Low-income elderly squeezed by new rule

AUSTIN (KXAN) - Holding an X-ray to the light, Dr. Bruce Malone thought about the cost to replace the patient’s hip. If the $16,000 procedure happens in the New Year, he will have some tough decisions to make.

"It would be at least a $1,200 reduction in the payments to doctors for that,” Malone said.

Because of a historic state budget shortfall, the Texas Health and Human Services Commission changed its policy for a subset of Texans called “dual eligible.”

“Dual eligible” refers to the “poorest of the poor” – usually elderly – who qualify for both Medicare and Medicaid coverage.

"The most common thing I would do in a dual-eligible Medicare/Medicaid person would be fix a broken hip,” he said, hanging the X-ray back in its place at Austin Bone and Joint Clinic.

The changes take effect Jan. 1

Malone, a partner at the clinic, has been an orthopedic surgeon in Austin since 1977. He also is the president of the Texas Medical Association, which deals with doctors across the state. A top concern in the foreseeable future for that group is doctors soon having to choose between paying for what some patients cannot or turning those patients away altogether.

"No Medicare. No Medicaid. It would be a disaster,” he said, shaking his head, referring to Jan. 1, when the policy change goes into effect.

Dual-eligible policy change

In order to save $1.1 billion of the current two-year budget cycle, HHSC chose to change how much in co-payments the state pays for people who have both Medicaid and Medicare coverage.

Generally, these are people who qualify for Medicare based on their age and Medicaid based on their income. This group makes up about 10 percent of the state’s Medicaid clients, or about 330,000 people.

Texas’ Medicaid budget is about one-fourth of the entire state budget. About 60 percent of that amount comes from federal funds and 40 percent from state funds.

For those dual-eligible clients, Medicare pays first. Medicaid covers services not paid for by Medicare, and Medicaid also pays for the person’s Medicare premiums and can cover co-pays.

“One of the options we suggested was ending the policy where Medicaid will pay the full co-pay for a Medicare service even if the Medicare rate is much higher than what Medicaid would have paid for the same service,” said Stephanie Goodman, HHSC spokeswoman.

TMA  said this change would make it very difficult for dual-eligible patients to receive the services they need. Without the state’s Medicaid match, the full cost would not be covered, and doctors might have to turn those patients away.

Texas’ policy changed after 17 other states made a similar move. Goodman said the Legislature directed the commission to follow that pattern.

"It would take a dramatic turnaround to sort of get us out of the Medicaid hole,” Goodman said of the $4 billion Medicaid shortfall Texas is now experiencing.

“It's a program that is so large and growing at such a fast pace that we're always looking at how to reign in those costs. How do you try to use the dollars more wisely?"

Effect on doctors and patients

Malone said certain sets of dual-eligible Texans would be at greater risk of losing their providers under this change: rural residents, inner-city residents, older residents and nursing home patients.

“Some doctors and clinics might be hesitant to see these people, because there is the question of how to pay for their services,” he said.

While dual-eligible situations only make up about five percent of his practice, he said the change might mean he has to drop out of the Medicare program entirely because of the financial stress of seeing patients.

“You would restrict your patient load to commercial insurers,” he said, knowing that only represents a portion of those in need. “The question is: Can those doctors continue to serve the patients in their community without that money?"

Malone fears many of those patients would either go without health care or be forced to seek more expensive treatment at emergency rooms, something most in that low-income group likely could not afford.

"If I decided I was going to restrict my practice to those patients and provide a service, I couldn't keep my doors open,” he said.

Working toward a solution

TMA and HHSC will meet next week to discuss concerns with the policy change. Goodman said the commission took notice after recent hearings and also a letter from Sen. Wendy Davis, D-Fort Worth.

“That was what actually prompted the commissioner to say, 'Let's take a step back. Let's work with the Texas Medical Association. Let's look and see if there's anything we need to do differently in this policy,”” Goodman said.

Davis sent the letter to Commissioner Tom Suehs after meeting with cancer care professionals in North Texas concerned with the difficulty this could create in patients receiving life-saving cancer treatment medications.

“These cuts are about to put at risk the lives of some our most vulnerable Texans,” Davis said. “These are poor, elderly patients who have