Texas ranks low in Medicaid doctors
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By Jason Roberson
The Dallas Morning News
DALLAS — When Ruth Guerra, 6, tries to write, holding the pencil puts just enough pressure on her left pinky to make it bleed. With her condition, if she falls down while playing or a classmate accidentally brushes against her, she bleeds.
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Last week, Sandra Ramirez, Ruth's 33-year-old single mother, took time off from her hourly job at the Dollar General after another one of Ruth's bleeding episodes.
Ruth's elementary school in Crandall sent her to Dr. Turner Lewis, the only pediatrician for miles in Kaufman County accepting new Medicaid patients. But Lewis did not have the advanced training to completely treat Ruth's hemangioma, a collection of rapidly growing blood vessels that makes her prone to bleeding.
Because of a shortage of specialists accepting Medicaid, Ruth must wait until Sept. 9 for surgery.
As the state seeks ways to trim Medicaid, an increasing number of doctors frustrated with reimbursements are opting not to see new Medicaid patients. As a result, Medicaid patients often grow sicker while hunting for a doctor.
"The inability to find a Medicaid doctor drives up the cost for everyone because they then frequent the emergency room," Lewis said.
Dallas ranks last among 15 major cities in the percentage of physicians accepting Medicaid, according to a study by Merritt Hawkins & Associates, an Irving-based health care consulting and recruiting company.
In that study, 1,162 medical offices were surveyed between September 2008 and March. Dallas had a Medicaid acceptance rate of 38.6 percent, compared with the national average of 55 percent.
For example, Medical City Children's Hospital has only a handful of pediatric cardiologists accepting Medicaid. When the group is booked solid, parents must go to Children's Medical Center Dallas, which does accept Medicaid.
But pediatric cardiologists there have to weave in Medicaid patients with patients of other insurance plans, which often carry better reimbursement rates. That has pushed the wait time to between six and 12 months.
Such a bottleneck puts pressure on regular pediatricians like Lewis who do not have the special training to handle heart problems. Rather than deal with the frustration of waiting for Medicaid specialists for their patients, many skip the program altogether, Lewis said.
A possible explanation for North Texas' low Medicaid acceptance rate is the relatively strong economy here. The Dallas-Fort Worth area fell into recession in late 2008. But so far, because of higher energy prices and the lack of a giant housing bubble, the blow has been somewhat softer for the local economy than for the U.S. as a whole.
Over the last 12 months, for example, payroll employment in the Dallas-Fort Worth area has fallen by 1.7 percent, compared with a 3.8 percent contraction in the nation as a whole.
"Doctors in the Dallas area don't have to rely on Medicaid," said Phil Miller, spokesman for the study. "They can cherry pick to some extent."
Another factor in Dallas-area doctors' resistance to Medicaid is the declining reimbursement rate for medical care.
Dr. Fred Ciarochi, an endocrinologist in Duncanville, no longer accepts new Medicaid patients unless they are referred by a colleague.
Several years ago, Ciarochi's staff conducted an analysis of how many hours he'd have to work to keep his practice financially healthy.
"I couldn't cover the cost of running the office if I only saw Medicaid patients," Ciarochi said of the results.
It does not appear conditions will improve anytime soon.
Under the $182.3 billion, two-year budget the Legislature approved last week, few changes were made to Medicaid, which state economists say is underfunded by at least $1.2 billion.
Nursing homes will get a 3 percent increase in reimbursements, as would clinics treating poor children. For ambulance services, the fee increase will be 2 percent.
Doctors get no raise.
Medicaid, a health insurance program funded by the state and federal governments, serves 2.7 million low-income families, nondisabled children, related caretakers of dependent children, pregnant women, the elderly and people with disabilities.
The program represents 26 percent, or $19.5 billion, of the state's expenditures.
A state is not required to offer Medicaid, but if it does, it must cover poor children and meet federal standards for ensuring that they receive care.
Medicaid patients Perry and Alexander Tarlton, ages 2 and 7, both have sensory processing disorders. Their mother, 29-year-old Jamie Tarlton of Seagoville, said she has been waiting three months to get an appointment for her sons to see a neurologist.
"I hate it," Tarlton said. "You go day to day living with their disabilities, and you're waiting and waiting and waiting, and you never get help."
A few managed care companies that have state contracts to administer Medicaid have created incentives to encourage doctors to accept Medicaid.
Doctors in El Paso, for instance, can earn up to $100 extra per Medicaid patient seen after normal business hours.
Other communities have created their own health care systems of sorts. Two years ago, Collin County signed an agreement with PrimaCare Medical Centers, which operates PrimaCare facilities in Frisco, Plano and McKinney. Qualifying residents receive treatment with a $20 co-pay.
When Collin County started the program, the cost for more than 950 emergency room visits topped $1.2 million, or about $1,315, on average for each visit. Today the average cost of those visits has dropped to $774.
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Copyright 2009 THE DALLAS MORNING NEWS
