Why Medicaid Patients Receive Lower Quality Healthcare

Introduction
Why are patients with Medicaid coverage not receiving the best quality of health care? One of the reasons is that physicians do not want to participate in the Medicaid program because the rate of payment from either the state or the federal government is slower than even that of private insurance (Brabury, 2015). As a result, access to quality care is limited for individuals who are enrolled in Medicaid. Another problem is that evidence-based practice (EBP) approaches to quality care are less likely to be utilized by physicians and nurses in facilities where Medicaid patients are accepted, thus reducing the quality of care that they receive (Calvin et al., 2006). Medicaid patients also tend to have poorer health and come from poorer backgrounds, which puts them at an additional disadvantage going in, as their health needs are more complicated and their outcomes less favorable, which impacts the perception of care received (Sastow et al., 2019). Finally, patients with Medicaid tend to experience greater treatment delays than individuals who are privately insured (Naghavi et al., 2016). Grembowski, Cook, Patrick and Roussel (2002) have analyzed the health care system from the perspective of exchange theory, which posits that the benefits and costs of an interaction between two parties are weighed to determine risks and benefits. Such an approach helps to understand why Medicaid patients receive lower quality care. However, patient-centered care is an approach that should be adopted regardless of how care is paid for, according to Connole (2012). An ever better theoretical approach for explaining how and why quality care should be delivered to all patients, including those on Medicaid, is adaptation theory put forward by Roy (2018). This paper will discuss the reasons Medicaid patients tend to receive lower quality care from health care providers, what theoretical approach explains this phenomenon, and what theoretical approaches can be applied to help address this problem.
Lack of Physician Participation
Although the Affordable Care Act (ACA) was supposed to increase the number of people who could receive health care coverage from the government, there has remained a problem in so far as physicians do not want to participate in the program because payment for their services is so slowly delivered (Brabury, 2015). The reason for slow payment is one part bureaucratic and another part regulatory. The bureaucratic machine of government is indeed hefty, but the government must also be on guard against fraud, as the majority of fraud is committed by those who apply for payment from the government. As the government is slow to verify the validity of payments, physicians and facilities would prefer not to be weighed down by this negative impact to their cash flow.
Lack of EBP Used in Medicaid-Participating Facilities
There is also a lack of EBP used among facilities that do participate in the Medicaid program (Calvin et al., 2006). EBP is important for providing quality care because it is based on the latest developments in research, whereas older methods of treatment and care can be based on outdated concepts or approaches that are either no longer relevant or have been found to be ineffective or inefficient over time. It is not a problem that Medicaid-participating facilities are unaware of EBP; rather, it is a problem that they often simply do not have the resources or funds available for implementing EBP.
Implementing new EBP means developing new protocols, policies and guidelines; training staff on new approaches and standards; developing measures, collecting data, evaluating outcomes, and reporting findings: it is a task that can be draining in terms of energy, time and resources. Facilities that are participating in the Medicaid program may already be tight on resources as a result of the first issue—the slowness of payments for services rendered. As facilities must wait on the state or federal government to render funds, cash flow is not at its most optimal, and budgets must be tightened year round, especially if there is an increase in the number of patients relying on Medicaid. The facilities tend to conduct themselves in a single, consistent manner, without regard for updating procedures, tools, equipment, policies and so on until absolutely necessary, simply because it requires investment.
Medicaid Patients Present with Poor Health Already
There is also a problem with Medicaid patients presenting with poor health already and coming from poor backgrounds. The more complicated their health care needs, the harder it is for Medicaid-participating providers to meet all those needs (Sastow et al., 2019). When those needs are not met, it creates the perception of low quality of care being received. Of course, it is not just a matter of perception, but also a matter of reality. Still, patients who are in poor health and from a poor socio-economic background tend to have a poorer experience overall when dealing with the health care system because the system, to be blunt, was not created to service them primarily. The system is generally a for-profit system, and for-profit providers are going to cater most diligently to the needs of those patients who keep them in business.
Treatment Delays
Treatment delays are also another reason that lower quality of care is rendered to Medicaid patients (Naghavi et al., 2016). Naghavi et al. (2016) note that there are a number of factors for delayed treatment—such as lack of access to care for underprivileged populations, such as those on Medicaid. However, the fact of the matter is that when compared to individuals on private insurance, treatment is not as forthcoming for patients with illnesses who are on Medicaid. They are not getting into facilities and are not getting diagnosed or receiving the type of preventive care that they nee.
How Exchange Theory Explains the Problem
Exchange theory can be used to explain the problem of Medicaid patients receiving lower quality of care compared to privately-insured patients (Grembowski et al., 2002). The way this sociological theory applies is that it looks at the costs and benefits of an interaction between two entities. In the case of health care, the exchange being made is health care services for payment. Because health care in America is so expensive, most patients are not out of pocket payers but rather rely on some form of insurance. Private-insurance is the most common, but Medicaid-insurance, which is government funded, is rising. However, government funded insurance is regulated in a bureaucracy that is not known for effectiveness or efficiency. Payments to providers can take much longer when coming from the government than when coming from the private insurance industry. With the ACA, more regulations have been put in place to make sure that providers are giving patients the right kind of care and not just engaging in one useless treatment after another in order to run up a tab that the government is then stuck with paying. This adds to the delay in processing payments. Providers would rather avoid the entire hassle of dealing with the government, especially now that providers who participate in Medicaid have to show that they are meeting regulatory requirements, such as engaging in preventive care and other approaches. This is often easier said than done, and thus participating in Medicaid can end up costing providers more in the long-run than it is worth. This is the cost, and the benefit of participation is that at least it is known that so long as the regulations are adhered to there will be payment forthcoming, which is not always the case with out of pocket payers or even with insurance agencies, which sometimes argue over costs and coverage.
Thus, from an exchange theory perspective, health care providers can see Medicaid patients as more trouble than they are worth—and that is a problem for an industry that is supposed to be focused on the health of every patient in an equitable manner. As providers focus on patients who have private insurance, Medicaid patients have to find providers who will receive them. These providers might be out of range for the Medicaid patient; if they are not on a bus route, it is harder for the patient to get there. If the provider does not use telehealth or eHealth, it is harder for appointments to be made. The problem of limited access to care arises, and thus the cost of the Medicaid patient trying to receive care arises and the patient holds off seeking care until it is very late in an illness. This accounts for the delay of care, and it negatively impacts patient health.
Unless every patient has equitable access to care, the American health care system will continue to favor patients with private-insurance, as they are more likely to pay more quickly than government-dependent patients. Although there are advocates of a single-payer system, or universal health care for all, there are opponents to this idea. The debate focuses on many different issues, such as why those who are young and in good health should be forced to pay the health care coverage of others. There are other debates over why health care costs are so high in the US as well. The subsidization of health care by the government does take away an element of free market competition based on the law of supply and demand. In a market where demand is not subsidized, prices tend to be lower for the services rendered. However, in the US consumer market for health care, demand is subsidized, which means that according to the law of supply and demand, prices are likely to rise. The issue of cost and benefits can thus be analyzed from the angle of what the government getting involved in the health care market does to the costs of services in general and whether government subsidization is beneficial or more costly for patients overall.
How Patient-Centered Theory and Adaptation Theory Could be Used to Addressed the Problem
Regardless of how the debate over government subsidization concludes, the patient-centered theoretical approach and the adaptation theoretical approach of Sister Calista Roy are two ways that the problem could at least be better addressed from a health care perspective. Health care providers should give their patients the highest quality of care possible, regardless of their socioeconomic status. This means that preventive care is just as important as treatment. Unfortunately, it is difficult for patients of lower socioeconomic status to receive preventive care. They are not often given that option, and access to care is limited.
Patient-centered care theory puts the patient’s own experience at the front and center focus of health care delivery. This means that a unique plan and procedure is drawn up for each patient or each type of patient that the provider is likely to receive. For patients who rely on Medicaid, more can be done by providers in the way of developing patient-centered approaches that would give those patients more access to preventive care. Preventive care would decrease the risk of delayed treatment, would address the problem of limited access to care (necessarily so, because access would be granted as a means of providing preventive care), and the health of the patients would be improved.
Preventive care depends upon planning and a focus on individual needs, and these needs can be summarized and analyzed without much cost to providers as the data is readily available for evaluation. The issue that keeps providers from engaging in preventive care is that preventive care works. It helps patients to lead healthier lives, and patients who lead healthier lives have fewer reasons to visit health care providers. For-profit providers cannot stay in business if the demand for their services drops off. Thus, even though providers should be engaging in preventive care, it is against their business interests to do so. This is the conflict of interest at the heart of health care, and it has to be addressed.
Adaptation theory posits that a person can be viewed in terms of a system. The different aspects of the patient’s life come together to explain how the whole patient can be viewed by the health care provider: so instead of a nurse or physician seeing a Medicaid patient as a person presenting with one or two symptoms and thus needing certain tests and then treatments, the care provider looks at the whole person, that person’s environment, that person’s health history, that person’s mental, physical, emotional and spiritual state, and develops a holistic view of that individual. The provider then helps the patient to adapt to changes in the person’s environment or life so that a better state of quality of life can be achieved. The focus is on reaching a kind of equilibrium or balance between the person and the environment. Rather than force a certain type of health perspective or plan on the individual, the approach is tailored to help the individual obtain care that is right for them based on the needs identified through an exploration of the patient’s personal makeup and environmental makeup (Alligood, 2017). The purpose of the adaptation model is to allow the care provider to maintain compliance and to increase the life expectancy of the patient (Ursava?, Karayurt & ??eri, 2014). This would help the Medicaid patient to receive higher quality care comparable to what privately-insured patients receive.
Conclusion
The health care system in the US does not cater to the needs of Medicaid patients, as those patients tend to have complex health needs that can drain a provider’s time and resources without giving the provider recompense in an adequate manner to make up for the costs of giving treatment. This creates a problem from an exchange theory perspective. Practically speaking, care providers do not want to be at the mercy of a government regulatory agency that might end up denying payment because of some slip-up on the provider’s part. The more reliable patient from a for-profit perspective is the privately-insured patient. That is why providers cater to communities where privately-insured patients are more likely to be found. Access to care for Medicaid patients is thus limited, and that impacts their health, delays their treatment, and reduces their odds of receiving quality care.
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