Illinois Medicaid and Obamacare--"The Ugly."

At about the time of the 2012 elections, I had planned some blog posts regarding “Obamacare” because it seemed a topic that was of interest about which I had an experienced, and maybe even, reasoned point of view. I had called the series “The Good, the Bad, and the Ugly.” But I only got through “the Good” post because I was surprisingly getting occupied in my medical office by people who had read this and wanted to discuss politics. While a little of this is fine and fun, I just thought that I was getting away from my actual job and probably giving away too much of my political point of view.

The physician-patient relationship is delicate and adding extra-medical considerations is not a good thing. (“My doctor doesn’t agree with me politically, does that mean that he will withhold some care to me that I need because of this?” Or “My doctor and I are so simpatico regarding politics that he should be more inclined to give me this prescription even if otherwise he might hesitate or object.”)

The “Bad” post was going to discuss whether there were better ways of accomplishing what the “Affordable Care Act” tried to accomplish. And the “Ugly” was going to describe how unsatisfactory the expansion of Medicaid could be—not financially for state governments. This is something about which I don’t really have enough knowledge to comment. No, it would tell how unsatisfactory the insurance actually is.

Well, the “Ugly” post is here because the Illinois Medicaid program is getting worse--ugly to the point that it might drive doctors away from the Southland. Remember my premise was that we have a mixed community of relatively affluent and poor right up against each other so that it’s important to maintain a balance. Otherwise, one could drive out the other. If Obamacare made the poor a bit more like the middle class, that could be a “Good” thing. But if it made, for instance, Medicare patient more like Medicaid patients or even uninsured patients, that would be “Ugly.”

Illinois Medicaid is enrolling all its non-elderly patients in the Chicago area into HMO insurance programs by January 2015 (why just around Chicago, hmmm?) and trying to enroll as many as will stay into similar HMO programs for its combined Medicare/Medicaid patients. These latter are the elderly poor who could not afford to pay their Medicare premiums. Previously Medicaid would just pay these premiums—both Part A for the hospital and Part B for the providers (e.g., doctors). Since Medicare is such a good deal, the Medicaid program comes out ahead, and the patients get really good care like the rest of the elderly. Now for Part B, these elderly are channeled into Medicaid HMOs.

The premise behind HMO programs is that there is a network of physicians—primary care providers (PCPs), that get paid a certain amount each month to “manage” the care of patients assigned to them, and specialists who get a fee for performing certain services beyond what a PCP could provide. Now it is a certainty that the Medicaid fees are going to be very low. PCPs can do better by assigning many, many of these patients to themselves and limiting their time with low-paying patients or enrolling few and trying to balance Medicaid with better-paying patients. The specialists are pretty much limited to the second process because it is hard to imagine running a specialty “mill” with limited patient contact because the diseases are usually too complicated, and often critically important, and demand more effort for a satisfactory outcome

So what could possibly be the problem? Of course, these Illinois Medicaid HMOs have abundant PCPs in a wide geographic area--including the important local hospitals--and have the full range of specialists enrolled in their programs so that referrals are timely and without difficulties. No, dear Southland reader, I didn’t think that you just fell off the turnip truck. You are an experienced Illinoisan. As you can imagine, the Illinois legislature set up the requirements to transfer the patients to these HMO programs but whether the HMO programs are up to the task is a completely different matter. My one-word answer is “Not.”

Here is one aspect. The Medicaid HMOs do not pay any specialist not specifically enrolled in their panels. This is a bit extraordinary in my experience. The specialist takes care of the patient in the hospital—usually working his or her butt off, and gets—nothing. Usually HMOs work like the devil to keep patients away from out-of-network physicians because the HMOs are required to pay--not the negotiated low, in-panel fees--but the “usual and customary” fees which are considerably higher. One of my incentives for writing this is the hubbub in New York expressed in a recent series of New York Times articles (see here, here, or here) where many patients are confronted with out-of-network fees. They are not happy. But here with Medicaid it is the doctors who are not happy.

Frankly, no physician specialist could possibly expect anything approaching the “usual and customary” from Illinois Medicaid. Something that was a percentage of the Medicare fee schedule would seem appropriate for these HMOs to pay. After all, it’s their responsibility to set up adequate panels of specialists that accommodate their patients. Or even the totally inadequate, but at least more-than-zero standard Illinois Medicaid specialist fees would seem to be the minimum that should be paid.

As a taxpayer, you might shout “hooray” because the less the program pays, the less pressure on you. (Or is it just the HMOs of Aetna, Blue Cross/Shield. County Care, etc. themselves that keep the money?) “Just cry me a river you rich, specialist doctor with your collection troubles—boo, hoo.” But as a Southland patient you should be concerned. If specialists are getting punished, they will leave your Medicaid-dominated area. This may not be a big deal for affluent, insured people willing to travel, though it might get a bit annoying to have to go from Olympia Fields or Flossmoor to down-town Chicago or to Indiana or New Lenox to get expert care for your swimmer’s ear. But it could be a really important issue for insured patients needing local emergency and in-patient specialty care.

Is this possible? Here is my experience. When I came to the area in 1992, the three hospitals that I am familiar with, St James in Chicago Heights, Olympia Fields Osteopathic (now St. James, also), and South Suburban Hospital as well as one that I was remotely familiar with, Ingalls, had this roster of “ENT” physicians (Ear, Nose, and Throat) that would see in-patient consults on call: St. James five, Olympia Fields three, South Suburban five, and I believe Ingalls had five or possibly more. Now through retirement and also several leaving the area, St. James Chicago Heights has zero, St. James Olympia Fields has zero, South Suburban Hospital has one, and Ingalls has one (plus more, I think, if the patient has commercial insurance). And it wouldn’t take much arranging for me to leave South Suburban Hospital.

So for these hospitals that total about 1298 beds (South Suburban 284, St. James Chicago Heights 312, St. James Olympia Fields 158, and Ingalls, 544) there are two or so active ENT doctors. BTW, how many ENT doctors are on the staff at Edward Hospital in Naperville for its 357 beds? 19. The rich get richer…

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