Tag: Providers

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Turns out they didn’t just do what the consultants said. Still increased the provider payments by $88M (but of course providers say that’s still not enough).

 
 

Clipped from: https://billingsgazette.com/lifestyles/health-med-fit/amendment-to-fund-medicaid-provider-rates-to-benchmark-fails/article_b08add74-c289-11ed-8ea0-bba0b8bc9b2a.html

An amendment to further increase Medicaid provider reimbursement rates failed in a 13 to 10 vote Tuesday before the House Appropriations Committee.

Carried by Rep. John Fitzpatrick, R-Anaconda, the amendment would have brought provider rates in line with the benchmarks suggested by Guidehouse, the team commissioned by the state to assess reimbursement falls short in four essential human services departments.

The amendment also added a 3% inflationary increase for each year between 2021 and 2024. An additional 3% increase would have covered 2025.

“The concern I have with this issue is that we’re making a big bet. And the bet is this: we’ve either provided them with enough money so that they can continue on and go through the next biennium and survive. Or two, we’ve short changed them and we’re going to lose service providers,” Fitzpatrick said.

Over the last two years, providers serving a large population of Medicaid recipients reported a 14% increase to their expenditures, much greater than the typical 2% inflation seen in a typical biennium, Fitzpatrick said.

Inflation, provider shortages and wage pressures have pushed services to the brink of closure in the years since the pandemic.

Perhaps the most significant being the 11 nursing homes that closed in 2022. The sudden decrease in skilled nursing beds has created a bottleneck in Montana’s hospital systems, creating a significant financial burden.

Rep. Bob Keenan, R-Bigfork, defended the work done in the Human Services Subcommittee where legislators voted to increase provider rates from the governor’s proposed budget, but did not opt to fully fund rates to the benchmarks.

“We had an opportunity this session to help (with the traditionally low reimbursement rates) and I was pretty excited about it because it’s been fairly lonely trying to advocate for these providers across the state,” Keenan said. “…I resist this amendment just for the simple fact that I’m really proud of what our subcommittee has done at this point in time,” Keenan said.

With the subcommittee’s budget vote, $87.5 million is directed to provider rates. With the Medicaid match, that amounts to $305 million directed into the Medicaid system.

Benchmark rates ‘foundational’

While the infusion of cash marks a historic budgetary increase for these Medicaid providers, dozens of leaders representing organizations for SUD treatment, children and adult behavioral health, nursing homes, in-home care providers, aging services, developmental disabilities, and more encouraged lawmakers to bring reimbursement in line with the benchmark rates.

“Funding these rates is not a fix for everything but it really is foundational. It’s what needs to happen first before we can begin to make a lot of those other fixes within the system,” said Erin McGowan, who spoke in support of fully funding the benchmark rates at an appropriations committee meeting last Thursday. McGowan is a lobbyist for various provider groups across the state including Homecare Montana and Confluence Public Health.

What’s missing from the subcommittee’s budget, said McGowan, is a regular cost of living adjustment that would prevent future underfunding of these services.

Many of the services included in the rate study are highly sensitive to inflation. Group home providers, for example, provide food and transportation to residents. When grocery and gas prices go up, so do the group home’s expenses.

Joshua Kendrick, CEO of Opportunity Montana, said that the rate increase would equate to a wage increase for staff.

Many who spoke during public comment explained that the staffing shortages are, in part, due to the inability to offer a competitive wage to current and future employees who could make better money working in food service.

Over the course of the pandemic, Youth Dynamics, which provides mental and behavioral health services for kids, lost 56 full-time employees and 83 part-time employees, said Dennis Sulser who represented the organization at the hearing.

Since July 1, 2022, 43% of the employees who provided a reason for their departure from Youth Dynamics said it was due to low wage or better job opportunities elsewhere, according to Sulser.

Countless providers expressed to lawmakers that the benchmark rate would just barely bring reimbursement rates up to their current costs.

Nonetheless, health department director Charlie Brereton, again pushed for the governor’s initial budget proposal in the Thursday meeting. The proposal mostly consists of one-time-only funding that would close 58% of the gap between current rates and the benchmark in 2024. In 2025, the rates would decrease, covering only 36% of the gap in 2025.

Brereton said the proposal centered on being responsive.

In an effort to address questions about not fully funding the benchmark rate, Brereton read a statement.

“The benchmark is average costs and reflects a wide array of provider practices. The average costs are important in identifying the accuracy of a rate but ultimately reflect an average of the costs. It’s a compass that shows where we should be headed, but not necessarily a minimum of what is needed to stabilize any provider type,” Brereton said.

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: How much of a rate increase is needed to deal with nursing facility challenges in PA? The answer is not 17%.

 
 

 
 

Clipped from: https://www.mcknights.com/news/despite-major-medicaid-boost-lack-of-staff-still-limits-nursing-home-admissions/

 
 

Tine Hansen-Turton, president and CEO of the Woods in Pennsylvania, discusses workforce solutions at a summit Tuesday. Credit: PHCA

Months after a 17% Medicaid increase kicked in, hundreds of Pennsylvania nursing home beds remain empty because facilities can’t hire enough staff to provide care, a new survey finds.

The Pennsylvania Health Care Association released its 2023 State of Nursing Facilities Report Tuesday showing that 57% of responding members have beds they cannot fill due to a lack of staff.

Thirty-one percent of respondents said they have 21 or more direct care positions open but cannot find certified nurse aides, licensed practical nurses or registered nurses to fill them.

The association held a Long-Term Care Policy Summit Tuesday in the state capital to bring together lawmakers, providers and others to brainstorm and share workforce solutions.

The PHCA survey showed:

• The average facility denied 17 admissions because of a lack of staff between November 2022 and February 2023.
  
• 81% of respondents are using staffing agencies to fill open positions.
  
• 93% of respondents anticipate either needing to use or increasing their use of agency
  
• Facility labor costs increased an average of 20% from 2019 to 2022.
  
• 93% of respondents anticipate either needing to use or increasing their use of agency workers to meet the new state staffing minimum that will begin in July.
  

In related news, LeadingAge Pennsylvania on Wednesday sent a letter to US Sen. Bob Casey Jr. (D-PA) outlining members’ concerns about the looming federal staffing requirement.

“We must recognize that providers are in crisis and residents’ access to care is at risk, due in large part to historic underfunding and a workforce crisis that predated the pandemic,” wrote President and CEO Garry Pezzano. “As we get back on our feet after the pandemic, we need to [give] common sense approaches a chance to make an impact before jumping to arbitrary staffing mandates on a national level. Common themes worthy of support include efficient and accessible training and competency programs, workforce immigration pipelines, faster turnaround times for staff licensing and test center coordination, and developing and incentivizing modern career pathways.”

New resources haven’t turned tide yet

Pennsylvania increased its Medicaid reimbursement rates by 17.5% last year after nearly a decade with little to no increases. That boosted rates by approximately $35 per resident per day. Association President and CEO Zach Shamberg said survey respondents “overwhelmingly” plan to use those extra funds to recruit and retain staff.

Despite that, nursing homes in the state continue to struggle.

“The problem is, we’ve made a promise to [aging] Pennsylvanians that we will care for them and that care, the availability of that care, and the accessibility to that care is very much at jeopardy today,” Shamberg said in opening remarks at the summit. “There are providers … who are having real difficulty keeping that promise.”

Pennsylvania has relied heavily on temporary nurse aides during the pandemic, giving frontline staff key training opportunities even as the state saw significant certification delays.

Joseph DeMattos, president and CEO of Health Facilities Association of Maryland, also attending the summit and said the tens of thousands of temporary nurse aides in his state during the pandemic played an “incredibly critical role” in caring for residents.

Shamberg said Pennsylvania facilities that used temporary aides each converted an average of eight into full time CNAs over the last few months, which has resulted in approximately 4,500 new, full-time workers.

But Centers for Medicare & Medicaid Services TNA waivers in all remaining states expire along with the public health emergency on May 11.

“The pandemic may be over but if we don’t get on the right track — if we don’t start addressing this today, then the challenges will be long lasting,” Shamberg said, noting that the association plans to make approval of nursing home medication aides a legislative priority this year.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: The legislature decided to just do exactly what the consultants said this time.

 
 

Clipped from: https://dailymontanan.com/2023/03/01/house-human-services-advances-bill-to-fully-fund-medicaid-rates-in-guidehouse-study/

 
 

The House Human Services Committee on Tuesday passed a bill to fully fund Medicaid reimbursement rates recommended in an in-depth study by a national consultant — plus the cost of inflation.

House Bill 649 passed 17-4 with bipartisan support following a lengthy hearing Friday where an onslaught of providers from across the health care and medical community spoke in support.

Levi Anderson, with the Western Montana Mental Health Center, said he had just sent a letter one week earlier notifying partners across the state the center was closing 31 community-based mental health crisis stabilization beds, which represent 65% of state capacity.

“That is a direct result of a lack of funding for those services,” Anderson said.

At the meeting Tuesday, Rep. SJ Howell, D-Missoula, said all the other bills the committee would deal with rest on HB 649. In other words, if legislators are to truly address the continuum of care, they need to address “deeply underfunded providers.”

“I think this might be the most important bill this committee is going to grapple with this session,” Howell said.

Howell joined all other Democrats on the committee and a majority of Republicans in voting in favor of the bill, sponsored by Rep. Mary Caferro, D-Helena.

“It is critical that we fully fund healthcare services before another nursing home closes and more Montanans are left to sleep the night in their wheelchairs,” Caferro said in an email Wednesday. “We have the data that proves Medicaid providers are underpaid. We have the money. Let’s solve the problem.”

The bill notes inadequate rates have resulted in the closure of 11 nursing homes and loss of 857 skilled nursing facility beds in the state. It is expected to be on the House floor Thursday.

In the last session, the legislature authorized the Department of Public Health and Human Services to spend $2.75 million to pay for an analysis of provider rates in the state.

The review by national consulting firm Guidehouse showed Montana was underfunding businesses that provide support and services for people who rely on Medicaid.

Republican Gov. Greg Gianforte proposed an increase to reimbursement rates, and a legislative subcommittee approved even higher rates.

Pointing to estimates from the Health Department that showed the work the subcommittee did pushed many rates close to 100% of the recommended benchmarks, Chair Rep. Bob Keenan, R-Bigfork, said, “I think we’ve solved the problem.”

At the hearing on HB 649, Caferro, a member of the subcommittee, agreed the group worked hard and got close to benchmarks — “but not quite.” She and other sponsors proposed to close the rest of the gap.

“If we don’t fully fund the Medicaid rate, then we will continue to see a decline in people’s health and well-being to the point of death,” Caferro said.

She pointed to one woman with Alzheimer’s who had been moved to three different nursing homes because of closures and couldn’t be with loved ones: “Well, then that lady passed away.”

Caferro characterized the effects of underfunding in Montana as “tragic and unnecessary.”

She pointed to waiting lists for in-home care for seniors, for children and adults who have physical disabilities, and for children and adults who have developmental disabilities. She said community crisis centers are sitting empty and children are being sent out of state for care.

“Medicaid provides health care in every corner of the state and all parts in between,” she said. “The problem is we are running out of providers due to a long history of underfunding.”

The bill would cost $12 million a year in state funding, she said. It would translate into more money for services because the federal government matches the money the state contributes.

Caferro earlier estimated the match as at least $3 of federal money to $1 of Montana money, and in some cases as much as $9 in federal money: “It’s a good bang for the buck.”

At the hearing, she said the estimated $2.5 billion surplus includes at least $150 million saved by the state because of an enhanced federal Medicaid match, and she believes that portion should go to fund services.

In response to a question at the hearing, Mary Windecker, with the Behavioral Health Alliance of Montana, said the last couple of years, more and more people have been leaving the health care industry in the wake of rising housing costs and inflation.

Vacancies are hitting 20% to 30% across all the sectors that were studied, she said.

“We do believe that there are people out there who would very much love to work in the industry again, but they have to be able to put a roof over their head and food on the table,” Windecker said.

Caferro said those people should not be asked to sacrifice their own economic well-being. She also said she appreciated the support for health care initiatives from a wide spectrum of groups.

“I’ve never been in a legislative session where the human service issues have been so prominent, and the sponsors and people bringing the issues are so diverse, and that makes me really happy,” Caferro said.

Proponents for her bill included representatives from the Montana Medical Association, the Montana Hospital Association, St. John’s United retirement community, the Human Resource Development Councils, the Montana Association of Counties, the Montana Coalition to Solve Homelessness, the Behavioral Health Alliance of Montana, the Centers for Independent Living, the Montana Health Care Association, Montana Women Vote, and many others.

Before approving the bill, the committee adopted an amendment that Rep. Laura Smith, D-Helena, said aligned Caferro’s bill with House Bill 2, the big budget bill.

Rep. Alice Buckley, D-Bozeman, said the bill offered legislators the opportunity to support their constituents and communities across the state.

“We were elected here to do the people’s work,” Buckley said.

In addition to Howell, Smith and Buckley, the following Democratic representatives voted “yes” on HB 649: Donavon Hawk of Butte; Ed Stafman of Bozeman; Minority Leader Kim Abbott of Helena; and Zooey Zephyr of Missoula.

The following Republican representatives also supported the bill: Lola Sheldon-Galloway, of Great Falls; Jodee Etchart of Billings; George Nikolakakos of Great Falls; Tom Welch of Dillon; Gregory Frazer of Deer Lodge; Mike Yakawich of Billings; Wayne Rusk of Corvallis; Greg Oblander of Billings; Ed Buttrey of Great Falls; and Jennifer Carlson of Churchill.

Voting “no” were Republican representatives Amy Regier of Kalispell, Caleb Hinkle of Belgrade, Ron Marshall of Hamilton, and Nelly Nicol of Billings.

Daily Montanan reporter Nicole Girten contributed to this story.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A local university is willing to foot the state’s share of the bill.

 
 

Clipped from: https://stateofreform.com/featured/2023/01/utah-bill-proposes-expanding-dental-care-coverage-to-adults-under-medicaid/

 
 

Senate Bill 19, a measure that would extend dental benefits under Medicaid to adults 21 years of age and older, advanced to the House after passage in the Senate by a vote of 19 to 0 with 10 abstentions Monday. 

 
 

 
 

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Sponsored by Sen. Evan Vickers (R – Cedar City), the measure passed with bi-partisan support and has the backing of the Utah Dental Association (UDA). 

Under current state law, only members who are pregnant, disabled, blind, age 65 or older, enrolled in Targeted Adult Medicaid (TAM) receiving treatment for substance use disorder, or children receiving Early Periodic Screening, Diagnostic and Treatment (EPSDT) have access to dental benefits through Medicaid. 

In partnership with the Utah Department of Health and Human Services (DHHS), the University of Utah School of Dentistry (UUSOD) administers dental care to these individuals through the school’s clinics and affiliated providers in over 150 locations throughout the state. 

“Back in 2008, the state eliminated all dental benefits for adults and the University of Utah School of Dentistry subsequently went to the legislature and said we’d like to partner and provide this care, and there are federal programs available that allow for that,” said James H. Bekker, Associate Dean for Professional and Community Partnerships at UUSOD. 

“The School of Dentistry participates in creating that pathway. And so we opened up gradually to first the TAM patients that have substance abuse disorder and then we added to that blind and disabled patients. And then we added to that elderly. So it’s just been something that’s happened gradually and we’ve been able to do well.”

SB 19 would allow the state to pursue federal Medicaid waivers that extend dental care to all adults 21 years of age and over who are eligible for Medicaid. The bill, like previous ones that expanded dental coverage eligibility, contains a zero fiscal note because UUSOD pays the state’s portion to receive federal matching funds to provide care. 

Should SB 19 pass, the number of Medicaid members eligible for dental coverage could grow from 70,000 to over 200,000, according to UUSOD estimates. 

“This program allows [dentists] to see the patients and be compensated at a much better rate,” Bekker said. “It’s clear that with [currently eligible] Medicaid patients, that’s about 70,000 patients throughout the state, the School of Dentistry can’t possibly see all those patients at our clinics.

And so we have created an associated provider opportunity so any dentist in the state of Utah can become associated with the School of Dentistry and thereby treat these populations in their own office. They bill directly to Medicaid, they’re reimbursed directly [by] Medicaid. It’s just that association that they need with a state entity in order to be able to qualify.”

As the legislative liaison to the UDA and its past president, Bekker says dentists in the state are supporting the proposal. 

General dentists had previously been reluctant to join the program and serve Medicaid patients because of low reimbursements rates, Becker noted. He has been working to change the perception that Medicaid does not pay adequately and recruit more dentists to participate and meet the potentially increased demand. 

“We’re doing what we can to educate dentists out there to understand that it’s different than it was,” Bekker said. “The compensation rates are better and this is a wonderful opportunity to enhance your practice and provide care to underserved populations.”

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: More NY nursing homes are closing beds unless they get their 20% bump this year.

 
 

Clipped from: https://www.mcknights.com/news/without-20-percent-medicaid-boost-states-providers-say-bed-reductions-will-continue/

 
 

 
 

New York state nursing home advocates want a 20% Medicaid boost to pay rates, a demand struggling for traction while the governor’s budget framework puts money into home-based care instead. 

The demand was delivered officially to Gov. Kathy Hochul (D) Friday in a letter signed by the heads of five organizations representing nursing home providers and healthcare workers. Her budget proposal is scheduled to be released Wednesday. Without changes, more beds will be taken out of service and some facilities could close, providers warned.

“New York has underfunded nursing home care for the last 15 years,” said Stephen B. Hanse, president and CEO of New York State Health Facilities Association/New York State Center for Assisted Living, adding that New York was the only state to cut Medicaid to nursing homes during the pandemic.

Hanse’s organization represents 400 skilled nursing providers whose more than 60,000 employees care for more than 65,000 nursing home residents and assisted living clients. 

The statewide average Medicaid reimbursement is $211 per resident per day, Hanse said. Divide that by the 24-hour care that is required and it equates to the state paying providers $8.79 per hour to care for each resident, he noted in an email to McKnights Long-Term Care News.

“This is unacceptable … and is a driving factor why New York has a long-term care staffing crisis as nursing homes cannot compete in the labor market for desperately needed workers,” he explained. 

In addition to Hanse’s group, the letter was signed by: LeadingAge New York; Greater New York Health Care Facilities Association; 1199 SEIU, United Healthcare Workers East; and Southern New York Association Inc., which represents more than 60 nursing homes encompassing 16,000 beds in southern New York, Westchester, and Long Island.

New York requires nursing homes to provide a minimum of 3.5 hours of care per resident per day. Facilities are also required to spend at least 70% of revenue on resident care with 40% of that amount patient facing. 

In 2021, New York gave a Medicaid boost of 1%, but operating costs have surged 42%, according to the Alliance for Senior Care. A letter to the editor in the Rochester Beacon from the seven members of that group said that more than 6,700 beds in the state are “off-line” and coalition members in western New York are limiting admissions due to staffing challenges. The head of Gurwin Healthcare System told Spectrum News that its two nursing homes, which operate a total of 580 beds on Long Island, are similarly limiting admissions and “temporarily closing beds.”

Hochul’s budget priorities released earlier this month did not include any mention of a Medicaid increase for long-term care, instead making investments into teams that would care for low-income adults in their homes, reported WSHU. A Hochul spokesman said the governor is “committed to ensuring that all New Yorkers can age with dignity and independence in the community of their choosing.” 

Hanse and other nursing home advocates will be ready to scour the budget to see what kind of legislative fight they will have on their hands.

“Home-based care is not an alternative to skilled nursing care, given the fact that residents of nursing homes are unable to be cared for in the community given their acuity levels and co-morbidities,” Hanse said.

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: NY NH providers say they have a 42% inflation factor that they are stuck dealing with, and if the state doesn’t give them a 20% raise like right now several of them will shut down.

 
 

Clipped from: https://www.northcountrypublicradio.org/news/story/47197/20230118/a-ticking-time-bomb-ny-nursing-homes-push-for-medicaid-rate-increase

Jan 18, 2023 —

A coalition of nursing homes says, if the state doesn’t increase its Medicaid reimbursement rates, the eldercare facilities may have to reduce the number of beds — or even shut down all together.

 
 

 
 

03:12

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Cara Chapman’A ticking time bomb’: NY nursing homes push for Medicaid rate increase

 
 

United Helpers Rehabilitation and Senior Care in Canton is one of a couple dozen skilled nursing facilities formally advocating for Gov. Kathy Hochul to increase the Medicaid reimbursement rates for long-term care by 20% in this year’s budget. Photo provided

According to the state’s health insurance assistance program, most nursing home residents use Medicaid to pay for their care. New York State sets the reimbursement rates the facilities get paid for those residents.

United Helpers COO Stacey Cannizzo said the state hasn’t adjusted those rates for inflation since 2007. 

“There is approximately a 42% inflationary factor that we have not been able to manage because our rates have been stagnant for so long,” she said.

United Helpers — which operates the United Helpers Rehabilitation and Senior Care facility in Canton — and a couple dozen other skilled nursing facilities say they collectively lost more than $81 million last year. Cannizzo said the Medicaid rates led to those losses; United Helpers actually closed its Ogdensburg facility in 2021 due to financial difficulties. 

The nursing homes, all of whom are nonprofits located throughout Upstate, formed a coalition in November. They want the governor to include a 20% increase to the Medicaid rates in this year’s budget, as well as a process put in place to ensure the state routinely looks at and adjusts reimbursement levels. 

Republican Assemblyman Matt Simpson — whose district covers all of Warren County and parts of Essex, Washington, Saratoga and Fulton counties — said raising the Medicaid rates for long-term care is one of his top priorities this session. He said both the rates and nursing home staffing have been at crisis levels for several years.

“It’s a ticking time bomb right now,” Simpson said, “and if we lose these facilities because we’re not correctly supporting them, it’s going to be devastating for those that need those services.”

Cannizzo said the stagnant Medicaid rates hinder efforts to attract and keep staff. Since nursing homes have to meet minimum staffing levels, lack of staff means facilities across the state are leaving beds empty. She said that can mean individuals are unable to access the care they need and hospitals don’t have a place to send patients who need post-acute care. 

Republican Assemblyman Scott Gray represents the St. Lawrence “River District” that comprises parts of St. Lawrence and Jefferson County. He said there’s “no question” the rates are overdue for an adjustment, but that the biggest objective is to keep people in their homes and make sure they can afford to age in place. Gray said that’ll help reduce the cost of Medicaid for long-term care.

“Essentially, if we can address and help and assist with aging in place and keep the Medicaid costs down, then we can pay for these adjustments that are necessary — providing we don’t wait 15 years to do it again.”

 
 

Stacey Cannizzo is the COO of United Helpers, which operates United Helpers Rehabilitation and Senior Care in Canton. Photo provided

Cannizzo said she thinks raising the Medicaid rates is an issue that affects every New Yorker. She said it could be the individual themselves, or a family member, friend or someone in their community who needs long-term care.

“These are people that have worked and paid taxes their entire lives, and we are committed to making sure that their needs are met — but we need the help and we need the support of the governor to make sure that we can afford to provide that care.”

Cannizzo said she’s “cautiously optimistic” that the rates will go up with this budget. Regardless, the coalition plans to take a long-game approach to keep the issue on people’s minds.

Gov. Kathy Hochul’s State of the State book, which outlines her priorities for the year, does not specifically mention Medicaid reimbursement rates for long-term care. But, similar to what Assemblyman Gray said, the plan proposes investing in teams to provide care for low-income adults in their homes and allow them to age in place. 

Hochul spokesperson Justin Mason said in a statement that the governor is “committed to ensuring that all New Yorkers can age with dignity and independence in the community of their choosing.” On whether she’s considering an increase to the Medicaid rates for long-term care, he said more information would be shared when she releases her executive budget later this month.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: TX dentists look upon the current state budget surplus with optimism for raising their own rates.

 
 

Clipped from: https://www.tdmr.org/72-percent-of-private-practice-dentists-plan-to-raise-fees-this-year/

The American Dental Association’s Health Policy Institute last month published the results of an ongoing survey it has been conducting since January 2022, quizzing some 3,000 participating private practice dentists each month to measure the impact of COVID-19 and other issues affecting the profession.

The report includes breakdowns by “ownership status, DSO affiliation, practice size, geographic location, sex, age group, and race/ethnicity.”  A PDF of the report is below.

Raising fees

The one remarkable statistic is that 72% of 1041 dentists across the country, representing a cross-section of private practice dentistry,  responded that they are planning to raise their patient fees in 2023.

Unfortunately, there are no survey results on why these dentists are raising their fees. But one can only conclude that the recent inflationary spiral which has hit dentistry hard plus the difficulties in staff recruitment are the reasons.

Bounty in the state budget

A few months ago, the Texas Comptroller of Public Accounts Glenn Hager estimated there would be a budget windfall for Texas of some $27 billion, thanks to high oil prices.  It was announced this week that the budget surplus is actually $32.7 billion.

Adverse effect on providers

As we have repeated in several stories, the situation is desperate for Medicaid dentists who have to cope with the same costs as private practice dentists but get fees substantially less.  The Medicaid dental fee schedule has only gone down since 2007.

The situation is becoming untenable for many who also have to put up with the erroneous behavior of DMOs, scrutiny of the OIG and the potential pitfalls and penalties of the Texas Medicaid Fraud Prevention Act and whistleblowers such as Joshua Lafountain.

We hope the legislature will look at raising Medicaid dental fees before the situation worsens.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A an OB that decided to pivot and focus on primary care (when ACA incentivized it) to meet the needs in their area can keep the payments for delivering said care.

 
 

Clipped from: https://www.ama-assn.org/practice-management/medicare-medicaid/ob-gyn-can-keep-205000-medicaid-pay-state-tried-recoup

A Hawaii ob-gyn who also provided primary care services to patients in an underserved area is entitled to retain the $205,000 in enhanced Medicaid payments the government was trying to recoup from him, the state supreme court has ruled.

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Hilo physician Frederick Nitta, MD, spent more than 60% of his time providing primary care to patients in the medically underserved area in which he practices medicine. But state officials claimed that he couldn’t collect higher Medicaid payments created under a 2010 law designed to encourage physicians to provide this care.

The Hawaii Department of Human Services (DHS) also had demanded that he pay back the $205,000 he had already been paid for the care he provided Medicaid patents and billed for at the higher rate.

After years of litigation, Hawaii’s highest court ruled in the physician’s favor.

“Congress clearly intended the enhanced payments as incentives for the provision of primary care services, regardless of a physician’s other practice areas,” the Hawaii Supreme Court said in its  November ruling (PDF).

The court quoted extensively from the amicus brief (PDF) that the Litigation Center of the American Medical Association and State Medical Societies and the Hawaii Medical Association (HMA) filed when Nitta v. Department of Human Services, State of Hawaii was at the appellate court level.

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“Amici highlighted the critical and worsening physician shortage in Hawai’i, noting that primary care has the greatest shortage, especially for Medicaid patients in East Hawai’i,” the Hawaii Supreme Court said, noting that DHS’ “continued recoupment efforts against physicians providing primary care services to Medicaid beneficiaries only worsens the shortage.”

The court referenced the AMA Litigation Center and HMA brief (PDF) cited articles and other reports that showed “‘on neighbor islands, in particular, patients often wait four to five months for a doctor’s appointment. On Hawai’i Island, it is sometimes two to three times more difficult to find a PCP [primary care physician]. Consequently, many residents seek care at the nearest hospital emergency room, costing them ‘upward of $600–$800 for an emergency room visit, as opposed to the average co-ay of $15–$50 for a visit to a primary care physician.'”

Who qualifies as “primary care?”

The Hawaii DHS had argued to the state supreme court that medical directory listings were the deciding factor of a physician’s practice characteristics. In refuting that argument, justices again referred to the AMA Litigation Center and HMA brief, noting that it “urged that the payments to Dr. Nitta were consistent with the ACA’s purpose to ‘benefit physicians that provide primary care services to the Medicaid population.'”

The AMA-HMA brief also pointed to Centers for Medicare & Medicaid Services (CMS) published questions and answers regarding how states can review a physician’s eligibility for the enhanced payment program.

“There, the CMS provided a nonexhaustive list of ways a state could verify a physician’s practice characteristics (i.e., how the physician represented himself in the community, medical directory listings, billings to other insurers, advertisements, etc.),” the court’s opinion said.

The AMA-HMA brief also “contended other evidence demonstrated Dr. Nitta’s PCP status,” the court noted. That includes “recognition by other doctors and medical providers in the East Hawaii community as a PCP,” and “acceptance and payment by medical insurers and a PCP” and “hundreds of written and oral testimony by people in support of a finding that he is a PCP.”

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And finally, the court cited the amicus brief’s argument that the DHS ” ‘formula to determine the sixty-percent-threshold requirement [was] in complete disregard for actual medical practice'” because paid billing codes don’t take into account the “‘percentage of total services provided in a managed care environment by that physician.’ “

Dr. Nitta reflected on the case in an interview with the Hawaii Tribune-Herald.

“I could have just paid them back. Instead, it’s probably costing me more to fight them in court over and over and over. But that doesn’t matter, because it’s not right what they’re doing.”

Find out more about the cases in which the AMA Litigation Center is providing assistance and learn about the Litigation Center’s case-selection criteria.