Justin Puckett, an osteopathic physician from Kirksville, Mo., will have a major decision to make at the start of 2015 — whether his family medicine practice can continue to treat Medicaid patients.
Looming over Puckett and other primary care doctors is a cut to their reimbursement rate that is set to take effect at the end of this year, barring action from a lameduck Congress reeling from Tuesday’s Republican electoral wave.
“We are still crossing our fingers,” he said.
Under President Barack Obama’s health care overhaul, primary care doctors across the country were paid more for treating Medicaid patients during the last two years. But that boost is set to expire, leaving some providers and their patients in a tough spot.
“It would basically be a door-closer,” said Keith Ratcliff, a physician from Washington, Mo.
Before the Affordable Care Act raised the Medicaid reimbursement rate in all states, Missouri doctors treating those patients got roughly half the amount of pay they would have received if those clients were covered by Medicare.
Rates can vary based on the type of care that was provided and many states already paid their primary care doctors at rate comparable to those paid by Medicare.
The payment disparity in Missouri between the two government-funded health insurance programs caused many doctors to limit the number of Medicaid patients they would treat, restricting access to the mostly low-income beneficiaries of the program.
For example, doctors would be reimbursed $54.74 by Medicaid for an office visit requiring a detailed exam and medical history before the rate boost took effect. During the last two years of higher rates, the same doctor would be reimbursed $105.16 for providing the same care.
As part of an expansion of Medicaid coverage authorized under Obama’s health law, the reimbursement rates were temporarily lifted in an effort to get more doctors to accept those patients.
“It was imperative that the people caring for these patients be reimbursed at a rate where it didn’t cost them money to see patients,” said Brian Bowles, the executive director of the Missouri Association of Osteopathic Physicians and Surgeons.
About 3,200 physicians are designated as general practitioners for the Missouri Medicaid program. It’s unclear how many providers expanded their Medicaid services because of the higher rates. The Centers for Medicare and Medicaid Services isn’t collecting data.
But those doctors who did take on additional patients are looking for relief and making some tough decisions.
LOOKING TO THE LEGISLATURES
Doctors are holding out hope that Congress will vote to extend the higher reimbursement rate for primary care physicians across the country.
Legislation is pending in both the House and Senate, and physician groups were hopeful a deal could be cut after Tuesday’s midterm elections. But Tuesday’s decisive victory for Republicans, giving them their first Senate majority since 2006, tempered those expectations.
The GOP has been resistant to making changes or fixes to the Affordable Care Act in the hope of being able to fully repeal the law.
In the absence of congressional action, states could decide to foot the bill for the higher reimbursement rates themselves, and at least 15 have already agreed to do so, in full or in part.
But Missouri isn’t one of them.
In his budget request for the current fiscal year, Democratic Gov. Jay Nixon asked lawmakers to use state funds to continue the higher rates. The state’s share of the cost would have been about $20 million for the year, according to state budget officials.
The Republican-led Legislature agreed to continue the rate boost, but only partly. It approved $4 million in additional spending.
That money, however, ended up being vetoed by Nixon as part of a showdown with Republicans over tax breaks for certain industries and declining state revenue.
“It’s very difficult operating a business where we provide such an important human service and yet at the same time all of our income is essentially controlled by a third party we don’t have any influence on,” Puckett said.
PREPARING TO GO WITHOUT
Now doctors face some difficult choices that will affect how the roughly 800,000 Missourians on Medicaid receive care.
Puckett said his practice is considering limiting the number of Medicaid patients it will see or laying off staff. About 30 percent of this patients at his center, Complete Family Medicine, are covered by Medicaid. The others have private insurance, Medicare or pay with cash.
He said the lower rates will force him to decide between restricting Medicaid recipients or cutting services for all his patients.
“It’s an ethical decision, not just a business decision,” he said.
Ratcliff said that if doctors cannot absorb the hit, then patients would seek more care in emergency rooms or have to travel for miles to see a doctor. He said federally qualified or rural health centers may have to pick up some of the slack. Those types of clinics are reimbursed differently for their care.
“Those are the only practices that may survive out in the more rural areas,” he said.
Heidi Miller, a doctor at the Family Care Health Centers in St. Louis (a federally qualified health center), said the lower reimbursement rates were unlikely to affect access to care in the state’s urban areas because many private primary care providers don’t see Medicaid patients anyway.
“I’ve had a number of new patients over the last dozen years who came to us because their private doctor was not able to see them due to a change in their insurance coverage,” she said. “It’s extremely hard to get a private doctor to take Medicaid.”