The other physician payment problem

News & Analysis For a decade, Aetna has offered a Com- passionate Care program (http://aet.na /1aNtP0F). “We’ve eliminated the require- ment for commercial members to give up curative treatment in order to be eligible for hospice services,” Harold L. Paz, MD, MS, ex- ecutive vice president and chief medical offi- cer at Aetna, told the audience at the IOM meeting. Plus, he said, commercially in- sured members are eligible for hospice care if their life expectancy is a year, not the stan- dard 6 months. However, Aetna must comply with CMS regulations for its Medicare members, Paz said. Nearly 3000 Aetna Medicare mem- bers enroll in the Compassionate Care pro- gram each year, he said. In 2012, 82% of them chose hospice care, virtually the same proportion as seen in commercially insured Aetna members, Paz said. Only a small num- ber of commercially insured patients have opted to receive palliative care and cura- tive care simultaneously, he said. “Notably, we have not seen increased costs as a result of this,” Paz said. In fact, for each member who has enrolled in the Compassionate Care program, Aetna esti- mates it has saved about $12 900, Paz said. “Certainly, palliative care is less costly than curative care.” Aetna has also seen “impressive results” in terms of satisfac- tion on the part of members and their families, he added. As of January 1, Cambia added about 20 codes to its Medicare Advantage plan, which pays for home health agencies, social workers, counselors, and palliative care providers that traditional fee-for- service Medicare does not, Csaba Mera, MD, deputy chief medical officer, said in an interview. “Our view is that hospice is built into palliative care,” Mera said. “But palliative care really should start much earlier. It doesn’t mean that you have to stop active treatment.” “Physicians have been trained that death is the enemy,” Cambia’s Maguire said. “I think if we could reframe the conversa- tion about wellness and living with quality for as long as possible, no matter your health condition, that’s the cultural shift that we need to make.” The JAMA Forum The Other Physician Payment Problem Andrew B. Bindman, MD cians’ willingness to care for Medicaid pa- tients. The Centers for Disease Control and Prevention found physician participation in Medicaid to be among the very lowest in these 3 states (54% in California, 56% in Florida, and 57% in New York) compared with the national average in Medicaid of 69%, (http://1.usa.gov/1IDgbrB) even though physicians in these same states ac- cept publicly insured patients in Medicare at rates that are not statistically different from the national average of 84%. Why the Disparities? Medicaid is jointly funded with resources from the federal and state governments. Although states, on average, pay only 38% of Medicaid’s total costs and no state con- tributes more than 50% toward Medicaid physician payments for care, state Medic- aid programs are allowed to determine physician payment rates. States set them low for the simple reason that this is one of the few ways that they can limit their costs for this entitlement program. States understand that low payment rates con- tribute to reduced physician participation and barriers to care, but they are rarely held accountable for the level of access that their programs provide. Andrew B. Bindman, MD One way physicians and other medical professionals have attempted to combat low Medicaid payment rates has been through the federal courts, by suing state Medicaid programs to raise rates, arguing that low pay- ment rates prevent Medicaid programs from providing adequate access to care. Federal courts have been sympathetic to the ac- cess concerns, and in several cases the courts have required states to either raise their rates or roll back proposed payment cuts. JAMA June 2, 2015 Volume 313, Number 21 (Reprinted) Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/934110/ by a UCSF LIBRARY User on 05/10/2017 jama.com American Medical Association A lthough the US Congress has now passed legislation to permanently repeal the controversial formula used to pay physicians for caring for pa- tients who receive Medicare, it is ignoring an even larger payment problem in Medicaid that has implications for an even greater number of patients. The Congressional Bud- get Office (CBO) estimates that in 2015 there will be 66 million (http://1.usa.gov /1HNCw7E) individuals enrolled in Medic- aid compared with 55 million (http://1.usa .gov/1Qc7utX) in Medicare. Much attention has been focused on a 21% decrease in physician payment for care provided to Medicare beneficiaries that would have occurred if Congress had not addressed the sustainable growth rate (SGR) formula used to calculate payment. Yet despite Medicaid’s larger patient population, physician payments for the same services are already 34% lower in Medicaid (http://bit.ly/1adaS00) than they are in Medicare. Medicaid payment rates vary widely across states, with the greatest disparity in Medicaid vs Medicare physician payments in many of the most populous states, includ- ing California, Florida, and New York. These disparities have a direct effect on physi-