Comments regarding Payments for Services Furnished by Certain Primary Care Phys

Executive Summary

Comments on proposed rules regarding vaccines under VFC program.

Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS?2370?P
P.O. Box 8016, Baltimore, MD 21244?8016
Attention: CMS?2370?P
Medicaid Program; Payments for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration Under the Vaccines for Children Program
Dear Sir/Madam:
The National Health Law Program (NHeLP) is a public interest law firm working to advance access to quality health care and protect the legal rights of low-income and underserved people. NHeLP provides technical support to direct legal services programs, community-based organizations, the private bar, providers and individuals who work to preserve a health care safety net for the millions of uninsured or underinsured low-income people. With the implementation of the new health reform law, and millions of newly insured individuals entering the health system, assuring access to care will be a key concern.  Medicaid enrollees already have challenges accessing primary care providers in some areas, so it is critical that access be improved in anticipation of the growing Medicaid population. We appreciate the ability to provide comments on the proposed rule regarding payments for Primary Care Physicians (?PCPs?) and charges for vaccine administration under the Vaccines for Children Program.
We are extremely supportive of the ACA?s increased investment in primary care and we thank CMS for proposing regulations to fully implement this policy. We would like to underscore, however, that CMS must work to ensure that this investment produces maximum effect and that programmatic Medicaid dollars are well spent. In addition to the specific regulatory comments which follow below, we would like to make a few broad recommendations for ensuring CMS optimizes this investment in primary care:
  • CMS should develop metrics to assess whether these dollars have served the ultimate goal ? increasing access to primary care for Medicaid recipients. CMS will need to develop some baseline measure of access (pre-2013) and then have some way to measure the impact of increased reimbursement on access (in Calendar Years (CY) 2013 and 2014, and beyond). This will require more than just reviewing numbers of participating providers, which can often be misleading, as providers may serve a minimal number of Medicaid patients and/or not accept new Medicaid patients. The measures should include nuanced data points such as waiting times, travel times/distances to providers, and provider panel sizes.
We realize access will be a difficult metric to develop, particularly in light of the dramatic changes to insurance status in 2014. However, we believe a demonstrable increase in access will be essential to justify a continuation of the increased funding for PCPs after CY 2014 and possibly increased funding for other services. (While primary care is clearly a threshold concern, we note that Medicaid enrollees often have similar difficulty accessing specialist services.) Providers, who have long argued that payment rates are the reason for low participation rates, should also have a responsibility in helping CMS document the benefits of the investment.1
  • The majority of Medicaid enrollees are in managed care plans, and that proportion is climbing. CMS must actively monitor managed care entities to ensure that increased primary care funding is sought and ultimately distributed to providers. Managed care entities may have an incentive to keep the extra funding (or simply avoid the administrative efforts to pursue it). If providers perceive that managed care organizations have kept the money, it may cause serious damage to Medicaid participation.
  • We understand that in developing this regulation CMS was limited by narrow statutory language. Nonetheless, we encourage CMS to continue to think broadly about the purpose of this primary care funding in the broader context of the ACA. We are concerned that inflexible restrictions by provider type and service type  will only serve to reinforce health care ?silo-ing? and undercut the broader ACA intent to better integrate care. We believe the ACA?s consistent focus on primary care and integrated care argues for a broad regulation.
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