Doctors Treating Elderly Poor Still Facing Struggles

Months after Texas physicians treating the state’s poorest seniors made a public plea for relief, there has been little movement to reverse a state policy that curbed their reimbursements for patients eligible for both Medicaid and Medicare.  

The policy change, made by budget-weary state lawmakers last session with an expectation that it would save an estimated $450 million over the next two years, has created unintended consequences for some doctors, who find themselves barely able to keep their doors open. 

Dr. Javier Saenz, a family physician in La Joya, loses his breath talking about the extent of his private practice’s struggles. He has exhausted his personal savings and has had to extend his credit line to keep his small business afloat.

“This is an emergency situation. We cannot sustain another couple months of this,” Saenz said. The way the math works out, he said, doctors “have to see six Medicaid patients an hour just to make their overhead. Who can do that?”

Saenz, like many other Texas physicians, treats a disproportionately high number of the roughly 330,000 senior patients who are eligible for both Medicare, the federal health plan for the elderly, and Medicaid, the joint state-federal program for the disabled and impoverished children. 

On Jan. 1, Texas followed the lead of several other states by ending the practice of using Medicaid funds to pay for dual eligible patients’ deductible, which is $140 this year. Lawmakers also changed doctors' co-pays for Medicare Part B services. Medicare used to pay for 80 percent of services; Medicaid would cover the remaining 20 percent. The state now limits its reimbursements to doctors treating dual eligible patients to the Medicaid allowable, which tends to be lower than Medicare rates.

When patients are so poor they cannot even pay for their deductible — as is often the case with Saenz’s clients in a rural section of the Rio Grande Valley — he either has to absorb the cost or turn patients away, which he has vowed not to do. Overall, he said, his once-solvent business has seen revenues decline by more than 20 percent over the last several months. At times, it has dipped by as much as 40 percent, he said.

The Texas Medical Association opposed the rule change when it was first proposed during the 2011 legislative session. It passed anyway. Since then, the organization of Texas physicians has taken on the cause by producing a series of advocacy videos and staging a rally to highlight the plight of physicians along the border and in more urban areas like Houston.  

“Just because [another state] does something that doesn’t make sense from a patient care standpoint doesn’t mean that Texas should do the same,” said Dr. Michael Speer, a Houston neonatologist and the president of the TMA. “The private practices are the ones that take care of the majority of the dual eligibles, but it’ll hit any clinic anywhere in Texas that’s taking care of dual eligible patients. It’s not limited to a single group."

Health care advocates reportedly met with Gov. Rick Perry in the spring to express their concerns. Outgoing Health and Human Services Commission chief Tom Seuhs and his deputies have visited the Rio Grande Valley to meet with concerned doctors. Saenz and TMA officials say they're still waiting for the state to take action. Meanwhile, HHSC is undergoing leadership changes following news that both Suehs and Medicaid chief Billy Millwee were leaving. 

In an email, Perry spokeswoman Lucy Nashed said the governor's office is "aware of the doctors’ concerns, and is working with the Texas Health and Human Services Commission to identify any potential solutions.”

Between January and April, HHSC responded to doctors' worries by revising several policies, including increasing cost sharing for renal dialysis and mental health services and transporting X-ray machines between facilities. It also increased Medicaid reimbursement rates for cancer patients to match Medicare rates.

“As our actions have indicated, we are sensitive to what we’re hearing from providers on this issue, especially as it relates to access to care and overall impact on a provider’s ability to serve those who need care," Geoffrey Wool, a spokesman for HHSC, wrote in an email. “But we have to weigh that against the intent of the legislation, which was to bring these payments more in line with what Medicaid pays for these services. We’ll continue to be mindful of these two dynamics as we move forward.”

Speer said he has little reason to feel optimistic, since lawmakers are starting the next legislative session with another gaping Medicaid shortfall.

“If they don’t pay now, they will pay later," he said. "They are going to pay when the dual eligible patient hits the ER and that patient has to be stabilized and admitted to the hospital. Why pay for that instead of helping the patients receive preventive care first?”

Roughly 10 percent of the total Medicaid population qualifies as dual eligible. The TMA warns that as reimbursement continues to fall, more physicians are making the choice to stop seeing patients who qualify for Medicaid, Medicare or both.

Most people "think that physicians are going to care for patients no matter what, and in general that’s the physician attitude and perspective. We want to take care of our patients," Speer said. "But sooner rather than later you’re seeing physicians take on that attitude because they have no more options."

For Saenz, the situation has become dire. The South Texas native said he has cut costs to the bone on things as minor as toilet paper. He spends more time reviewing every procedure, test or vaccine provided to his patients, to ensure he is billing for every service he provides. In an effort to keep his staff of 25 employed, Saenz said, he has just taken his last draw on a bank loan he hoped would help him endure a short-term problem.

“We go day to day, week to week,” he said, adding, "Everyone in the office is working harder. They understand that we all have to do more in the office and work together to stay in business.”