Reimbursement Plan Aims To Steer Patients To Family Doctors

By Associated Press
January 14, 2008

ALBANY — Instead of waiting for hours in an emergency room or landing in a nursing home, New Yorkers with government health coverage will soon have the opportunity to avoid those costly treatment venues by going to their own family doctor.

In his State of the State address Wednesday, Governor Spitzer proposed changing the way New York reimburses hospitals and doctors for services — part of overall changes aimed at making health care cheaper for taxpayers and better for patients.

The current system for reimbursing doctors in the pay-per-visit Medicaid and Family Health Plus programs hasn't been updated since 1981, the state health commissioner, Dr. Richard Daines, said. When primary care doctors are paid a fee that reflects the service they deliver, patients will have more options, he said.

While managed care programs tend to pay doctors about what private insurers pay, a doctor treating a Medicaid patient under the pay-per-visit system receives $67.50 per visit, whether it's an expensive, complex treatment process or a simple booster shot, Dr. Daines said.

"If we are able to pay higher rates to primary care doctors, it will be easier to find a family doctor," Dr. Daines said.

Patient advocates like the proposal.

"The most serious and most expensive health care problems that New Yorkers face — asthma, diabetes, HIV/AIDS, hypertension, stroke — these are things that can be treated and sometimes prevented if you've got strong, community-based primary and preventive care," Michael Kink, the legislative council for Housing Works, an organization serving low-income people and people with HIV/AIDS, said. "We shouldn't be waiting until people get really sick and incur really kind of high-cost, high-complexity illnesses."

"If you've got a Medicaid card in your pocket, you're going to see more primary care doctors in your neighborhood," Mr. Kink said. "You may see doctors sooner."

It's unclear what types of procedures and visits will start to reimburse doctors at a lower rate. Health officials said they won't know until the state budget comes out later this month.

Hospitals and health care providers tend to have very small profit margins, and changes in reimbursements raise concerns that if primary care physicians are paid more, other specialties could be paid less, a spokesman for the Healthcare Association of New York State, William Van Slyke, said.

"Any reduction, period, in health care reimbursement increases the challenge of providing community care," Mr. Van Slyke said.

Hospitals support providing preventive and outpatient care but are apprehensive about the transition.

"It's a necessary shift to a new way of the government funding of health care," Mr. Van Slyke said. "Our concern is that we have to get to this new system first before we pull the rug out from under the old one ... What we need is time to transition and financial support to keep the existing system viable while we move to the more outpatient-based system."

Officials at the state health department said data suggests some providers may not be thrilled with the changes, but most would find a balance between procedures paying more and those paying less.

"A year ago I was one of those hospital executives waiting to hear what the budget would do, so I've been on that end of it," Dr. Daines said. "So it's a perspective that I've brought that there are rates of change that can be tolerated and there are bottom line issues. We're sensitive to those."

The CEO of Adirondack Medical Center, Chandler Ralph, said she supports increasing the reimbursement rate for primary care physicians, but believes no payment should ever be less than the actual costs of the care.

"You have to be sure the reimbursement system is fair to every physician," she said. "I have physicians who are asking me to pay (them) to be on call in the emergency room. One of the key factors of that is when they get called in, in the middle of the night, to either a patient with no insurance or a patient with low reimbursement, that's no longer sustainable."

If the reimbursements cut down on total income, the center will probably have to cut back on community services, Ms. Ralph said. That could eliminate diabetes classes, wellness classes at businesses, and exercise classes for the elderly.

Reimbursement Plan Aims To Steer Patients To Family Doctors

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