Yet More Reasons Why Doctors Do Not Participate in Medicaid

Claims about Medicaid’s effectiveness should be approached with caution simply because the population covered by Medicaid differs from that covered by private insurance in ways a variety of ways that are likely to affect overall health.

For example, Medicaid patients are more likely to be no-shows for medical appointments. No-shows are typically defined as either not showing up at all or calling to cancel on the same day. In one orthodontic practice, Medicaid patients accounted for almost 40 percent of missed appointments but only 27 percent of all appointments. Children most likely to miss dental visits were those with lots of cavities, poor behavior, multiple missed appointments, and no phone.

Broken appointments translate into a reimbursement rate of zero. Surveys of dentists suggest that they are even more important than low reimbursements in dentists’ refusal to participate in Medicaid.

The pattern does not change for more involved procedures like cochlear implants. At Children’s Hospital in Cleveland, Ohio, access to cochlear implants is the same whether patients are covered by Medicaid or by private insurance. But medical complications do vary with a patient’s insurance status. From 1996 to 2008, 133 children received unilateral cochlear implants. Complications in Medicaid-insured children were 5 times those in privately insured patients with 10 complications in 51 Medicaid-insured patients and 3 complications in 61 privately insured patients. Medicaid patients missed 35 percent of follow-up appointments. Privately insured patients missed 23 percent of follow-up appointments.

Given that behavioral differences exist for something as simple as keeping an appointment, challenges to getting high-quality care to Medicaid patients cannot be solved by just expanding Medicaid budgets.

Comments (11)

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  1. Devon Herrick says:

    I’ve talked to doctors who confirmed this. Indeed, this may be related to over-use of emergency rooms by Medicaid enrollees. It is often assumed that Medicaid enrollees utilize ERs more frequently than privately insured and the uninsured patients due to a scarcity of doctors who will see them. There is undoubtedly some merit to that argument. But non-compliance or unfamiliarity with protocols could also explain both phenomenon. It would be interesting to research who misses appointments (no shows) and if they tend to use the ER for primary care-appropriate conditions.

  2. JFA says:

    “[C]hallenges to getting high-quality care to Medicaid patients cannot be solved by just expanding Medicaid budgets.” We have to consider the cause of Medicare patients missing appointments. To the extent that it is because they forget about the appointments, can’t find baby sitters to watch the kids, etc., then expanding budgets won’t to anything to solve the challenges of getting high-quality care to Medicaid patients. To the extent that they miss appointments due to not be able to get transportation to the doctor’s office, expanding Medicaid budgets may solve some of the challenges. I imagine people on Medicaid tend to cluster around one another, so budget expansions would lead to more Medicaid enrollees in a specific area. Because doctors’ offices need a critical mass of patients to open in a particular area, an increase in the number of Medicaid patients in a particular area increases the likelihood of a doctor’s office being opened in that area (at the margin). The doctor’s office is now closer to the patients, making transport less of an issue. Also, increasing reimbursement rates would also incentivize doctors to locate where Medicaid patients are.

    Also if Medicaid budgets were expanded to cover transport cost to and from the hospital or doctor’s office (either cab fare or a Medicaid Super Shuttle) or paying childcare during doctor’s visits, this would reduce the challenges involved in giving high-quality care.

    This issue also brings up a problem with the idea of giving vouchers (or tax credits) to pay for private insurance. To the extent that the challenges of providing high-quality care to Medicaid patients cannot be solved by expanding budgets, giving Medicaid patients vouchers (or tax credits) to pay for private insurance will actually not solve anything.

    I think John Goodman’s idea of giving a tax credit for private insurance is a great idea, but if the challenges faced in caring for Medicaid patients is not solvable by switching them to private insurance, promoters of tax credits need to be careful in how they sell the idea.

  3. Devon Herrick says:

    I don’t recall the exact proportion, but no shows are relatively common in Britain where office visits are “free.” A few years ago the British NHS was discussing charging a $25 fee to no shows.

  4. SPM says:

    Personally, I’m not surprised to hear that doctors are becoming increasingly likely not to accept Medicaid patients because of the problems they pose: longer reimbursement times, lower reimbursements, and no-shows by patients.

    More and more doctors will begin to move toward cash-only patients in order to reduce costs, and thus one more reason why many people will not be able to keep their doctors as Obama promised.

  5. Perry says:

    My wife’s hospital provides free transportation to Medicaid patients and still has problems with no shows.

    • JFA says:

      The question is not whether there will or will not be no-shows (one of the numbers from above is that the privately insured missed 23 percent of follow-up appointments… that seems like a problem to me). The question is whether there will be a higher or lower rate of no-shows if you provide transportation. So while there may still be a problem with no-shows, one would expect that there would be less of a problem if transportation is free. In this case the proper way to analyze the issue is not to say there are problems at one hospital and then generalize that free transport doesn’t work. You at least want one other hospital (preferably one that is similar to the one your wife works at) in your analysis that does not provide free transport, and then compare the numbers.

    • John R. Graham says:

      I think free transportation is only part of the solution. If it’s a single mother, free transportation does not solve what do to with the kids. If she has a low-wage job where she’ll get fired for absence, free transportation will not help.

      We are talking about challenges here that cannot be solved within the healthcare “system”.

  6. Buster says:

    Medicaid patients missed 35 percent of follow-up appointments. Privately insured patients missed 23 percent of follow-up appointments…

    That could be a clue. “Follow up appointment” are often of little value. I have a health problem, so I make an appointment. The doctor prescribes medication that alleviates my problem. My doctor sometimes advises me to go come back in a month for a follow up appointment. Basically, why doesn’t the doctors just say… “hey, come back if you have any problems” rather than have his or her office assistant set up a follow up visit.

    Initial appointments for a medical complaint have a much lower no-show rate than follow up appointments regardless of insurance.

  7. Dennis says:

    We stopped seeing Medicaid patients in our private surgical practice after several years, almost exclusively because of the high rate of no-shows and because these patients were much less likely to comply with treatment recommendations. A large proportion of the no-shows were for initial visits so I do not agree with Buster.

  8. Bob Hertz says:

    John G raises a good point.

    Most nations allow sick leave for medical appointments. Most American employers allow this also.

    Any cheap labor employers who do not allow sick leave — primarily in restaurants and retail, I suspect — should be fined and penalized and sued until they do.

    These employers are the shame of America in many ways. I am revolted beyond measure when some conservatives (not all) defend their social cruelty.

    • John R. Graham says:

      That’s not here I was meaning to go with my point. But I can see how people would react to it that way!