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Health Care Access for Medicaid Patients – Physicians and Dentists Interview Study


i. executive summary




When physicians and dentists were asked what the greatest business challenges in accepting and treating Medicaid patients are, they responded:
§ Low/slow reimbursements
§ Excessive paperwork/authorization problems
§ Abuse of system/lawsuits

    When physicians and dentists were asked what the greatest medical challenges in accepting and treating Medicaid patients are, they responded:
    § Sicker/needier patients
    § Non-compliant/undependable patients
    § Difficulty in making referrals
    § Treatment not covered
    § Patients’ bad attitudes

    According to physicians/dentists interviewed, treating Medicaid patients takes more time and resources. They are sicker/needier than other patients and tend not to comply with instructions/prescriptions due to lack of education and other personal/health issues.

    Although Medicaid patients are generally a more difficult, time-consuming and expensive population to work with, according to responding physician/dentists, most doctors indicated they would be willing to take/take more Medicaid patients if reimbursements were on the same par as Medicare or other insurance programs.

    Dentists were less likely to accept Medicaid patients than physicians, and spoke of low reimbursements and treatments not covered as reasons why. One dentist noted the difficulty, or impossibility, in finding specialist dentists to perform procedures such as wisdom teeth removal or root canals for Medicaid patients.
    Executive Summary

    Beyond the solution of increasing reimbursements, physicians/dentists offered several suggestions to “fix” Medicaid:
    § Institute a patient co-pay
    § Provide protection from lawsuits
    § Speed up the payment of reimbursements
    § Penalize no-shows
    § Allow necessary treatments
    § Allow paper claims
    § Change punitive system
    § Institute better screening.


    Physicians and dentists from the five Missouri regions who were interviewed for this study gave consistent responses, and no notable differences were found.

    iI. introduction



    Directors of the Washington University in St. Louis Center for Health Policy want to understand what challenges physicians and dentists face in their decision to take/not take Medicaid patients, and also to understand challenges physicians/dentists face in their practices, in general.

    The Research & Planning Group Inc., a marketing research firm based in St. Louis, was selected to conduct the Physician and Dentists Interview Study about health care access for Medicaid patients.

    iii. methodology



    The Center for Health Policy compiled lists of physicians and dentists in five regions throughout Missouri, and sent letters informing the doctors of a confidential interview study with a randomly selected group of Missouri physician/dentists. The letters, signed by Dr. William A. Peck, Director of the Center for Health Policy, noted that The Research & Planning Group, a marketing research firm based in St. Louis, would conduct the study. (A copy of the letter can be found in Appendix A, page 73.)

    Using the lists compiled by the Center for Health Policy, professional research interviewers from The Research & Planning Group contacted and interviewed Missouri physicians and dentists during November and December 2005.

    The Discussion Guide used by the interviewers was designed by The Research & Planning Group and approved by the Center for Health Policy. The Discussion Guide was not sent to potential respondents prior to the interview. (A copy of the Discussion Guide can be found in Appendix B, page 74.) The average time to complete the Discussion Guide with a responding physician/dentist was 15 minutes.

    Research interviewers from The Research & Planning Group conducted in-depth interviews with 39 physicians and 11 dentists, for a total of 50 interviews. Participating physicians and dentists were paid an incentive of $150 to thank them for their time.

    Detailed Interview Completion Tables by region for physicians and dentists are on the following page:
    Methodology

    Interview Completion Table: PHYSICIANS


    Region
    St. Louis City
    St. Louis County
    Cape Girardeau
    Boot-
    heel
    Spring-field
    Total
    Interviewed
    12
    6
    7
    5
    9
    39
    Declined
    6
    5
    4
    4
    4
    23
    Retired/Left
    0
    0
    2
    1
    0
    3
    Wrong Number
    4
    2
    2
    3
    3
    14
    Not Applicable*
    0
    0
    4
    0
    2
    6
    Left Message
    21
    23
    29
    15
    25
    113
    Total List
    43
    36
    48
    28
    43
    198

    * Doctor’s specialty was pathology or radiology.



    Interview Completion Table: DENTISTS

RegionSt. Louis CitySt. Louis CountyCape GirardeauBoot-
heelSpring-fieldTotal
Interviewed*
2
2
2
2
3
11
Total List
32
31
19
12
43
137


    *Several dentists from each region called The Research & Planning Group to schedule appointments as soon as they received the letter from the Center for Health Policy. Interviewers therefore did not need to make initial interview scheduling calls to dentists’ offices. One dentist’s office from the Bootheel region called The Research & Planning Group office to decline to participate in the study.









    iV. analysis of findings
    Takes/Does Not Take Medicaid:

    Those physicians/dentists who said they take more than 10 Medicaid patients per week were categorized as Takes Medicaid Patients.

    Those who said they take between 1 and 10 Medicaid patients per week were categorized as Takes Few Medicaid Patients. No dentist said he/she takes between 1 and 10 Medicaid patients per week.

    Those physicians/dentists who said they take zero Medicaid patients per week were categorized as categorized as Does Not Take Medicaid Patients:
    PHYSICIAN Respondents
    Response
    St. Louis City
    St.
    Louis County
    Cape Girar-deau
    Boot-heel
    Spring-field
    Total
    Takes Medicaid Patients
    3
    1
    5
    4
    5
    18
    Takes Few Medicaid Patients
    7
    3
    1
    1
    4
    16
    Does Not Take Medicaid Patients
    2
    2
    1
    0
    0
    5
    Total
    12
    6
    7
    5
    9
    39



    DENTIST Respondents
    Response
    St. Louis City
    St.
    Louis County
    Cape Girar-deau
    Boot-heel
    Spring-field
    Total
    Takes Medicaid Patients
    0
    0
    0
    1
    1
    2
    Takes Few Medicaid Patients
    0
    0
    0
    0
    0
    0
    Does Not Take Medicaid Patients
    2
    2
    2
    1
    2
    9
    Total
    2
    2
    2
    2
    3
    11


    A detailed table of physician/dentist responses on number of Medicaid patients seen each week can be found in the Complete Verbatim Responses section on pages 31 – 32.
    List of Physician Types:

    St. Louis City:
    1. Allergist
    2. Anesthesiologist
    3. Dermatologist
    4. Neonatology – 2 respondents
    5. Neurologist – 3 respondents
    6. Pediatric Ophthalmologist
    7. Radiation Oncology
    8. Surgical Oncology
    9. Vascular Surgeon
    St. Louis County:
    1. Family general practitioner
    2. General Surgeon
    3. OB Gyn
    4. Pain management
    5. Psychiatrist
    6. Urologist

    Cape Girardeau:
    1. Adult Hospitalist
    2. Allergist
    3. Anesthesiologist
    4. Emergency Room Physician
    5. ENT
    6. Family general practitioner
    7. Pediatrician
    Bootheel:
    1. Family general practitioner
    2. General surgeon
    3. Neurosurgeon
    4. Pediatrician
    5. Urologist

    Springfield:
    1. Anesthesiologist – 2 respondents
    2. Cardiovascular surgeon
    3. ENT
    4. Family general practitioner – 2 respondents
    5. Pediatrician – 2 respondents
    6. Pulmonologist

    1. Business Challenges for Physicians and Dentists:

    According to physicians and dentists interviewed, the greatest business challenges in general are:
    § Low/slow reimbursements
    § Insurance/paperwork issues
    § Costs of doing business
    § Cost of malpractice insurance
    § Collections
    § Medicaid
    § Staffing
    § Abuse of system/lawsuits
    § Other issues such as time management, obtaining information, competition, and recruitment

    When physicians and dentists were asked what the greatest business challenges in accepting and treating Medicaid patients are, they responded:
    § Low/slow reimbursements
    § Excessive paperwork/authorization problems
    § Abuse of system/lawsuits

    Low/Slow Reimbursements

    Whether they take Medicaid patients or not, low/slow reimbursements are the major problem with Medicaid, according to physicians/dentists interviewed:
        “Getting paid the proper amount so I can stay in business. The insurance companies don’t like to pay the doctors and the government is the worst offender.” (St. Louis County/family general practice/Takes Medicaid)

    Business Challenges for Physicians and Dentists:
        “The high cost of treating Medicaid patients. They demand a lot of service and want the most costly medicines.” Bootheel/neurologist/Takes Medicaid)

        “The very poor reimbursements for our services. We tend to be more scrupulous in taking and treating these patients because we know our reimbursements will be much less. Also, I can’t prescribe the medications they need because Medicaid or the parents refuse to pay.” (Springfield/pediatrician/Takes Medicaid)

        “I like to treat my patients the same, and try to give equal care even when I’m paid very little. The biggest challenge is getting reimbursed for the patients we take care of.” (Springfield/anesthesiologist/Takes Medicaid)

        “Reimbursements from insurance companies and Medicare have not kept up with cost-of-living increases.” (St. Louis City/dermatologist/ Does Not Take Medicaid)

        “They do not pay enough to cover my costs. It takes an extraordinary amount of time to get paid – a lot more work to retrieve a very small amount of money.” (St. Louis County/general surgeon/Takes Few Medicaid)

        “We can’t breakeven because reimbursements are so low. When I see Medicaid patients, I can’t cover the overhead involved. Medicaid patients abuse the system because it’s free, so they come in more often with more demands.” (Bootheel/urologist/Takes Few Medicaid)

        “Medicaid’s payments are so small that it doesn’t even cover the cost of seeing the patient.” (Springfield/family general practice/Takes Few Medicaid)


    Low/slow reimbursements are also an issue with insurance providers other than Medicaid, according to these physicians:
        “Trying to deal with insurance companies and bargaining with them.” (Cape Girardeau/ENT/Takes Medicaid)

        “To get enough revenue from patients and providers. My revenues keep dropping as the insurance companies regularly delay payments and challenge my diagnostic procedures.” (St. Louis City/neurologist/ Does Not Take Medicaid)

        “We do have challenges from some insurance companies, such as ones that are capitated and the HMOs.” (Springfield/family general practice/Takes Few Medicaid)

        “I have to depend on insurance companies to pay me promptly. It’s become a balancing act between payments and expenses.” (St. Louis City/dentist/Does Not Take Medicaid)


    Excessive Paperwork/Authorization Issues

    Excessive paperwork and authorization issues were seen more often as Medicaid patient problems, although a few physicians mentioned them as general business problems:
        “I have to work harder to make any money. The paperwork is excessive and I have to hire more people to handle it.” (Bootheel/family general practice/Takes Medicaid)

        “So many insurance companies have different pre-authorizations for surgery that we have hired one person just to handle that.” (Springfield/family general practice/Takes Medicaid)

        “The insurance companies expect patients to change doctors to comply with their plan, so there is a lack of continuity.” (St. Louis City/ dentist/Does Not Take Medicaid)

        “If patients’ expenses aren’t totally covered by their insurance company, they are unhappy, and it’s difficult to convince them to do what is necessary.” (Springfield/dentist/Does Not Take Medicaid)


    One doctor expressed the belief that pre-certification is easier with Medicaid patients:
        “With Medicaid patients, we don’t have as many people telling us what we can and cannot do. It is sometimes easier to pre-certify these patients for things than with other insurance companies.” (St. Louis/ neonatologist/Take Medicaid)

    With Medicaid patients, paperwork and authorization is a problem for these doctors:
        “The paperwork is excessive and requires more overhead in help and time.” (Cape Girardeau/anesthesiologist/Takes Medicaid)

        “Getting treatment approved, and for patients already on treatment, getting them re-approved. This means a lot of manhours getting

        approval, and this eats into revenues.” (St. Louis City/neurologist/ Does Not Take Medicaid)

        “Getting authorization and getting paid. The forms and bureaucracy are excessive. It’s too burdensome on my staff and takes too much time. Medicaid is a difficult patient group, in general.” (St. Louis County/psychiatrist/Does Not Take Medicaid)


    Abuse of System/Lawsuits

    Abuse of system/lawsuits was mentioned as a Medicaid business challenge more often than as a general business challenge:
        “My concern is Christ said it’s not the poor who will sue you. I challenge that. Times have changed. The poor are the first to sue and are abusing the system. The government should leave the poor to the church and the doctors. The Medicaid patients won’t pay you anything, and what the government pays is a fraction of what it costs you to see them. You give away your services.” (Cape Girardeau/ ENT/Takes Medicaid)

        “Medicaid patients are a more litigious group of people. I almost do volunteer work seeing them.” (Bootheel/general surgeon/Takes Medicaid)

        “They abuse the system. They expect something for nothing – society owes them something. They are demanding and expect specific medications that we can’t prescribe.” (Cape Girardeau/family general practice/Does Not Take Medicaid)


    As a general business challenge, one physician expressed the belief that in his area, people are more apt to sue their doctors:
        “The malpractice situation. In Missouri, people want to sue their doctors.” (Bootheel/pediatrician/Takes Medicaid)

    These issues were mentioned by responding doctors as general business challenges:

    Costs of Doing Business
        “Seeing enough patients to cover all the practice expenses which keep increasing.” (Cape Girardeau/pediatrician/Takes Few Medicaid)

        “The financial balance of trying to maintain an up-to-date, state-of-the-art practice and still afford it, because patients are taking more time and effort.” (Springfield/cardiovascular surgeon/Takes Few Medicaid)

        “Keeping costs down. My practice is blue collar, and many are facing hard times.” (Cape Girardeau/dentist/Does Not Take Medicaid)


    Cost of Malpractice Insurance
        “The cost of malpractice insurance is ridiculous and the drug companies have pharmacy committees that try to dictate policy.” (St. Louis County/family general practice/Takes Medicaid)

        “Our malpractice insuror went bankrupt. We found another and had an increase in premiums.” (Bootheel/pediatrician/Takes Medicaid)


    Collections
        “The rate of response for accounts receivable is poor. Difficulties in collecting is a major problem.” (Cape Girardeau/anesthesiologist/ Takes Medicaid)

    Staffing
        There are not enough adequate support personnel.” (St. Louis City/ neonatologist/Takes Medicaid)

        “Sometimes collections staffing is difficult. I need friendly, well-trained, hardworking people.” (Springfield/dentist/Takes Medicaid)

        “Obtaining adequted, motivated personnel – people who are capable of being polite to patients and have adequate business skills.” (Bootheel/ general surgeon/Takes Medicaid)


    Medical Challenges for Physicians and Dentists:

    According to physicians and dentists interviewed, the greatest medical challenges in general are:
    § Treating diseases/conditions
    § Treatment not covered/formulary
    § Keeping up-to-date
    § Insurance/costs for patients
    § Non-compliant/undependable patients
    § Workload/hours
    § Scheduling tests/facilities/follow-up care
    § Obtaining timely information
    § Coordinating patient care

    When physicians and dentists were asked what the greatest medical challenges in accepting and treating Medicaid patients are, they responded:
    § Sicker/needier patients
    § Non-compliant/undependable patients
    § Difficulty in making referrals
    § Treatment not covered
    § Patients’ bad attitudes

    Patient non-compliance and formulary/authorization issues were mentioned as both general medical challenges and Medicaid challenges. Patient non-compliance was mentioned more often by doctors as a Medicaid challenge.

    Patient Non-Compliance as a Medicaid Challenge
        “Medicaid patients are the least compliant population of patients as far as follow-up, taking medications, and appointments.” (St. Louis City/ neonatologist/Takes Medicaid)

        “That group of people is non-compliant with their prior medical treatments. They come in with uncontrolled hypertension and

    Medical Challenges for Physicians and Dentists:
        diabetes, and these difficulties require more care.” (Cape Girardeau/ anesthesiologist/Takes Medicaid)

        “Medicaid patients are the least motivated to care for themselves. There is a higher incidence of drug use and more smoking and alcohol consumption. They are a higher medical risk as they don’t take care of themselves and are eager to sue.” (Bootheel/general surgeon/Takes Medicaid)

        “The no-show rate is very high and wastes my valuable time.” (St. Louis City/neurologist/Takes Few Medicaid)

        “When I was seeing these patients, it was lack of follow-up on the patients’ part.” (St. Louis City/dermatologist/Does Not Take Medicaid)

        “Getting patients to show up on time and even to show up at all for their appointments.” (St. Louis County/pain management/Takes Few Medicaid)

        “Many Medicaid patients don’t return when they are scheduled because they don’t have transportation. Their way of life is unhealthy – they smoke and drink.” (Springfield/family general practice/Takes Few Medicaid)

        “The non-compliance of Medicaid patients. You are treating people with health conditions like high blood pressure or high cholesterol. They come in and then don’t do follow-ups or follow instructions that I’ve given them. They are late or they don’t show up at all.” (Cape Girardeau/dentist/Does Not Take Medicaid)

        “Medicaid patients don’t and won’t take any responsibility for work done. They aren’t dependable and don’t show up for appointments. I’ve worked at a free clinic, and they are undependable.” (Springfield/ dentist/Does Not Take Medicaid)

        “There are more missed appointments with Medicaid patients. Getting them to follow-up on appointments, instructions, etcetera is a challenge.” (Bootheel/dentist/Does Not Take Medicaid)


    Patient Non-Compliance as a General Medical Challenge
        “Getting the patients to comply, getting them to take their medications. Many forget to take their medications or they don’t like the side effects

        or they can’t afford it, so in any event, the medication isn’t taken.” (St. Louis County/family general practice/Takes Medicaid)

        “Patients’ compliance or lack of it. They either use too much medication or don’t finish the treatment.” (Bootheel/family general practice/Takes Medicaid)

        “Patient compliance is a big challenge.” (Cape Girardeau/dentist/Does Not Take Medicaid Patients)


    Treatment Not Covered as a Medicaid Challenge
        “It is impossible to get post-procedure care. Medicaid does not pay for anything outside of the hospital. This is very challenging and makes it difficult to care for patients properly.” (St. Louis County/vascular surgeon/Takes Few Medicaid)

        “Medicaid won’t pay for circumcizing, for instance, or for x-rays. It’s difficult treating and prescribing for them.” (Cape Girardeau/family general practice/Does Not Take Medicaid)


    Treatment Not Covered as a General Medical Challenge
        “The formulary changes. I get a patient regulated on a drug and then the insurance company demands a generic or a less expensive drug.” (Bootheel/family general practice/Takes Medicaid)

        “Mainly the biggest challenge is battles with insurance companies about prior authorization for testing. The formularies the insurance companies dictate may not be your choice.” (Cape Girardeau/family general practice/Takes Medicaid)

    According to responding doctors, medical challenges with accepting and treating Medicaid patients also include:

    Sicker/Needier Patients
        “Many or most are extremely ill, which increases your liability and the amount of resources you have to devote to them. They can’t afford their medications.” (Cape Girardeau/adult hospitalist/Takes Medicaid)

        “Treating people with oral problems who smoke and drink and don’t take care of their health. Medicaid people are an unhealthy group of people. The office needs fumigating when some of them leave.” (Springfield/dentist/Does Not Take Medicaid)

    Difficulty in Making Referrals
        “Finding other clinicians willing to take and treat them.” (St. Louis County/psychiatrist/Does Not Take Medicaid)

        “Medicaid patients aren’t healthy and need more treatment than our average patient. We find it hard to refer them to specialists in big cities – they won’t take them.” (Bootheel/urologist/Takes Few Medicaid)

    Patients’ Bad Attitudes
        “Medicaid patients don’t have respect for the free services and free medications they receive. Their perceptions and attitudes are bad.” (St. Louis County/family general practice/Takes Medicaid)

        “These patients come in when it’s unnecessary for minor illnesses, and yet often seem sicker than other children. They are around a lot of smoking parents and the parents take drugs. There is also more child abuse with the Medicaid children.” (Bootheel/pediatrician/Takes Medicaid)

    Other general medical challenges mentioned by physicians/dentists are:

    Treating Diseases/Conditions
        “Severe lung disease is hard. Multiple surgeries, obstructions. Despite everyone’s best efforts, patients are sicker.” (St. Louis City/neurology/Does Not Take Medicaid)
    Keeping Up-to-Date
        “Fighting disease and staying current with the latest treatments.” (St. Louis County/family general practice/Takes Medicaid)
    Insurance/Costs for Patients
        “The inaccessibility of medicines because of expense to the patients. Trying to jump through hoops to get medications covered by HMOs.” (St. Louis City/allergist/Takes Few Medicaid)

        “A number of patients aren’t covered by insurance and are challenged by the economy, so keeping patients motivated is a problem. We want them to seek care on a regular basis.” (Cape Girardeau/dentist/Does Not Take Medicaid)

        “Having patients who are willing to pay for higher-dollar services like crowns and bridges.” (Springfield/dentist/Does Not Take Medicaid)

    Workload/Hours
        “Time constraints – trying to see so many patients. Trying to fit them all in.” (Springfield/pediatrican/Takes Medicaid)

        “The number of patients seeking help. I have more patients than I can handle, and we have to double-book.” (St. Louis City/neurologist/ Takes Few Medicaid)

    Scheduling Tests/Facilities/Follow-Up Care
        “Getting the necessary studies schedule and performed.” (St. Louis City/surgical oncology/Takes Medicaid)
    Obtaining Timely Information
        “Getting patient information in a timely fashion from outside sources. Medical errors in the health care system.” (St. Louis County/OBGyn/ Takes Few Medicaid)
    Coordinating Patient Care
        “The problem is getting medical procedures done quickly and efficiently.” (St. Louis City/neurologist/Takes Few Medicaid)


    Suggested Changes to Medicaid:

    According to responding physicians and dentists, changes the state would have to make to the Medicaid program to make it worthwhile to accept/accept more Medicaid patients are:
    § Increase reimbursements
    § Institute a patient co-pay
    § Provide protection from lawsuits
    § Speed up the payment of reimbursements
    § Penalize no-shows
    § Allow necessary treatments
    § Allow paper claims
    § Change punitive system
    § Institute better screening
    Increase Reimbursements
        “Pay at Medicare rates.” (St. Louis City/surgical oncologist/Takes Medicaid)

        “Reimbursements need to be improved to at least 50 percent.” (Springfield/family general practice/Takes Medicaid)

        “Proper coverage for the physician’s services and providing transportation for these people. It shouldn’t be up to the hospital to transport them.” (St. Louis City/neurologist/Takes Few Medicaid)

        “Reimburse more and we would deal with the other problems. Pre-certifications for medications should be approved – it’s an unnecessary step to get approval.” (Springfield/family general practice/Takes Few Medicaid)

    Institute Patient Co-Pay
        “Better compensation for the physicians. The patients need to share some responsibility by paying part of the fee. They tend to overuse the system because they get free care.” (Cape Girardeau/allergist/Takes Medicaid)

    Suggested Changes to Medicaid:
        “I feel if you make the families partially responsible for the payment, even it it’s only a $5 co-pay, it would give them some feeling of ownership.” (Springfield/pediatrician/Takes Medicaid)
    Protection from Lawsuits
        “Protect us from lawsuits. The Medicaid patient will sue us three to one. The poor sue us first.” (Cape Girardeau/ENT/Takes Medicaid)
    Quicker Reimbursement
        “Better reimbursement or some sort of benefit, maybe getting payments more quickly.” (St. Louis County/psychiatrist/Does Not Take Medicaid)

        “They would have to pay on time and pay what they owe. They would have to give me no more paperwork than what insurance companies demand.” (Cape Girardeau/dentist/Does Not Take Medicaid)

    Penalize No-Shows
        “Start stipulating that after so many no-shows or tardies, patients lose coverage.” (St. Louis County/pain management/Takes Few Medicaid)

        “No-shows would have to be penalized. Some dentists book 16 Medicaid patients for one to show up.” (St. Louis City/dentist/Does Not Take Medicaid)

    Allow Necessary Treatments
        “Allow and approve necessary treatments and pay enough.” (St. Louis City/dentist/Does Not Take Medicaid)
    Change Punitive System
        “If one thing goes wrong, you get the entire system down on your head. I’m talking removing your license, I’m talking possible jail terms. That scares a lot of doctors away. For example, something could be mis-billed – not fraud, I don’t mean that, they deserve whatever they get – but just something mis-billed, you get the state on your back.” (St. Louis County/dentist/Does Not Take Medicaid)

    Better Screening
        “We need to screen applicants better so you don’t have people who can’t afford to pay the doctor. The Division of Family Services needs to work on it.” (Bootheel/family general practice/Takes Medicaid)

        “Better screening procedures for people to be let into the program. They must make certain the need is really there. Some of the Medicaid patients abuse the system.” Springfield/dentist/Does Not Take Medicaid)



    Taking More Medicaid Patients in the Past:

    When asked if there ever was a time when their practice accepted more Medicaid patients, more physicians responded no, they did not take more Medicaid patients in the past than they do now:

    Response
    St. Louis City
    St.
    Louis County
    Cape Girardeau
    Boot-
    heel
    Spring-
    field
    Total
    Yes, took more
    4
    4
    4
    1
    3
    15
    No, did not take more
    8
    2
    3
    4
    6
    24
    Total
    12
    6
    7
    5
    9
    39


    When asked if there ever was a time when their practice accepted more Medicaid patients, a little more than half of the responding dentists said yes, they did take more Medicaid patients in the past than they do now:

    Response
    St. Louis City
    St.
    Louis County
    Cape Girar-deau
    Boot-
    heel
    Spring-
    field
    Total
    Yes, took more
    1
    1
    0
    2
    2
    6
    No, did not take more
    1
    1
    2
    0
    1
    5
    Total
    2
    2
    2
    2
    3
    11


    For those physicians/dentists who said they did accept more Medicaid patients in the past, reasons why they no longer take Medicaid patients are:
    § Low/slow reimbursements
    § Non-compliant/undependable patients
    § Sicker/needier patients
    § Paperwork/red tape
    § Abuse of system/lawsuits
    § Too many rules
    § No internet access
    Taking More Medicaid Patients in the Past

    Low/Slow Reimbursement
        “I can’t stay in business with what they currently pay.” (St. Louis County/family general practice/Takes Medicaid)

        “I can’t afford to keep it up. I’m losing money financially.” (Bootheel/ dentist/Takes Medicaid)

        “Sometimes they will overwhelm your practice and I can’t make a living accepting many. They don’t show up for appointments or value your services.” (Springfield/dentist/Takes Medicaid)

        “The reimbursement is low and the whole program is a big hassle.” (St. Louis County/psychiatrist/Does Not Take Medicaid)

        “It’s financial. My office manager has said keep it less than ten percent or I’ll go bankrupt.” (Cape Girardeau/pediatrician/Takes Few Medicaid)

    Non-Compliant/Undependable Patients
        “Because they are no-shows.” (St. Louis City/neurologist/Takes Few Medicaid)

        “The aggravation factor. Compliance is an issue. These patients won’t change their lifestyle. The don’t show up for appointments and some have poor hygiene. You have to air the room when they leave.” (Springfield/family general practice/Takes Few Medicaid)

    Sicker/Needier Patients
        “It’s harder to deal with Medicaid patients. I am compensated less, and I had to call the police once with a troubled patient.” (Cape Girardeau/allergist/Takes Medicaid)

        “Usually they are the most needy, and we work harder because of major medical problems, like a disabled child. Their expectations are too unreal medically, and they object if I prescribe a medication allowed by Medicaid and not one of their choice. They make appointments more often than necessary, and many like to hang around and talk to my staff about their problems.” (Cape Girardeau/pediatrician/Takes Few Medicaid)


    Paperwork/Red Tape
        “I bought this practice from another dentist, and he used to take Medicaid patients. He stopped because the paperwork became too difficult to handle. He had to pay someone to file all the paperwork for him.” (Springfield/dentist/Does Not Take Medicaid)
    Abuse of System/Lawsuits
        “They are a higher risk group socially and medically. You are more likely to be involved in a lawsuit, and then your malpractice insurance is increased.” (Springfield/family general practice/Takes Few Medicaid)
    Too Many Rules
        “There weren’t as many rules and regulations then. I can’t afford as many now.” (Cape Girardeau/ENT/Takes Few Medicaid)
    No Internet Access
        “I took Medicaid patients for 28 years, but because of electronic billing, I can no longer accept Medicaid patients. My office doesn’t have internet access.” (Bootheel/dentist/Does Not Take Medicaid)


    Responding Dentists:

    Responding dentists were more unlikely to take Medicaid patients than responding physicians. This finding is echoed in the Social Service Professionals study, in which a common refrain was the impossible task of finding a dentist who will accept Medicaid patients. No responding dentist said he/she took a few (1 – 10) Medicaid patients per week: dentists either took zero Medicaid patients or took more than 10 per week.

    Responding dentists gave these reasons as the greatest business challenges in accepting Medicaid patients:
    1. Low/slow reimbursements
        “The slight payment they give you can arrive six or seven months later. It happened to me when I took Medicaid people. I am not paid enough to make it worthwhile, and Medicaid tells you what tests can and cannot be done.” (St. Louis County/dentist/Does Not Take Medicaid)

    2. Excessive paperwork
        “I can’t afford to accept Medicaid patients and stay in business. There is such a large discrepancy between normal fees and payments from Medicaid. It’s a lot of hassle to get reimbursed – so much paperwork is involved. I’d just as soon treat them for nothing and avoid Medicaid hassles.” (Cape Girardeau/dentist/Does Not Take Medicaid)

    Responding dentists gave these reasons as the greatest medical challenges in accepting Medicaid patients:
    1. Sicker/needier patients
        “It is so hard to find a dentist who will take Medicaid patients, that the patients are getting so sick that they have to be hospitalized by the time they come in. If there was better coverage and dentists weren’t so frustrated, Medicaid wouldn’t spend so much on dental hospitalizations.” (Bootheel/dentist/Takes Medicaid)

    Responding Dentists


    2. Non-compliant/undependable patients
        “The non-compliance of Medicaid patients. You are treating people with health conditions like high blood pressure or high cholesterol. They come in and then don’t do follow-ups or follow instructions I’ve given them. They are late or they don’t show up at all.” (Cape Girardeau/dentist/Does Not Take Medicaid)

    3. Treatment not covered under Medicaid
        “The fees paid aren’t conducive to practicing quality dentistry. I would have to use alternative methods, such as silver fillings instead of white or gold fillings.” (St. Louis/dentist/Does Not Take Medicaid)

    Additional Comments:
        “The main obstacle is low reimbursements. Medicaid patients get a lot less attention.” (St. Louis City/surgical oncologist/Takes Medicaid)

        “There should be better reimbursements for routine medical care. A lot of Medicaid people miss out on day-to-day care.” (Cape Girardeau/ER physician/Takes Medicaid)

        “Better reimbursement. I actually narrowed all Medicaid patients to kids under 12. They aren’t to blame for being in a dire situation.” (Springfield/dentist/Takes Medicaid)

        “They should require Medicaid patients to show up for appointments – so many missed appointments allowed, and then you are kicked out of the program.” (Cape Girardeau/allergist/Takes Medicaid)

        “Medicaid patients abuse the system. Reimbursements should be comparable to other insurance company reimbursements.” (Springfield/pediatrician/Takes Medicaid)

        “I think a co-pay would encourage many doctors. I’m in a rural clinic, so we don’t discriminate.” (Bootheel/family general practice/Takes Medicaid)

        “If they would start a co-pay, I might bend some.” (Cape Girardeau/ Does Not Take Medicaid)

        “If we obtained a co-pay and we had lower malpractice costs, we’d be encouraged.” (Springfield/family general practice/Takes Few Medicaid)

        “Mainly to see more restrictions about who is eligible. Also, that all physicians are treated equally when claims are paid is another incentive for doctors.” (Cape Girardeau/family general practice/Takes Few Medicaid)

        “When you’re a doctor in Medicaid, you don’t have a very good support network. For example, there’s no oral surgeons in the plan. So if I have a 16-year-old who needs wisdom teeth out or a difficult root canal, there were only two oral surgeons in the area that took Medicaid, and now they don’t.” (St. Louis City/dentist/Does Not Take Medicaid)

        “The big issue with the medical system is focus on education and preventative care. It’s harder to get funding for preventative than for

    Additional Comments:
        actual treatment after the fact. But that saves money on future, serious problems. Funders don’t see returns on preventative, and they should.” (Springfield/cardiovascular surgeon/Takes Few Medicaid)

        “Force private doctors to take more Medicaid patients. It is our duty to help and heal all sick people, no matter what their ability to pay. We are seeing more Medicaid patients than ever.” (St. Louis City/ neonatologist/Takes Medicaid)

        “I’d like to see Missouri ban the program. I’d rather see the Medicaid patients without the card that pays ten percent. They could pay ten percent directly.” (Cape Girardeau/ENT/Takes Medicaid)

        “If you want an upper-crust practice, it’s hard to combine that type of patient with Medicaid recipients.” (St. Louis City/dentist/Does Not Take Medicaid)

        “After 28 years of taking Medicaid patients, it was very hard to tell them I could no longer see them. I had to stop because of internet billing.” (Bootheel/dentist/Does Not Take Medicaid)

    v. conclusions


    Physicians and dentists interviewed believe the following:

    § The remuneration for Medicaid patients is below their office costs, and is significantly below remuneration for non-Medicaid patients;

    § Treating Medicaid patients takes more time and resources than treating non-Medicaid patients;
      § Medicaid patients are sicker and needier than other patients; and
        § Medicaid patients tend not to comply with instructions and prescription direction.


        There are additional factors that are mentioned less often than those listed above, but nonetheless, play a part in discouraging medical/dental practices from accepting Medicaid patients. These additional factors include a high no-show rate among Medicaid patients for appointments, a perceived tendency to sue, insistence upon service that is not reimbursable, and demands for non-covered prescriptions.

        Many Missouri physicians interviewed indicate they would be willing to accept more Medicaid patients if reimbursements were at least on par with Medicare or other insurance programs. There was a consensus among responding doctors that Medicaid patients are generally a more difficult, time-consuming, and expensive population for the physician/dentist to work with.

        Dentists are less likely to accept Medicaid patients than physicians. The chief reason, after inadequate reimbursement, is that many treatments are not covered by Medicaid. When specialist dentists need to be found to perform common procedures such as wisdom teeth removal or root canal work, it is often not possible to find any dental specialist to whom a general dentist can refer a Medicaid patient.

        While the problems are multiple, it is apparent that physicians will be more willing to accept Medicaid patients, in spite of the problems, if reimbursements are closer to the real costs and payments are timelier. Improvements in reimbursement amounts and timeliness of payment should be met with better response from physicians. As stated, physicians appear more willing to accept Medicaid patients if their financial loss could be minimized.

        The situation with dental care is more complex due to the inability to make common treatment procedures acceptable to Medicaid. Dentists feel that even if they were able to cope with the lack of reimbursement, their hands are tied because they are not allowed to conduct often-needed dental treatment, treatment that is considered normal among the non-Medicaid patient population.

        Physicians/dentists from all Missouri regions who were interviewed for this study gave consistent responses, and no regional or significant differences were noted in their opinions.




        vi. complete verbatim responses



        1. Do you take Medicaid patients at the present time? _____ Yes _____ No


        PHYSICIAN Respondents

        Response
        St. Louis City
        St.
        Louis County
        Cape Girar-deau
        Boot-heel
        Spring-field
        Total
        Takes Medicaid Patients
        3
        1
        5
        4
        5
        18
        Takes Few Medicaid Patients
        7
        3
        1
        1
        4
        16
        Does Not Take Medicaid Patients
        2
        2
        1
        0
        0
        5
        Total
        12
        6
        7
        5
        9
        39



        (IF YES: ASK) Approximately how many Medicaid patients do you see per week?

        ResponseSt. Louis CitySt. Louis CountyCape GirardeauBootheelSpringfieldTotal
        0
        1
        2
        1
        4
        1
        4
        1
        1
        6
        2
        1
        1
        1
        3
        3
        2
        1
        3
        5
        1
        1
        2
        10
        1
        1
        1
        3
        15
        1
        1
        1
        1
        4
        20
        1
        1
        1
        1
        4
        25
        1
        1
        30
        1
        1
        40
        1
        1
        60
        2
        1
        3
        90
        1
        1
        100
        1
        1
        1
        3
        12
        6
        7
        5
        9
        39

        1. Do you take Medicaid patients at the present time?



        DENTIST Respondents

        Response
        St. Louis City
        St.
        Louis County
        Cape Girar-deau
        Boot-heel
        Spring-field
        Total
        Takes Medicaid Patients
        0
        0
        0
        1
        1
        2
        Takes Few Medicaid Patients
        0
        0
        0
        0
        0
        0
        Does Not Take Medicaid Patients
        2
        2
        2
        1
        2
        9
        Total
        2
        2
        2
        2
        3
        11



        (IF YES: ASK) Approximately how many Medicaid patients do you see per week?

        ResponseSt. Louis CitySt. Louis CountyCape GirardeauBootheelSpringfieldTotal
        0
        2
        2
        2
        1
        2
        9
        10
        0
        0
        0
        0
        1
        1
        30
        0
        0
        0
        1
        0
        1
        Total
        2
        2
        2
        2
        3
        11



        1. What are the biggest challenges your practice faces in treating your average patient?

        treatment not covered/formulary

        Takes Medicaid Patients:
          “The formulary changes. I get a patient regulated on a drug and then the insurance company demands a generic or a less expensive drug.” (Bootheel/family general practice)

        Takes Few Medicaid Patients:
          “Formularies and approval of medication issues. Low reimbursements.” (St. Louis City/neurologist)
          “The insurance restrictions and prescription reimbursements for our patients.” (Springfield/family general practice)

        Does Not Take Medicaid Patients:
          “Making sure treatments are covered by insurance. Also, paperwork is too extensive.” (St. Louis County/urologist)

          “Mainly the biggest challenge is battles with insurance companies about prior authorization for testing. The formularies the insurance companies dictate may not be your choice.” (Cape Girardeau/family general practice)

          “If patients’ expenses aren’t totally covered by their insurance company, they are unhappy, and it’s difficult to convince them to do what is necessary.” (Springfield/ dentist)

        paperwork/obtaining information:
          Takes Medicaid Patients:

            “The paperwork is overwhelming and much too time consuming.” (Bootheel/ neurologist)
          Takes Few Medicaid Patients:
            “Timely access to information and medical records from other facilities.” (St. Louis City/radiation oncology)

          2. What are the biggest challenges your practice faces in treating your average patient?
            “Organizational challenges in the system – getting records, information, etcetera.” (St. Louis City/anesthesiology)
            “Administrative requirements from external organizations and accreditations. Getting records, etcetera.” (St. Louis County/OBGyn)


          cost of medications for patients

          Takes Medicaid patients:
            “The severity and complexity of the disease, and people who are unable to afford needed medications.” (Cape Girardeau/adult hospitalist)

            “The patients can’t afford the cost of medications and the co-pay is very high for medications prescribed.” (Cape Girardeau/allergist)

          Takes Few Medicaid Patients:
            “The inaccessiblity of medicines because of expense to the patient. Trying to jump through hoops to get medications covered by HMOs.” (St. Louis City/allergist)

            “The patients’ lack of ability to pay for the medications I’ve prescribed.” (Springfield/family general practice)

            “The cost of medicines for patients.” (Springfield/pulmonologist)


          Patient Compliance

          Takes Medicaid Patients:
            “Getting the patients to comply, getting them to take their medications. Many forget to take their medications or they don’t like the side effects or they can’t afford it, so in any event, the medication isn’t taken.” (St. Louis County/family general practice)
            “Compliance, preventive medicine visits, and getting children immunized. The parents don’t always do what we’ve suggested.” (Springfield/pediatrician)

          Takes Few Medicaid Patients:
            “In terms of medical patients, getting to show up and on time.” (St. Louis County/pain management)

          Does Not Take Medicaid Patients:
            “At one level, it’s patient education, compliance, getting them to accept treatment. At another level, it’s whether or not insurance will pay for the co-pay.” (St. Louis City/ neurologist)

            Patient compliance is the big challenge. (Cape Girardeau/dentist)


          low reimbursements

          Takes Medicaid Patients:
            “Frankly, the reimbursements. The feeling that the government has taken over and stolen my generosity. They should do away with the entire Medicaid program.” (Cape Girardeau/ENT)

            “I like to treat my patients the same, and try to give equal care even when I’m paid very little. The biggest challenge is getting reimbursed for the patients we take care of.” (Springfield/anesthesiologist)

          Takes Few Medicaid Patients:

            “Our reimbursements are down and it’s hard to break even.” (Bootheel/urologist)

          Does Not Take Medicaid Patients:
            “Reimbursements from insurance companies and Medicare have not kept up with cost-of-living increases.” (St. Louis City/dermatologist)


          workload/hours

          Takes Medicaid Patients:
            “The very long hours we doctors have to put in.” (Bootheel/pediatrician)
            “The time crunch in seeing all the patients that are scheduled.” (Springfield/ anesthesiologist)

            “Time constraints – trying to see so many patients. Trying to fit them all in.” (Springfield/pediatrician)

          Takes Few Medicaid Patients:
            “The number of patients seeking help. I have more patients than I can handle, and we have to double-book.” (St. Louis City/neurologist)
          Does Not Take Medicaid Patients:
            “Having enough time to see everybody and take care of their needs.” (St. Louis County/dentist)


          scheduling tests/facilities/follow-up care:

          Takes Medicaid Patients:
            “Getting the necessary studies scheduled and performed.” (St. Louis City/surgical oncology)

            “Arranging follow-up care. If patients don’t have insurance or are on Medicaid, it’s more difficult to get them seen after they leave us.” (Cape Girardeau/ER physician)

          Takes Few Medicaid Patients:
            “Access to operating room time.” (St. Louis County/general surgeon)


          cost to patient

          Takes Medicaid Patients:
            “Money is always an issue – that the patient has enough money to finish the treatment plan. Some people have other priorities besides dental care.” (Springfield/dentist)

          Does Not Take Medicaid Patients:
            “The patients have a hard time affording the services. The cost is very expensive for the average patient.” (St. Louis City/dentist)

            “Keeping costs down. My practice is blue collar, and many are facing hard times.” (Cape Giardeau/dentist)


          staffing

          Takes Medicaid Patients:
            “There are not enough adequate support personnel, and an inability to access appropriate health care support.” (St. Louis City/neonatologist)

            “Obtaining adequate, motivated personnel – people who are capable of being polite to patients and have adequate business skills.” (Bootheel/general surgeon)

          other

          Takes Medicaid Patients:

            “Developing relationships with patients who are under-privileged. Obtaining their trust. Getting them in for prenatal care and for follow-up. Getting them to trust the system.” (St. Louic City/neonatologist)

            “The need to manage their pre-existing diseases.” (Cape Girardeau/anesthesiologist)

            “Misinformation. Patients are misdiagnosed by their primary care doctors so often that the patients come here thinking they have sinus problems, and it isn’t.” (Springfield/ENT)

          Takes Few Medicaid Patients:

            “In general, seeing patients effectively, but thorougly.” (St. Louis City/pediatric opthamology)

            “Keeping up with evolving technology.” (St. Louis County/vascular surgeon)

            “Using antibiotics that will taste good or dissolvable tablets or a patch that children won’t be upset with.” (Cape Girardeau/pediatrician)

            “Patients are definitely sicker these days. They have more combined medical problems today, more interrelated medical problems. It’s more work and more effort is needed. There is better technology today, but it costs more to use that technology.” (Springfield/cardiovascular surgeon)

          Does Not Take Medicaid Patients:
            “The insurance companies expect patients to change doctors to comply with their plan, so there is a lack of continuity.” (St. Louis City/dentist)

            “Treating patients who have anxiety and mental problems.” (St. Louis County/dentist)
            “There are really no challenges.” (Springfield/dentist)

          3. What are the greatest business challenges faced by your practice?


          low reimbursements

          Takes Medicaid Patients:
            “I am not in private practice, but the problem as I understand it is keeping in the black. We see Medicaid patients and we give them what they need, and we need to be adequately reimbursed for it.” (St. Louis City/neonatologist)

            “I’m paid by the hospital, but I can see problems coming because of lack of reimbursement.” (Cape Girardeau/adult hospitalist)

            “Third party payers. We don’t make nearly as much as we did in the past.” (Cape Girardeau/allergist)
            “Trying to deal with the insurance companies and bargaining with them. We also have to bargain with the uninsured. I had a black patient who ran up a $55,000 bill in the hospital and who owed me $6,000. He filed for bankruptcy after we saved his life. We got nothing.” (Cape Girardeau/ENT)
            “A lot of pediatric patient cases are very complex, and yet we get paid very little for our efforts.” (Springfield/anesthesiologist)

          Takes Few Medicaid Patients:
            “Payor issues – getting reimbursed in a timely fashion and at appropriate rates.” (St. Louis City/pediatric opthamologist)

            “Getting reimbursed for my time.” (St. Louis City/neurologist)

            “Appropriate reimbursements.” (St. Louis City/allergist)

            “To get enough revenue from patients and providers. My revenues keep dropping as the insurance companies regularly delay payments and challenge my diagnostic procedures.” (St. Louis City/neurologist)
            “We do have challenges from some insurance companies, such as ones that are capitated and the HMOs.” (Springfield/family general practice)

            “Poor payment from patients on Medicaid. No other business problems.” (Springfield/pulmonologist)
          3. What are the greatest business challenges faced by your practice?

          Does Not Take Medicaid Patients:
            “Decreasing reimbursements and higher costs.” (St. Louis County/urologist)
            “Mainly, it’s poor reimbursements and the climbing expenses of running a practice.” (Cape Girardeau/family general practice)


          timely reimbursement

          Takes Medicaid Patients:
            “Reimbursement of funds.” (St. Louis City/surgical oncology)

          Takes Few Medicaid Patients:

            “Getting reimbursed for care.” (St. Louis City/anesthesiologist)
          Does Not Take Medicaid Patients:
            “Paying bills. I accept assignment, and have to depend on the insurance companies to pay me promptly. It’s become a balancing act between payments and expenses.” (St. Louis City/dentist)

          costs of doing business

          Takes Few Medicaid Patients:
            “Diminishing revenues and increasing fixed costs.” (St. Louis County/vascular surgeon)

            “Seeing enough patients to cover all the practice expenses which keep increasing.” (Cape Girardeau/pediatrician)
            “The financial balance of trying to maintain an up-to-date, state-of-the-art practice and still afford it, because patients are taking more time and effort.” (Springfield/ cardiovascular surgeon)
          Does Not Take Medicaid Patients:
            “I built a new office with new equipment and it was very costly. I’m $1 million dollars in debt.” (St. Louis City/dentist)


            “All the rising costs of lab fees, supplies, and utilities. We get many bankrupt patients. Dealing with insurance companies over the last few years, we get about 25 to 30 percent errors.” (Cape Girardeau/dentist)


          cost of malpractice insurance

          Takes Medicaid Patients:
            “The cost of malpractice insurance is ridiculous and the drug companies have pharmacy committees that try to dictate policy.” (St. Louis County/family general practice)
            “Our malpractice insuror went bankrupt. We found another and had an increase in premiums.” (Bootheel/pediatrician)

          Takes Few Medicaid Patients:
            “Malpractice insurance costs and issues.” (St. Louis County/general surgeon)

            “The office overhead, and the malpractice insurance cost. Missouri is better than it was with the new law passed, but not where it should be.” (Bootheel/urologist)

            “Malpractice costs are a concern because you can’t be without it. Also, providing services that are timely and affordable for our patients.” (Springfield/family general practice)

          collections

          Takes Medicaid Patients:
            “The rate of response for accounts receivable is poor. Difficulties in collecting is a major problem.” (Cape Girardeau/anesthesiologist)
            “The economics – collecting from all payers. The poor reimbursements for our services.” (Springfield/pediatrician)

            Medicaid

            Takes Medicaid Patients:

              “It’s the Medicaid patients. We have to have a limit on how many we will see a day. The reimbursements are 15 to 20 percent.” (Bootheel/neurologist)

              “Our hospital lost over $300,000 in revenue in just the cardiac division this past year. It is predominately Medicaid patients that we see. Our pay depends on certain criteria for the Medicaid and Medicare patients.” (Springfield/anesthesiologist)


            excessive paperwork

            Takes Medicaid Patients:
              “I have to work harder to make any money. The paperwork is excessive and I have to hire more people to handle it.” (Bootheel/family general practice)

            staffing

            Takes Medicaid Patients:
              “Sometimes collections staffing is difficult. I need friendly, well-trained, hardworking people.” (Springfield/dentist)


            Abuse of system/lawsuits

            Takes Medicaid Patients:
              “The malpractice situation. In southeast Missouri, people want to sue their doctors.” (Bootheel/pediatrician)

            other
              Takes Medicaid Patients:

                “Since I don’t deal with the business end, I don’t look at costs, but volume is a big issue. Having space and availability, and making room for all the babies we need to see.” (St. Louis City/neonatologist)
                “We don’t get feedback from the hospital on our billing. We don’t see the benefits, and I’m legally responsible.” (Cape Girardeau/ER physician)

                “I’m dependent on referrals, so it’s mainly acquiring new patients as a general surgeon.” (Bootheel/general surgeon)

                “My time management – trying to get everybody seen in the allotted time. Also, keeping patients happy while they wait. Reimbursement is a challenge. So many insurance companies have different pre-authorizations for surgery that we have hired one person just to handle that.” (Springfield/family general practice)

                “I’m a St. John’s Health System practitioner. They handle most of the business aspects.” (Springfield/pediatrician)

              Takes Few Medicaid Patients:
                “Acceptable contracting with the insurance companies.” (St. Louis County/pain management)

                “Recruitment of specialists for high-risk pregnancies, because they don’t want to come to St. Louis. Also, decreased reimbursement along with increased overhead. That affects patient time.” (St. Louis County/OBGyn)

              Does Not Take Medicaid Patients:
                “Trying to run an efficient and smooth practice. Finding and using a computer and effective database.” (St. Louis City/neurologist)

                “Competition from other dermatology practices as well as spas.” (St. Louis City/ dermatology)

                “Keeping the government out of my business.” (St. Louis County/dentist)

                “Converting my colleagues to know that mercury is bad for everybody.” (St. Louis County/dentist)

                “My practice has slowed down at the present time. I was swamped six months ago, but with the economy, people are more concerned with filling their gas tanks than with filling their teeth.” (Springfield/dentist)


              4. What are your greatest medical challenges?


              treating disease/conditions

              Takes Medicaid Patients:
                “The diagnosis of skin disorders is difficult at times.” (Cape Girardeau/allergist)
                “The very elderly group of patients with advanced disease processes.” (Cape Girardeau/anesthesiologist)

                “I can’t always operate on people who are too sick with chronic illnesses like diabetes. I define my limitations and send them to an internal medicine doctor or a family practitioner before I’ll chance an operation.” (Cape Girardeau/ENT)

                “Chronic cough. You can’t fix 25 percent of it. Cancer is another major challenge.” (Springfield/family general practice)

                “My cardiovascular patients usually come in here with congestive heart failure.” (Springfield/anesthesiologist)

                “With the aging population, there are more problems. People live longer and have more medical problems. They are sicker and have more complex diseases.” (Springfield/anesthesiologist)
              Takes Few Medicaid Patients:

                “Achieving the local goal – tumor control and preserving life. Curing cancer.” (St. Louis City/radiation oncology)

                “Sick patients that are getting sicker all the time.” (St. Louis City/anesthesiologist)

                “Limited available, effective treatment.” (St. Louis County/pain management)

                “Deciding which patients to operate on and which patient not to.” (St. Louis County/ general surgeon)
                “The geriatric patients who have multiple diagnoses.” (Springfield/family general practice)

                “Dealing with tobacco addictions.” (Springfield/pulmonologist)
              4. What are your greatest medical challenges?

              Does Not Take Medicaid Patients:
                “Severe lung disease is hard. Multiple surgeries, obstructions. Despite everyone’s best efforts, patients are sicker.” (St. Louis City/neurology)
                “Seeing people that are sicker than they used to be. It makes it harder to manage them.” (St. Louis County/urologist)
                “I treat a lot of older people who are on many medications. I’m concerned if they’ll have a reaction to the anesthetic or a reaction from the drugs.” (St. Louis City/dentist)

                “The potential for some patients to have an emergency while being treated, and a lot of my geriatric patients are on a lot of medications.” (St. Louis City/dentist)

                “People can have drug interactions and allergies.” (St. Louis County/dentist)

                “Habitational surgeries. Getting the profession aware that root canals are bad, and that habitations are dead areas of bone that need to be worked on – that they exist.” (St. Louis County/dentist)

                “Making sure my elderly patients are reporting all medicatons they take to my office. Many are seen by a family practitioner or a cardiologist. I need all medications reported from all sources.” (Cape Girardeau/dentist)

                “Patients with a long list of medications, which sometimes means we have to consult with their doctors. Many cardiologists and oncologists want their patients’ teeth and gums cleaned before surgery.” (Cape Girardeau/dentist)


              keeping up-to-date

              Takes Medicaid Patients:
                “Fighting disease and staying current with the latest treatments.” (St. Louis County/ family general practice)

              Takes Few Medicaid Patients:

                “Keeping up with changing technology. Also, getting patients to comply with instructions on care and follow-up.” (St. Louis County/vascular surgery)

                “Staying abreast clinically and keeping up with all of the latest medications and medical journals.” (Cape Girardeau/pediatrician)
                “Keeping up with the latest technology, and finding time to study and get trained in it.” (Bootheel/urologist)

                “Trying to assess the utility of new treatments, medications, and techniques – if and how they are appropriate for each patient. The expense of this is high. It’s a moral question, too. Does every patient deserve all these treatments despide costs?” (Springfield/cardiovascular surgeon)

              Does Not Take Medicaid Patients:
                “Keeping up with new medical information and technology.” (St. Louis City/ dermatologist)


              insurance/cost for patients

              Takes Medicaid Patients:
                “Children on ventilators – getting them the equipment they need, because many insurance companies are denying coverage for what my patients needs.” (St. Louis City/neonatologist)

                “The patients are upset with the cost they pay. Patients smoke and don’t control their cholesterol.” (Bootheel/neurologist)

              Takes Few Medicaid Patients:
                “The difficulty in getting medications approved for my patients.” (St. Louis City/ allergist)

                “Whether patients can afford treatment and lodging if they need to stay in town for a lengthy period of time.” (St. Louis City/radiation oncologist)

              Does Not Take Medicaid Patients:
                “Making sure patients have the health care they need, and some type of coverage for any major illness. There are a percentage of patients who aren’t compliant with medical treatment or delay it.” (Cape Girardeau/family general practice)
                “A number of patients aren’t covered by insurance and are challenged by the economy, so keeping patients motivated is a problem. We want them to seek care on a regular basis.” (Cape Girardeau/dentist)


                “Having patients who are willing to pay for higher-dollar services like crowns and bridges.” (Springfield/dentist)


              non-compliance/not dependable

              Takes Medicaid Patients:
                “Patients’ non-compliance. The sickest of the sick kind of patient who we often see on public aid, who doesn’t understand or ignores our orders because they just don’t get it.” (Cape Girardeau/adult hospitalist)

                “Patients’ compliance or lack of it. They either use too much medication or don’t finish the treatment.” (Bootheel/family general practice)

                “Parents don’t always realize that the children need to come in for regular visits, not just when they are sick.” (Springfield/pediatrician)

                “Patient compliance. Sometimes people with heart problems forget to pre-medicate.” (Springfield/dentist)

              Obtaining Timely Information

              Takes Medicaid Patients:
                “The data required for patients isn’t always available: dealing with hospitals where the nurses are unaware of what is happening, and the bottom line rules the hospitals, and where the patient’s interest isn’t always at heart.” (Bootheel/general surgeon)

              Takes Few Medicaid Patients:
                “Getting patient information in a timely fashion from outside sources. Medical errors in the health care system.” (St. Louis County/OBGyn)


              coordinating patient care

              Takes Medicaid Patients:

                “Coordinating patient care.” (St. Louis City/surgical oncology)


              Takes Few Medicaid Patients:
                “The problem is getting medical procedures done quickly and efficiently.” (St. Louis City/neurologist)

                “Formulary issues and pre-approval.” (St. Louis City/neurologist)


              other

              Takes Medicaid Patients:
                “Keeping up with the changing residents and fellows.” (St. Louis City/neonatologist)
                “Having enough time with patients so they understand what illness they have and what our treatment will be and why.” (Cape Girardeau/ER physician)

                “I’ve been in practice for 18 years, so there aren’t many challenges left anymore. With pediatrics, I guess behavioral challenges are the hardest – getting the children to cooperate and complete treatment.” (Springfield/pediatrician)
              Takes Few Medicaid Patients:
                “Making sure kids are served properly and referred for proper care.” (St. Louis City/ pediatric opthamologist)

                “Meeting patients’ expectations. Patients want a quick fix and they want to self-prescribe after seeing medications advertised on TV.” (Springfield/family general practice)

              Does Not Take Medicaid Patients:
                “Patients with psychological or neurological problems. They think something is wrong with their teeth and that they have a dental problem, when it isn’t that.” (Springfield/dentist)

                “I find no medical challenges – patients are very cooperative with treatment.” (Springfield/dentist)

              5. What are the greatest business challenges in accepting and treating patients who are on Medicaid?


              Low Reimbursements

              Takes Medicaid Patients:
                “Not being reimbursed for what we do. However, with Medicaid patients, we don’t have as many people telling us what we can and cannot do. It is sometimes easier to pre-certify these patients for things than with other insurance companies.” (St. Louis City/neonatologist)

                “Getting paid a proper amount so I can stay in business. The insurance companies don’t like to pay the doctors and the government is the worst offender. They don’t want to pay you at all.” (St. Louis County/family general practice)
                “The payment is almost zero. If you get ten percent, you are fortunate. You eat the bill and you are paying out-of-pocket. That’s why I left private practice!” (Cape Girardeau/adult hospitalist)

                “We don’t get paid much – just barely enough for overhead, and they break appointments or don’t show up for scheduled appointments.” (Cape Girardeau/allergist)
                “The money I lose on accepting straight Medicaid patients.” (Bootheel/family general practice)

                “The high medical cost of treating Medicaid patients. They demand a lot of service and want the most costly medicines. We are a rural health clinic, and we get a lot of patients losing their Medicaid because of the politics of balancing the budget in our state.” (Bootheel/pediatrician)

                “We can’t survive on the type of reimbursements we receive.” (Bootheel/neurologist)

                “The cost to the practice in accepting and treating Medicaid patients.” (Springfield/ family general practice)

                “The very poor reimbursements for our services. We tend to be more scrupulous in taking and treating these patients because we know our reimbursements will be much less. Also, I can’t prescribe the medications they need because Medicaid or the parents refuse to pay.” (Springfield/pediatrician)

                “The fact that I won’t probably be paid.” (Springfield/anesthesiologist)

              5. What are the greatest business challenges in accepting and treating Medicaid patients?
                “We have to accept all Medicaid patients at a teaching hospital. The reimbursements are very poor, so you work for close to nothing.” (Springfield/anesthesiologist)

                “Very poor reimbursement. This is the top challenge. Really, there’s no other than that.” (Springfield/pediatrician)

                “I’ve been a dentist for 25 years in rural Missouri. Reimbursements are so low.” (Bootheel/dentist)

                “The reimbursements are poor – about 50 to 60 percent lower than my customary fee.” (Springfield/dentist)

              Takes Few Medicaid Patients:

                “Losing money for every patient who walks through the door. Because the rate of reimbursement is so low, and the manhours it takes to get paid makes us lose money on each patient that we see.” (St. Louis City/pediatric opthamologist)

                “They do not pay enough to cover my costs. It takes an extraordinary amount of time to get paid – a lot more work to retrieve a very small amount of money.” (St. Louis County/general surgeon)

                “Because I have no choice of who I treat, because it’s based on who the surgeon operates on, I have to take whatever the insurance company reimburses me.” (St. Louis City/anesthesiologist)

                “It’s hard to afford seeing them because the reimbursement is so low.” (St. Louis County/OBGyn)

                “Getting paid essentially nothing, especially since it takes so long to see patients for my speciality.” (St. Louis City/neurologist)

                “The miserable coverage for appropriate medications in my specialty. My medical care group decided we couldn’t afford to accept Medicaid patients.” (St. Louis City/allergist)

                “We can’t breakeven because reimbursements are so low. When I see Medicaid patients, I can’t cover the overhead involved. Medicaid patients abuse the system because it’s free, so they come in more often with more demands.” (Bootheel/ urologist)

                “We couldn’t keep afloat as there are almost no reimbursements for these patients. My other patients subsidize the Medicaid patients.” (Springfield/family general practice)

                “The cost factor. Medicaid’s payments are so small that it doesn’t even cover the costs of seeing the patient.” (Springfield/family general practice)

                “It’s an economic problem for the medical provider. Reimbursements are so low.” (Springfield/cardiovascular surgeon)

                “The reimbursements are so low, it’s hardly worth my time.” (Springfield/ pulmonologist)

              Does Not Take Medicaid Patients:
                “I used to see patients on Medicaid and I was losing money, so I stopped.” (St. Louis City/dermatologist)

                “They tie your hands because of cost. I don’t do Medicaid for those reasons. I would have to use mercury fillings and I won’t do that. Medicaid only pays 20 percent of what it costs. I don’t know any dental office that can operate on that. If you could get it up to 70 percent reimbursement, I think that would be fair.” (St. Louis County/ dentist)

                “I can’t afford to accept Medicaid patients and stay in business. There is such a large discrepancy between normal fees and payments from Medicaid. It’s a lot of hassle to get reimbursed – so much paperwork is involved. I’d just as soon treat them for nothing and avoid Medicaid hassles.” (Cape Girardeau/dentist)

              timely reimbursements

              Takes Medicaid Patients:
                “Getting reimbursed.” (St. Louis City/surgical oncology)

              Does Not Take Medicaid Patients:
                “There are liability issues when you provide limited care. Also, it takes months to be paid. When I accepted Medicaid patients, I had problems with the system. Trying to collect co-payments from the patients is difficult.” (St. Louis City/dentist)

                “The slight payment they give you can arrive six or seven months later. It happened to me when I took Medicaid patients. It happened to me when I took Medicaid people. I am not paid enough to make it worthwhile, and Medicaid tells you what tests can and cannot be done.” (St. Louis County/dentist)


              Excessive Paperwork/Authorization Problems

              Takes Medicaid Patients:
                “The paperwork is excessive and requires more overhead in help and time.” (Cape Girardeau/anesthesiologist)

                “There is a lot of paperwork involved, and in the emergency room, it’s up to the doctors to do it. There is no office staff. For follow-up tests, we have to do a lot of paperwork. Pre-authorization paperwork is also something we must do.” (Cape Girardeau/ER physician)

                “I can’t prescribe without going through leaps or hoops. Some of it is socio-economic diseases, such as middle ear infections, because the parents smoke and there is poor hygiene.” (Springfield/family general practice)

              Takes Few Medicaid Patients:

                “Medicaid patients go to many different places, so retrieving their records is difficult. They enter the system late, so their disease is advanced.” (St. Louis County/OBGyn)

              Does Not Take Medicaid Patients:
                “Getting treatment approved, and for patients already on treatment, getting them re-approved. This means a lot of manhours getting approval, and this eats into revenues.” (St. Louis City/neurologist)

                “Getting authorization and getting paid. The forms and bureaucracy are excessive. It’s too burdensome on my staff and takes too much time. Medicaid is a difficult patient group, in general.” (St. Louis County/psychiatrist)

                “An unwieldy amount of paperwork and the small reimbursements aren’t worth it. I’d rather do charity work. The Medicaid pateints don’t show up, I’ve heard.” (Cape Girardeau/dentist)

                “You have to abide by government standards even though you may have your own plan of treatment.” (St. Louis City/dentist)


              Abuse of System/Lawsuits

              Takes Medicaid Patients:
                “My concern is Christ said it’s not the poor who will sue you. I challenge that. Times have changed. The poor are the first to sue and are abusing the system. The government should leave the poor to the church and the doctors. The Medicaid patients won’t pay you anything, and what the government pays is a fraction of what it costs you to see them. You give away your services.” (Cape Girardeau/ENT)

                “The medical/legal aspects of dealing with Medicaid patients. Medicaid patients are a more litigious group of people. I almost do volunteer work seeing them.” (Bootheel/ general surgeon)
              Takes Few Medicaid Patients:
                “The parents abuse the system because it is free. They go to the emergency room for a splinter or to my office for something that could have been a phone call.” (Cape Girardeau/pediatrician)
              Does Not Take Medicaid Patients:
                “They abuse the system. They expect something for nothing – society owes them something. They are demanding and expect specific medications that we can’t prescribe.” (Cape Girardeau/family general practice)


              no difference

              Takes Medicaid Patients:
                “There is no difference for me in treating my patients.” (St. Louis City/neonatologist)

              doesn’t know

              Does Not Take Medicaid Patients:
                “This isn’t applicable to me. I don’t take Medicaid patients.” (Springfield/dentist)

              6. What are the greatest medical challenges in accepting and treating patients who are on Medicaid?


              sicker/needier patients

              Takes Medicaid Patients:
                “Many or most are extremely ill, which increases your liability and the amount of resources you have to devote to them. They can’t afford the medications.” (Cape Girardeau/adult hospitalist)

                “I’m an allergist dealing with respiratory disease like asthma, and many of these patients continue to smoke cigarettes. Cleanliness is a big problem. They have more dust mites and bugs in their homes, and they suffer more than other patients because of it.” (Cape Girardeau/allergist)

                “They are obese and they have the highest percentage of smokers and drinkers. They load up the emergency rooms. We see these people who have abused themselves and we have to deal with their medical problems.” (Cape Girardeau/ENT)

                “Payments don’t cover our expenses because Medicaid patients need education on preventive medicine, such as cholesterol control and smoking. Their general health is poor.” (Bootheel/neurologist)

                “The complex medical history of this group, particularly the elderly.” (Springfield/ anesthesiologist)

                “With the aging population, there are more problems. People live longer and have more medical problems. They are sicker and have more complex diseases.” (Springfield/anesthesiologist)

                “Patients tend to be more ill than non-Medicaid patients. Also, compliance problems, such as not picking up the prescription, not finishing medications.” (Springfield/ pediatrician)

                “It is so hard to find a dentist who will take Medicaid patients, that the patients are getting so sick that they have to be hospitalized by the time they come in. If there was better coverage and dentists weren’t so frustrated, Medicaid wouldn’t spend so much on dental hospitalizations.” (Bootheel/dentist)

                “Meeting their needs. Sometimes they expect me to take care of them and they need other kinds of treatment – oral surgery, periodontal treatment, root canals.” (Springfield/dentist)
              6. What are the greatest medical challenges in accepting and treating Medicaid patients?

              Takes Few Medicaid Patients:
                “These patients don’t have the support systems like nutrition, and there are problems with the ability to follow them on treatment.” (St. Louis City/radiation oncologist)

                “Environmental control is important, and people can’t afford the air-conditioning and required pillow covers they need.” (St. Louis City/allergist)

                “Patients are not seeking out medical care before they get very sick, and not having resources available to them.” (St. Louis City/anesthesiologist)

                “Educating patients and encouraging compliance with treatment.” (St. Louis County/pain management)

                “Usually they are the most needy, and we work harder because of major medical problems, like a disabled child. Their expectations are too unreal medically, and they object if I prescribe a medication allowed by Medicaid and not one of their choice. They make appointments more often than necessary, and many like to hang around and talk to my staff about their problems.” (Cape Girardeau/pediatrician)

                “The education level of these patients – they don’t understand my instructions. Their lifestyle is extremely unhealthy. They smoke, drink and abuse drugs much more than the average patient. The family violence problem is another factor.” (Springfield/ family general practice)

              Does Not Take Medicaid Patients:
                “The people are often in poor health and don’t follow-up as they should. They are reluctant to make appointments. Many of the older patients don’t remember what medications they are on.” (St. Louis City/dentist)

                “You’re treating patients at the lower end of society, so the level of education about health is not that high. Their health is poor. You’re seeing a demographic that is sicker than the average population because their nutrition isn’t where it should be.” (St. Louis County/dentist)

                “Some patients are not clean and they are in poor health to begin with. They are unwilling to comply with instructions.” (Cape Girardeau/dentist)

                “Treating people with oral problems who smoke and drink and don’t take care of their health. Medicaid people are an unhealthy group of people. The office needs fumigating when some of them leave.” (Springfield/dentist)


              non-compliance/not dependable

              Takes Medicaid Patients:
                “Medicaid patients are the least compliant population of patients as far as follow-up, taking medications, and appointments.” (St. Louis City/neonatologist)

                “Follow-up and patient transporation is a problem with these patients.” (St. Louis City/surgical oncology)
                “That group of people is non-compliant with their prior medical treatments. They come in with uncontrolled hypertension and diabetes, and these difficulties require more care.” (Cape Girardeau/anesthesiologist)

                “Getting the Medicaid patient to comply with orders given to them.” (Bootheel/family general practice)

                “Medicaid patients are the least motivated to care for themselves. There is a higher incidence of drug use and more smoking and more alcohol consumption. They are a higher medical risk as they don’t take care of themselves and are eager to sue.” (Bootheel/general surgeon)

                “Medicaid patients are a lower IQ generally, and don’t understand my directions about follow-ups and complying with my treatment regimen.” (Springfield/ pediatrician)

              Takes Few Medicaid Patients:
                “The no-show rate is very high and wastes my valuable time. I’m overbooked, and having no-shows is a problem. I could have used the time for other patients still waiting for appointments. Low return and prescriptions are a problem with Medicaid patients, as well as transportation.” (St. Louis City/neurologist)
                “Patients who don’t adhere to follow-up and don’t comply with recommended treatment plans.” (St. Louis City/pediatric opthamologist)

                “Getting patients to show up on time and even to show up at all for their appointments.” (St. Louis County/pain management)

                “Having this population of patients comply with instructions for home health care and for follow-up.” (St. Louis County/vascular surgeon)
                “The lack of compliance. Many Medicaid patients don’t return when they are scheduled because they don’t have transportation. Their way of life is unhealthy – they smoke and drink.” (Springfield/family general practice)

                “Compliance by patients – being educated enough to care for themselves. They don’t see the connection between their bad health habits and their poor medical health.” (Springfield/cardiovascular surgeon)

                “Non-compliance. Patients don’t take their medications, they don’t quit smoking, they don’t follow the treatment plan.” (Springfield/pulmonologist)

              Does Not Take Medicaid Patients:
                “When I was seeing these patients, it was lack of follow-up on the patients’ part.” (St. Louis City/dermatologist)

                “The non-compliance of Medicaid patients. You are treating people with health conditions like high blood pressure or high cholesterol. They come in and then don’t do follow-ups or follow instructions that I’ve given them. They are late or they don’t show up at all.” (Cape Girardeau/dentist)

                “Medicaid patients don’t and won’t take any responsibility for work done. They aren’t dependable and don’t show up for appointments. I’ve worked at a free clinic, and they are undependable.” (Springfield/dentist)
                “There are more missed appointments with Medicaid patients. Getting them to follow-up on appointments, instructions, etcetera is a challenge.” (Bootheel/dentist)

              bad attitude

              Takes Medicaid Patients:
                “Medicaid patients don’t have respect for the free services and free medications they receive. Their perceptions and attitudes are bad.” (St. Louis County/family general practice)
                “These patients come in when it’s unnecessary for minor illnesses, and yet often seem sicker than other children. They are around a lot of smoking parents and the parents take drugs. There is also more child abuse with the Medicaid children.” (Bootheel/ pediatrician)



              Difficulty in Making Referrals

              Takes Few Medicaid Patients:
                “Getting other doctors to consult on a patient.” (St. Louis County/general surgeon)
                “The coordination of services and finding someone else who will see them.” (St. Louis City/neurologist)
                “Medicaid patients aren’t healthy and need more treatment than our average patient. We find it hard to refer them to specialists in big cities – they won’t accept them.” (Bootheel/urologist)
              Does Not Take Medicaid Patients:
                “Finding other clinicians willing to take and treat them.” (St. Louis County/ psychiatrist)


              Treatments not covered for certain services

              Takes Few Medicaid Patients:
                “Treatments not being covered, which would delay treatments.” (St. Louis City/ radiation oncology)

                “It is impossible to get post-procedure care. Medicaid does not pay for anything outside of the hospital. This is very challenging and makes it difficult to care for patients properly.” (St. Louis County/vascular surgeon)
              Does Not Take Medicaid Patients:
                “Medicaid won’t pay for circumcising, for instance, or for x-rays. It’s difficult treating and prescribing for them.” (Cape Girardeau/family general practice)

                “The fees paid aren’t conducive to practicing quality dentistry. I would have to use alternative methods, such as silver fillings instead of white or gold fillings. I’ve also heard there are a lot of no-shows, and your patients don’t want to be with them in the waiting room. Medicaid patients are of low caliber, so they usually don’t keep appointments and they don’t appreciate what is done for them. Their IQs are low.” (St. Louis City/dentist)

                “The fees paid are just a fraction of what normal insurance pays.” (Bootheel/dentist)

              no difference

              Takes Medicaid PAtients:
                “There is no difference for me in treating my patients.” (St. Louis City/neonatologist)


              doesn’t know

              Does Not Take Medicaid Patients:
                “This isn’t applicable to me. I don’t take Medicaid patients.” (Springfield/dentist)



              7. Was there ever a time when your practice did accept more Medicaid patients?


              physicians:


              Response
              St. Louis City
              St. Louis County
              Cape Girardeau
              Bootheel
              Springfield
              Total
              Yes
              4
              4
              4
              1
              3
              16
              No
              8
              2
              3
              4
              6
              23
              Total
              12
              6
              7
              5
              9
              39



              dentists:


              Response
              St. Louis City
              St. Louis County
              Cape Girardeau
              Bootheel
              Springfield
              Total
              Yes
              1
              1
              0
              2
              2
              6
              No
              1
              1
              2
              0
              1
              5
              Total
              2
              2
              2
              2
              3
              11



              (If YES, PROBE: What are the specific reasons why you no longer accept
              Medicaid patients?)


              low reimbursements
                Takes Medicaid Patients:

                  “I can’t stay in business with what they currently pay.” (St. Louis County/family general practice)

                  “The payments won’t let my practice survive financially.” (Bootheel/neurologist)

                  “I can’t afford to keep it up. I’m losing money.” (Bootheel/dentist)

                  “Sometimes they will overwhelm your practice and I can’t make a living accepting many. They don’t show up for appointments or value your services.” (Springfield/ dentist)
                7. Was there ever a time when you accepted more Medicaid patients?

                Takes Few Medicaid Patients:
                  “Simply said, I can’t afford Medicaid patients.” (St. Louis City/allergist)
                  “It’s financial. My office manager has said keep it less than ten percent or I’ll go bankrupt.” (Cape Girardeau/pediatrician)

                  “Reimbursement is so low now, and the paperwork is too lengthy.” (Springfield/ pulmonologist)

                  “They didn’t pay me enough. If it cost me $50 to do the work, they would pay me $30. You can’t pay overhead that way.” (St. Louis County/dentist)

                Does Not Take Medicaid Patients:
                  “Reimbursements were so low and patient follow-up was so poor. Between the two, I was losing money and it became impossible to continue to see these patients.” (St. Louis City/dermatologist)

                  “The reimbursement is low and the whole program is a big hassle.” (St. Louis County/psychiatrist)
                  “Because of poor reimbursements and the demands on my time. And also, because they are non-compliant patients.” (Cape Girardeau/family general practice)


                slow reimbursements

                Does Not Take Medicaid Patients:
                  “15 or 20 years ago, I took Medicaid patients, and it took months to be paid. I’d get an IOU from the state telling me I’d be paid, but they couldn’t pay at the time. I hear the program is even more restrictive now.” (St. Louis City/dentist)

                non-compliance/not dependable

                Takes Few Medicaid Patients:

                  “Because they are no-shows.” (St. Louis City/neurologist)

                  “Because they didn’t show up for appointments or they weren’t punctual.” (St. Louis County/pain management)

                  “The aggravation factor. Compliance is an issue. These patients won’t change their lifestyle. They don’t show up for appointments, and some have poor hygiene. You have to air the room when they leave.” (Springfield/family general practice)


                sicker/needier patients

                Takes Medicaid Patients:

                  “It’s harder to deal with Medicaid patients. I am compensated less, and I had to call the police once with a troubled patient.” (Cape Girardeau/allergist)
                Does Not Take Medicaid Patients:
                  “We were so busy with Medicaid patients and reimbursements were so low, it became necessary to stop seeing them.” (St. Louis County/urologist)

                paperwork/red tape

                Does Not Take Medicaid Patients:
                  “I bought this practice from another dentist, and he used to take Medicaid patients. He stopped because the paperwork became too difficult to handle. He had to pay someone to file all the paperwork for him.” (Springfield/dentist)

                abuse of system/lawsuits

                Takes Few Medicaid Patients:
                  “They are a higher risk group socially and medically. You are more likely to be involved in a lawsuit, and then your malpractice insurance is increased.” (Springfield/ family general practice)

                too many rules
                  Takes Medicaid Patients:
                    “There weren’t as many rules and regulations then. I can’t afford as many now.” (Cape Girardeau/ENT)


                  no internet access

                  Does Not Take Medicaid Patients:
                    “I took Medicaid patients for 28 years, but because of electronic billing, I can no longer accept Medicaid patients. My office doesn’t have internet access.” (Bootheel/ dentist)

                  8. How would the state Medicaid system have to change to make it worthwhile for your practice to accept more Medicaid patients?


                  increase reimbursements

                  Takes Medicaid Patients:
                    “It’s pretty straightforward – pay better.” (St. Louis City/neonatologist)

                    “Pay at Medicare rates.” (St. Louis City/surgical oncologist)

                    “They should increase the reimbursement rate and pre-screen the Medicaid patients at the primary level before reaching me.” (Cape Girardeau/anesthesiologist)
                    “The essential factor is the need to increase reimbursements.” (Bootheel/neurologist)

                    “The problem of reimbursements should be addressed if doctors are going to continue in practice. Reimburse for the Medicaid patients, the same as we receive for the Medicare patients.” (Bootheel/general surgeon)

                    “At our rural clinic, we are paid $50 a visit, but for other doctors in Missouri, they really need higher reimbursements.” (Bootheel/pediatrician)

                    “Reimbursements need to be improved to at least 50 percent.” (Springfield/family general practice)

                    “There are reimbursement issues. We get one-tenth of the normal insurance reimbursement. In anesthesia, there should be less stringent requirements. I can have four rooms for one doctor with normal insurance, and only two room for Medicaid.” (Springfield/anesthesiologist)

                    “If the Medicaid program would reimburse physicians even 50 percent, it would make it more worthwhile.” (Springfield/anesthesiologist)

                    “Improve reimbursement.” (Springfield/pediatrician)

                    “Revise the fee schedule. Medicaid is so inefficient in its administration.” (Bootheel/dentist)
                  8. How would the Medicaid system have to change for you to accept Medicaid patients?

                  Takes Few Medicaid Patients:

                    “Proper coverage for the physician’s services and providing transportation for these people. It shouldn’t be up to the hospital to transport them.” (St. Louis City/ neurologist)

                    “More reimbursement and decrease paperwork.” (St. Louis City/neurologist)

                    “Increase reimbursement.” (St. Louis City/anesthesiologist)
                    “Increase reimbursements and decrease bureaucratic policies of getting paid.” (St. Louis City/pediatric opthamologist)

                    “If the system would improve the reimbursements that one deserves for seeing these patients. My group would expect comparable payments to Medicare, if possible.” (St. Louis City/allergist)
                    “Reimbursement would have to be much better – comparable to other insurance companies. It currently isn’t close and it is very unfair for complicated surgeries such as the ones I perform.” (St. Louis County/general surgeon)
                    “Match Medicare reimbursements or the reimbursement schedules of other insurance companies.” (St. Louis County/OBGyn)
                    “Medicaid reimbursements should be comparable with Medicare. These patients flood the emergency rooms because doctors won’t accept them. They should raise reimbursements to 80 percent of the bill.” (Bootheel/urologist)

                    “They would have to reimburse doctors at the same level as private insurance or Medicare.” (Springfield/family general practice)

                    “Reimburse more and we would deal with the other problems. Pre-certifications for medications should be approved – it’s an unnecessary step to get approval.” (Springfield/family general practice)

                    “Don’t keep cutting reimbursements.” (Springfield/cardiovascular surgeon)

                    “Better reimbursement for charges is the only thing that will make it worthwhile.” (Springfield/pulmonologist)


                  Does Not Take Medicaid Patients:
                    “Reimbursements are completely ridiculous. Sleep studies are very expensive – upwards of $1,000. Medicaid reimburses somewhere between $55 and $200. (St. Louis City/neurologist)
                    “The reimbursement schedule would have to come up to par in order to make it worthwhile to see Medicaid patients. Not just to cover manhour costs to file claims, but to pay other personnel and take home money as well.” (St. Louis City/ dermatologist)

                    “Make reimbursements comparable to Medicare and other insurance companies.” (St. Louis County/urologist)

                    “They’d have to change the fee schedule. I’d have to be paid 80 to 90 percent of my fee.” (St. Louis City/dentist)

                    “They would have to compensate me – say 90 percent of my customary fee.” (Springfield/dentist)

                    “Pay better reimbursements and less paperwork.” (Springfield/dentist)

                  patient co-pay

                  Takes Medicaid Patients:
                    “Better compensation for the physicians. The patients need to share some responsibility by paying part of the fee. They tend to overuse the system because they get free care.” (Cape Girardeau/allergist)
                    “I feel if you make the families partially responsible for the payment, even if it’s only a $5 co-pay, it would give them some feeling of ownership.” (Springfield/ pediatrician)
                  Does Not Take Medicaid Patients:

                    “The simple solution would be if we see them only with a co-pay or not at all.” (Cape Girardeau/family general practice)


                  protection from lawsuits

                  Takes Medicaid Patients:
                    “Protect us from lawsuits. The Medicaid patient will sue us three to one. The poor sue us first.” (Cape Girardeau/ENT)
                    quicker reimbursement

                    Does Not Take Medicaid Patients:

                      “Better reimbursement or some sort of benefit, maybe getting payments more quickly.” (St. Louis County/psychiatrist)

                      “Timely reimbursement, enough reimbursement, and a lot less paperwork.” (Cape Girardeau/dentist)

                      “They would have to pay on time and pay what they owe. They would have to give me no more paperwork than what insurance companies demand.” (Cape Girardeau/dentist)

                    penalize no-shows

                    Takes Few Medicaid Patients:
                      “Start stipulating that after so many no-shows or tardies, patients lose coverage.” (St. Louis County/pain management)

                      “Higher reimbursements, of course, and penalizing the no-shows.” (Cape Girardeau/ pediatrician)

                    Does Not Take Medicaid Patients:
                      “I would need to be compensated for my work with a fair fee. No-shows would have to be penalized. Some dentists book 16 Medicaid patients for one to show up.” (St. Louis City/dentist)



                    allow necessary treatments

                    Does Not Take Medicaid Patients:
                      “Allow and approve necessary treatments and pay enough.” (St. Louis City/dentist)

                    allow paper claims

                    Does Not Take Medicaid Patients:
                      “Accept paper claim forms.” (Bootheel/dentist)

                    change punitive system

                    Does Not Take Medicaid Patients:

                      “Less red tape. They require filings, paperwork. You have to react when they say to. Also, if one thing goes wrong, you get the entire system down on your head. I’m talking remove your license, I’m talking possible jail terms. That scares a lot of doctors away from that. Why would I want to be hassled like that? For example, something could be mis-billed – not fraud, I don’t mean that, they deserve whatever they get – but just something mis-billed, you get the state on your back. It’s a different level of scrutiny, and I don’t mind scrutiny, but I’m only getting 20 percent on my dollar for production, that costs me money to do that.” (St. Louis County/ dentist)


                    better screening

                    Takes Medicaid Patients:
                      “We need to screen applicants better so you don’t have people who can’t afford to pay the doctor. The Division of Family Services needs to work on it.” (Bootheel/ family general practice)

                      “Better screening procedures for people to be let into the program. They must make certain the need is really there. Some of the Medicaid patients abuse the system.” (Springfield/dentist)



                    other

                    Takes Medicaid Patients:
                      “The politicians are unfair to the doctors and are un-American. Their policy belongs in Cuba or North Korea. They must let patients know how much the doctor actually receives on the explanation of benefits.” (St. Louis County/family general practice)

                      “This is not applicable to me. The hospital accepts all at this time.” (Cape Girardeau/adult hospitalist)

                      “It would be helpful for emergency room doctors to know if we are treating Medicaid patients. Laws need to be changed so we would know where to refer them for follow-up testing.” (Cape Girardeau/ER physician)
                      “It has improved because of electronic billing, but it’s hard to find out if patients are eligible for dental work. What is category G? I can’t keep seeing Medicaid patients because I’m losing money. It’s just not worthwhile for me, and that’s unfortunate.” (Bootheel/dentist)
                    Takes Few Medicaid Patients:
                      “Not running out of money before year-end.” (St. Louis City/radiation oncologist)

                    9. As you think back over this interview, is there anything else you can honestly say could be done that would encourage your practice to accept more Medicaid patients?


                    increase reimbursments

                    Takes Medicaid Patients:
                      “The main obstacle is low reimbursements. Medicaid patients get a lot less attention.” (St. Louis City/surgical oncologist)

                      “Up the ante. I get about 20 percent on my Medicaid patients, if I’m lucky.” (St. Louis County/family general practice)

                      “If I were in private practice again, I would accept more Medicaid patients only if reimbursement is similar to Medicare.” (Cape Girardeau/adult hospitalist)

                      “There should be better reimbursements for routine medical care. A lot of Medicaid people miss out on day-to-day care.” (Cape Girardeau/ER physician)
                      “The main issue is we lose money taking them. It should be equal to Medicare reimbursements – they are 60 percent.” (Bootheel/neurologist)
                      “It’s all a matter of financial return.” (Bootheel/general surgeon)

                      “It’s strictly a reimbursement problem. For the past ten years, Medicaid has given the exact same reimbursement for the EPSDT exam. I generally do not accept Medicaid patients, but I get unassigned Medicaid babies through St. John’s emergency room.” (Springfield/pediatrician)

                      “Better reimbursement. I actually narrowed all Medicaid patients to kids under 12. They aren’t to blame for being in a dire situation.” (Springfield/dentist)

                    Takes Few Medicaid Patients:
                      “They need to reimburse at a rate that gives the general idea of solvency.” (St. Louis City/radiation oncologist)
                    Does Not Take Medicaid Patients:
                      “At this stage in my practice, there’s nothing they could do, unless they paid enough and on time, and they eliminated a lot of the paperwork.” (Cape Girardeau/dentist)



                    less paperwork

                    Takes Medicaid Patients:
                      “Less paperwork – streamline the process.” (Cape Girardeau/anesthesiologist)
                    Takes Few Medicaid Patients:
                      “Streamline the paperwork.” (Springfield/family general practice)
                    Does Not Take Medicaid Patients:
                      “I’d want efficiency in paying claims and claims paid in a timely manner.” (Springfield/dentist)

                    fix no-show/abuse of system

                    Takes Medicaid Patients:
                      “If Medicaid could do some kind of incentive program for patients compliance.” (St. Louis City/neonatologist)
                      “They should require Medicaid patients to show up for appointments – so many missed appointments allowed, and then you are kicked out of the program.” (Cape Girardeau/allergist)
                      “Medicaid patients abuse the system. Reimbursements should be comparable to other insurance company reimbursements.” (Springfield/pediatrician)


                    institute patient co-pay

                    Takes Medicaid Patients:
                      “I think a co-pay would encourage many doctors. I’m in a rural clinic, so we don’t discriminate.” (Bootheel/family general practice)

                      “If they insisted on some type of co-pay, we’d be encouraged.” (Springfield/ anesthesiologist)

                    Takes Few Medicaid Patients:
                      “If they would start a co-pay, I might bend some.” (Cape Girardeau/pediatrician)

                      “Make a rule that Medicaid patients must pay a co-pay.” (Bootheel/urologist)

                      “If we obtained a co-pay and we had lower malpractice costs, we’d be encouraged.” (Springfield/family general practice)


                    single-payer system

                    Takes Few Medicaid Patients:
                      “I am a believer in a single-payer system. Overhead would be two percent, not 25 percent, for that type of government program.” (St. Louis City/allergist)


                    restrict eligiblity

                    Does Not Take Medicaid Patients:
                      “Mainly to see more restrictions about who is eligible. Also, that all physicians are treated equally when claims are paid is another incentive for doctors.” (Cape Girardeau/family general practice)


                    Fix referral problem

                    Does Not Take Medicaid Patients:
                      “When you’re a doctor in Medicaid, you don’t have a very good support network. For example, there’s no oral surgeons in the plan. So if I have a 16-year-old who needs wisdom teeth out or a difficult root canal, there were only two oral surgeons in the area that took Medicaid, and now they don’t. It’s a matter of being paid for services rendered. The state of Missouri is having financial difficulties, so I doubt they could pay more.” (St. Louis City/dentist)

                    focus on education/preventative care:

                    Takes Few Medicaid Patients:
                      “The big issue with the medical system is focus on education and preventative care. It’s harder to get funding for preventative than for actual treatment after the fact. But that saves money on future, serious problems. Funders don’t see returns on preventative, and they should.” (Springfield/cardiovascular sugeon)

                    require/convince providers to provide service

                    Takes Medicaid Patients:
                      “Force private doctors to take more Medicaid patients. It is our duty to help and heal all sick people, no matter what their ability is to pay. We are seeing more Medicaid patients than ever.” (St. Louis City/neonatologist)

                    ban program

                    Takes Medicaid Patients:

                      “I’d like to see Missouri ban the program. I’d rather see the Medicaid patients without the card that pays ten percent. They could pay the ten percent directly.” (Cape Girardeau/ENT)

                    other

                    Takes Medicaid Patients:
                      “I don’t turn people away.” (Bootheel/pediatrician)

                      “We have no restrictions. Gov. Blunt has restricted durable goods like hearing aids for the deaf and CPAP for people when they have sleep apnea.” (Springfield/family general practice)
                    Takes Few Medicaid Patients:

                      “Patients have to be very sick before they can get the proper help.” (St. Louis County/ vascular surgeon)

                      “Dual-eligible people are confusing – those who are eligible for Medicare and Medicaid. We need help on that.” (St. Louis City/neurologist)

                      “There is an uneven distribution of hospitals that take Medicaid patients.” (St. Louis City/anesthesiologist)

                    Does Not Take Medicaid Patients:
                      “Get sleep studies reimbursed. People need these as sleep deprivation is very dangerous.” (St. Louis City/neurologist)
                      “If you want an upper-crust practice, it’s hard to combine that type of patient with Medicaid recipients.” (St. Louis City/dentist)

                      “I do charity work now as it is. But the charity work I do, the patients get better and they do what I suggest. (St. Louis County/dentist)

                      “After 28 years of taking Medicaid patients, it was very hard to tell them I could no longer see them. I had to stop because of internet billing.” (Bootheel/dentist)








                    Appendix A –
                    Letter sent to physicians/dentists






                      November 2, 2005

                      Dear Dr,

                      Washington University Center for Health Policy is conducting a confidential telephone interview study with a randomly selected group of Missouri physicians and dentists. Your confidential opinions will be very helpful as we make recommendations concerning patient and medical issues important to all of us. We have asked The Research & Planning Group, an independent research firm, to speak with you to hear your ideas so we can learn more about issues that face all Missouri physicians and dentists.

                      Your time is valuable and so is your opinion. For participating in this 15-20 minute interview, you will be offered a cash honorarium of $150, payable to yourself or a charity of your choice.

                      We hope that you will participate when a research professional from The Research & Planning Group calls; we value your opinion. Your opinions will be kept in confidence and grouped with other physicians' and dentists' responses. No individual's identity will be revealed.

                      from The Research & Planning Group to arrange a time for a confidential interview with you. If you wish to schedule an interview before being called, please call The Research & Planning Group at (800) 318-7094 ext. 100, ask for Debra, and she will arrange a convenient time for a telephone interview with you.

                      Thank you for your cooperation. Your input will be valuable in helping us better understand the opinions and needs of Missouri physicians and dentists.

                      Sincerely,

                      Washington University Center for Health Policy

                      William A. Peck, M.D. Director


                      Washington University School in St. Louis, Campus Box 1133, One Brookings Drive, St. Louis, Missouri 63130-4899 (314) 935-9l08, Fax: (3l4) 935-9199









                      Appendix B –
                      discussion guide










                      Physician/General Dentist Medicaid Study
                      Interview Guide – FINAL
                      11-8-05
                      Study No. 14357
                      Washington University Center for Health Policy


                      83
                      the research & planning group
                      Interviewer:_____________________________________________________________

                      Physician/Dentist Interviewed:_____________________________________________

                      Physician Type: General Dentist _______Family/General Practice ______

                      Internal Medicine _____ OB/Gyn _______ General Surgery ______
                      Other ________________________

                      Phone: _____________________________

                      Date: ________________________ Length of interview: _____________________

                      Missouri Area:
                      ____ St. Louis CITY ____ St. Louis COUNTY _____ Cape Girardeau

                      ____ Springfield _____ Poplar Bluff/Bootheel


                      Introduction:

                      Hello, Dr._________________. My name is ___________________. I am calling from The Research & Planning Group on behalf of the Washington University Center for Health Policy. You recently received a letter from Dr. William Peck, Director of the Center for Health Policy, regarding statewide, confidential interviews we are conducting with physicians and dentists. We are interested in hearing your frank opinions about your concerns with accepting Medicaid patients. The interview is strictly confidential. We will use your words, but not your name in our report. The $150 honoraria are for your participation in this study, because we recognize that your time is very valuable and we appreciate your time.

                      This interview will take about 15 minutes to complete. May we begin?

                      1. Do you take Medicaid patients at the present time? _____ Yes _____ No
                      (IF YES: ASK) Approximately how many Medicaid patients do you see per week?


                      2. What are the biggest challenges your practice faces in treating your average patient?












                      3. What are the greatest business challenges faced by your practice?












                      4. What are your greatest medical challenges?















                      5. What are the greatest business challenges in accepting and treating patients who are on Medicaid?



















                      6. What are the greatest medical challenges in accepting and treating patients who are on Medicaid?












                      7. Was there ever a time when your practice did accept more Medicaid patients?

                      _____NO

                      _____YES

                      (If YES, PROBE: What are the specific reasons why you no longer accept
                      Medicaid patients?)








                      8. How would the state Medicaid system have to change to make it worthwhile for your practice to accept more Medicaid patients?













                      We have just about completed our interview. Thank you for your frank opinions.

                      9. As you think back over this interview, is there anything else you can honestly say could be done that would encourage your practice to accept more Medicaid patients?








                      This concludes our interview. Please tell me how and where your thank you courtesy check should be sent:

                      Name:_______________________________________________________________

                      Address:________________________________________________________________

                      ________________________________________________________________________

                      On behalf of Washington University Center for Health Policy, we thank you for your participation in this state-wide study.