Access Granted

HHSC Improves Pediatric Specialty Care for Medicaid Children

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Medical Economics Feature - October 2010

Tex Med. 2010;106(10):39-42 .

ByKen Ortolon
Senior Editor

Big Spring pediatrician Steve Ahmed, MD, practices in a medically underserved area where the vast majority of his patients live below the federal poverty level.

"These are poor people," Dr. Ahmed said. "Some of them don't even have vehicles. Some of the young moms don't even drive."

That used to be a problem when Dr. Ahmed needed to refer children to a pediatric subspecialist. The nearest are located 100 miles away in Lubbock. Sometimes, he had to send kids to Dallas if a subspecialist was not available in Lubbock.

But thanks to a telemedicine network that partnered Dr. Ahmed with pediatric subspecialists at Texas Tech University Health Sciences Center, patients in Big Spring now have access to specialty care without leaving their home town. Using seed money from the Texas Medicaid program, Texas Tech is setting up a network of more than 30 sites throughout the Texas Panhandle and West Texas to use live interactive video and sound delivered via the Internet to connect pediatric specialists with children living in areas that lack such specialists.

Dr. Ahmed says the program works well for his patients.

"We set up an appointment with a specialist, and we call the patient to our office," he said. "We have a separate room for telemedicine. If there is no surgery involved, the patient can get the second opinion done right away rather than traveling 100 miles."

The program is among several pilot programs the Texas Health and Human Services Commission (HHSC) hopes will improve access to care for children on Medicaid throughout Texas.

Texas Medical Association officials are optimistic these initiatives will have a significant impact on improving the health of Texas children.

"It's too early to be able to measure the outcomes," said San Angelo pediatrician Jane Rider, MD, a member of TMA's Ad Hoc Committee on Medicaid and CHIP. "But we are very hopeful that access will improve both in quantity and quality for the children."

Finding Innovation

HHSC's pilot programs are funded by $150 million the Texas Legislature set aside as part of the settlement in the Frew v. Hawkins lawsuit that found the Texas Medicaid program lacking in providing adequate access to care for children on Medicaid.

Wm. Brendle Glomb, MD, HHSC associate medical director responsible for the Frew initiatives, says the money funded about two dozen pilot programs that seek to expand access to care. But, a handful of those projects specifically target increasing access to pediatric subspecialty care in rural and underserved areas.

Among those projects is the telemedicine program Dr. Ahmed participates in. Some of the others include:

  • A clinician-directed care coordination initiative that pays both primary care doctors and specialists for telephone consultations;
  • A second telephone-based consultation and referral service run by The University of Texas Southwestern Medical Center;
  • A mental health project that integrates mental health professionals into primary care practices; and
  • A medical school loan repayment program that encourages physicians to increase the number of Medicaid children in their practices.

Dr. Glomb says an additional initiative, a health home pilot program that should begin later this year, also will impact pediatric subspecialists even though it is primarily designed for primary care physicians.

Michelle Long, who coordinates implementation of the new access programs for HHSC, says most of them are intended to use technology to share medical guidance and expertise to areas far beyond where the subspecialists are physically located.

"The problem is that, even in urban areas where there are a lot of doctors, there is still a shortage of pediatric subspecialists," Ms. Long said. "The goal of these projects is to get the most we can from those specialists, either by enhancing communication and coordination between primary care providers and specialists or by making it easier for children to get the access to specialists they need."

Dr. Glomb says most of the Frew initiatives are two-year pilot projects to test the effectiveness of certain innovations in improving access to care. Once the projects are complete, they will be evaluated to determine how successful they were and whether they can be replicated across Texas.

He says a wide range of individuals and groups, including physicians and other health care professionals, institutions, and organizations such as TMA, recommended the proposals. TMA, the Texas Pediatric Society, and the Texas Academy of Family Physicians submitted joint recommendations that were either adopted by HHSC or had similar goals to programs funded with the Frew dollars.

One of those recommendations was to create a Frew advisory committee to help HHSC vet proposed projects. That committee played a major role in recommending which initiatives got funding.

Dr. Rider chairs the committee and is "very pleased" HHSC listened to the ideas from those on the front lines in caring for Medicaid children.

Behavior Change

Dr. Glomb says the challenge for some of the initiatives is that many physicians are already set in the way they practice medicine or the referral patterns they use.

"We're old dogs, and it's hard to teach us new tricks," he said. "It's hard to get physicians to change the way they have been doing things. If they are used to referring patients in a certain way or talking with subspecialists in a certain way, it's just awfully hard to encourage them to do something new or different."

The care coordination project is an example. That program is designed to foster quicker, more efficient consultations between specialists and primary care physicians and providers by having Medicaid pay both parties for telephone consultations on children who receive clinician-directed care coordination.

Dr. Glomb says neither Medicaid nor private health plans have ever paid for phone consultations even though they are a fairly routine part of medical practice. He says officials hope primary care doctors will use the consultations to determine more efficiently which children really need to be seen by a specialist.

To be paid for the consultation, the primary care doctor must seek prior authorization from HHSC. The program will pay for two consultations per specialist, per six-month period.

HHSC and the Texas Department of State Health Services (DSHS) have developed guidelines for the consultations, as well as training modules that can be found on the Texas Health Steps provider training website.

Dr. Glomb says few physicians have billed for such consultations so far, despite efforts to publicize the program.

Dr. Rider has billed for consultations. She has used the phone visits to help coordinate care for children with special needs and premature babies who have multiple health issues and are being seen by multiple subspecialists. She says the payments offset the time and expense involved in coordinating care among several physicians.

Specialists are paid $28.07 for a telephone conversation of at least 15 minutes. The primary care doctor contacting the specialist does not get paid separately for the telephone consult, but does receive a monthly payment for coordination of care, which includes any necessary specialist telephone consultations in addition to other coordination services. Those payments range from $58.42 to $91.47 per month based on the place of service and the amount of time devoted to the coordination of care for a specific client.

"It takes a lot of time to determine who's doing what and help the patient keep up with it, make sure that the patient is not getting confused, that there aren't medication interactions that the subspecialists aren't aware of because they don't realize the patient is seeing somebody else," she said.

The Texas Pediatric Access to Subspecialist project, or Texas PASS, also uses telephone consultations. HHSC contracted with UT Southwestern to offer primary care physicians access to UT Southwestern faculty subspecialists with expertise in pediatric cardiology, child psychiatry, endocrinology, gastroenterology, hematology/oncology, infection diseases, nephrology, and neurology.

Medicaid primary care physicians in Northeast and North Central Texas may call a toll-free number any time day or night, explain their situation with a patient to a program coordinator, and get a call from the appropriate subspecialist within 30 minutes. Physicians can learn more about the program by calling (877) 282-PASS or (877) 282-2722.

Going on Camera

The telemedicine initiative also is a partnership between HHSC and medical school faculty. HHSC contracted with both Texas Tech and The University of Texas Medical Branch (UTMB) in Galveston to create regional telemedicine networks in their areas.

Dr. Glomb says Medicaid has always paid for telemedicine services. What's different about this program is HHSC is providing the seed money to buy the equipment, establish the Internet connection, and provide information technology support services at both ends of the telemedicine encounter.

"Using telemedicine just makes sense, especially in the more rural areas of the state where parents may have to travel hours just to see a doctor," Dr. Glomb said. "We're bringing the knowledge and expertise of specialists to remote areas that couldn't be reached before."

Both Texas Tech and UTMB will establish networks that include 30 remote telemedicine sites. Texas Tech's network offers a variety of subspecialty care, while the UTMB network focuses solely on psychiatric treatment.

UTMB uses existing mental health-mental retardation facilities in rural counties and sets up equipment to conduct telepsychiatry visits. Psychiatrists, not social workers or other midlevel professionals, see the patients, Dr. Glomb says.

The UTMB network has operated for about a year, and Dr. Glomb says it already has cared for thousands of patients in the coastal area, East Texas, South Texas, and Central Texas.

Meanwhile, Texas Tech already has nearly 20 telemedicine sites that are active or being developed.

The two-year telemedicine pilot ends in July 2011. Dr. Glomb says HHSC hopes both networks can be self sustaining with the revenues generated from telemedicine visits by then.

Another project seeks to integrate mental health services into primary care practices. In September 2008, HHSC contracted with The University of Texas at San Antonio Health Science Center to establish six pilot sites to train midlevel behavioral health practitioners to work in primary care physicians' offices to screen, assess, and identify mental health and behavioral health symptoms in children. The project is designed to allow primary care doctors to manage the patients' care or refer them for more specialized treatment.

Austin pediatrician John Hellerstedt, MD, who also serves on the Frew advisory committee, thinks the mental health integration project is among the most promising of the Frew initiatives.

"Essentially, what it means is you will have someone with mental health qualifications colocated in a primary care practice, and it will become a matter of course that any new patients will be introduced to this new resource," Dr. Hellerstedt said, adding that it should help overcome existing barriers to adequate mental health care, including shortages of pediatric mental health providers, as well as family hesitation about seeking mental health care.

 "I'm really hopeful this Medicaid pilot is successful and demonstrates improved services, improved satisfaction, and maybe even some decrease in behavior-related problems and symptoms."

Making Medicaid Pay

Finally, HHSC hopes to attract not only more pediatric subspecialists, but also more primary care physicians to Medicaid through a new Children's Medicaid Loan Repayment Program.

The program, strongly supported by TMA, repays up to $140,000 in student loans over four years for physicians and dentists who meet certain requirements for treating children on Medicaid. HHSC accepted 300 doctors and dentists into the program in 2009 and recently selected another 300 for 2010. About 60 percent of the first-year recipients are physicians, with about 20 percent practicing pediatric subspecialties. The 2010 class included about 30 percent primary care doctors, 30 percent subspecialists, and 30 percent dentists.

Physicians may get more information about the loan repayment program by visiting the DSHS web site or by calling (512) 458-7518.

Dr. Rider says the Frew advisory committee is watching that program carefully to see if it helps keep pediatric subspecialists in the Medicaid program.

"As long as it stays funded at the level that is was originally funded - and that's the big thing in doubt - it could have a tremendous effect," added Dr. Hellerstedt.

Dr. Glomb says HHSC officials are optimistic about the potential impact of these programs, but says success in improving access to subspecialists really depends on state budget constraints. At the direction of legislative leaders, HHSC recently enacted a number of Medicaid funding cuts, including a 1-percent cut in physician payment rates.

"We're optimistic, but we're also realistic," Dr. Glomb said. "We know that in these economic times that have not bypassed medicine by any stretch, it's going to be a challenge for practices to continue to see Medicaid patients. If it were up to anybody in Medicaid, there would not be a cut because we realize that we face a challenge in keeping providers on board."

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 e-mail at Ken Ortolon .

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