SB 7 also completes the STAR+PLUS rollout to remain- ing counties not covered by the model. The 2011 legislature expanded the STAR managed care model for acute care ser- vices statewide and included pharmacy, dental, and inpatient hospital services. The new areas included 200 rural counties formerly under the Primary Care Case Management (PCCM) model and in South Texas, previously exempted from managed care. STAR+PLUS was expanded to the El Paso, Hidalgo, and Lubbock areas. HHSC estimates the 2011 expansions will save the state $263.3 million in the 2012–13 biennium. Managed care and other cost-containment strategies helped cut Medicaid costs by approximately 5 percent during those years. Officials expect that trajectory to continue. Under SB 7, the Legislative Budget Board predicts $6 million in cost savings through the 2014–15 biennium.
Senator Nelson says the move was necessary. “Overall, the data shows that we are providing more efficient care, reduc- ing fraud, and putting the program on a more sustain- able cost trajectory. The old Medicaid was going in the wrong direction, not only in terms of its cost, but also in terms of its poor record of achieving healthy outcomes for patients. Moving forward, there needs to be continued focus in ensuring that we are delivering services in the most efficient, most effective manner.”
ROADBLOCKS Physicians say the road for- ward is littered with road- blocks, something state of- ficials acknowledge but say the state is on its way to re- pairing. Dr. Holcomb, a pulmon- ologist in San Antonio, says some HMOs bolstered their primary care networks since Medicaid managed care landed in large urban areas, and they “have held together fairly well.”
When it comes to spe-
cialty care, however, network adequacy appears elusive in some areas. Dr. Holcomb also runs a pulmonary clinic in Gonzales, part of the rural expansion. When he used one HMO’s
website to refer a patient to a specialist listed 75 miles away in Victoria, he found the physician was retired and his office closed.
Physicians also report poor communication by health plans, in addition to other administrative barriers. With roughly 20 Medicaid HMOs in the state, physicians typically deal with a handful of plans.
Harlingen pediatrician Stanley Fisch, MD, says access to specialty care is not as much of a problem in South Texas largely because physicians there have no choice but to see Medicaid patients, who make up a majority of the patient population in the Rio Grande Valley. Still, even though the state acknowledges the need for more doctors in the program, the credentialing process gets increasingly more difficult. His practice just hired a new doctor; enrolling her in four HMOs “took a huge amount of time,” delaying the practice’s ability to see more patients.
Only one of those HMOs, Driscoll Children’s Health Plan,
2013 LEGISLATIVE SESSION YIELDS MEDICAID WINS
While there’s more work ahead, TMA’s hard work during the 2013 leg- islative session yielded several wins to bring relief for physicians in the Medicaid program. Among those victories:
• Senate Bill 1150 by Sen. Chuy Hinojosa (D-McAllen) and Rep. Bobby Guerra (D-Mission) requires the Health and Human Services Commis- sion to incorporate a “provider protection plan” in its contracts with Medicaid managed care organizations.
• Senate Bill 1803 by Sen. Joan Huffman (R-Houston) and Rep. Lois Kolkhorst (R-Brenham) improves transparency during Medicaid fraud investigations by defining a “credible allegation of fraud” and provid- ing timelines and procedures for payment holds and appeals. (See “Fighting for Fairness,” September 2013 Texas Medicine, pages 35–38.)
• Senate Bill 644 by Senator Huffman and Rep. John Zerwas, MD (R- Simonton), requires the Texas Department of Insurance (TDI) to ap- point a stakeholder workgroup to design a standard prescription drug preauthorization form applicable across all payers, including Medicaid and the Children’s Health Insurance Program.
• Senate Bill 1216 by Sen. Kevin Eltife (R-Tyler) and Rep. Sarah Davis (R- Houston) requires TDI to appoint a stakeholder workgroup to design a standard preauthorization form for health care services, also appli- cable to Medicaid and all other payers.
October 2013 TEXAS MEDICINE 17
CONES: SIMFO / GETTY IMAGES; ASPHALT & SAWHORSE: ISTOCKPHOTO / THINKSTOCK
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60