Some primary care doctors still lack 2013 Medicaid pay boost

Washington In South Dakota, things appear to be on track for delivering enhanced pay rates to primary care doctors that furnish primary care services to Medicaid patients, but that's not the case everywhere.

On June 21, the Centers for Medicare & Medicaid Services approved a modification to South Dakota's Medicaid program so that the pay increase could take effect. Several days after that, the state began making the first such payments to physicians and other qualified health care professionals, according to the South Dakota State Medical Assn.

Because these rate changes officially went into effect on Jan. 1 under a provision of the Affordable Care Act, South Dakota made retroactive payments for claims with service dates of Jan. 1 through June 26, the state medical association reported. But physicians in other states have yet to see much progress on this pay increase, which was one of the ACA's chief tactics in providing additional support to primary care doctors.

Medicaid long has paid physicians at rates far below what Medicare pays for the same services. Under the ACA, states were directed to increase rates for primary care services provided by primary care doctors up to 100% of Medicare rates for calendar years 2013 and 2014. To accomplish this, states had to clear changes to their Medicaid plans with CMS.

There also is a requirement that physicians attest their eligibility for the enhanced rates. With 2013 more than half way over, physicians in some states still are reporting administrative delays and other problems that are slowing down the process of delivering these enhanced payments.

“The primary care rate bump was a wonderful provision for primary care physicians and their mid-level practitioners conceptually, but poorly executed by the federal government,” said Yarnell Beatty, vice president of advocacy with the Tennessee Medical Assn. “The feds waited until the last minute to issue regulations, then made state Medicaid agencies jump through hoops to get 50 state plans approved at the same time.”

Many states probably won't be able to implement this pay increase until Sept. 1, said Matt Salo, executive director of the National Assn. of Medicaid Directors. While a few already have been able to move the money, some might not be administering higher payments until December, he said.

At this article's deadline, CMS had approved all of the state plan amendments for enacting this pay increase except California. Steven Harrison, MD, who directs a residency program at Natividad Medical Center in Salinas, Calif., said the pay increase would make a “huge difference to the bottom line” of the safety net hospital his program works with, and whose patient base is about 85% Medicaid.

Norman Williams, spokesman for California's Dept. of Health Care Services, said the department was working actively with CMS to get the primary care rate increase approved. “At this point we are responding to CMS' 'Requests for Additional Information,' a standard part of the State Plan Amendment approval process. We tentatively anticipate implementation in September, with the increase retroactive to Jan. 1,” Williams said.

Attestation forms confuse doctors

As California primary care doctors await final approval for their raises from the federal government, Ohio's Medicaid program is trying to straighten out several administrative glitches before it pays anyone at the higher Medicaid rates, said Ann Spicer, executive vice president of the Ohio Academy of Family Physicians.

The state has gone through a series of attestation deadlines, delays that arose primarily from issues related to the process, Spicer said. To qualify for the pay increase, physicians must be board certified in one of the traditional primary care categories — family medicine, general internal medicine and pediatrics, or a subspecialty of those categories. Doctors in these specialties who are not board certified must attest that at least 60% of the codes they submitted to Medicaid in 2012 were for primary care services.

In Ohio, Spicer said, attestation forms either hadn't gone through to Medicaid, or there were problems with the form itself. Some of the questions on the form related to board certification didn't make sense to some physicians, who had trouble answering them and as a result had their attestations denied, she said.

Issues also arose with respect to the 60% threshold. Spicer said Ohio Medicaid “had decided that perhaps they hadn't included some codes that should have been included … so they were re-evaluating [the codes] according to a more lenient threshold that they feel they should have used in the first place.” The Ohio attestation deadline has been extended to Aug. 16. Anyone who attests successfully before close of business on that date will receive enhanced payments retroactive to Jan. 1, she said.

The payments themselves may not begin showing up at practices until September. Spicer said there's much skepticism in the state that physicians ever will receive this extra money, but “I'm operating on the theory that they will, and I'm very aggressively trying to make sure we get as many qualified as we possibly can.”

In Georgia, primary care physicians might not see enhanced payments until Nov. 1, said Fay Brown, executive vice president of the Georgia Academy of Family Physicians. Brown said this is a blow to physicians who expanded their practices to more Medicaid patients “with the expectation that these payments were forthcoming.” Family physicians in the state have been working in concert with the Medical Assn. of Georgia, as well as with pediatricians and internists, to register concerns with Georgia Medicaid about the delay, Brown said.