This year might make or break James Island pediatrician Dr. Helen Bertrand. A steady increase in Medicaid patients during the past decade could push her out of business.
Medicaid reimburses doctors less than the cost of care, driving many physicians to limit the number of Medicaid patients they accept.
In the past decade, the number of children covered by Medicaid has increased dramatically, Bertrand said. Exact numbers were not available from S.C. Department of Health and Human Services.
"Coverage does not mean access," Bertrand said. "If it's not adequate coverage, you can't get the kids seen."
And the ranks of Medicaid beneficiaries are expected to grow. Under the proposed South Carolina cigarette tax plan, the threshold for children would shift from 200 percent of the federal poverty level to 250 percent.
Children who fall between 150 percent and 250 percent of the federal poverty level would receive State Children's Health Insurance Program, or SCHIP.
The children's insurance program expanded earlier this year, moving the band of coverage to 150 percent to 200 percent, from the previous 133 percent to 150 percent. That increase made coverage available to another 80,000 children, said Jeff Stensland, director of public information for the state's Medicaid agency.
Unlike traditional fee-for-service Medicaid, SCHIP is a managed care plan called Healthy Connections Kids and is based on the state's health plan.
To complicate matters further, in March, managed care plans became available for traditional fee-for-service Medicaid patients. Medicaid patients must choose between two or three plans, depending on where they live, or one will be chosen for them. They can opt to remain in fee-for-service, but they must actively choose to do so.
"Now the phone calls are beginning," Bertrand said, as she and her staff must help patients navigate the new plans, which might or might not include her practice. One hanging point is medication to control behavior, she said. Paperwork is required for approval, and some plans are cutting dosages.
"It's out of our control," she said.
The system is confusing for patients, too. Natalie Backman brought her 2-month-old son, Tyler, to monitor his milk allergy. Tyler also was due for his two-month check-up, but Bertrand had to check what kind of Medicaid managed care plan he had before she could combine the visits.
Slightly less than half of Bertrand's patients have Medicaid. She has three full-time employees and has heard some say the day of the single practitioner is over. Her salary for 2007 was less than half what she made 20 years ago. Participating in medical research studies has helped her stay afloat, she said.
Rich Lindrooth, director of Medical University of South Carolina's Center for Health Economic and Policy Studies, said private practices must ration Medicaid levels to meet overhead costs. Doctors need a mix, he said, although hospital practices can cover more Medicaid patients.
Also, larger pediatric practices with several doctors might be better able to absorb a larger Medicaid patient load and overhead cost.
Compounding the problem of low reimbursement is the greater need for health care in the Medicaid population.
"If Medicaid patients required the same work as regular patients, the system would work," Bertrand said. "They need a lot of guidance. Pediatricians are in a position to have a huge impact on poverty if we are paid well and fairly enough to provide real medical homes that influence health care behaviors and choices."