Health systems interpret Medicaid

Although Springfield may have an access problem for Medicaid patients, it's not because local doctors are restricted from working with them.

According to officials with both St. John's Health System and Cox Health Systems, doctors have no restrictions placed on them regarding the number of Medicaid patients they see, or the cost of Medicaid-reimbursed services provided by their practices.

"We have no limiting policy on our physicians seeing Medicaid patients," said Donn Sorensen, senior vice president and chief operating officer for St. John's Physicians & Clinics, which comprises 380 physicians in 60 clinic locations in southwest Missouri and northern Arkansas.

In fact, Sorensen said, St. John's two years ago changed its structure so that the clinics are governed by the physicians who work within St. John's Health System, "but not under the hospital.'"

"There are no demands or expectations placed on the physicians for how they do," Sorensen said, adding, "We expect that we will take care of our fair share of Medicaid patients and indigent patients here in Springfield."

Steve Edwards, senior vice president of regional services with Cox Health Systems, said Cox also doesn't place any limits on its 155 employee physicians regarding Medicaid acceptance.

Cox has three types of physicians working within its system: employee physicians, independent physicians and physicians who have service agreements to essentially serve Cox managed care patients exclusively. Edwards said all of Cox's employee physicians see some Medicaid patients.

"We ask our physicians to do their share. We cannot expect them to do more than their share," Edwards said.

Edwards said Medicaid patients represent 18.9 percent of the patients seen by Cox-employed physicians. At the Cox Family Medical Care Center, a graduate education clinic that trains family physicians, Medicaid recipients are 55 percent of the patient base.

"It looks like our physicians are taking care of their share, but it's a strain, and hopefully people understand the financial ramifications are why physicians are limiting their practices," Edwards said.

Dollars and cents

The issue of Medicaid access almost always circles back to reimbursement how much will be paid for services rendered. Sorensen said Medicaid generally pays about 30 percent of what other payers pay, so St. John's writes off about 70 percent of its fees charged to Medicaid. And that doesn't include what the system writes off for indigent, or charity, care.

"We will go ahead and bill Medicaid. They've got their own fee schedule, and they'll just pay us what they pay us, and that's it. That's all we get ... in the state of Missouri reimbursement is quite low," Sorensen said. "Our policy on charity is that any physician, any manager, can review with a patient a criteria for charity, and we'll write off our whole bill," he added.

Edwards noted that Medicaid reimbursement varies from service to service, and also among physician specialties. He said doctors with pediatric-related specialties can expect to write off between 50 percent and 60 percent of their fees, and internal medicine specialists can expect to write off about 70 percent. He noted that some specialists write off as much as 75 percent to 86 percent, but on average specialists are writing off about 80 percent of their fees.

Edwards added that it's important for people to realize that physicians typically spend about 55 percent of what they earn on office overhead, leaving the remainder for write-offs and their personal salaries.

Edwards and Dr. Bob Kipfer a Ferrell-Duncan gastroenterologist who chairs the joint operating committee designed to provide physician input on all Cox Health Systems decisions said the general public typically doesn't comprehend the stresses and challenges faced by physicians.

Doctors must balance their work schedules and the number of patients they can see in a day, and still take care of overhead, which is why they can't limit their practices to just Medicaid patients. Also, physicians often have contractual obligations for keeping a specific number of patients in their practices.

"Nobody wants to turn anybody away, and ideally we'd take care of them all," Kipfer said. "And we'd face the same problem if it was (commercial) insurance that paid 10 cents on the dollar."

Edwards said, "Physicians get paid more than the average person, true, but (they have to) finance training," and balance extremely busy schedules. "They give up a lot of their personal lives to be physicians."

As for the hospital systems themselves, in the first 10 months of this fiscal year, for services rendered in emergency rooms, urgent-care clinics and inpatient care at the hospital facilities, Cox already has written off $42,461,484 of its Medicaid charges, and Edwards said by the time the fiscal year ends, that amount is expected to be nearly $51 million. In July alone, Cox wrote off $5 million for Medicaid, and those statistics exclude what the physicians and clinics write off.

For St. John's Health System, during its 2001 fiscal year that ended June 30, the system-wide Medicaid shortfall, including physicians and clinics, was $84,995,000. St. John's also did an additional $10,434,000 in charity care, for about $95 million written off in total, according to Cora Scott, director of community relations for St. John's Health System.

But Sorensen said that's all part of what St. John's is about.

"Our mission statement and the mission statement of St. John's and the physicians is to improve the health and the quality of life for the communities, with particular or specific concern for the economic poor, and that makes it very challenging for us," Sorensen said.

Costs, patient demands

Sorensen said locally, regionally and nationally, reimbursement for medical services is going down. At the same time, the expenses for delivering care, for drugs and for technology are going up, not to mention general inflation. But he said patient demands are also a concern.

"Patients' and the public's expectations for care and desire for care and need for care are going up," he said. Through the Internet and other media, patients have become more knowledgeable about health care innovations, "so that their expectations and demands are going up for the care," Sorensen said.

"And it's kind of hard for us to say no, but on the other hand ... expenses are going up ... it's very tough," he added.

As for drug expenses, Kipfer said, Missouri recently reduced the Medicaid budget for prescriptions, making less money and less coverage available for medicines. In the long run, that can cost the state more.

For example, Kipfer said, there's a drug that's used to treat stomach-acid conditions for which the state created a policy requiring specific documentation of particular laboratory findings before Medicaid would pay for the medication.

For many patients, Kipfer said, taking the necessary steps to get the documentation is difficult, and as a result, they stop taking the medicine.

"We are seeing more and more patients that come to the emergency room with bleeding because their intestinal condition is off treatment," Kipfer said. And, because untreated acid conditions often present themselves with chest pain, several patients who go to the emergency room undergo expensive heart tests and may even be admitted to the hospital for several days with Medicaid paying for those measures.

Kipfer has met with state officials on the issue, and he said he understands why they want to eliminate what's perceived as the "needless use" of medicines.

"In (the state's) defense, we know that probably half of that (particular) medicine is prescribed for patients that probably don't need to be on it long-term and don't have a documented reason for it ... they (required documentation) for good reason," he said.

"I certainly don't want to lay financial guilt on patients. Patients are not the problem, it's society's problem. Most patients don't choose to have the circumstances that lead to needing Medicaid," Kipfer added.

On the state level

Greg Vadner, director of the Missouri Division of Medical Services, is aware that Missouri is a low-paying state for Medicaid. He said the state does have fee schedules for physicians, and the process of determining those is complex.

"We look at each year in the department, in the Medicaid agency, and we look at what we pay, we look at what (doctors') usual and customary charges are if we can get ahold of them for those services. We look at what Medicare pays, and we do comparisons and make a recommendation to the budget office as far as the next year's funding," Vadner said.

But once that's done, he added, the process is still far from finished. The budget office can approve, reject or modify the requests, and then they go to the governor's office.

The governor then presents them in the state budget package to the General Assembly.

"Then the General Assembly can add, subtract or change and they often do and then when they're finished, of course, they can appropriate the money, or lack thereof, depending," Vadner said.

Even after that, the budgeted amounts for Medicaid expenditures may be subject to veto by the governor, which in tight budget times is a possibility.

"Kind of the big picture of this rate increase issue ... the physicians and the dentists have gotten very little rate increases over the last 14 to 15 years. And then about three or four years ago, we began being successful in getting them rate increases," Vadner said. "We've seen new money, but certainly not at the level that many people would like to see."

Vadner said he would defend physicians and health care providers for their concern about reimbursement because "they obviously have legitimate needs." He said in the last couple of years, legislators and the governor's office have been very receptive to concerns about Medicaid reimbursement, and that's why some of the rates are being increased.

"Is it enough? Well, obviously, there's a shortfall. Revenue face facts Missouri is a low revenue state, and we are, in the big picture, a lower paying state as a result," he said.