Wednesday, January 13, 2010

What do the health reform bills do ... to increase Medicaid pay for primary care?

Beyond the "big" issues - like the tax on high cost health plans, employer mandates, and national versus state health exchanges - being negotiated by the House and Senate leadership, there are a myriad of other issues that have to be resolved before Congress votes on a final bill. In some cases, the differences are narrow, but for others, the bills take a very different approach to the policies, priorities and funding issues involved.

Take primary care. The House and Senate alike agree that primary care needs to be supported, and both bills have provisions to increase primary care workforce. But below the surface there is a big difference on how much money the federal government should spend on primary care, particularly when it come to increasing payments to physicians.

Both the House and Senate bills will increase Medicare payments to primary care physicians. But the House would also spend $57 billion over five years to increase Medicaid payments for primary care services so that they are on par with applicable Medicare rates. More than just primary care physicians would benefit under the House Medicaid pay parity proposal, since any physician - regardless of their specialty - who bills for the specified primary care services (mainly, office visits and other evaluation and management codes) would get the fee increase. The Senate bill does nothing to increase Medicaid pay rates.

Yesterday, the American College of Physicians joined with 118 organizations to urge House and Senate negotiators to include the Medicaid pay parity provision. The letter explains that, "Medicaid rates average just 66% of Medicare rates for primary care services and are woefully inadequate to cover the cost of providing care ... The inadequacy of Medicaid reimbursement levels must be addressed in conjunction with the Medicaid expansion or we risk leaving our poorest and most medically-vulnerable residents behind despite the remarkable promise offered by health reform." As reported in MSNBC several months ago, low Medicaid payment rates are the principal reason why few physicians accept large number of Medicaid recipients.

Both the House and Senate bills would add about 15 million more persons (mainly, adults without kids) to Medicaid, but unless the House pay parity provision is accepted, most of them will have a hard time finding a doctor who is accepting Medicaid. Jonathan Cohn writes in the New Republic that, "increasing the reimbursements in an existing public insurance program that already underpays doctors and hospitals would seem like a no-brainer--which, as it happens, it is, for a great many reasons." Also read Jacob Goldstein's Wall Street Journal blog on the same topic.

The House of Representatives is pushing for the Medicaid pay parity provision to be accepted in the final bill, but the $57 billion price tag is making it a hard sell for fiscally-minded conservative Democrats, who want to keep the total costs of the final bill below $900 billion. Still, expanding Medicaid to cover tens of millions more people won't give them access to care, unless Medicaid pay rates are increased to make it possible for doctors to take care of them.

Today's question: Do you accept Medicaid patients? Would you accept more if the Medicaid reimbursement was increased to no less than the Medicare rates?


PCP said...

Perhaps a good starting point for the 57 billion dollars would be the extra 10-15 Billion(depending on Senate vs House version) that has been appropriated for expansion of Community health centers/Federally Qualified health centers and other such Gov't supported clinics. These clinics already receive Medicare/Medicaid payments rates far in excess of private practices.
Surely better payment to Private Doctors would significantly reduce the need for such clinics.
Of course we all know that will not happen, because that 10-15 billion is the cost for the vote of our self avowed Socialist Senator from Vermont.
With various such payoffs to Lawmakers/Industry representatives etc, is it any wonder that Funds are short? The whole notion that 35 million people (typically poorer and sicker) will be covered in a budget neutral way, while increasing payments to Doctors and Hospitals is laughable at best.
We all know where this is going. Bait and switch. Those of us supporting this will find that when the dust settles, we will end up being asked to see 20% more patients for 20% less revenue per patient. That is not a hamster wheel I feel able nor willing to get on.
Health system reform, where waste is cut from the system and benefits are rationalized, with the Primary Care Doctor at the center of the reinvented system are clearly not happening. Witness the pilot testing of Advanced Medical Homes headed by Nurse Practitioners.
The whole model of primary care is supposedly being reinvented to make it more attractive to younger physicians and yet we are being asked to consider NPs our peers.
What this will clearly evolve into is a system where those on Gov't insurance ie medicare/medicaid/public exchange-option or whatever they call it/Tricare etc will all end up in one pool seen by mid-levels loosely supervised by Physicians(if at all). Then there will be the 15% or so who will choose private physician care ie Concierge care with Private insurance for the incidental expenses.
That would be a very sad day for our country. Ironically the egalitarians amongst us would be those who would have created the disparities.

Jay Larson MD said...

Going from pitiful reimbursement to woeful reimbursement for office visits will have meager affects on primary care physicians seeing the additional insured Americans. General internists are already too stressed and to add more strain only accelerates the extinction process.

Harrison said...

An increase in the Medicaid payment rate to being on par with the Medicare rate would probably allow our practice to accept Medicaid patients.
We cannot now because the demand would be high, and we would see our schedules filled with 40% to 50% of the slots taken by patients who have a payer source that doesn't even cover the overhead.
The current Medicare rate is also inadequate.
$60 for 99213, $95 for 99214, $125 for 99215. Hmmm?
A 99215 visit is supposed to take at least 45 min. In a day you may be able to fit in 10 of these. $1200 in real money for the day.
4 and 1/2 days per week of that. $5400 in real money coming in to the practice per week. Half to overhead.
And the physician is left with $120,000 per year at best.

Specialists start with job offers of $500,000 or more.

Of course I'm exaggerating. But not by a whole lot.

If the government is going to take on the job of assuring that we all are covered, then it will have to be smart about it.
Change the incentives.
Put more care in the hands of primary care physicians.
And pay them adequately so the job is attractive to physicians who can put in the time and thought to educate patients and have the result be better and more appropriate care to more people.