Medicaid patients have trouble finding specialists [Ocala Star-Banner, Fla.]

Oct. 21--Thomas Walker is 59 years old but looks older.

He has lost 60 pounds, because he can't tolerate the smell of food, since suffering a stroke in the spring.

"I have to spit it out because I'll throw up if I don't," he said. "There was two weeks when I lived on nothing but lemons and limes."

And his face goes blank as he searches for words he used to know before the stroke. He sometimes pauses in mid-sentence as if waiting for someone to remind him what he was talking about.

"I can't walk right. I can't have a conversation ... without forgetting the words," he said at his doctor's office. "I want help. It's frustrating not finding it."

There are doctors who can help, but Walker can't pay for it out of his meager $698-a-month disability check, and many of the specialists he needs don't take Medicaid.

"When we call a neurologist's office, they say, 'We don't take Medicaid,'?" Walker said. "We've been trying for months ... but it's always the same answer."

Walker said he's telephoned Medicaid offices in Tallahassee and gets the names and telephone numbers of specialists, but being on the list doesn't guarantee that a doctor will see him. He and his caretaker have contacted nearly 10 doctors specializing in stroke and neurological problems, but there were no takers.

His desire to keep trying is plummeting like his weight.

"I'm so tired of it. Not being able to find a doctor for this stroke isn't right," Walker said.

It's a challenge faced by Medicaid patients across Florida and the United States.

Only 59 percent of Florida doctors were accepting new Medicaid patients in 2011, according to the National Ambulatory Medical Care Survey Electronic Medical Records Supplement.

Nationally, the average was nearly 70 percent.

When the patient has private insurance or Medicare, which is government-funded health care for the elderly, that all changes.

More than 80 percent of doctors nationally were willing to take on new patients if they had private insurance, the study showed. The study did not differentiate between general practitioners and specialists.

More than 64,000 people in Marion County rely on Medicaid to pay their medical bills, according to Florida'sAgency for Health Care Administration.

In Florida, 18 percent of Florida's nearly 19 million residents receive Medicaid benefits.

Florida'sMedicaid rolls could grow by 1.5 million people if the Affordable Care Act remains in place and Florida accepts new federal guidelines to offer more people Medicaid.

"It's a struggle ... finding specialists (for Heart of Florida patients)," Heart of Florida chief executive Kerrie Jones Clark said. "It's a huge struggle."

In many cases the patients end up in emergency rooms or back at Heart of Florida, she said, unable to find the specialized care they need.

"It's one of the challenges that is being debated on the national platform but affecting us right here in Marion County," she said.

Many medical experts say the primary reason behind the specialists' reluctance to accept new Medicaid patients comes down to money.

Medicaid pays primary care doctors in the United States just 66 cents for every dollar that Medicare pays for identical procedures. For all services -- primary care and specialty care -- it's 72 cents, according to a 2009 study by the Urban Institute in partnership with the Kaiser Family Foundation'sCommission on Medicaid and the Uninsured and the California HealthCare Foundation.

In Florida, that primary Medicaid reimbursement drops to 55 cents on the dollar compared with Medicare. For all specialty services, Medicaid in Florida pays 63 cents on the dollar compared to Medicare.

Clark said she's not surprised money is a factor.

"What they (specialists) do is very expensive. They have to know they're going to get paid," she said.

Internist Dr. Melvin Seek said Medicaid patients eventually are seen by the specialists they need but sometimes too late to make a difference.

Seek estimates that about one in four Medicaid patients won't get the kind of specialized care they need when they need it.

He said his group of doctors sees Medicaid patients once a month at the Department of Health.

Seek said the growing unwillingness of many specialist doctors to accept Medicaid patients is generally based on three issues: money, time and potential lawsuits.

When given the choice between treating potential patients with Medicare or private insurance and treating those with Medicaid, financial pressure will push many doctors to treat patients who pay more.

"Money will win," he said.

Seek said he doesn't even bother submitting Medicaid bills because the low reimbursement rate doesn't warrant the office time and expense.

"It's also a generational thing," he said.

Younger doctors don't want to work the same long hours that their predecessors did, Seek said, and adding Medicaid patients to their rolls only has them working longer.

Medicaid patients also are more likely to sue if a procedure goes wrong or a diagnosis is missed, he said. They're also more likely to miss appointments, which translates to wasted time in the doctor's office.

Part of the solution is holding specialists to the "standard of the community" and encouraging doctors to accept poor patients, Seek said.

He said he also believes in educating patients about bad behavior that contributes to poor health and teaching them to take better care of themselves.

Dr. Scott Rivkees, pediatrics chairman at the University of Florida College of Medicine, also isn't surprised that many physicians are unwilling to accept Medicaid.

"It's my personal belief every doctor should share ... in (accepting Medicaid) patients. But that's not the way health care is set up right now," Rivkees said. "There are financial pressures that are in play in the marketplace."

The doctors' costs are rising while Medicaid isn't keeping up, he said.

Last month, 41-year-old April learned she had cervical cancer. April did not want her last name used for this story.

She is on Medicaid, lives with her sister and doesn't drive a car. She doesn't want her sister inconvenienced any more than she already is by asking her to drive her out of Ocala for medical care.

She called area surgeons asking if they accepted Medicaid patients.

"There just weren't any doctors here taking you ... but I don't want to have to leave town for a doctor," she said.

Her sister said she can't afford to miss work to drive April from one doctor to another, or worse yet, to specialists outside the Ocala area.

April's family doctor finally found her a doctor at Moffitt Cancer Center in Tampa that would accept her Medicaid.

Florida'sAgency for Healthcare Administration, which oversees the state's Medicaid program, said it is limited in its ability to provide specialists to Medicaid recipients.

"For people who rely on Medicaid, finding an available specialist is challenging," AHCA spokeswoman Shelisha Coleman told the Star-Banner in an email. "It is also important to understand that within the fee-for-service (FFS) Medicaid system the state can enroll Medicaid providers but has no authority to require enrolled providers to accept a certain number of Medicaid clients or to accept new Medicaid clients."

The ACHA email went on to say its staff continues to help Medicaid clients navigate the health care system and find the doctors they need.

AHCA said no one was available to be interviewed for this story.

Dr. Stephen Fisher, president of the Marion County Medical Society said the problem of Medicaid patients finding local doctors to take them "will grow as big as Medicaid grows."

"The issue is reimbursement," he said.

Fisher, a primary care doctor, said when specialists don't want Medicaid patients, the problem also trickles down to general practitioners.

"But we (general practitioners) still have a responsibility ... toward the patient," he said. (Without finding specialized care) I feel as if I've left the patient down."

Asked when he last accepted a new Medicaid patient, Fisher said "probably within the last year," and that it usually occurs only when one is strongly recommended to him. "It's almost always a child," he said.

But considering the potential problems and lack of reimbursement when it comes to Medicaid patients, "with what we've learned, it's better not to get involved."

Contact Fred Hiers at 867-4157 or fred.hiers@starbanner.com.

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