medicaid patient,” said Glenn Finney, MD, assistant professor of neurology at the University of Florida in Gainesville. “I would say that right now the only neurologists who can regularly take Medicaid patients are at large institutions that receive federal aid to offset the costs.”
Dr. Nardin said that she has encountered difficulty in referring Medicaid-insured patients to subspecialists. “I work at a safety net hospital, where around 40 percent of our patients have Medicaid. Since we‘re a community hospital, we don‘t have certain subspecialties and surgical specialists on the faculty, and it‘s often very difficult to get a consult — even here in Boston, in a city with a lot of academic medical centers.”
For Medicaid patients who don‘t live in a city that has a good-sized academic medical center, access to neurology care can be even more difficult. “Here in Florida, since we‘re a geographically large state, if you‘re not within close distance to a major academic institution with a neurology division, you may have to travel several hours to find a neurologist that will see you,” Dr. Finney said. “And a lot of our patients on Medicaid can‘t travel easily. Either they can‘t afford to, or they have neurologic conditions that prevent or curtail entirely their ability to drive themselves or go somewhere alone.”
WHERE PATIENTS END UP
So what do they do? “They end up seeing no neurologist at all for their problem, and rely on local generalists,” Dr. Finney said. “Although fewer and fewer primary care physicians are taking Medicaid as well. They may get their care through the emergency department. Or at best, they see a neurologist very occasionally, even if more frequent visits would provide better care and prevent complications from their illness.”
In some cases, even the academic medical centers are cutting back on Medicaid care.
“Our department still takes Medicaid patients, but several other branches of our institution do not,” Dr. Finney said. “I care for people with dementia, memory and cognitive disorders. Sometimes they need more in-depth cognitive testing done by a neuropsychologist, and we can‘t find anyone to do it for Medicaid patients, even at our own institution. It‘s not because of any desire not to see these patients. In fact, they‘ve offered some limited programs at a reduced rate, for people with epilepsy, with neuropsychologists in training. But they literally can‘t afford to care for Medicaid patients.”
Neurologists and their patients are particularly vulnerable to the vagaries of Medicaid. As a cognitive specialty, the heart of neurology is the physical examination and patient history, which reimburse — in any form of insurance, but particularly within Medicaid — at lower rates than procedure-based specialties.
People with certain neurologic conditions, especially those that can affect a younger population — such as migraine, epilepsy, and multiple sclerosis — are also more likely to end up on Medicaid because of their disease. “A lot of patients who have uncontrolled epilepsy and can‘t drive find that it impairs their ability to work,” said Dr. Finney. “They‘re younger and can‘t get Medicare, so they will end up on the Medicaid rolls trying to get control of their seizures and return to a good quality of life.”
Dr. Friedland noted that people with multiple sclerosis face particular challenges if they‘re on Medicaid. “Their care is chronic and recurring and it doesn‘t generate enough income to cover the costs of the practice,” he said. “And the patients don‘t need EEGs and EMGs, which are relatively more remunerative for neurologists.”
The longer these patients go without treatment, the more complicated their conditions may become — and ultimately, the greater the cost to both them and to society. “There are many treatable neurologic conditions that, if left untreated, affect not only the person‘s well-being but their productivity in society. Untreated or poorly treated epilepsy or migraine really debilitate patients,” Dr. Nardin said. “There‘s a big social cost to leaving these patients without access to the care they need to be fully functioning members of society.”
OPTIONS TO CONSIDER
What‘s the answer? “A financial situation in which doctors and departments, and functional units in an institution, lose money through their daily work is untenable. Certainly everybody agrees that care costs are going up very fast, but you can‘t deal with it by paying doctors less,” Dr. Friedland said. He suggests that, for a start, reimbursement rates need to be reconsidered. “One question is whether a dermatologist really should be paid more than one $100 to do a five-minute skin biopsy, while an hour‘s consultation with a dementia patient provides payment of less than $100.”
More broadly, Dr. Nardin said that these findings point to the need to rethink health care reform. “The recently enacted Affordable Care Act will increase the number of people who are insured in part by expanding Medicaid,” she said. “Sixteen million people are projected to get publicly subsidized private insurance and 16 million to get Medicaid. But now, we have data that tells us that just having the Medicaid card doesn‘t mean that you‘re going to have access to care.”
There are two options to fix that, she suggests — either legislation requiring Medicaid to reimburse sufficiently to cover costs, or replacing the patchwork of health insurance coverage in the current system with true national health insurance, providing standard coverage and full benefits to everyone equally. “If we really want to reform our health care system, we have to keep our eye on the prize,” she said. “Our goal isn‘t just a health insurance card, but people being able to see a doctor when they need to.”