Breaking barriers in Medicaid access [PODCAST]

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Join us in this insightful podcast episode as we discuss the challenges and importance of Medicaid access in the United States. Our guests include Fatima Al-Shimari, an epidemiologist, and medical students Miriam Al-Saedy and Salsabeal Al-Saedy. We delve into the limited availability of Medicaid providers and its impact on health care access for low-income individuals. We explore the disparities across states and regions, the role of government reimbursements in provider acceptance, and the benefits of increasing reimbursements. We also address potential arguments against such increases and highlight the positive outcomes they can bring. Additionally, we discuss the implications of stable coverage and improved access to care on reducing health disparities and improving health outcomes for low-income populations. Our guests emphasize the role of health care professionals in advocating for equitable policies and ensuring access to care for all patients. Tune in to gain valuable insights and understand the proactive approaches policymakers can take to strengthen and expand Medicaid programs.

Fatima Al-Shimari is an epidemiologist. Miriam Al-Saedy and Salsabeal Al-Saedy are medical students.

They share their stories and discuss the KevinMD article, “Raising reimbursements: the Medicaid imperative.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Fatima Al-Shimari as well as Miriam and Salsabeal Al-Saedy. Fatima is an epidemiologist, Miriam and Salsabeal are medical students, and together they co-wrote the KevinMD article “Raising reimbursements: the Medicaid imperative.” Everyone, welcome to the show.

All right, so I’m going to ask each of you just to briefly share your story and journey to where you are today. Fatima, why don’t you go first?

Fatima Al-Shimari: Thank you so much for having us tonight. I’m honored to be here. So Miriam, Salsabeal, and I all grew up in Washington State, and our lives were shaped incredibly by our refugee parents as they navigated the complexities of coming to a new country and facing language barriers. They encountered a lot of cultural misunderstandings along the way that really permeated their health care experiences, and we were there, as the oldest daughters in our families, alongside them along the way, helping them navigate and realizing the critical need for compassionate, culturally competent care.

So it took me a while, but I realized that medicine is my calling and this is the direction that I want to head into. I’ve been an epidemiologist for some time, just doing research about health care disparities and underserved populations, but what I realized later on is that I want to be on the front line with these two incredible colleagues of mine, just making that difference in person, being there and making it, rather than waiting for the policy changes to trickle down to the patient level. So that’s where my journey circled to. I’ll pass it to Miriam.

Kevin Pho: Yeah, Miriam, tell me your story and journey to where you are today.

Miriam Al-Saedy: Definitely. Well said, Fatima. So yeah, basically, I’m from Seattle, born and raised here. I went to the University of Washington for undergrad, then I went to medical school in Spokane, then back here, and it’s been a great journey, because now I get to rotate here in Everett, Washington, where I used to volunteer in high school. So I got to see different levels: as a volunteer, as an undergrad student, as a medical student, and probably even as a future doctor here. So it’s very nice, actually, this whole journey and where we’re from. My sister is here with me on this journey, too, so I’ll have my sister go next.

Salsabeal Al-Saedy: Yeah, very similar stories to both my sister and Fatima. I actually have a very similar story to my sister; we have almost essentially the same exact format, I guess. We went to the university together, with the same major and the same minor, entered the same medical school, and had similar life experiences, and then I am also going to be rotating and doing my clerkship years in Everett as well, or at least in the Puget Sound region in Seattle. Yeah, very exciting stuff.

Kevin Pho: Perfect, perfect. So one thing that Fatima mentioned was culturally competent care, and that means a lot of things to a lot of people, right? So here I’m going to ask you, when someone says culturally competent care, what is it? What does that mean to you?

Miriam Al-Saedy: Definitely, that’s a good question. So culturally competent care basically is you try to understand the patient, where they’re at and where they’re from, without any assumptions, really. So when you talk with a patient, especially as students, you’re trying not to make assumptions. You ask for some kind of story, and you get to know who they are in a short amount of time. You can’t really take the time to get to know the person in a short 10-minute visit, so what you can do is ask them where they’re at, really briefly, what they’re doing here, what their preferences are in health care, and what they hope to get out of the visit. This way, you understand the culture in a short amount of time.

You can always read on your own, go study, but nobody really has time to do that unless you’re intentionally doing it. But with each patient you visit, you gain a little bit of the culture from every patient. So that’s how I understand culturally competent care: trying to understand each patient from their perspective rather than assuming what their cultures are.

Kevin Pho: And Salsabeal, during your training in medical school, or even through undergrad, was there any exposure or any formal teaching when it comes to culturally competent care?

Salsabeal Al-Saedy: We do have a course in our medical school called Leadership in Health Care, where we get to investigate how we present ourselves and our communications, especially from the patient perspective, and the power dynamics, to better understand the role we play in them. In particular, it’s about being more empathetic toward patients. We need to understand them, and even in a short amount of time, you can pick up some clues. And then there is the exposure we have. We have different patients, standardized patients, and then we have guest speakers come in, just a wide variety.

Kevin Pho: All right, so let’s talk about the KevinMD article. The article all three of you wrote is about Medicaid, “Raising reimbursements: the Medicaid imperative.” Fatima, tell us, how did this article come together?

Fatima Al-Shimari: Absolutely. So when Miriam, Salsabeal, and I meet up, we love to discuss things related to science and health care, and one of the things we realized is that our health care experiences growing up converge, where access to health care was a constant struggle. We immediately understood the challenges that are faced by Medicaid patients, because they’re just so ingrained, and we saw how difficult it was for our parents and others in the community. I myself have been a medical interpreter for my family and for others in the community, trying to translate those misconceptions about health care along the way, just understanding where people are coming from, and finding doctors who could communicate back effectively and appreciate these cultural nuances, as Miriam mentioned earlier, culturally competent care, and who accept Medicaid insurance as well, in addition to all these other factors.

Witnessing that gap really ignited this fire within us to try and make a difference. I had been following your podcast for some time, and I couldn’t think of a better place to send our article. But really, we said, “Why don’t we write something about this?” And that’s why we called it the Medicaid imperative, because really, that’s the direction that we should be going in. It’s inevitable. We have to raise reimbursements in order to improve quality and access to care.

Another way we wanted to make a difference was through raising awareness about vaccines and medications for Medicaid patients and how to effectively use them, and I think this is a perfect segue. Miriam, if you want to elaborate and share the story about EpiPens and access.

Miriam Al-Saedy: Definitely. Actually, I have a really interesting story. Just last month, while we were celebrating the Eid holiday in our community with lots of food, there was actually a girl suffering from an anaphylactic reaction. I went to the scene, and she was surrounded by several bystanders, and she did not have any family with her other than an uncle, who really didn’t know what to do at the time. I heard people say that she ate something with peanuts, and as I was absorbing the surrounding information, and from a rapid assessment of skin, airway, and breathing, I made a decision that she needed an EpiPen injection now.

I asked if anyone had already injected an EpiPen, and they said no. As I prepared to inject the EpiPen, I was actually met with resistance from the people surrounding the girl, saying that they already gave her medicine, and they were physically stopping me from injecting an EpiPen. I stood my ground and asked, “Was that medicine an EpiPen injection?” And nope, it was an antihistamine. So that is when I decided to use my clinical expertise and knowledge and injected the EpiPen in this challenging situation, where several people are dismissing your decision. That is where confidence and clinical expertise come into play. No matter what the situation is, one should be confident in their clinical skills and education to be able to tackle any situation like that, especially when minutes matter, like during an anaphylactic reaction.

So ultimately, what I learned is that EpiPen hesitancy is real, and it’s something I’ve been working on promoting awareness of through educational YouTube videos, and all three of us are actually working on a scholarly project on anaphylaxis awareness. What is intriguing to me is that there needed to be a medical student to figure out that this girl is having an anaphylactic reaction. Anyone should be able to recognize anaphylaxis, and the EpiPen should be the first-line therapy.

But then there’s health literacy, and people in the community understanding what’s going on, and people not carrying EpiPens, and you can’t really find EpiPens anywhere, because you have to have a prescription. You can’t really get it over the counter. AEDs you can probably find, but it’s very interesting, because I don’t think you need a prescription to get an AED, but you need a prescription to get a lifesaving medication, which is an EpiPen. So I don’t know, Salsa, if you want to add more to the full EpiPen journey here.

Salsabeal Al-Saedy: Yeah, so an EpiPen without insurance costs roughly about $700. We think the EpiPen should be stocked right next to the AED or Stop the Bleed kits, as it is a lifesaving tool, and schools and workplaces should have it on site, because anyone at any time can get a life-threatening anaphylactic reaction. In 2017, there was a 400 percent spike in EpiPen costs. Medicaid reached an agreement that they will no longer be overcharged for EpiPens, protecting access for Medicaid beneficiaries who rely on these lifesaving drugs, while Medicaid saves hundreds of millions of dollars.

And how this relates to Miriam’s story and raising Medicaid reimbursements is that the government should raise the reimbursement rates to clinics. We’ve already come so far with the reimbursement; we’ve come so far with Medicaid. We’ve made great strides, including covering essential medications, for example, medications for diabetes, and when we have greater coverage for these medications, we’re raising greater awareness among the less affluent communities about these drugs and the necessity of these drugs. However, one thing that we can still work on is ensuring that these people know how to use these drugs appropriately, in particular the EpiPen.

Kevin Pho: And Miriam, during that story that you were telling me, what were the reasons behind them trying to prevent you from giving that EpiPen? What were some of the reasons behind their hesitancy?

Miriam Al-Saedy: Definitely. No, that’s a great question. Well, I may appear young, but that’s not really the concern there. I think the main issue is that they’re afraid; there’s a fear of needles. So the main two things behind EpiPen hesitancy are fear of needles and fear of calling 911. Some people actually know that if you inject the EpiPen, you have to call 911, because they have to monitor after injecting the EpiPen to see if there’s any secondary reaction and to make sure that the anaphylaxis is being properly treated. But yeah, the main concern really is it’s a needle. People are afraid of needles, and they don’t want to inject the needle, and they’d rather give pills by mouth instead of injecting a needle.

But the issue here is understanding the different mechanisms, the difference between a by-mouth medication, which is an antihistamine, and an injected EpiPen, which is completely different. So there are issues there in terms of: Do people understand what an anaphylactic reaction is and what the main treatment for that is? There’s a lot of confusion there. Some people think of antihistamines because it’s something you just drink, liquid by mouth, and then you say, “I’m good.” And sometimes people will not get an anaphylactic reaction; they previously had a reaction that was just hives, not necessarily anaphylaxis, and they took an antihistamine, and they think that’s all they need. But you never know when one gets an anaphylactic reaction; just different amounts of the allergen could trigger an anaphylactic reaction. So there are a lot of issues there, but with community training and education, I believe that could be fixed.

Kevin Pho: Now, Fatima, when you were telling the story about the reasons behind why you wrote the article, you alluded to how difficult it was, as you were growing up, when you saw family members trying to access the health care system, right? So paint us more of a picture about that. Tell us some of the difficulties that you saw in trying to access health care.

Fatima Al-Shimari: So one of the things that we grew up with is accompanying our parents to their doctor’s appointments, being the ones in the family that speak English and that are translating these medical terms, or at least trying to, when you’re like 10 and 12 years old. It could be really challenging. But then you’re on the other end, when you’re a part of the health care team, really listening to your parents’ concerns about why they don’t want certain medications, or, as Miriam mentioned earlier, why they don’t want needles versus a pill. That touches on how they don’t want the problem to escalate. They think that a pill is keeping it under control, basically, but when you escalate to a needle, or when you escalate to actually going to the hospital and seeing the doctor there, there are different levels. A lot of people come from places where sickness is a taboo, and if you’re ill, you don’t want other people to know about it, because that could be seen as a weakness.

So understanding these, when you’re going to the doctor with your parents and this is the perspective that they’ve instilled in you, it doesn’t really conflict as much, because you’re saying, “OK, this is what I grew up with.” But when you’re exposed to the medical world, when you become a medical student like my two colleagues, or when you’re working at an office or a clinic, you really become exposed to these things and start saying, “Hey, this isn’t right. This isn’t consistent with what we know about health care. Vaccines, COVID vaccines, are perfectly safe, and we can take them, and they’re not going to cause you to die.”

So that’s really where it started out: this cultural competency versus being on the other end and having to translate from Arabic to English what our parents are saying, what community members and families who request you as an interpreter are saying about why they don’t want this certain vaccine or why they don’t want this certain medication. Sometimes doctors will say, “Well, OK, we can try something else.” And I’ve also worked with doctors who say, “Well, why? What are your concerns about this? Why is it that you’re afraid to take this injection but not this pill?”

So it’s really coming to understand those, realizing that a lot of these misconceptions are really rooted in their experiences in their countries of origin, or from different generations, and these have been passed down to them, and really trying to address those one patient at a time, because it’s a generational thing. We are in this new generation where we grew up here, and we want them to realize, as parents and as aunties and uncles in the community, that we’re not just being too Americanized, and that we still understand the culture. We still have our roots and our thinking and our customs that align with them, but we’re helping them realize that this is where technology has progressed, this is how medicine has progressed, and really getting them up to speed on that.

Kevin Pho: Your article is about the Medicaid reimbursement rate. So how does that tie into that lack of access when it comes to the Medicaid population accessing care?

Miriam Al-Saedy: Because usually Medicaid patients don’t get the recommended treatment. They always have to do a step trial in order to finally reach it. So not only does it take a long time to finally reach it, because insurance would say, “You haven’t tried this for X amount of weeks or X amount of months, so we can’t give you coverage or go to the next step until you do that trial-and-error process,” but that’s taxing on the patient, to constantly go back to the provider, take time out of their day, and do this whole trial-and-error process, whereas patients that have commercial or private insurance can get it within a matter of weeks.

So that’s the huge issue: There’s always going to be a halt, and it’s a long process to get to the recommended medication, even though providers know this is what would work greatly for them and has greater efficacy and safety. But it’s just how the insurance is set up: They have to go through a whole trial-and-error process, and patients don’t like that, especially since it’s such a lengthy process, and they’re not feeling any better, if not feeling worse. But there are no loopholes that we can jump on.

Kevin Pho: What would be a common condition where that step process would commonly come into play within the Medicaid population?

Miriam Al-Saedy: So I’ve worked in the dermatology clinic, and I’ve seen this often when we’re trying to get Medicaid patients on at least a biologic. We have to try and fail topicals, try and fail oral pills, which are immunosuppressives, try and fail first-generation Humira, a first-generation biologic, and we know the one, or at least a certain drug or biologic, that works so well, but it’s going to take them at least a year, a year and a half, before they finally get access to it. Some pharmaceuticals would have patient assistance programs, but some patients will get denied because they don’t necessarily meet the criteria. So it’s a bit tricky, and it’s a very lengthy process.

Kevin Pho: Now, in terms of your take-home messages, I’m just going to ask each of you: What needs to be done next? How can we solve this problem going forward? What ideas do you have? All right, so Miriam, why don’t you go first?

Miriam Al-Saedy: Definitely. Yeah, so as both a future physician and a patient, I’ve experienced both: how physicians prescribe certain treatment plans, but patients are not able to comply with them due to a preventable cause, that is, insurance coverage and time for prior auth approvals, which delay treatment and lead to worse outcomes. I experienced it myself, really, as a medical student, and it made me question how I could improve the health care system as a future physician. But really, it starts with changing the health care system and insurance, because once you fix that, patients are able to not feel stressed out, and physicians are able to not feel stressed out, because once physicians are burnt out, patients get burnt out, and the system just gets ruined. So it starts stepwise, fixing one problem at a time.

Kevin Pho: All right, and that’s awesome. Well, tell me about your solutions and next steps going forward and some of your take-home messages.

Salsabeal Al-Saedy: The take-home message would be increasing awareness, especially for life-threatening conditions, and having not just an AED or Stop the Bleed kits, but having other things that can help and save a couple of minutes.

Kevin Pho: All right. And Fatima, tell me about some of your solutions to the issues that you brought up, as well as some of the take-home messages that you want my audience to come away with.

Fatima Al-Shimari: Kevin, so I think my take-home message would be that doctors are doing the best they can to provide equitable access to care. I mean, during my premed journey, I was shadowing Dr. Daniel Lowe at a community clinic here in Washington, and really, he was the doctor that I wish I had growing up. Observing him, I saw that with patients who would come late to their appointments, he would make a concerted effort to accommodate them, even if it meant him going home later that day. He showed me that equity isn’t just a buzzword and that doctors really are making an active and constant effort to work around these social determinants that dictate our ability as Medicaid patients to access care.

But really, doctors can’t do all of this alone. They need the government to support the doctors and to encourage more to start accepting Medicaid patients, and we firmly believe fair reimbursement rates are essential to attracting and retaining these health care providers that are dedicated to serving Medicaid patients. So like Miriam and Salsabeal said, I want to just re-emphasize that we’re advocating for policy changes, fostering collaboration between these stakeholders, and possibly leveraging technology to streamline the reimbursement processes, so that we can break down these barriers in access.

Kevin Pho: Well, thank you all for sharing your stories, time, and insight. Thanks again for being on the show.

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