POSTED: 1:30 a.m. HST, Jul 18, 2011
LAST UPDATED: 8:43 p.m. HST, Jul 19, 2011
When 86-year-old Mililani resident Ella Miyamoto enrolled in Medicaid in April after a series of ministrokes left her disabled, her doctor immediately dropped her from his practice.
"He informed me that the process was inadequate and burdensome and he never got paid for his services," said Miyamoto's daughter, Barbara Gurney.
Left without a primary care physician or a referral to one, Gurney began calling around for a new physician but was rejected by at least 20 offices, she said.
"My mother has dual coverage (Medicare and Medicaid) but they just weren't interested," said Gurney, a 59-year-old Wahiawa resident. "That's the whole plight. If you say Medicaid, they don't want you."
Two months later, with her mother's prescription drugs running out, Gurney finally found a doctor with the help of a "friend of a friend." Miyamoto, who no longer can swallow and must be fed through a tube, had her first appointment with the new doctor earlier this month.
Miyamoto is one of a growing number of residents having trouble finding a primary care doctor willing to accept new patients who are covered by public health insurance. Doctors say reimbursements are significantly lower than private health plans for the same services.
For example, Medicare, which covers those over age 65, will pay $111.34 for a new patient office visit in Hawaii, or about 80 percent of what private insurance pays. Medicaid, insurance for those with low income, reimburses $68.82 for the same visit, according to the Centers for Medicare & Medicaid Services and Hawaii State Med-Quest Division websites.
Because of the lower reimbursements and cumbersome paperwork involved, it's tough to find doctors willing to accept Medicaid patients.
"Medicare is bad enough. Medicaid is worse. I can sweet-talk a few of my friends here to maybe take one (patient), but it's difficult," said Michael Chan, a cardiologist at Pali Momi Medical Center and Hawaii Medical Center West. "For me some of the office diagnostic procedures are really almost not even worth doing because the reimbursement is something that doesn't even cover the costs or hardly covers the costs."
In addition to low reimbursements, doctors complain that the Medicaid system has become increasingly onerous and time-consuming.
Medicaid paperwork contributes to an estimated $70,000 per year doctor's offices in Hawaii spend on managing insurance, according to a study by local nonprofit Access Care Today released in the February issue of the Hawaii Medical Journal.
The survey, mailed to 1,000 local private practitioners in 2009, sought to measure the willingness of doctors to care for publicly insured versus privately insured patients. Seventy-five physicians responded to the study. Of those, between 73 percent and 85 percent reported often or always accepting private insurance plans compared with between 25 percent and 30 percent that accepted Medicaid or Medicare plans.
The reasons cited by doctors for the wide discrepancy in access to care include reimbursements below contracted rates, delayed payments, difficulties in being able to refer patients and restrictions in coverage of medications and diagnostic testing.
"Neighbor island seniors have endured a primary care doctor shortage for years. The fact that now even Honolulu seniors are having a tough time finding a PCP (primary care physician) shows how acute the PCP shortage really is," said Barbara Kim Stanton, AARP state director. "Even in urban Honolulu it's a problem finding a primary care physician for Medicare patients."
The shortage could get worse if more than 30 million people nationwide gain health coverage in the upcoming years under the 2010 health care reform law.
Many also worry that a dramatic increase in the Medicare and Medicaid populations in the coming decades will worsen the chances of finding a primary care doctor.
There are 204,491 Medicare beneficiaries in Hawaii and about 267,000 Medicaid recipients. Medicare's 65-and-older beneficiaries represent 14.3 percent of the total population but are expected to increase to 18.7 percent in 2020 and to 22.3 percent in 2030, AARP said.
There are 2,427 primary care doctors in Hawaii, according to the state Department of Human Services. More than 40 percent of Hawaii physicians will reach retirement age in 10 years, according to the Hawaii Primary Care Association.
"Many of our seniors on Medicare will not have access to a PCP who will accept a Medicare patient," Stanton said. "Not only do we need a significant increase in the number of PCPs, we also need to have deterrents addressed, such as insufficient PCP Medicare reimbursements and excessive red tape."
Primary care doctors routinely spend at least two uncompensated hours per day dealing with managed care pre-authorizations, pharmacy benefit managers, restrictions in prescribing medicines, confidentiality requirements and coordinating care, the Access Care Today study said.
"It's not a question of money," said Richard Ridao, a Honolulu and Ewa internist who doesn't accept Medicaid because of "the frustrations of the documentation requirements."
"I'd rather donate my services for free," said Ridao, who provides free services to as many as 10 uninsured patients a month. "We want to take care of people. It's frustrating because you don't want to have to manipulate a system and worry about what insurance will or won't cover. It's frustrating if you have to base your care on coverage, which I refuse to do."
Alan Tice, a semiretired former internist and infectious disease specialist who conducts clinical trials at the University of Hawaii John A. Burns School of Medicine, left his practice in January.
"It's so much paperwork, and I was by myself trying to practice," said Tice, who practiced medicine for 40 years. "I can't really afford to take care of patients from a time standpoint or a financial standpoint. It's just not viable. It's a crisis for our traditional medical care system, which has worked remarkably well in the past but isn't going to be able to work in the future."
For Miyamoto it would have been difficult at age 86 to find a new doctor without the help of her daughter.
"Unless you're very persistent like I am or know where to go, you're stuck," said daughter Gurney.
What Gurney fears is the situation getting worse as her generation ages.
"Everybody's going to get old. What's going to happen to everybody when we get to this age?"