Some on Medicaid to pay fees
CHARLESTON, W.Va. - For many of us, it's printed right on the insurance card: if you decide to go to the doctor, be prepared to fork over $20 on your way out the door.
If you go to the emergency room, be sure to have a few $100 bills in your pocket.
Those are co-payments. They're small change as far as health care costs go, but health insurance companies have discovered even a small up-front charge makes patients think twice before making an unnecessary appointment or ER visit.
Patients with Medicaid currently have little reason to avoid unnecessary visits to doctors' offices and hospitals, however. No matter how many times they go, no matter how serious or trivial their medical need, Medicaid recipients pay the same thing: nothing.
That soon will change, though, as West Virginia moves forward with its expansion of Medicaid under President Obama's Patient Protection and Affordable Care Act.
More than 91,500 West Virginians are expected to join the federal insurance program next year, in addition to the 350,000 state residents already enrolled in Medicaid.
That will require Medicaid to act more like a private insurance company, meaning at least some recipients will be required to make co-payments.
Rob Alsop, Gov. Earl Ray Tomblin's chief of staff, said co-payments for Medicaid probably would not be much. Some recipients simply could not afford them, and the federal government prevents states from setting exorbitant co-payment requirements.
West Virginia's Medicaid recipients currently only have co-pays for certain prescriptions.
Penney Hall, communications manager for the state Bureau for Medical Services, said co-payments for prescription drugs are very low for state Medicaid recipients. Patients pay between 50 cents and $3 out of their pockets depending on the price of the drugs.
The Mountain State is one of only 11 without co-payments for medical services, according to a report from the Kaiser Commission on Medicaid and the Uninsured. Six states have no co-payments at all: Connecticut, Hawaii, Nevada, New Jersey, Rhode Island and Texas.
West Virginia's co-pay system likely would be based upon a patient's income, Alsop said.
"Obviously you can't charge a co-pay to someone that doesn't have an income.
"We could say, 'Everybody under 30 percent of the federal poverty line doesn't have to pay a co-pay.' We can draw all sorts of lines," he said.
Money from co-payments would go back into the state's Medicaid fund, which would help offset costs for the program.
Alsop said he is not sure how much co-payments would bring into the state, however. The state still has not set a plan for co-pay, because the federal government has not yet released the final rules for states' Medicaid expansions.
Under current Centers for Medicare and Medicaid rules, states cannot charge Medicaid recipients more than $8 for non-emergency trips to a hospital emergency room.
For inpatient care, states can charge patients as much as half the cost for their first day of treatment, or set a nominal fee. For outpatient care, states only can charge a $4 co-pay if patients' income is below the federal poverty line.
That doesn't seem like much, but state Sen. Evan Jenkins, D-Cabell, said studies have proven even small co-payments encourage health care consumers to reconsider unnecessary medical services.
Jenkins also serves as executive director of the West Virginia State Medical Association.
"With a little financial skin in the game, they will think about that co-pay when deciding whether or not 'I really need to go to the doctor,' " he said. "When something is free, we don't place a very high value on it. We may take it for granted and we may over-utilize."
And that is exactly what is happening at hospitals around the state.
Dale Wood, chief quality officer for Charleston Area Medical Center, said most people who arrive at emergency rooms are soon sent back home.
"Depending on the type of hospital, it may be as high as 80 percent go home," he said.
Sometimes, that makes sense. Patients might require a specific medical test, which emergency rooms can perform with very short turnaround times. Other times, patients might not know the severity of their condition and go to the ER out of an abundance of caution.
"But then another fairly large percentage of those who go home probably could have been seen by their primary care physician," Wood said.
Many patients without insurance rely on hospital emergency departments for their basic medical needs, since ERs are required by law to provide care for sick people regardless of their ability to pay.
Some Medicaid patients also go to the emergency room any time they have an ailment, no matter how insignificant, since they do not have to pay anything out of pocket for the visit.
Officials hope expanding Medicaid will curb the former type of ER overuse, and co-pays will put an end to the latter variety.
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