A man enters the Columbia Family Health Center

A man enters the Columbia Family Health Center on Friday. A new Missouri law would have allowed health care providers to charge Medicaid patients for missing scheduled appointments or canceling with less than 24 hours notice. But the law cannot be implemented because it conflicts with federal law. 

COLUMBIA — A new law that took effect Friday  was supposed to allow medical providers to charge Medicaid patients for missing appointments. But that isn't going to happen — at least not yet.

The law, which was passionately debated in the Missouri General Assembly, is in conflict with federal regulation. Missouri would have to receive special permission from the federal government to pass it, and the state has yet to do so.

If it does receive approval, however, it could affect more than Medicaid patients. Those same federal rules say that if doctors charge Medicaid patients for no-shows, they must charge everyone else, too.

Two laws at odds

MO Healthnet, Missouri's Medicaid provider, provides medical insurance to over 950,000 low income and vulnerable citizens in Missouri, including people with disabilities, the elderly and pregnant women.

On Sept. 15, the General Assembly overrode Gov. Jay Nixon's veto and voted to permit medical providers to charge late fees to these patients for missed appointments if they do not cancel within 24 hours. It also permits providers not to allow patients to schedule another appointment until they pay the fee, which ranges from $5 to $20 depending on the number of no-shows in a three-year period.

But the federal agency that administers the Medicaid program, the Center for Medicare & Medicaid Services , allows doctors to charge patients only if they also charge the same amount to non-Medicaid patients

In order to change Medicaid law, Missouri would need to ask for a 1115 waiver.  Approval is not automatic; the federal government recently rejected at least two other states' requests for changes on the grounds that they made medical care less accessible.

"When you make changes to Medicaid, the federal government wants to have a say in it. You have to run it up through the food chain," said Jeff Howell, executive of government relations at Missouri Medical Association. "That’s when they issue waivers or changes to the program such as this. But the state has to ask permission from the federal government."

"We are inefficient"

Sen. David Sater, R-Cassville, who sponsored the bill, said it is up to the departments now to file for a waiver since the House and Senate already passed the law. He is confident Missouri will receive approval from CMS.

Sater said he personally spearheaded the provision after his many years as a pharmacist made him realize "the status quo isn't working."

When people miss appointments, Sater said, it contributes to long waiting times and causes medical providers to lose revenue and the opportunity to serve others. 

"We are inefficient. I want people’s health care to get better, and the use of taxpayers' money to get better," Sater said."My main objective is for people's well being. I’m not trying to hurt people."

Julie Brookhart, public affairs specialist from CMS, said in an email that once the state requests approval, CMS will evaluate it against its own regulations to decide whether it will allow the change. 

CMS lists the following criteria for approving changes to Medicaid policy:

  • increases strength and coverage to low-income citizens;
  • increases access to medical providers for low-income citizens; 
  • improves health outcomes for low-income citizens;
  • increases the efficiency and quality of care for low income citizens through service delivery networks. 

Implications for Medicaid patients

Medical providers and community outreach leaders don't seem too sure that this bill follows those criteria. 

Gloria Crull, chief executive officer of Columbia’s Family Health Center, said the bill has its pros and cons, but overall she doesn’t see it working practically.

Missed appointments are a major problem for medical providers, said Crull, whose center is targeted to serve uninsured and underinsured patients. Providers lose revenue and last-minute cancellations keep other patients from filling those appointment spots.

According to a study done by the Medical Group Management Association, the average practice faces a 5-to-7 percent no-show rate. A study in the BMC Health Services Research Journal estimated that the average cost of a no-show appointment was $196 per patient at regular healthcare clinic.

"Medical practices are not inexpensive to run and dental practices are even more expensive," Crull said. "That lack of revenue is a problem, and a person that could have been served isn’t."

The Family Health Center served 17,714 patients in 2015, Crull said. Sixty-eight percent of those patients were either uninsured or on Medicaid.

However, Crull said low-income patients face many more barriers when making their medical appointments. Many cannot take time off work or they lack reliable transportation.

"Lower income people are usually working jobs that are hard to get off from. Sometimes they will have scheduled off but at the last minute they're told they need to work," Crull said. "And, needless to say, the job takes precedence because that’s providing income to the family."

Nearly half of Missouri’s Medicaid patients are children, and almost 50 percent of births in 2012 were covered by MO Healthnet.

"Living in poverty creates factors that you would not have experienced if you have never been low income," Crull said. "Living in poverty is not easy. It is stressful."

Anthony Nichols, manager of Community Action’s Mobility Management project in central Missouri, helps provide transportation for low-income and disabled citizens. Nichols said this bill could push some struggling low-income patients over the edge.

Nichols said people are not intentionally missing appointments. They often face situations out of their control, such as not having money for the bus or their car breaking down.

"When they miss appointments, it’s something unrelated that they cannot help such as a lack of transportation, which is one of the biggest barriers," Nichols said. "It’s not their fault, they're not just lazy."

Nichols added that lower income citizens are made even more vulnerable by this law because people in poverty already experience a high amount of stress.

"They wake up in the morning, and while you and I just carry on, the first thought they have is 'How do I keep the lights on? How do I feed my children?'" Nichols said. "Rather than living your average day, they’re living in toxic stress."

Nichols said people with mental health problems could be especially affected if they do not have access to their medicine.

"People come in here and they’re on the verge of tears and they need any kind of help they can get," Nichols said. "So removing any kind of help just seems like further impediment. People just need a break."

Crull said she does not think the program would work, even if medical providers try to enforce it, because she doesn't think low income people would be able to pay the fees.

Additionally, offices would have to spend money to implement a billing system and keep track of those added fees.

The new law does not just apply to doctor's appointments. The bill applies to therapists, dentists, eye doctors, chiropractors and potentially anyone else who provides a medical service to others.

"This kind of problem affects more than just Medicaid patients and the medical community," Crull said.

"If you don’t have healthy residents, you don’t have a healthy community, and then you don’t have a healthy economy because people are sick and don’t work," Crull said. "It’s a trickle-down effect."

Supervising editor is Mark Horvit.

  • Senior Missourian reporter. Investigative Journalism major. My email is kajmb3@mail.missouri.edu. I can also be reached in the newsroom at 882-5720.

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