AAFP Tells HHS How to Improve CHIP, Medicaid Managed Care

Tame Physicians' Administrative Burden, Safeguard Patient Access

July 22, 2015 01:44 pm News Staff
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The AAFP recently sent a detailed letter to HHS Secretary Sylvia Burwell in response to the release of a proposed rule(www.gpo.gov) covering certain aspects of Medicaid managed care and the Children's Health Insurance Program (CHIP).

In the seven-page July 15 letter,(7 page PDF) AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., noted that during the past four years, enrollment in Medicaid managed care plans increased by 48 percent, and the plans currently have 46 million beneficiaries.

He applauded HHS' commitment to "modernizing and strengthening" Medicaid and CHIP managed care programs by taking steps to align the rules governing those programs with other sources of health insurance.

"The AAFP supports consistency across public and private health plans as a means to promote accountability by the plans, improve care provided to beneficiaries and reduce administrative hassles for medical practices," said Blackwelder.

Story Highlights
  • AAFP Board Chair Reid Blackwelder, M.D., recently fired off a letter to HHS with detailed suggestions on how to improve a proposed rule covering Medicaid managed care programs and the Children's Health Insurance Program.
  • Blackwelder pointed out that enrollment in Medicaid has increased by 48 percent in the past four years.
  • The AAFP called for changes in Medicaid in a number of areas, including use of technology to improve provider network directories and enhanced health plan network adequacy standards.

However, Blackwelder didn't hold back when it came to outlining AAFP concerns with certain elements of the current system, administrative burdens, network adequacy and program integrity.

Network Directories

Provider directories were a top item on Blackwelder's fix-it list.

He acknowledged the role of physicians in "contributing to the accuracy of provider directories," but told CMS to make health plans ultimately responsibility for the accuracy and timeliness of directory information and updates.

Health plans have information technology at their fingertips, said Blackwelder, and they should use electronic methods to immediately update physician information.

"Electronic communications should have an embedded hyperlink to the plan's provider directory for the physician to access," he insisted. "Any changes or updates the physician makes on that Web page regarding contact information and availability should update the health plan's online provider directory instantaneously."

Furthermore, Blackwelder continued, it's time to standardize the list of provider information in such directories.

To that end, he noted that health plans need to collect only minimal information from health care professionals, specifically limited to

  • their full name;
  • contact information, including address, ZIP code, phone number and website address;
  • office hours and other information related to availability;
  • status regarding acceptance of new Medicaid patients; and
  • a timeline for when physicians who accept new Medicaid patients will actually be able to see those patients in the office.

Insurers also should prepopulate the Web page physicians access to change or update their information with the insurance products and networks in which the physician currently participates, Blackwelder suggested.

Making these changes would result in fewer administrative hassles for physicians and trim the need for direct communication between CMS, health plans and physicians to once a year, a move that would save busy family physicians precious time.

Health Plan Network Adequacy

Noting that the proposal requires that states account for a number of factors when assessing network adequacy, Blackwelder said the Academy agreed with the "time and distance" adequacy requirements proposed by CMS, but he pushed for standards for appointment wait times, as well.

He pointed to 2014 research that showed that only about half of physicians listed in official plan directories were taking new Medicaid patients, and even among those who were, 25 percent couldn't see a new patient for a month.

"Standards on appointment wait times would add an additional beneficiary protection that would ensure health care's main entry point stays open and easily accessible for patients," said Blackwelder.

Knowing that family physicians in some states have reported problems with being cut from provider networks, Blackwelder questioned the wisdom of allowing states the flexibility to develop and enforce their own specific network adequacy standards.

"While we recognize this approach is consistent with CMS' general approach for the Medicaid program, we are concerned with the states' previous lackluster performance and enforcement of network adequacy standards, especially when it's unclear how financially strapped state Medicaid programs will respond," he said.

Blackwelder also expressed great concern with "patient churning" between health plans, the back-and-forth movement of millions of patients between Medicaid and subsidized coverage in state or federal health insurance marketplace plans.

"In addition, 19.5 million people will move between Medicaid and ineligibility for all insurance subsidy programs," said Blackwelder, because they're either at 138 percent of the federal poverty level or have access to affordable employer-sponsored health insurance.

He urged CMS to be "mindful of the importance of continuity of care" while they work to develop network adequacy and patient enrollment policies. "Strive to minimize the effect of patient churn between various plans" when embarking on that important work, Blackwelder urged.

Other Important Issues

Blackwelder touched on a number of other issues of concern to the Academy; for instance, he asked CMS to

  • set payment rates for primary care physicians at or above Medicare rates for all primary care services provided to Medicaid managed care and CHIP enrollees,
  • implement standards to ensure that capitation rates for Medicaid managed care programs are actuarially sound and risk-adjusted but that they don't create scenarios such as those previously seen with Medicare Advantage programs in which physicians experienced "constant harassment" from health plans intent on inspecting patients' medical records "to support the plans' claims about the health acuity of their enrollees,"
  • secure a high level of standardization and harmonization of quality measures and methodologies across reporting programs to eliminate variance among payers, and
  • work with payers to secure their commitment to paying prompt attention to the billing claims process.

If payers commit to taking on that last responsibility, said Blackwelder, then physicians can spend their time addressing the medical conditions of their patients "with some assurance of timely compensation for their services and no fear of going broke while the payers in question haggle over who is the primary payer. "

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