State’s low reimbursement rates for Medicaid put young patients at risk

Dec. 02--Kadence Sek was born three weeks premature with blood clots in her brain and holes in her heart.

"We almost lost her," said her mother, Cassie Sek.

Kadence is now 17 months old. Brain damage to her cerebellum means that her motor skills aren't as developed as they should be. Kadence doesn't have the sensation of hunger, and she doesn't fully understand eating -- she is fed five times a day through a gastrointestinal tube for now. She's about a year behind schedule when it comes to eating, and she's about two to three months behind schedule when it comes to walking and speech.

Cassie Sek, her husband, Isaac Sek, and her 10-year-old sister, Miah, have high hopes for Kadence.

Kadence does speech therapy, and a therapist visits her home to help teach her to eat. She also does physical therapy for walking. The Seks have seen progress in their daughter. In the beginning, they couldn't leave medical appointments without crying or being frustrated. Now they are watching Kadence pull herself up, stand for seconds by herself and even take some steps.

"It's so exciting," Cassie Sek said. "It makes everything worth it because we've been through so much with her. I've seen her ups and I've seen her downs."

Kadence is one of 57,138 kids in Clark County who are on Apple Health, Washington's version of Medicaid, according to the latest Washington State Health Care Authority statistics. Her family has Molina Healthcare, one of the three care plans in Clark County the Washington State Health Care Authority contracts with to manage Medicaid.

Kadence's primary physician, Dr. Tsering Lhewa, at the Child & Adolescent Clinic, serves as the home base of medical care for the Seks, helping them coordinate care with "all of the -ology" specialists Kadence needs, as Cassie Sek joked.

But low reimbursement rates for treating Medicaid patients in Washington make the Seks a success story, not the standard of care for everyone. Because of low Medicaid reimbursement rates, clinics across the state are decreasing or ceasing care for Medicaid patients. Some have even had to close.

Barriers to care

The low reimbursement rates are causing health care access problems for adults and the nearly 50 percent of children in Washington who are on Medicaid, a similar percentage to Clark County. Apple Health has more than doubled its child participants statewide since 2008, and Clark County has added more than 30,000 kids in the same time frame.

This week, a Georgetown University report announced the number of uninsured children in the U.S. increased for the first time in nearly a decade, with most of those children residing in states that haven't expanded Medicaid after the passage of the Affordable Care Act. Apple Health has provided a different result for Washington -- expansion of health insurance for kids.

But since many of those children can't find a doctor, or they have to travel for care, their insurance is less effective and useful. It's what Sarah Rafton, the executive director for the Washington Chapter American Academy of Pediatrics, calls "a hollow promise."

In 2014, the Vancouver Clinic stopped accepting new Medicaid clients, citing a lack of financial sustainability. Now the Child & Adolescent Clinic and Sea Mar are all that's left for primary pediatric Medicaid care in Clark County. Medicaid reimburses only two-thirds of what Medicare covers, and Medicare rates are considered "the floor" to cover a doctor's costs, Rafton explained.

"This isn't about doctors who are making a lot of money or want to make a lot of money," Rafton said. "We see clinics breaking down. A system is breaking down."

This year the Legislature approved a 9.5 percent rate increase across the board for pediatric primary and specialty care. But state Rep. Monica Stonier, D-Vancouver, said even greater rates are needed to provide relief for struggling clinics and to open access for Medicaid patients.

Last session Stonier introduced a bill aimed at raising the reimbursement rates for treating children and pregnant mothers. The bill got a hearing, but died in the Appropriations Committee. This session, she's introducing a similar bill, but expanded in scope.

This session's bill, which she refers to as "the Medicaid parity bill," calls for $80 million in state funding to raise Medicaid reimbursement rates for primary care providers to the same level as Medicare rates, both for adults and children. About $30 million of the funding would be directed to pediatrics.

"So many of our kids in Washington state actually do have coverage from Apple Health, but don't necessarily have access to medical services because the doctors in their area are not taking Medicaid, and the reimbursements are so low," Stonier said.

Stonier said she's proud of how the issue has received bipartisan support, specifically in Clark County. State Rep. Paul Harris, R-Vancouver, co-sponsored the bill last session.

"There's lots of people on Medicaid who can't get in or have issues finding a primary care physician that will take Medicaid," Harris said. "If we can get the reimbursement rates up, it will open up access for them."

Searching for a solution

Legislators knew in 2008 that Medicaid reimbursement rates would need to increase. But in 2009, when the economic downturn hit, the state was unable to grant the increases, Rafton explained. In 2013 and 2014, the federal government provided funding to make up the reimbursement gap between Medicaid and Medicare for states.

After that federal funding ended, some states decided to use their own money to keep those higher reimbursement rates. Washington opted against that route, and Medicaid reimbursement rates in the state have mostly stayed the same since then, Rafton said.

That means some clinics have capped the number of Medicaid patients they'll see or eliminated taking Medicaid patients for fear of losing so much money that it significantly alters the way they can provide care, or will force them to close. When a clinic closes in an area, patients have to travel further for care.

And in more impoverished areas, where medical care is generally needed more, clinics are financially hit harder because a lot of patients are on Medicaid. Clinics that rely on Medicaid also can't pay their doctors as much, recruit doctors as easily or expand their staffs.

"If half your potential patients are on Medicaid, it becomes difficult to be sustain your practice," Rafton said.

This is the start of a snowball effect. Instead of visiting lower-cost primary care physicians, Medicaid patients rely on the emergency room or urgent care centers, where they'll encounter pricier treatment.

"With adequate reimbursement for pediatricians, we can reduce downstream high-cost hospital and emergency room visits," Lhewa said. "It's having all these widespread effects, societal costs and complications."

The funding is essential for children because good pediatric care can change the trajectory of a child's life, Rafton and Lhewa explained.

"We can find the problem early and prevent all these medical complications," Lhewa said.

Rafton also explained that children are relatively inexpensive to treat. According to the American Academy of Pediatrics, children make up 43 percent of all Medicaid enrollees, but only account for 19 percent of Medicaid spending.

In Washington, children make up around 65 percent of the Medicaid population, and on average their health care costs $2,539 per year per child.

"The cost to do that is not very high, but the benefit is very high," Lhewa said. "I just worry: What would happen to these thousands of kids if we weren't here?"

Even though increased reimbursement rates will come with a price tag in the tens of millions of dollars, Harris and Stonier believe it's the best financial approach in the long run. They both expect Stonier's bill to get a better reception in the upcoming session.

"Folks that are generally reluctant are legislators that just can't be convinced that we will have the revenue to invest," Stonier said. "The challenge I see is that if we don't find the revenue, and we don't invest in making sure that people have quality access to health care all across the state, then we're going to continue to pay for it many times over."

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