Dual-Eligible Glitches Fixed; Misguided Policy Remains

A combination of poorly informed government decisions and bureaucratic bungling is creating a medical emergency for thousands of dual-eligible Texans and the physicians who care for them. "Dual-eligibles" are people old enough to qualify for Medicare as their health insurer and poor enough to qualify for Medicaid assistance. Hundreds of thousands of them live across Texas. But budget cuts and bureaucratic bungling threaten their care – and more.

  Javier Saenz, MD, is a Rio Grande Valley family physician who cares for many these patients. They make up about half of his practice. Since January he's treated them as always, but has received no Medicare payments and very little in payments from Texas through Medicaid. As a result, he is exhausting personal savings and turning to bank loans to make payroll and keep his medical practice open to serve his patients. He doesn't know how long he can hold out.

 "If all I see are my most needy patients, I can't stay in business," Dr. Saenz told the Texas Medical Association. "If I can't stay in business, then I can't help anybody."

 Dr. Saenz is not alone. Physicians who care for dual-eligible patients in poor communities from rural Texas to inner cities are caught in this vise.

 The jaws of this vise are coming from several directions. As part of a cost-saving move the Texas Legislature ordered, the Texas Health and Human Services Commission (HHSC) adopted a new policy of not paying coinsurance and deductible payments for Medicare Part B services for patients eligible for both Medicare and Medicaid when Medicare's payment exceeds the Medicaid allowable for the same service.

 Several serious Medicare and Medicaid computer errors have compounded the situation.

 A trio of computer glitches were identified that resulted in claims paying $0 during the patients' annual Medicare deductible period, even though physicians should have been paid up to the amount Medicaid would have paid for the service if the patient weren't covered by both Medicare and Medicaid. One of the problems stemmed from a processing error in the state's Medicaid claims-payment system. In the other, state and federal computers were not talking to each other properly because of problems tied to the new national rule requiring physicians, providers, and public and private insurers to use a new billing standard known as HIPAA 5010.

 With TMA demanding action, state and federal officials say they corrected the computer problems, and the claims Dr. Saenz and others filed for taking care of these patients will be reprocessed. But those officials have not yet announced when that will happen.

 TMA is calling on state leaders to take emergency action to help these patients and the doctors who care for them.

 TMA argued against the change from the start. TMA spoke against the Texas Legislature's decision to direct the HHSC to make the cut as part of broader efforts to close the state's $27 billion budget deficit.

 Late last year, association President C. Bruce Malone, MD, presciently warned HHSC that the changes were about to "penalize the physicians who care for the sickest and frailest Medicare patients. They hit particularly hard practices in rural, inner-city, and border Texas, as those practices serve a disproportionate number of dually eligible Medicare patients. In addition to compromising the financial viability of these practices, we fear that the rules could result in fewer physicians willing to set up a practice in the communities that most need them."

 Dr. Malone noted that TMA recognizes the need to reduce costs and is "a ready and willing partner with HHSC and the legislature to identify pragmatic solutions for reducing Medicaid costs," but said the proposal is "misguided." He urged HHSC to work with TMA "to identify other mechanisms to reduce Medicaid costs that will not jeopardize the ability of physicians to care for this population."

 Further, TMA sent a letter to HHSC Commissioner Tom Suehs in December 2011 urging that he support using higher-than-expected savings from the policy change to mitigate the size of the payment reduction.

 TMA has made progress. In early January, TMA, state specialty societies, and the Border Health Caucus  met with HHSC to discuss the impact of the cuts on patients and physicians. HHSC has limited authority to mitigate the cut without legislative intervention, but it made two changes:

  • Oncologists will receive Medicare parity for chemotherapy drugs starting April 1.
  • Cuts in payments to psychiatrists and psychologists will stop May 1.

 Let the LBB Hear You!
The state Legislative Budget Board  (LBB) is the only entity that can mitigate or halt cuts when the legislature is not in session. TMA urges you to contact the LBB and urge it to take a stand for vulnerable patients and their physicians. The LBB mailing address is PO Box 12666, Capitol Station, Austin, TX 78711. The phone number is (512) 463-1200. The fax number is (512) 475-2902.

 Over the next month, TMA and county medical societies will host several town hall meetings with legislators and HHSC starting in McAllen on March 27.