The Colorado Medicaid program is inadequately reimbursing doctors for the cost of providing office-based primary care, and the payment shortfalls are reflected in declining patient access and diminished quality of care for thousands of children, according to a new study by a research team at the Children's Hospital in Denver.
"The payment and administrative policies and the lack of participation of primary-care pediatricians is associated with inadequate preventive care and poor acute care," said Stephen Berman, M.D., director of the hospital's Children's Outcomes Research Center and co-author of the report along with the center's James Todd, M.D., and Carl Armon. The title of their 16-page report is "Access to Primary-Care Physicians and Preventative Primary-Care Services for Colorado Children Enrolled in Medicaid."
The researchers used two surveys of pediatricians-one conducted in late 1999 and early 2000, the other performed last year-augmented with clinical performance data from the Colorado Health Plan Employer Data and Information Set (HEDIS) for 1999-2002.
The surveys and data sets "document a decreasing capacity of private, primary-care physicians to care for children enrolled in Medicaid," the report said. At the same time, several key pediatric quality measures went in the tank as the state shifted from a majority HMO-based form of Medicaid coverage to a majority fee-for-service based system that did not rely on assigning primary-care physicians to patients.
According to the surveys, the number of pediatricians who would accept all Medicaid patients dropped from 41.4% of those surveyed in 2000 to just 23.9% in 2003. Similarly, 57% of physicians in 2000 said that Medicaid reimbursements did not cover their overhead costs for a patient visit, a number that jumped to 83% by 2003.
Medicaid pays pediatricians $32.62 for the most commonly coded office visit, while Medicare pays $47.38, Berman said. Meanwhile, the overhead for a typical pediatrician's office ranges from $50 to $60 per patient visit, he said. The numbers explain the declining physician participation rate in the state's Medicaid program, he said.
"They're saying, 'We can't do this,'" Berman said.
These changes in physician acceptance took place just as the number of enrolled children rose and state program shifted administrative gears. In 1997, about 75% of Colorado's roughly 200,000 Medicaid children were covered by HMOs, Berman said. By 2004, due to low reimbursements, the number of participating HMOs had dropped from five to two, and HMO coverage had plunged to 14.6% of enrollment, Berman said.
By 2004, unassigned fee-for-service replaced HMOs as the state's dominant Medicaid payment mechanism, serving 62% of an enrollment that had swelled to 240,000 children.
Comparing data for children with unassigned fee-for-service show significant declines between 1999 and 2001 in the percentages of children who'd had a visit to a primary care physician, the report found. Immunization rates rose for most vaccines but were below those of HMOs and substantially below those of the Kaiser HMO in 2001 in all 12 categories listed, according to the report. Kaiser dropped its Colorado Medicaid HMO in 2002, Berman said.
"Too often, children enrolled in Medicaid, especially when they are in the unassigned fee-for-service program, do not see a primary-care physician, fail to have their recommended preventive visits and are not up to date on immunizations," the report said. "The de facto lack of access that unavailability of primary-care physicians creates may be one reason why Medicaid patients have a significantly higher rate of vaccine-preventable diseases in Colorado, higher rates of complicated appendicitis and an increased incidence of severity of diabetic ketoacidosis."
Berman said at greatest risk are between 80,000 to 100,000 Medicaid children who receive care from office-based primary-care pediatricians, many of them in areas without publicly supported safety-net clinics or hospitals. Berman said that while the study focused on pediatricians, he recognizes family physicians play a significant role in treating children covered by Medicaid, but he said many of the problems with the Medicaid program affect both specialties in similar ways.
Berman said his group has sent copies of his report to Colorado legislators and are trying to set up a meeting with top state Medicaid officials to go over their findings.
"In the past, the legislators and the Medicaid administrators and the governor's office would say the system is just fine," pointing as evidence to the care from safety-net providers such as Denver Health and the Children's Hospital.
Berman said his hope is that the new data will convince policymakers to raise Medicaid payments to at least 100% of Medicare and change some burdensome administrative policies that discourage physician participation.
"If they don't do that, Colorado kids won't get the care, including immunizations, that they need."