AUSTIN, Texas – Members of the Border Health Caucus say they have not really been listened to in recent legislative sessions but are hopeful that this year things will be different.

The BHC is part of the Texas Medical Association and comprises physicians from the Texas-Mexico border region. They are pushing for restoration of a 20 percent funding cut imposed by lawmakers two sessions ago for “dual-eligible” Medicare-Medicaid patients.

Dr. Javier 'Jake' Margo, MD, of Rio Grande City.
Dr. Javier ‘Jake’ Margo, MD, of Rio Grande City.

The physicians say they have been encouraged by comments made to them this past weekend by state Rep. John Zerwas, a member of the House Republican leadership team and a physician for more than 30 years. They heard Zerwas speak at a private TMA event in Austin.

“Dr. Zerwas said this is the time to ask for a reimbursement of the 20 percent cut. That we should work with legislators on both sides of the aisle and to seize the moment,” said Dr. Javier “Jake” Margo, MD, a family practice doctor from Rio Grande City. “We intend to do this.”

The TMA held a news conference at the state Capitol on Tuesday to focus on improving payments for physicians who see Medicaid patients. As part of the event the TMA gave out a brochure which explains the “dual eligible” funding issue. This is how the TMA explains it:

During the 82nd Texas Legislature, lawmakers made several funding cuts without knowing their complete impact, creating a medical emergency for thousands of “dual-eligible” Texans and the physicians who care for them.

“Dual-eligible” patients are low income seniors and people with disabilities who qualify for both Medicare and Medicaid. Texas has about 465,000 dual-eligible patients, who are among the sickest and most vulnerable people in our state.

When physicians treat dual-eligible patients, Medicare pays the physician 80 percent of the amount owed. Previously, Medicaid paid the remaining 20-percent coinsurance for the patient. Medicare also requires patients to pay an annual deductible – $147 in 2014 – which Medicaid used to pay because the patients are so poor.

Beginning Jan. 1, 2012, Texas Medicaid quit covering the Medicare deductible. It also decided to pay physicians and providers no more than the amount Medicaid pays for the same service, which, in most instances, eliminated payment of a patient’s coinsurance.

The Texas Legislature in 2012 subsequently reinstated full payment of the annual deductible for dual-eligible patients. Yet, the patients’ physicians still face a cut of 20 percent for the coinsurance amount.

Dr. Margo is president of the RGV chapter of the Texas Academy of Family Physicians and president of the Hidalgo-Starr County Medical Society. He gave this analogy for the “dual eligible” funding cut: “Imagine going to the grocery store and buying a week’s worth of groceries and not paying anything and saying ‘I will pay you next week.’ And this goes on for four or five months. When you, as the store owner, finally go to get your payment the customer tells you he or she is only going to pay you about a fourth or fifth of what they took.”

Margo said that, unfortunately, more and more legislators seem to think of Medicaid as an entitlement program. “Some people in the state seem to think these are entitlements that need to be done away with. But, there is a whole population that is literally dealing with life and death issues and Medicaid is the only thing that is sustaining them. That is not to take away personal responsibility but if they cannot get in to see a doctor, which is one of the big access to care issues we are seeing, then it does not really matter if they have funding at that point.”

Margo said funding for Medicaid is more important for the border region and rural areas because that is where the need is greatest. “We are completely overwhelmed by the vast quantity of Medicaid patients we have on the border. But, unfortunately, every session we see more money cut from Medicaid programs. The need is so great. It is hard to get support when so many feel it is superfluous.”

Dr. Yasmin Maldonado, MD, of Brownsville.
Dr. Yasmin Maldonado, MD, of Brownsville.

Margo ended his interview with a shout out to physicians working in rural and border areas. “They are not getting paid anywhere near what they could be getting paid in more affluent areas and yet they still go to work with a smile on their face and still take care of their friends and family.”

Dr. Yasmin Maldonado, MD, is a physician from Brownsville and president of the Cameron-Willacy County Medical Society. Maldonado said she was not in the meeting with Rep. Zerwas but is encouraged by what other doctors have told her.

“I would like the legislators to know that the residents of the Rio Grande Valley are confronting major problems related to access to care. We are asking that the 20 percent cut for dual-eligible patients be reimbursed. We want to give the patients the care they deserve,” Maldonado said.

“Every session we ask for help and every year access to care gets worse. The Medicaid patients are having problems seeing a doctor because more and more doctors do not want to see Medicaid patients any more. In the border area, I would say that 75 to 80 percent of patients are either on Medicaid, Medicare or are dual-eligible. The specialists – the neurologists, the ophthalmologists, the neurosurgeons – they do not want to come and the doctors are leaving town. That is why people are being hurt. It takes four to five months to see a specialist.”

Maldonado said another problem doctors have is dealing with the “red tape” brought about when Medicaid HMOs were introduced.

“We love our patients, we know what to do but we are tied up with all these health plans that do not allow us to practice medicine. They (HMOs) want everyone to receive the same treatment. Medicine is not that. We cannot do a recipe for everybody. We have to individualize the treatment and give the best care we can for each patient,” Maldonado said.

“In the old days it was easier to treat our patients. The health plans are trying to decrease the cost but they do not care so much about quality of care. We have to find a balance. The cost may be decreased but the quality of care is not maintained. What we have right now is just a decrease in cost that is producing a lot of harm for our patients.”

Maldonado concluded her interview by urging border residents to contact their state representatives and senators. “The legislators are probably are not well-informed. They do not know what is happening. The people are suffering. They know it is a problem but I do not think it is being picked up. We need the support of our patients, the citizens. Now is the time to do it.”

Dr. Victor Hugo Gonzalez is a McAllen-based physician and immediate past president of the Hidalgo-Starr Medical Society. Gonzalez said the importance of Medicaid in assisting the whole infrastructure of healthcare along the border and in rural areas could not be overstated.

“We have been suffering with the 20 percent dual eligible cut from a few sessions ago, suffering with the sequestration, and with the fact that all the Medicaid programs that have gone into HMOs. Although the HMOs have maintained the same reimbursement rate the administration costs have gone up. So, the reality is doctors have taken a cut.”

Dr. Victor Hugo Gonzalez, MD, of McAllen.
Dr. Victor Hugo Gonzalez, MD, of McAllen.

Gonzalez said he is particularly concerned about a change occurring March 1 in a few counties, including Hidalgo. “We are going to have a Medicaid Demonstration Program. What that means is that all the dual eligible patients are going to be pushed into MCOs. It means all the dual-eligible patients in Hidalgo and five other counties are going to be required to be in a Medicare Advantage plan. I will get paid the same but now I have to hire someone else to make sure I get pre-authorization with whatever plan. This will significantly impact the bottom line.”

Asked what the cuts and the move to Medicaid HMOs have meant for his practice, Gonzalez said: “I have been forced to stop hiring staff. I have had to figure out how to save money and one of the ways to do it is to decrease my health benefits, so the staff has to pay more. It has forced us to cut back on staff. It has been unhealthy for our patients. It has been unhealthy for our communities. It is a time bomb. Unless we react it is going to explode.”

Gonzalez said he is also concerned about physicians nearing the retirement age not being replaced. “I know many doctors who are close to retiring and for some, these Medicaid cuts are the straw that has broken the camel’s back. Many are deciding to retire or move away. It is very difficult to recruit a young physician with a big educational debt in such an uncertain economic situation. We will not be replacing those doctors that retire so access to care will continue to decrease in our community.”

At the TMA news conference, leaders of the organization said legislators need to take six key steps this session:

1)    Improve physicians’ Medicaid payments
2)    Cut Medicaid red tape and administrative hassles
3)    Hold Medicaid HMOs accountable for establishing adequate physician networks to care for patients
4)    Restore funding for Medicare-Medicaid “dual-eligible” patients
5)    Stop unfair and unreasonable fraud and abuse orders
6)    Find a creative solution to pull down federal dollars to ensure working poor adults have access to health care.

Dr. Austin I. King, MD, president of the TMA, said Texas Medicaid is at a tipping point, pointing out that physician participation rates have dropped from 67 percent in 2000 to 34 percent in 2012. “Either it can continue on its current path pushing physicians out of the program, or it can make needed changes that will improve patients’ access to care and save taxpayers money,” King said.

King added: “The state is trying to balance the budget on the backs of physicians, and our backs are breaking. We can’t take it anymore. We need a plan not just for the present but also for patient care of the future.”

Dr. Douglas W. Curran, MD, a physician from Athens, Texas, said he understands the plight of border physicians because rural East Texas also has a lot of people that can only access healthcare through Medicaid.

Asked if Rep. Zerwas gave any indication of Texas expanding Medicaid to draw down millions of additional federal dollars, Curran said: “Dr. Zerwas talked about what is happening in some other states with the expansion of Medicaid. Republican states, states like Indiana, Ohio and Pennsylvania and Arkansas. He said those are options we can look at. Those are our tax dollars at work, your tax dollars and mine. I do not have any heartburn about using federal monies as long as we careful. I practice in a small town. I get being careful with money.”

Editor’s Note: Coincidentally, Dr. Javier ‘Jake’ Margo of Rio Grande City is the featured physician of the month in the January, 2015, newsletter from the Texas Academy of Family Physicians. Click here to read the profile.