Beginning January, 2013, state Medicaid programs must begin paying physicians more for providing primary care services. The Affordable Care Act boosts traditionally low Medicaid rates to Medicare levels for 2013 and 2014 for certain primary care services. The goal, according to the Centers for Medicare and Medicaid Services, is to increase physician participation in Medicaid ahead of the program’s expansion in 2014.
CMS officials issued a final rule spelling out the new pay parity rules in November of 2012. The increased primary care payments will be available to physicians specializing in family medicine, general internal medicine, or pediatric medicine. Adult and pediatric subspecialists such as cardiologists, endocrinologists, and gastroenterologists, can also take advantage of the increased payments. The payments do not extend to obstetricians and gynecologists, according to the final rule.
Neil Kirschner, Ph.D.
Neil Kirschner, Ph.D., of the American College of Physicians, which represents both primary care and subspecialty internists, explained how the policy could affect access to care during the 2013-2014 period and beyond.
Question: How significant is the additional payment and do you think it will encourage more physicians to accept new Medicaid patients?
Dr. Kirschner: If you look at the latest data from the Kaiser Family Foundation, Medicaid only pays about two-thirds of what Medicare pays across all the states for primary care services. In some states it will make a big difference. In other places, such as the state of Washington, which pays very highly, it probably won’t make much of a difference.
Whether and to what extent it will increase the number of primary care providers that participate in the program remains an open question. Several factors are at play, such as the extent to which primary care providers have capacity for new patients. Also, the program is only for 2 years. Do primary care doctors and related specialists want to add a patient load that may see decreasing reimbursement in the very near future?
Research shows that payment alone isn’t the only reason primary care and related specialists shy away from participating in Medicaid program. In a lot of states, there are administrative burdens associated with enrolling in the Medicaid program and in submitting claims. Another problem is that once a primary care physician sees a patient under Medicaid, it can be difficult to find a specialist for follow-up.
Question: What can states do to make the increased payments more effective in achieving the goal of expanding access to primary care?
Dr. Kirschner: They could facilitate enrollment, as well as improve systems for submitting claims. They could also make some commitment that they are aware of the potential gains and that they are at least considering continuing this after the federal government stops funding the difference in payments in 2014.
Question: In the final rule, the CMS said that Medicaid will pay the higher rate for certain services not covered by Medicare. Which services?
Dr. Kirschner: As long as it is allowed by the Medicaid program, the pay parity will apply to non–face-to-face contacts, such as for telephone consultations or for electronic Internet consultations. It will also apply to consultation codes. It was a big issue for specialists when Medicare decided that it would no longer pay consultation codes. This will allow for the payment of those consultation codes and may make this policy of greater interest to specialists and subspecialists. It also appears that the pay parity will apply to a wider variety of preventive codes. Medicare has begun paying for preventive services using a "G code" process, but it’s only for specific services. Under the parity rule, it will pay for more general categories of preventive services.
Question: The CMS chose not to narrow the scope of the rule to apply only to primary care physicians. As a result, endocrinologists, cardiologists, gastroenterologists, and other subspecialists will now be able to take advantage of the higher payments. Was this a good move?
Dr. Kirschner: Pediatricians, who are one of the major provider communities within Medicaid, have complained for a long time about the difficulty in getting specialty follow-up; this policy could help address that problem. On a broader level, many subspecialists do provide primary care, at least at some level, for a number of their patients. So to the extent that they do provide primary care services, they should be recognized.
Question: What happens in 2015 when these increased payments stop?
Dr. Kirschner: If the payments are reduced, and the other factors that make Medicaid difficult for providers to participate in aren’t addressed, I think you may see some physicians decrease their participation. That is a possibility.