cially for dual-eligible patients, is a top priority.
“This is a hard population to take care
of. As an adult pulmonologist, that’s most of what I see under Medicaid, and these people have nighttime ventilators and all sorts of complicated problems,” Dr. Holcomb said. The 2011 Texas Legislature directed
the Texas Health and Human Services Commission (HHSC) to limit payment for those patients’ services by discontinu- ing Medicaid coverage of their Medicare deductible and the copayment (which is 20 percent of most services) when the Medicare payment exceeds the Medicaid allowable, which is almost always the case for physician services. According to HHSC, the policy change saved Medic- aid nearly $450 million. In January, HHSC restored coverage of the annual Medicare deductible (cur- rently $147 per beneficiary), but the 20-percent coinsurance cut remains. The cut hit many physician practices
hard, particularly those in rural and border areas where doctors who serve a disproportionate number of dual-eligible patients were forced to retire early, lay off staff, or take out loans to keep their doors open.
But it’s an issue affecting the entire state, says Dr. Curran, also a TMA trust- ee. “This impacts our ability to pay our employees. And it limits our ability to recruit young physicians.”
Harlingen ophthalmologist Victor Gonzalez, MD, already lost six young physicians he trained to other parts of the state.
When patients can’t get care in a Har- lingen emergency department, “they will end up in San Antonio, Houston, or Dal- las at a much greater expense,” said Dr. Gonzalez, Hidalgo-Starr County Medi- cal Society president and member of the TMA Border Health Caucus. “When the health care infrastructure collapses, it hurts everyone.” Adding to frustrations are new rules physicians say fail to differentiate be- tween honest mistakes and outright fraud, and expand the Office of Inspec- tor General’s ability to hold payments before — rather than after — a fair in- vestigation. (See “Guilty ‘Til Proven In-
nocent,” December 2012 Texas Medicine, pages 16–22.) “If there is real fraud going on, by all means, stamp it out. But there ought to be clear due process,” said Dr. Kenton, a member of the Medicaid Congress. Instead of just financially penaliz- ing physicians for billing mistakes, the state should seek first to engage physi- cians in a corrective action plan if they are having trouble coding properly, sug- gests Barry S. Lachman, MD. He, too, is a member of the Medicaid Congress and medical director of the Parkland Com- munity Health Plan.
That’s a model his health plan follows and one the state should, too, he says.
“Unless we get physicians the technical assistance they need, we are not helping them practice better.” Dr. Cardenas added that streamlin- ing HMO operations and holding health plans accountable are increasingly im-
portant as the state continues to expand Medicaid managed care. “When you have to stay on the phone for 20 minutes before you get a peer-to- peer preauthorization, and when you get put through the same rigmarole over and over again, we are no longer talking about managed care. This is managed access,” he said.
Most of the congress’ recommenda-
tions likely will require only administra- tive changes by HHSC. Commissioner Kyle Janek, MD, ac- knowledges the payment and admin- istrative pressures that continue to squeeze doctors and threaten the pro- gram and says he wants to take those “problems” and “turn them into opportu- nities” for reform.
But he stands by the fraud rules his agency approved.
“This is not optional,” Commissioner Janek said. “We are not being unreason-
Texas physicians who accept all new Medicaid patients
100% 80% 60% 40% 20% 0 2000 2002 2004 2006 2008 Source: TMA Survey of Texas Physicians, 2012 April 2013 TEXAS MEDICINE 29 2010 2012
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