Ciampi: A vote for Medicaid expansion is a vote against your neighborhood doctor

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ciampiBy Michael Ciampi, M.D.  — As the Maine Legislature and the public debate Medicaid expansion, there an aspect of the equation that has not been mentioned, but needs to be considered.

Because the Medicaid system is so inefficient, because it puts so much administrative burden on doctors, and because their payment rates are so low, most private doctors have made the difficult decision not to accept Medicaid patients.  They came to the realization that they were actually losing money for each patient they saw who was covered under this government program.  If you are losing money with each patient, you cannot make it up with more volume.

It is a simple matter of econonmics.  A doctor’s office is a small business.  If it loses too much money, it will shut down.  There have been several examples over the past few years locally where local doctors have had to shut down their practices and either join big box medical groups or move out of state, often because of Medicare and Medicaid rates being so low.

One might say, “All doctors are rich.  They can afford to lose a little money here and there.  It’s for the public good.”  The truth is that while reimbursement for services has been essentially flat for the past 12 years, while expenses (payroll, malpractice, health insurance, lights, heat, etc.) have gone up at least 30 percent or more.  Few primary care doctors are thriving today.  Giving away services is not an option for most if they want to make a living and pay their employees.  If a doctor can’t stay in business, he/she cannot help anyone.

An example of the undue burden that Medicaid places on small practices is that, when a physician accepts Medicaid, if a patient with that coverage calls for an appointment who needs an interpreter, the doctor, at his expense, must be sure there is one there.  If the patient comes in for the appointment, what he will collect from the state is not even enough to pay the interpreter.  If the patient does not show up, the doctor pays the interpreter anyway, at an even bigger loss.  No other business would put up with this.  Why would a doctor’s office?

Big hospital clinics are allowed to bill twice what private doctors can for Medicare and Medicaid services.  Those clinics will be the only ones which will be able to afford to see this population of patients.  Care in those clinics tends to be impersonal, generic, and much more expensive.  Often patients do not see a doctor, but a nurse or physician’s assistant.  Even then, they often don’t see the same provider twice.

Many private doctors would rather see a few patients without insurance and either give them a discounted rate, help them with a payment plan, or see them for free as an act of true charity.  Unfortunately, financial pressures are making this harder to do.  Once a patient goes on Medicaid, that option is essentially eliminated.

Voting for Medicaid expansion is a vote to further weaken our healthcare system by accelerating the decline of the neighborhood doctors that had been the backbone of medicine in years past.

If you are OK with the extinction of your local family doctor’s office, then vote for Medicaid expansion.  But remember, the next time you need to be seen, take a number and have a seat.  Someone will be with you…whenever.

Michael Ciampi, M.D., runs a cash only medical practice in South Portland, Maine. Ciampi Family Practice has drawn national attention for its innovative approach to delivering health care. (Note: This column originally appeared at RayRichardson.net. It is reposted here with permission.)

5 COMMENTS

  1. A long, long time ago; the Federal government in its infinite wisdom and benevolence decided that the best way to control spiraling costs, was to breakdown generic charges into specific components, analyze the skill sets and time to perform those tasks and then set a price(reimbursement rate) for each task.

    So CPT codes were born.

    To keep track of the billing complexities of what are called DRG related codes, i.e. each procedure has to be associated with relevant diagnosis or it won’t be paid by Medicaid/ Medicare; I and a handful of others became experts in automated billing since filling out a HCFA 1500 now became laborious. One urologist went from 10 billing codes to over 100 after I automated his system.

    Some practice managers considered it war; and the ‘nuke’ was a billing system like Medical Manager, which could electronically bill at the close of the day, submit claims, get their bank account credited electronically, and, if lucky, get back a handful of claims to review for errors and re bill with the next batch.

    Overnight, the practice got money in the bank, a huge improvement over the long waits for a check from a third party payer.

    A miracle I performed many times over for distressed practices; and once again enabling physicians to practice medicine and not bill collection.

    Costs did not go down; since practices now realized they were missing a lot of small charges and with the computer they could capture every penny spent. A dermatologist got 35 cents for a skin ‘pop’, sometimes many would be performed to find the cause of an allergy. So costs continue to rise rapidly, and my billing system was the weapon of choice in the battle with the Federal government.

    Eventually, it became very clear that practices who almost entirely relied on Medicaid/Medicare never had enough income to cover expenses. North of Bangor, the few practices I would visit didn’t have enough money to pay for the computer and I remember one doc who had an autoclave with the chrome worn off. He bought it when he set up his practice; and now was eyeing retirement.

    Then there was collecting co-pays, etc. A deadbeat dad rarely paid up; yet the practice delivered care. An OB/GYN wouldn’t bill until delivery; so you could have a year’s worth of charges outstanding. I was in one office where the mother came in pregnant with her second child, and the bill for the first hadn’t been paid yet!!

    A doctor’s fees had traditionally been calculated by a practice analyst based on the cost of setting up and running the practice, the amount of debt to be paid off, etc.

    Now the practice was squeezed between what the analyst determined was a appropriate fee, and what the Federal Government would reimburse them for.

    Bill out $50 and get paid $35, and attempt to collect the difference from the patient or another payer….OR live on the reimbursement and write off the rest as ‘bad debt’.

    Unsustainable; so some practices decided to go back to the old way of paying for their services and refuse to join the Med’s. Cash-only practices started to pop up and it seems to be a trend. Sounds cruel and heartless, but you try living on what the Government thinks your services are worth.

  2. A long, long time ago, the Federal government in its infinite wisdom and benevolence decided that the best way to control spiraling costs, was to breakdown generic charges into specific components, analyze the skill sets and time to perform those tasks and then set a price(reimbursement rate) for each task.

    So CPT codes were born.

    To keep track of the billing complexities of what are called DRG related codes, i.e. each procedure has to be associated with relevant diagnosis or it won’t be paid by Medicaid/ Medicare; I and a handful of others became experts in automated billing since filling out a HCFA 1500 now became laborous. One urologist went from 10 billing codes to over 100 after I automated his system.

    Some practice managers considered it war; and the ‘nuke’ was a billing system like Medical Manager, which could electronically bill at the close of the day, submit claims, get their bank account credited electronically, and, if lucky, get back a handful of claims to review for errors and re bill with the next batch.

    Overnight, the practice got money in the bank, a huge improvement over the long waits for a check from a third party payer.

    A miracle I performed many times over for distressed practices; and once again enabling physicians to practice medicine and not bill collection.

    Costs did not go down; since practices now realized they were missing a lot of small charges and with the computer they could capture every penny spent. A dermatologist got 35 cents for a skin ‘pop’, sometimes many would be performed to find the cause of an allergy. So costs continue to rise rapidly, and my billing system was the weapon of choice in the battle with the Federal government.

    Eventually, it became very clear that practices who almost entirely relied on Medicaid/Medicare never had enough income to cover expenses. North of Bangor, the few practices I would visit didn’t have enough money to pay for the computer and I remember one doc who had an autoclave with the chrome worn off. He bought it when he set up his practice; and now was eyeing retirement.

    Then there was collecting co-pays, etc. A deadbeat dad rarely paid up; yet the practice delivered care. An OB/GYN wouldn’t bill until delivery; so you could have a year’s worth of charges outstanding. I was in one office where the mother came in pregnant with her second child, and the bill for the first hadn’t been paid yet!!

    A doctor’s fees had traditionally been calculated by a practice analyst based on the cost of setting up and running the practice, the amount of debt to be paid off, etc.

    Now the practice was squeezed between what the analyst determined was a appropriate fee, and what the Federel Government would reimburse them for.

    Bill out $50 and get paid $35, and attempt to collect the difference from the patient or another payer….OR live on the reinbursement and write off the rest as ‘bad debt’.

    Unsustainable; so some practices decided to go back to the old way of paying for their services and refuse to join the Med’s. Cash-only practices started to pop up and it seems to be a trend. Sounds cruel and heartless, but you try living on what the Government thinks your services are worth.

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