The Register-Herald, Beckley, West Virginia

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June 7, 2014

New Medicaid repayment is threat to rural health clinics

Effects of a lawsuit

— A 3-year-old lawsuit that altered how rural health clinics are reimbursed for treating Medicaid patients now poses a threat to those very clinics, a local doctor says.

The resident of Summersville Pediatrics says his clinic is just one of many facing up to this problem.

“Summersville Pediatrics is a rural health clinic,” Dr. Mark Tomsho said. “In West Virginia, there are about 50 or 60 rural health clinics. They can be hospital-associated or private clinics that fulfill certain criteria and fulfill ongoing criteria.

“The benefit of that is that they get an enhanced reimbursement from Medicaid for seeing Medicaid patients. Without that, practices and clinics would not be able to financially see Medicaid patients or they would only be able to see a very limited number. This allows rural health clinics to serve the financially less-fortunate in West Virginia.”

Tomsho said this lawsuit changed the way Medicaid pays back clinics. Clinics are reimbursed by the state which is reimbursed by the federal government.

“The state has used a methodology called ‘The Alternative Payment Methodology’ for several years,” he said. “A couple of years ago some federally qualified health clinics (FQHCs) felt this payment system was not fair.

“They filed a lawsuit. In the evolution of the change, the state has come up with the state plan amendment that amends how they will calculate the reimbursement to FQHCs. They have to treat FQHCs and Rural Health Clinics the same, so it affects us, too.”

Tomsho said it averages out to be about $29 lost per patient, per visit.

“We see in the range of 24,000 Medicaid visits per year in our clinic,” he said. “This is a cut, going forward, of about $750,000.

“Our clinic cannot survive a cut of that magnitude. It would require massive cuts of physicians, nursing staff, ancillary staff. It would just devastate Summersville Pediatrics.”

The take-backs created by the plan pose an even bigger problem, Tomsho said.

“If the new calculation ended up in favor of the clinic, they get more money. If the calculation says the clinic was overpaid, they will have to take money from the clinic.

“This becomes retroactively applied to Oct. 1, 2012. Since then, we have seen about 40,000 Medicaid visits. You multiply that by $30 and you get about a million dollars that has to be paid to the government. That would bankrupt our clinic that I have had for 28 years.”

This doesn’t just affect his practice, Tomsho said.

“If this affects even half the clinics the way this affects me, many of these clinics will have to cut services and staff. If this take-back is enforced, it will be devastating.

“This rule applies to all rural health clinics. Minnie Hamilton Health Care in Calhoun County is also in the same boat. They could be losing as high as $50 per patient.”

Even more importantly, Tomsho said, is how it could affect patients.

“This is the most vulnerable section of West Virginia’s population,” he said. “It’s those who are financially disadvantaged. It would be harming them in a way that would take a very long time to repair.

“They’d have to find new physicians, if they even could. There would be travel concerns for some. There would be those with special needs, chronic conditions and immediate needs that we wouldn’t be able to care for. We’re the only pediatric practice in Nicholas County and we serve several other counties. Other rural health clinics serve the same purposes.”

Tomsho says he hopes the public will step forward and tell the government that this does more harm than good.

“This is a government agency,” he said. “I truly don’t think anyone would want to harm the health care access of the citizens. I think if people called their local delegates and the governor and said, ‘What’s going on with rural health clinics?’ then something would be done.

“People should also call their local clinic and find out if it’s a rural health clinic. If it is, ask if they know about this reimbursement issue and the state.”

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