By Phil Galewitz July
27, 2017
Members
of the Trump administration and Republicans on Capitol Hill repeatedly say the
country’s Medicaid system is “broken” and enrollees struggle to get care
because many doctors refuse that coverage.
The
top U.S. official overseeing Medicaid — Seema Verma — doesn’t have to look far
to find an example. Her husband, Dr. Sanjay Mishra, is one of them.
Mishra
is a child psychiatrist in Carmel, Ind., and a partner and medical director of
Indiana Health Group, a large medical practice specializing in mental health.
That group doesn’t accept Medicaid.
“It’s
sadly ironic, but given what I know … I am not one bit surprised,” said Dr. J.
Wesley Boyd, associate professor of psychiatry at Harvard Medical School, who co-authored a study this
year on the struggles faced by children enrolled in Medicaid as they seek care.
Verma
is administrator of the Centers for Medicare & Medicaid Services and a
former consultant who helped design Indiana’s Medicaid program.
Jane
Norris, a CMS spokesman, said Verma’s husband does not accept Medicaid because
that “helps avoid any further conflict of interest or complication of her
recusal obligations.”
A
spokesman for Indiana Medicaid said Mishra stopped participating in the program
in 2007, when Verma began consulting with the state.
Neither
Mishra nor a spokesman for his medical group returned calls for comment.
Mishra
is one of many specialists nationwide, particularly mental health
professionals, who don’t accept Medicaid. Most say the program’s reimbursements
are too low.
Matthew
Brooks, CEO of the Indiana Council of Community Mental Health Centers, would
not comment on Mishra. But he said that in Indiana patients’ ability to get
care “is negatively impacted by the limited number of providers, especially in
rural areas.”
Dr.
James Bien, a pediatrician in West Lafayette, Ind., said he often finds it hard
to refer patients — both those who have private insurance and those with
Medicaid — to psychiatrists because there is a shortage of such specialists.
“It’s really tough. You sort of feel helpless sometimes,” he said. “It’s an
even tougher challenge for kids on Medicaid.”
Recently,
when looking for help for a teenage patient who attempted suicide, Bien had to
refer the boy to a doctor nearly 70 miles away in Indianapolis.
In
another case, Bien said, he looked as far as Chicago to find help for a teenage
boy with severe depression who was acting aggressively toward his parents and
struggling in school. He eventually found a child psychiatrist willing to take
this patient more than an hour’s drive away. The family still had to wait weeks
for an appointment.
Many
families who need a child psychiatrist face long waitlists. And this problem
starts with the supply issue. According to the American Academy of Child and
Adolescent Psychiatry, there are about 8,300 practicing child and
adolescent psychiatrists in the United States — and more than
15 million youths in need of one.
That
limited access can have far-reaching consequences. The longer a psychiatric
illness or family dysfunction continues, the more difficult it is for the child
to succeed. Untreated problems can worsen and lead to difficulties in school.
The
challenge is further complicated by the fact that fewer than half of child
psychiatrists take Medicaid, said Dr. Peter Metz, a child psychiatrist and
professor at the University of Massachusetts Medical School. “It’s a big
issue,” he added.
In
a 2011 New England Journal of Medicine
study, researchers from University of Pennsylvania posing as mothers
of children seeking psychiatry appointments were denied 83 percent of the time
when they said they had Medicaid and 49 percent when they said they had private
insurance.
Boyd
and colleagues identified the same problem in their study. Researchers posing
as the parent of a depressed 12-year-old who had private insurance or would pay
out-of-pocket got an appointment with a psychiatrist or pediatrician 37 percent
of the time. When the researchers making the call said they had Medicaid
coverage, that figure dropped to 22 percent, the study found.
Metz
said there’s a simple reason why Mishra and many child psychiatrists don’t take
Medicaid. “It’s financial, it’s because of the low reimbursement rates that
Medicaid pays,” he said. Although rates vary by states, Medicaid often pays the
specialists less than half the fee they could collect using private insurance
or charging a patient directly, according to several psychiatrists.
Paul
Gionfriddo, CEO of Mental Health America, an advocacy group, said a cut in
federal Medicaid funding would make it harder for states to increase
reimbursement rates to providers and entice more of them to see enrollees.
“It
would be better if Seema Verma’s husband were to accept Medicaid, not just for
the appearance of supporting the program his wife oversees, but to increase
access by one more provider,” he said.
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