“It was a very dysfunctional agency that abused its authority and power in placing payment holds that weren’t justified, to the point of driving many pro- viders out of Medicaid,” Senator Hinojosa said. “We reformed it. We restruc- tured it. And we put safeguards in place for due process. There’s no doubt there’s fraud out there. The problem is the OIG targeted the wrong people. We want to make sure we aren’t running off our providers who are taking care of these needy people.” Along with these types of improvements, however, the vice chair of the Sen-
“We want to make sure we aren’t running off our providers who are taking care of these needy people.”
ate Finance Committee and budget conferee says “we should not walk away” from other opportunities to boost Medicaid funding. Now that Medicaid has moved almost entirely to managed care, other TMA-
backed reforms included in Senate Bill 760 by Sen. Charles Schwertner, MD (R-Georgetown), increase oversight and accountability of Medicaid HMOs’ net- work adequacy. San Antonio pediatrician Ryan Van Ramshorst, MD, says physicians’ first-
hand experience suggests Medicaid plans are not holding up their end of the bargain, and shortfalls become an issue when he’s done all he can to treat a child and needs to find a specialist. In TMA’s 2014 physician survey, 53 percent of physicians reported similar difficulties finding such services. “I go on the [HMO] websites, and their lists are not up to date. I make five
phone calls to doctors on the list, and they are not accepting new patients or any patients at all,” said Dr. Van Ramshorst, a member of TMA’s Ad Hoc Commit- tee on Medicaid, CHIP, and the Uninsured. “I’m left with the decision to keep managing a patient when I’m not as comfortable as I wish I was. But if I don’t, they don’t get any care. It goes back to managed care taking taxpayer dollars and doing what they are supposed to do.” SB 760 raises current Medicaid access criteria — based on mileage standards
used for commercial health plans — to measures using the patient’s geographic location and the number and distribution of health professionals within the re- gion, akin to Medicare Advantage plans. TMA believes the new standards are more suitable for low-income populations. The bill would suspend enrollment by health plans if they fail to maintain adequate networks. Frustrated by the decision not to join other states in continuing the Medic-
aid-Medicare parity payments, however, Dr. Van Ramshorst said, “We need to change the conversation. Medicaid needs improvements, but it’s not a broken program. It’s a vital safety net, and combined with CHIP, it’s the single largest insurer for kids. We need to do better by the beautiful and vulnerable patients I take care of and otherwise would not have a physician.” TMA still has concerns about parts of the HHSC sunset bill, Senate Bill 200,
that call for a consolidation of HHSC, the Department of Assistive and Rehabili- tative Services, and the Department of Aging and Disability Services. It also set up the possible elimination of many of the advisory councils that offer an avenue for physician input. TMA continues to analyze provisions in a separate DSHS sunset bill, Senate Bill 202, although lawmakers heeded medicine’s call to keep DSHS a separate, stand-alone agency and make other changes that allow it to focus on its core public health functions. Nevertheless, thanks to hard work before the session and key physician rep-
resentation, TMA officials say the sunset process yielded a series of preliminary wins that primed medicine for legislative success. Early sunset recommenda- tions, for example, heeded TMA’s call for administrative simplification within the Medicaid program, paved the way for the due process improvements in SB 207, and raised awareness among lawmakers of the dangers of scope-of-practice expansions. Three physicians served on the sunset panel, including past TMA Council
August 2015 TEXAS MEDICINE 35
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