Local doctors react to planned Medicaid primary care payment increase

Dec. 23, 2012 @ 02:22 PM

Although there’s not really a set policy for how many Medicaid patients doctors and other Duke Primary Care providers can see, Dr. John Anderson, chief medical officer for the network, said that is something that’s monitored.

About 5 percent of patients seen by Duke Primary Care’s 165 physicians, nurse practitioners and physician assistants who provide care in a seven-county area around Durham are in the Medicaid program, Anderson said.
The percentage share varies by individual practice in the network, he said, with some of the network’s practices seeing a greater share of Medicaid patients than others.
An increase in Medicaid fees for certain primary care physician services is expected to go into effect Jan. 1 as a provision of the federal health overhaul. It’s “not a huge increase,” Anderson said, but he believes it’s going to help.
“The reimbursement certainly doesn’t, it doesn’t pay to see a large number of those patients,” he said. “It’s gonna get better as we get parity, the plan is for Medicaid rates to be comparable to Medicare rates, it’s still not great.”
Medicaid fees paid to certain primary care service providers such as family medicine physicians, pediatricians, and internal medicine doctors are set to increase to at least the rates paid by Medicare in calendar years 2013 and 2014 under the Patient Protection and Affordable Care Act.
The increase is set to start Jan. 1. However, Brad Deen, a spokesman for the N.C. Department of Health and Human Services, said increased rates will not be paid until the federal government grants permission. Retroactive payments will be made to make up the difference, he said.
Julia Paradise, an associate director at the Kaiser Commission on Medicaid and the Uninsured, said the increase in Medicaid fees for primary care physician services is not optional for states, which share the cost of the Medicaid health coverage program with the federal government.
For the first two years, the federal government has planned to pick up the increase. The federal government will pay up to the difference between a state’s Medicaid fees on July 1, 2009, and the Medicare fees in 2013 and 2014, according to a report from the Kaiser Commission on the Medicaid and the Uninsured.
That means that if a state’s current rates have been reduced since 2009, the state would have to pay more to get its Medicaid rates to 2009 levels, and the federal government would fill in the rest, Paradise said.
According to a 2012 survey by the Urban Institute detailed in the Kaiser Commission on Medicaid and the Uninsured report “How Much Will Medicaid Physician Fees for Primary Care Rise in 2013?,” Medicaid physician fees nationally in the year were 66 percent of Medicare fees on average. For surveyed primary care services, Medicaid fees were, on average, 59 percent of Medicare fees nationally.
In North Carolina, Medicaid fees were 82 percent of Medicare fees on average in 2012 for all services, according to the survey. For primary care services, Medicaid paid on average 85 percent of Medicare in the state.
“North Carolina’s rates are much closer to Medicare’s than they are in the country as a whole,” Paradise said. “So naturally, the impact of the primary care increase that’s in 2013 and 2014 is going to be bigger in states whose rates are pretty low, compared to states more like North Carolina…”
The change in Medicaid payments is not a change in a single rate, but in a “wide array” of rates for services that primary care physicians can bill Medicaid for providing, Deen said.
Highlighting one example, Deen said the Medicaid rate in the state for established patient office visits is $55.94. The expected Medicare rate in 2013 for that service is $72.17. The increase for that one service would generate $3.8 million in additional Medicaid dollars for participating primary care providers through the increase.
The N.C. Division of Medical Assistance is estimating that the change in Medicaid rates for 115 different primary care services will yield a total increase of $19.2 million in 2013, Deen said.
Dr. Steven Stack, chair of the American Medical Association Board of Trustees, said there’s a “well-recognized need” to invest in primary care, and it’s “well-recognized that Medicaid rates are too low to provide anywhere near the cost of providing care to Medicaid beneficiaries.”
“One of the hopes is that by investing in getting Medicaid patients access to primary care is so we can do health maintenance,” he said. “We can treat their blood pressure, treat their diabetes, treat their other chronic illnesses before they become acutely ill. The hope would be we’d be able to save money … (and provide) better health and better quality over time.”
He said that with the proposed expansion of Medicaid – which is optional for states – there will need to be providers who will serve those patients, including at community practices as well as at hospitals.
“If they don’t (implement) the pay raise, there’s not going to be a network to provide any of it,” he said.
Stack said there is concern about Congressional leaders proposing to cut the Medicaid primary care increase. The American Medical Association joined a Dec. 5 letter urging U.S. House and Senate leaders to oppose any possible elimination of the increase. The N.C. Medical Society also joined the letter.
Robert W. Seligson, executive vice president and CEO of the N.C. Medical Society, said the Medicaid increase would encourage primary care providers to take on additional Medicaid patients, but he said it’s not going to be enough.
“We’ve got a shortage of primary care providers right now,” he said. “A reasonable reimbursement will get them to take on patients,” he added.
A study published in the health policy journal Health Affairs in November found that while 96 percent of office-based physicians surveyed accepted new patients in 2011, 31 percent were unwilling to accept new Medicaid patients.
The study, by Sandra Decker, an economist at the National Center for Health Statistics, examined data from the 2011 National Ambulatory Medical Care Survey Electronic Medical Records Supplement.
Decker found that higher Medicaid-to-Medicare ratios correlated with greater acceptance of new Medicaid patients, according to a description of the study at http://content.healthaffairs.org/content/31/8/1673.abstract.
Decker also reported that an estimated 76.4 percent of U.S. office-based physicians were accepting new Medicaid patients in 2011 in North Carolina. That’s compared to 69 percent for all states.
Elaine Matheson, pediatric nurse practitioner and medical director of Durham Pediatrics, which is part of Duke Primary Care, said about 15 percent of the practice’s patients are covered through Medicaid.
“I’m assuming that the increase is going to be better, having a better reimbursement for the work that’s being done,” she said. “We’re committed to caring for patients covered by whatever insurance,” she added.
Dr. Howard Eisenson, chief medical officer of the Lincoln Community Health Center, said in an email that the current rate of reimbursement is better for Federally Qualified Community Health Centers like Lincoln.
He said that’s because those health centers typically provide much of their services to low-income, often uninsured, and medically vulnerable populations, and much of the care is already “discounted or otherwise inadequately compensated.” The center has an unusually large uninsured population, he said.
The amount of Medicaid payments is not a big issue for centers like Lincoln, he said, but he said the expansion of Medicaid would be a “great help.”
“Medicaid expansion would benefit Lincoln … greatly because, then, more of our patents would be insured,” he said in the email.
Dr. Steven Wegner, the chief medical officer for Community Care of North Carolina, a program that manages the care of Medicaid patients in the state, said the effect of the pay increases would be “marginal but important.”
Wegner said Medicaid already pays a high percentage of Medicare for primary care services in North Carolina. Coverage for Medicaid patients by primary care providers is “spotty” in the state, but said he believes Durham physicians do a good job of seeing them. He said he believes the increase would prevent doctors from dropping Medicaid patients as profits are getting squeezed in other areas.
“Medicare is not going up as fast as they need it, Medicaid patients typically are more ill, and require more time, so its’ just a matter of the doctors saying, ‘I’ve got to pay the expenses of the practice, and I can do it better by not seeing Medicaid, and seeing some other patients whose insurance reimburses more,’ ” he said.