Tuesday January 17, 2012
Doctors are asking the state to reconsider payment cuts for care provided to low-income seniors, saying the change could cause some physicians to stop treating such patients and consequently disrupt life-saving care. The change, which took effect Jan. 1, involves seniors covered by two government health care programs. The so-called “dual-eligible” patients generally qualify for Medicare based on their age and for Medicaid because of their income. When such seniors get health care, Medicare is billed first. The federally funded program pays 80 percent of the cost, leaving the rest to the patient. But if seniors are poor enough to also qualify for Medicaid, that program historically covered the co-pays. That required dollars from Texas’ coffers, because the program is funded by the state and federal governments. The new rule ends such co-pay coverage if the Medicare rate for care is higher than the Medicaid rate. Since Medicare gives doctors more for virtually every type of care, the change essentially ends supplemental payments from Medicaid. Federal law prohibits doctors from charging dual-eligible patients for Medicare co-pays. So the change essentially means a 20 percent payment cut for physicians. The rule has applied to hospital care for several years. But outpatient care is newly affected. The state projects the change will save $475 million during the two-year budget cycle, said Stephanie Goodman, a spokeswoman for the Texas Health and Human Services Commission. In all, Texas has about 333,000 dual-eligible patients, she said. Doctors said the change undoubtedly will cause some doctors to stop seeing dual-eligible patients. The government programs already pay substantially less than private insurers, so any cuts are difficult to absorb, they said. That is particularly true for specialists who provide more expensive types of outpatient treatments, said Dr. Bradford Holland, a Waco ear, nose and throat physician. The cut amounts to a larger dollar figure for them, he said. “The bottom line is getting tougher and tougher to maintain,” said Holland, who estimates about 10 percent of his patients fall into the dual-eligible category. Dr. Bruce Malone, president of the Texas Medical Association, said cancer doctors are especially worried. Some who provide outpatient chemotherapy fear they will have to refer people to hospitals for care because the drugs alone cost more than doctors will be paid under the new formula. Other types of physicians who will be hit hard are ophthalmologists, orthopedists and those who provide advanced wound care, he said. Malone, an orthopedic surgeon in Austin, cited hard numbers from his practice to illustrate the issue. One of the most common procedures he performs on dual-eligible patients is surgery to repair a broken hip, he said. Medicare allows $843 for such care, Malone said. That includes an initial visit, the surgery itself, several days of hospital care and three months of follow-up treatment, he said. The 80 percent doctors receive from Medicare is $674. That is only $211 more than his fixed overhead costs for providing such care, Malone said, stressing that it covers a three-month period. At a minimum, the lower payments will disrupt patients’ care, if not cause doctors to stop working with dual-eligible patients, Malone said. But it also could mean patients having to travel to a hospital that provides certain services, like outpatient cancer treatment, he said. That would cost the state more money in the long run, since hospital-based care is generally more expensive, Malone said. That is one of the chief arguments doctors make for excluding certain types of care from the new rule, Malone said. Exemptions Representatives from the doctors’ group and the state met last week. The result was an agreement that doctors will compile a list of the types of care they think should be exempt from cuts. The state then will review the list to see if changes should be made to help physicians disproportionately affected by the change, said Goodman, the state commission spokeswoman. “Our hope is very much that we could ensure an adequate provider base,” she said. Family Health Center, which provides basic care to a large share of Waco’s Medicare and Medicaid patients, won’t be affected significantly by the change, executive director Dr. Roland Goertz said. Its status as a Federally Qualified Health Center means it gets paid in a different way for more care provided under Medicare and Medicaid. But Goertz said he is concerned the change could make it more difficult for Family Health to refer patients for specialty care. Midsize cities like Waco generally only have one or two practice groups per medical specialty, so if one decides not to take dual-eligible patients, it would be a problem, he said. Dr. Jim Rohack, director of Scott & White’s Center for Healthcare Policy, agreed. Already, only 40 percent of Texas doctors accept new Medicaid patients. If more drop out of the program, patients will have more difficulty getting care. That, in turn, will send more people to the more costly emergency rooms, Rohack said. It also likely will result in people waiting longer to seek care, meaning they will come in sicker and be more costly to treat, he said. “Our legislators often look at the short term but don’t seem to look at the effect on all the moving parts” of the system, Rohack said.