Buried in the Affordable Care Act was what seemed a sweet deal for doctors willing to treat Medicaid patients: an estimated 70 percent pay boost.
There was a good reason for it. The law was adding millions of people to the health insurance program for the poor, at a time when fewer doctors would sign on because it pays them so little.
But the two-year bump has had a mixed impact. It hasn't been a boon for every physician willing to work with Medicaid, a program that manages to be both critical safety net and political tangle.
Some, like Palm Harbor physician Esther Browne-King, are still chasing after private managed care companies for their money. Others, like St. Petersburg allergist Mona Mangat, find quirks in federal regulations are shutting them out of the raise.
And even those benefiting from the increase fear what will happen when it ends in December. Wesley Chapel pediatrician Jose Jimenez is serving more poor kids now with the extra money. So he's among many hoping for the unlikely: that the state will find the money to keep the higher rates going.
As for the goal of increasing physician participation? Many doctors say they don't know anyone who is accepting Medicaid solely because of the temporary hike.
"Just doing a two-year patch … probably isn't enough," said Dr. Bruce Flareau, president of BayCare Physician Partners. Doctors "have been holding back saying, 'What's the sustainability of that reimbursement?' "
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When the U.S. Supreme Court upheld the Affordable Care Act, it made the Medicaid expansion optional. Florida chose not to extend benefits to nearly 1 million adults.
From the start, authors of the law knew a Medicaid card wouldn't be of much use if too few doctors accepted it.
Nationwide, Medicaid fees for primary care in 2012 averaged just 60 percent of fees from Medicare, the plan for seniors and the disabled, according to the Kaiser Commission on Medicaid and the Uninsured. Florida's Medicaid program pays even less than the national average.
Medicaid nationwide typically paid physicians $38 for a 15-minute office visit with established patients. Under Kaiser's estimate, that means Medicare would pay about $64 for a similar visit.
The disparity has an impact. One survey of 15 urban areas found that fewer than half of physicians, including specialists, accept Medicaid, according to Merritt Hawkins, a national health care consultant.
So for 2013 and 2014 the law brought Medicaid primary care payments to the Medicare rates. Julia Paradise, an associate director at the Kaiser commission, said it was the best that could be done. "The fact it was limited to two years was a reflection of funding issues," she said.
So far, only Maryland has indicated it will continue the rates, said Matt Salo, executive director of National Association of State Medicaid Directors.
Gov. Rick Scott's proposed budget has no funding for the doctors, and some Florida legislators believe they're taking care of the matter with a 2011 law that moves nearly all Medicaid patients into managed care.
That law also requires managed care companies pay doctors Medicaid rates equal to Medicare, or else face fines. Yet that requirement doesn't kick in until the companies have been in operation for two years.
Legislators appear satisfied they've done enough.
"Our reforms to Medicaid have already addressed the issue of physician payment rates for the future," said Rep. Richard Corcoran, R-Land O'Lakes, chairman of a special committee on the Affordable Care Act.
Some physicians are skeptical the state will force the managed care companies to pay the higher rate.
"My hope is that it will be enforced," said Jimenez, the Wesley Chapel pediatrician, who serves on the Hillsborough Medical Association board. "But it's vague the way it's written."
The Florida Medical Association has estimated it would cost the state about $150 million to guarantee the higher rates next year. The association wants the state to step up.
"From our standpoint, it has nothing to do with the Affordable Care Act," said Jeff Scott, the FMA's general counsel. "It's just something that should have been done a long time ago, and it's something that should continue on."
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At Small World Pediatrics, about half of the children Jimenez sees are on Medicaid.
"It's absolutely huge, the difference between the new rates and the old rates," he said. In fact, about 20 percent of his gross earnings last year were due to the increase in Medicaid reimbursement, which has allowed him to accept more patients and hire a new office staffer.
Jimenez said he harbors some hope that the state will continue the higher rates. If not, he may have to scale back the number of Medicaid patients he can take. "If the rates go back down, I'm worried that the access issue will get worse," he said. "And if it happens, who will see all these patients?"
Dr. Karalee Kulek-Luzey, medical director of Pediatric Health Care Alliance in Tampa, said her practice also is able to help more poor children due to the higher rates. It's something they hope to continue — if possible.
"Who pays for it after 2014 is a negotiation process," she said. "I would hope they understand it's a best use of their resources."
Browne-King, the family medicine doctor in Palm Harbor, says half of her patients are on Medicaid, and some come from as far as Hernando County. But the managed care companies with which she contracts still haven't begun paying her the higher rates, and she's not sure how much longer she can handle so many Medicaid patients.
"I'm still waiting," said Browne-King.
So is Dr. Mangat, a St. Petersburg allergist who chairs the board of Doctors for America, a national movement of physicians and medical students dedicated to health care reform, including Medicaid expansion.
Mangat, among the few in her specialty who take Medicaid, had thought she would qualify for the higher reimbursements. But because of how the regulations are written, allergists who are medical doctors are not eligible for the increase. Yet allergists who are doctors of osteopathic medicine are eligible.
Mangat said she wants Florida to continue the two-year bump for her colleagues. But she doesn't believe it will happen.
"Their rhetoric is that Medicaid is a broken system," she said. "There's no way they're going to put more money into it."
Jodie Tillman can be reached at firstname.lastname@example.org or (813) 226-3374.