Colorado Medical Society

Medicaid specialty access gap

Saturday, November 01, 2014 12:15 PM

In November 2013 the Colorado Medical Society Board of Directors voted to place a high priority on access to specialty care in the Medicaid Accountable Care Collaborative (ACC) program, while also advocating to maintain primary care reimbursement at least at Medicare parity levels. At that time primary care physicians were receiving Medicaid payments on par with Medicare under the Affordable Care Act and the Regional Care Collaborative Organization (RCCO) program was paying per-member per- month fees to primary care. With those gains for primary care, the next big obstacle was increasing access to specialty care.

Access to specialty care is important for many reasons – reasons related to the patient’s needs, reducing emergency department visits, and for fully functioning medical neighborhoods. Because the issue is so complicated, the board of directors created a Medicaid Reform Committee and tasked the committee with addressing the problem.

Chaired by Deb Parsons, MD, the committee is comprised of Colorado RCCO medical directors and other practicing physicians, and is routinely attended by RCCO policy staff and the Colorado Department of Health Care Policy and Financing (HCPF), the agency that oversees the state’s Medicaid program. This summer, the committee polled CMS specialist members to gain their insight on what is and is not working in Medicaid, and how to move forward on preferred strategies to common problems.

Alan Kimura

Alan Kimura, MD, MPH, a partner in Colorado Retina Associates, discusses his experiences as a specialist accepting Medicaid patients.

“This is an important topic because we now have one million people in Colorado on Medicaid,” said Meredith A. Niess, MD, MPH, the study’s designer. Niess is a NRSA primary care research fellow in the Department of General Internal Medicine at the University of Colorado. “That’s 20 percent of our population, approximately. It’s the second largest insurer in the state.” One out of three outpatient providers do not accept Medicaid and more accept only a limited number. The access gap is real, she said.

She polled 1,600 specialists and, with a 52 percent response rate, found a balanced perspective on the real and perceived barriers to accepting Medicaid patients. Specialists reported that they are most concerned with low reimbursement rates; high patient no-show rates; patient non-adherence; high administrative burden; the floodgates idea, where if you accept some Medicaid you’ll be inundated; and patients who are socially complicated.

“Yes, reimbursement is still the biggest concern but there is a bigger picture here,” Niess said. “The survey shows that Colorado physicians need more support, like care management and access to behavioral health care, in order to provide quality care for Medicaid patients.”

Jeff Perkins, MD, a practicing rheumatologist and the founder and CEO of Colorado Center for Arthritis and Osteoporosis, carefully studied the financial impact to his practice. “Some common perceptions made my practice anxious about this whole process. One of the best cures for anxiety is data so we started looking at the data from our patient population.” After examining a host of metrics, he found no significant reason – financial or otherwise – to justify excluding this patient population from his practice.

Judy Zerzan, MD, MPH, chief medical officer and director of HCPF’s Client and Clinical Care Office, addressed the concern about slow payment, citing the fact that Medicaid pays over 90 percent of claims in less than eight days. “Certainly there are other administrative burdens but I think that is super fast.”

She described some of the delivery system reforms Medicaid is embarking on to help both providers and Medicaid clients. Most significant is the Accountable Care Collaborative program, which has saved between $44 million and $64 million over two years with fewer emergency room visits and fewer re-hospitalizations and imaging.

For specialists specifically, Medicaid is using targeted reimbursements and e-consultations. Next up is telehealth and Project ECHO, Zerzan said, which will arm primary care providers with the confidence to treat issues they would have previously referred to a specialist to free up specialists’ time for more complex issues. “We’re excited with what we’re doing with specialty care.”

“This is challenging for our practice on many fronts. We’re not participating at the rate Meredith said would be ideal, but we are trying to do our part,” said Alan Kimura, MD, MPH, a partner in Colorado Retina Associates. “Medicaid gives those who would be outside the health care system a chance to preserve or recover their health, and that’s why we’re in this field.”

Perkins challenges all specialists to address their fears. “Consider re-examining your practice’s policies regarding Medicaid. Gather as much data as you can about how things are now, and then design and implement a test to change your policy on Medicaid. Analyze the data once you implement that test and if it didn’t work out the way you thought, make adjustments and repeat. In graphic form, plan, do, check, act and repeat. Not only with Medicaid but with any challenge you face in your practice, if you approach problems in this way – it’s amazing what you can accomplish and the problems you can solve.”