Doctors shun Medicaid

Hawaii’s chance to get a handle on the number of publicly insured residents denied access to primary care slipped away last week when the Obama administration shelved a plan for a mystery shopper program to measure access to medical services.

A common complaint among patients covered by government health plans such as Medicaid is the difficulty in finding primary care doctors willing to accept public insurance, though there is no hard evidence to gauge the scope of the problem.

The mystery shopper program, scrapped after doctors and politicians criticized it as government snooping, would have measured the level of access for patients insured in a public program versus higher-paying private insurance offered by companies such as Hawaii Medical Service Association.

Local health care providers had hoped the short-lived proposal to survey difficulties in accessing care here and in eight other states — through people posing as patients with different kinds of insurance coverage seeking primary-care appointments — would have prompted government action, making it less burdensome for doctors to accept publicly insured patients.

"It’s already a crisis and it’s going to get much worse," said Stephen Kemble, assistant professor of medicine at the University of Hawaii John A. Burns School of Medicine. "There are a lot of patients who have experience being unable to find doctors who will take them with Medicaid. I’ve recommended specifically for months a secret-shopper study because I think the state needs to know how bad it is."

A recent survey of 273 clinics in Chicago showed overall, doctors denied appointments to 66 percent of Medicaid children, compared with 11 percent with private insurance — illustrating a huge discrepancy medical providers say is also prevalent in Hawaii.

Local physicians for years have struggled with balancing the mix of patients with higher-paying private insurance and those with lower-reimbursed, government-sponsored health plans.

"The bottom line is you have to be able to pay the bills to keep your practice open, otherwise you can’t see anybody," said Alistair Bairos, a Kealakekua general surgeon. "So doctors make a decision at some point to see people who have (private) insurance."

Up until a few years ago, most local doctors were willing to take at least some patients covered by government insurance as part of their ethical obligation to serve the community’s health needs, Kemble said. But fewer are now willing to do so since the state converted a large portion of the Medicaid program in February 2009 to two mainland managed-care providers whose administrative policies are criticized for being too burdensome, he said.

"It’s been burdensome manage-care policies, not reimbursement levels, that have driven doctors away from doing that," Kemble said. "Almost all now do not take new patients with Medicaid. You spend too much time trying to get authorization for everything you do. No private doctor can afford that."

Access to care could become more critical if more than 30 million people nationwide gain health coverage in the upcoming years under the 2010 health care reform law.

Exacerbating the problem is a shortage of primary care doctors.

"Even if people were accepting all patients regardless of insurance, we already have a provider-shortage problem. You put those two problems together and you have people who can’t get access to care," said Matthew Nagato, spokesman for the Hawaii Primary Care Association, which represents 14 community health centers statewide. "Definitely on the neighbor islands and in rural areas, it’s a very real problem because it’s hard to attract providers and get them to stay in rural communities."

According to the Hawaii/Pacific Basin Area Health Education Center, there was a 28 percent shortage last year of local primary care doctors — general practitioners, internists and family physicians. There were 962 primary care doctors practicing in Hawaii last year, but 1,232 were needed here, according to a report presented in June 2010 at the Hawaii Physician Workforce Summit.

Another problem is the state’s aging physician work force.

"In Hawaii more than 40 percent of physicians will be reaching retirement age in the next 10 years, so the problem is actually going to get worse as some of these doctors — almost half of them — reach retirement," Nagato said.

Turnover is already starting.

Alice Dean-Daniel, a 69-year-old Kailua-Kona resident, said she has had at least eight to 10 primary care providers in the past decade since being diagnosed with breast cancer, despite having dual coverage under HMSA and Medicare.

"It’s just been constant turnover of primary care physicians," she said. "Some of the issues are related to just the whole medical system reimbursements and all those administrative hassles. It’s just hard for them to do it. There’s a lack of continuity of care. I’m very frustrated because right at the moment I don’t have a doctor. The whole system just needs help."

Instead of the primary care survey, the U.S. Department of Health and Human Services said in a statement last week it would "pursue other initiatives that build on our efforts to increase access to health care providers nationwide."

"The Obama administration has made the recruitment and retention of primary care professionals a top priority," an HHS spokesman said in an email.

In the meantime, Hawaii patients unable to access primary care in an office setting eventually get seen elsewhere, said Bairos, the Kealakekua surgeon.

"Virtually all people in Hawaii get seen in the end (in the emergency room)," he said. "People have pride, so if sometimes they can’t find a doctor or can’t afford a doctor, they wait until some condition has really progressed. It’s just a very inefficient way and inhumane way for society to manage its health care problem."