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Working for Tips

March 30, 2015

New York Medicaid officials are doing an “experiment” that should strike fear, anger, and outrage in the hearts of doctors who take care of medicare patients in New York (NY has the highest Medicaid budget of any state).

As any doctor who has a high volume of Medicaid patients knows, medicaid pays practically nothing.  Doctors who take Medicaid usually have to carry a bigger patient load to survive.  Medicaid patients are often sicker than the general population, with complicated diseases that are compounded by their environments.  They seek treatment in emergency rooms more often than other populations, have less access to healthy lifestyle choices, and live in more dangerous neighborhoods.

Visits to hospitals and emergency rooms are expensive (unlike doctor visits that are reimbursed for pennies on the dollar), and Medicaid officials want to decrease costs.  They’ve decided that if doctors worked harder, people would be healthier.  To make them work harder, they’ve decided to link their pay to hard work.  So if patients are healthier, that means the doctor is working harder and thus deserves monetary compensation for his efforts.  If the patients are sicker, the doctor is ineffective and does not deserve to be so rewarded.

NY medicare is suggesting that the doctors, many minority, who work with the poor, also many minority, should join together into Accountable Care Organizations that, in effect, give bonuses to doctors whose patients are healthier.  Here is how Anemona Hartocollis of the New York Times explains this awesome idea: (

Medicaid officials hope to inspire these providers to work together and take a more active role in looking after their patients’ health, rather than simply waiting for them to show up when ill. The hope is that if they can do a better job of getting patients to, for example, quit smoking or manage their diabetes doctors could reduce costly visits to hospitals and their emergency rooms.

For each group the state will set goals for a range of measures, such as how well the group manages diabetes cases — based on those patients’ eyesight, cholesterol readings, kidney function and other tests — and whether it can reduce preventable hospital admissions, such as those created by poor follow-up care. A group can get a bonus each year by making progress toward its goals.

In the future, if the experiment works, providers may be paid solely based on outcomes rather than volume of services, with better-performing groups earning more than those whose patients are in worse shape.

New York is spending $1 billion a year for five years on this experiment. $5 billion.  To save money.

Look, people.  Doctors who take care of Medicaid patients are not sitting around twiddling their thumbs waiting for someone to come in with a disease.  They are doing their professional best to take care of the people who come to see them.  Let’s take a look at a composite person who might seek the doctor’s care:

This patient, unlike many of this doctor’s patients, has a job.  It is minimum wage, but there are plenty of people out there who would be glad to take the patient’s job if, for instance, they had to be absent in order to go to the doctor.  The patient probably has to take the whole day off because public transportation is slow, and the doctor has long wait times because his patient load is so big and his patients have so many problems.  The patient will probably have gone to an emergency room for his/her care a number of times because the ER is open 24 hours and he/she doesn’t have to ask the boss for time off.  He/she might only be able to get to a doctor during the day on the weekends because it’s too dangerous in the neighborhood to be going out at night.  The patient finally gets in to see the doctor, having made an appointment and managed to show up for it.  The doctor sees that her problem list includes diabetes, high cholesterol, and emphysema.  He checks on the dose of her diabetes drug and decides to change to a different drug.  He suggests that she/he try to eat a little better and smoke a little less.  He tells the patient to follow-up with him in a week to see if the new diabetes drug is working.  The patient goes to the pharmacy but is told the new medication requires pre-approval.  The patient doesn’t know what to do about this and so leaves empty-handed.  The following week the babysitter doesn’t show.  He/she now misses the follow-up appointment and now also doesn’t have a job.  So the patient goes to smoke a cigarette.

But, according to New York’s medicaid officials, this patient is doing poorly because the doctor isn’t working hard enough.

How ’bout using some of that $1 billion a year to pay doctors a reasonable amount so they have a lighter patient load?  How about financing weekend or evening office hours?  How about providing free transportation to doctor visits?  How about providing home visits or work visits from doctors or nurse practitioners so that patients get their follow-up care?  How about using all that money to improve living conditions, invest more in local schools, subsidize healthy food, provide high-quality child care, raise the minimum wage, and create job opportunities?  Because these things are what improves patient’s health.  Not tipping the doctor.


From → Healthcare

  1. thetinfoilhatsociety permalink

    How about making formularies illegal? Denying low income patients access to certain medications, not even necessarily the most expensive ones, is just wrong. And pre-auths can take months to go through, as I know from experience.

    How about sending letters to patients telling them if they have COPD and they DON’T quit smoking that they will not be eligible for higher tier medications to alleviate their symptoms? Britain is already doing that with type II diabetics; they are not eligible for medications like victoza if they haven’t lost weight or controlled their blood sugars for ‘x’ amount of time with blood tests to back it up.

    I agree that not being able to get to the doctor is a huge problem. I also agree that this is a stupid idea, it takes two to tango and if the patient is not going to be an equal partner in the decision making it’s never going to work.

    Your example of the the smoker is exactly what I mean. If you have money for cigarettes you have money for healthier food. If patients don’t take responsibility for their choices it’s not the provider’s fault and the provider isn’t the one who should be penalized.

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