Medicaid for everyone but where is the supply?

By | January 29, 2009, 9:00am PST

Summary: The House-passed stimulus bill puts nearly $100 billion into Medicaid, mainly to cover the newly-unemployed regardless of what jobs they lose. But where will the supply come to meet this demand?

The House-passed stimulus bill puts nearly $100 billion into Medicaid, mainly to cover the newly-unemployed regardless of what jobs they lose. (The map illustrates how states already differ in Medicaid eligibility. From Workworld.)

But where will the supply come to meet this demand?

It’s not coming from technology, although there is $20-23 billion in the plan for health IT.

IT requires users, in this case primary care doctors, and their supply is going down. With 70% of our physicians in specialties, and most medical students prepared to follow, it’s hard to see where these new users will come from.

Doctors are already complaining as states freeze reimbursement levels under Medicaid. Patients covered by the program complain they can’t get care. Yet the proposal would place millions more people into the program, without addressing supply.

Unlike the federal Medicare program, Medicaid is run by states, so there is minimal standardization. As many as half the states are cutting Medicaid rolls to make ends meet. Others are looking at controversial tax increases.

This lack of standardization is likely to extend now to health IT, since states would control the health IT dollars under the plan.

Add this to increases in SCHIP coverage, now going through Congress, and you have a situation where unprecedented demand comes up against falling supply in a market with no price elasticity.

The economists’ answer to that is called shortage. That’s what happened when Massachusetts mandated health insurance a few years ago. Demand rose, supply fell. Ready buyers appeared with no sellers.

It’s very possible that the Obama Administration is depending on these consequences to pass more far-reaching health reform. Demand that can’t be supplied will pressure politicians to accept major changes to the system.

Those changes will have to include a plan to increase the number of primary care doctors, and reduce our reliance on specialties, or the market will not clear.

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Disclosure

Dana Blankenhorn

Dana Blankenhorn has been a journalist, writer and part-time futurist for over 30 years. At the present moment I run only a personal blog in addition to my ZDNet open source blog. DanaBlankenhorn.Com has the subtitle The War Against Oil. In the past I have used it to write about political history, e-commerce, personal matters, some ideas related to open source, and The World of Always On, which is the idea of using sensors, motes and RFID to turn WiFi links into platforms for applications which live in the air. My IRA account at Schwab holds a few tech shares, most notably some Intel and Applied Materials, but there are no open source companies in it. I don’t even own any CBS stock.

Biography

Dana Blankenhorn

Dana Blankenhorn has been a business journalist since 1978, and has covered technology since 1982. He launched the Interactive Age Daily, the first daily coverage of the Internet to launch with a magazine, in September 1994.
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Underwriting
DanaBlankenhorn 1st Feb 2009
There are two types of underwriting that go on in health insurance. There's the choice of risks -- the "pre-existing condition" mess. And there's the choice of how much to coverage, with many, many people exceeding their coverage limits and finding that, when they really need it, they don't have any coverage at all.

Government by its nature tends to eliminate these risks. Either government mandates on insurance carriers, as in the Netherlands, or government-run care, as in Canada. The horrors tend to go away in both those systems, which cost 50% less -- on average -- than what we have here.

Supporters of the current system don't talk about the horrors because these are questions they can't really answer. So they create other horrors -- waiting lists for specialist care, etc. -- horrors which are real in other systems but horrors citizens subject to them accept, for the most part, as part of the deal.
0 Votes
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Just worthless paper!
Christian_<>< 29th Jan 2009
Just crank up the printing presses, the economy would collapse in seconds if all of the loans were called from China and other countries.

No money is backed by the Gold standard so it is only valued at whoever is pulling the strings behind the shadow Gov...
0 Votes
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My PCP is a specialists
Ken_z 29th Jan 2009
He's an internist and a cardiologist.

That is a good combination for what used
to be a GP.

In terms of GPs, I think it's a difficult area
for young docs to go into. A young
person spends a fortune getting through
pre-med, then another fortune for a
medical education. Now there are the
poor years of a residency, followed by a
lifetime of having the government and
insurance companies reducing the fees
you can charge.

Supply may need to change its definition.
The Physician Assistant program
developed from a desire to maintain the
talent young men gained as combat
medics during Vietnam.

Then there is the Nurse Practitioner.
Minimum experience with additional
training and they are ready to go.

Before we get too excited about
delegating some of the work a GP does,
give a few minutes of thought to the GP.
That has to be one of the most boring
jobs in medicine. It's like the dentist
spending all day filling cavities. How long
before the poor guy (or gal) goes nuts.

If you want adequate, good quality supply
I believe you need to have delegation, with
physician oversight. It provides the care
you need and, as a nice little benefit,
reduces costs.
0 Votes
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Are you finally getting it???
techboy_z 29th Jan 2009
"Doctors are already complaining as states freeze reimbursement levels under Medicaid. Patients covered by the program complain they can?t get care. Yet the proposal would place millions more people into the program, without addressing supply."

"Add this to increases in SCHIP coverage, now going through Congress, and you have a situation where unprecedented demand comes up against falling supply in a market with no price elasticity."

This is just a small foretaste of what government reaching further into healthcare will do for it.

Obama may try to use the resulting problems as political capital for "Universal Healthcare", but people are rapidly waking up to the scam of socialism as they find out what "stimulus" means...U.H. will be no different: more government control in our lives and businesses, higher taxes, and less return for them...all while paying for those who don't work for what they receive.
0 Votes
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RomneyCare is the model
DanaBlankenhorn 30th Jan 2009
It's a bipartisan desire to have more preventive
care, because that cuts costs. Socialism has
nothing to do with it.

But as we saw in Massaachusetts this creates
demand without guaranteeing supply, and
something must be done to raise supply.

The idea of using more nurse practitioners and
physicians' assistants is one option.
0 Votes
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Lower Quality
brucelund 30th Jan 2009
Nurse practitioners and PAs make more mistakes - using more of them will lower cost AND quality - you often still get what you pay for. Canada sees this in spades. Have a routine problem - pregnancy w/o complications - and UH is great because there are no money issues and the care system does not have to do much. Get a hard or unique problem and you will be wishing for the bad old system if you are around to wish....
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Don't tell my wife
Ken_z 30th Jan 2009
When undergoing chemo she had her port inserted by
a PA and the same PA took it out when she was done
with the chemo.

Why use a PA? The oncologist recommended him -
and said he did the best jobs simply because he did the
procedure far more often than the doctors. Experience
is rather nice it comes to procedures.,

Then there was the fact that the procedure as done in
an area of the hospital designed for these types of
procedures and there was extensive backup steps away
if there was a problem.

It was also cheaper, but that didn't matter with
insurance covering the procedure.

Use of a PA or NP needs to be defined, with training to
ensure that the person is actually qualified. You can
limit areas where a well trained, intelligent individual
can provide care and you'll generally end up with equal
or better care.
0 Votes
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Absolutely agreed
DanaBlankenhorn 30th Jan 2009
Data-based medicine and systemization of
procedures allow people trained mainly in those
procedures (along with exception handling) to do
a lot more of the heavy lifting in our medical
system.

I just wish I could find a PA who could take a
blood pressure reading manually....
0 Votes
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You Canadian?
DanaBlankenhorn 30th Jan 2009
I know of no survey from Canada where Canadians
say they would willingly trade their system for
that of the U.S.

And I happen to think the Canadian system is
rather extreme, because it tries too hard to
limit private medicine and private insurance.
These are good safety values which allow those
who can afford better care to get it, and not
burden the public system.

Ouillet oui!
0 Votes
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your politics blind you...
kckn4fun 30th Jan 2009
...to the solution.

UH can work, as long as ALL doctors are required to service uniform cross sections, e.g., you want to work with private insurance and make more money?

Well, first you need to spend 50% of your time with govt covered insurance.

Doctors and ANYONE who argue against it are simply protecting income, and that is one of the root problems in healthcare today: greed.
0 Votes
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As a specialist (Urologist) and participant in the NY Medicaid system, I think people should first learn what the ridiculous fee structure is for Medicaid patients before they comment on "doctor greed". A comprehensive Consultation (30-45 min) is reimbursed at $25. Follow up visits $7. Medicare comparable fees are ~$250 and ~$60. Surgical reimbursements are ever worse averaging ~10 percent of Medicare fees. Medicare fees are ~50 percent or less of usual and customary fees. (Chevy charges $95/hr and $145/hr for electrical).Liability risks are higher with Medicaid patients because of poor compliance and follow up. Current malpractice cost is ~$62,000 per year. (Neurosurgeons pay ~$300,000 per year). Current Medicaid reimbursement is far less than what it costs the doctor to treat the patient. The vast number of doctors do not participate in Medicaid for that reason and I will be dropping the program. I have not even discussed the scam with phony Medicaid ID's, multiple different names, including other people's children on your plan etc. I am also required by hospital policy to treat patients in the emergency room, (when I am on call) regardless of their ability to pay. This includes surgery. This is usually done with no reimbursement. Unfortunately I am still liable. Unless reimbursement rates are reasonable and fair doctors will simply refuse to participate in the program and you will have clinic style medicine. Force doctors to participate and many will retire. You will have rationing of care as the wait to see doctors increases. The quality of care will drop dramatically as you will be seeing mainly "physician extenders" who are less qualified, and have less training and experience than the physicians.
For your information, physician Medicare fees were set by the government in 1984 and have not kept up with the inflation rate. In many years we had either no increase or a cut in fees.
Be careful what you wish for because you might get it.

UroDoc
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You sound like a labor organizer
DanaBlankenhorn 30th Jan 2009
Medical associations are starting to become more
like labor unions, and it's a trend I frankly
applaud.

Let's have some honest and fair negotiations on
these points.
0 Votes
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I don't think most doctors are greedy...
DanaBlankenhorn 30th Jan 2009
I think it has more to do with prerogatives and
power than money.

Most doctors want mostly to be left alone to
practice medicine as they see fit.

But that world doesn't exist. Reminds me of a
"Scrubs" episode with Dick Van Dyke as a doctor
who wasn't up on the latest procedures. The head
of the hospital canned him. "Why do you think I
spend weekends at seminars learning the latest
procedures? For my health?"

I'm sure it will be on a cable channel near you
soon.
0 Votes
+ -
Dr.s have been screwed for years
Ken_z 30th Jan 2009
Around a quarter of a century ago my wife (a
physical therapist) was talking to a bone doc
she had known for years - before she started
working with special need kids. He had quit
taking Medicare patients because of the cuts in
fees paid. Figured that with the increase in
paperwork, coupled with the cut in fees he was
making a loss. His solution? Forget Medicare
and, when he was needed on a case, do it for
free.

I'm on Medicare now and have no complaints
compared to what I had as a one man company.
Talk about scams and rip offs - a $1,200+ a
month for more limitations than you can count.
When my wife came down with acute leukemia
we got $100,000 + dumped on us by the
insurance company and we're dumping the
company on the state insurance commission.
Medicare is a DREAM for us when compared to
what we had.

You might be better off with your policy -
especially if you're under a nice corporate policy
and your company is one of the few that isn't
laying off employees. 100,000+ this week
alone,

Getting laid off? Something like 90% of
employees laid off can't afford COBRA medical
coverage.

Unless you are wealthy you probably will be
wishing for universal care if you get hit with a
serious medical condition, or find that you no
longer have employee supported health care.

The wisest thing younger people can do today
is to start thinking about universal care, talk
about directions it should take and how private
gap coverage can be profitable for the
insurance companies as well as protective for
you.
0 Votes
+ -
Underwriting
DanaBlankenhorn 1st Feb 2009
There are two types of underwriting that go on in health insurance. There's the choice of risks -- the "pre-existing condition" mess. And there's the choice of how much to coverage, with many, many people exceeding their coverage limits and finding that, when they really need it, they don't have any coverage at all.

Government by its nature tends to eliminate these risks. Either government mandates on insurance carriers, as in the Netherlands, or government-run care, as in Canada. The horrors tend to go away in both those systems, which cost 50% less -- on average -- than what we have here.

Supporters of the current system don't talk about the horrors because these are questions they can't really answer. So they create other horrors -- waiting lists for specialist care, etc. -- horrors which are real in other systems but horrors citizens subject to them accept, for the most part, as part of the deal.
0 Votes
+ -
Dana Blankenhorn is absolutely correct on the question of supply, and, as UH becomes implemented, that is one factor the govt will use as an excuse to increase PCPs and decrease the number of specialists just as it did in Canada and Europe. We will also be much more likely to be seen by nurse practitioners and physicians assistants because the govt can pay them less per patient. Because there will be a shortage of specialists there will be waiting lists - especially critical as our population ages. People who favor UH should ask why it is that so many people(who can afford it) come from Canada and other developed countries to the USA when they need surgery. Ask also why those countries still have long waiting periods even to see a PCP, and why hospital emergency rooms are still packed every night. AND, people should be recognizing that UH is going to cost billions more than our govt tells us. Keep in mind what has happened with the bailout.
0 Votes
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70-30
DanaBlankenhorn 1st Feb 2009
That's the current US ratio between specialists and generalists.

I personally have no argument with doctors opting out of a system they don't like and only seeing "paying" patients. But the number of such "paying patients" is limited.

I also agree that more of us are going to be seen by PAs and NPs -- and I suspect we'll find a way to turn chiropractors and others into health coaches as well, because we're going to need a ton of them.

I'm just skeptical that, once our system becomes like others in the industrial world, we're going to get all nostalgic for the way it was -- the way it currently is. Canadians aren't, and Europeans aren't either. Some do want reforms on the margins, and even if those systems choose not to reform we have medical tourism -- which can deliver high quality at much lower prices than here -- to provide the specialist supply Classicride wants.

So I agree with the premises, but disagree on the consequences.

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