Interesting letter from doctor about Medicaid

[MSNative]

I'm not trying to start a political debate, I just found this letter to the editor very informative. This doesn't espouse one side or another per se. Rather it recounts the experience of one doctor trying to get the best care for his patients. Regardless of your stance on ACA, Medicaid, etc. I think this adds some interesting perspective for people on both sides of the debate. I'd be curious what others think about this - especially those with Medicaid experience. I learn so much reading other perspectives here so please share.

 

http://online.wsj.com/news/articles/SB10001424052702304198504579570231173457524?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304198504579570231173457524.html

[Kathryn]

I can only read the first line.

[JustEm]

can't see the article without subscribing

 

[MSNative]

Weird. I see the whole thing and don't subscribe. Oops. Well, if you are interested, you can search

"The Bureaucrat Sitting on Your Doctor's Shoulder"

I'm sorry to post a bad link.

[NoseInABook]

You can read the whole article here: http://online.wsj.com/news/articles/SB10001424052702304198504579570231173457524?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304198504579570231173457524.html

 

It's infuriating to me that Medicaid refuses to cover certain procedures and medicine. What it covers seems to switch monthly and it's very hard to push through even the most basic medications needed such as acid reflux medicine for an infant with GERD. As a foster parent, every foster child who enters my home has Medicaid so we do have experience with it ourselves. Oddly enough, I've known people who say that they just had a prescription filled that Medicaid refused as as little as a week before. Not a fan that Medicaid patients clearly get less medical attention.

[JustEm]

nope that link says you need to log in or subscribe as well

 

[kewb]

Interesting but I found it to be a bit of poppycock.  I have been battling insurance companies over these same issues for years.  It is nothing new.  In this case the bureaucracy is medicaid instead of the insurance company.  

[JustEm]

You can read the whole article here: http://online.wsj.com/news/articles/SB10001424052702304198504579570231173457524?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304198504579570231173457524.html

 

It's infuriating to me that Medicaid refuses to cover certain procedures and medicine. What it covers seems to switch monthly and it's very hard to push through even the most basic medications needed such as acid reflux medicine for an infant with GERD. As a foster parent, every foster child who enters my home has Medicaid so we do have experience with it ourselves. Oddly enough, I've known people who say that they just had a prescription filled that Medicaid refused as as little as a week before. Not a fan that Medicaid patients clearly get less medical attention.

couldnt read the article but experience has been entirely different than yours.

 

My children have been on Medicaid since birth and I was on it during pregnancy.  since the medicaid expansion my dh and I now qualify for it all the time.  We have never had any issue getting any meds or medical attention needed taken care of.  None of us have every really needed any on going medications though so that may be where the biggest problem is or my state just covers a lot.  In the last 5 years what medical procedures and issues are covered has not changed at all.  I'm sure specific medicines have though.  I've also never felt that we get less medical attention than others.

[MSNative]

Interesting. I've really had very little experience with that. The few times I've had to deal with my ins. co. it has been pretty amiable. (Knocking on wood). I guess the difference might be that you were the one fighting your ins instead of hoping your physician would or did you have to get your physician in on it, too? Given that it's taking me 1 month to get in to see a specialist, I'm not optimistic that I could count on a physician to advocate for me.

 

The whole article made me somewhat hopeless about the whole state of our healthcare - current and suggested reforms. So much seems wrong. Your post confirms it.

 

Eta - responding to kewbs post but forgot to quote.

[poppy]

Many doctors hate Medicaide and always have - that's nothing new. It is a huge insurer and thus has more bargaining power in terms of price and policy than the people who live off of profits from medical care would like. Capitalism at work.

[TechWife]

This is nothing new, really. I fought similar battles when I worked in health care administration 20 years ago. Then it was HMO's and other managed care plans. Now it is everyone.

 

The doctor is right, though. The doctors should have the ability to change the plan of care as needed in an emergent situation.

[Denise in Florida]

You can read the whole article here: http://online.wsj.com/news/articles/SB10001424052702304198504579570231173457524?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304198504579570231173457524.html

 

It's infuriating to me that Medicaid refuses to cover certain procedures and medicine. What it covers seems to switch monthly and it's very hard to push through even the most basic medications needed such as acid reflux medicine for an infant with GERD. As a foster parent, every foster child who enters my home has Medicaid so we do have experience with it ourselves. Oddly enough, I've known people who say that they just had a prescription filled that Medicaid refused as as little as a week before. Not a fan that Medicaid patients clearly get less medical attention.

 

In your opinion has the situation improved/worsened or not really changed since ACA?  I remember lots of paperwork confusion with my mom's medical treatment with Medicare but was 8 or 9 years ago, and I don't know if it has changed.

 

So much of the insurance paperwork mill that I encounter with our plan (group insurance through employer) has not changed either way.  

I am not sure if my question falls in to the banned topics area. If it is not appropriate please let me know. 

[AmandaVT]

I deal with insurance companies on the billing side. In my state, Medicaid is by far the easiest, most transparent of the companies I work with. VT has a large medicaid population because of Dr. Dynasaur though, which ensures that all children and pregnant women are insured. 

[Kathryn]

My older son is on Medicaid and we've never had any problems with having doctor visits, therapy, or medications covered. I can't read the article, so I don't know what the complaint is.

[Ravin]

In Arizona a very recent (this month) 9th circuit decision ruled that it was up to a patient's doctor, not Medicaid, to determine when something covered is "medically necessary" or not. The case was over incontinence products. Medicaid wanted to say they could only be approved if someone was getting sores, etc. But the court said that preventative measures were appropriately categorized as medically necessary.http://m.ahwatukee.com/mobile/news/valley_and_state/article_f7a0a262-f8c3-5b57-a29b-66eb181936a0.html

[NoseInABook]

Prescription medicine has gone up in price and fewer are covered after the ACA. Well child doctor's visits are the same as before. There aren't many offices who accept Medicaid here either. We go to a dental clinic because I haven't found one dentist who accepts Medicaid AND will enroll new patients. We also have two doctor's offices to choose from in a fairly large city, there's one more if you're willing to drive quite a while (over 30 minutes one way). Perhaps it's likely that I've noticed because my biological children have Medicaid as well and what was covered for them 5, 6 years ago isn't covered now for the baby who was in my care? It used to be I could pay out of pocket for a certain prescription if needed but now it's $130 and a fight to get Medicaid to cover it. 

 

And oof, sorry that the link wouldn't work. I googled it and could read the entire article. The gist was that a doctor was upset that he couldn't change the surgery game plan without having to fight with Medicaid to cover it and often, it wouldn't be covered. He wrote about a case where Medicaid wanted to cover a chest Xray but not a neck Xray and the child had a malignant tumor in his neck that was discovered only after he pushed Medicaid to allow him to do it. Often, doctors won't push the limits for Medicaid to cover something. I've been told many, many times that they couldn't prescribe a certain antibiotic for a child who needed something stronger than amoxicillin UNTIL he had a week's worth of the amox because Medicaid would refuse to cover it unless the other antibiotic had been tried first. A bio child of mine went without occupational therapy for six months until I could change his Medicaid plan because one refused to do more than 6 therapy sessions and another would allow the weekly sessions that were deemed necessary by a professional. It just seems to switch depending on who you are speaking with.

[Ravin]

We've had problems, when trying to get a neuropsychological eval for DD, they'd only cover it if there was an injury or nerve problem because she was over age 6.

[ThisIsTheDay]

I can't read the article. But my clients who have Medicaid seem to have coverage that is a whole lot better than mine.  I have a $2000 deductible per person, right off the bat. I can't afford to go the doctor unless absolutely necessary. My clients pay either nothing or token co-pays for dr. visits and scripts.

[jewellsmommy]

Ds gets Medicaid. At first he had medicaid through optima. Then we discovered that he had a right to tricare. So now he is tricare primary then medicaid secondary. Despite both, we still pay a bit for some medication. It's nothing too big though. I consider us to be extremely blessed thus far. Ds has had wonderful care. We (dh, dd & me) are BCBS. He and dd see the same pediatrician and pediatric dentist. We just have to pay a lot more for dd. Ds has had great therapists, evals,  psychiatrists etc. Occasionally there is a snaffoo, but only one medication has ever been denied. All in all, I consider our experience to be a positive one. Our fingers are crossed that it will remain this way.

[mommymilkies]

You can read the whole article here: http://online.wsj.com/news/articles/SB10001424052702304198504579570231173457524?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304198504579570231173457524.html

 

It's infuriating to me that Medicaid refuses to cover certain procedures and medicine. What it covers seems to switch monthly and it's very hard to push through even the most basic medications needed such as acid reflux medicine for an infant with GERD. As a foster parent, every foster child who enters my home has Medicaid so we do have experience with it ourselves. Oddly enough, I've known people who say that they just had a prescription filled that Medicaid refused as as little as a week before. Not a fan that Medicaid patients clearly get less medical attention.

1. Medicaid is different in different areas.

 

2. People have these exact same problems with private insurance companies.  I spent 13 months screaming at idiots at BCBS NC because they apparently can't read or just like messing with me.  They kept claiming they wouldn't cover things because I should have Medicaid in IL.  We lived in NC.  We did not live in or work in IL.   The idiocy was mind blowing. 

 

However, you are right about the last line.  IME as a Medicaid patient, you get treated clearly different by some people or are denied care.  It's pretty much a race to see who can get a care provider here because so many won't take Medicaid-a big issue in an impoverished rural area.

 

I did recently start having problems with prescriptions, as well.  They are VERY particular about when we can refill a medication.  That means that we can not travel within a few days of a med refill because my dd's very important medication can only be refilled the day she runs out, so if they do something dumb, we will have to wait around and she'll have to wait to eat until lunch.  And I went to get new antibiotics for my 3 yo with a pretty severe strep case tonight.  She had an allergic reaction to the amoxicillin.  The insurance will only pay for 2 out of our 3 bottles of zithromax unless I go in 4 days (with one day of meds left) and beg them to refill it.  It's really stupid.

[Χά�ων]

Huh. In my state there are different medicaid plans. Some cover almost nothing and are fine for children who are healthy and have no need of speech/ot/pt. I switched DS to the only plan that pays for OT, PT & speech. He takes medications that are stupidly expensive and is seen by some provider or other 3-4 times a week and has had so many procedures and tests I cannot keep them straight. I never have to fight with them over if they will cover something. DS gets all the therapy he needs. The tests are always covered and I never have to call and beg for them to cover a procedure the doctor feels is needed. They covered him to see a specialist on the other side of the state for a second opinion and even reimbursed gas for me to take him. They covered an ER visit for DS when we were out of state with no issue.

 

My only complaint is that Mayo does not take out of state medicaid.

[twoxcell]

couldnt read the article but experience has been entirely different than yours.

 

My children have been on Medicaid since birth and I was on it during pregnancy. since the medicaid expansion my dh and I now qualify for it all the time. We have never had any issue getting any meds or medical attention needed taken care of. None of us have every really needed any on going medications though so that may be where the biggest problem is or my state just covers a lot. In the last 5 years what medical procedures and issues are covered has not changed at all. I'm sure specific medicines have though. I've also never felt that we get less medical attention than others.

Our experience has been similar. We have only run into a couple of medicines that weren't covered. Everything else has been covered completely including doctors visit, lab work, etc.

[Pawz4me]

From my understanding Medicaid is different from state to state.  So I don't think it's possible to make blanket statements.

 

My only experience is this, and it was a long time ago -- We've always had very good private insurance through DH's employer.  The employer covers DH, we pay for the family coverage.  Years ago when youngest DS needed speech therapy for apraxia we were "lucky" enough that the insurance covered it (after I appealed the initial denial).  Our speech therapist told me that Medicaid had much better coverage for speech therapy than almost any private insurer, and that they required her to reschedule, within the same week if at all possible, any appointment that had to be canceled, either by her or by the patient.  So whenever she was sick or there was bad weather we often missed one or both of two weekly appointments because she had to get her Medicaid patients in.  So from my perspective it seemed like we were paying $$$ every month for insurance, paying a co-pay for each visit, and paying through state taxes so that other kids could get better services than ours did.  I know that's just one experience and maybe means little to nothing (especially now, so many years later).  But it rankled a bit, and it makes me very leery of believing that those on Medicaid are having it any rougher than those of us with private insurance.

[AmandaVT]

I can only speak to VT, but Medicaid covers all medical/psych/dental and depending on the plan, vision with $0 copay and a very low monthly fee that is income dependent. My mom was on the VT health plan for a bit when she had a part time job and her insurance was $30 a month for full coverage. She pays more now out of pocket now with her full time job. We paid a LOT more with BCBS when we had our son - over $2000 out of pocket. And we have good coverage. $250 deductible and 20% copay. My SIL had my nephew at the same hospital and paid $0 because she was on Medicaid. 

 

Medicaid isn't a stigma here. Over 50% of the claims I process are Medicaid. 

[QueenCat]

Interesting but I found it to be a bit of poppycock.  I have been battling insurance companies over these same issues for years.  It is nothing new.  In this case the bureaucracy is medicaid instead of the insurance company.  

 

So very true. Some of my worst insurance battles were for my son, when he was little, so about 15 years ago.

[QueenCat]

Prescription medicine has gone up in price and fewer are covered after the ACA.

 

I don't buy that for a second. Primarily because ACA IS NOT an insurance plan. Each insurer, and each plan from that insurer, has it's own determining factors for coverage. I know that we have much better insurance coverage, including for prescriptions than ever before. We pay less for prescriptions, and the two that did not used to be covered are now. And those were our most expensive ones. Most people I know irl have similar experiences with better prescription coverage.

[JFSinIL]

I can't read the article, either. My son has been solely on Medicaid for a year now (before we used it only for co-pays and had him still on our PPO.  Obamacare changed all that).

 

  While the Medicaid primary we are forced to use is an awful doctor, his staff got me the referral to a neurologist who is WONDERFUL, and Medicaid covered Joe being hospitalized 24 hours for a MRI, video EEG, blood work - the whole shebang (he had had not extensive testing for years and was overdue).  Now if only dental was covered, too, in Illinois. Sigh. 

[Alice]

I can't read the article due to not subscribing. Googling it I found a couple of responses that quoted parts of it so I got some of the gist of what he was saying. 

 

My experience as a physician is that Medicaid and insurances are all painful to deal with. Most (if not all) doctors hate being told what to do and hate dealing with insurances or bureaucrats of any kind. Some of that is our own control issues. We just don't like having someone else dictate how we should practice.  I do understand the need for cost-cutting and such but it is really frustrating to order a test or medication for a patient and then have someone who has never seen the patient tell you that it isn't covered. Bureaucrats and insurance companies like dealing in statistics and from a public health/broader society standpoint that makes sense but it doesn't always make sense for an individual patient.

 

As an example: I had a patient who was having chronic headaches and I ordered an MRI. There weren't any absolute red flags but there was something about the patient's story that concerned me and my gut feeling was that we needed to rule out tumor or other structural anomaly. I ordered an MRI instead of a CT scan because there is more and more evidence that the radiation in CT scans is not benign for kids and we try and limit exposure. The insurance denied it because he didn't meet a checklist of criteria for scan and they said even if we did one it had to be a CT first and not an MRI. Another example: A patient had chronic back pain and I ordered a MRI (see above for why not CT). The insurance said he had to have Xrays first even though they agreed that the Xrays would be unlikely to show what we were looking for. So I had to order Xrays and expose the kid to unnecessary radiation (and cost the company more money) because it met some checklist. That kind of thing is frustrating. Or all the meds where we order one and then get notice saying it isn't covered. We take dozens of insurances at my office and Medicaid and it's impossible for me to remember that X insurance covers this particular nasal spray or inhaler but Y insurance covers a different one. And it isn't always that one is better than another or even cheaper, it has to do with what is "on formulary" and what contracts they have. It's all frustrating. 

 

Insurance companies, bureaucrats, politicians, reformers do things by the numbers. They look at the statistics and evidence and say that if you have 3 out of 5 of these symptoms it warrants a test and that in patients with only 2 out of 5 of those symptoms you only have a 1% chance of finding anything on the test. So let's not do the test. However, medicine is messier than that. You use science and statistics but as cliched and cheesy as it is to say medicine is also an art. It's knowing your patient and that this particular kid never complains and wouldn't miss soccer practice for anything and so maybe his back pain is something more serious even though he doesn't have neurological findings or anything on physical exam. 

 

And here's the thing, I am willing to fight for coverage for patients to an extent but if I fought for every insurance decision I didn't agree with I'd stop seeing patients because all my time would be talking to insurance companies. Or in reality I'd spend all my time on hold with insurance companies. I have fought for patients and I will do it again but I have to limit it to those that I really think are life-threatening. Which means a fair amount of patients on medications that I think are second best or who have to wait for procedures I think they need. 

 

As for the ACA I haven't seen a lot of change for patients, except for me personally. Our family's insurance costs went WAY up due to the ACA and we had to switch some of our doctors which I wasn't happy about. But as far as care, I'm not sure it's making much of a difference either way for most people. I'm sure it's positive for those people who didn't have insurance before. As a doctor, it's adding to the number of hoops we have to jump through: things like the way we document and "meaningful use". It's going to spawn a whole new industry....I have a friend whose husband just got a job with a company that is specifically contracting with doctors and hospitals to help them navigate the new requirements. Which just tells me it's too complicated, it's like all the coding and billing specialists that have sprung up because insurance is too complicated. 

 

 

[Denise in Florida]

I am learning a lot with this thread. I had no idea medicaid was different from state to state, although I guess I should have picked that up from things I have seen in the news.

 

My only experience has been with employer provided group insurance, the coverage and paper work varies so greatly there.

 

My mom was under a mix of VA and Medicare for several years before she passed. The paperwork was a nightmare but the Doctors were all very good and I don't remember a problem with medication. 

 

 

[redsquirrel]

In my area it is very, very difficult to find a doctor who accepts medicaid. There is not a single OB who accepts it in my county. I live in a rural area and it is at least an hour if not 90 min drive to another county (in any direction) and most of the surrounding counties are even more rural than we are and might not even have an OB.  Add into that, 50% of the births qualify for medicaid and that is a lot of pregnant women without care. The hospital accepts medicaid so I think women just forgo prenatal care and show up at the hospital in labor. It's that or be able to take time off from work and have the $$ and the car to drive an hour to a medicaid clinic.

 

There is one dentist in the county who accepts medicaid and to get an appt you have to call on the last weekday of the month, between the hours of 10-12. I have heard of people taking 6 months of calling just to get an appt.

[JFSinIL]

I might add - Illinois does offer dental via Medicaid - for children only.  It is a false economy, I think, to deny adults dental care - down the line there will be more expenses if folks get infections, etc. from denial of preventative dental care.  Our own dentist goes on about various dire ailments made worse (and thus more costly to treat) if oral health is neglected.

 

When the neurologist ordered the MRI (etc.) for Joe, I got a call from the state saying it would be better (cheaper for them) if Joe had the MRI at a free-standing center instead of at the hospital the neuro preferred to use (his staff could run over the the doctor building next door, etc.) .  When I mentioned that Joe was due to be sedated for the MRI, they back-tracked and said then he'd have to be at the hospital.