May 29, 2012 — A coalition of medical societies representing some 100,000 specialists says a well-intentioned federal effort to improve the care of some of the nation's sickest and neediest patients could backfire, in part by cutting provider compensation.
The patients in question are roughly 9 million "dual-eligibles" who are enrolled in both Medicare and Medicaid. They represent a disproportionately large share of Medicare and Medicaid spending, in part because they are generally sicker, and also because the 2 programs — each with its own benefits, billing systems, and provider networks — sometimes work at cross-purposes.
Under the auspices of the Affordable Care Act, the Center for Medicare and Medicaid Services (CMS) is hatching demonstration projects that would turn over the care of dual-eligibles to state-operated managed care programs. The goal is to improve the lives of these patients, expand their access to care, eliminate duplicated services, and lower costs.
However, in a letter last week to the CMS, the Alliance of Specialty Medicine (ASM) warned that the demonstration projects could inadvertently disrupt the care of dual-eligibles and restrict their access to specialty care. The ASM, which consists of 12 medical societies, asked the CMS to hold off rolling out the dual-eligible demonstration projects for at least 1 year while the kinks get worked out.
The ASM consists of the American Association of Neurological Surgeons, the American Association of Orthopaedic Surgeons, the American Gastroenterological Association, the American Society of Cataract and Refractive Surgery, the American Urological Association, the Coalition of State Rheumatology Organizations, the Congress of Neurological Surgeons, the Heart Rhythm Society, the National Association of Spine Specialists, and the Society for Cardiovascular Angiography and Interventions.
The letter is the latest example of organized medicine attempting to erect speed bumps in the path of healthcare reform. Medical societies have successfully lobbied the CMS to postpone the implementation of a new set of diagnostic codes called the ICD-10, which stands for the International Statistical Classification of Diseases and Related Health Problems, 10th Revision; new standards for electronic claims called Version 5010; and requirements for drug and medical device makers to report payments made to physicians.
Will Cash-Strapped States Pinch Provider Rates?
For a federal government keen on curbing budget-breaking costs in Medicare and Medicaid, dual-eligibles represent an obvious target for economizing.
Roughly 40% of dual-eligibles are individuals with disabilities who are younger than 65 years, and 60% are low-income individuals aged 65 years and older. Fifty-seven percent have a cognitive or mental impairment compared with 25% of other Medicare beneficiaries. Dual-eligibles are also 8 times as likely to be in a long-term care facility. Six in 10 have multiple chronic conditions.
More morbidity means more spending. In 2007, dual-eligibles made up 15% of Medicaid enrollees, yet accounted for 39% of Medicaid spending, according to the CMS. Likewise, dual-eligibles amounted to 15% of Medicare enrollees and 27% of that program's cost in 2006.
In its letter to the CMS, the ASM applauded the government's attempt to integrate the 2 entitlement programs for the sake of dual-eligibles and providers alike. However, the organization expressed misgivings about the ability of state-run plans to achieve the goals of the demonstration projects. For one thing, the ASM said, most Medicaid managed care plans focus on children and families, "and have little or no experience with the more complex needs of the frail elderly or patients who are mentally ill, developmentally disabled, or institutionalized." The CMS must ensure that it has the "necessary infrastructure and processes in place" to oversee the state dual-eligible plans before the demonstration projects begin.
The specialists also worry that state dual-eligible plans will reduce their reimbursement, which in turn could drive away physicians and reduce patient access to care. Cash-strapped state Medicaid programs already are notorious for stingy reimbursement, and the ASM fears more of the same with the dual-eligible plans, particularly if a state fields only 1 or 2 plans. The ASM reasons that a wider field of plans would compete harder for providers by offering higher payment rates.
Yet another concern is how patients will be enrolled in state dual-eligible plans. Some of the states seeking to participate in a demonstration project have proposed passive enrollment; that is, a patient is automatically signed up for a plan unless he or she opts out. The ASM says this approach is "offensive" because it runs contrary to the notion of patient-centeredness and shared decision-making. Patients who fail to opt out, perhaps because they are uninformed, may end up in a plan that does not include their established providers, and may experience "harmful disruptions in care" as a result.
The ASM is asking the CMS to delay the implementation of the dual-eligible demonstration projects for at least 1 year, just as they are approaching their launch dates. In May 2011, the CMS announced that it had awarded up to $1 million apiece to 15 states to design dual-eligible programs. The states were given 12 months to develop a model that could go live sometime in 2012. For some states, the design period began in April 2011; for the rest it began in May 2011. The CMS said it would work with states to implement the most promising submissions and held out the possibility of additional funds (if available).
The 15 states that received the design grants are California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington, and Wisconsin.
Comments
Post a Comment