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$33.27, the Medicaid allowable for this code. Prior to policy change, physician would have been paid up to the Medicare allowable ($66.90). This is, in essence, a 50-percent payment cut.


• Example 2: Established dual-eligible patient visits physician office for routine visit; Medicare deductible has been met. Physician bills Medicare CPT code 99213. Medicare allowable is $66.90. Medicare pays $53.52, 80 percent of the allowable. Physician bills Medicaid for the remaining 20 percent. Medicaid allowable is $33.27, so no coinsurance will be paid. Under old policy, Medicaid would have paid an additional $13.38 so that physician’s entire


payment equaled Medicare’s $66.90 allowable. This is a 20-percent payment cut.


The dual-eligible payment cut unfairly penalizes physicians who care for the sickest and frailest Medicare patients. The policy change hit particularly hard practices in rural and inner-city Texas, along the Mexico border, and many of those serving nursing homes. Those practices serve a disproportionate number of dual-eligible Medicare patients. In addition, the cut is already causing physicians to limit how many dual-eligible patients they are willing to treat, restrict their Medicaid participation, and forego practicing in communities that most need them.


Stop the Medicare Meltdown — repeal the SGR


Since the turn of the century, nothing has so regularly and completely vexed and frustrated physicians more than our annual game of chicken with Congress over Medicare payments.


Medicare patients and military families are never out of danger. Year after year, the specter of congressional action or lack of action threatens to jeopardize health care for Medicare patients. And, because TRICARE rates for military families are based on Medicare, they’re in danger, too.


A PHYSICIAN’S STORY


Javier Saenz, MD La Joya


Dual-Eligible Budget Cuts Running Doctors Out of Business


“You know, everybody talks about, ‘We need more primary care doctors, we need more people to go to the rural areas.’ And this law gets passed. This rule gets passed. I mean, you’re pretty much running all the family doctors in small towns out of business. Is that what they want?”


This is because federal law requires Medicare payments to physicians to be modified annually using the Sustainable Growth Rate (SGR) formula. Because of flaws in how it was designed, the formula has mandated physician fee cuts every year for the past decade. Only short-term congressional fixes have stopped the cuts. In 2010 alone, Congress had to intervene five times to stop a 25-percent cut. It took emergency action in December 2011 and again in February 2012 to stop a 27.4-percent cut. That would have meant an annual loss of $1.71 billion to physicians for the care of elderly patients and Texans with disabilities.


Most commercial insurers pay physicians based on a percentage of the Medicare rate, which has changed little over the past decade. This double hit has meant a flat-lining of physician payment rates that threatens the viability of many physician


60 TEXAS MEDICINE January 2013


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