Medicaid rates haven't kept up with Medicare's
Medicaid rates haven't kept up with Medicare's
Medicaid physician fees haven't kept up with Medicare fees, and this could be contributing to problems with accessing care, according to a recent study on Trends in Medicaid Physician Fees, 2003-2008.
The study, published in Health Affairs, was conducted by researchers at the Urban Institute in partnership with the Kaiser Family Foundation's Commission on Medicaid and the Uninsured in Washington, DC, and the California HealthCare Foundation in Oakland.
Medicaid historically has reimbursed physicians under fee-for- service at levels below what Medicare and private health insurers would pay for the same services. The study finds that Medicaid fees increased by 15% from 2003 to 2008, but fell in real terms because the gains did not keep pace with inflation. Medicaid fees did grow faster than Medicare fees during that period, however, rising from 69% of Medicare in 2003 to 72% by 2008. Increases were greatest in Medicaid fees for primary care and obstetrical services.
Some payments increasing
Despite the impact of the recession, some states have managed to avoid cutting Medicaid provider reimbursement rates, and in some cases, even increased rates. "We did not cut but in fact increased some physician payments. We are launching an all-payer, patient-centered medical home pilot in 20 physician practices statewide," reports Trish Riley, director of the Governor's Office of Health Policy and Finance in Augusta, ME. "We were able to provide funds in the budget for Medicaid to participate in that pilot, despite cutting $500 million from the budget and for the first time in memory having a budget that is lower than the last biennium's."
Maine also is preparing to convert hospital payments to DRG/APC next year. In addition, funding was provided for a new "Doctors for Maine's Future" scholarship program that will support a new medical school collaborative involving physicians doing rotations in Maine's rural hospitals to encourage doctors to practice in the state.
North Dakota gives increases
North Dakota Medicaid has given rate increases to hospitals, physicians, chiropractors, ambulance services, and dentists, who also will receive a 6% inflationary increase in the second year of the biennium. All Medicaid providers that did not receive a specific rate increase will receive a 6% inflationary increase each year of the biennium.
The state also passed a bill allowing nurse practitioners to serve as primary care providers for Medicaid clients. "We are anticipating implementation of that later this calendar year. It is expected that this will assist with assuring Medicaid clients have access to the services and referrals needed," says Maggie Anderson, director of the Division of Medical Services for North Dakota's Department of Human Services.
Barriers to access ID'd
An April 2009 study, Medi-Cal Physician and Dentist Fees: A Comparison to Other Medicaid Programs and Medicare, found that overall, Medi-Cal fees were 83% of the Medicaid national average in 2008. This report by the Urban Institute, funded by the California HealthCare Foundation, compares 2008 Medi-Cal physician fees for selected procedures with fees paid by other states' Medicaid programs and by Medicare.
California's fees rank 47th overall among states when adjusted for geographic differences in the cost of providing medical care. Among the 10 largest state Medicaid programs, California ranks ninth. Also, considerable variation exists in Medi-Cal fees across procedures in relation to national averages, with relative fees ranging from less than 70% to more than 140% of the national average.
From 2003 to 2008, Medi-Cal physician fees grew, on average, by only 2%. This compares to 15% growth in average Medicaid fees nationwide and 21% general inflation during this period. Medi-Cal reimbursement for most dental care procedures also falls short of those for Medicaid nationally.
According to Toby Douglas, chief deputy director of the California Department of Health Care Services and the state's Medi-Cal director, "the financial environment in the state is very difficult and Medi-Cal, as the second largest state-funded program, must be part of the budget solution."
Mr. Douglas says there are three ways in which Medi-Cal costs can be reduced: Eligibility rollbacks, reimbursement rate reductions, and benefits cuts. "Recent budgets have touched upon all of these areas, but eligibility reductions are no longer permitted under new federal requirements," he says.
The state's governor recently sent a letter to the president seeking program flexibilities to slow the rate of growth within Medi-Cal and allow the state to manage Medi-Cal within the framework of available resources. "Discussions with the president's staff are ongoing," says Mr. Douglas. "If the effort is successful, flexibilities could come in Medi-Cal rates, benefits, and cost-efficiency rewards."
A component of the governor's 2007 health care reform proposal was across-the-board reimbursement rate increases. "Unfortunately, the proposal failed," says Mr. Douglas. "The governor continues to look at ways to ensure that the state is able to provide health care for our most vulnerable populations."
Grants improved access
A May 2009 report, Specialty Care in the Safety Net: Efforts to Expand Timely Access, conducted by the San Anselmo, CA-based Pacific Health Consulting Group, examined the barriers to access in specialty services for uninsured and Medi-Cal populations in California, particularly orthopedics, gastroenterology, neurology, and dermatology. The researchers evaluated the impact of grants funded in 2007 by Kaiser Permanente Community Benefit Programs and the California HealthCare Foundation to regional provider coalitions to develop strategies to improve access.
According to the report, more than half of the regional coalitions plan to implement one or more of five types of improvement activities. These include development and implementation of referral and clinical care guidelines, training for primary care providers to expand their scope of practice to incorporate specialty care activities, expanded specialist networks, web-based referral or consult systems, and referral coordination improvements.
According to Bobbie Wunsch of the Pacific Health Consulting Group, the program "gave rise to a lot of technical assistance, grant funding and peer learning along the area of specialty access. We wanted to look at what and how [these] had been impacted by the work that the foundation had done."
Ms. Wunsch says the research identified some promising trends, such as expanded specialty services, use of web-based referrals, and use of telemedicine to provider specialty services, both in urban and rural areas. For example, a subspecialist might be available by telemedicine to several community health centers, so patients don't have to travel long distances to see that provider.
Ms. Wunsch says she anticipates that state budget cuts to Medi-Cal could result in increasing problems with access, however, particularly in the areas of optional services, psychology, podiatry, and optometry. "Any cuts that come from the state budget on counties with public hospitals will have an indirect effect on the Medi-Cal population. If the counties then require funding cuts from the public hospitals, there is no question that access will be impacted. It's hard to know how deep the cuts will be in Medi-Cal." The impact of any cuts will probably be exacerbated in the counties that provide health care services to large numbers of Medi-Cal patients, she adds.
Ms. Wunsch says the theory is that the funding that was provided will act as venture capital to accelerate the development of collaborative programs at the community level. "There is a very delicate balance between Medi-Cal funding and the lack of funding for care for the uninsured," says Ms. Wunsch. "In the current environment, when you have large numbers of newly uninsured coupled with potential major changes in the MediCal program, I think we have to assume that we might not move as far as we might have in a better economic situation. When you consider that, coupled with the fact that even more people are delaying care, the picture isn't as rosy as it might have been."
Contact Ms. Anderson at [email protected], Mr. Douglas at [email protected], Ms. Riley at (207) 624-7442 or [email protected], and Ms. Wunsch at (415) 459-7813 or [email protected].
Medicaid physician fees haven't kept up with Medicare fees, and this could be contributing to problems with accessing care, according to a recent study on Trends in Medicaid Physician Fees, 2003-2008.Subscribe Now for Access
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