The Centers for Medicare & Medicaid Services’ (CMS) first attempt since 2002 to modernize Medicaid reimbursement and other policies could benefit rheumatologists.
The proposed rule would update the “current regulatory framework to reflect the maturity and prevalence of Medicaid managed care delivery systems, promote processes for ensuring access to care and align, where feasible, private and public healthcare coverage programs.”1
However, the rule doesn’t go far enough to address the growing issues of access to care that beneficiaries face in rural America, according to a Washington, D.C. rheumatologist.
Angus Worthing, MD, a member of the ACR’s Government Affairs Committee and chair of the Rheumatism Society of the District of Columbia’s Public Policy Education Committee, says the proposed rule likely doesn’t “have the teeth to ensure” access for Medicaid beneficiaries.
“Health plans will need to certify the adequacy of provider networks every year, and states must ensure that all services are available to beneficiaries,” says Dr. Worthing, who has practiced since 2008 with Arthritis & Rheumatism Associates in Washington, D.C., and Chevy Chase, Md. “Theoretically, both the MCOs [managed care organizations] and the states would be accountable for ensuring access to care, but the specific standards by which these would be judged are not yet known. If changes work, it would be particularly helpful for specialties with shortages, such as rheumatology and especially pediatric rheumatology.”
If enacted, the measures of the proposed rule could help reduce administrative burdens for rheumatologists participating in both Medicaid and Medicare Advantage, Dr. Worthing says. He adds that if rheumatologists are allowed to coordinate such care as referrals, they may “find it easier to get needed diagnostic studies and consults for their rheumatology patients.”
The changes also might “encourage” states to recruit rheumatologists who currently don’t participate in Medicaid.
“This would likely require increased reimbursement, however, and the proposed rule does not include more funding,” he says. “Overall, this could increase access to rheumatologic care and treatment, but it remains to be seen how the states and the District of Columbia will respond.”
Richard Quinn is a freelance author in New Jersey.
References
- Centers for Medicare & Medicaid Services. Medicaid and children’s health insurance program (CHIP) programs; Medicaid managed care, CHIP delivered in managed care, medicaid and CHIP comprehensive quality strategies, and revisions related to third party liability. 1 June 2015.
