04/06/2012

No easy cure for struggling Medicaid
Rapid City Journal includes Community Health Center of the Black Hills and quote from Dr. Nancy Babbit

Five-year-old Jenasis Brown and her younger brother, Roy, are two of the approximately 115,000 South Dakotans who qualify each month for health care through Medicaid or its corollary for kids, the Children's Health Insurance Program. But qualifying for Medicaid — and finding a doctor or a dentist who will take you as a new patient — can be two very different things, according to Dr. Karla Murphy, president of the South Dakota State Medical Association.

At a time when Medicaid enrollments are rising because of a bad economy, the number of doctors and dentists accepting Medicaid

patients is declining in South Dakota. One in seven South Dakotans is already a Medicaid recipient and nearly 70 percent of those are children. The Affordable Care Act, new federal health care legislation aimed at reducing the number of uninsured people, is expected to add another 54,000 South Dakotans to Medicaid rolls between 2014 and 2019.

Murphy worries about that. Combined with projected shortages of physicians in the state, South Dakota may not have the necessary medical infrastructure to care for that many new Medicaid patients, she said.

Ninety percent of the state's approximately 2,000 physicians say Medicaid reimbursement rates already don't cover their overhead costs to provide the care, much less allow them to make a profit, and future cuts to provider payments promise to make that situation worse.

"The payments made are less than it costs us to provide this service," Murphy said.

That fact makes Angella Kegler feel stigmatized as a Medicaid recipient, and acutely aware that she is a financial burden to her doctor, Dr. Nancy Babbitt.

"I am very aware what a financial hardship I am for those providers. I feel badly that I'm costing them money to treat me," Kegler said.

Kegler, 37, is one of the rare able-bodied adults who qualify for Medicaid. As a

full-time college student, who is a year away from earning a degree in the human services field, Kegler is also the single parent of two minor children. Because of her extremely low income when she quit her job three years ago to return to college, she qualified for Medicaid about 18 months ago.

At that time, she was refused treatment at the Rapid City clinic where she had been a patient for 10 years, because the clinic doesn't accept new Medicaid patients.

"My doctor couldn't see me anymore," Kegler said.

As a Medicaid recipient, her only options for care in Rapid City were family practice physician Babbitt or the Community Health Center of the Black Hills.

SDSMA's 2011 Medicaid Reimbursement Report shows 35 percent of the state's doctors said they currently do not accept new Medicaid patients and 47 percent said they plan to decrease their Medicaid patient loads because of recent cuts to reimbursement rates. Additionally, more than 76 percent of doctors said any additional cuts will force them to either limit or refuse to see Medicaid patients completely.

The Medicaid picture with the state's dentists may be even bleaker.

Brown was surprised to be refused dental service at her family's longtime dentist office recently. Her husband got laid off from his management-level job in July 2011 and lost the health insurance that came with it, making their children eligible for health care through CHIP.

Brown and her husband live without health or dental insurance, so she cancelled her 6-month check up. But she was disappointed to learn that she also needed to find a new dentist for her kids.

"They refused to keep my children's appointments and stated they did not accept Medicaid," Brown said.

That's a common scenario, according to Dr. William Donhiser of Black Hills Pediatric Dentistry, one of the rare Rapid City dental clinics that does accept new Medicaid patients.

About 80 percent of the state's dentists participate in the Medicaid program, said Paul Knecht, executive director of the S.D. Dental Association, but the number that take new Medicaid patients is far fewer.

"There's a significant percentage saying no to any new Medicaid patients," Knecht said.

Brown, who works at a childcare business, said she's not proud to have her kids on Medicaid and she's grateful that they now get dental care at Black Hills Pediatric Dentistry.

"I am thankful to get what we have, at a time when circumstances left us unable to provide insurance for our children," she said.

But she finds it frustrating to be treated like a second-class patient by some providers.

"It is frustrating when Medicaid tells us it is time for this checkup or that immunization, and … still be turned down because they won't receive as much funding as they would with private insurance," Brown said. "Wouldn't it make sense if providers were paid the same from self-pay patients, private insurance companies and Medicare/

Medicaid? I think so."

Babbitt is a Rapid City primary care physician whose clinic recently stopped taking new Medicaid patients because it pays only about 44 cents of every dollar that she bills for services. In a recent survey of all of Rapid City's primary care private clinics, showed few were accepting new Medicaid patients. The Community Health Center of the Black Hills, a federally-subsidized clinic that is reimbursed differently by the Centers for Medicare and Medicaid than private clinics are, accepts new Medicaid patients. By law, a community health center must treat anyone regardless of ability to pay. So does Regional Health's Regional Medical Clinic -- Aspen Centre at 640 Flormann St.

But concentrating all Medicaid patients in a few large community health clinics in the largest urban centers is not feasible in a state like South Dakota, where many of the poor live in isolated rural areas and small towns and must rely on medical services closer to home, Murphy said.

Babbitt would love to see reimbursements equalized and said Medicaid should pay the same as Medicare, if it wants to maintain provider availability.

A spokesperson for the state Department of Social Services, which administers Medicaid in South Dakota, said it is not aware of any patients having trouble finding a dentist or doctor to see them. DSS also claims that last year's 4-1/2

percent cuts to Medicaid payments for primary care doctors didn't reduce the number of providers with state Medicaid contracts.

Babbitt said that may be true, but it is entirely beside the point.

"This is a completely different issue than the fact that many doctors have stopped taking new Medicaid patients, which does not require us to drop our contract," she said.

For physicians who take a professional oath to care for people and to improve public health, rejecting Medicaid patients is "not an easy decision to make," Murphy said. "That's an interesting conundrum. You balance, as a business person, your patients and the employees in your office and paying their salaries and benefits. I think physicians do the best they can do with the resources they have."

Murphy and the SDSMA were encouraged by Gov. Dennis Daugaard's recent initiatives to address primary care physician shortages by increasing medical school enrollments in that area and to offer tuition forgiveness programs in medically underserved areas, which in South Dakota defines 59 of 66 counties.

"We're not completely doom and gloom about the future. We see some encouraging things happening," Murphy said.