Dollars and Sense: Countering Medicaid Cuts
“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”
Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”
Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.
“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”
Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”
One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)
In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.
Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.
“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”
In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.
In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.
