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Dr. Janek: Because we’ve now gone to a system of managed care through- out the state, it means that what’s left is on the direct fee-for-service [side]. Estimates around this building are that between 10 and 25 percent of the case- load is in fee-for-service, [where] we may have to institute some rate cuts. I hope we don’t get there. I think we can do without it. And again, that’s the wrong direction if we get to that point. I want to go back and create the mod- el for Medicaid, even in managed care, that encourages doctors to get into the system. One of the models we hope to discover, create, stumble upon — I don’t care how we get there — is [one] where providers are at the table saying, “We’ll share in some of the risk, but we want some of the reward. Pay more when the quality is good. We can do more with less in certain areas. But we also need to be able to do more with more in other areas.” Whether that’s an ACO [account- able care organization], or an IPA [inde- pendent practice association], or some new alphabet soup that hasn’t been in- vented yet, we’ve got to get doctors back in the game to at least share in the risk, while participating in the rewards.


Texas Medicine: Patient responsibility is a factor that impacts costs and out- comes but is often out of doctors’ control. What is HHSC doing to get patients in the game, too?


Dr. Janek: Most of the time, it comes down to financial incentives. The federal government gives very little latitude to do that. Even when it lets you [use] co- pays, premiums shares, and the like, it still is very clear and known by the pa- tients themselves that even if they don’t pay, [doctors] still have to take care of them. There’s the rub. It could be that the incentive out there is not so much financial. Maybe the incentive out there is to do more for yourself, participate in wellness programs, stop smoking, lose weight, and we’ll make sure that you get better latitude in clinic hours, easier ac- cess to clinics, rather than longer waits in emergency rooms. I’m not saying that’s the [answer], but we have to find some sort of incentive, financial or oth-


erwise, to get patients back in the game. Just like the doctors want to be available for the rewards if they take the risk, we have to get patients back in the game to take more control of their well-being.


Texas Medicine: The dual-eligible pay- ment cuts last session were another hit to doctors and access to care, particu- larly in certain regions of the state. Will you advocate to restore those cuts?


Dr. Janek: We’re working hard on that. In an attempt to restore some of that, you have to figure out how much money you can get to do that and where it is going to come from in other parts of the budget. To say we can do it for some doctors and not others is very problem- atic. We are not about to go look at the books of every practitioner in the state who is a Medicaid provider. Right now, our best hope is that we can restore some of those cuts on the deductible


side. We think that is the best place to look right now, and that’s what we are exploring. I don’t know that we are go- ing to get this done. It requires the co- operation of the legislature because it is money that would otherwise be avail- able for other things.


Many of these doctors are also pri-


mary care providers, and because of the [Patient Protection and Affordable Care Act], one of the bright spots was a provision for straight 100-percent fed- eral dollars [to raise Medicaid payment rates] for primary care doctors. We are working to determine what that number is going to be, what the conditions of it are. But certain primary care doctors should see an increase in their Medicaid reimbursement paid for with federal dol- lars. That’s supposed to be available Jan. 1. I see nothing right now that tells me it won’t. But we are working hard with [the federal government] to make sure those dollars are available.


Texas Medical Board appearance?


Pending


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