Medicare reimbursement rates 2014 update: What will it take to put a “fix” into the “Doc Fix” for real Medicare payment reform? For doctors, seniors and Tricare beneficiaries, the nail-biter has become a familiar. Lawmakers invariably defer the cuts in Medicare payments to providers, commonly referred to as the “doc fix” which was originally a payment reimbursement formula developed back in 1997.

Everyone agrees this formula is broken and beyond repair. But these “kick the can” deferrals are always temporary due to the difficulty of finding offsetting funds, or cuts, to pay for a permanent fix. (This payment issue is important to Tricare beneficiaries because Tricare’s reimbursement rate to its providers is tied to the Medicare payment rate). In 2010 alone, Congress delayed the cuts with temporary patches five times — with the longest patch lasting one year.

Now to this year. The Congressional Budget Office (CBO) on Feb. 5 lowered its estimated 10-year cost of freezing Medicare physician pay by a whopping $100 billion-plus. This is a move viewed by many as a potential “game changer.” In that this may help to create an opening for Congress to pass a permanent Medicare “doc fix” perhaps this year. CBO’s latest estimate is $138 billion, which is down considerably from its August 2012 estimate of $245 billion to replace the current doc fix formula.

CBO’s latest estimate is $138 billion, which is down considerably from its August 2012 estimate of $245 billion to replace the current doc fix formula.

The current physician payment patch doesn’t expire until Dec. 31 of this year, but lawmakers have said they want to tackle the issue as part of a broader budget discussion. The new CBO estimate makes that task a little more manageable, though still difficult, according some lawmakers during this week’s hearing on the subject.

Although it is vexing as to how best to move into a new payment model, there is broad consensus that any new model must reward quality and value, reward efficiency, and reward collaboration for a beneficiary centered approach to care. The Military Officers Association of America (MOAA) has long advocated for a permanent fix to this flawed formula.

A repeal of the current formula would provide a stable payment system to providers — and most importantly, will protect access to care for seniors and Tricare beneficiaries, now and into the future. Hopefully, Congress and the administration can take advantage of the fact that the cost of repealing the doc fix is lower than it has been in many years and will replace this formula with a new system that encourages quality of care while reducing costs. [Source: MOAA News Exchange | Kathryn M. Beasley | 20 Feb 2013]

Tricare prime update: Tricare Management Activity has a new online tool for retirees under age 65 and surviving spouses to verify if their Prime network will end Oct. 1, forcing them to use Tricare Standard. With the new fiscal year, managed care networks operating beyond 40 miles of military treatment facilities or base closure sites will be halted under next-generation Tricare support contracts.

The change, to impact 171,000 beneficiaries, is intended to cut Tricare costs for taxpayers. At the website www.tricare.mil/psazip, Tricare users can type in their zip code and learn whether their Prime service area will exist after Sept. 30. They also can find contact information for contractors and can sign up for email alerts on additional changes planned to Prime service areas. There are three Tricare regions in the United States.

South Region will be most heavily impacted by rollback of managed care networks. The contractor there, Humana, now offers Prime everywhere across Alabama, Arkansas, Florida, Georgia, Kentucky (Fort Campbell area only), Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee and Texas (excluding the El Paso area).

Effective Oct. 1, Humana’s networks will shrink to those within 40 miles of a military treatment facility or of a base-closing site.

In North Region, military managed care for under-65 retirees and survivors will end in these areas: Springfield, Mass. (into Connecticut); Kankakee, Ill.; Gary, Ind.; Auburn, Mich.; St Louis, Mo.; Charlotte, Greenville, Raleigh/Durham, Wilmington and Winston-Salem-Greensboro, N.C; Akron and Cincinnati, Ohio; Pittsburgh, Pa. and Milwaukee, Wis.

In West Region, Prime networks will end in: Des Moines, Iowa; Minneapolis, Miss., Springfield, Mo.; Eugene, Medford, Portland and Salem, Ore.; Portland and Yakima, Wash, and the Outer Islands of Hawaii. [Source: Stars & Stripes | Tom Philpott | 21 Feb 2013]