Medical Economics Feature - April 2009
Tex Med . 2009;105(4):51-53.
By Ken Ortolon
When Corpus Christi pediatrician Adam Wiraszka, MD, was a medical student at the Akademia Medyczna Wroclaw in Poland, he never expected to one day examine children's teeth in Texas.
But that's just what he and numerous other pediatricians and family physicians across Texas are doing under an initiative state Medicaid officials launched last September to boost access to early oral health screenings for young children.
"I don't think it is extremely complicated," said Dr. Wiraszka, who performs the oral examinations as part of Texas Health Steps exams for his Medicaid patients. He says the oral exams involve collecting oral health histories from the parents; assessing the health of the child's gums and teeth; educating the parents on dietary issues, including avoiding giving the child too much sugar; and applying a fluoride varnish to help prevent cavities.
The Oral Evaluation and Fluoride Varnish in the Medical Home program is one of several Texas Health and Human Services Commission (HHSC) initiatives to improve access to health care for children on Medicaid. The initiatives are funded with $150 million the Texas Legislature approved in 2007 as part of the Frew v. Hawkins lawsuit that claimed deficiencies in the state's Medicaid program.
HHSC has not identified enough projects to utilize the full $150 million in the current biennium, which prompted plaintiffs in the Frew case to complain the agency is not moving fast enough. However, state officials and physicians believe they could significantly improve access to care for patients. The initiatives also could bring more physicians into Medicaid by reducing some of the administrative hassles and increasing payment for some services, such as the oral health exams.
A Multipronged Approach
Olga Rodriguez, Frew coordinator for HHSC, says many of the projects already under way or planned constituted a "multipronged approach" to recruiting more physicians and other health care professionals into the Medicaid program.
The first prong was the September 2007 fee increases for physicians, dentists, and other professionals. Those increases boosted payments for children's services by roughly 25 percent for physicians in the children's Medicaid program. The Texas Medical Association and state specialty societies are advocating further increasing those rates in this year's legislative session to keep up with the costs of caring for children in Medicaid.
Ms. Rodriguez says another major effort to get more doctors into the program is a physician loan repayment program that was launched in March. Under that program, physicians who meet certain levels of Medicaid participation would be eligible for up to $140,000 over four years to help offset their medical school debt. The program would be open to physicians who already see Medicaid patients or those participating in the program for the first time.(See "TMA Backs Expanded Loan Repayment Program.")
"We have heard many times from physicians that they would practice in underserved areas and see Medicaid patients, but they can't afford to pay their large student loans," said San Angelo pediatrician Jane Rider, MD, who chairs HHSC's Frew Technical Advisory Committee, which reviews and makes recommendations on how to spend the strategic initiative funds from the settlement. "We hope the loan repayment program will enable more physicians to choose to serve the Medicaid patients."
HHSC hopes to enroll up to 300 physicians and dentists in the program each year, with a maximum of 1,200 participating by the end of the fourth year. Since the Frew lawsuit focused on improving Medicaid access for children, 200 of those slots will go to pediatricians and other primary care physicians who treat children. Another 50 will be reserved for pediatric subspecialists and the remaining 50 for dentists.
Frew plaintiffs sought to require participating physicians to see a higher number of Medicaid patients to qualify for the loan repayments, but TMA's Select Committee on Medicaid, CHIP, and the Uninsured contended that would reduce the number of physicians likely to participate. The committee successfully argued for a lower threshold they believe will get more doctors into the Medicaid program.
HHSC officials launched an online application for the program in early March (log on to www.dshs.state.tx.us/chpr/CMLRP.shtm ). Applications are due by June 1, and HHSC will select applicants by mid-July.
Austin pediatrician John Hellerstedt, MD, a member of the Frew Advisory Committee and TMA's Select Committee, believes the loan repayment program will be a "resounding" success.
"The success will hinge on HHSC being able to craft the selection criteria in such a way that they get the biggest bang for their buck," he said. "I think the selection criteria have to be such that people who are already in practice will either want to add a few more kids to their Medicaid panel, or people who are starting out in practice would open their doors to Medicaid clients either at all or to a greater degree than they would have otherwise."
Dr. Hellerstedt applauded HHSC for being "very receptive to input from the medical profession to get it right."
Making It Simple
Ms. Rodriguez says HHSC is optimistic - based on other states' experience in loan repayment programs and early reaction from medical schools, residency programs, and physicians - that the loan repayment program will be an effective tool in recruiting new physicians into Medicaid.
However, she says, literature shows that raising rates or loan repayment assistance alone is not always effective in boosting physician participation. Thus, HHSC has several plans to help reduce administrative hassles in the program.
First, HHSC revamped its online provider application to make it easier to fill out. For example, support staff at a group practice can now copy and paste into the application common information for each physician in the practice, rather than having to fill out each application from scratch.
In addition, the online program does not let physicians submit an application if any key elements are missing. That, says Ms. Rodriguez, eliminates the necessity of sending an application back to the physician for missing or incorrect information.
HHSC also is expanding to all Medicaid patients a swipe-card program originally developed for the foster care managed care program. The cards will provide eligibility information, as well as some basic medical history data, including prescription drug claims. HHSC hopes eventually to link the cards to the state's ImmTrac data.
"I think that will be a tremendous benefit to the physician because it lets us know without any question the eligibility of the patient and also can give us some limited medical history information," said Dr. Rider, who also serves on the TMA Select Committee.
HHSC spokesperson Stephanie Goodman says the cards will speed patients' check-in at the doctor's office and save Medicaid money.
"We send Medicaid clients a letter every month that serves as their proof of insurance through Medicaid," she said. "That's obviously very costly for us to do a monthly mailing. So we feel like getting them a card will be much simpler for them. It will speed the process when they check in, and it will save money because it's a lot cheaper than doing those monthly mailings."
Finally, HHSC is looking to simplify its prior authorization process and eliminate prior authorization for some services for which it believes it's no longer necessary or if it's less expensive than the cost associated with processing the preapproval.
HHSC also hopes to increase physician participation in Medicaid and build referral networks between primary care doctors and pediatric subspecialists through initiatives that would boost payment for some services.
One of those is the oral health exam program in which Dr. Wiraszka participates. The program, instituted in conjunction with a first dental home initiative, pays physicians to perform oral exams and apply fluoride varnish on young children beginning at age 6 months. Physicians receive $34.16 in addition to the fee they receive for the regular Texas Health Steps visit.
To qualify for the program, physicians must complete a training course. Physician assistants and advanced nurse practitioners working in a pediatrician's or family physician's office also can perform the screenings upon completion of the training course. Information on in-person trainings for oral health exams is posted online . HHSC also offers training through webinars. To get information on future webinars, click here .
Ms. Rodriguez says HHSC is not trying to turn physicians into dentists. But because the medical home is the "first point of entry" to health care for most of the children, it is using physicians to deliver that early oral health care.
"And then the intent is not for the physician to continue providing oral examinations, but to direct patients to a dental home," she said.
In January, HHSC also introduced a new reimbursement code that allows pediatric subspecialists to bill for telephone consultations with primary care physicians. The agency also is working on a pilot to create a consultation and referral network in conjunction with some of the state's medical schools. The hope, Ms. Rodriguez says, is to provide a more streamlined referral process for pediatric subspecialty care.
To find out more about these and other Frew -related initiatives, go to HHSC's Frew Advisory Committee Web page.
TMA Backs Expanded Loan Repayment Program
While Medicaid's new physician loan repayment program is designed to increase the number of doctors treating children on Medicaid, TMA is backing legislation to greatly enhance an existing loan repayment program designed to attract physicians to rural and underserved areas.
TMA seeks about $19 million for the next two years to enhance a loan repayment program that it says has failed to keep up with medical education costs.
The current program provides $9,000 per year for up to five years - for a total of $45,000 - to help medical graduates repay their student debt. TMA's proposal would increase that amount to a maximum of $140,000 over four years.
Hurst pulmonologist Woody V. Kageler, MD, who chaired a special TMA workgroup on physician education loan repayment, says new medical graduates have lost interest in the current program because repayments are too small to help them maintain viable practices in rural and underserved areas. Loan repayment amounts under the current program have not been updated since the 1980s. Because of the low repayment amounts, interest in the program has waned to the point that not all funds appropriated during the last biennium were used.
TMA says its proposal would be complementary to the new Medicaid loan repayment program created with money from the Frew v. Hawkins settlement.
TMA's legislation had not been filed as of early March, but the association was discussing the issue with state Sen. Judith Zaffirini (D-Laredo), chair of the Senate Higher Education Committee. Meanwhile, state Rep. Warren Chisum (R-Pampa) has filed legislation to create a new loan repayment program using revenue from a change in how smokeless tobacco is taxed.
TMA officials say they have concerns about some provisions of Representative Chisum's bill but stand ready to work with him to ensure the state has a comprehensive program to recruit much-needed physicians to rural and underserved areas.
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Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
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