A medical school classmate (actually one year behind me), Larry Casalino, MD, PhD, a well-known health services researcher at Weill Cornell Medical College, has written a Perspective in the November 7, 2013 issue of the New England Journal of Medicine (Professionalism and Caring for Medicaid Patients – The 5% Commitment?”).  This commentary is sure to make some docs madder than stink.  Although, I thought he wrote it in a “fair and balanced way.”

He points out that more than one fifth of the US population is insured via Medicaid – a number that will expand greatly when the ACA is fully implemented. But 30% of office based physicians do not accept new Medicaid patients. In fact, he points out that the higher paid specialties and physicians in higher-income areas are even less likely to accept Medicaid patients.

Yes, it is true that Medicaid reimbursement rates are dismally low. Larry points out that his practice lost money on most MediCal (California’s version of Medicaid) patients. And these patients were complicated and often required more time than non-Medicaid patients because of behavioral health problems and transportation issues and social services needs.

Many of the physicians that refuse to accept Medicaid are handsomely reimbursed:

  • According to the Medscape Compensation Report, the mean income of Orthopedic Surgeons in 2012 was >$400,000, but 40% of orthopedic practices do not accept new Medicaid patients
  • Dermatologists’ mean income was >$300,000 yet 45% of them do not accept new Medicaid patients
  • Despite a high prevalence of mental health disorders amongst Medicaid recipients, 56% of psychiatrists do not accept them – their mean income, by the way, is only $186,000


A medical professional argument

Larry makes the argument that medical professionalism – a commitment to putting patients’ interests first – should lead to a consideration of caring for a “reasonable number” of Medicaid patients. He suggests 5%.  That, he says, translates into office-based physicians seeing approximately one Medicaid patient per day. For surgeons, it means operating on one Medicaid patient every 1-2 weeks.

He points out that spreading the care of Medicaid patients across a larger number of physicians would be a “service to a physician’s colleagues as well as to patients.”  ERs could decompress and referrals to specialists would be easier to arrange.

I know there are legitimate and, in some cases, compelling counter-arguments. Some docs have huge medical school loans to pay off, others are in relatively low-paying specialities.  But the question remains. What should be the commitment of medical professionals, relatively privileged in our society compared to others, to ensure that the most vulnerable amongst us has access to timely care in reasonable settings (e.g., office vs ER)?  It is a question we had better grapple with as millions more people become insured via the Medicaid program.

Leave me your comments, suggestions.  How can we carry on this conversation?


  1. Hi, I’m on Medicare. Let me tell you how a $200 medical condition is costing my health plan over $10,000.

    Many doctors in this area do not accept medicare patients-I said, Medicare-not Medicaid. I belong to a plan that has hospitals, 3, cancer clinics and the MD Anderson oncology radiology clinic. It has it’s ERs and Urgent Cares. But it can take months to get into a specialist, if that specialist accepts Seniors on their plan.

    Perhaps this reality is why this is one of the states that refused to expand Medicare. I don’t know about now, but their was a group of doctors that did surgeries on their own dime, and the hospitals cooperated, for the working poor. I don’t think that the hospitalists would allow this to happen anymore.

    On the current standards, what’s going on now, and projections about ACA, I don’t see medical care getting better.

    Shortage of doctors, lack of accessibility of doctors by patients, and the strangulation of medical care through regulation and laws by the FDA, DEA, state regs for Medicaid, and most of all, the policing of private insurance and health systems.

    I won’t go into the details, but I was hospitalized for an infection. I was released, although I, the nurses, and one of the doctors protested. It’s speculation that one more IV bag of Augmentin could have killed the infection. To add insult to injury, I was released without any antibiotics-and it was Friday night. My PCP had recommended that Augmentin be prescribed, and the hospitalist didn’t know how to read an EHR.

    I’ll stop here with the note that something that should have been resolved while I was in the hospital for about $200; could have been cured afterwards for $200, wasn’t. I did go to my PCP-got a shot in the rear-and horse pills-but he wouldn’t do any follow-up-as that should cure this. From May to October, I had constant fever, boils, sore throat, urinary problems, so many aches and pains, fatigue, sleeping for about 12 hours a day, etc. In July I found an old Urgent care doctor that ran a strep test-it was hot. The antibiotics didn’t kill the infection.

    It took until October to get a change of primary care physicians. A cardiologist cut through the red tape to save my life. The new PCP ran a strep test. I still had strep. I don’t have strep now. My son went to the VA to make sure that I wasn’t getting it from him. My grandson doesn’t have health care. I paid for his visit and test.

    I’m sick and tired of hearing that people like me don’t have skin it-My PCP co-pays are $5. Yeah- I don’t have skin in it. I’m paying with my body–and I wonder how many doctors that wouldn’t run a strep or blood test thought that I was annoying, because I didn’t have skin in “IT” and I didn’t have anything to do but bother them. I was told at the hospital that I was old and didn’t know what was going on, later I was told that I now have chronic conditions and “WE Talked about that”

    Everytime, I hear the smug comment about patients with low co-pays, subsidies, etc. Just want to run up costs, because they don’t have any skin in the game-I just want to throw up-that’s just an emotional response to the term so I won’t contact any medical staff about that.

    You guys really know how to tun up the bills. I’ll give you a clue—CAT and PET scans, MRIs and other forms of imaging do not show infections raging through the body. As the cardiologist said-somehow I dodged the bullet. I am still so weak.


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