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Medicaid expansion boosts providers’ workload

Steven Hartman, medical director at El Pueblo Family Health Services, chats with Rachel Davis Rankin at the clinic in Bernalillo. (Adolphe Pierre-Louis/Albuquerque Journal)

Steven Hartman, medical director at El Pueblo Family Health Services, chats with Rachel Davis Rankin at the clinic in Bernalillo. (Adolphe Pierre-Louis/Albuquerque Journal)

Copyright © 2015 Albuquerque Journal

The first wave of patients insured under New Mexico’s expanded Medicaid program began showing up at clinics this year bringing improved revenues for some, lower payments for others and in general increasing the workload for providers in a state that has a chronic shortage of medical staff.

Between Jan. 1, 2014, when the expansion took effect, and Nov. 1, around 177,000 New Mexicans enrolled in the Centennial Care Medicaid plan, according to the state Human Services Department.

The federal Affordable Care Act, also called Obamacare, offered federal money to states that expanded Medicaid benefits to adults earning 138 percent of the federal poverty level, or about $16,105 for a single adult. Before that, Medicaid covered primarily low-income children and pregnant women, disabled people and people over age 65 who qualified because of low incomes.

Gov. Susana Martinez decided in 2013 to expand New Mexico’s program, one of the few Republican governors who agreed to do so.

While thousands of additional New Mexicans now have insurance coverage to pay for care, medical facilities are concentrated in a few cities. Smaller cities and rural areas are severely short of providers to meet that demand.

At Sage Family Medicine in Farmington, a private clinic run by Nurse Practitioner Jodi Padgett, the growing numbers of new Medicaid patients who call for appointments – up to 15 a day, according to Padgett’s office manager, Lacey McCarty, represent a financial dilemma. Medicaid typically pays $85 for a routine office visit compared to the $100 to $120 that the clinic receives from a private insurance company, McCarty said.

“We haven’t turned anyone away, but we are definitely looking at that,” McCarty said.

Biz_jd_04jan_Bernalillo-Health-workersThe nonprofit Presbyterian Medical Services, based in Santa Fe, also has a clinic in Farmington and about 40 other primarily rural locations statewide. Presbyterian Medical Services, a separate entity from Presbyterian Healthcare Services, is designated as a Federally Qualified Health Center, which receives federal grants to serve the under- and uninsured.

Such clinics receive a flat rate reimbursement for treating a patient, regardless of the type of service provided. Private for-profit providers receive fees for each type of service provided to a patient during a visit, said Steven Hansen, CEO of Presbyterian Medical Services.

He said the number of Medicaid patients visiting PMS clinics was 11 percent higher than in 2013, while the number of uninsured patients decreased by 5 percent.

PMS typically receives a flat fee of between $120 and $155 for a patient visit, while an uninsured patient paying on a sliding scale depending on income could have paid as little as $25.

“So you can see the benefit to us to see Medicaid patients,” Hansen said.

He said private practitioners are not restricted to a flat fee and can bill Medicaid more for complicated patient visits.

At El Pueblo Health Services in Bernalillo, which has a similar federal designation and also serves uninsured as well as insured patients, the increased number of those who now have Medicaid coverage has been a boon, said Steven Hartman, El Pueblo’s medical director.

Medicaid reimbursement is higher than the sliding scale or county indigent fund payments the clinic received from many previously uninsured low-income patients. In the July to September quarter of 2013, the clinic saw 134 sliding scale and 145 indigent fund patients. In the same period this year, there were 59 sliding scale and 47 indigent fund patients.

“So now they are coming in with a (Medicaid) payer source, it’s a benefit to our clinic. For us it’s much better,” Hartman said.

Hartman said his clinic currently has sufficient capacity to care for the Medicaid patients who are coming to El Pueblo, but if that changes he may have to seek additional staff and that could be a problem.

Hansen echoed Hartman’s concerns about hiring extra medical staff.

“When we’re interviewing, we’re competing with Phoenix and San Diego, unless they’re looking for a frontier position,” Hansen said. “It’s been a challenge for many years and it’s becoming a greater challenge now,” he said.

Medicaid expansion has had an impact in Albuquerque, too. UNM Hospital saw the number of Medicaid patient visits jump by 12 percent from 234,889 in 2013 to 263,148 in 2014, according to spokesman John Arnold.

Presbyterian Health Care Services saw an 11 percent increase in the number of Medicaid patient appointments at its 11 primary care facilities in the Albuquerque metro area from 84,227 in 2013 to 93,176 in 2014, said David Arredondo, executive medical director, Presbyterian Medical Group. He said they have added Saturday opening hours at some clinics to help meet the demand.

Biz_jd_04jan_New-Mexico-Medical-shortage-Provider shortage

A recent study of New Mexico’s health care workforce by a committee created by state law in 2012 paints a stark picture. The study estimated the state has 1,957 primary care physicians, but 855, or 44 percent of those, are concentrated in Bernalillo County, the state’s most heavily populated.

The situation is the same for nurse practitioners and certified clinical nurse specialists, with an estimated 533 or 49 percent of the state’s 1,089 advance practice nurses located in Bernalillo County.

Even so, staff at First Choice Community Healthcare clinic in Bernalillo County, which serves many Medicaid and uninsured patients, say it can take up to four weeks to get an initial appointment.

“In New Mexico, the southeast and the northwest have the severest shortages,” said committee chair Richard Larson of UNM Health Sciences Center.

Without redistributing the current workforce, the study estimates the state needs 153 primary care physicians, 271 nurse practitioners/clinical nurse specialists and dozens of other specialists to meet gaps in service.

“This is not a new problem,” Larson said, “but we have some new solutions.”

He said the Legislature has provided funding for nine new residency positions in New Mexico to allow physicians to complete their required training.

There are also state tax credits and loan repayment programs available to physicians who work in rural communities. The committee also looked at ways communities can attract doctors, such as providing housing or office space. “The more a community can do to incorporate a new physician into the community, the more likely they can retain them,” Larson said.

Carolyn Montoya, interim chair of the practice team at the UNM College of Nursing, said the school received $1.6 million from the Legislature to increase the number of nurse practitioner and midwife students it accepts this year by 24 places. Those students will graduate in 2017.

“We really do try to take students from rural areas with the idea that we will place them in their own area for clinical (work) rotations. The strategy is so they can return (when they qualify),” Montoya said.

Also, the governor has pushed for infrastructure needed to access telemedicine programs in rural parts of the state.

There is also a shift in thinking about medical roles.

Alfredo Vigil, a physician with extensive experience in family care clinics in Española and Taos and a former state health secretary, said more emphasis is being put on using community health workers and mid-level professionals such as nurse practitioners and physician assistants to do routine work previously done by physicians.

“New Mexico has been one of the states on the cutting edge of doing this,” Vigil said.

But he cautioned it will take time to train professionals and bring them into the system. In the meantime, Vigil said, “The name of the game is not perfection, but doing the best we can.”