Posts Tagged Medicaid

What If No One Was on Call [at the Legislature]?

What If No One Was on Call [at the Legislature]?

2017 Legislative Recap

In times of illness, injury and emergency, patients depend on their physicians. But what if no one was on call? Public health would be in jeopardy. However, the same holds true during a legislative session. What would happen if the Medical Association was not on call, advocating for you and your patients at the legislature? Keep reading to find out.

Moving Medicine Forward

Continued success in the legislative arena takes constant vigilance. Click here to see our 2017 Legislative Agenda.

If no one was on call… Alabama wouldn’t be the 20th state to enact Direct Primary Care legislation. DPC puts patients and their doctors back in control of patients’ health and helps the uninsured, the underinsured and those with high-deductible health plans. SB 94 was sponsored by Sen. Arthur Orr (R-Decatur) and Rep. Nathaniel Ledbetter (R-Rainsville) and awaits the Governor’s signature.

If no one was on call… the Board of Medical Scholarship Awards could have seen its funding slashed but instead, the program retained its funding level of $1.4 million for 2018. The BMSA grants medical school loans to medical students and accepts as payment for the loan that student’s locating to a rural area to practice medicine. The BMSA is a critical tool for recruiting medical students to commit to practice in rural areas. As well, the economic footprint of every physician is at least $1 million, which improves both community health and local economies.

If no one was on call… Medicaid cuts could have been severe, possibly reducing access for patients within an already fragile system in which less than 20 percent of Alabama physicians participate. Due to work done during the 2016 second special session and the 2017 session, sufficient funds were made available for Medicaid without any scheduled cuts to physicians for 2018. Increasing Medicaid reimbursements to Medicare levels — a continuing priority of the Medical Association — could further increase access to care for Medicaid patients.

Beating Back the Lawsuit Industry

Personal injury lawyers are constantly seeking new opportunities to sue doctors. While Alabama’s medical liability laws have fostered fairness in the courtroom and improved the legal climate, each year personal injury attorneys seek to undo parts of the very law that helps keep “jackpot justice” and frivolous suits in check.

If no one was on call… an $80 million tax increase on physicians to fund a new government-administered malpractice claims payout system called the Patients Compensation System could have passed. The PCS would administer damage claims for physical injury and death of patients allegedly sustained at the hands of physicians. Complaints against individual physicians would begin with a call to a state-run 1-800 line and would go before panels composed of trial lawyers, citizens and physicians to determine an outcome. In addition, any determinations of fault would be reported to the National Practitioner Databank. The Patient Compensation System would undo decades of medical tort reforms which the Medical Association championed and is forced to defend from plaintiff lawyer attacks each session. The PCS deprives both patients and doctors of their legal rights.

If no one was on call… physicians could have been exposed to triple-damage lawsuits for honest Medicaid billing mistakes. The legislation would create new causes of civil action in state court for Medicaid “false claims.” The legislation would incentivize personal injury lawyers to seek out “whistleblowers” in medical clinics, hospitals and the like to pursue civil actions against physicians and others for alleged Medicaid fraud, with damages being tripled the actual loss to Medicaid. The standard in the bill would have allowed even honest billing mistakes to qualify as “Medicaid fraud,” creating new opportunities for lawsuits where honest mistakes could be penalized.

If no one was on call… physicians would have been held liable for the actions or inactions of midwives attending home births. While a lay midwife bill did pass this session establishing a State Board of Midwifery, the bill contains liability protections for physicians and also prohibitions on non-nurse midwives’ scope of practice, the types of pregnancies they may attend and a requirement for midwives to report outcomes.

If no one was on call… the right to trial by jury, including jury selection and jury size, could have been manipulated in personal injury lawyers’ favor.

If no one was on call… physicians could have been held legally responsible for others’ mistakes, including home caregivers, medical device manufacturers and for individuals following or failing to follow DNR orders.

Protecting Public Health and Access to Quality Care

Every session, various pieces of legislation aimed at improving the health of Alabamians are proposed. At the same time however, many bills are also introduced that endanger public health and safety, like those where the legislature attempts to set standards for medical care, which force physicians and their staffs to adhere to non-medically established criteria, wasting health care dollars, wasting patients’ and physicians’ time and exposing physicians to new liability concerns.

If no one was on call… legislation could have passed to lower biologic pharmaceutical standards in state law below those set by the FDA, withhold critical health information from patients and their doctors and significantly increase administrative burdens on physicians. ICYMI, read our joint letter to the Alabama Legislature opposing the bill.

If no one was on call… allergists and other physicians who compound medications within their offices could have been shut down, limiting access to critical care for patients.

If no one was on call… numerous scope of practice expansions that endanger public health could have become law, including removing all physician oversight of clinical nurse specialists; lay midwives seeking allowance of their attending home births without restriction or regulation; podiatrists seeking to amputate, do surgery and administer anesthesia up the distal third of the tibia; and marriage and family therapists seeking to be allowed to diagnose and treat mental disorders as well as removing the prohibition on their prescribing drugs.

If no one was on call… state boards and agencies with no authority over medicine could have been allowed to increase medical practice costs through additional licensing and reporting requirements.

If no one was on call… legislation dictating medical standards and guidelines for treatment of pregnant women, the elderly and terminal patients could have been placed into bills covering various topics.

Other Bills of Interest

Rural physician tax credits… legislation to increase rural physician tax credits and thereby increase access to care for rural Alabamians did not pass but will be reintroduced next session.

Infectious Disease Elimination… legislation to establish infectious disease elimination pilot programs to mitigate the spread of certain diseases failed to garner support on the last legislative day.

Constitutional amendment proclaiming the State of Alabama’s stance on the rights of unborn children… legislation passed to allow the people of Alabama to vote at the November 2018 General Election whether to add an amendment to the state constitution to:

“Declare and affirm that it is the public policy of this state to recognize and support the sanctity of unborn life and the rights of unborn children, most importantly the right to life in all manners and measures appropriate and lawful…”

If ratified by the people in November 2018, this Amendment could have implications for women’s health physicians.

Coverage of autism spectrum disorder therapies… legislation passed to require health plans to cover ASD therapies, with some restrictions.

Portable DNR for minors… legislation establishing a portable DNR for minors to allow minors with terminal diseases to attend school activities failed to garner enough votes to pass on the last legislative day.

If the Medical Association was not on call at the Alabama Legislature, countless bills expanding doctors’ liability, increasing physician taxes, and setting standards of care into law could have passed. At the same time, positive strides in public health — like passage of the direct primary care legislation — would not have occurred. The Medical Association is Alabama physicians’ greatest resource in advocating for the practice of medicine and the patients they serve.

Click here for a downloadable version of our 2017 Legislative Recap.

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New American Health Care Act Comes Under Fire

New American Health Care Act Comes Under Fire

Earlier this week, members of the House Energy and Commerce Committee released legislation as part of the House Republicans’ efforts to repeal and replace Obamacare. Although the legislation cleared its first hurdle with a lengthy, contentious markup session that began Wednesday, the House Ways and Means Committee approved the American Health Care Act. The House Energy and Commerce Committee continued debating the legislation well into Thursday. Many health care organizations are speaking out against the legislation.

In brief, the 123-page legislation proposes to:

  • Eliminate the Obamacare taxes on job creators, increased premium costs, and limited options for patients and health care providers.
  • Eliminate the individual and employer mandate penalties.
  • Prohibit health insurers from denying coverage or charging more to patients based on pre-existing conditions.
  • Help young adults access health insurance and stabilize the marketplace by allowing dependents to continue staying on their parents’ plan until they are 26.
  • Establish a Patient and State Stability Fund, which provides states with $100 billion to design programs that meet the unique needs of their patient populations and help low-income Americans afford health care.
  • Modernize and strengthen Medicaid by transitioning to a “per capita allotment” so states can better serve the patients most in need.
  • Empower individuals and families to spend their health care dollars the way they want and need by enhancing and expanding Health Savings Accounts (HSAs).
  • Help Americans access affordable, quality health care by providing a monthly tax credit for low- and middle-income individuals and families who don’t receive insurance through work or a government program.

Although Democrats and Republicans are beginning to speak against the bill, perhaps most critical of the legislation has been the American Medical Association, which issued a letter to congressional leaders stating that it cannot support the bill.

“While we agree that there are problems with the ACA that must be addressed, we cannot support the AHCA as drafted because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations,” it said.

AMA President Dr. Andrew Gurman introduced the letter on the AMA’s website by stating: “We all know that our health system is highly complex, but our core commitment to the patients most in need should be straightforward. As the AMA has previously stated, members of Congress must keep top of mind the potentially life-altering impact their policy decisions will have.”

Similarly, the American Nurses Association and the American Hospital Association have expressed strong opposition to the proposed American Health Care Act citing fundamental changes in Medicare and Medicaid, which the groups argue could limit access to care while “in no way improving care.”

“It appears that the effort to restructure the Medicaid program will have the effect of making significant reductions in a program that provides services to our most vulnerable populations,” wrote Richard Pollack, CEO and president of the American Hospital Association, in his letter to members of Congress.

The legislation does not yet have a score from the Congressional Budget Office, which could provide an estimate of the bill’s cost and impact on coverage levels. However, White House representatives have indicated a score will soon be released.

Other medical groups are expressing concern about the speed at which the bill appears to be moving.

“We are concerned that by rushing to a mark-up … in the Energy and Commerce and Ways and Means Committees, there will be insufficient time to obtain non-partisan estimates of this legislation’s impact by the Congressional Budget Office, or for medical organizations like ours and other key stakeholders in the health care community to offer substantive input on the bill,” the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Congress of Obstetricians and Gynecologists: and the American Osteopathic Association said in a joint statement.

Click here for a look at what the American Health Care Act would keep, change and/or repeal versus the ACA.

The Medical Association is closely monitoring the legislation.

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RCO Implementation On Schedule; New Regions Offered to Other Probationary RCOs

RCO Implementation On Schedule; New Regions Offered to Other Probationary RCOs

MONTGOMERY – The Alabama Medicaid Agency has been notified that Envolve, a wholly-owned subsidiary of Centene, is ending its agreement as a capital contributor with all five Alabama Healthcare Advantage (AHA) organizations that had planned to operate as Regional Care Organizations this fall.

Alabama Medicaid Commissioner Stephanie Azar said the AHA organizations have notified the Agency that they intend to end their pursuit of full certification, pending a final decision by the five regional boards in the upcoming days.

While the immediate result would be the loss of five probationary RCOs, the Agency is still in position to implement Regional Care Organizations by Oct. 1, 2017, under a 2013 state law that allows current probationary RCOs to provide services in additional regions, Commissioner Azar said.

The law requires the State to first offer existing probationary RCOs the opportunity to provide services in other regions if no RCOs are certified in a region. The withdrawal of AHA would leave Regions B, D and E without a certified RCO.  The Agency has implemented a process to offer the vacant regions to other probationary RCOS.

Two probationary RCOs have availed themselves of the process. Alabama Community Care – Region A and My Care Alabama have taken initial steps to qualify to offer services in these three regions. Both organizations are already probationary RCOs in the north Alabama region (Region A) and Alabama Community Care – Region C is also a probationary RCO in the western region of the state. Both have put in writing interest to provide services in Regions B, D, and E and are working closely with the Agency to accomplish this goal. As a result, the Agency has confidence the state can have at least one certified RCO in each of the regions by Oct. 1, 2017.

If for some reason no probationary RCO becomes fully certified and contracts to offer services in these regions, then state law allows the state to offer “alternative care providers” the opportunity to operate in those regions.

Gov. Robert Bentley emphasized that Regional Care Organizations represent the best plan to transform the Medicaid health care delivery system in Alabama.

“We will continue to move forward with our Regional Care Organizations, because we must have a delivery system for Medicaid that provides high-quality care, while working to reduce the cost of healthcare. In Alabama, we have already started engaging in conversations with President Trump and incoming Health and Human Services Secretary Tom Price. We are closely monitoring Congress as they work to repeal and replace the Affordable Care Act,” he said. “As the federal government works with states to help develop a plan, in Alabama, we will continue to support RCOs because we feel it’s the best plan for the state.”

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Alabama Medicaid Pushes RCO Start Date to October 2017

Alabama Medicaid Pushes RCO Start Date to October 2017

The State of Alabama’s shift to managed care has been long in the works, and it looks as though the wait will be a little longer before the regional care organizations will be officially operational, according to the Alabama Medicaid Agency.

While Gov. Robert Bentley has said repeatedly that he remains committed to moving forward with the RCO system, earlier this week he admitted that there are too many questions and not enough answers to allow the system to become effective this summer as originally planned.

“The election changed things, but I think long-term funding is the real issue,” Gov. Bentley said. “I believe a managed care system based on outcomes rather than on fee-for-service is the best way to go for our Medicaid patients.”

Alabama has been working since 2013 toward a managed care system that would shift some of the state’s 1 million Medicaid patients to care through the RCO system, ensuring patients receive check-ups and preventive care while limiting expensive ER visits later on.

Also earlier this week, Alabama Medicaid issued clarification regarding reimbursement by RCOs for services provided to RCO Enrollees by out-of-network providers. This guidance only applies to the populations and the services included in the RCOs. For a listing of the populations and services included in the RCO please visit the Medicaid website.

Posted in: Medicaid

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Opinion: All Americans Need Access to Affordable, Quality Care

meigsEditorial contributed by John Meigs Jr., M.D., president of the American Academy of Family Physicians, member of the Medical Association Board of Censors, and a family physician in Centreville, Ala. Editorial reprinted by permission.

Since Election Day, health care analysts have tried to forecast the fate of our health care system. Much remains uncertain, but what is undisputed is the goal that all Americans must be able to obtain affordable, high-quality and efficient health care. This must be at the center of any national health care strategy. That’s why America’s family doctors are starting this new year by encouraging the Trump administration and the 115th Congress to focus on this essential priority.

The American Academy of Family Physicians has long supported and advocated for meaningful patient-centered health care for all, an underlying tenet of many health care reform proposals, including the 2010 Affordable Care Act. We recognize that our current health care system is not perfect and new approaches can certainly improve the law. However, the nearly 200 million Americans who currently have health care coverage through the individual, small group and employer-based markets — as well as Medicaid — should not have their coverage and insurance protections jerked out from underneath them.

Within any changes, the overarching policy must ensure everyone has access to health care. Because America’s family doctors see more than half a million patients a day, we know what policies and programs ensure access to consistent, comprehensive and preventive care, particularly for low-income individuals and families. Financial barriers to care have crumbled as a result of Medicaid, the Children’s Health Insurance Program and Medicare. Medicaid and CHIP currently enroll nearly 73 million children and low-income Americans. Medicare preserves access to care for nearly 56 million elderly and disabled people. Equally important, patients who have privately purchased health insurance — particularly those with high-deductible plans — must not have to overcome financial obstacles to receive care.

Patient-centered care is at the heart of health care reform, which is why we must have a payment system that rewards the value of care over the volume of services provided. Our nation’s policy must build on the Medicare Access and CHIP Reauthorization Act — or MACRA — to ensure family physicians in all practice settings can continue to practice patient-centered care.

Our lawmakers also must commit to building a physician workforce that can meet the growing demand for primary care. They must support efforts to maintain a steady pipeline of primary care physicians through graduate medical education reforms and extension of the community-based Teaching Health Center program that attracts students to family medicine.

Health care is a personal matter, which is why primary care is the foundation of our health care system. Time and time again, primary care physicians have been counted on to provide care to millions of Americans from all parts of the country — for they have proven their expertise to improve health outcomes while lowering costs.

It is imperative that we have national health policies that ensure all Americans can sustain a continuous relationship with their primary care physicians. The only way we can do this is with legislation and regulations that ensure all Americans, regardless of health or financial status, can get needed health care in a timely, efficient, affordable and personalized manner. America’s family doctors pledge our support in helping to achieve this vision.

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RCO Implementation Changes and Service Delivery Network Timelines

RCO Implementation Changes and Service Delivery Network Timelines

The Alabama Medicaid Agency is working with Centers for Medicare and Medicaid Services to amend the approved 1115 waiver to allow for an Oct. 1, 2017, start date for the Regional Care Organization program.

The deadline for probationary RCOs to demonstrate the existence of an adequate service delivery network by submitting to Medicaid signed contracts from their network providers is Jan. 10, 2017. As probationary RCOs work to meet this service delivery network adequacy deadline, providers may be contacted by probationary RCOs with whom they are not currently contracted.

Information about RCOs, implementation or other aspects of this managed care program may be found on the Agency’s RCO webpage

Posted in: Medicaid

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Reading Gives You Wings with Marsha Raulerson, M.D.

Reading Gives You Wings with Marsha Raulerson, M.D.

BREWTON — According to Dr. Seuss in I Can Read with My Eyes Shut!, “The more that you read, the more things you will know. The more you learn, the more places you’ll go.” That’s a philosophy Brewton pediatrician Marsha Raulerson can easily get behind.

For more than 30 years, Dr. Raulerson has celebrated her young patients and encouraged their sense of adventure through reading by providing them with new books during their visits to her clinic. What began as the STARS program, or Steps to Achieve Reading Success, has for the past 20 years been affiliated with the National Reach Out and Read Program. Ten years ago, Dr. Raulerson, working with Polly McClure, launched the Alabama Chapter, American Academy of Pediatrics’ Reach Out and Read Alabama, that gives young children a foundation for success by incorporating books into pediatric care and encouraging families to read aloud together.

“We’ve given out truckloads of books to our patients,” Dr. Raulerson said. “I give a book to every child for every visit, no matter what the age of the child. My community probably contributes about $10,000 a year so we can buy new books because every patient can have a new book.”

In fact, no child who visits Dr. Raulerson’s clinic leaves empty handed. The books she chooses for her patients are not only age appropriate, but also story appropriate to each patient’s particular situation. The majority of her patients have special needs, and each book is intended to give her patients hope.

“I was a reading specialist before I went to medical school, and I would give books to my patients when I was a resident at the University of Florida. I’ve been giving books away since 1978, so my whole career, really. My feeling is that if you can read, you can do anything. I tell my patients that I majored in English in college, not science or math. But, when I went to medical school and had to take biology and chemistry, I could never have done that without the ability to read. If you can read, you can do anything you want!”

Dr. Raulerson laughed when she first realized how long she had been practicing in Brewton, and how many patients had come through her clinic. She shook her head and smiled an easy smile when she admitted that it didn’t initially dawn on her just how many generations of patients she had treated.

“I have grand-patients!” she laughed! “I have a lot of families of three generations of patients, and I remember them all. All my patients are so special to me, and they’ve all received so many books from the clinic. Now, when they tell me that those books helped to create a special bond with their children and grandchildren, that’s heartwarming.”

Given her years of advocacy for children, it’s difficult to imagine the landscape of medicine in Alabama without Dr. Raulerson, but she in fact very nearly did not get accepted into medical school. A native of Jacksonville, Fla., she took her qualifying exams for her doctorate when she ultimately settled on medical school. While she said she felt she was always meant to be a medical doctor, one person sealed the deal for her. Her name was Robbie.

Dr. Raulerson taught school to help put her husband through medical school, and then her husband was drafted and sent to Vietnam. While there, the Raulersons decided to adopt a Vietnamese child. When her husband found the youngest female child in the nursery of an orphanage, he knew this was their child. She was only a few weeks old. The Catholic priest agreed to the adoption to the Baptist couple, and Dr. Raulerson flew to Tokyo to meet her daughter, Robbie.

When Dr. Raulerson got home with Robbie, she was 5 months old and weighed only 8 lbs., was malnourished and very ill. She knew exactly what to do to take care of her daughter, but if any doubt was left as to whether she could be a physician, she wouldn’t doubt much longer. Dr. Raulerson said when she began applying to medical school, she knew the odds would not be in her favor. It was a time when there were not many women in the medical field, and she had a family. Every school she applied to turned her down, except one.

“I was accepted at Emory because of Robbie. They had a different way of interviewing at Emory. They would interview three applicants sitting at a long table. Each applicant was asked what was an event in your life that was really important. There was a football player at the end of the table that talked about being a quarterback. The other girl at the table talked about being homecoming queen. Then they asked me,” Dr. Raulerson paused. The story hanging in her throat fighting to get free. “I told them about when I saw my daughter for the first time. And, I got a telegram that night admitting me to Emory.”

Ironically, Dr. Raulerson transferred to one of the schools that initially rejected her application. Dr. Raulerson’s husband was already a standout fellow at the University of Florida, and his department petitioned the admissions committee to consider an applicant from Emory. She still laughs when she tells the story of being admitted to a school that initially rejected her because she had a family.

Many in Alabama haven’t had the pleasure of meeting this woman who loves to laugh and read to her patients. But after her work with the #IAmMedicaid social media campaign this spring, more people in the state definitely know her name. She estimates between 70 and 80 percent of her patients are Alabama Medicaid recipients, and many of the children in the campaign are her patients. In the end, BP oil money was partially used to reinstate the physician cut that was implemented on Aug. 1 and to shore up the embattled Medicaid budget. Still, according to Dr. Raulerson, it won’t be enough.

“That campaign had to work. It had no choice BUT to work,” she said. “Many of my patients’ families can’t pay their bills. We don’t have enough doctors now, so what happens when we can’t fund the ones who choose to stay? The system is broken.”

During the Regular and Special Legislative Sessions, Dr. Raulerson’s editorials about the importance of fully funding Alabama Medicaid appeared in many of the state’s newspapers. Although the Alabama Legislature is not in session today, there is still work that can, and should, be done, according to Dr. Raulerson.

Perhaps it’s because of her and her husband’s early struggles with starting their own family, or seeing so many of their patients live below the poverty level in Escambia County. Either way, as long as Dr. Raulerson can string together her outspoken words, the children of Alabama will always have another advocate.

“I’m doing a lot more writing now,” she explained. “I feel like I have to. An article I wrote in 1997 about the importance of fully funding Medicaid is just as important today as it was 20 years ago. Nothing has really changed in all that time other than the number of our patients on Medicaid. Something has to change. We have to change. We have to choose to support our kids.”

Dr. Raulerson is a past president of the Medical Association of the State of Alabama, the Alabama Chapter, American Academy of Pediatrics, and VOICES for Alabama’s Children. She is a board member of The Children’s First Foundation.

Posted in: Physicians Giving Back

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Primary Care Cut Restored; Physicians Must Re-Attest to Qualify

Primary Care Cut Restored; Physicians Must Re-Attest to Qualify

In a press conference Thursday, Sept. 22, Gov. Robert Bentley and Alabama Medicaid Commissioner Stephanie Azar announced that the primary care cut, which became effective Aug. 1, will be restored on Oct. 1. However, Medicaid-enrolled primary care physicians who qualify for the Primary Care Enhanced Physicians Rates must self-attest in order to continue to receive the payments. No dates have been set by Medicaid for the attestation process. Medicaid will be sending a notice out to providers shortly on how to re-attest.

To qualify for the reinstated bump beginning Oct. 1, physicians will need to re-attest and meet one of the following requirements:

  1. A physician must have a specialty or subspecialty designation in family medicine, general internal medicine, or pediatrics that is recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS), or the American Osteopathic Association (AOA), and they actually practice in their specialty.
  2. A NON-board certified physician who practices in the field of family medicine, general internal medicine, or pediatrics or a subspecialty under one of these specialties, is eligible if he/she can attest that 60 percent of their paid Medicaid procedures billed are for certain specified procedure codes for evaluation and management (E&M) services and certain Vaccines for Children (VFC) vaccine administration codes.

Alabama Medicaid: Primary Care Enhanced Physician Rates “Bump” Certification and Attestation Form

*Note: Practitioners (physician assistants or certified registered nurse practitioners) providing services under the personal supervision of eligible physicians may qualify.

When the cuts originally took effect on Aug. 1, they amounted to 30 to 40 percent of medical practice revenue, according to Executive Director Mark Jackson.

“Regardless of what kind of business you’re in, if you’re seeing cuts of 30 and 40 percent, it’s going to make a major impact on your bottom line,” Jackson said.

The restoration of the bump will also allow the state to continue to implement RCOs. This renewed funding should put the rollout of the RCOs on track by next July, according to Azar.

Posted in: Medicaid

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The New Capitated System: How Do Physicians Respond?

Doctor with female patient

Editor’s Note: This article was originally published in the 2015 Winter Issue of Alabama Medicine magazine

On May 17, 2013, Gov. Robert Bentley signed into law Act 2013-261, Ala. Code Sections 22-6-150 et seq., which changes the Alabama Medicaid System from a fee-for-service to a managed care program (the “Act”). This will dramatically change the way nearly 1 million Alabama Medicaid beneficiaries receive their care, and change the way providers are paid. The Alabama Medicaid Agency will allocate a fixed, capitated per-member per-month payment to newly formed regional care organizations (“RCOs”) in return for the RCOs providing health care services to the Medicaid beneficiaries assigned to the RCO. The RCOs will provide the health care services through physicians and other health care providers who enter into provider agreements with the RCOs.

Each RCO is required to establish a network of health care providers in order to deliver care to its enrollees. The network can include physicians, hospitals, pharmacies, podiatrists, chiropractors, psychologists, dentists, therapists, social workers, rural health clinics and other health care providers. RCOs do not have to directly contract with providers, but can also contract with a managed care organization that will contract with providers. Under the law, RCOs are required to contract with any willing physician, hospital or other provider to offer services to beneficiaries in the RCO region if the provider is willing to accept the same payment and contract terms offered by the RCO to other comparable providers.

RCOs can pay providers either on a fee-for-service basis or on a capitated basis. In addition, RCOs can implement value, performance and other payment methodologies. If a RCO decides to not credential a provider in its network, the RCO must give the provider written notice of the reason for its decision, and follow credentialing requirements set out in federal regulations.

There are now 11 organizations across the State of Alabama that have been granted probationary certification as Medicaid Regional Care Organizations or “RCO”s. Physicians have begun receiving notices from some of these RCOs asking them to return a letter of intent to participate in the RCO network of providers. RCOs must be able to demonstrate to the Medicaid Agency that they have an adequate provider network in place by April 1, 2015. The RCOs are now on a fast track to put together the Primary Care Networks, and will be sending provider contracts out later this year. This will be the time physicians and other providers will be negotiating with the RCOs for the best agreement they can get.

The letters of intent being sent out are non-binding on physicians, and merely acknowledge the physician is willing to negotiate with the RCO. However, the issuance of the letters of intent by the RCOs may trigger discussions among physicians that may have antitrust implications. While a physician who simply sends in a letter of intent is acting individually, and without antitrust issues, if that physician begins discussing with other physicians whether or not the physicians should send letters of intent, the physicians involved in the discussions may be deemed to be acting collectively, and antitrust issues arise.

Under antitrust laws, physicians are considered horizontal competitors who compete with each other for patients just as car dealers are horizontal competitors who compete for customers. Any distinction in the law for professions has long been abandoned. Violations of the antitrust laws carry very severe penalties including potential criminal prosecution, trebled damages and an award of the plaintiff’s attorney fees. The enormous legal fees involved in defending an antitrust investigation by the Department of Justice or the Federal Trade Commission alone can be devastating to a physician practice.

To protect physicians who negotiate with RCOs, the Act provides immunity from liability under the antitrust laws by putting these negotiations under an exemption to antitrust known as the “State Action Doctrine.” This doctrine is set forth by the U.S. Supreme Court and exempts actions of a state from application of the antitrust laws. To qualify for the exemption, the state must clearly articulate and express a state policy to exempt the anticompetitive conduct and then actively supervise the anticompetitive conduct. The most difficult prong of the two-part test to meet is the requirement of active state supervision. The Medical Association of the State of Alabama has worked with the officials and attorneys for the Medicaid Agency to give physicians the maximum protection possible from the potential violation of the antitrust laws. It will be up to individual physicians and other providers, however, to assure they understand and follow to the letter the Medicaid Regulations designed to allow the Medicaid Agency to supervise the collective negotiations. Failure to do so can remove the antitrust immunity provided by the Act and leave the physicians and other providers vulnerable to the sanctions of the antitrust laws.

If carefully followed, the Act and the Medicaid Regulations provide the necessary elements to exempt collective negotiations from antitrust liability. Before talking with other physicians about the pros and cons of contracting with a Medicaid RCO, physicians should apply through an online process to the Medicaid Agency for a Certificate to Collaborate (the “Certificate”). The electronic application is available at Once the application is approved, a Certificate will be issued which will allow for collective negotiation, bargaining, and cooperation regarding payment and health care delivery. Careful attention must be paid to the Medicaid Regulations to assure the Certificate to Collaborate continues in force. To satisfy the State Action Doctrine, it is required the active state supervision be continuous, so just getting the Certificate alone is not sufficient. The Medicaid Regulations provide for continual monitoring and supervision of the negotiation process. Physicians and other providers must have someone in their offices knowledgeable of the requirements, and carefully assuring that they are followed.

In addition, the State Action Doctrine immunity only applies to collective negotiations with regard to Medicaid. It does not immunize any collective actions regarding private insurance companies or health maintenance organizations. Care must be taken to assure that the negotiations are limited to Medicaid beneficiaries.

The Certificate is not necessary for physicians to attend informational sessions on the new system, but is necessary for physicians to discuss among themselves whether or not to participate or on what terms to participate.Now is the time for physicians to get their Certificates, as the provider contracts will be next on the agenda for the RCOs. In all likelihood, physicians in the different regions who jointly negotiate with the RCOs either solely as physicians or in collaboration with one or more hospitals will be in

Now is the time for physicians to get their Certificates, as the provider contracts will be next on the agenda for the RCOs. In all likelihood, physicians in the different regions who jointly negotiate with the RCOs either solely as physicians or in collaboration with one or more hospitals will be in position to get better contracts than those who individually negotiate. The antitrust immunities in the Act give physicians and other providers greater ability to join together in new organizations to negotiate with RCOs and provide care to their enrollees.

Independent Practice Associations (“IPAs”), Preferred Provider Organizations (“PPOs”) and Physician Hospital Organizations (“PHOs”) are examples of the types of entities that will regain popularity in the development of the new provider networks. With the antitrust immunities furnished by the Act IPAs, PPOs and PHOs, as well as other entities, will be effective means for physicians and other providers to join together collectively and negotiate with RCOs. IPAs are entities in which physicians can integrate either partially or fully their practices into a separate entity that will negotiate with the RCOs and actually provide the care to enrollees of the RCO. PPOs are entities physicians can form to negotiate with RCOs for fees to be paid to the physicians but do not provide the care to enrollees. Care is provided through the individual medical practices. PHOs separate entities formed by hospitals and members of their medical staffs to negotiate and provide both hospital and physician services to enrollees.

The Act is changing the landscape for the provision of health care services for Medicaid beneficiaries. Other articles will deal with topics to help physicians negotiate the changes, including terms to carefully consider in signing provider contracts. Needless to say, as the time grows closer, physicians and other providers will be discussing options and strategies for responding to the changes.

bronzemvpArticle contributed by John T. Mooresmith, Esq., Burr Forman, LLP. Burr Forman, LLP, is an official Bronze Partner of the Medical Association.


Posted in: Legal Watch

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Physician Groups Issue Joint Statement on Medicaid Funding Cuts

Physician Groups Issue Joint Statement on Medicaid Funding Cuts

April 8, 2016 | MONTGOMERY – Without Fully Funding Medicaid, Patient Care at Risk

With the passing of the General Fund budget, lawmakers appropriated $700 million for Medicaid next year, $85 million short of what is needed to fully fund Medicaid. Now the Medicaid Agency is left with the tough decisions of which programs to cut, and how deep to reach into the pockets of Alabama’s citizens who can already barely afford their medications and health treatments. Services at risk of being cut are prescription drug coverage for adults, eyeglasses for adults, outpatient dialysis, prosthetics and orthotics, hearing programs, Program of All Inclusive Care for the Elderly (PACE), among other programs and services that patients across Alabama need to survive.

Medicaid is a critical component of our health care system, covering the young and elderly. More than half the births in Alabama and 47 percent of our children are covered by Medicaid, as well as 60 percent of Alabama’s nursing home residents. Without full funding, the Medicaid program will collapse, leaving these individuals without coverage. While uncompensated care is delivered every day in all 67 counties of this state, without Medicaid, charity care needs could skyrocket, crippling the health care delivery system and potentially placing the burden on those with private health insurance through higher premiums and co-pays.

Alabama Medicaid is the backbone of our state, supporting the health and welfare of the young and elderly citizens that physicians have pledged to protect during their medical careers. Consequently, we cannot support any solution other than fully funding a program that touches so many lives. Allowing Alabama Medicaid to continue with adequate funding is a smart investment in Alabama and her citizens. The current appropriated budget will have dire consequences.

Physician practices, hospitals and nursing homes are among the economic engines driving many Alabama communities. Closure of these health care providers will have a devastating impact on the state of Alabama and the health and prosperity of its citizens. The ripple effect will be felt from Mobile to Huntsville.

Therefore we call on the legislature and the Governor to work toward a permanent revenue solution to fully fund Medicaid.

Our organizations strongly believe that Medicaid matters … to all Alabamians.

For more information or comment, please contact:

Mark Jackson, Medical Association of the State of Alabama, (334) 954-2500
Linda Lee, Alabama Chapter, American Academy of Pediatrics, (334) 954-2543
Jeff Arrington, Alabama Academy of Family Physicians, (334) 954-2570

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