RISE IN MEDICAID PATIENTS BURDEN DOCTORS

Medicaid in Missouri is growing, in ways that are considered both good and bad.

In the past 10 years, the state has moved steadily toward becoming a national leader in assuring that most residents have some form of health insurance. Since 1990, over 388,000 residents have been enrolled in Medicaid, which nearly doubles the number of people who receive medical assistance through the program.

But with growth has come problems with payments to hospitals and those in private practice. The rate of reimbursement for services is not completely covered by Medicaid, which means every time a Medicaid patient is seen, the doctor pays a portion of the bill.

This has led to some doctors refusing to accept Medicaid, which formerly had offered a ready source of income.

"Ten years ago, reimbursements were a lot better," said Dr. Jonathan Thomas, an obstetrician and gynecologist in Cape Girardeau who still takes Medicaid.

Medicaid was initiated in 1965 as a jointly-funded, federal-state health insurance program for certain low-income and needy people. It covers approximately 36 million individuals, including children, the elderly, blind, and disabled, and people who are eligible to receive federal assisted income maintenance payments.

In the richest states, the federal government finances 50 percent of total Medicaid expenditures for the state. In the poorest states, it's 80 percent.

Missouri receives about 60 percent federal support, said Dr. Scott Weiner, a pediatric hospitalist who works at Southeast Missouri Hospital and St. Francis Medical Center.

The program's growth spurred the federal government to legislate various cost-containment measures beginning in the 1970s, notably one in 1983 that set standard payments for the care of patients with a particular diagnosis.

As an example, Thomas said Medicaid reimburses him roughly half of the cost of a delivery.

"A doctor doesn't even break even," he said. "A lot of people don't realize that Medicaid doesn't pay 100 percent of a doctor's expenses."

For gynecology, Medicaid pays Thomas back about 10 to 15 percent of what he charges.

Reimbursements on average in Missouri are a little more than 50 percent of a doctor's costs, he said.

Regardless of the low reimbursements, Thomas said he and many other physicians in Cape Girardeau provide Medicaid services.

"I've kind of taken the attitude that they need to see somebody," he said.

Hospital decision

Although hospitals also end up losing money on Medicaid, its benefits weigh more heavily, said Dwight Fine, spokesman for the Missouri Hospital Association.

"In general it's a good program," Fine said. "It just needs some fine tuning."

He stresses the decrease in the uninsured as a result of broadening Medicaid in the past decade. Only 8.5 percent of Missourians now have no health insurance, compared to a national average of 15 percent, Fine said.

The fastest growing area in the state for Medicaid enrollments is the Bootheel, where over 25 percent of the population participates in the program. More than 50 percent of children in the region are enrolled.

Much of the growth is connected with a state expansion of Medicaid eligibility in 1998. It opened up to children in families with incomes up to 300 percent of the federal poverty level. For a family of four, the federally defined poverty level is a gross yearly income of $17,050 or below.

"There is no reason to have an uninsured child in Missouri, other than the parents don't know what's available," Fine said.

The problem for those insured through Medicaid comes when doctors in various specialties don't accept the program, Weiner said. It is becoming increasingly harder for Weiner to refer his patients to specialists in private practice once they leave his care in the hospital.

Another difficulty for doctors is the expedience of getting reimbursed by Medicaid, Thomas said. It takes him about 30 days to get paid by Medicaid, as long as all his paperwork is in order. When it isn't, it can take six months to a year to get reimbursed.

Fewer dentists

Finding a dentist who accepts Medicaid is much harder in Southeast Missouri, said Dr. Jake Lippert, executive director of the Missouri Dental Association. The reason is twofold: Low reimbursement and a declining number of dentists.

The state has attempted to inch dentists' rate of reimbursement up since 1998. Presently, it amounts to about 50 percent of what is billed, Lippert said.

But when overhead costs amount to 65 to 70 percent of billing, the dentist ends up paying at least 15 cents from every dollar billed for serving a Medicaid patient, Lippert said.

Considering that most physician's overhead amounts to 40 to 50 percent of what is billed, dentists bear a larger burden under Medicaid, he said.

The number of licensed dentists in the state is steadily decreasing, which complicates the problem. About 70 licensed dentists either die or retire each year, while the only dental school in the state at the University of Missouri at Kansas City graduates a class of 80 each year. Of those, Lippert said about 25 remain in Missouri.

Most medical professionals are hoping that efforts to increase reimbursement are successful. The Missouri Dental Association has asked for incremental growth that would lead to a 75 percent rate of reimbursement. A request for $7.03 million in this year's proposed budget was cut out by Gov. Bob Holden, along with a $22.5 million request from doctors who are part of the Missouri Medicaid Reform Coalition. Weiner, a coalition member, said the $22.5 million, coupled with federal matching funds of $35.5 million, would raise the level of reimbursement for Medicaid-insured children to 100 percent. This would greatly improve children's access to a wider range of doctors, Weiner said.

One of the hardest ideas to get across to legislators and the general public is that many of these families don't fit the Medicaid stereotype of people spending their lives living on government aid.

"These are families with parents often working one or two jobs, or who are struggling working in small companies with poor insurance," Weiner said.

When Thomas accepts a Medicaid patient, he said he focuses on her future more than her present.

"Another reason to take Medicaid is who says that anyone is going to be on it for life?" Thomas said. "If I treat somebody right when she's down and out, she is more likely to come back when life gets better."

MEDICAID FACTS

Reforms in Medicaid over the past decade have allowed Missouri to improve health insurance coverate:

* Medicaid was initiated in 1965 as a jointly-funded, federal-state health insurance program for low-income and elderly people.

* In the richest states, the federal government pays only 50 percent of the bills for Medicaid. In the poorest states, it pays 80 percent.

* Missouri gets a 60 percent reimbursement for its Medicaid program. The fastest growing area in the state for Medicaid enrollments is the Bootheel, where over 25 percent of the population participates in the program.

* The percentage of Missourians without health insurance dropped from 13.2 percent in 1996 to 8.6 percent in 1999.

* Only Rhode Island, Minnesota and Iowa have fewer residents without health insurance.

* Missouri ranked second among all states in improving rates of insurance coverage between 1997 and 1999.

* Since 1990, more than 388,000 Missouri residents enrolled in Medicaid. That number is double those patients who get assistance in the program.