Dollars and Sense: Countering Medicaid Cuts

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”