“The specialist rescheduled me again,” the patient told me, looking embarrassed.  ”I think he doesn’t want to see me any more.”

“I’m sure that it isn’t that he doesn’t want to see you,” I replied.  ”This has to be a miscommunication with the front desk.  It happens all the time; it drives doctors crazy.”

“I don’t know,” he continued.  ”I just got on Medicare, and I wonder if maybe he doesn’t want me any more because of that.”

Whether it is Medicare, Medicaid, or a commercial insurance (or no insurance at all), patients are paranoid about their coverage.  They feel vulnerable – that they somehow came to the ball wearing an ugly gown and nobody wants to dance with them.  Insurance has become like the smell of the bathroom or like feminine hygiene – you know people do it, but nobody wants any details.

There are several reasons, I can guess, for this universal discomfort:

1. People hate to appear cheap.  Insurance is how people pay their doctors, and (at least for primary care) they don’t want doctors disliking them because their insurance doesn’t pay well.
2. People don’t have any idea how much their insurance pays.  Obviously this is impossible for patients, since each doctor has negotiated a different contract with each insurance company.  One doctor may have negotiated well (perhaps as part of a large group) and is paid $80 for an office visit, while another is paid only $50 for the same work.  If a specialist bills for an office visit (99213), they are paid substantially more than the primary care physician billing the exact same code (for the same reason).  Most patients have no idea about this variability, but they do know that whatever the card does is a mystery.
3. Most people don’t get to choose their insurance coverage.  Employers usually give only a single plan, although some will give a choice of plans.  Regardless, the plan most people have is not what they would choose if they had a choice.
4. Insurance changes so often that even if someone learned about a plan it would become obsolete in a very short time.
5. Most doctors don’t know what each insurance pays, so they tend to complain about them all, making patients feel uncomfortable.

We’ve dropped two insurance plans in the past 12 months, picking one of them back when they renegotiated.  Each time we dropped a plan, patients were rarely angry with us.  They assumed that we were getting screwed by the insurance company (which we were in both cases), and felt sad that their inability to choose a different insurance plan made it impossible for them to come to our practice.  When we came back to the one plan, patients were grateful to us, still having terrible things to say about the insurance company for putting them through the exile from their doctors.

This doesn’t even consider the situation of the Medicaid patient, who is often made to feel bad about their insurance.  Some offices openly treat Medicaid patients as lesser patients because of their insurance paying so badly.   A recent study showed that 1/3 of doctors would not accept new Medicaid patients last year.  In an article in the Washington Post, Sarah Kliff discusses the reasons for this.  The first reason is obvious:

Decker [who performed the study] finds a positive correlation between Medicaid reimbursement rates and how many providers accept Medicare. In Wyoming and Alaska – largely rural states that pay Medicaid providers about 50 percent more than Medicare reimburses – the vast majority of providers accept Medicaid. In New Jersey – where reimbursement is the lowest – only about 30 percent say they’ll take new patients.

I hope that doesn’t surprise anyone.   The article goes on to discuss the effect the expansion of Medicaid in the ACA will have on this:

… Avik Roy pointed out a few weeks ago, states with Democratic governors actually tend to have lower reimbursement rates. Faced with crunched budgets, some have chosen to cut provider payment rather than reduce services.

That could mean that the states with the highest likelihood of expanding Medicaid might be those with the lower reimbursement rates – and fewer doctors willing to accept these patients by proxy. That could prove true in a state like California, where 1.8 million residents are expected to gain coverage – but fewer than 60 percent of providers accept new patients in the program.

So the poor paying states will get more people on the roles with the least providers accepting Medicaid.  Demand, meet supply.

The article concludes with one small ray of light:

The law increases Medicaid reimbursements for primary care doctors to match those of Medicare providers. That means that everyone on the right side of this chart will move over to the left. And that could entice more providers to participate. Decker estimates using this data set that it would raise the Medicaid participation rate to 78.6 percent, an 8.6 percent increase from where it stood in 2011.

Read that carefully: Medicaid reimbursement for PCP’s will be raised to match those of Medicare providers.  My patient certainly doesn’t seem to think of Medicare as a standard of generosity to doctors, and most physicians see Medicare as the ground floor of reimbursement they accept only out of necessity or duty.  So this ray of light is a cold shaft in a very dark dungeon.  It raises the reimbursement from pitiful to pathetic.

It seems clear that the makers of government policies and the writers of insurance policies don’t grasp this.  We have repeatedly seen insurance companies pandering to the specialists and giving the scraps to primary care.  This is crazy, as my job as PCP is to keep people well enough to not need care.  My job is aligned with the interests of the insurers, including Medicaid and Medicare: I want my patients well enough to not utilize specialists or hospitals.  Why don’t they understand this?  Who chooses to pay the $100,000 bill for the nursing home patient sent to the ICU while playing “hardball” in negotiations with primary care physicians who could prevent the admission altogether?

If my patients had a vote, they would do differently.  I think they are tired of apologizing.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).