Medicaid reform

According to the settlement of Frew v. Hawkins, the state must fulfill its obligations under a consent decree and a set of corrective orders. What will these changes mean for your practice and your patients?

The Texas Medicaid system has long been characterized as arduous for both patients and health care providers, but after the settlement of the 14-year-old Frew v. Hawkins lawsuit and a healthy allocation of state and federal funds, the Texas Health and Human Services Commission has $1.8 billion to make changes to the system and increase access to care for Texas’ most needy children.

Enforced by U.S. District Judge William Wayne Justice’s ruling in April, the state must develop initiatives to increase access to federally mandated early periodic screening, diagnosis and treatment services for Medicaid beneficiaries under age 21. The judge ruled that Texas has not met requirements of the federal EPSDT program, called Texas Health Steps in this state, to ensure this population receives regular medical and dental checkups.

Through House Bill 15, the 80th Texas Legisla­­ture appropriated more than $700 million in state general revenue to HHSC for three main goals: to increase medical and dental providers’ reimbursements for caring for pediatric Medicaid beneficiaries, to implement the 11 corrective action plans as approved by the Frew plaintiffs, and to finance other medical and dental initiatives to fulfill the consent decree and corrective orders.

More money for physicians

Low reimbursement is one of the main barriers to physicians participating in the program. To counter this, nearly three-quarters of the funds will go toward increasing provider reimbursement in hopes of stabilizing the current base of health care providers and attracting more specialists, sub-specialists and dental providers to serve this population.

“For doctors, it really has been frustrating,” says Douglas Curran, M.D., a family physician from Athens and TAFP past president. “Physicians, especially family docs, feel the need to care for these patients, but we can’t afford to do everything we want to do. We have to limit access to care because the pay just isn’t there.”

Critics often point to the numbers of doctors leaving the program or no longer accepting new Medicaid patients as the main problem with access to care. According to a 2006 Texas Medical Association survey, only 38 percent of Texas physicians accept all new Medicaid patients, compared with 67 percent in 2000.

“We’re not getting paid enough to take care of those patients who really need care,” Curran continues. “For those of us who went into health care to take care of people, it just rips your heart out to turn these patients away.”

HHSC convened the Physician Payment Advisory Committee, a panel of physicians and dentists from around the state, to develop methodologies for dispersing $253 million of the funds among the medical and dental community. The committee combined two funding streams—$203 million in general revenue set aside to increase payment for professional services and $50 million for targeted sub-specialty increases—to increase reimbursements for medical and dental services.

After two meetings and a fiscal analysis to make sure the proposals stayed within the allocated funds, PPAC recommended:

• Applying an across-the-board 2.5-percent update to restore payment for cuts made in 2003,
• Increasing reimbursement for pediatric evaluation and management services by 27.5 percent,
• Additionally increasing reimbursement for THSteps screening services, a subset of E&M services, to 100 percent of Medicare rates for new patient visits and 92 percent of Medicare rates for established patient visits,
• Updating non-E&M procedure codes to parity with 2007 Medicare relative value units to ensure that all rates increase by at least 5 percent,
• Increasing payments for immunization administration by 30 percent, and
• Giving target increases to providers who do not regularly use E&M codes such as pathologists, radiologists and anesthesiologists.

The rate increases went into effect Sept. 1, 2007.

Eleven plans for action

Negotiated between the plaintiffs and defendants earlier this year and upheld as “fair, reasonable and adequate” by Judge Justice at a hearing in July, the corrective action plans aim to fulfill four objectives: increase the number of children who receive THSteps medical and dental checkups, increase participation of medical and dental providers, improve utilization of medically necessary services, and improve coordination of care. The plans have a $45-million budget in general revenue and run the gamut from informing families of available wellness checks and when they’ve missed a checkup to developing online educational training modules for providers.

Of the 11 CAPs, nine particularly affect physicians:

• Case Management,
• Checkups
,
• Health Outcomes and Dental Assessment,
• Managed Care,
• Outreach and Informing,
• Adequate Supply of Health Care Providers,
• Health Care Provider Training,
• Toll-free Numbers, and
• Transportation.

Adequate Supply of Health Care Providers aims to maintain the number of providers in the program and recruit additional physicians and dentists by providing sufficient reimbursement and target increases. The plan ensures patients can find physicians in their areas through a Web-based provider search. The database will include demographic data, office hours and whether the physician is accepting new Medicaid patients. This CAP also mandates that patients must have a primary care provider within 30 miles and a specialty care provider within 75 miles, unless living in a sparsely populated area.

Other pertinent CAPs—Checkups, Health Outcomes and Dental Assessment, and Provider Training—focus on getting eligible children correct preventive care and keeping providers up-to-date on federally required checkup elements.

Jane Rider, M.D., a pediatrician from San Angelo and PPAC member, says that measurement of the 12 proposed health care indicators will be performed primarily through claims data, although they may require some chart audits. This may be difficult for some physicians, she says, “but we’re trying to make these as non-invasive as possible.” The text of the corrective order encourages health plans and other contractors who already conduct reviews to coordinate their audits to prevent duplicate work.

With the Case Management plan, the THSteps program must provide case management to all clients who need and want the service, and must inform health care providers of the available services. Access to resources such as case managers and transportation will help providers care for more patients, Rider says.

As part of the agreed court order, the state must regularly review and evaluate progress on the CAPs over the next four years based on each plan’s benchmarks. Some of the studies listed in the plans will keep an eye on physician supply, the effectiveness of communication and checkup reminders, the role of managed care, and the progress of specific counties, so additional tactics can be formulated and initiated if the plans fall short of their goals.

Other strategic initiatives

HHSC held additional hearings to get feedback on other strategic medical and dental initiatives. The commission will use $150 million in general revenue for these projects to spark “fundamental or critical improvements in the Medicaid program,” according to the HHSC Frew expenditure plan submitted to the Governor and Legislative Budget Board on Sept. 1. It is unclear whether the $150 million is a one-time allocation or if it will receive ongoing funding. At this time, HHSC has indicated the latter, but there is no assurance it will receive further funding after this biennium.

To be considered for implementation, the initiatives must fit primarily within three criteria: whether the proposed project supports one or more of the established objectives, whether the impact of the project will produce “meaningful results,” and the extent to which positive results can be expected. Additionally, they will be judged on factors such as feasibility, cost-effectiveness, the number of children impacted and eligibility for a federal match.

Some of the recommended strategies suggested in H.B. 15 include to:

• Develop a system of medical and dental vans, which will start their rounds in south Texas,
• Support loan repayment and stipends for health care professionals who agree to practice in underserved areas and serve children enrolled in Medicaid,
• Make improvements in medical transportation,
• Implement additional targeted rate increases to further improve care within Medicaid,
• Improve the Medicaid ID card to remind patients of well-child visits, and
• Improve specialty care within underserved communities, by such means as establishing specialty care clinics.

TAFP, TMA and the Texas Pediatric Society submitted their recommendations for initiatives to support. The allied groups recommend promoting and using a physician-centered medical home, improving access to specialty care services for children in underserved communities, reducing Medicaid administrative requirements, and implementing a technical advisory committee to provide guidance on future strategic initiatives.

One of the initiatives slated for immediate implementation is the mobile medical and dental vans program, in addition to a continued expansion of outreach efforts, says Ted Hughes, a spokesman for HHSC. Hughes explains that the state is moving forward, but it is too early to say which other proposals will be funded. “We’ve got more money to do more outreach and we’re moving forward with that. It remains to be seen what form that will take because there has to be a lot of back and forth between the providers and the people who are covered by Medicaid.”

Attorney Susan Zinn, lead counsel for the children in the Frew case, says the proposals are promising but the state is moving slowly on implementing other initiatives. “We’re very pleased some of the proposals have been implemented on time,” Zinn says. “We’re discouraged the state is not moving fast enough to make use of the strategic initiative funds.”

An HHSC-formed group of state agency employees from the Medicaid and CHIP Division, DSHS, the Office of Eligibility Services, the Office of Family Services, and others will analyze each project and develop operational plans for the proposed strategic initiatives. Then a 16-member technical advisory group comprised of representatives of the plaintiffs and the medical, dental, advocacy and academic communities will advise the commissioners on “what they think is the best way to spend that money,” Hughes says. “We’re gathering feedback.” There’s an ongoing effort on the part of the Medicaid division to keep the providers’ interests in the forefront of their planning.”

The technical advisory group was named at the end of September and pediatrician Rider will serve as the group’s chair. “This is a huge program,” she says. “There will always be opportunities for improvement and we’re taking huge steps now. Not everyone will be satisfied, but we’ll come out of this with some good changes.”

Throughout the process to identify and develop strategic recommendations, HHSC has solicited help from professional medical organizations around the state. The collaborative effort of the proposed solutions will help contribute to its success, Rider says. “By engaging these parties, it makes the process a whole lot more transparent and people feel as if they are a part of it. Anyone involved in designing a solution will be more apt to follow through with it. The solutions will be more apt to succeed and we’ll see longterm changes in the program.”

Rider has already seen some of the proposals in action. “In the past six to eight months, I’ve seen significant improvements in transportation, I’ve seen clearer instructions to patients,” she says.

Responsibilities of the Physician community

Participation of Texas physicians and dentists in THSteps is crucial to the success of the Frew initiatives. Zinn says she would like to see more children receiving medical and dental checkups, and one key part of that is activating the provider community. “I’d like to see an increase in the number of doctors and other health care professionals who sign up with the Medicaid program to take care of children, and those who already see these patients to continue to do so and make room for more children.”

Updating physician reimbursement may help bring physicians back into the program to care for Medicaid beneficiaries, Hughes says. “Increasing the access to care for the younger age population is going to be enhanced by a fee structure that wants to reward doctors for taking in new patients and doing those additional screening services.”

Rider identifies the most important action for providers to take. By opening their doors to THSteps clients, physicians will show the Legislature that rate increases increase access to care, which will validate future updates.

“This session, the Legislature gave more money for physician reimbursement—we’ll see an average 27-percent increase—but if we want to be able to ask for more in the future, we have to show that by giving more money, they got a product,” Rider says. “By increasing reimbursement and increasing provider participation in the program, we increased care for the children.”

Part of planning for the future means devoting resources to the youngest Texas, Athens family physician Curran says. He recalls a piece of wisdom his grandfather used to share about the importance of nurturing each year’s seed corn—the corn that starts the next year’s crops.

“In the same way, when taking care of the children, we’re making our communities, our state and our country better by investing in future generations. I’m pleased the state is stepping up to make these improvements for the children.”