OP-ED

How Can Patients on Medicaid Possibly Be Worse Off than Those Who Don’t Have Insurance?

“Extraordinary claims require extraordinary evidence,” said Carl Sagan.

The claim that health insurance improves health outcomes is hardly ground breaking. Studying whether insurance affects health status is like wondering whether three meals a day lead to a higher muscle mass than total starvation.

Well that’s what I thought. Until I read the study on Oregon’s Medicaid program by Baicker and colleagues in the NEJM earlier this year and, more recently, Avik Roy’s short treatise “How Medicaid Fails the Poor”.

Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance. That is, no insurance no difference.

The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables. There is only so much rigor social science can achieve compared to the physical sciences. Yet this is about as good a study as is possible.

The one thing the study did not lack was sample size. It’s useful to bear in mind sample size. Large effects do not need a large sample size to show statistical significance. Conversely, if study with a large sample size does not show even a modest effect, it means that the effect probably does not exist.

There are several interpretations of the Medicaid study, interpretations inevitably shaped by one’s political inclination. The ever consistent Paul Krugman, consistent in his Samsonian defense of government programs against philistines and pagans, extolled critics of Medicaid as “nuts” and asked, presumably rhetorically, “Medicaid is cheaper than private insurance. So where is the downside?”

Unlike Krugman I am not a Nobel laureate and am about as likely to win a Nobel Prize as I am of playing the next James Bond, so it’s possible that I am missing something blatantly obvious.  Could the downside of a government program paying physicians, on average 52 cents, and as low as 29 cents, for every dollar paid by private insurance in a multiple payer system be access?

Indeed, it’s darn impossible for patients on Medicaid to see a new physician.  As Avik Roy explains “…massive fallacy at the heart of Medicaid….It’s the idea that health insurance equals healthcare”.

But wait. It gets better.

I am accustomed to US healthcare throwing more plot twisters than Hercule Poirot’s sleuth work. But one I least expected was that patients on Medicaid do worse than patients with no insurance (risk-adjusted, almost). I am not going to be that remorseless logician, which John Maynard Keynes warned us about, who starting with one mistake can end up in Bedlam, and argue that if you are for Medicaid that is morally equivalent to sanctioning mass murder. Rather, I ask how it is possible that possessing Medicaid makes you worse off than no insurance whatsoever.

To some extent this may artifactually appear so because poverty correlates with ill health, and studies that show Medicaid patients faring worse than uninsured, cannot totally control for social determinants of health.


However, I found a plausible explanation during a recent conversation with a physician specializing in physical medicine and rehabilitation (PMR). She ran a special clinic one day a week in which she saw adolescents for free. These kids had no insurance. They were mainly from the local Hispanic and African American communities.

She did not accept Medicaid patients. This point is worth parsing out again. This doctor is happy to see patients uncompensated but not Medicaid patients, partially compensated.

Why so, I asked, bewildered and feeling that I must be in Bedlam.

The physician explained that the transaction costs in billing Medicaid are so high, that it’s not worth the tiny return. Plus one is exposed to unintentional billing fraud, audits, compliance and perpetual war with formularies and pharmacies. She ran her practice as a small business and kept her support staff to a minimum; she simply could not afford the legal and coding help that this would entail.

Ahh, I asked with that “gotcha” feeling, why could she not see Medicaid patients for free on the clinic day that she sees other youngsters uncompensated.

She explained that if she saw all Medicaid patients for free she would technically be committing fraud. Unless she made a nuanced determination to waive fees on an individual basis. At any rate it would unduly burden her, and it was a good deed that best remained unpunished.

Again this is worth parsing out because this is so mind-boggling. Seeing all patients on Medicaid for free is fraud! That’s what this physician believed and what I am told many physicians believe.

I am a simpleton. When I hear “fraud” I think of Madoff, Ceausescu and saying you were given the wrong beer after finishing two-thirds of the bottle at a restaurant. I also understand that after attending law school one’s tryst with simplicity ends forever.

Even though this is probably an exaggerated application and interpretation of the Anti-Kickback Statue, it is difficult to resist the urge to violently shake the framers of Medicaid statutes and yell “what on earth were you thinking, sir and madam?”

Medicaid is a prickly issue. It polarizes. The left sees any attack on Medicaid’s effectiveness by the right as an excuse to throw the program out and replace with nothing. This is plainly shooting the messenger, sometimes. The Pavlovian reaction is understandable as some on the right see in Medicaid scientific vindication of their anti-welfare stance.

But if an individual loses 30 pounds despite a complete diet inquiring about the underlying problem, whether there is a malignancy or not, does not challenge the value of eating.

How utterly incurious must one be to not wonder after the Oregon experiment and several other studies, why? How can you possibly not at the very least inquire whether Medicaid is a structurally sound program?

Roy’s opinions are a little to the right in health policy. But he accepts as do many on the right that the poor should not be thrown under the bus. On Medicaid, the left and right are in that rare agreement.

The mark of a civilized society is how it deals with the poor who are sick. An intelligent society distinguishes itself from an ideological one by acknowledging that the system in which the poor remain sick needs restructuring.

A Manichean view would regard rapacious capitalism as the cause of all ills. But rules and regulations of leviathanic proportion hurt. And we would shock even Mr. Limbkins if we asked for “More” of the same.

Saurabh Jha, MD (@RogueRad) is an Assistant Professor of Radiology at the University of Pennsylvania. His scholarly interests include the value of imaging and dealing with uncertainty in clinical decision making. Jha views most problems in medicine as problems of imperfect information. He trained in the UK and migrated to USA for more predictable weather and a larger yard.

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erotic thoughtHeatherDaniel BS. HartRadsDoc64 Recent comment authors
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Heather
Guest
Heather

As a person that has had very good insurance to no insurance to Medicaid to good insurance again, I have experienced being a patient under all these umbrellas. What I found are very clear problems. First, I had a difficult time finding a doctor who would accept me as a Medicaid patient. And, when I did, I was treated more like a number than a person. Unfortunately, more doctors than not were stern and acted bothered they had to deal with me. I had one doctor actually cuss when he saw I had Medicaid. I was in shock and didn’t… Read more »

Bob Hertz
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Bob Hertz

Radsdoc, I appreciate how you are trying to work through the costs of health care. It ain’t easy. You wonder why technology raises health care costs, while it lowers costs in other sectors.. You blame government. The Say that in the past we could treat heart attacks with two weeks of bed rest. Now we have angioplasty and stents. I had a heart attack myself and I went home in 3 days. What I think has happened is that hospitals used to charge $15,000 for two weeks of care, and now they charge $15,000 for 3 days of care. The… Read more »

Bob Hertz
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Bob Hertz

Lot of good ideas here, but let me offer one clarification: the $450 billion spent on Medicaid does NOT all go toward primary care for poor people and their ER use. over two thirds of the $450 billion goes for nursing homes and for very expensive care for disabled persons. The young mothers and their children in the shabby clinics are not what is driving Medicaid spending. One other note while I am thinking of it: Radsdoc64 wants private ambulance services………I think we have that now! Many Americans are hit with $1500 bills that are not covered by insurance or… Read more »

Saurabh Jha
Guest
Saurabh Jha

I am under no illusion, and neither should anyone else, that treating the most economically disadvantaged section of society costs. Of course, I think it is worth the cost.

MD as HELL
Guest
MD as HELL

Even county EMS bills patients in North Carolina. Whether they collect from the uninsured is unlikely, but they do bill Medicaid/Medicare/Tricare/Blues/Commercial.

Funded by tax dollars unleashes the taxi mentality. It must never be free. It must cost the user something and the programs supporting the patient must collect the copay and fully pay the provider of the service.(Medicaid/Medicare, etc.

It should have been that way all along…would have prevented lots of abuse.

But these are political programs, afterall. No real actuarial basis for them.

The government will never enforce any negatives on the 47%ers.

Bobby Gladd
Guest

“The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables. There is only so much rigor social science can achieve compared to the physical sciences. Yet this is about as good a study as is possible.”
___

WHAT? With degrees of freedom in the single digits (on a per patient basis, after only a couple of years)? Statistical naivete on steroids. Glomming them all together just gets you a a blob, a “Glom”, the ostensibly impressive aggregate “n” notwithstanding.

Saurabh Jha
Guest
Saurabh Jha

How many extra Medicaid participants are needed to show a detectable effect with statistical significance?

Answer: 17 million!

What if study fails to demonstrate an effect?

Answer: further research is needed!

There is truth, damn truth & degrees of freedom.

erotic thought
Guest

Great common sense here. Wish I’d thought of that.

S. Hart
Guest
S. Hart

Strawman? It’s the title of your blog post.

Saurabh Jha
Guest
Saurabh Jha

Pat yourself on the back! It’s all about having good intentions!

S. Hart
Guest
S. Hart

Quick follow-up – given your own comments to Peter1 about the value of randomization over cross-sectional data (and that you’re a physician so you understand RCTs) – the Oregon study should absolutely put to rest the spurious notion that Medicaid is worse than no coverage. And it should absolutely put to rest the notion that Medicaid doesn’t improve people’s access to care. While evidence of health benefits of coverage may be less clear, can you show me *any* evidence from the Oregon papers that people suffered by getting Medicaid? Doesn’t that answer the question in your title? “How can patients… Read more »

Saurabh Jha
Guest
Saurabh Jha

The penchant for citing studies that support one’s argument is prevalent across the political spectrum. So forgive me for not taking a binary view on this. I did not say the Baicker study showed Medicaid patients did worse than uninsured. Nevertheless, congratulations for destroying a strawman. I did say that some studies did show that remarkable finding (they do) that risk-adjusted Medicaid patients do worse and expressed incredulity (see comment regarding Carl Sagan). I also expressed incredulity that many physicians would rather see patients for free than Medicaid patients. This is the voice from the trenches, not ivory towers. For… Read more »

S. Hart
Guest
S. Hart

Roy likes to cite cross-sectional studies with minimal risk adjustment for the things that truly differentiate Medicaid patients from others – education, health literacy, clinical complexity, and social circumstances. They’re terrible studies for evaluating the causal impact of Medicaid – and if you read the original papers, the authors generally don’t claim they are doing so – Roy knowingless takes them out of context. The Oregon studies are air-tight in terms of casual inference, but only small numbers of people in the study actually had diabetes or high blood pressure in the first place. (By the way, do we not… Read more »

RadsDoc64
Guest

Saurabh- As you seem to concur, the private charity model can work with PCP’s . I also see no reason why urgent care centers could not be funded and operated in similar fashion- with funds and time donated voluntarily by private citizens, corporations, religious organizations, etc and staffed by voluntary medical providers. All of the above could be incentivized by revising the tax code to include tax credits or tax deductions to donate time and money to build and sustain private medical charities. I disagree about the idea of interdependence blurring the concept of individual rigthts or private property. If… Read more »

Saurabh Jha
Guest
Saurabh Jha

There is a lot of political philosophy and a smidge of objectivism in your post.

Private charity would be messy, non-uniform and, over time, systematically punish the givers. It may not.

What if a person needs emergency bypass surgery or management of arrhythmia? Would you want to live in a society where he cannot access those because his income falls below FPL?

To a large extent, it becomes irrelevant whether healthcare is a right or not.

The most vulnerable section of society cannot be abandoned to the caprice of charity.

RadsDoc64
Guest

Correct me if I’ m wrong, though given what you have pointed out above, I think you just described Medicaid, not private charity: “… messy, non-uniform and, over time, systematically punish the givers.” Even despite the current system, of extremely high taxation to involuntarily fund a poorly function government medical program like Medicaid and others, leaving them with less disposal income, every year Americans donate hundreds of millions of dollars to health-related charitable organizations such as American Red Cross, American Heart Association, Leukemia & Lymphoma Society, St. Jude’s Children’s Hospital, the Dana Farber Cancer Center, the American Cancer Society, and… Read more »

Peter1
Guest
Peter1

Doc64, Charity donations are already tax deductible – for only those who itemize, one of my pet peeves. Expanding tax compensated care is getting to single pay. If you want taxpayers and insured to save money then you’re going to have to reduce prices. How do you plan to do that? Negotiating with hospitals is mostly ineffectual even with non-emergency care. Who do you negotiate with – the radiologist, the surgeon, the anesthesiologist, the doctors group, the drug company, the device provider? What standards does the hospital use to judge why patient A pays more than patient B? What negotiating… Read more »

RadsDoc64
Guest

Peter1, yes, on the palatial granite lobbies and consolidation into mega hospital systems that jack up overhead costs, creates local provider cartels, lower competition and result in inflated medical prices. Bear in mind these are all responses to and consequences of government regulation in one form or the other – and bad government policy in the health insurance market – not of a free market. Regarding charity care, Medicaid is not “charity” by any stretch of the imagination or rational definition – since it is based purely on coercive govt taxation – rather than voluntary contributions. As such, it violates… Read more »

Peter1
Guest
Peter1

“Bear in mind these are all responses to and consequences of government regulation in one form or the other” Hogwash. Government does not dictate architectural design. The fact that hospitals are in competition with each other is the reason they build what people blindly perceive will give them the best care – competition is the devil. Mega hospital systems are a natural course of corporate expansion. What you despise is capitalism health care – how do you wish it be ended, by “government” action? I see by your comments you are a Libertarian – one step above anarchy. Libertarians profess… Read more »

Saurabh Jha
Guest
Saurabh Jha

I would be inclined to agree with 64 on this. The hospital prices is not free market capitalism. There are no price signals. The consumer, for want of a better term, does not incur the marginal cost of the marginal benefit.

Prices are distorted by third party payers.

The system has a lot of faults but adhering to free market capitalism is not one of them.

The role of the government is both necessary and necessarily complicates. The pill and its side effects are inseparable.

Peter1
Guest
Peter1

Well Doc64, you must be for people in the health system earning less so “middle-classes” can afford their services? Does that include you? I’m no supporter of the medical/insurance-industrial complex (I’m uninsured by choice) but as with most physician sponsored “solutions” their main goal is to make docs life better, not necessarily patients lives, and they are driven by PCPs outside the hospital system, where, for the most part, costs don’t drive financial hardship. It’s the hospital charges that are killing us, the ones where there is no way to “negotiate” before services are provided. As with all negotiation each… Read more »

Saurabh Jha
Guest
Saurabh Jha

I am inclined to agree. It’s the worst form of healthcare, other than all other forms of healthcare (to slightly and clumsily paraphrase Churchill).

RadsDoc64
Guest

Peter1- <> I am ‘for’ health care providers earning whatever income they will – same , higher, or lower- through a completely private system of voluntary trade by mutural benefit to mutual advantage between consumers and providers of health care services. I am ‘for’ patients having personal and portable, tax deductible real health insurance policies which protect them from bankruptcy by covering catastophic health caree costs, rather than the 3rd party payer scheme of utilizing and enriching 3rd party payer and government middlemen/ bureaucrats to process paperwork just so I can get a chest xray or lab test. I am… Read more »

Saurabh Jha
Guest
Saurabh Jha

In this perfect system that you so eloquently describe will ambulance services be provided by the market or the government?

Because when I am having a questionable MI I really want to make sure that I get the tier care I paid for, nothing more, nothing less.

RadsDoc64
Guest

Private ambulance services would be abundant since there would be no shortage entrepreneurial, skilled health care providers looking to earn a living by plying their trade and fulfilling a real need in society for stabilitizing emergency medical services and transport.

Not sure what government could possibly add running an ambulance service in terms of medical skill, efficiency or anything- except in terms of layering on tons of waste/ fraud/ cost and bureaucratic paperwork-about the only thing government does well.

Saurabh Jha
Guest
Saurabh Jha

In a restaurant you get Caviar when you order Caviar.

If I suddenly collapsed in a shopping mall how will the passerby know whether to call Ambulance Caviar for the Hot Heart Institute with a door to balloon time of 15 minutes, or Ambulance Good Enough for the Oliver Twist Institute for the Destitute with a door to balloon time of eternity?

Barry Carol
Guest
Barry Carol

RadsDoc64 – Thanks for one of the more interesting comments I’ve read in some time, especially as it relates to the cost of hospital care. I printed out the Friedman paper and will read it later. What I wonder about is the comparison of current U.S. hospital costs to those in other developed countries which I believe are much lower. Aren’t they also subject to similar stringent government regulation? Also, to what extent has the massive proliferation of new medical technology developed over the last 50-60 years impacted healthcare costs in the U.S. and elsewhere? My perception is that during… Read more »

RadsDoc64
Guest

Thanks for your comments, Barry Carol. Regarding the price of hosptial care, I have no doubt that hospital prices in other countries are lower, though I would examine closely the concept of “similar stringent regulation”. Most of the health care systems in the rest of the world are government run and paid for – completely socialized single payer. In contrast, the US has been over 50% socialized since the institution of Medicare and Medicaid, has only increased over the past 50 years and is well on its way to a wholly run government system. In a government run single payer… Read more »

Saurabh Jha
Guest
Saurabh Jha

Free at point of service increases demand, I agree.

But demand is also a function of what is there. You can’t demand something that does not exist.

In your analysis you should ask whether the US healthcare would have reached this size through the market.

Peter1
Guest
Peter1

“dictating whatever arbitrary price it wants”

That is completely false. You state this as if the providers, device makers and drug companies are slaves – they are not, and any negotiated prices/compensation has to be tempered with the fact that these entities can withdraw their services.

Peter1
Guest
Peter1

So you’re for compulsory non-group individual policies which are tax deductible? How do you police hospital “price gouging” when there are no competitors in a market? “some of which are fascist in nature” Examples? “A crap system everywhere it’s been tried” Seems no one in those “crap systems” are looking to overthrow them. “equally lousy care on waiting lists for all” http://www.washingtonpost.com/blogs/wonkblog/post/americas-waiting-times-are-the-worst-in-the-world/2011/05/09/AFGIxr2G_blog.html Wait lists are a creature of cost control, or if you will rationing. Everyone is trying to manage them to balance between cost and access, especially in a growing aging population. You seem to think we can have… Read more »

Peter1
Guest
Peter1

“The consumer, for want of a better term, does not incur the marginal cost of the marginal benefit.” The uninsured cash pay sure as hell does. The insured see their deductibles, co-pays and premiums rising but are locked in a “can’t do without” service. The employer system sees the “marginal benefit”, especially those self insured. We accept and support fire departments and water/sewer systems and road construction and police as necessary government run services paid through taxes, and we support private utilities being regulated by government, but somehow can’t fathom health care and its necessity as better handled by government.… Read more »

Saurabh Jha
Guest
Saurabh Jha

The costs are diffused, therefore no longer marginal, and the benefits uncertain, so also not marginal. Regardless, the pricing is distorted. Imagine if hotel in Vegas has guaranteed 90 % occupancy. The 10 % price is affected by the certainty of the 90 % occupancy.

The comparison to other public services is interesting. I don’t have a counterpoint at this moment but will have to think a bit about the NHS.

RadsDoc64
Guest

I would say alternatively that the mark of a civilized society is how its government and its citizens deal with the issue of individual rights. Does its government respect and protect the individual’s right to his or her own life, liberty or property? Do its laws forbid violation and punish violators of those rights? Or does the government actively violate the rights of its citizens through its laws and serve as an agent for the legalized and institutionalized violation of individual rights, liberties and property rights of its citizens ? This is the difference between a civilized society where individual… Read more »

Saurabh Jha
Guest
Saurabh Jha

In your model of voluntary private charity the do-gooders will be out of business quite soon. This can work at the level of the PCP but not emergency department. Indeed, this was one of the reasons that EMTALA was instituted.

It’s good to protect individual rights, but society is far more interdependent today than 200 years ago. Defining private property is difficult.

Peter1
Guest
Peter1

“An excellent example of a working model for providing care to the indigent has been operating in NJ for years and is described here.” “As the declining economy erodes America’s middle class, the nation’s healthcare system continues to spiral out of control, sending even more patients to this free clinic: From 1,700 patient visits in 2007, the clinic is on track to see 3,000 this year.” “Meanwhile, people like Amal found it hard to buy individual health insurance policies. Policy-makers in New Jersey, where Amal lives, have so generously defined the benefits required for a standard policy that individual insurance… Read more »

Bobby Gladd
Guest

Ayn Rads, your “rights” exist to the extent that the rest of society will uphold and defend them.

RadsDoc64
Guest

Bobby Gladd, You seem to be confused regarding the difference between rights and permissions- like many people- including all statists. Clearly, my individual rights still exist, regardless of whether an individual or group or government chooses to respect and protect them. For the purpose of clarification: “A right is the sanction of independent action. A right is that which can be exercised without anyone’s permission. If you exist only because society permits you to exist—you have no right to your own life. A permission can be revoked at any time. If, before undertaking some action, you must obtain the permission… Read more »

Saurabh Jha
Guest
Saurabh Jha

Regardless of how intuitive the definition of a right, safeguarding its purity and its logical origins is down to the will of the majority. It should not be (ideal world) but it is (real world).

In a system in which a certain section of the population is systematically disenfranchised, for whatever reason, these people will have little sympathy for the property rights that you so neatly define, if it means that they can vote for policy that makes their lives easier and if those policies interfere with the theorems of Ayn Rand or Euclid..

RadsDoc64
Guest

Saurabh, I think you will agree that you cannot safeguard, protect or implement any principle or policy without first defining and understanding what it is you are trying to implement or protect. As such, definitions matter. What your comment demonstrates though is the importance of definitions – as well as the well accepted fact that pure “democracy” in and of itself is synonym for – or political system – which leads to freedom, but rather tyranny. When the mob is empowere to vote on any and every issue- including the issue of whether or not any individual in society has… Read more »

Bobby Gladd
Guest
Bobby Gladd

Wonderful, Ayn.

Bobby Gladd
Guest

“Without legal protections and institutions to carve out the issue of individual rights from democratic vote, democracy just degenerates into packs of wild dogs seeking to devour each other for survival.”
__

Do you inhabit a permanent irony-free zone?

“Legal protections”

Which have to be administered by society. Again, your “rights,” as empirical matters, exist to the extent that others will uphold and enforce them.

Theoretical philosophizing is great fun, to be sure, but it falls short of encompassing coherent reality, as aggravating as that might be.

Deductive axiomatic proofs work fine in Algebra I.

Peter1
Guest
Peter1

I read your article several times and still don’t get it.

“The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables.”

Is this even possible given all the variants?

Did the study tell us how they are worse off? Could we say then that Americans seeing doctors are worse off than those who don’t see doctors?

I would say that the “right” is better described as not wanting to be “seen” throwing the poor under the bus. Policies, especially in the south, feed them slow untraceable poison.

Saurabh Jha
Guest
Saurabh Jha

The Medicaid expansion in the Oregon study was on the basis of a lottery, providing the randomization that is near impossible, as you recognize, is social science research. Several other studies have shown that Medicaid patients have worse outcomes than the uninsured, after risk adjustment. These studies are not as well designed as the Oregon, meaning no randomization. The crucial point is Medicaid does not mean access. The question to ask then is why is access so difficult. I am sure you are right in stating that many on the right do not want to be seen to throw the… Read more »

Saurabh Jha
Guest
Saurabh Jha

In the long run, as Keynes said, we are all dead.

Saurabh Jha
Guest
Saurabh Jha

Colin, thanks for your response. If a large study failed to show that stents (very costly) improved cardiovascular outcomes over medications (far cheaper), I doubt we would be discussing the nuances of hypothesis testing. For a program that costs $450 billion a year, which is being expanded, and which will have a tab of $ 7 trillion over 10 years, failure to show a difference with statistical significance is significant. I would suggest a Bayesian rather than a frequentist approach. What were your priors (minus post hoc adjustment)? Did the results change them? Can your priors ever be changed? I… Read more »

Bobby Gladd
Guest

“I expected Medicaid to move the dial”
__

Premature. That’s all.

Colin
Guest
Colin

1. Thanks for the piece. These studies are really interesting and come as close to testing certain policy assumptions as any studies that I can remember. 2. People have overreacted to these studies as far as how important they are for Obamacare. Sarah Kliff has a good piece about how we should be measuring success/failure for that program: http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/02/four-ways-to-tell-if-obamacare-is-working/ 3. “Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance. That is, no insurance no difference.” You accepted a null hypothesis here, which is fallacious under null hypothesis significance testing. Remember… Read more »

Saurabh Jha
Guest
Saurabh Jha

Shane, thanks for sharing experience. More voices from the trenches ought to be heard.

Shane Irving
Guest

Being based in Oregon I’ve had the pleasure of watching the development and failings of Oregon Medicaid from the inside. Yes, the reimbursements are horrible. The CCO that I am familiar with reimburses specialists at around 25% less than Medicare (which is even less when you remember that Oregon has some of the lowest Medicare rates in the US). Last year they switched to a highly managed care model with a huge amount of hoops put in place for Pre Auths and Referrals. Then the denial and constant medical necessity appeal process started. Five times as much work for less… Read more »