Greenwich residents on Medicare, Medicaid struggle to find health care specialists – Featuring Input from CSMS EVP/CEO Mattew Katz
GREENWICH — Alyssa Williams was shopping at Target in Stamford nearly five years ago when her then-2-month-old daughter’s face turned blue. The baby was rushed to Greenwich Hospital, where doctors diagnosed her with reactive airway disease.
The infant was then transferred to Yale New Haven Children’s Hospital for 10 days, where doctors found she was also living with a partially collapsed left lung.
“I lost like 60 pounds in three months,” said Williams, a Greenwich mother of three. “After she turned blue that time, it was really bad. There was no time for me to even sleep.” Back then, every few hours, she would have to wake up to give the baby albuterol through a nebulizer.
Now 4 years old, her daughter, who was eventually diagnosed with asthma, occasionally uses the nebulizer and has difficulty breathing when temperatures dip below 55 degrees. A typical cold can send her to the hospital, and a runny nose can persist for months.
For nearly five years, the mother and daughter trekked to New Haven for appointments with a specialist. Williams had trouble finding a pediatric pulmonologist, in Greenwich or nearby, that would accept her Husky A (Medicaid) insurance.
Williams, who receives $600 a month from Social Security for herself and her two young daughters, doesn’t drive and has her own health problems. She often asked friends or family for rides to New Haven when her daughter had an appointment or a surgical procedure. If no one was available, she was forced to take the bus, a train and a cab to the hospital with her sick daughter in tow.
“It’s just ridiculous,” said Williams. “Were talking about, like, hours of traveling.”
Williams is not alone in her struggles.
Many local residents on Medicare and Medicaid experience difficulty finding specialists who will take those two insurances. Greenwich medical providers, case workers and individuals living with different illnesses told Hearst Connecticut Media they have encountered long wait lists or found specialists who accept only private insurance. For others, scheduling an appointment with a specialist can mean traveling 80 miles or more round-trip.
The medical community is aware of the dearth of specialists who accept Medicare, which is for those age 65 and older, or Medicaid, for individuals with low-incomes or qualifying disabilities.
Nurse practitioner Beth Kaplan, who treats patients at the Family Centers health center, said she often struggles to find specialists for her clients. She spoke about a client with a severe undiagnosed skin condition whom she had tried to treat multiple times. During flare-ups, he developed painful and open sores all over his body. After six months of searching for a local dermatologist, he recently saw one in Danbury, almost 40 miles away.
“That’s a little ridiculous, in my opinion,” said Kaplan, who has also provided care to Williams in the past. “Unfortunately, there really (was) no one to send (him) to in Greenwich” who would take his insurance.
The problem is especially acute for people living with severe mental illnesses, said Patricia Schumacher, a case manager with the town Department of Human Services. The agency serves about 2,500 individuals, about 30 percent to 40 percent of whom have mental health issues. About 60 percent of the agency’s clients use Medicare and/or Medicaid, according to case managers.
“If you’ve already got someone that is uncomfortable in their own skin, maybe distrustful, doesn’t have the energy, because they’re feeling depressed or anxious, and then you tell them, ‘Well, I can’t get you an appointment unless you go up to Norwalk or Stamford,’ that’s another huge barrier to someone that’s already sort of under-functioning,” Schumacher said. “And so, that person then continues to struggle, possibly without the care that they need. There shouldn’t be a wait list for people who are feeling suicidal in Greenwich.”
Greenwich Hospital offers a behavioral health clinic, but the wait list has remained stagnant, said Schumacher. Joseph Flynn, director of psychiatry there, said the need is growing locally and nationally for psychiatric and behavioral health services, which has resulted in an overall shortage of providers.
Family Centers provides some behavioral health services to patients on Medicare and Medicaid, but it does not serve individuals with severe mental health issues.
The F.S. Dubois Center in Stamford provides the highest level of psychiatric services, but it serves primarily uninsured people. So, case workers must prove their clients on Medicare or Medicaid can’t be seen anywhere else, Schumacher said.
“It’s a difficult thing to navigate,” she said. “If all the planets align, which is rare, you can get someone in in a couple of weeks. But that rarely happens.”
Low reimbursements and administrative burdens are among the reasons Connecticut doctors are withdrawing from accepting Medicare or Medicaid, said Matthew Katz, executive vice president and CEO of the Connecticut State Medical Society.
In general, Medicare pays about 70 percent to 80 percent of what commercial insurers — such as Anthem or Aetna — will pay for a visit or a procedure, he said. “And Medicaid pays about 70 percent of what Medicare pays on average,” or 45 percent to 50 percent of what doctors earn from commercial insurance.
“They’re losing money, many of them, if they take Medicaid,” Katz said. “So many of them … especially in Greenwich, don’t take Medicaid because they can’t afford to keep their doors open.”
The administrative burden that comes with accepting Medicaid compounds the issue for doctors who want to serve patients with that insurance. Medicaid frequently changes its rules, often requiring more prior authorizations before doctors can serve low-income patients or people living with disabilities.
For example, during the summer, a doctor who accepted Medicaid could provide three services to a patient during one visit. But after a recent rule change, a doctor can administer only two services in one visit. As a result, doctors feel limited in their capacity to serve patients, said Katz.
“The insurance is delaying the service with the hopes of the patient giving up or maybe not needing it after all — or going somewhere else to get it — or paying themselves,” he said. “These are schemes and attempts to reduce service provision.”
Closer to home
In July, after five years of searching for a doctor to treat her daughter, Williams finally found a children’s pulmonologist at a pediatric specialty center and outpatient clinic in Greenwich that opened late last year. The center is operated in a collaboration between Greenwich Hospital and Yale New Haven Children’s Hospital. Cutting down on her almost one-hour drive to New Haven has been a relief, Williams said.
Her daughter isn’t the only person in the household affected by a lack of nearby medical specialists who will accept her insurance plan. After Williams grew concerned about an itchy and raised spot on her back last year, she went to a nurse practitioner in her public housing complex. The nurse recommended Williams look for a dermatologist.
On Monday, one year later, she’ll finally see a skin doctor in Danbury. The appointment is about an hour drive each way without traffic.