Providers close doors to poor

By Marshall Allen

Sunday, Nov. 16, 2008 | 2 a.m.

Budget cuts in the state’s Medicaid program are forcing a major shift in where Nevada’s poor can seek health care.

Cancer patients who had received outpatient treatment at University Medical Center, for instance, will have to seek treatment at other hospitals and clinics because UMC, citing reductions in Medicaid payments, says it can no longer afford to offer cancer treatment.

Low-income children with bone and spine problems may need to leave Las Vegas altogether for treatment, because pediatric orthopedists are no longer accepting payment from Medicaid because of cutbacks to their reimbursements.

And on Tuesday, UMC administrators will tell Clark County commissioners what treatments and programs they may need to drop because Medicaid payments don’t cover the hospital’s costs, and the hospital can’t afford to go in the hole.

Indeed, the Nevada State Medical Association said other pediatric specialists may also stop taking Medicaid patients because the government reimbursements don’t cover the cost of delivering the care.

“I really feel we’re heading for a precipice and I think somebody needs to be candid about this,” said Dr. Carl Heard, chief executive of Nevada Health Centers, a nonprofit organization that operates clinics for low-income patients. “I just don’t know that we’ve seen a path to follow or that the leadership is stepping up to fill the void.”

Health care experts — including the Medicaid administrator — say the cutbacks are a shortsighted way to save money at the expense of patients who have dire medical needs. Such reductions will lead to increased costs down the road when those patients — having gone without intermediate care — end up receiving costly emergency room care.

Bottom line: Nevada is in the throes of a growing crisis in providing health care for those who can’t afford it, and faces dire consequences in years to come. It’s an ongoing cycle of inefficiency.

The cutbacks illustrate a chronic problem with health care. Health care financing is driven by annual budget cycles that discourage paying now for services such as prevention and disease maintenance, even if the short-term cost will save money in a future budget cycle. Thus, reimbursements are slashed by Medicaid and services are cut by providers to meet immediate shortfalls, even though it will likely increase costs in the future.

“The state doesn’t get off cheap,” said Larry Matheis, executive director of the Nevada State Medical Association, which represents doctors, and a former administrator of the Nevada State Health Division. “It just fails to meet its obligations in a timely way and then has bigger costs. And in the meantime a lot of people have been hurt.”

Chuck Duarte, administrator for Nevada Medicaid, said he knows that it costs more in the long run to cut programs that help people manage their diseases or prevent problems. “That being said, those are long-term savings,” Duarte said. “I’ve got a short-term cash crisis.”

So the financial dominoes are falling: A state budget crisis resulted in cuts to Medicaid, the state’s insurance program for the poor, which in turn chopped reimbursements to hospitals and doctors.

The cutbacks are magnified because they come during an economic downturn, when more people qualify for Medicaid services.

Dr. Mark Barry, a pediatric orthopedist, said Medicaid cut reimbursement rates to his specialty by 41 percent in September. His specialty has not seen a Medicaid payment increase in 15 years. He’ll finish caring for the hundreds of children on Medicaid he is treating, but the drastic reduction makes it impossible to take any more, he said.

“That really troubles me greatly,” he said. “The business aspects of affording to take care of these kids is interfering with good medical care.”

Barry said there are five pediatric orthopedists in Las Vegas. Each told the Sun that Medicaid patients are not being accepted.

Duarte said the young orthopedic patients may have to be sent — at Medicaid’s expense — outside Nevada for treatment.

Medicaid cut reimbursements to hospitals by 5 percent, which translates to shaving $20 million from projected revenue at UMC, hospital officials said.

The effects of UMC’s cutbacks could be tragic. The hospital has said it will eliminate its outpatient cancer services, meaning the 400 people now enrolled will be forced to go elsewhere for care. UMC officials emphasize that the services — mostly chemotherapy — are available throughout Las Vegas, but that’s downplaying the harsh reality that most of them won’t be able to afford the treatment elsewhere, and other cancer-care providers are unlikely to foot the bill for chemotherapy drugs that can cost $10,000 per dose.

More than half the cancer patients are self-pay or Medicaid, UMC officials said, and about 150 of them are undocumented, which means they do not qualify for any of the government assistance available to low-income residents.

UMC officials have not said what other cuts in services are on the table. UMC, the county’s “safety net” hospital, provides services that are not available elsewhere, such as the burn unit and trauma center — and takes charity patients who are denied elsewhere. According to statistics gathered by UNLV, UMC shoulders almost the entire burden for charity care in Clark County — 84 percent of about 5,400 cases in 2006 and 91 percent of about 5,000 cases in 2007. Sunrise Hospital Medical Center — the runner-up — had 15 percent of the county’s charity cases in 2006 and 4 percent in 2007. Many of the for-profit hospitals in Clark County treat no charity patients.

The cuts being considered by UMC will be in services that are available elsewhere, said Brian Brannman, the hospital’s chief operating officer. Thus, UMC is “pushing back,” he said, against the assumption that it’s the only facility to provide charity care. All hospitals have a moral obligation to treat patients who cannot pay, he said.

“If everybody sees the undocumented guys, then we spread it around,” he said.

Nancy Menzel, a professor at UNLV and president of the Nevada Public Health Association, said the reductions at UMC have moral and financial implications. If only people with insurance can get cancer treatment, that’s a social injustice, she said.

And there is no escaping the costs of treatment, Menzel said.

“They will get their care at the most expensive trajectory of their disease, when they are acutely ill and have to be brought to the emergency room,” Menzel said of patients who are denied ongoing treatment.

Every expert interviewed by the Sun agreed that the long-term costs will be higher than the short-term savings from cuts to Medicaid, or cuts to services by providers.

Duarte, the Medicaid administrator, added that the cutbacks have additional long-term consequences. Medicaid funds the infrastructure for hospitals and other services statewide, Duarte said, and health care providers and administrators will now be reluctant to make investments for poor patients.

Heard, of Nevada Health Centers, said the cutbacks are the latest example of “boom and bust” funding cycles in Nevada. The financial cutbacks are severe because it takes years to rebuild what has been taken away, he said. The inconsistent funding cycle has “crippled” Nevada’s health system and the result is poor public health, he said.

The real tragedy may be that short-term cutbacks proceed even as experts know they are not in the best interests of health care efforts — morally or financially. Before the 2007 legislative session, about 100 health care experts from a wide range of fields met dozens of times to develop the Nevada Strategic Health Care Plan, a report by the Legislative Committee on Health. The focus groups collectively said there is no centralized responsibility for health care planning in Nevada, no regular assessment of community needs, no detailed analysis of uninsured population and inadequate planning for health care manpower needs.

Matheis, executive director of the medical association, said nothing has been done to improve the planning functions. And now the state is haphazardly responding, again, to a fiscal emergency.

“We have a new crisis so we’re lurching, trying to respond with no long-term plan or long-term vision,” Matheis said.