Will Accountable Care For Medicaid Work In The Ghetto?


Patients might only be able to get to a doctor during the day on the weekends because it’s too dangerous in the neighborhood to be going out at night……The patient goes to the pharmacy but is told the new medication requires pre-approval.  The patient doesn’t know what to do so the patient goes to smoke a cigarette…………...

Accountable care for Medicaid.  No, we need real solutions.


New York officials are doing an “experiment” that should strike fear, anger, and outrage in the hearts of doctors who take care of Medicare patients. (New York has the highest Medicaid budget of any state.)

As any doctor who has a high volume of Medicaid patients knows, Medicaid pays practically nothing.  Doctors who take Medicaid usually have to carry a bigger patient load to survive.  Medicaid patients are often sicker than the general population, with complicated diseases that are compounded by their environments.  They seek treatment in emergency rooms more often than other populations, have less access to healthy lifestyle choices, and live in more dangerous neighborhoods.

Visits to hospitals and emergency rooms are expensive (unlike doctor visits that are reimbursed for pennies on the dollar), and Medicaid officials want to decrease costs.  They’ve decided that if doctors worked harder, people would be healthier.  To make them work harder, they’ve decided to link their pay to hard work.  So if patients are healthier, that means the doctor is working harder and thus deserves monetary compensation for his efforts.  If the patients are sicker, the doctor is ineffective and does not deserve to be so rewarded.

New York is suggesting that the doctors — many minority — who work with the poor — also many minority — should join together into accountable care organizations that, in effect, give bonuses to doctors whose patients are healthier.  Here is how the New York Times explains this awesome idea:

Medicaid officials hope to inspire these providers to work together and take a more active role in looking after their patients’ health, rather than simply waiting for them to show up when ill. The hope is that if they can do a better job of getting patients to, for example, quit smoking or manage their diabetes doctors could reduce costly visits to hospitals and their emergency rooms.

For each group the state will set goals for a range of measures, such as how well the group manages diabetes cases — based on those patients’ eyesight, cholesterol readings, kidney function and other tests — and whether it can reduce preventable hospital admissions, such as those created by poor follow-up care. A group can get a bonus each year by making progress toward its goals.

In the future, if the experiment works, providers may be paid solely based on outcomes rather than volume of services, with better-performing groups earning more than those whose patients are in worse shape.

New York is spending $1 billion a year for five years on this experiment. $5 billion.  To save money.

Look, people.  Doctors who take care of Medicaid patients are not sitting around twiddling their thumbs waiting for someone to come in with a disease.  They are doing their professional best to take care of the people who come to see them.  Let’s take a look at a composite person who might seek the doctor’s care.

This patient, unlike many of this doctor’s patients, has a job.  It is minimum wage, but there are plenty of people out there who would be glad to take the patient’s job if, for instance, they had to be absent in order to go to the doctor.  The patient probably has to take the whole day off because public transportation is slow, and the doctor has long wait times because his patient load is so big, and his patients have so many problems.  The patient will probably have gone to an emergency room for care a number of times because the ER is open 24 hours, and he doesn’t have to ask the boss for time off.  He might only be able to get to a doctor during the day on the weekends because it’s too dangerous in the neighborhood to be going out at night.

The patient finally gets in to see the doctor, having made an appointment and managed to show up for it.  The doctor sees that her problem list includes diabetes, high cholesterol, and emphysema.  He checks on the dose of her diabetes drug and decides to change to a different drug.  He suggests that he try to eat a little better and smoke a little less.  He tells the patient to follow-up with him in a week to see if the new diabetes drug is working.

The patient goes to the pharmacy but is told the new medication requires pre-approval.  The patient doesn’t know what to do about this and so leaves empty-handed.  The following week the babysitter doesn’t show.  He now misses the follow-up appointment and now also doesn’t have a job.  So the patient goes to smoke a cigarette.

But, according to New York officials, this patient is doing poorly because the doctor isn’t working hard enough.

How about using some of that $1 billion a year to pay doctors a reasonable amount, so they have a lighter patient load?  How about financing weekend or evening office hours?  How about providing free transportation for doctor visits?  How about providing home visits or work visits from doctors or nurse practitioners so that patients get their follow-up care?  How about using all that money to improve living conditions, invest more in local schools, subsidize healthy food, provide high-quality child care, raise the minimum wage, and create job opportunities?

Because these things are what improves patient’s health.  Not tipping the doctor.

Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine for real.