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1. Healthy Families Facing Minimum 6 Month Enrollment Freeze
Healthy Families, a program that provides affordable health insurance for more than 900,000 California children, is considering closing its doors to new enrollees next month. Faced with a $17.2 million shortfall, the Managed Risk Medical Insurance Board (MRMIB) – which oversees Health Families – has recommended indefinitely wait-listing all children who apply for Healthy Families coverage beginning December 18.
Healthy Families provides medical, dental, and vision care to children whose families earn too much to receive Medi-Cal but can’t afford private insurance. With health care costs continuing to climb and more working families facing economic hardship, enrollment in the low-cost health insurance program is at an all-time high, with more than 27,000 new enrollees every month.
CMA testified at a public hearing on the potential enrollment freeze last week, telling MRMIB that wait-listing eligible children will ultimately cost the state more as working families postpone treatment and seek care for their uninsured children in emergency rooms.
MRMIB will decide on December 17 whether to freeze enrollment; and if they do it would take effect the next day. The freeze would likely stay in effect until at least June 30, 2009. Physicians are encouraged to inform eligible families of the possible enrollment freeze and urge them to enroll eligible children before December 18.
If MRMIB approves the enrollment freeze, as many as 162,000 eligible children could be denied Healthy Families coverage from December 18 to June 30, which is when the board is scheduled to meet and discuss its 2009-2010 budget.
CMA has been active in the fight to support Healthy Families at the state and national levels. CMA continues to lobby Congress to support reauthorization of the federal State Children’s Health Insurance Program (SCHIP), which provides California $2 for every $1 it spends on the Healthy Families program. SCHIP is facing reauthorization next year. CMA has also joined with a coalition of other provider and patient groups to advocate for continued support for this invaluable program.
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Contact: Dave Ford, 916/444-5532 or dford@cmanet.org.
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2. Survey Finds Widespread Dissatisfaction Among Primary Care
Physicians; Predicts Massive Shortfall by 2025
The United States faces a shortage of 35,000 to 40,000 primary care physicians by 2025, according to a recent survey of more than 12,000 primary care physicians. The survey was conducted by Physicians’ Foundation for Health Systems Excellence, which was founded in 2003 and funded by more than $100 million from CMA’s successful racketeering lawsuit against some of the nation’s largest for-profit HMOs.
The survey depicts widespread frustration and concern among primary care physicians nationwide. Forty-nine percent of them say that over the next three years they plan to reduce the number of patients they see or stop practicing entirely. The reported reasons for the frustration include increased time dealing with nonclinical paperwork, difficulty receiving reimbursement, and burdensome government regulations. Physicians say these issues keep them from the most satisfying aspect of their job: taking care of their patients.
The Physicians’ Foundation believes the future of primary care could have a
significant impact on the American health care debate.
“At a time when the new Administration and new Congress are talking about ways to expand access to health care, the harsh reality is that there might not be enough doctors to handle the increased number of people who might want to see them if they get health insurance,” says Walker Ray, MD, vice president of the Physicians’ Foundation.
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3. Medi-Cal Update
In September, CMA successfully sought an injunction against the 10 percent Medi-Cal provider rate cut. Recently, the 9th Circuit Court of Appeals denied the state’s request for a hearing on the issue of standing, a threshold issue critical to CMA’s ability to pursue our request for an injunction. This ruling preserves the injunction against the cuts. CMA is currently preparing briefs to address the state’s separate appeal to the 9th Circuit on the injunction itself. We expect a hearing on this appeal sometime in early 2009.
The Department of Health Care Services, which oversees the Medi-Cal program, has indicated that it will apply the injunction against the 10 percent cuts to both fee-for-service Medi-Cal and physician services under Medi-Cal managed care. The CMA-won injunction saved California physicians roughly $64 million this fiscal year on the fee-for-service side alone. The injunction will also generate millions of dollars in additional savings for physicians who see Medi-Cal managed care patients.
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4.
Family PACT Waiver Deadline Extended to November 30
As we reported last month in CMA Alert, California is at risk of losing federal funding for its Family PACT Program if it cannot reach an agreement with the Centers for Medicare and Medicaid Services (CMS) officials over eligibility verification for the program.
Family PACT, which provides provide comprehensive family planning services and preventive health screenings to eligible low income men and women, has operated since 1999 under a Medicaid waiver that was set to expire last month. Without the waiver, the state will lose more than $300 million in federal matching funds and many low-income women will lose access to these vital health care services.
CMS has extended the deadline and given the state until November 30 to sign a letter confirming its intent to comply with the new eligibility requirements. CMS has also agreed to give the state 18 months to come into compliance. State officials are still considering their options.
CMA believes that the burdensome new rules will discourage low-income women from seeking family planning and prenatal care, ultimately increasing the costs to the state and federal government.
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Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
5. Court Weighs CMA Lawsuit Against Balance Billing Regulation
On November 21, a state court in Sacramento heard CMA’s legal challenge of the Department of Managed Health Care (DMHC) regulation that defines “balance billing” as an unfair billing pattern. CMA filed the lawsuit—which seeks to invalidate and stop enforcement of this regulation—with a coalition of organizations representing other health care providers, including hospitals, ER doctors, anesthesiologists, radiologists, and orthopaedists.
At the hearing, CMA’s attorneys argued that DMHC lacks the authority to pass or enforce the regulation. DMHC argued it does have the authority to pass the regulation and indicated that it will take enforcement actions against providers who “balance bill” patients. CMA believes that even if the court ultimately decides that DMHC can define balance billing as an unfair billing pattern, DMHC lacks the authority to take enforcement actions against providers.
Prior to the hearing, the court issued a tentative ruling finding that DMHC has the authority to define “balance billing” as an unfair billing pattern. This ruling is only tentative, pending the issuance of the judge’s official ruling, which will be made within 90 days of the hearing. Until we receive a final ruling from the judge, the regulation – which took effect on October 15 – is still in effect.
If the judge maintains this opinion in his final ruling, the CMA-led coalition plans to appeal and take any other action necessary to bar DMHC from taking enforcement action based on the regulation.
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Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet.org.
6. Deadline to Request CPPI Quality Data is December 5
Over the last month, some 20,000 California physicians received letters from the California Physician Performance Initiative (CPPI). These letters contain raw and relative performance scores for physicians on 15 quality measures based on claims data from Medicare and United Health, Blue Cross, and Blue Shield PPOs. The letters do not contain the underlying data.
CMA has serious concerns about the accuracy and integrity of the data used to establish these scores and the potential use of these scores or these metrics by payors to do pay-for-performance or create tiered networks. In order to address CMA concerns and to improve the quality of the data, CPPI has created a reconsideration process that physicians should use to verify the data.
CMA urges all physicians to request their data from CPPI and verify its accuracy. We understand that this may be a time-consuming process, but it is critical for physicians to take the time to verify their data. If you do not raise concerns now, payors will use this data in the future to adjust your reimbursements and change the flow of patients to your practice.
CMA also asks that you share any corrections or concerns about the data with us. (Please do not send any patient information covered by HIPAA.)
Step by step instructions on obtaining and reviewing your patient data is available at http://www.cmanet.org/cppi. Once you have completed the reconsideration process, please also take CMA’s online survey, also at http://www.cmanet.org/cppi, to tell us what, if anything, was wrong about your performance scores.
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Contact: CMA member help line, 800/786-4CMA (4262).
7. Highlights from AMA Interim Meeting
The California delegation to AMA’s House of Delegates presented a number of important resolutions at the association’s interim meeting in Orlando earlier this month. Summaries of the California resolutions that the AMA House adopted as policy are available here.
8. Member Benefit of the Week: Magazine Discount Program
The CMA Magazine Program gives members up to 50 percent off subscriptions to hundreds of popular magazines. The same low rates apply to new subscriptions and renewals. Renewals with the discount are available no matter how your subscriptions were originally ordered. If you find a lower valid advertised price for any magazine offered through this program, simply send in the promotional offer with your order and pay the lower amount. Subscriptions for both office and personal use are available through this membership program.
Click here for more information on your membership benefits.
Contact: CMA’s member help line, 800/786-4CMA or vsatt@cmanet.org.
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