Primary care doctor payments for treating Medicaid patients, set to rise 73 percent on average, have... [+]
A huge pay raise promised under the Affordable Care Act for primary care doctors who treat the nation’s poor covered by Medicaid health insurance is nearly three months behind schedule and may take another three months before it kicks in, state Medicaid directors say.
Under the health law, a primary care doctor – a family physician, a pediatrician or an internist – who treats a Medicaid patient will see their reimbursement rise to the level of the Medicare health insurance program for the elderly for scores of primary care services. Doctors do have to apply to their state Medicaid programs and meet certain criteria in part proving that they have historically treated certain numbers of Medicaid patients.
Though the pay increase will vary because Medicaid rates differ from state to state, the average pay increase will be about 73 percent given Medicare last year paid on average 66 percent of what Medicare pays for certain primary care services, according to a Henry J. Kaiser Family Foundation study. Doctors in some states could see payment increases of 100 percent or more.
The idea behind the pay increase, which is funded by federal dollars for two years, is to get more doctors to accept Medicaid patients and prevent other physicians from dropping out of a government program that hasn’t been well funded. Amid a primary care doctor shortage, eligible patients will need all of the doctors they can get given the health law expands Medicaid coverage to millions more Americans effective Jan. 1, 2014 for participating states.
Because Medicaid is funded via a match of funds from states and the federal government, cash-strapped states that have cut from their programs in also lost federal dollars, allowing payment rates to fall far behind.
“The purpose of the increase in Medicaid physician fees for primary care is to encourage greater Medicaid participation among physicians as the program expands in 2014 and demand for care increases,” the Kaiser report said. “If the enhanced payment rates succeed in increasing physician participation and beneficiary access as intended, interest in extending the higher Medicaid rates beyond 2014 is likely to be high.”
But the Obama administration says the checks will eventually reach doctors and payments will be retroactive to Jan. 1 of this year so physicians who are approved to participate in their states will get what they are due.
“The Medicaid enhanced payments for primary care physician fee was made possible by the Affordable Care Act and is in full effect for calendar years 2013 and 2014,” a spokesman for the Centers for Medicare & Medicaid Services says. “States are moving quickly to implement the higher payment and a number of states have already submitted State Plan Amendments (SPAs) which will permit federal funding to flow to states for the increases. In addition to submitting the required SPAs, states are also in the process of reprogramming their claims processing systems to pay at the appropriate, higher rates. CMS has made it very clear that states must make enhanced payments to eligible providers retroactive to January 1, 2013.”
Exactly how federal dollars will be doled out to doctors is unclear in part because an increasing number of states in recent years don’t pay physicians on a fee-for-service basis.
Many doctors are paid bundled rates by health plans like Humana (HUM), Amerigroup, a subsidiary of Wellpoint (WLP), Aetna (AET) or UnitedHealth Group (UNH) or physicians may be employees and are therefore paid through their clinic, practice or other entity, complicating the rollout of the pay increase. Therefore, the payments for services aren’t necessarily apples to apples comparison when it comes to paying the same as Medicare rates.
“How you do this in a managed care environment is the big challenge,” Matt Solo, executive director of the National Association of Medicaid Directors said in an interview. “It is not at all clear.”
Solo estimates the money might not reach doctors until late in the second quarter of this year, which would be by June 30.
“The money will flow,” Solo said. “It will eventually flow.”
Meanwhile, doctor groups wait patiently for their funds.
"It is vital that Medicaid receive sufficient funding to support an adequate network of caring physicians and maintain its purpose as a social safety net,” said Dr. Jeremy A. Lazarus, AMA president. “New federal funds authorized for primary care payment increases by the Affordable Care Act are an important step in the right direction to encourage more physician participation in the Medicaid program. The AMA and other physician organizations have urged state Medicaid programs and governors to move forward with filing the necessary paperwork with the federal government so that increased Medicaid payments can be paid to eligible primary care physicians.”
