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lature’s decision to underfund Medicaid by $4.7 billion in fiscal year 2013 and to defer to fiscal year 2014 nearly $2 billion in some payments to school districts. Still, Dr. Floyd says that won’t stop TMA from pushing for

funding it considers essential to preserving access to care or defending against new payment cuts that could harm access. “We are in the mode of last session. We don’t want to lose

any ground. And we need physicians to keep seeing these pa- tients,” Dr. Floyd said.

A top budget priority for TMA will be to restore Medicaid

coverage of the Medicare Part B coinsurance and deductible for dually eligible patients — those covered by both Medicare and Medicaid.

In 2011, the legislature directed the Texas Health and Hu-

man Services Commission (HHSC) to limit payment for those patients’ services to the Medicaid allowable, meaning that if Medicare paid more for a service, which is almost always the case, the state would not pay any more. The legislature ap- proved the cut because officials estimated it would save nearly $300 million, an amount that since grew to $465 million. Be- fore the change, which HHSC implemented on Jan. 1, 2012, Medicare paid 80 percent of a dual-eligible patient’s visit to a doctor; Texas Medicaid paid the other 20 percent and covered the Medicare deductible for those patients. The cut hit many physician practices hard, particularly

those in rural and border areas where doctors serve a dispro- portionate number of what Dr. Floyd describes as a very vul- nerable population of senior patients with complicated condi- tions and little income to spare.

“These patients have been left out on a limb with no lifeline.

They are on fixed budgets, managing pennies,” he said. “Not to mention the physicians who are no longer paid a portion of what they were counting on to take care of these patients.” That has discouraged, if not prevented, them from continuing to treat the more than 400,000 dual-eligible patients across the state. Some doctors have moved, worked longer hours, or even taken out loans to cope. Left unaddressed, TMA leaders say those reductions could

be compounded by potential Medicaid and Children’s Health Insurance Program (CHIP) payment cuts. Anticipating a slow economy, the LBB instructed all state

agencies to include a 10-percent across-the-board reduction in their 2014–15 appropriations requests. For HHSC, that turned into a proposed 1-percent cut to Medicaid and CHIP payments, which TMA opposes. Sen. Jane Nelson (R-Flower Mound), chair of the Senate Committee on Health and Human Services, “can’t imagine ad- ditional reductions to physician reimbursement rates next ses- sion.” The committee also is “gathering information about the impact of changes to dual-eligible payments on access to care as we approach next session.” Similarly, Rep. John M. Zerwas, MD (R-Simonton), ac- knowledged to TMA Fall Conference attendees in October that the dual-eligible cut was “clearly having a large impact” on access to care and that it was “one place [the legislature] could

realistically go back to and take a serious look at, partly be- cause revenues are up. We can’t go back and restore all of the cuts, but this is one area we might be able to see remedied.”

STOPPING A MEDICAID MELTDOWN TMA also is advocating for broadening forthcoming PPACA

provisions that will increase Medicaid payment rates for cer- tain primary care physicians — specifically, pediatricians, fam- ily physicians, and general internists — to Medicare parity to stem the exodus of primary care physicians from Medicaid. HHSC is ready to implement the two-year raise, which spans from Jan. 1, 2013, to Dec. 31, 2014. TMA would like to see the PPACA rate increase extended

through 2014–15 and expanded to subspecialists, without whom it says primary care doctors cannot effectively treat patients.

But the association is prepared for an uphill battle on that

front, as well, TMA Vice President for Advocacy Darren White- hurst says. Even though the federal government is picking up the tab for the primary care rate increase for two years, the costs to increase specialty physician fees will be significant. “That shows up on the budget as a huge increase in spend- ing and more spending on medical care for the poor than for education. So this could further reinforce Republicans’ argu- ments that Medicaid costs are out of control,” Mr. Whitehurst said.

Nor are lawmakers expected to budge in their rejection of an expansion of the Medicaid program prescribed under the federal reform law, which the U.S. Supreme Court declared optional.

“I do not see us expanding Medicaid as directed by the Af-

fordable Care Act,” although other avenues for expansion will be a “main debate,” Senator Nelson said. Because payment inadequacies aren’t the only headache contributing to a meltdown in Medicaid participation rates, the TMA-led Physician Medicaid Congress is devising a broad legislative and regulatory proposal for reforming the program into one that is viable long-term, says John Holcomb, MD, chair of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured. Onerous billing procedures, inconsistencies across partici- pating HMOs, and Medicaid expansion were just a few items members of the Medicaid congress began tackling at the TMA Fall Conference and will continue to address. Add to that list new rules that fail to differentiate between honest mistakes and outright fraud and that expand the Office of Inspector General’s (OIG’s) ability to hold payments and prosecute under what doctors say is a guilty-until-proven-in- nocent approach. (See “Guilty ’Til Proven Innocent,” December 2012 Texas Medicine, pages 16–22.) “I don’t know how we are going to get new doctors into these programs with all of this hanging over their heads,” Dr. Holcomb said. “Bringing Medicaid rates to Medicare parity will continue to be a high priority. But all of these other issues could be easily fixed, and the legislature and [HHSC] have

January 2013 TEXAS MEDICINE 21

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