Should ALL Medical Doctors Be Required to Accept Medicare and Medicaid $$$ as a Condition of Licensure? Can the Gods be humble and care for their lowly helpless subjects? My take as a practicing physician. Donald H Marks

Should All Medical Doctors Be Required to Accept Medicare and Medicaid as a Condition of Licensure?

By Donald H. Marks, MD PhD, FACP   

physician scientist 3rd generation veteran


Summary: 

Medicare and Medicaid are two government programs that provide health coverage to millions of Americans. Yet, in the USA, having insurance coverage is not the same as having access to care. One major reason is that not all doctors accept Medicare and Medicaid patients. In 2018, 90% of physicians accepted new Medicare patients, while only 72% accepted new Medicaid patients (AMA). The main reasons cited for this discrepancy are the supposed low reimbursement rates and the high administrative burden of dealing with these programs. We as medical professionals can reduce this coverage gap created by our fellow providers who opt out, by insisting that all medical licensure boards tie their granting of a medical license to acceptance of all insured patients, including those with Medicare and Medicaid.


Medicare covers 67 million citizens ages 65 and over, as well as 8 million younger adults with certain chronic conditions or disabilities. Medicaid is a joint federal-state program that provides health insurance to low-income individuals and families. To date, 41 states (including DC) have adopted the Medicaid expansion, and as of June 2023, approximately 94 million persons are covered by Medicaid and Children’s Health Insurance Program CHIP.  


Having insurance coverage is not the same as having access to care,  because not all doctors accept Medicare and Medicaid patients. Are you shocked, surprised or offended? According to a survey by the American Medical Association, in 2018, 90% of physicians accept new Medicare patients, while only 72% accepted new Medicaid patients. The main reasons cited for this discrepancy are the supposed low reimbursement rates and the high administrative burden of dealing with these programs. I have faced this very frustrating situation in my own medical practice and in my own personal life as an over 65 medical patient, turned away by a large local hospital-affiliated orthopedic surgery group and a large acute care outfit affiliated with the local referral hospital because they did not accept Medicare Advantage. 


Some healthcare equity advocates argue that all medical doctors should be required to accept Medicare and Medicaid as a condition of their medical license. They claim that this would ensure access to quality health care for all Americans, regardless of their income or age. They also point out that medical doctors have a social responsibility to serve the public good, and that accepting government insurance is part of their professional duty.


Even StarTrek faced this issue of medical equity and access to care on Star Trek Voyager Series 7, Episode 5  https://bit.ly/42AIrh3 

Some opponents contend that medical doctors should have the freedom to choose their patients and their payment methods. They assert that forcing medical doctors to accept Medicare and Medicaid would violate their autonomy and their property rights. They also warn that such a mandate could reduce the supply and quality of doctors, as some would retire early, relocate to other states, or opt out of the system altogether.

In a commentary from the  AMA Journal of Ethics, the issue of physicians opting out of Medicare is examined, highlighting that while less than 1% of physicians had elected to opt out as of 2022, this decision can lead to oversubscription of remaining practices and potential harm to eligible patients. The commentary suggests reconsidering the opt-out mechanism, especially given that resident training is supported by Medicare funding.


Public Funding of Physician Training

All physicians in the United States receive some form of public funding during their training. This funding can come from a variety of sources, including:

  • Federal funding: The federal government provides funding for medical schools, residency programs, and other healthcare training programs through a variety of programs, such as the National Institutes of Health (NIH) and the Health Resources and Services Administration (HRSA). Another form of federal funding, which I benefited from, is military sponsorship.

  • State funding: Many state governments also provide funding for medical schools and residency programs.

  • Local funding: Some local governments also provide funding for healthcare training programs.

In addition to government funding, many physicians also receive financial assistance from private sources, such as scholarships and loans. However, even these private sources of funding often rely on government support in some way. For example, many student loans are guaranteed by the federal government.


Obligation to Accept Medicaid Patients

Because all physicians receive some form of public funding during their training, many healthcare equity advocates argue that medical doctors have an obligation to accept Medicare and Medicaid patients.

There are a number of reasons why physicians should accept Medicaid patients. First, it is a way to repay the public for the investment that was made in their training. Second, it helps to ensure that everyone has access to quality healthcare, regardless of their income. Third, it can help to reduce the burden on the uninsured healthcare system.

The ethical implications of doctors refusing to see Medicare or Medicaid patients are significant, raising concerns about patient access to care, health equity, and the physician's professional responsibilities. 


  1. Compromised Patient Access to Care: Medicare and Medicaid are essential safety nets for vulnerable populations, including the elderly, disabled, and low-income individuals. Refusing to accept these patients can create significant barriers to accessing necessary medical care, potentially leading to delayed diagnoses, worsened health outcomes, and increased health disparities.

  2. Exacerbated Health Disparities: Medicare and Medicaid beneficiaries often face greater health challenges and socioeconomic disadvantages. Denying care to these patients can further perpetuate existing health inequities and contribute to a two-tiered healthcare system where access is based on financial means rather than medical need.

  3. Violation of Professional Obligations: The American Medical Association's Code of Medical Ethics emphasizes the physician's duty to care for all patients regardless of their socioeconomic status or insurance coverage. Refusing to see Medicare or Medicaid patients can be seen as a breach of this ethical obligation and a betrayal of the physician's commitment to serving the community.

  4. Potential Legal Ramifications: While physicians generally have the right to choose whom they treat, there are certain legal obligations, such as the Emergency Medical Treatment and Labor Act (EMTALA), that require hospitals to provide emergency care regardless of a patient's ability to pay. Additionally, some states have laws prohibiting discrimination based on insurance coverage.

  5. Erosion of Public Trust: Refusing to accept Medicare or Medicaid patients can damage the public's trust in the medical profession and create a perception that physicians prioritize profit over patient well-being. This can undermine the doctor-patient relationship and erode confidence in the healthcare system as a whole.


Challenges

There are a number of challenges that physicians face when accepting Medicaid patients. One challenge is that Medicaid reimbursement rates are often (but not always) lower than those of private insurance companies. This can make it difficult for physicians to cover the costs of providing care to Medicare/Medicaid patients.

Another challenge is that Medicaid patients often can have more complex medical needs. This can make it more time-consuming and difficult to provide care to Medicare/Medicaid patients.

While it's important to encourage healthcare providers to participate in government healthcare programs like Medicaid and Medicare, denying medical doctors a medical license solely for not accepting these programs may not be the most effective or ethical approach. Instead, it may be more effective to incentivize their participation through other means, such as matching Medicare Medicaid to BC/ BS or Kaiser rates. Here's why:

1. Ethical Considerations: Denying medical doctors a medical license based solely on their participation in specific insurance programs could be seen as discriminatory and heavy-handed. All licensed medical professionals should be treated equally, but their primary commitment should be to provide quality health care to patients, regardless of their insurance status.

2. Access to Care: Restricting access to care by revoking licenses may be counter-productive, by exacerbating the shortage of healthcare providers, especially in underserved areas. A better approach may be to encourage more doctors to accept Medicaid and Medicare patients by offering realistic reimbursement rates which also represent the cost of providing care, and lowering administrative barriers.

3. Focus on Quality of Care: Licensing should primarily ensure that medical doctors are qualified and capable of providing high-quality care. Accepting or not accepting specific insurance should not be the sole determinant of a physician's qualifications.

4. Individual Choice: Doctors often have valid reasons for not participating in government insurance programs, such as administrative burdens or low reimbursement rates. Some hold that it is essential to respect their professional judgment and provide incentives for participation rather than punitive measures.

5. Incentivize Participation: Instead of punitive measures, it may be better to create incentives for medical doctors to participate in Medicaid and Medicare. These could include improved reimbursement rates, reduced administrative burdens, or offering tax incentives for providers who accept a certain percentage of patients from these programs.

6. Patient Choice: Patients should have the freedom to choose their doctors. Forcing doctors to accept specific insurance could limit patient choice and interfere with the doctor-patient relationship, which is crucial for effective healthcare.


Of course it's crucial to encourage medical doctors to participate in Medicaid and Medicare without resorting to revoking medical licenses, although the alternative of denying access to healthcare to the sick is even more onerous, IMO. By addressing the issues that deter doctors from participating and providing incentives, we may perhaps ensure that more healthcare providers accept patients from these programs while upholding ethical standards and individual choice.


From a health equity and ethics standpoint, are medical doctors who refuse to accept Medicaid or Medicare simply greedy? 

Health equity is the principle that everyone should have a fair and just opportunity to attain their highest level of health, regardless of their income, race, ethnicity, gender, disability, or other factors that may affect their access to health care (CDC What is Health Equity? | Health Equity | CDC). By electing not to accept Medicaid or Medicare patients, even though these programs provide essential life-supporting health insurance for millions of low-income, elderly, and disabled Americans (https://www.who.int/health-topics/health-equity), those non-participating medical doctors are actively and intentionally denying patients the right to health and contribute to the health disparities that result from their unequal access to quality health care.

One might argue that doctors who refuse to accept Medicaid or Medicare are greedy because they prioritize their own financial interests over the health needs of their patients. According to a report by the Medicaid and CHIP Payment and Access Commission (MACPAC), the average Medicaid payment for 18 selected conditions was 6 percent higher than Medicare in 2012 (https://www.cdc.gov/nchhstp/healthequity/index.html ). Moreover, the average Medicaid payment for all but two of the conditions was higher than Medicare. This means that doctors who reject Medicaid patients are not only discriminating against poor and needy patients, but also losing out on potential revenue.


Another reason why doctors who refuse to accept Medicaid or Medicare might be considered greedy is that they are ignoring the social determinants of health that affect their potential patients’ well-being. Social determinants of health are the conditions in which people live, learn, work, play, and worship that influence their health risks and outcomes (https://www.cdc.gov/healthequity/whatis/index.html). These include factors such as discrimination, racism, poverty, education, employment, housing, transportation, economic status, and environment. By turning their backs on Medicaid or Medicare patients in favor of better paying patients, those doctors are failing to address the root causes of poor health and perpetuating the cycle of disadvantage and disease.

Therefore, from a health equity standpoint, doctors who refuse to accept Medicaid or Medicare could be considered greedy because they violate the principle of fairness and justice in healthcare. They also miss the opportunity to improve the health outcomes of patients and reduce the burden of preventable diseases on society.


The American College of Physicians, the internal medicine professional society to which I belong as an Emeritus Fellow, has a vision for improving healthcare access in America. ACP provides a comprehensive, interconnected set of policies for a better U.S. healthcare system for all. 

The first of ACP comprehensive recommendations is that USA should transition to universal coverage, which includes essential benefits, which I and most US citizens and healthcare providers agree. Prior US presidents, including FDR, Nixon and Clinton have agreed. 


ACP vision challenges the U.S. not to settle for the status quo, but to implement systematic health care reforms. An additional set of ACP policy papers, published in Annals of Internal Medicine, address issues related to coverage and cost of care, health care payment and delivery systems, barriers to care and social determinants of health, and more. 


Although essentially a commendable set of proposals, I look forward to ACP giving more attention to the "essentially uninsured", meaning those with unaffordable premiums, high deductibles, and poor access to providers. Not being able to afford healthcare is equivalent to not having access to healthcare. For many, it's essentially not available. In addition, if a drug is priced in a way that results in it being unaffordable, it is essentially not available to those in need, and in that sense of no efficacy. Drugs found to have no efficacy should have their approval from FDA revoked.

 

Solutions

The issue of whether medical doctors should be required to participate in Medicare and Medicaid is a complex and controversial one. It involves ethical, economic, and legal considerations that affect both doctors and patients. 


Instead of withholding licenses, policymakers and healthcare leaders could explore alternative solutions to address the issue of doctors refusing to see Medicare or Medicaid patients, such as:


  • Increasing Reimbursement Rates: Raising Medicare and Medicaid reimbursement rates could incentivize more physicians to accept these patients.

  • Expanding Access to Community Health Centers: Community health centers provide comprehensive care to underserved populations, regardless of their ability to pay. Expanding access to these centers could help bridge the gap in care for Medicare and Medicaid beneficiaries.

  • Promoting Value-Based Care: Shifting towards value-based care models that reward quality and outcomes rather than volume could encourage physicians to focus on patient needs, regardless of insurance coverage.


I welcome your comments on all these issues.



References


  1. Physicians who refuse to accept Medicaid patients breach their contract with society https://www.statnews.com/2017/12/28/medicaid-physicians-social-contract/


  1. What is Health Equity? | Health Equity | CDC

https://www.cdc.gov/nchhstp/healthequity/index.html

https://www.cdc.gov/healthequity/whatis/index.html


  1. Health Equity. WHO. https://www.who.int/health-topics/health-equity


  1. Should Physicians Be Able to Refuse to Care for Patients Insured by Medicare?" AMA Journal of Ethics, December 2023.

  2. Reducing the influence of politics in healthcare, by Donald H. Marks, on this blogsite. 

  3. Jonas Salk, Polio Vaccine and Vaccinating Against Hate by Donald H. Marks, on this blogsite. 

  4. Better is Possible: ACP's Vision for the U.S. HealthCare System. My comments. by Donald H. Marks, on this blogsite. 




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