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On Treating The Poor Without Going Through Texas Medicaid

Just over three years ago, the demise of Project Access Dallas was ushered in by the creation and approval of the State of Texas Medicaid 1115 Waiver. With no intended malice, the state reined in the rapid rise of Medicaid costs by expanding Medicaid HMOs across the state. But independent physicians haven't seen much of that money. For those who have a desire to treat the underserved, what's the best thing for them to do?
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Before you get too far into this article, let me tell you — it’s all about Texas Medicaid. It’s generally believed that most Dallas physicians don’t take care of Texas Medicaid patients, so this article might not seem to be relevant to most readers. But, I ask that you hang in there with me.

While I was volunteering in a local charity clinic recently, a young adult female Hispanic patient asked for my assistance. She was worried about a pelvic ultrasound report she had received after visiting a local hospital ED a few weeks earlier.

Just over three years ago, the demise of Project Access Dallas was ushered in by the creation and approval of the State of Texas Medicaid 1115 Waiver. With no intended malice, the Texas Health and Human Services Commission implemented its plan to rein in the rapid rise of Medicaid costs by expanding Medicaid HMOs across the state. Because Medicaid is jointly funded by both federal and state governments, a waiver had to be developed and submitted to obtain federal government approval of the state’s planned changes to Medicaid.

The young woman had been experiencing an unusual amount of lower pelvic pain for a number of months and had not been able to find a physician who would see her. A few weeks earlier, her pain escalated suddenly and she went to a local emergency room where she received an examination and a pelvic ultrasound.

The waiver was approved by the federal agency, called the Centers for Medicare and Medicaid Services, and with the approval, Texas also received a federal commitment to infuse additional funds ($29 billion) over the subsequent five years to help reform the healthcare safety net’s delivery system. The waiver also covered the uncompensated health care provided by many of the state’s hospitals that help create our safety net. Interestingly, the hospitals that qualified as safety-net providers ranged from those in small rural West Texas counties to the largest private urban/suburban not-for-profit and for-profit hospital systems.

The ultrasound report had been sent electronically to the charity clinic at the time her post-ED follow-up appointment was secured. The clinic’s full-time primary care physician, a good friend of mine, had just finished his long day and wished me luck as he left for home. Typically he would have fielded this type of case during a daytime appointment. But the patient, so concerned about something she heard in the ED, took the first available appointment in the evening — the evening I was to volunteer.

It took more than a year, but the new Medicaid waiver funds began to flow into the state’s safety-net hospitals. The infusion was like a blood transfusion to some of the state’s “anemic” facilities, helping them create new systems of care for the poor, uninsured and vulnerable populations that have difficulty receiving care. For the other, more fortunate, hospitals, the funds were cause for celebration as their bottom lines improved considerably. Noticeably absent, with only a few exceptions, was any meaningful financial support for the physicians who routinely supported the improvement in care delivery for the same at-risk populations.

My experience volunteering typically has been a very rewarding opportunity, rounding out my life’s work as a physician and increasingly keeping me connected to the critically important work of creating a more just society. In volunteering, I received the gift of meeting literally hundreds of colleagues committed to helping relieve much of the unnecessary suffering among the poor.

It is more than a coincidence that since the waiver, most, if not all, of DFW’s hospital systems have reported some of the largest profit margins in a generation. It is hard, if not impossible, particularly in Texas, to say anything negative about successful hospital business operators who can generate higher profit margins. In fact, the community receives a tremendous benefit from the increase in employment (but not necessarily taxes from nonprofit hospitals). As we look around, we simply can point to the building boom as evidence of the tremendous economic impact that the 1115 Medicaid waiver has had on North Texas.

When I introduced myself to the patient, I noted the cold, moist stickiness of her palm when I shook her hand. Her quivering voice told me that this interaction was going to be somewhat different than the typical hypertensive diabetic patient I was accustomed to seeing in the evening clinic. As I pulled up the pelvic ultrasound report on the computer, I read the words that must have been communicated in haste by the ED physician, as he reinforced the importance of keeping her follow-up appointment, while prescribing some pain medication to hold her over until her visit. As I completed the report, I read the words “consistent with a high probability of carcinoma” and slowly realized that her fear must have tortured her as she waited for her appointment.

As it turns out, the North Texas healthcare building boom has not been strategically focused on improving the delivery system for the area’s vulnerable populations. Instead, there are more than 100 different “waiver-funded” projects underway, some of which fund primary and behavioral healthcare access. However, the actual delivery system reform desired by the CMS has yet to materialize in meaningful ways, particularly the critically needed clinically integrated primary-specialty care when patients enter the healthcare system through local hospital EDs.

She asked the obvious question before I even had a chance. Somehow she had already figured out that if she had been referred to a primary care charity clinic with a report suggesting a “high probability of cancer,” the local ED physician did NOT know how to help her gain access to a cancer specialist. In fact, she asked if the hospital ED physician had actually seen a patient like her before (e.g., uninsured, in pain, high probability of cancer).

She didn’t know I knew that the hospital she had visited was receiving waiver funds that reimbursed it for her uncompensated care, as well as additional funds to help achieve “health delivery system reform.”

In Texas (at least in North Texas), this is our reality. An alternative view may point to a booming economy along with unprecedented wealth accumulation and low unemployment. Yes, there is also a world-class public hospital — Parkland — and a world-class medical school with a residency program that reduces the wait for urgent specialty services so frequently referred from Dallas hospitals (those receiving waiver funds).

I picked up the phone and called my buddy. I knew he would answer after a long day because he was one of those physicians who had committed his career to serving on the front lines of America’s journey to create a more just healthcare system. Talking to him always encouraged me because in his work he showed no disconnect between what he did every day and what he believed. As we discussed the case and his recommended solution, my anger grew with each sentence. He described how I should carefully reassure the patient that he would help her gain “special” Parkland access for potential cancer patients who need semi-urgent access to avoid the long lines at the oncology clinic.

I was astonished that she was so happy. She settled back in her chair and listened as I explained that we would be able to help get her condition evaluated fairly quickly. As she got ready to leave, she said thank you, and I felt empty because all I did was make a phone call to a buddy who told me how to navigate a broken system. I was disgusted.

We have a choice here. We can “soldier on” and simply turn our heads to focus on our own private practices and revenues. Or, we can volunteer occasionally to serve on the front lines in a local charity clinic, or behind the scenes in the political process to try to create a more just healthcare delivery system. My hunch is that if you take some time to get involved, you may experience the same disgust with the broken system that we all have come to tolerate, and you may come to the conclusion that doing nothing is not an option. Maybe waiver money is not really the core issue. Maybe complacency and inaction play the bigger role in a broken system.

So, if you live in Texas, and you know the system is broken, what would compel you to act?

Dr. Jim Walton, the author, is president of the Dallas County Medical Society and CEO of the Genesis Physicians Group. 

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