with no facilities open to them on a cotninuing basis, the poor turn to the emergency rooms of the local hospitals. This in turn leads to higher hospital costs which in return are passed on to other consumers of hospital services. Even families on public assistance, with medicaid privilege, are turning to the emergency room as the health care facility of first resort. This is due to the fact that few doctors are participating in the medicaid program as will be demonstrated in the third part of this paper.

III. THREE MEDICAID SURVEYS

Since 1971, there have been three separate surveys concerning El Paso County Physicians and their acceptance of Medicaid for payment of services. The first survey was taken in the summer of 1971 by Ms. Joan Temko from the Legal Services Department of El Paso County. The second survey was finished in late 1972 and was conducted under the auspices of the Community Health Center of Colorado Springs. The third survey was completed by the author who was aided by Ms. Becky Clark, a summer work student with the Legal Services Department of El Paso County.

LEGAL SERVICES SURVEY (1971)

239 physicians and surgeons were surveyed and 69 responses were received yielding a 29% response. (A copy of the survey is attached.) [See exhibit A.] The questionnaire was brief and requested the following information: Physician's Name, Specialty, Number of Medicaid Patients, Total Number of Patients or approximate percentage of medicaid patients of entire practice. Three additional questions were asked: (1) Do you have any other provisions for low income people, i.e., reduced rate, deferred payment? How many patients does this include? (2) What is the maximum percentage of medicaid patients you find acceptable for your practice? (3) Are you now able to take on new Medicaid patients? Comments from the physicians on the medicaid program were also invited.

TABLE A-MEDICAID PATIENTS PERCENTAGE OF TOTAL PRACTICE

Other provisions such as reduced rate or deferred payment

41 physicians responded in the affirmative, i.e., they utilized either a reduced rate or a deferred payment. 28 doctors signified they utilized a reduced rate for some patients. In many cases this appears to be a quite arbitrary decision with some doctors granting reduced rates to teachers, nurses, tax collectors,

grocery store owners and landlords! Most doctors stated that the number of such patients was very low and only 5 physicians indicated that such patients accounted for more than 10% of their practice. 35 doctors stated that they granted deferred payments although this question is of questionable value since many of the physicians indicated nearly all their patients pay on a deferred payment basis.

Ability to take on new medicaid patients

46.4% of the physicians did not answer this question. Another 21.7% were not taking any new medicaid patients and an additional 4.4% were not taking any new patients. The remaining 28.5% responded affirmatively but with many reservations and qualifications such as "a few", "if it's important", "occasionally", "sometimes", etc. It appears many physicians were reluctant to answer this item because they feared "becoming swamped with new medicaid referrals". Complaints on medicaid

Complaints on medicaid voiced by the medical profession could generally be broken down into five separate categories. (1) Medicaid does not pay usual and customary fees. The usual reimbursement is approximately 60% of the normal fee. (2) Nearly all physicians stated that there was too much paper work involved in order to receive a reimbursement. (3) Many physicians claimed that delays in receiving reimbursement were too common and too long-up to six months. (4) Numerous doctors complained that there were too many people on medicaid; others were opposed to the government's entrance into the medical field. (5) A substantial number of physicians expressed the belief that Medicaid patients over-utilize medicaid privileges for trivial matters, do not keep appointments and fail to cancel, and are not grateful to the doctor for his services and ignore his advice.

CONCLUSION

The survey appears to be a fairly reliable barometer of the views and attitudes of the medical profession toward medicaid usage. Although medicaid patients make up less than 10% of an average physicians clientele, the complaints indicate tremendous frustration and anger toward a problem-filled system that promises much and delivers little except more problems. Comparing Tables A and B, it can be seen that most physicians felt they were operating at the maximum tolerable level of medicaid patients or even above that level. Also of important notice is the fact that less than 1% of the physicians indicated they were willing to accept a new medicaid patient, although many were willing to charge a reduced rate.

Community health center survey (free clinic)

In late 1972, the Community Health Center conducted a survey of the medical profession and its acceptance of medicaid patients. This survey was prompted by the complaints of Medicaid recipients who claimed it was difficult and sometimes impossible to find a physician who would accept medicaid payment for medical services. Of particular interest was the difficulty that new public assistance recipients encountered in their attempts to receive medical care via the medicaid program.

Since most medicaid patients make their initial contact for an appointment with the doctor's nurse or secretary, it was decided to use the same procedure for purposes of the survey. A call was made to the doctor's office and an attempt was made to procure an appointment after announcing that payment would be made by Medicaid. The results are as follows:

General practitioners

At the time of the survey, there were 36 GP's listed in the yellow pages. Of this number, only 7 would accept a new medicaid patient and two of these stated that their acceptance was limited to emergency situations or to a one time visit. Two other GP's were listed with the Colorado Springs Medical Society but neither was willing or able to accept medicaid patients. The rate of acceptance is 18.4%. Internal medicine

After a General Practitioner, one of the doctors most frequently contacted by Medicaid recipients is usually a specialist in Internal Medicine. 27 doctors listed as specialists in Internal Medicine were contacted and 13 of these were willing to accept a new medicaid patient. However, of these 13, 6 placed qualifications upon their acceptance. Such qualifications included being referred by another physician, "really being sick", and waiting lists of 3 weeks or more. 6 other doctors

mentioned that they were taking no new patients and 2 others indicated they had filled their "quota" of medicaid patients. The rate of acceptance of new medicaid patients among specialists in Internal Medicine is 48.1%

Osteopath (D.0.)

Osteopaths are licensed to practice medicine in the State of Colorado if they pass the same qualifying exam as a Medical Doctor (M.D.). In Colorado Springs, they now form an important part of the health care delivery system. 19 Osteopaths were contacted and 9 of them were willing to accept new medicaid patients. The acceptance rate of medicaid among Osteopaths is 47.4%.

OB-GYN

20 physicians were listed as OB-GYN specialists and 9 were willing to accept new medicaid patients. An additional five stated that they had reached their "quota" and were unable to accept any additional medicaid patients. Two other physicians were listed with the Colorado Springs Medical Society as specialists in OB-GYN but neither physician was accepting new medicaid patients. The medicaid acceptance rate among OB-GYN physicians is 40.9%. Pediatrician

Only 11 doctors were listed as pediatricians. (Although Colorado Springs is reported to have an excellent ratio of doctors to the general population, there is an acknowledged shortage of pediatricians in the Pikes Peak area.) Of the 11 doctors contacted, only 1 was able to take a new medicaid patient and in this situation there existed a long waiting list. An additional Pediatrician was listed with the Colorado Springs Medical Society but was not accepting medicaid patients at that time. The acceptance rate for medicaid among pediatricians is 8.3%.

Ear, nose, and throat

This is another area of apparent doctor shortage with only 7 doctors listed as specialists in this area at the time of the survey. Of this number, 5 were willing to accept a new medicaid patient. An additional ENT specialist was listed with the Colorado Springs Medical Society but this physician was not participating in the Medicaid program. The rate of acceptance of medicaid patients among ENT specialists is 62.5%.

Diseases of the skin-allergists

7 physicians were listed as being specialists in this area and 2 were willing to accept new medicaid patients at the time of the survey. The rate of acceptance of new medicaid patients by Allergists is 28.6%.

CONCLUSIONS

133 physicians were contacted for the survey and 46 responded that they were accepting medicaid patients with new medicaid cards. This is an overall acceptance rate of only 34.6%. The number of Medical Doctors accepting new medicaid patients was 37 out of 114 for an acceptance figure of 32.5. The highest percentage of physicians accepting new medicaid patients was found among Ear, Nose, and Throat Specialists where the acceptance rate was 71.4% and the lowest acceptance rate of 8.3% was found among pediatricians. Consequently, it does not appear that the equality of care and freedom of choice requirements of the medicaid program are being met in the Colorado Springs

area.

Department of Social Services survey (1973)

Problems involving medicaid usage and acceptance have been known by the medical profession and also by state and local representatives of the Department of Social Services. New attempts were made to establish procedures which would alleviate some of the problems disturbing to the medical profession. It was hoped that this survey would show whether these and other efforts were leading towards a greater acceptance of medicaid usage. The results of this survey, however, did not support this hope and indicated increasing difficulties with medicaid usage and acceptance. The methodology chosen was identical to that of the previous survey conducted by the Community Health Center. General practitioners

38 physicians were contacted in this category. Only 6 were willing to receive new medicaid patients. 5 others indicated they had reached their quota of

medicaid patients. 7 indicated they were unable to take any new patients, 2 physicians were on vacation and not available. Their calls were being handled by another doctor who did not accept medicaid. Of the 6 who were able to take new patients, 3 were able to set appointments only 10-14 days in the future. 4 nurse-secretaries indicated the doctor would not accept medicaid but would be willing to accept a reduced payment if the patient could not afford it. 5 others gave a referral to the Colorado Springs Medical Center which does not accept new medicaid patients and another 3 asked the caller to contact his/her caseworker. The acceptance rate by General Practicioners of new medicaid patients was 15.8%.

Internal medicine

32 physicians were contacted in this category. This includes 5 doctors who were listed as specialists in Cardiology and Internal Medicine. Of the 32 contacted, only 11 doctors were seeing new medicaid patients for the first time. 4 were accepting no new patients. One doctor was unable to be reached although efforts were made on 5 consecutive days. 2 indicated that arrangements could be worked out for a reduced rate although no commitment could be given at that time. 4 nurse-secretaries referred the caller to a doctor who was not able to take any new patients. 2 of the 11 who were accepting new medicaid patients had waiting lists in excess of two weeks unless it was an emergency. One nurse-secretary felt impelled to give a lecture on medicaid, food stamps, and lazy people. The new medicaid patient acceptance rate is 34.8 among specialists in Internal Medicine.

Osteopaths (D.0.)

22 physicians and surgeons are listed as osteopaths. Of this number, 3 limit their practice to surgery and were not contacted. Of the remaining 19, 9 were willing to accept new medicaid patients although the waiting time for the appointment ranged from one day to three weeks. 4 of the doctors were not accepting any new patients although 2 stated that something could be worked out if the matter was serious. Of the 10 who were not accepting new medicaid patients, 5 were able to give a referral to a doctor who was participating in the medicaid program. In general, receptionists for the osteopaths tended to be more considerate and understanding than their counterparts for the medical doctors. Four receptionists for D.O.'s requested that the caller return a call to the doctor if the illness became more serious or acute. Only two receptionists from the entire MD group, indicated the same consideration. The acceptance rate of new medicaid patients by osteopaths is 47.4%.

OB-GYN

The results from this group of specialists were identical to the previous survey conducted in 1972. 21 of the 22 doctors were finally contacted. 9 were accepting new medicaid patients; 9 indicated that they had reached their quota or were not accepting new medicaid patients; 3 indicated they would have no openings for weeks. 4 doctors who were not accepting medicaid patients referred the caller to the same doctor who stated that medicaid was usually accepted but that the first office visit required a $20 cash fee. 9 doctors who were not accepting new medicaid patients made referrals or suggestions to contact another specific doctor. Only 2 of the 9 were successful suggestions or referrals. The acceptance rate of new medicaid patients by OB-GYN specialists was 40.9%.

Pediatrician

Not one pediatrician could be found who would accept a new medicaid patient. Of the 12 doctors contacted, 8 indicated they were not accepting new medicaid patients; 3 stated they would not accept medicaid payment but would consider charging 2 price; 1 doctor stated that no new patients were being accepted. Receptionists at two of the offices suggested that the caller contact the Department of Social Services or his/her caseworker. Another suggested a call to the City-County Health Department to find out when and where the clinics for children were being held. The acceptance rate of new medicaid patients by Pediatricians was 0%.

Ear, nose, and throat

This area of specialty also produced the same results as the 1972 survey. 5 doctors were accepting medicaid payments and gave appointments without much delay. 1 doctor was not accepting Medicaid patients and 1 doctor was not accepting any new patients at the time of the survey. The same 5 doctors accepting

new medicaid patients in 1972 were continuing to accept new medicaid patients in 1973. The acceptance rate of new medicaid patients by ENT specialists was 71.4%.

Ophthalmologists

This group was not surveyed in 1972 since routine eye exams are not covered by medicaid payments. However, they were included in this survey since infections and diseases of the eye are relatively common and such services are covered by medicaid payments. 14 doctors were contacted and 8 were participating in the medicaid program with a willingness to accept new medicaid patients. 4 stated that there were no openings for weeks or were not accepting new patients at all. One doctor gave advice for home treatment and one declared he was not accepting medicaid patients. The acceptance rate of new medicaid patients among ophthalmologists was 57.1%.

Overall, 50 of the 151 physicians surveyed were accepting new medicaid patients with the resultant acceptance rate of 33.1%. If the specialists in Ophthalmology are deleted from this survey, a direct comparison can be made with the 1972 survey. At that time, 34.6% of the physicians surveyed accepted new Medicaid patients. In 1973, this figure has dropped to 30.7%. In view of the rapidly rising population in El Paso County and the continuing rise in the Medicaid population, the decline in doctors participating in the Medicaid program must be viewed as a serious matter. It is the conclusion of this study that, despite an area with sufficient and excellent medical facilities with a reported excess (?) number of medical personnel, the poor of this community have not and are not receiving equal or even adequate health care. It is also quite apparent that many of the requirements of the Medicaid program which were delineated in the first part of this paper are not being met. At best, the Medicaid program in Colorado Springs provides an illusion of equality. At worst, it is a system which is denying health care to the medically indigent-a system which is rapidly fostering a health care crisis for the City of Colorado Springs.

RECOMMENDATIONS

1. Support the Socio-Economics Committee of the Colorado Springs Medical Society in its attempts to obtain more equitable reimbursement for Medicaid fees.

2. Cooperate with the Health Planning Council of Colorado Springs and the Director of Public Health in setting up outreach clinics in neighborhood areas. (This would be an implementation of the recommendations found in the Health Report of 1944 and the Kearney Report of 1971.)

3. The Department of Social Services should explore the possibility and feasibility of establishing a Health Care Corporation (HCC) or a Health Maintenance Organization (HMO) with a prepaid enrollment plan for Medicaid recipients similar to plans already operating in New York and California.28

28 On September 12, 1973 the United States House of Representatives overwhelmingly passed H.R. 7974 which provides 250 million dollars which provides assistance for the establishment of health maintenance organizations. Since this bill also has the backing of the Administration, it is likely to become law within 90 days. Efforts should be made to obtain some of these funds to establish a HMO in Colorado Springs.