Serving Vulnerable Populations, Including Medicaid/Medi-Cal


(Appalenia Udell, Esq.) #1

DPC seems like a natural conduit for providing healthcare to vulnerable populations often plagued with complex health issues that cannot be divorced from socio-economic circumstances. The regulatory morass and limited means of these patients have arisen as the two largest obstacles. What else gets in your way? What else upsets you, personally and professionally? What would be the ideal integration of DPC and vulnerable populations?

(Robin Dickinson) #2

Thanks @appalenia for starting this conversation!

I’d be really interested in figuring out a Medicaid pilot that would be simple. As you know, in my current practice I switch over to FFS billing if someone’s income drops and they qualify for Medicaid. It would be lovely if instead I could just bill Medicaid for the membership.

My first thoughts are a fear that they will want me to collect data, that they will want me to sit down and bill for every person every month rather than have something automatic (though honestly, I’d cope if that happened), and that they would set the terms of the agreement. I’d also worry about my lower prices (set for my lower income area and my lower overhead practice) would set a precedent for others in the state who just couldn’t manage at my PMPM price and then the whole thing would fail if no one else would take patients.

Just some random initial thoughts…

(Appalenia Udell, Esq.) #3

@Robin_Dickinson, speaking to another CO IDPC today extremely interested in partnering on the Medicaid pilot. How would you propose to address the following:

  1. DPC “hopping,” that is, how do we preserve patient freedom of choice and also prevent duplication of service/non-compliance with treatment plan?
  2. What happens when another primary care need arises (e.g., your patient is hospitalized or admitted to a SNF)? Should that impact when and how you are paid? How should transient patients be managed? Transfer to another DPC? Should there be a network of DPCs?
  3. How would you feel if you didn’t partner with HCPF directly, what if the arrangement were with one of the sub-administrators (MCOs)? Would you be willing to take on a substantial “number of lives,” or are you really only interested in a more direct third-party payor kind of arrangement?

(Robin Dickinson) #4

We can’t completely prevent that, especially if patients aren’t used to having a specific person to go to. But see below for further thoughts.

Those aren’t primary care.

Hopefully not! I would never sign up for that. One of my Medicaid babies is in and out of the hospital and I spend hours coordinating care, talking on the phone with mom, etc. Very sick patients sometimes need to be hospitalized and if I’m not paid for all the extra work of managing them, what’s the point?

There isn’t a network and waiting for a whole network of Medicaid pilots would be a long wait. I would manage them the same as anyone else. If they move and are no longer my patient, they are no longer a member and I no longer get paid. I would not want to be responsible for keeping track of that though. Babysitting is not my business. :slight_smile: Maybe make the patients sign something that they understand that if they see another primary care doctor, they will be bumped from the DPC pilot program and not get to come back. And then have it set up automatically on Medicaid’s end that if they receive a charge from another PCP for a primary care CPT code, patient and I both receive a letter that they are out. The only exception would be if the other doctor billed in error

It depends. A lot of people feel that the 3rd party is why a previous pilot in another state failed. I’m not hoping to repeat that. That said, the RCCOs other than Denver Health seem pretty reasonable and without a lot of administrative burden. DH Medicaid has been a nightmare to deal with because they automatically enroll my long time patients and then refuse to pay me. Stinkers.

I’m not sure what that means. I’m not taking on any more patients than I was already. If they want me to just be the doctor of record on patients I’ve never seen, that would be stupid. They aren’t getting DPC care. That’s just the way insurance works where people are randomly assigned to a doctor. DPC is all about relationship. A patient is not MY patient until I have spent an hour with them and know them.

What I want to do is be able to bill Medicaid a DPC membership instead of FFS for my current Medicaid patients. Again, there is discussion that another pilot failed because there were crap-tons of patients dumped on a DPC all at once and it just wasn’t possible to keep up. The whole point is to be able to provide high quality care, not volume.

Sorry if any of this sounds pissy. I’ve had a long day and the thought of dealing with any nonsense from Medicaid (which is highly likely because administrators just don’t “get” stuff) is making me think this is a terrible idea. :slight_smile:

(Appalenia Udell, Esq.) #5

@Robin_Dickinson while you are direct, and clear, you are never pissy, and even if you were, rightfully so, this needs to be a rigorous discussion.

(cjs56) #6

I think some of the Medicaid patients have become very demanding over the years. At one time, I found Medicaid patients to be very humble, grateful and respectful. Now, many are coached into dubious disability requests and opioids requests to sell on the street to maintain financial viability. Many have not had the mental health care that they need, and are quite frankly, living a very dangerous life.
But, if you were running a D.P.C. practice, maybe…maybe…there would be some Medicaid patients and families out there that could afford a reasonable yearly rate and realize that they have a good physician that respects them and treats them well. I would imagine that if a D.P.C. physician was flooded with Medicaid eligible patients and not interested in chronic pain management with opioids and not a specialist in disability management, then that physician could be honest up front with those Medicaid patients and see if they would sign the D.P.C. contract under those constraints.
If they do sign, then a D.P.C. physician may just find himself/herself with a humble patient population.

(Robin Dickinson) #7

Here in Colorado it’s illegal for us to take fees from patients with Medicaid so I have a hybrid… I take Medicaid when my patients’ income drops and they qualify and DPC the rest of the time. I grew up in what I consider a “normal” neighborhood (working class) and live in one now. From my experience, people who have Medicaid have been kicked around so much that they are understandably a bit sensitive to anything that seems like being kicked around a bit more. Sometimes a new patient will seem a bit “off” but once they see that my practice is a safe place, we’ve all got along gorgeously. :slight_smile:

(cjs56) #8
  1. Thanks Robin.

  2. hybrid sounds good. so, when FINANCIALLY able, the patients stay off medicaid and are able to join a DPC. Correct?

  3. when not financially able, the patients go back on Medicaid. Correct?

  4. and when the patients have to go back on Medicaid, you bill Medicaid since you have not opted out?

  5. i grew up middle class too, but have seen a decline in the medicaid appreciation factor.

Am I saying all this correctly?

(Robin Dickinson) #9

Yup. I bill Medicaid FFS when their income drops under 133% of the FPL and they qualify and they pay the monthly DPC fee when they get over that amount and no longer qualify for Medicaid.

(cjs56) #10

that’s pretty good. That way you can go back and forth as needed.

But,…suppose MANY of your DPC patients that did not qualify for Medicaid today…suddenly…lost their job or could not afford the DPC fee anymore.

Then, they would switch to Medicaid…see you as a physician…and you may be stuck with the low Medicaid fees for an unknown time period…maybe forever…

if they were not able to get off Medicaid.

That could put a DPC physician out of business if there was too many switching back to Medicaid.


(Appalenia Udell, Esq.) #11

Our CO Minimum Wage was just increased by $1/hr which kicked a lot of people off Medicaid, so the problem is actually the inverse of what you proposed @cjs56. Realistically, the Medicaid populations, at least in CA and CO, are very fluid and responsive to shifts in contract/seasonal work. The Medicare patients (including the permanently disabled) are more static, but Medicare is easy to opt-out of. From our perspective, there is absolutely no reason a DPC-Medicaid hybrid can’t flourish with proper financial planning.

(cjs56) #12

I see. You propose the opposite view…that is… with the $1.00/hr. increase in wages and thus too much money to qualify for Medicaid and so now removed from Medicaid. Succintly said…too much money to qualify for Medicaid.

Now off Medicaid, this MAY increase the D.P.C. patient volume if the patients choose to join a D.P.C. practice and can afford it. More than likely, if patient was on Medicaid, then chances are they are way to poor to afford a DPC fee even with $1 dollar more per hour. That’s $40.00 more per month. You would have to have a DPC fee of half that for a patient to even consider it.

In other words, if you are poor enough to qualify for Medcaid, chances are you not going to get off Medcaid without a real struggle.

I asked a bus driver in San Diego yesterday…How were you able to get off Medicaid?

Her answer was simple…I wanted more so I found a job.

Once off Medicaid, the patients may choose not to join a DPC (still can’t afford it).

But, wage increases are very rare.

More likely, are job layoffs which put people on Medicaid.

So, again, a hybrid DPC/Medicaid has the potential to swing the Medicaid way…and the DPC physician suddenly has more Medicaid patients than planned for.

The California Medicaid patients are for all practical purposes doomed to be on Medcaid because the cost of living is so high and the wages are so low that they really hardly ever get off.

It’s better for them if they stay on Medicaid. What they would call a “learned helplessness.”

It’s not seasonal in Los Angeles or San Diego or Oakland or San Bernardino. That is year round honest to goodness poverty. What they call generational poverty. Or, what my father, an attorney would say…“It’s awful tough being born poor.”

It may be seasonal in the agricultural city of El Centro but their unemployment rate is 25 PERCENT all the time.

I do not know if one can create a contract with a new DPC patient that would state if you the patient ever found yourself on Medicaid, then I will continue to take care of you as long as you re-join my DPC practice when able to.

This again to me sounds like it might not be legal and could also backfire by the patients being on Medicaid forever and never getting to the point

of rejoining the DPC practice.

These are things to think about.

(Robin Dickinson) #13

You probably don’t have to make them contract to it…most people when they lose Medicaid don’t have many good options. You don’t typically go from minimum wage/Medicaid level employment to a company job with full benefits! Plus, once patients have been with me, they never want to leave. My patients who have left have usually had really compelling reasons.

(Appalenia Udell, Esq.) #14

Actually, I was in charge of the patient migration projections for ACA implementation and what we found in CA is that 5 million or so patients migrate into and out of Medi-Cal at least once per year, so the elasticity of the Medi-Cal budget has to accommodate surge of about 24% during peak enrollment.

I think there is a real danger in typecasting Medicaid or Medi-Cal recipients, or any class of patient for that matter.

(cjs56) #15

Got it. Thanks. That is what I was hoping. If off medicaid, then that would cause patients to go to D.P.C. practice.

(cjs56) #16

That is good to hear that there is flexibility for the Medicaid in CA.

I have not seen that flexibility in my years.

But, it could be good for DPC practices.

My experience comes from the trenches and what I see and what patients tell me.

Thinking about business options is not typecasting.

It is pragmatic.