Stranded with Medicaid

     Two weeks ago, Mr. R., age 44, had his first doctor's appointment with me.  He hadn't had a medical check-up in decades because he'd never had insurance.  But he and his family just got approved for Medicaid, the state funded insurance for people who are poor.  (A family of four can get Medicaid if the total family income is less than $382 per month--which is $4,604 per year.  An individual qualifies if his monthly income is less than $205 per month--$2,460 per year.)
     I gave Mr. R. a button-down gown, examined him from top to toe, and said, "I need to remove that mole on your arm, immediately."
     "But I've had it all my life," he countered.
     "All the more reason," I said, and refused to argue.  The nurse set up the surgery room.
     Yesterday the pathology report came back:  malignant melanoma.  Mr. R. returned to the clinic to have his sutures removed, and I gave him the news.  He would need a second surgery to remove a wide area all around this ominous skin cancer, or it could spread to his liver, brain, or lung--and cause death.
     "But that mole has never bothered me at all," he said.
     "That's why it's so scary," I told him.  "Melanoma doesn't hurt, and may look like the same freckle you had as a kid.  But it grows downward, and can metastasize to other organs before you have a single symptom."
     "Whoa," was all he could answer.
     I breathed a sigh of relief, as I studied the lab's microscopy report.  The patient's melanoma was 0.38 cm in depth, and was characterized as a "carcinoma in situ," with a Clark's scale of 2a--which meant there was a low probability that the cancer had spread outside the area of the innocent-looking mole.
     If I could get him to a specialist, and make sure a much larger area of full-thickness skin was excised around the original surgery site, he would be home free.  I told him that, after a second surgery, he would have to come back every six months for a complete skin exam (patients rarely identify melanoma correctly).  Any new or changing freckles would need to be biopsied.  "No problem," he said.  I had already done blood tests, an ultrasound, and a chest x-ray to check for evidence of the cancer having spread to his liver or lungs.  All the studies were fine.
     Then my referral clerk informed me that there wasn't a single dermatologist in the county who would see the patient.  "No one takes Medicaid," she said.  "I've called them all."
     "What about Shands Hospital?"  I asked.  Shands is funded with state and federal dollars, and I knew that the University of Florida doctors there accepted Medicaid.
     "I sent the referral to Shands," she said, "and spent all morning talking to the dermatology and plastic surgery people. "  She let out a deep, exhausted breath.  "They won't accept a Medicaid patient who isn't already in the system."
      I knew she was right.  In the past two years I had sent numerous referrals to Shands Dermatology, requesting that they see patients with skin problems too serious for me to handle alone.  In every case, the response was a form letter telling me that the Dermatology Clinic was not accepting patients with that insurance at this time.  The rejected patients were always the ones with Medicaid.
     So I made a personal call to the Plastic Surgery department.  I wasn't sure if, based on his pathology report, this patient needed a one-centimeter, or three-centimeter--or even larger--margin of skin removed from around the melanoma to ensure it would never come back.  And I needed someone to do the surgery.
     One of the plastic surgeons, Dr. D., spoke to me.  I explained my dilemma.
     "Sure, we can take him," Dr. D. answered, without hesitation.  "I'll do the surgery."
     Yes, I rejoiced!  It was just like the old days, before most doctors had left private practice to sign on with hospitals, HMO's and large, multi-specialty groups.
     Back then, I never used to have trouble getting proper care for my patients, no matter what insurance they had.  Even when they had no insurance, and couldn't pay at all, I could find a specialist who would take care of seriously ill patients.  Doctors in private practice have the luxury of making their own decisions about which patients they'll accept, and their primary motive is to do what's right, not to collect payment.  Besides, if a specialist were to come through for one of my patients who couldn't pay, I'd be sure to send many other patients--who could pay, or had "good" insurance--in the same direction.  I was perpetually grateful to these big-hearted physicians:  to my mind, they were the essence of what's honorable about our profession.
     Then, very gradually, things began to change.  First, those dependable doctors left solo practice and joined groups.  Then, they weren't so interested in seeing my patients--although they still tried to help.  Maybe they were forced to follow rules that originated in a narrow view of business success, rather than in human ethics.
     I knew the trend was irreversible when a patient came to my clinic nine or ten years ago, with a true emergency:  he had amputated his finger with a chainsaw.  It was hanging from a flap of skin.  I splinted and bandaged it, then called every orthopedist I knew, begging one after another to see my patient.
    "Send him to the E.R.," they advised.  But the patient absolutely refused to go, especially not by ambulance.  He couldn't afford the E.R.  "I'll just lose the finger," he said.
     He kept asking me, a family doctor, to fix him, and he was bleeding badly.  Finally, one orthopedist gave me step-by-step instructions, over the phone, for repairing the finger:  stitch the tendons, staunch the bleeding, set the bone, administer IV antibiotics, apply a splint--"and hope for the best," he explained.  Then, as an afterthought, he said, "The guy will probably be all right."
     I rushed back to the patient, petitioning my Catholic saints with prayer after prayer, as I followed the orthopedist's directions.  Then the patient went home.
     Every day for two weeks I checked his wound, dressed it, and said a Hail Mary.  Six weeks later he was healed!  He could move his finger in almost every direction.
     But this time will be different, I thought.  Dr. D. at Shands said he'd accept my melanoma patient--what a relief.  I asked him to sign the faxed consult request.  "Sure," he said.  "But let me check it out with the office manager."
     Then he called back.
     "I can't believe it," he apologized.  "I had no idea the system worked like this.  The office manager says I can't take your patient."
     "Are you being told what to do by an office manager at Shands?"  I asked.  "What about me?  I need you.  And what about my patient?"
     "It just seems so crazy," he said.  "We do take Medicaid--but we can't take a patient who isn't already in the system."  He meant that the patient had to have been referred from a Shands physician, not a community doctor like me.
     "Not even for melanoma?"  I asked.
     "I guess not," he answered.  "But if I were in private practice, I'd take your patient."  I liked his conviction, and suggested he leave Shands to open a private practice.
     "Well, not right now," he demurred.  "Things are too uncertain."
      Then he tried to help, in the same way the orthopedist had helped me years before.  He gave me step-by-step instructions for doing a second skin surgery of my patient's melanoma site.  He told me how big the margins would have to be, based on the latest guidelines, and he said the depth should be to subcutaneous tissue, as I had done in the initial surgery .
     Therefore, I'm going to see Mr. R. next week, and do the surgery he needs.
     But now my billing specialist tells me the codes for this surgery aren't covered by Medicaid, not for family doctors.  "They'll only cover those particular surgery codes for dermatologists or surgeons," he explained.
     "Did you call the people at Medicaid?"  I asked.  "Did you ask them why they won't pay for a surgery the patient needs, and I've agreed to do?  Do they know there isn't a specialist who will do it?"
     "They say they won't cover it because family doctors don't do that surgery," he said, shrugging his shoulders.
     I wonder how the people at Medicaid know what family doctors do, and don't do.
     Mr. R. said he's glad he isn't going to Shands.  "I like it here," he told me.  "I want you to do my surgery."
     Despite my patient's confidence,  I'm already calling on those Catholic saints to stand by during the surgery.  To be honest, I put them to work all the time, week after week--and, so far, they haven't let me down.