Medicaid's muddled preventive care picture
■ The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out.
Joel V. Brill, MD, a gastroenterologist in Arizona, is glad that his state will be expanding Medicaid under the Affordable Care Act, but he has reservations about just how rigorous the program will be in covering a key preventive service he provides — colorectal cancer screening.
Theoretically, there are 52 different Medicaid programs, if you count the 50 states, the District of Columbia and Puerto Rico, said Dr. Brill, who advises the American Gastroenterological Assn. on coding and Medicare payment. So “there's probably 52 different interpretations as to whether they would encourage colorectal cancer screening in their Medicaid populations.”
As millions more people join Medicaid in 2014 in states that have decided to expand, it remains to be seen exactly which populations of patients are going to be eligible for colorectal cancer screening, he said.
Concerns such as Dr. Brill's have arisen among physicians and policy analysts who anticipate a convoluted preventive care landscape in Medicaid in the midst of expansion. Depending on whom one asks or the circumstances of the patient involved, certain key preventive benefits might be covered for no additional out-of-pocket cost, covered with a modest co-payment or not covered at all.
A study in the July issue of Health Affairs underscored the potential inequities and widespread confusion that surrounds the Medicaid preventive coverage issue.
The findings suggested that not all adult Medicaid beneficiaries will have free access to a core list of preventive care benefits under the ACA. The health system reform law requires Medicare and most private insurance plans — as well as Medicaid, for those newly eligible for the program under the expansion — to cover for no additional out-of-pocket cost any services that the U.S. Preventive Services Task Force rates an “A” or a “B.” By offering the care for free to the patient, the provision was designed to encourage more people to get screened for deadly cancers, for example, or to follow up on heart disease counseling or diabetes tests they need.
But this isn't necessarily going to be the case for existing Medicaid beneficiaries, for which coverage of these services is not a requirement under traditional program rules, the study said. Not all adults on Medicaid may be eligible for the same zero co-pay preventive benefits, because the ACA doesn't treat the newly and currently eligible the same way.
“Preventive services save lives by detecting diseases before they can progress. Why should some Medicaid beneficiaries be left out when it comes to coverage for this kind of care?” asked Sara Wilensky, PhD, the report's lead author, in a statement. She's with the Dept. of Health Policy at the George Washington University School of Public Health and Health Services in Washington.
The study's researchers drew their findings from a review of 24 of the then 44 USPSTF A- and B-rated services, document reviews of Medicaid policies in all 50 states and the District of Columbia, and interviews with state Medicaid officials. (The number of those services since has increased to 51.) Wilensky said in an interview that the researchers looked at two questions: whether a state covered A- and B-rated services for existing Medicaid beneficiaries, and whether it charged any co-pays.
State coverage map is a patchwork
The investigation found that “most states do not cover all of the services, and about half charge co-pays for preventive care,” Wilensky said. Maine and Nevada were the only states that covered all of the A- and B-rated services for existing Medicaid beneficiaries, she said.
Judith Solomon, vice president for health policy with the Washington-based Center on Budget and Policy Priorities, a liberal think tank, said it was ironic that the ACA added preventive benefits to Medicare and were requiring them in nongrandfathered private coverage, but that some of the poorest, most vulnerable people eligible for Medicaid now weren't going to get the same deal.
Solomon noted that such inconsistencies also can be found in the final regulations on Medicaid alternative benefit plans, the equivalent to the essential health benefits that private plans will be required to cover starting in 2014. Before the ACA, states had the option of taking up these plans for certain Medicaid populations. However, the reform law amended the alternative benefit plan provision, requiring them to start providing essential health benefits as defined by the ACA, including any preventive services mandated without cost sharing. Again, although these benefits are required for the Medicaid newly eligible, they remain optional for existing beneficiaries, she said.
This situation potentially will sow more confusion for doctors who see Medicaid patients and wonder what preventive benefits they are eligible for, Dr. Brill said. In addition, patients on Medicaid tend to drop in and out of the program. “If someone had Medicaid and is no longer eligible but then became eligible again, would they be classified as a current or new eligible?” he asked, noting that the answer is going to depend on how each state decides to interpret these situations.
Confusion over Medicaid benefits coverage is not new. As Wilensky noted in her research, it's not always clear if a state covers a preventive service, such as screenings for diabetes, depression or early signs of heart disease. In many instances, a state will use vague language such as “the program covers all medically necessary, age-appropriate screening based on generally accepted standards of care,” she said.
For a doctor, this language may be hard to interpret, she said. “If you're a physician, what does that mean to you? Can you give that screening mammogram, can you not? Can you give that screening diabetes test, can you not? If you can, when will it be accepted?”
Physicians tend to look at their patients as people with individual needs and situations, not in terms of what insurance they have, said M. Eugene Sherman, MD, chair of the American College of Cardiology's advocacy steering committee. Taking that into consideration, it's going to be very confusing for a physician “to be able to look at a patient and say, 'Yes, you have Medicaid, but I can't do these preventive services because you've been on Medicaid too long,' or 'Yes, you're new to Medicaid, so I can recommend these tests,' ” he said.
A potential result of this is cost-shifting, something that Dr. Sherman said physicians wanted to avoid under the ACA. Consider a case in which an existing Medicaid patient needs a cholesterol screening but isn't eligible for the free preventive service in that state, and the practice does not recognize that this patient has had Medicaid for five years. If the practice has its own lab, “then they're going to eat the cost of the service that's not reimbursed. If they send it to a hospital or contracted lab that does their services, then that provider is basically not going to be reimbursed,” he said.
As the advocacy chair at the ACC, Dr. Sherman said his message to fellow cardiologists is to consult immediately with their respective Medicaid contacts, whether it's a fully state-run program or a managed care program, to try to solve this problem. “We want there to be no difference in the way a patient appears, because they've had Medicaid for a period of time as opposed to just receiving Medicaid.”
Some will try to align benefits
Solomon, with the Center on Budget and Policy Priorities, offered that some states may try to revise their preventive benefits so there isn't a distinction between the preventive benefits that the newly and currently eligible Medicaid beneficiaries receive. All of these states likely will be expansion states to begin with — states that tend to have higher income eligibilities and more robust benefit packages to start. “For states that don't expand, this isn't really relevant, because they don't have any new eligibles. So they're going to be in the same place they are today,” she said.
That doesn't mean Medicaid beneficiaries in those states are going without all needed preventive care, however. Texas, for instance, is one nonexpansion state that Wilensky, the George Washington University researcher, singled out as doing a fairly good job in terms of covering the task force-recommended services. The state has no co-pays for preventive services and also fully covers adults' well exams, she said.
The ACA also provides a financial incentive to those states that decide to cover all A- and B-rated services for existing beneficiaries. Those that decide to cover all of the recommended preventive services and immunizations without cost sharing would receive a 1% increase to federal matching rates to cover service expenditures. But while this may help give states the impetus to align their services, “I haven't seen any states reacting to that,” Solomon said.
Still, not all health system observers are seeing major Medicaid coverage discrepancies or predicting mass confusion in 2014. Kathleen Nolan, director of state policy and programs for the National Assn. of Medicaid Directors, contends that most states do cover these preventive services for current beneficiaries and plan to use that same foundation for expansion populations. “We have not heard of anyone saying that they need to supplement their expansion plans to meet the new requirements for preventive services,” she said.
Ordering aspirin to prevent cardiovascular disease or mammograms for women who need them aren't just going to be covered for the expansion population, she said. “I think there are a only few instances where a recommended preventive service may not be covered in the current program as the way it's described in the task force recommendations,” she said.
The view from the field
Some of the disconnect on this issue may be a function of how the benefits are treated on paper versus how they are treated in practice. In reviewing coverage for screening mammograms, Eugenia Brandt, head of state government relations for the American College of Radiology, said that in some instances, the states don't outline coverage of that preventive service explicitly in their guidelines. But the services themselves actually are covered when beneficiaries access them, she added.
“It's illogical to conclude that just because states are not required to cover these preventive services that they don't cover them,” Nolan said.
An Obama administration official said the study overlooked significant federal efforts under way to improve preventive care access to Medicaid beneficiaries. In addition to implementing the ACA provisions to expand coverage of services, CMS also has been working to remove barriers to effective prevention strategies, wrote Stephen Cha, MD, MHS, chief medical officer for CMS' Center on Medicaid and CHIP Services, in a Health Affairs blog post responding to the study. For example, under a new regulation, Medicaid “will now reimburse for preventive services administered by a health worker who has been recommended by a licensed health professional,” he wrote.
States might consider their criteria for covering medically necessary services as applying in these cases, but Wilensky cautioned in her study that these are different from preventive services, which are used to detect problems in asymptomatic, healthy people. A medically necessary test is considered to be for patients who already might have established health problems, she said.
An additional factor at play is that even if a Medicaid program covers a particular screening or other preventive service, it might not necessarily cover it at no additional cost to the patient, as favored by the ACA. Nolan noted, however, that co-pays associated with these services typically are nominal in size and unenforceable.
“States can under CMS regulation and with permission charge co-pays, but very few states use co-pays for office visits. … They also cannot be applied to pregnant women and children, thereby reducing their relevance to the [task force recommendations] even further — since many recommendations are related to these groups,” she said.
From the physician standpoint, the decision-making equation over ordering tests might prove simpler. Marc Price, DO, a solo family physician in Malta, N.Y., said that under his Medicaid contract, he cannot bill for any out-of-pocket cost the patient doesn't pay. “I have no recourse to get that money back. I'm also not allowed to bill the patient if they don't show up for their appointment, for a no-show fee or late fees,” he said.
But as with many physicians, Dr. Price doesn't worry about cost if a Medicaid patient needs a cholesterol screening, a blood glucose test or any other type of recommended preventive service, he said. “I always put the patient first. … There are some services that I'm aware I'm not getting paid for, and I'm not sure exactly which services those are for each patient, but there are some that I 'give away,' so to speak.”