Some of the discounts are so steep that they may threaten access to
care, the authors argue.
Medicaid is the biggest public health program in the U.S. and
currently accounts for about $1 out of every $6 spent on medical
care. Medicaid expenditures also represent almost half of all
federal funds spent by states.
When Medicaid fees are too low relative to payments from Medicare,
doctors may refuse to treat Medicaid patients, potentially making it
much harder for poor people to get treatment, argue Dr. Charles
Mabry of the University of Arkansas in Little Rock and colleagues in
the Journal of the American College of Surgeons.
“Lack of proper payment can cause some Medicaid patients to have
needed surgical procedures delayed,” Mabry told Reuters Health by
email. “Our hope was that by researching and publishing on these
wide variations in payment, it would spur states to rethink the
methodology for how they determine payment.”
Even though the federal government picks up part of the tab for
care, Medicaid payment rates as well as enrollment eligibility and
covered benefits are determined by individual states.
To assess the degree of variation between Medicare and Medicaid
payments for surgery, Mabry and colleagues calculated how much fees
varied for some of the most common procedures done by general
surgeons in nearly every state across the country. The analysis
excluded only Kansas and Tennessee.
The largest discount they found was in New Jersey, which paid $1,011
less for surgery to remove all or part of the small intestine
through Medicaid than the amount paid by Medicare for the same
At the other extreme, the biggest premium was in Alaska, which paid
$1,382 more for insertion of a tunneled central venous port under
Medicaid than Medicare would pay for the procedure. These ports are
often used to administer chemotherapy and other intravenous
medicines, to get frequent blood samples, or to provide nutrition to
When they looked at mastectomies, often done for women with breast
cancer, Medicaid paid $226.47 in Connecticut, 69 percent less than
the $725.35 Medicare payment for the same procedure in the same
For an enterectomy, typically done to remove a tumor or obstruction
in the small intestine, New Jersey’s Medicaid payment of $332 was 75
percent less than the $1,343.16 payment under Medicare.
A minimally invasive gallbladder surgery that includes insertion of
a small tube to help drain bile commands a Medicaid payment of
$343.20 in Missouri, 51 percent less than the $697.23 Medicare
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To fix a ventral hernia, a bulge through an abnormal opening in the
wall of the abdominal muscles, Medicaid in New Hampshire pays $300,
61 percent less than the $762.28 Medicare payment in the state.
The analysis has several limitations, including the narrow focus on
a handful of surgical procedures and the reliance on published
payment schedules in each state, which may not necessarily reflect
what surgeons actually get paid, the authors note. The analysis also
lacked data on certain bulk payments or additional funds paid by
Medicaid that might minimize the apparent discounts in some cases.
The paper didn’t examine how access to care might be adversely
affected by steep discounts in Medicaid payments relative to
Medicare or private insurance. But, the authors conclude, it’s
likely some people struggle to find surgeons or experience delays in
care as a direct result of low fees that motivate doctors to refuse
One woman with sickle-cell disease and Medicaid coverage is a
case-in-point for Dr. Constantine Manthous, who retired from Yale
University and works in private practice in New London, Connecticut.
He recalled meeting her after she had spent a decade in a wheelchair
because she couldn’t find a surgeon to repair her hip. She didn’t
receive surgery until the hip fell out of its socket, requiring
constant hospitalization and morphine.
“By that time she was so ill she died of late complications from the
decade delay,” Manthous, who wasn’t involved in the study, said by
email. “You and I would have gotten the hip immediately.”
SOURCE: http://bit.ly/1PJXVFa Journal of the American College of
Surgeons, online January 13, 2016.
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