ANNAPOLIS – Eastern Shore pediatricians are giving up on HealthChoice.
Maryland’s ambitious Medicaid program was designed to provide poor patients with a cohesive system of medical care: a primary care provider, health education to curb risky behavior and a network of specialists to provide help for complicated health problems.
But physicians and other care providers participating in HealthChoice say they aren’t compensated enough to cover costs of treatment and so must leave the program to keep their practices afloat.
The problem is most pronounced on the Eastern Shore, where the exodus of specialists from HealthChoice has left pediatricians and other primary care providers without medical support for their poorest patients. The specialist flight isn’t unique to pediatrics, but that’s where it’s worst.
“I have 10 orthopedic surgeons right outside my door and none of them will see a Medicaid patient,” Easton pediatrician Brian Corden said. “They tell me they won’t see Medicaid patients because they lose money.”
Corden estimates 35 to 40 percent of his patients are insured through the Maryland Children’s Health Program. Eastern Shore specialists who accept state insurance are so scarce that he sends many patients across the Chesapeake Bay – to Annapolis or Baltimore – to find adequate care.
Corden doesn’t fault the specialists for refusing Medicaid patients, he said. He loses money on them, too.
“The fees they provide us are so low that when I see a (Medicaid) patient I actually lose money,” Corden said. “They don’t even cover the cost of running my office.”
Health department Deputy Secretary Debbie Chang says raising physician reimbursements is the department’s top priority. But the state can’t increase money it spends on Medicaid until federal regulations on matching state spending are changed, Chang says.
Fayette Engstrom, a retired Easton pediatrician, is a spokeswoman for Eastern Shore pediatricians like Corden who meet to discuss HealthChoice issues. Engstrom says the situation in Easton is spreading statewide.
“In Salisbury and Western Maryland we’re hearing a lot of rumblings,” Engstrom said. “We hear (specialists) talking very seriously about leaving Medicaid.”
Legislators are hearing the same thing. The House Economic Matters Committee was warned earlier this week that Garrett County may be forced out of HealthChoice next year.
Chairman Michael Busch, D-Anne Arundel, has heard about Western Maryland physicians’ groups that are “less inclined to participate (in HealthChoice). . . because of the rates.”
The number of state-insured children jumped this summer when the MCHP program expanded to cover families at 300 percent of the federal poverty level.
Corden said he believes the expansion will ultimately hurt MCHP, driving pediatricians out of the program who cannot sustain a practice on Medicaid payments.
That’s what happened in Dorchester County, where Dr. Ahmed Gawad is the only practicing pediatrician.
Dorchester has a population of 30,600, about 7,000 of whom are children. Five years ago, Gawad’s practice employed two other pediatricians, but they’ve left for “financial reasons,” he says.
“It has been getting harder and harder getting the revenue,” Gawad said. “I’m the only one holding the fort at this point.”
Medicaid insurance payments are about a third of what commercial insurance will pay for procedures and appointments, Gawad said. In a county where 25 percent of children live below the federal poverty level, earning enough revenue to pay the office bills becomes difficult. About 60 percent of his patients are MCHP-covered, Gawad says.
Because federal antitrust laws forbid doctors from discussing their financial situations with each other, Gawad and Corden are reluctant to disclose details of their own payment problems.
A 2001 report by the American Academy of Pediatrics illustrates the discrepancy between Maryland Medicaid reimbursement and Medicaid reimbursement nationwide. The report provides examples of medical procedures and payments made at the state and national levels.
Maryland compensates a physician $29 for attending a baby’s delivery; the national average is $95.22. “Initial newborn care” nets a $25 reimbursement in Maryland; the average Medicaid payment nationwide is $62.07.
Federal guidelines bind the state to using 1997 fee-for-service data when calculating MCO reimbursements. Providers and officials agree the 1997 standard, which was already behind national standards, puts reimbursements about 10 years behind national rates.
Insurers who contract with HealthChoice pay providers slightly higher rates than what they’re reimbursed by the state, but those payments are still too low for many physicians to stay in business.
“We need to work with the federal government to allow them to allow us to use different pricing standards,” said Chang from the health department. “It’s one of the things that’s keeping reimbursements down.”
The General Assembly and the DHMH have taken steps toward fixing the HealthChoice problems on the state side. This year, the Assembly approved a measure requiring DHMH to revise the process for setting fee-for-service rates “in a manner that ensures participation of providers.”
But doctors suffering under the system for the past few years are losing faith in the possibility of change, and some don’t have the resources to wait for reforms that will take at least another session to legislate and a few years to put in place.
“I’m giving up on this,” said Corden. “I’ve given it eight months now and I have not seen any progress. The state certainly is not interested in doing anything. I feel like I’m crying wolf.”