The Texas Medical Association says the state's plan to drop a hybrid fee-for-service Medicaid payment program in key urban areas in favor of a Medicaid HMO would be the last straw for physicians, who will be forced out of the already critically weakened Medicaid program.
"The system is broke, but the fix isn't what the Texas Health and Human Services Commission is proposing," said Bohn Allen, M.D., president of the society and an Arlington, Texas, general surgeon. "Our biggest concern is the bureaucracy of the HMO system will drive physicians out."
Allen said he dropped Medicaid two years ago because he couldn't generate enough cash flow from meager reimbursements to operate.
"It was a terrible decision," he said.
In a survey reported by the state association in January, only 46% of physicians interviewed said they would take new Medicaid patients, down from nearly 70% in 2000, Bohn said. Those physicians willing to remain with the program overwhelmingly prefer the primary-care case management (PCCM) system the commission said it would terminate, Allen said.
Under the decade-old PCCM system, physicians are paid $3 per member per month to manage the patient and give them a medical home. In addition, they are reimbursed on a fee-for-service basis. Medicaid payments run a meager 50% of Medicare reimbursement rates, Allen said, and Medicare pays only about 45% to 50% of billed charges.
"The system has been declining over the past three years over the draconian cuts in the budget," Allen said. "For the physicians who want to remain in Medicaid, the PCCM is the best one for them."
The Texas HHSC announced Thursday it will eliminate PCCM and replace it with an HMO-only system for Medicaid patients residing in the state's major urban areas, where the bulk of the state's Medicaid-eligible residents reside.
Last year, with a $10 billion budget deficit looming and a constitution that requires a balanced biannual budget, the Texas Legislature cut $2 billion from the state's Medicaid fund, which pays for care for about 24% of the state's 22 million residents, Allen said.
"The Health and Human Services Commission contracted with the Lewin Group to determine what model of care is the most cost-effective approach for serving Medicaid patients. The report, which did not examine the quality or availability of care within HMOs, found that the HMO and PCCM models provide comparable cost savings," the Texas Medical Association said in a prepared statement today.
Lack of access will be most acute for patients in need of specialists, particularly pediatric subspecialists, according to the TMA. Services in orthopedics, neurology, and gastroenterology are "almost nonexistent in many of the Medicaid managed-care service areas," the association said.
"Physicians in Bexar, Harris, and Dallas service areas tell us that the only model in which subspecialists continue to participate is the PCCM," Allen said. "If PCCM is repealed, the subspecialty network will collapse, forcing more patients to delay care or utilize the emergency room for services."
Allen said the association would ask the state to reconsider pulling the plug on the PCCM program, then point to the 2005 legislative session for a more comprehensive fix.
"We're already making preparations for the next legislative cycle," he said. "We certainly are going to be contacting all of our legislators and the governor and lieutenant governor and telling them of our concerns," he said. "We want to try to get them to restore the funding so beneficiaries will have continued access to care."