Most physicians will nod their heads in agreement as they read “Physician Satisfaction with Medicaid Managed Care: The Missouri Experience” by Gazewood and colleagues (J Fam Pract 2000; 49:20-26). The results from that article concur with our feelings about caring for patients with Medicaid coverage. It is a frustration that is common among family physicians.
As with any study that coincides with our prejudice, physicians will be pleased to see that someone has done the research necessary to provide data. This data can then be quoted to those who manage managed Medicaid programs as proof that there are problems. The bullets on an executive summary of the results would look something like this:
- Medicaid continues to be a frustrating endeavor for many physicians in primary care.
- Physicians in Missouri are dissatisfied with Medicaid managed care in comparison with fee-for-service Medicaid and commercial managed care.
Gazewood and coworkers sense that autonomy in making clinical choices is the critical issue for determining whether a clinician will be satisfied with the Medicaid revolution that is sweeping the country. Their study gives lesser weight to the role of equitable compensation for the provision of health care services. They argue that it might be necessary for the designers of Medicaid managed care to incorporate physician autonomy into the formula for success.
Autonomy and compensation
I have difficulty separating autonomy and compensation. In some ways they are so intertwined that discussing them separately seems shortsighted. Autonomy in making clinical choices is limited by rapidly disappearing specialty clinicians, who choose not to participate in Medicaid because of low compensation rates for their services. In many primary care practices this has accelerated to a crisis issue. For example, in my community there are delays of several weeks to have children seen by neurologists, since there are only 2 in the state who will evaluate Medicaid patients.
As a family physician, I am taking increasingly greater risks in the care of my Medicaid patients, because I can rarely find local assistance in the specialty ranks. The delays prevalent in the specialty care provided 100 miles away by waiting list only has taught me much about compromise and marginal quality care.
I have such autonomy at this level of care that it frightens me.
This crisis is not simply a specialist/generalist issue; family practice as a discipline must also bear a sizable portion of the blame. We now have a number of family physicians in residency training who consistently stay away from any Medicaid contract, as they begin their practice. Is this because of the frustration that family practice residents endure while caring for this group of patients during their training? Is it because of an attitude taught by frustrated faculty?
Whether a residency program practice, with its legions of seemingly ungrateful Medicaid patients, or the specialist preceptors who will not provide care or consultation are to blame is unknown. But I am concerned that we may be creating a catastrophic trend. Many of our most talented residents are not the least bit anxious about making the decision not to include Medicaid in their insurance panels when starting practice. Will the next generation of clinicians be prepared or motivated to care for the poor and disabled?
Somehow as clinical teachers we have failed; somehow we have not been able to mentor and explain one of the traditions of our profession and specialty. The findings of Gazewood and colleagues are not limited to Missouri. They seem to permeate the spectrum of primary care.
Autonomy may make clinicians more satisfied, but the problem is much more sinister and perverse. It is no longer politically correct for those of us in primary care to shake our fingers at our specialist colleagues and accuse them of “cherry picking” or taking the “cream off the top,” since these phenomena are now also firmly entrenched in primary care.
I am not confident that autonomy in clinical decision making is going to change this. The circle has been broken.