I read many rants on Medicare (and write some myself), but what about Medicaid?  To those who don't know, Medicaid is a health insurance plan funded by the federal government, administered by the individual states, aimed at people who are living in poverty.

We accept Medicaid mainly for the kids.  A significant proportion of Children are on Medicaid or other related plans, and so most pediatricians accept it.  A lower percent of family and internal medicine practices accept it (see below).

In general, our practice tries hard not to disrespect our Medicaid patients (as other practices are known to do), treating them the same as our "paying" patients.  Still, while many of the stereotypes about these patients do not apply to every patient, these stereotypes came to be for a reason.  Perhaps it is a minority of the Medicaid population, but it is a substantial minority.

So here is the stupid things about Medicaid.

  1. Reimbursement - I sound like a broken record, but the reimbursement for medicaid is very bad - especially for adults.  With the complexity (both medically and socially) of the adult Medicaid population, it is extremely hard to make ends meet on what they pay.
  2. Different Medicaid for different states - This is bad if, like us, you live on a state line.  You need to deal with totally different plans with their own idiosyncratic rules.  At least with Medicare you need to learn one set of hoops to jump through.
  3. No humans - If you have problems with the way Medicaid does things, you rarely can get a person on the phone.  There are no medical directors to appeal to.  In general, if you have a problem with their decision, you have to live with it.  This is not true with the Medicaid managed care products.
  4. Medicaid Managed Care - Yes, you can get a human, but generally someone who knows only what is in front of them on the computer screen and yet has power to say you are wrong.  They have totally different rules, different formularies, more arduous authorization processes with each of these plans.  We have two of them in our state and it is like having to choose between hanging or being shot.
  5. Drug Seekers - No, not all Medicaid patients are drug seekers, but a disproportionate number of them are.  These people are constantly finding ways to get you to write a controlled drug, often going to other providers when you won't comply.  Drug seekers hurt all Medicaid patients in that they put a cloud of suspicion over any Medicaid patient that seems to be in pain.
  6. ER overuse - The cost to Medicaid patients of going to the ER is the same as it is to go to see you.  Nothing.  This means that far more of them will be willing to take their kid to the ER for an ear infection, even when you have a walk-in clinic they can go to.  This means that you don't know really what medications many of them have gotten, since their care is so fragmented.
  7. Entitlement - The entitlement mentality is one in which the person does not think they should be expected to pay for things.  They are so used to getting a free-ride that they recoil at the idea of paying for things.  I get many requests for prescriptions of OTC medications or cough/cold equivalents that are prescription.  I have to pay for them, why shouldn't they?
  8. Cancellation - Patients can mysteriously be canceled for Medicaid, and have no recourse but to wait until the next month to be reinstated.  This means that we are caught having to decide if we are going to charge normal amounts for these folks with no insurance, hoping when it is reinstated they will pay retroactively; or we try and drag our feet until it is reinstated.  If we do the former, we are stuck with a bill to a person who cannot pay.  If we do the latter, we may harm people.
  9. Formularies - These have gotten out of hand lately.  It used to be that we could write generics and they would all be accepted.  Any of the cheap cough/cold medications would also be paid for without having to hoop jump.  Now they only accept certain generics and pay for certain cold medications.  Often the pharmacist has no list as to what is accepted, and so they have to run one drug through at a time.  It is costing us dollars to save them pennies.
  10. Fear of Audit - Like Medicare, it is a criminal offense to bill incorrectly to Medicaid.  This means that if you don't document exactly to the letter of the law (see Happy for more details on that one), you could be brought up for defrauding the government.  With how little you get paid, it is sometimes not worth the trouble and you just end up down-coding the visit to play it safe.

There are some things I do like about Medicaid.  The drug coverage is much better than Medicare, and they do pay for well care (and at a good rate for children).  But the pains of dealing with it have many providers saying "No" to Medicaid, which is a shame because serving the poor should be the rule for physicians, not the exception.

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