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The Special Place in Medicaid for the Special Needs Child


There's a common perception that patients get worse care on Medicaid than private insurance. Several respected studies support this. Many fellow physicians tell me that the reimbursements are too low and the required red tape is too burdensome. In general, this is true. We've all seen the patients who leave the hospital face a difficulty of finding a physician that will care for Medicaid patients. That leaves them without continued care and they are readmitted for complications of conditions that would have easily been managed in the outpatient setting. Often times, people focus on the many facets of Medicaid that perpetuate its reputation as an inefficient and ineffective system. They claim them as reasons to not support expansion of Medicaid enrollment as part of the ACA. Due to poor education, drug or alcohol dependency, and other compounding social factors inherent to having a chronic and complicated medical condition, some Medicaid patients are not adherent to our medical advice.  We are deterred by the poor compliance as we physicians like to see good results for our work. Reimbursements are low and the cost of running a practice continues to rise. If the ACA is upheld by the Supreme Court this month, which means the reimbursement rates for Medicaid will increase to the level of Medicare, accepting Medicaid is not usually a viable option for the private practitioner. 

Thinking about all things can get us down right depressed but there is one area of success that makes it necessary to maintain and improve Medicaid- the special needs children. I have seen their families navigate both private and public coverages and it is striking how much support and specialized services a Medicaid patient gets with successfully advocates. No, they do not received care with a private physician. They receive care at an academic facility, usually a children's medical center. Many special needs children have endocrinologists monitor their growth, orthopedists perform the sequential procedures to correct their deformities, developmental pediatricians follow their development, and even night nurses come a few times a week to give their families some respite. 

In comparison, I've seen special needs children born to parents who initially attempt to get the best care their private insurance can offer. With expensive- to- treat conditions, their insurance quickly transfers the mounting costs to the families, usually via rescission, or lifetime caps. Even with limits on these practices by the ACA, insurance still has wiggle room to place most of the financial burden on the families. Eventually, we see a drift of the special needs children from the private sector into academic centers where the faculty remains focused on delivering the care. They can do so in an environment where the pressures to weigh the financial burden of accepting a Medicaid patient is lessened. And eventually, the patients and their families settle in a system that will deliver the care needed if the families remain committed. But then, shouldn't the main focus be getting their children proper medical care? Unfortunately, this sometimes occurs only after many battles waged with insurance denials, mounting debt, possible stigma of being on "Medicaid," bake sales, and other unnecessary heartache.

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