Medicaid fee disputes between specialties
It shall be a policy of CMS regarding Medicaid fee disputes between specialties:
- CMS affirms current policy (235.975 Out-of-Network and Network Adequacy) that states, “It is the basic right and privilege of each physician to set fees for services that are reasonable and appropriate, while always remaining sensitive to the varying resources of patients and retaining the freedom to choose instances where courtesy or charity could be extended in a dignified, ethical and lawful manner.”
- Because it is the strong preference of the board of directors that CMS represent the entire house of medicine as one voice, CMS does not involve itself in Medicaid fee disputes that benefit one specialty over another, except when serving as a convener of the involved specialties to achieve consensus or as otherwise determined by the Council on Legislation and approved by the board of directors.
CMS will vigorously advocate for increased fees and/or improved processes in the Colorado Medicaid program that benefits all specialties or where there is a consensus desire from the house of medicine.
(Board action, Jan. 19, 2018)
Medicaid block grants
Colorado Medical Society supports adequate Medicaid funding provided by the state and federal government.
240.991 Medicaid Specialty Access
The Colorado Medical Society places a high priority on access to specialty care in the Medicaid Accountable Care Collaborative Program and advocates to maintain primary care reimbursement at least at Medicare parity levels.
CMS will explore and find consensus on specialty access tactics including, but not limited to:
- Innovative use of and payment for telemedicine.
- Direct Regional Collaborative Care Organizations contracting with:
- Specialists who agree to health information exchange and referral tracking; and,
- Ambulatory Surgery Centers.
(BOD-1, AM 2014)
240.992 Pharmacy Benefit Manager (PBM) Adjudication for Physician Dispensing
The Colorado Medical Society supports the alignment of Colorado statutes with federal law to allow physicians to continue to engage in the dispensing of prescription medications to patients, and the adjudication of such transactions with Pharmacy Benefit Managers (PBMs).
The Colorado Medical Society affirms the need to remove restrictions on the adjudication of physician dispensed prescription medication transactions with Pharmacy Benefit Managers (PBMs).
(RES 14-P, AM 2013; Reaffirmed, BOD-1, AM 2014)
240.993 Medicaid Expansion
The Colorado Medical Society (CMS) supports the expansion of Medicaid under the terms of the 2010 Patient Protection and Affordable Care Act (ACA).
To facilitate successful expansion of access to health care under Medicaid and the ACA, we recommend that the following reforms be addressed urgently. We stand ready to work with the state and other stakeholders on these changes to enhance the value of the Medicaid program to patients and taxpayers.
CMS has championed the longstanding goal of achieving health care coverage for all Coloradans. We have argued that efforts to redesign Medicaid and the larger health care system have to be about more than just improving coverage. They have to be about providing cost-effective, quality and safe medical care. That is one of the reasons we strongly support the Accountable Care Collaborative and it’s focus on cost-effectively improving the health of Medicaid patients through the use of local, patient-centered systems of care. Improving upon the ACC by developing and following a clearly defined, transparent pathway addressing the following high priority areas will accelerate the already promising cost, quality and patient satisfaction trends within the program. CMS strongly encourages efforts to address these systemic issues:
- Access to care – Ensure appropriate access to care by enhancing reimbursement rates for all physicians to equitable levels that are at least at parity with Medicare.
Preserve and innovate liability protection – Maintain Colorado’s relatively stable medical liability climate and provide enhanced protections for the use of evidence-based approaches to care management, including, but not limited to, shared decision making models.
- Utilize the HB1281 pilots and other initiatives to test and accelerate the adoption of alternatives to fee-for-service payment, including bundled payments and other methodologies.
- Support 12-month continuous eligibility for children in Medicaid, per existing law.
Patient engagement – Maximize clear, shared accountability between patients and physicians across the spectrum of care.
- Explore and promote other options to facilitate patient engagement, health literacy, healthy behaviors and reduce avoidable use of high cost services.
- Provide incentives for patients and physicians to use patient decision aids and shared decision-making tools.
Administrative simplification – Eliminate unnecessary administrative complexity, increase efficiency and standardization of Medicaid administrative processes.
- Streamline provider enrollment procedures, standardize use of nationally recognized transaction codes (CAHQ/CORE), maximize efficiency of prior authorization using electronic procedures, improve eligibility determination timeliness and transition to Medicare 1500 electronic claims submission.
- Develop and document a well-defined, fair administrative process for cases of suspected fraud and abuse that includes due process for providers.
(Motion of the Board, January 2013; Reaffirmed, BOD-1, AM 2014)
240.994 Medicaid/Medicare Parity in Reimbursement Rates
If the state of Colorado elects to receive federal dollars to expand its Medicaid program under the Affordable Care Act, the Colorado Medical Society supports the rapid enactment of parity between Medicare and Medicaid physician reimbursement that encourages physician participation.
(LATE RES 8-P, AM 2012; Reaffirmed, BOD-1, AM 2014)
240.995 Remove Exemptions from Medicaid Prescribing
The Colorado Medical Society support if proposed legislative relief to remove from 25.5-5-501 1(a) the exemption for generic substitution for medications to treat biologically based mental illness, cancer, epilepsy and HIV.
(RES 4, AM 2010; Reaffirmed, BOD-1, AM 2014)
240.996 Medicaid Guiding Principles
Goal of the “Medicaid Reform Task Force: To improve the quality of care for Medicaid recipients and increase the efficiency of the program which would create cost savings and enhance provider participation.
Improve access to care
- Ensure access and coverage for all eligible persons
- Primary care centered; patient-family centered to promote continuity of care
- Ensure local control and local networks to enable availability and sustainability of the medical home
- Establish a personal medical home for all Medicaid clients
- Organized, coordinated, and continuous care that integrates dental, specialty, and mental health services for any patient
- Team-based care
- Establish a well-coordinated care management system for specific high risk, high cost conditions and disease states
- Emphasis on prevention and wellness programs
- Utilize incentives to leverage more provider participation
- Ensure an adequate network of local providers with broad specialty facilitated referral network
- Improve reimbursement rates that are adequate and equitable
- Medicare parity or “not for loss”
- Does not diminish access or quality of care
Improve quality of care and health outcomes
- Ensure cultural competency by providing care appropriate to patient beliefs and values; respectful
- Promote evidence-based medicine with appropriate individualization of care
- Emphasize collaborative team-based care with physician and health care professional direction
- Establish best practice guidelines
- Utilize performance measurements that enable continuous quality improvement
- Create shared accountability for all parties
- Facilitate transparency of data to providers
- Educate and improve patient health literacy
- Encourage patient responsibility
- Achieve cost savings
- Create a shared accountability amongst all parties, including health care professionals, care managers, local networks and administrators, for the overall improvement of the program
- Utilize limited resources in the most cost efficient manner
- Savings reinvested back into the Medicaid health care system
- Reduce inappropriate, ineffective services and cost
- Seek and leverage all potential state and federal dollars to improve the infrastructure
Enable informed decision-making
Enabling more informed decision-making by physicians and patients at the point of care is essential to improving the quality and efficiency of care. The Medicaid Reform Task Force supports a Medicaid care management delivery system that encourages and supports the interoperable exchange of health information using secure health information technology applications. Functions should include:
- Functional data systems for tracking and reporting
- Share data at all levels (i.e. state, local provider)
- Use of immunization and disease registries, as appropriate
Promote culture of collaboration among all stakeholders
- Create an atmosphere of open dialogue to share information at all levels
- Promote continuous consensus building among all health care stakeholders
- Establish a meaningful relationship between medical professionals and stakeholders to achieve consensus policy input and development
(BOD-1, Progress Report, Attachment 1, AM 2007; Reaffirmed, BOD-1, AM 2014)
240.997 Medicaid Pharmacy Benefits
The Colorado Medical Society (CMS) endorses the concept that the Medicaid program may establish a list of preferred drugs that should be used for treatment of Medicaid beneficiaries, provided that such list should include drugs of every class of clinically useful medication, selected so as to establish cost savings and yet preserve professional choice in selecting agents of expected clinical effectiveness without inefficient and time wasting approval procedures.
The CMS supports a preferred drug list as developed by a committee including practicing physicians of multiple specialties for Medicaid in order to encourage cost-effective, quality health care.
(Late RES-36, AM 2003; Revised, BOD-1, AM 2014)
240.998 Medicaid Reimbursement and Patient Access to Physicians
The Colorado Medical Society shall continue to work with legislators, other appropriate individuals and private/state organizations to educate them regarding:
- The economic pressures on physicians in private practice that prevent them from providing the access to Medicaid patients they would prefer,
- The lack of availability of physicians to care for Medicaid patients,
- The need to increase levels of Medicaid reimbursement to at least Medicare levels, and
- That any Medicaid fee schedule must recognize the value and cost-effectiveness of physician cognitive services and patient care management, without losing sight of the need for fair reimbursement to physicians rendering procedural services.
(Late RES-31, AM 2002, RES-12, AM 1985; Reaffirmed, BOD-1, AM 2014)
240.999 Medicaid Position Paper
The Colorado Medical Society (CMS) supports efforts to create a streamlined Medicaid program that will promote state innovation and efficient use of funds, while maintaining the program’s role as a safety net for the state’s poorest and most vulnerable populations. This Policy is detailed in the CMS Position Paper on Medicaid.
Additional Information: Medicaid White Paper
(Motion of the Board, March 1996; Reaffirmed, BOD-1, AM 2014)