Impending Threat to Health Care Access for the Poor and the Elderly

 In the newspapers for weeks now have been articles on the Medicare Rate Cut across all medical services that took effect January 2002 and would total 17% over the next three years.  Medicare is a Federally Supported Health Insurance source for the elderly and disabled.  Congress is currently reviewing Medicare’s new payment formula and the medical community is in hopes that congress will pass a bill to correct this flawed formula. Tom Scully, the Center for Medicare and Medicaid Services’ top official, feels this bill will pass and the net result will be a less than 1% increase to the current conversion factor.  This statement is not heartening, as Medicare’s cut this year was 5.4% and the medical community is aware that changes in conversion factor are not in direct correlation with expected service revenues.  Medicare can still make changes to the relative value of each service, the value to which the conversion factor dollar amount is multiplied.  (A local mental health practice took almost a 10% cut on some services for 2002.)  Medicare cuts have been well advertised due to the devastating effects on the Medicare-covered population with pertinence to all medical services.  Private medical services providers across the United States have been refusing to accept Medicare patients since announcement of 2002 cuts.  Of concern within the medical community is the tendency of other health insurance companies to mimic Medicare’s payment policies. Anders Gilberg, a government affairs representative for the Medical Group Management Association, points out that while Insurance sources are drastically cutting payments, the government’s own measure of medical cost inflation, the Medicare Economic Index, shows costs for medical services rising at 3% a year. 

Not as well known are other factors that are devastating to the ability of smaller groups within the United States population to receive medical care.

 Within the North Carolina Medicaid covered population, medical providers received a bulletin from Medicaid in March 2002 announcing a rate cut of 5% in medical service payment allowables.  Because Medicaid sets its payment on Medicare fees, the true cut in fees is much larger (see the above paragraph on Medicare cuts for 2002).  Additionally, Medicaid made this rate cut effective retroactive to October 1, 2001.  Medical service providers who serve Medicaid clients are currently being forced to pay back monies already received for services provided to the community in good faith since last October.  Says a local medical administrator, “If this is not illegal, it is certainly unethical”.

 The North Carolina Medicare and Medicaid covered population in need of mental health services is becoming increasingly aware as they receive medical bills that mental health care providers are hit with a psychiatric reduction by Medicare that is not paid by Medicaid.  Medicare sets an allowable for health care services and will generally pay 80% of what they allow the service provider to bill; for mental health services, Medicare only pays 50% of what they allow health care providers to collect.  This psychiatric reduction was created to encourage covered individuals to “think carefully about how medically necessary mental health services are” since they would be responsible for a higher amount of the cost.  Medicaid as a secondary source of insurance to Medicare does not pay the additional fee caused by Medicare’s psychiatric reduction; instead it is passed on to the individual to pay.  The North Carolina community has the intellect to realize persons who qualify for Medicaid are poor and cannot afford these bills.  The mental health provider is generally left with a disproportionately high bad debt ratio as compared to other providers.  Many private mental health providers refuse to see patients with these insurance types.  Many regulatory bills have been presented and considered within our government to create mental health parity with regards to payment for services, none have yet passed to end this discrimination.

 In addition to the exodus of private mental health providers for the poor and elderly in NC due to insurance cuts and lack of parity for mental health, by July 1^st, 2003, the NC Department of Health and Human Services plans to have dismantled approximately 1/3 of current mental health services at local centers across North Carolina.  By July 2004, the state hopes that the mental health centers will be reduced to a referral source with a network of private mental health providers to refer to; this referral source will be renamed the Local Management Entity.  These drastic changes were approved by the NC legislature in September 2001 as An Act to Phase in Implementation of Mental Health System Reform at the State and Local Level (HB 381).

This Act was passed in attempts to increase the range of treatment options available to patients, to increase “consumer choice,” to allow private programs access to public funds, to enhance the efficiency of program operation and to decrease costs.  By January 2003, each Area Program is to have submitted a Local Business Plan to the Secretary that includes all private providers and which providers have stated their willingness to be network members.  This very large change has been greeted with shock and hesitation by some area mental health administration and a frenzied job search by many of our state agencies’ mental health providers.  Private providers who have hoped this change may offer opportunity are being forced into the “here and now” of current budget cuts and the struggle to continue with current operations.

 Oftentimes, local citizens forget the strength of their own voice in expressing concerns and fighting for their rights.  This was not the case, as noted recently, with a group advocating for persons with Alzheimer’s Disease.  For years, Medicare has automatically denied payment for all psychotherapy services to persons with Alzheimer’s based upon the increasing inability of persons with Alzheimer’s to retain information from one session to the next.  However, there are a great number of people with Alzheimer’s for which psychotherapy is medically appropriate.  By advocating, this Alzheimer’s group was able to convince Medicare to remove the computer edit automatically rejecting all payment for psychotherapy to persons with Alzheimer’s.  Medicare now pays claims and audits for appropriateness of this care.

 The medical community is struggling with the ability to afford continued care to the poor and elderly.  Providers are cutting all costs possible, writing to government representatives, lobbying in Washington, DC and eventually refusing to provide services when all else fails.  The medical community hopes that our citizens will find their voice before they lose their care. 

Securing Care for Individuals Covered by Medicaid-Only

 Due to both a shortage of Psychiatrists in North Carolina and Recent Rate Cuts by Health Insurance Companies, ACT has supplemented its psychiatry provider employee pool with both Nurse Practitioners and Physician Assistants and put a freeze on accepting in New Medicaid-only covered individuals for care effective May 2002 (Medicaid had the largest rate cut, 10.4%). 

 Facilities that have received assignment of Nurse Practitioners and Physician Assistants will not only receive their credentials and professional liability policies, but will also receive copies of Protocols for care established between these provider types and their Medical Supervisor and copies of Supervisory Agreements.  Nurse Practitioners and Physician Assistants are legally able to provide the same services as our MDs and DOs, but have additional supervisory requirements that ACT has put in place.  The main differences our clients will notice is increased availability of our psychiatry providers and NP and PA immediate accessibility to their MD Supervisor by phone for the purpose of collaboration on complex care issues.

Facilities contracted with ACT are already aware that Medicaid will not pay for available psychology services on-site without an MD or DO making direct (over-the-shoulder) supervision during services.  North Carolina Medicaid, as a sole insurance source, is also refusing to credential Physician Assistants and non-psych-certified Nurse Practitioners although these provider types are used routinely for care throughout the United States.  Though many Nurse Practitioners have extensive experience in the provision of Psychiatry services, only 4 Nurse Practitioners in North Carolina are Psych-certified at this time, thus, Medicaid’s rule is currently a barrier to care for individuals with Medicaid as a sole insurance source.  As an insurance source coupled with other insurances such as Medicare, Medicaid defers to the Primary Insurers rules.  Many other insurance types, such as Medicare, will allow PAs and NPs onto their Provider Panels (they will pay for provider services).  Due to both severe rate cuts and barriers to care, ACT clinicians are reviewing current Medicaid-only clientele and will be recommending transfer of more stable individuals back to their Primary Care Physicians and for less stable individuals, will be reviewing continued treatment options.  Though only 3% of ACT clients are currently covered by Medicaid-only, we realize this change is a stress to our customers and we will work to make these changes a smooth transition.  As consumer voice is important in determining future regulation, we encourage you to contact your North Carolina and your NC Medicaid representatives to dispute these rate cuts and barriers to care by provider type.

 For clients that are currently receiving ACT services or that you would like to refer that are covered only by Medicaid, consider the following:

A. Can the individual qualify for Medicare and maintain Part B coverage?

Determining Medicare Eligibility

1. Individual is Age 65+, individual / individual’s spouse worked for at least 10 years in Medicare-covered employment and individual is a citizen or permanent resident of the US, or
2. Individual is a younger person with a disability or with End-Stage Renal disease.  Must have been entitled to disability benefits under Social Security or the Railroad Retirement Board for 24 months

·         To Apply for Medicare, Call the Social Security Administration Toll free 1-800-772-1213 (TTY-TDD # 1-800-325-0778) or apply online at www.ssa.gov .  Persons nearing 65 should apply 3 months before their birthday so that Part B coverage will not be delayed.  If these persons are already on Social Security, they will be automatically enrolled.

·         If in individual does not yet have Social Security, but is disabled, call 1-800-772-1213 (TTY-TDD # 1-800-325-0778) to set up an appointment with a Social Security Representative.

 Maintaining Part B Coverage

• Medicare Part A is free

• Medicare Part B costs $54.00/ month in 2002

• Individuals can apply for Medicaid (if they are Medicaid-covered) to pay for the Part B premium.  Individuals may qualify for Medicaid to pay if:  1.  the individual has Part A Medicare, 2. his/her assets are not more than $4,000 for a single person, or $6,000 for a couple, and 3.  his/ her monthly income is below Medicaid-set limits.  Ask your SSA Representative about Medicare Savings Programs.

  B. Is there an alternate provider who can provide for type/ frequency of care needed and accept Medicaid as the only source of coverage?  Mental Health Centers are reimbursed for treating Medicaid-only covered clientele.   ACT is unable to provide pro-bono (free) services to Medicaid-only covered individuals due to regulations stipulating how a provider may legally provide pro-bono services.  ACT’s compliance with this regulation would be prohibitively expensive.  Some private mental health providers in your community may be able to accept and be able to collect for services provided to individuals with Medicaid-only.  If services by other private providers are offered on-site

 C. Can the individual’s DSS Caseworker or another caregiver arrange to pay for services out of Unmet Medical Needs or other funds?  ACT does have its own fee schedule that is applied to private pay individuals.  Should there be a funding source available, ACT simply needs information on this funding source and signature of the person responsible for this funding source.  The ability to utilize other funding sources is generally dependent upon providing evidence that ACT can offer a service that others cannot.  An example would be that ACT provides on-site services and that your non-ambulatory clients in need require this service.

Update on the Mental Health Equitable Treatment Act of 2002 

On Monday, April 29^th, 2002, President Bush publicly supported passage of the Mental Health Equitable Treatment Act of 2002, with amendments, while speaking at the University of Mexico.  He stated “We are determined to confront the hidden suffering of Americans with mental illness….They deserve a health care system that treats their illness with the same urgency as a physical illness.”  Though President Bush warns that the US not significantly run up the cost of health care, the non-partisan Congressional Budget Office has estimated full parity in coverage would raise costs by less than 1%.  In the US, over 54 million people every year have a mental disorder but fewer than 8 million seek treatment (Surgeon General’s Report 1999).  President Bush stated, “We must work for a welcoming and compassionate society, a society where no American is dismissed and no American is forgotten.”  Democrats feel they have enough votes to pass this bill in legislation.  We are as of yet, uncertain as to the amendments desired for the bill and the final outcome of bill passage on mental health costs for ACT clientele.

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