WhiteCoat

Refuse Medicaid patients, get sued

According to a July 23 article in AM News, the Illinois attorney general is suing two Illinois clinics because they made a business decision not to accept new Medicaid patients.

Let’s look at the facts:
According to the AMA, Illinois is one of 17 states in a medical liability crisis.
Three of the American Tort Reform Association’s top six “judicial hellholes” are located in Illinois.
Illinois pays next to nothing for physicians to see Medicaid patients. This article implies that Illinois is paying physicians $30 per visit for Medicaid patients when it costs the physicians $300 per hour just to keep the doors open.
No, I take that back. In some cases, Illinois doesn’t pay next to nothing to healthcare providers who see Medicaid patients. Instead, Illinois pays nothing at all. Illinois’ Medicaid program already owes $1.5 billion in late payments to pharmacists, doctors, nursing homes, and other medical providers who have provided care to Medicaid patients. See the article “Illinois Medicaid Takes on New Costs – Governor accused of ignoring unpaid bills” and the article “Illinois’ Medicaid money to hospitals MIA“.
Oh, and by the way, the public hospitals in Cook County are cutting services because the county and state don’t have the money to pay for them. See Doctors leaving Stroger Hospital

So Illinois has one of the worst malpractice climates in the US, it costs the involved clinics money every time they see a state-funded patient, the state isn’t paying the clinics the small amount of money the state owes them for taking care of state-funded patients, and the state is partly to blame for closures at the county hospitals where state-funded patients could go to be seen. The clinics make a responsible business decision to stop seeing patients because they lose money and increase liability every time they take care of a patient. Now Lisa Madigan has the gall to sue the clinics?

Let’s look at what will happen if this lawsuit is successful:

  1. Illinois continues to collect billions of dollars in taxes to fund care of public aid patients
  2. Illinois cuts back on more medical services and closes more public clinics because of “lack of funding”
  3. Public aid patients have nowhere to go for care, so they seek care at private clinics
  4. State doesn’t pay private clinics for taking care of public aid patients
  5. Private clinics lose more and more money until they make business decision to stop seeing public aid patients
  6. State sues private clinics to force them to continue caring for publicly-funded patients without being paid or being grossly underpaid
  7. State saves billions of dollars per year in what amounts to court-ordered involuntary servitude against health care providers.

Good business decision, Ms. Madigan. Way to attract more health care providers to do business in Illinois. What’s next – suing people who decide to quit their state government jobs to force them to keep working for substandard wages? Does your dad have anything to do with this lawsuit?

I included the complete text of the AM News article below for those who don’t have access to the AM News web site.

Refusal of new Medicaid patients spurs antitrust suit

The Illinois attorney general has accused two clinics of collusion, but doctors say payment cuts forced their independent decisions to trim program caseloads.

By Amy Lynn Sorrel, AMNews staff. July 23/30, 2007.

In a case that some experts say adds a new twist to physicians’ antitrust fears, the Illinois attorney general is suing two private medical clinics for allegedly refusing to take new Medicaid patients in order to force an increase in reimbursement rates.

The antitrust lawsuit filed by Attorney General Lisa Madigan in June accuses the Carle Clinic Assn. and Christie Clinic, both in Champaign County, Ill., of collectively boycotting new Medicaid patients by adopting identical policies in 2003. The two groups employ more than 90% of physicians in the area.

According to the complaint, the clinics declined Medicaid enrollees who either were not already registered patients or who had not seen a clinic physician for at least three years. Both groups continued to accept patients referred by a nearby free health center for consultations but sent them back to the center for ongoing treatment.

Similarly, with hospital emergency department referrals, the Carle and Christie clinics treated Medicaid patients only for the condition for which they were referred, and did not provide follow-up care.

The restrictive policies “left many of the 20,000 Medicaid-eligible children and adults in Champaign County at risk by leaving them with fewer choices to obtain quality primary medical care — if they could access primary care at all,” Madigan said in a statement.

As a result, the lawsuit alleges, many of those patients were forced to get medical attention at area hospital EDs, at a higher cost to the state. Madigan is seeking to require the Carle and Christie clinics to open their doors to new Medicaid patients and to recover civil fines and damages for their anticompetitive conduct.

“Medical clinics, like other businesses, must adhere to the antitrust laws. These laws prevent competitors, in all fields, from agreeing with each other to act collectively to limit access to services in order to raise prices,” she said.

The Carle Clinic Assn. and Christie Clinic deny the allegations. Officials from both medical groups said they made lawful, independent business decisions to curtail their services, as did many other Illinois physicians. The Medicaid policies were sparked by significant state cutbacks on Medicaid reimbursements in 2002.

At that time, Carle Clinic was already seeing a significant increase in its Medicaid patient load, President and CEO R. Bruce Wellman, MD, said. The state is going too far in its lawsuit, he said.

“If the government can force private businesses to accept below-cost rates, what sort of environment are you going to create?” he asked. “Do grocery stores give away 10% of their groceries?”

In 2006, the clinic saw more than 31,000 Medicaid patients from 84 counties, he said. Already working at capacity, the medical group cannot afford to take more new patients without displacing existing ones or charging private patients more.

To address problems with access to care caused by the Medicaid cuts, Dr. Wellman said, Carle, Christie and other local medical groups met in 2002 through the United Way of Champaign County to help expand resources at the Frances Nelson Health Center, the local federal health clinic.

Madigan, however, cites the encounter and other meetings between Carle and Christie as examples of conspiring to agree to change their policies to pressure the state to increase Medicaid funding after legislative efforts failed.

Dr. Wellman said the accusations, though untrue, highlight the larger need to fix the state’s reimbursement shortfalls so that access to care is not further jeopardized — a problem best solved through legislation, not the courts.

One major consequence of the suit is that it will discourage doctors from cooperating to find a solution to the access problems, he said.

“There are reasons for us to be talking,” he said, for example, to find out if another practice has the capacity to take patients that one cannot. “Everybody wants us to cooperate. How can you do that now in this environment without the litigation risk?”

Christie Clinic CEO Alan Gleghorn in a statement also denied any antitrust violations and said the practice already serves nearly half of Champaign County’s Medicaid population.

The group looks forward to defending the allegations and working with the state “to find efficient and effective ways to serve all patients throughout east-central Illinois,” he said.
Scrutiny intensified

The lawsuit is the first antitrust case of its kind in the Medicaid context, according to antitrust experts Gregory R. Piche and Gregory S.C. Huffman. At a time when doctors already face antitrust scrutiny for trying to negotiate with health plans for reasonable reimbursements, the Illinois attorney general’s approach raises concerns about the way the government views other physician practice decisions, they say.

Speaking about antitrust law in general, Piche, a partner with Holland & Hart in Denver, said the government cannot force private physicians to provide medical services at unreasonably low rates. However, he warned, state and federal governments can enforce antitrust laws designed to prevent illegal agreements.

“What [doctors] can’t do is talk to their competitors to come up with a collective approach to dealing with the problem,” he said. “No matter how compelling the social issue is, it’s still illegal, and you can’t use an economic boycott to reach socially desirable goals.”

Huffman, a partner with Dallas-based Thompson & Knight, agrees that, in general, doctors have the right to decide whether to provide a service. Whether that draws suspicions of a conspiracy depends on whether the practice acted independently and whether the business decision makes sense from a business standpoint” for each of the parties involved, he said.

Piche added that the clinics’ combined market power may have raised a flag with Madigan because they have the ability to influence prices.

“There’s nothing illegal about having market power. But when you do, you have to work with more responsibility” than when you don’t have that clout, he said.

ADDITIONAL INFORMATION:
Case at a glance

State of Illinois, ex. rel. Lisa Madigan, attorney general of Illinois v. Carle Clinic Assn., Christie Clinic Assn.

Venue: Circuit Court of the 6th Judicial Circuit, Champaign County, Illinois
At issue: Whether two private Illinois medical clinics violated state antitrust laws when they allegedly collectively developed identical policies to limit their Medicaid patient loads as a way to force a reimbursement increase.
Potential impact: The doctors involved deny the allegations and say the government is going too far in dictating the way they run their practices. Some legal experts say the case raises concerns for doctors about the way the government views decisions to stop seeing patients in public programs. Attorney General Lisa Madigan says such alleged anticompetitive decisions hurt access to care.

14 Responses to “Refuse Medicaid patients, get sued”

  1. Vira says:

    Great. I’m on medicaid at the moment because my husband broke his back at work and workers comp. is screwing us around, and I can’t find a doctor for my 3 children or myself. My kids have NEVER been to the dentist-my oldest is 13! I have serious heart problems and ruptured disks in my back. Now what am I going to do?

    With private insurance it’s so expensive just to go get a check up from a doctor and now I can’t even find one who will accept me or my children because we are on medicaid! The dentists in Southern Illinois are WORSE! I managed to get into a dentist Dr. Rommel, which he left town because he was fraudulently overcharging medicaid and messing up patients teeth, thankfully he didn’t mess up mine,BUT that was 7 years ago! I hope these people can figure something out. I’m having a hard enough time already, I don’t need this on my shoulders too.How am I supposed to see a doctor when I’m sick? how are my CHILDREN supposed to see a doctor when they get sick??????This is bull! Too many greedy hands in the pot!!!!!

  2. Lori says:

    I think it is a disgrace to the people of this country when middle class people can’t afford medical insurance and when they ask for help from the state, all doctors turn them away. I am a mother of 4. I make too much for medicaid but if I got insurance through my job it would take at least 2 weeks of my full pay check to pay JUST the premium. Not to mention the deductible. My daughter who is legally blind needs glasses. Their teeth are abcessed and no dentist will see them. And the two oldest have high blood pressure problems that need monitored. SO can someone tell me what is to be done? I have people telling me that I am neglecting my children if I don’t get this taking care of. Now I am at the point of choosing utilities and rent or medical attention for my children. This is a sorry excuse for a government that allows this to happen!

  3. Laura says:

    I am frustrated here. As open as my state of Illinois is to homeschooling, they are just as beligerrant about dental work!

    I have pain in my mouth on top and bottom left side and I am not sure if it’s from dental cavities or my teeth eroding against each other or just sensitive fillings. Point is, I need to see a dentist and there is NOBODY I can see around here.

    I just got off the phone with 1-800-DENTIST and even THEY could not tell me anywhere I could go for help. I have 2 daughters who badly need orthodontic work and I do have a part time job with my husband working full time, but still I could never get my girls the care they needed, so my older one still has major malocclusion problems.

    Does anyone know if either presidential candidate will hear our plight in Illinois and do something about this? That will probably determine who I choose to vote for!

    in pain and living on Ibuprofen daily (probably eroding my internal organs in the process?)
    ~Laura

  4. Maxine says:

    Help. I found this post but am looking for any information on the same laws for california. I am on ssi, should have got ssd, but my attorney sold me down the river, which I found out with much research and going to the top. I ended up with medical. Have chronic illness’s and trying to find proper medical care is a joke! I have talked to a attorney who has told me Not only is this a problem, I have been denied medical care, from the clinics who do take it, in my town, and he said I have been black balled! Could have to do with my chronic illness’s, something that could have happened while under there care, afraid of lawsuit, so it has left me with all but one who will see me? I thougth throught the state programs, or the law in the good old Free USA, we are all entitiled to proper medical care. I am finding this is a joke, hitting nothing but dead ends. Not only that, humilated, treated like a wellfare case and so forth. A very prejeduce medical insurance and looked down upon. What can be done about this? It is uncalled for in this country. I am 52 and feel that I am going to die young if I cannot get under a good doctors care. Any help, advice would be appreciated. Also contacted the Medical field office and the top, trying to find out what my rights were, and was basically told, no doctor has to take medical, they are not controlled by the states, and if they don’t like the color of your hair they can refuse to not see you. All I can say, I hope all these big high and mightly do gooders who make these laws, get ill before there time, loose everything they have, including there health and boy you would see a change in the medical system in this country real quick!!!!!!!!!!!!

  5. Smapp07 says:

    I find this article to be disgusting, and the author has not even bothered to reply to these responses. When you are sitting on the top it’s easy to look down your nose. Doctors over price their appointments, for those seeing only Medicaid patients it becomes an issue, but for those doctors who take primarily private insurance holders the cost of Medicaid is absorbed by them. BCBS gets a discount for you using specific physicians, why doesn’t Medicaid? Don’t assume we are all ignorant, I have been on Medicaid, and fortunately am not any longer, I feel sad for the state of Medicaid in this country, and especially in this state. I hope the people who have posted above find the necessary care, and speak to congressmen and women. Talk to everyone you know about what is happening. The Senator from IL is a candidate for Presidency and hopefully that comes along with a positive change in the Medicaid system. Best of luck to all of you! Remember you are not alone!

  6. sympatheticdoc says:

    In response to Smapp07, this is not the fault of the doctors. I am a specialist who moved my whole family to go work at Carle, and found their administration to be despicable. Doctors have absolutely no control over reimbursement. Doctors, even in private practice, cannot set prices for reimbursement. Insurers are in charge of this whether they are private or public aid. The Carle Clinic Association and Carle Foundation Hospital ARE a monopoly, and there are many more problems than just this suit which harm the interests of patients. Even privately insured patients get screwed there. I have been screwed by this organization when I spoke up against their ridiculous policies. Because they have a 50 mile no compete clause in my contract, I will have to relocate, even though I have patients who want me to continue as their doctor. I will be filling my own suit against them. It is a difficult situation as far as the inadequate funding for Medicaid, because physician reimbursement and case load are not balanced well. Most doctors are lucky to receive 30% of what is billed, and Medicaid reimbursement is even less or sometimes significantly delayed or refused. I agree that it is a tragedy to enforce rigid policies with regard to treating certain Medicaid patients who clearly are in need, especially children. If hospitals would run more efficiently and private insurers would stop raping the public, then affordable quality healthcare could be achieved. I spent several years working in a Los Angeles County Hospital in south Central LA treating a high percentage of the underinsured, and saw how poor administration wasted millions of dollars. Unfortunately, in comparison to Carle with regard to quality of care, I did not see much difference, and in some instances felt it was worse at Carle. This problem of treating the underinsured ultimately affects all areas of healthcare delivery, as patients flood to emergency rooms for primary care. Because of EMTALA, you must be treated if you present to an emergency room. It is illegal to send people away. The entire system needs an overhaul, and the only presidential candidate who has any concept of the problem in any capacity is Senator Obama. I tried to stand up for the rights of patients and it cost me my job, and possibly my career. I have no sympathy for Carle in this, and I am certain they deserve to be sued.

  7. Anony-mouse says:

    Sympatheticdoc, I sincerely hope your suit against Carle is successful, and your career is long and fulfilling. I admire your integrity.

  8. Ariel says:

    I am a fresh primary care resident from Chicago. The current situation in Illinois is a joke for physicians. Not only do they have the most ridiculous lawsuit hell in the entire country, but as long as they prefer to “mandate” that we treat people for free rather than giving us some incentives, I am not even considering practicing here.

    Going to Wisconsin for now. As soon as I am able, I will open a cash-based practice, or, if worst comes to worst I might return to my old job as fitness instructor. A big gym in the south have offered me 80K to be a fitness doc at their facillity. Work 8-4, Frodays and weekends off. No medicare, medicaid, insurance looters or ambualnce chasers.
    yes, I would be insane to not consider it.

    Politicans have messed up healthcare badly and obama will probably make it even worse by “mandating” more. Not working for free anymore. Politicans, what about trashing those lawschool diplomas of yours and getting a real job?

  9. Cheryl says:

    Perhaps Illinois is a “hell hole” because patients get injured and the Illinois Department of Professional and Financial Regulation do not discipline the bad doctors. Actually, it is very difficult for injured patients to successfully sue a doctor because the AMA and other professional organizations (such as the AAOS) intimidate plaintiff patients’ doctors from testifying against the defendant doctor. The AMA (and groups like AAOS) consider the doctors’ testimony against defendant doc to be “practicing medicine”!!!

    So who exactly protects the patients (esp in Ill and esp at Carle Clinic)? And where is the accountability for horrible physician errors and bad doctors?

    http://advocateyourself.blogspot.com

  10. Joseph says:

    I know their pain. My son went to Doctors Care today for stitches in his thumb after slicing it on a garden statue. After 40 minutes of waiting in the back treatment rooms, they come in and tell us they won’t treat him because they aren’t his PCP and they need his dr.’s authorization. Well his dr’s office is closed on the weekends, and it didn’t warrant a trip to the ER. Well we ended up going to the ER anyway and after the screwed us around we lost an hour of treatment time. This is in SC not IL, so it’s nice to see no matter what state you live in, some dr’s offices are the same. I will be filing suit against this dr’s office, and I hope the state of SC yanks their medicaid privledges.

  11. SoHereIsAName says:

    I am curious as to why Joseph(may 2, 2009 6:43pm) thinks his regular doctor is to blame in any way. This is completely the fault of your medicaid. Medicaid in many states absolutely flat-out requires referal from the ‘PCP’ or they WILL NOT PAY for service provided. Only exception is ER and labor/delivery which are under EMTALA. I assume Doctor’s Care is an urgent care(therefore not under EMTALA) and therefore would NOT GET PAID 1 penny for your son’s care unless you were going to pay for it. So blame Medicaid, not your doctor who just chose to not work for free. I doubt you do.

  12. Vanessa Smith says:

    WALGREENS TAKECARE CLINIC WONT TAKE MY MEDICAID, OR MY MONEY!!!!!!
    I liked the low cost and convenience of the TakeCare clinic at a Spring Hill, Fl Walgreens, until my most recent experience that is. I have Medicaid, but they dont accept it, so on 2 visits I paid the $60 for the convenience and in so doing thought I was saving the state Medicaid system (and the Taxpayers) a huge hospital bill too. My sons newly assigned Medicaid Dr (the health dept voicemail!!) was unavailable so When I brought my son to the New Port Richey Walgreens TakeCare clinic for a bad ear infection, I signed in and waited an hour, since they were out to lunch. Upon return the Nurse did her intake interview and discovered he had Medicaid, and then refused to treat him, stating that “it would be fraud to accept cash from someone who is medically needy and receiving medicaid benefits”. I called corporate who verified that this is in fact their policy.
    Fraud? Isn’t it discrimination to refuse to treat a group of people based on their economic status, or the fact that they have medicaid? I understand they dont take medicaid (they are working on that) but why wont they let Medicaid recipients pay cash for a clinic visit? Its not like they are billing patients and Medicaid at the same time, they simply wont treat you unless you withhold the fact that you have Medicaid, even if your willing to pay cash for your visit. I am going to talk to a lawyer about this. Has anyone else had this experience?

  13. Danial Kleczka says:

    Yes, I was seeing my doctor of 7 years, I lost my job, I paid cash for my monthly visits, when I got Medicaid she told me she could no longer see me as a patient because I was on medicaid, she would no longer accept my cash payments. I have now been without medical care for 4 months, but I have Medicaid!

  14. Jodes HOLICH says:

    Requiring doctors to take Medicaid patients and then paying them little or nothing at all is ridiculous! I don’t work for for nothing and no one should. These are highly trained professional people who probably owe hundreds of thousands of $ in education loans which are never forgiven plus the upkeep of the office,etc. really the blame is with the state Medicaid Medicare program. Why don’t they get their stuff together and pay on time and maybe the doctors won’t take exception to these patients. And quit belly aching! I have insurance and still have to pay large copays everytime I walk into an office. 675.00 on an MRI which I needed. No one helps me. If the state doesn’t change no doctor will accept u for any but emergency reasons. Which is being abused already coming into the er for a ” sore throat” or ” cold symptoms” really you can blame the fellow Medicaid patients for abuse of the symptoms. It’s emergency room not take advantage cause I don’t have to pay.use your head.

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