Medicaid sets temporary payment increase for primary care

Physicians who will be paid Medicare rates in 2013 and 2014 want to see the parity provision extended beyond the two years authorized.

By — Posted Nov. 12, 2012

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Primary care physicians hailed the release of a long-awaited final rule that temporarily hikes Medicaid payment rates to Medicare levels for the primary care services they provide, but some specialty physicians who were excluded from the enhanced payments said the policy should have been applied more broadly.

Nationally, Medicaid’s average payment rate for physician services is just two-thirds of what Medicare pays. Setting primary care fee schedules on par with Medicare’s is encouraging in that it is intended to improve access to care for Medicaid patients, said Geraldine McGinty, MD, chair of the American College of Radiology’s Commission on Economics. At the same time, the same patients being treated by primary care doctors also are going to need imaging, and radiologists believe the care they provide is just as important as primary care, she said.

“Our contribution to the continuum of care and to the patient’s diagnosis and treatment is generally invaluable,” Dr. McGinty said. “We don’t see any reason why all the providers who would potentially be taking care of Medicaid beneficiaries wouldn’t be recognized in the same way.”

The final rule, which the Centers for Medicare & Medicaid Services released Nov. 1, sets Medicaid payments for primary care services provided by primary care physicians at 100% of Medicare rates for calendar years 2013 and 2014. States will receive an additional $11 billion from the federal government during this period to administer the enhanced pay rates. The Affordable Care Act authorized the temporary pay parity provision.

The health system reform law was fairly prescriptive in terms of the types of doctors who would qualify for this pay increase, said Deborah Bachrach, New York’s former Medicaid director and special counsel in the health care practice at Manatt, Phelps & Phillips LLP in New York. Physicians who deliver primary care services in the fields of family, general internal or pediatric medicine are eligible, as are subspecialists of these fields. Recipients of the enhanced rates either must be board certified, or at least 60% of the codes they submit to Medicaid in 2012 must be for primary care services.

CMS in the final rule also said it would allow nurse practitioners and physician assistants to qualify for the pay bump, provided they’re under the supervision of physicians who also qualify for the increase, Bachrach said.

Although more specialists are needed in Medicaid, “the terms of the statute itself didn’t permit CMS to go any further” than these eligibility designations, she said.

Some specialty societies whose members were excluded from the pay bump said CMS overlooked their role in delivering primary care services to Medicaid beneficiaries, even if they don’t necessarily meet the traditional definition of primary care.

“As any patient who has had cancer will tell you, it is the medical oncologist who assumes most of their care because of the frequency and intensity of patient visits required,” said Blase N. Polite, MD, MPH, chair of the health disparities advisory group with the American Society of Clinical Oncology. The primary and specialty care designations deemed eligible for higher pay in the final rule “are in many cases really quite arbitrary when it comes down to the real world care that these patients receive,” Dr. Polite said.

Bachrach said it would have been a great advantage to include ob-gyns in the list of specialties eligible for enhanced payments. “I would note that in many states, 40% of deliveries are in Medicaid. But again, the statute by its terms didn’t permit it.”

Albert Strunk, MD, deputy executive vice president and vice president for fellowship activities with the American Congress of Obstetricians and Gynecologists, made the case for including ob-gyns in a June comment letter to acting CMS Administrator Marilyn Tavenner. Medicaid programs in 30 states and the District of Columbia already have recognized ob-gyns as primary care professionals through their managed care organizations. Additionally, “27 state Medicaid programs recognized ob-gyns as providers of primary care case management,” he wrote, adding that the proposed rule failed to acknowledge these designations.

James Fasules, MD, senior vice president of advocacy and health policy with the American College of Cardiology, said the pay bump should have been applied across all evaluation and management services. “This is a complaint that many of the primary care doctors have, and the specialists who see patients in the clinics — that reimbursement for an office visit isn’t high enough.” Dr. Fasules conceded that this would be difficult to do from an economic standpoint, as there’s only a certain amount of additional money the federal government can spend on the provision.

Pediatric societies such as the American Academy of Pediatrics and the Children’s Hospital Assn., in the meantime, were encouraged that both pediatricians and pediatric subspecialists would be eligible for the payment increase.

Pediatricians provide more than 60% of the office visits for children covered under Medicaid, AAP President Thomas K. McInerny, MD, said in a statement. The final rule makes a landmark financial investment to value these services appropriately, he said.

Still, some primary care organizations remain concerned that a two-year pay increase won’t be adequate to bolster access to care for Medicaid patients over the long run. Access-to-care problems will resurface unless Congress permanently funds and extends this provision, said Jeffrey Cain, MD, a family physician in Denver and president of the American Academy of Family Physicians.

CMS has requested data to evaluate the impact of the temporary primary care pay bump, Bachrach said. In the event that raising payment rates corresponds to an increase in physician capacity within Medicaid, a strong case could be made to extend the pay boost. Enhanced payments eventually may be extended to specialists as well, if additional capacity is deemed to be required, she said.

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How Medicaid pay parity will work

Eligible physicians who provide certain primary care services under Medicaid will be paid at Medicare rates for two years for those services.

  • Eligible physicians must have a specialty designation of family medicine, general internal medicine, pediatrics or a related subspecialty.
  • At least 60% of codes eligible physicians submit to Medicaid in 2012 must be for primary care services, or the physicians must be board certified in their specialties.
  • Midlevel practitioners, such as physician assistants, may be eligible for the enhanced payments, provided they are supervised by physicians who also qualify for the increase.
  • States will receive 100% federal funding for the difference between the Medicaid state plan payment amount for selected evaluation and management services as of July 1, 2009, and the Medicare rates in effect for calendar years 2013 and 2014.
  • The Medicaid payment ceiling for children’s vaccine administration will be raised.
  • The increases will not apply to federally qualified health centers and rural health clinics.
  • The estimated federal cost of the pay boosts is $5.5 billion a year for each of the two years.

Source: Medicaid Program; Payments for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration Under the Vaccines for Children Program, Centers for Medicare & Medicaid Services, Nov. 1 (link)

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External links

Medicaid Program: Payments for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration Under the Vaccines for Children Program, Centers for Medicare & Medicaid Services, Nov. 1 (link)

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