See Medicaid patients without going broke

August 23, 1999

This pediatrician's winwin partnership with his state bureaucracy gives indigent children a medical homeand the practice a profit.

See Medicaid patients without going broke

This pediatrician's win-win partnership with his statebureaucracy gives indigent children a medical home-- and the practice aprofit.

The author (above) is able to provide regular care to Ca Vaugio Butlerand Sophia Bayne, thanks to a public-private partnership.

Sheila was one of the scrawniest babies I'd ever seen. No matter howmuch her mom tried to feed her, she wasn't gaining enough weight. Sheilahad Prader-Willi syndrome, a genetic disorder that leaves children thinas a rail when they're infants, but often obese by the time they're 6.

Sheila would require a lot of care. A few years back, her case mighthave strained our practice. She's on Medicaid, and traditionally the program--withits time-consuming, high-risk patients--hasn't been a break-even deal forphysicians. Accept too many Medicaid patients, and you can go broke.

Here in South Carolina, however, the state Department of Health and EnvironmentalControl has ad-dressed the problem. A creative partnership with DHEC allowsdoctors like me to see patients like Sheila without absorbing a financialdrubbing. A DHEC nurse/case-manager who works out of my office referredSheila to a nutritionist, who followed with home visits and later ordereda special weight-building additive for Sheila's baby formula. A nurse practitioner,also assigned to my practice by DHEC, gives Sheila her immunizations andEPSDT screens.

Thanks to this team approach, Sheila is thriving now. Other indigentchildren get the care they need, too.

I had long been skeptical of public health workers, particularly the9-to-5 doctors. But my attitude started to change in 1989 when physicianshere in Easley faced a crisis.

South Carolina had just expanded its Medi-caid program, making more newbornseligible for coverage. At the same time, however, an ob/gyn residency programin neighboring Greenville County stopped accepting all but the highest-riskpregnant Medicaid patients from here in Pickens County. So these women wouldbe giving birth at our local hospital, Palmetto Baptist Medical Center.We anticipated a flood of new patients. The immediate question was, whowould see them?

The state and our local medical community cobbled together a partialsolution: The local DHEC office would provide prenatal care, while ob/gynsand some FPs took turns delivering babies.

The bigger question was, who would be the infants' regular doctors oncethey left the hospital? My two partners and I--the only pediatricians inPickens County with privileges at Palmetto Baptist--typically saw newbornsat the hospital and discharged them. But then they had nowhere to go. Localphysicians weren't accepting new Medicaid children, other than the seriouslyill or injured.

Medicaid paid so poorly that my practice usually didn't bother to fileany claims. But if we tried to stack the new Medicaid children on top ofour existing practice, we'd take an economic hit. Worse, we'd also risklosing some of our private-pay patients, who might chafe at the idea ofbelonging to an unofficial "Medicaid clinic." Other local primarycare doctors had the same worries.

But our consciences wouldn't allow us to remain indifferent to thesechildren. We've seen the way inadequate medical care affects the poor: Thesick simply get sicker.

Desperate for help, one of my partners and I approached public healthphysician Ronald D. Rolett, director of the district DHEC office. What abouta DHEC clinic for these children? That would take doctors like me off thehook. Ron said state money was scarce, and that such a clinic would takeseveral years of planning and grant writing.

But I found that Ron cares about people as much as we Main Street doctorsdo. The chief difference is that we treat one patient at a time, while Rontries to keep the entire community healthy.

Even though a new DHEC clinic wasn't feasible, Ron had no intention ofwalking away. He wanted to help solve the problem of free-floating Medicaidpatients. Our solution was simplicity itself: We'd convince every primarycare doctor in the county to make room for a fair share of Medicaid newborns,to be assigned by the local health department. Each kid would have a "medicalhome."

The doctors agreed to the plan, especially after a prominent FP signaledhis willingness to go along. Nobody wanted to be a Medicaid clinic, butnobody wanted to be perceived as the practice that didn't care, either.

And it didn't hurt that around this time the state Medicaid program raisedreimbursement rates for well-child services. Also, because the number ofnew Medicaid patients was relatively small, no practice had to increaseoverhead significantly. So Medicaid had become unexpectedly profitable.

The countywide system of assigning Medicaid newborns to private doctorsfunctioned well. Still, each baby we added became a permanent patient, andby 1993 our Medicaid census was so high that we were running out of appointmentslots for well-child screenings. We toyed with--and then rejected--the notionof sending Medicaid patients to DHEC for immunizations. After all, we wantedpatients to view us as their medical home--an important concept if theywere to break the habit of visiting the ER for every cough, fever, and sorethroat.

Again, DHEC stepped forward--this time to form public-private partnershipswith doctors to ensure that Medicaid children received regular primary care.My practice would be one of four pilot programs overseen by DHEC CommissionerDoug Bryant and Maternal Child Health Director Marie Meglan. But it wasup to us to create specific solutions.

Ron Rolett and I put our heads together and came up with this: What ifDHEC assigned a nurse practitioner to perform on-site well-child screeningsat my practice one day a week? We lacked the office space to accommodatea new hand Monday through Friday, but even a part-time NP would alleviateour appointment crunch.

Soon NP Brenda Greer was peering into children's throats, giving shots,and treating acute illnesses. Compassion is Brenda's way of life: In recentyears, she's worked in Eastern Europe as a medical missionary. Patientsadore her.

We generate more in-come from Brenda's services than we pay to "rent"her from DHEC. With her arrival, therefore, it seemed we had figured outhow to succeed at Medicaid--at the same time fulfilling the role of medicalhome.

By 1998, however, Medicaid was looking like its penny-pinching old selfagain. The state hadn't raised the program's rates since 1989, so whileour expenses were rising, income wasn't. South Carolina offered doctorsa capitated Medicaid plan in 1998 as a more attractive alternative. Thepayments exceeded what traditional Medicaid shelled out and even rivaledwhat we might have received from a poor-paying commercial plan.

Now the question was, would the administrative demands of managed careoverwhelm our practice? We had grown to six doctors.

The DHEC came to the rescue again, loaning us a friendly RN, Sherry Booth,to work out of our office as a full-time case manager for Medicaid patients.She handles most of the paperwork to switch them from traditional to capitatedMedicaid, and pulls the necessary strings when a child needs physical therapyor a nutritional consultation. My employees are happy not to be tied upon the phone dealing with these issues.

Sherry also gets to know the moms. If they miss an appointment, she callsand gets them to schedule another one so their babies can stay current onimmunizations. She'll even arrange transportation. She'll also visit patients'homes to demonstrate how an asthmatic child should use an inhaler. Whileshe's there, she might recommend that the family remove a dust-catchingcarpet.

Not only do these efforts to keep patients healthy reduce the odds thata child will go to the ER with an asthma attack--they help keep costs down,which is vital in a capitated plan.

Like Brenda Greer, Sherry serves as another set of eyes and ears forour practice. Moms tell her things that they'd never tell a doctor. We alsorely on Sherry to monitor families with a history of child abuse. She counselsparents about how to handle the anger and frustration that come with raisinga family. I sleep much easier at night knowing that Sherry is on the job.

We give Sherry office space and a phone, but DHEC bills Medicaid formost of the services she performs. Of course, Sherry could render theseservices if she were stationed elsewhere. But again, our close collaborationreinforces the notion of the medical home in patients' minds: Here's whereyou come when you need help.

The success of our DHEC partnership and the three other pilot programslaunched in 1993 has encouraged other South Carolina doctors to follow suit.Today, almost 90 practices have teamed up with DHEC to "bond"children to a primary care doctor. The arrangements vary, reflecting localpreferences, but typically the DHEC assigns a worker to the doctor's officeto provide preventive care and link patients to needed support services.

And the partnerships are bearing fruit. In 1990, only 45 percent of SouthCarolina's Medicaid-dependent children under 3 saw a primary care physician.By 1997, this figure had reached 80 percent. The number of annual visitsto a primary care doctor per child rose from 1.5 to 4 during the same period.

What's even more remarkable is that our practice in Easley has made adifference in children's lives without an ongoing state grant, a fund-raisingcampaign, or financial losses on our part. Medi-caid accounts for about15 percent of my billings now, more than triple the amount in 1989. Whileit's not a gold mine, the program generates a modest profit--something wenever expected when we set out to meet a community need.

As our experience illustrates, though, what works today probably won'twork tomorrow. The challenge of serving indigent patients will change withtime, given evolving forms of health care delivery. We'll have to alterour approach, but I'm confident we'll continue to rely on public-privatepartnerships.

If you're struggling to find a way to treat the have-nots in your community,contact your state or county public health department. You may find peopleas kind and wise as Ron Rolett, Brenda Greer, Sherry Booth, Doug Bryant,and Marie Meglan--not to mention Ressie Crumpton, the nurse who overseesour local health department branch.

Put aside your preconceived notions about health care bureaucrats. Publichealth workers and private-practice doctors have more in common than youthink. Like a catcher and a shortstop, we play different positions on thefield, but we belong to the same team.

By W. Kent Jones, MD, Pediatrician / Easley , SC



W. Kent Jones. See Medicaid patients without going broke.

Medical Economics

1999;16:88.