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Meeting Request to Discuss Alabama Medicaid Physician Office Visit Limit Policy: Improve Access to Affordable Care for Alabama Cancer Patients

To Whom it May Concern in the Offices of Commissioner Azar,

Thank you for the opportunity to share our concerns and provide critical insight into some of the unintended consequences of the Alabama Medicaid physician office visit limit policy. As you are aware, Alabama’s Medicaid program limits enrollees to 14 physician office visits a year without means to request more and without any additional considerations for specialized disease states. The result is that cancer patients exceeding their limit across the state are experiencing significant delays in care while new treatment protocols are established. This delay can lead to disease progression, poorer overall outcomes, and ultimately higher costs to Medicaid once patients are diverted into the hospital outpatient setting.

With all of this in mind, we at Southern Cancer Center (SCC) would like to request a meeting with you to offer our experience, insights, and expertise in support of developing solutions to the current visit limit policy.

Established in 2007, SCC is Alabama Gulf Coast’s only community-based multidisciplinary oncology practice. We are comprised of 28 providers with eight clinic locations across Daphne, Foley, Mobile, and Huntsville. Through an integrated, team-based approach, we are dedicated to finding and providing the most advanced therapies and innovative treatment options for the patients we serve fighting cancer and diseases of the blood. We treat roughly 16,500 patients per year, over 1000 of which are enrolled in Alabama Medicaid programs.

Treating patients with cancer is a highly individualized process which requires the patient’s physician and care team to consider numerous factors when designing an appropriate treatment regimen. No two patients need the same required medications, dosage, scans, or number of visits to the office to achieve positive outcomes. Limiting cancer patients to a designated amount of office visits does little to manage overall utilization since they will still need to seek continued treatment elsewhere. In our experience, this does not result in savings to the system but instead merely interferes with the development of important physician/patient relationships and diverts care to the highest cost sites of service.

There are many ways in which this policy is rendering it almost impossible for us to provide our Medicaid patients with the same quality care we deliver non-Medicaid patients with similar disease states. Here are a few examples:

New Medicaid patients typically exhaust their annual visits before they are referred to us. It often takes time to secure a correct diagnosis, which consumes their allotted visits and renders the patients unable to follow through with their full treatment plans at our facility;

Ongoing patients in active treatment often reach their limit mid-way through the year, forcing them to decide whether to leave our practice or to try to pay for their visits out of pocket;

• According to a study published in the Journal of Clinical Medicine Research1, more than half of patients diagnosed with some of the most common cancers are also being treated for chronic co-morbid conditions. These patients trigger the limit even earlier in the year because they are forced to split their visits between multiple specialties to receive necessary care; and

• Since the limited allowable office visits include all specialties including primary care, patients are incentivized to delay going to their doctors when they are acutely sick to preserve visits for their chronic care needs. Patients who ration care this way are less likely to adhere to the treatment plans we set and are more likely to present in the emergency room with advanced disease that requires high-cost inpatient care.2

Alabama is the second most restrictive state in the country when it comes to Medicaid physician office visit limits. According to our policy team’s 50 state Medicaid program review, 36 states do not have physician office limits while only 14 states do. Out of these 14, only five states do not offer a policy mechanism for providers to request more visits if medically necessary. The third most restrictive state was Mississippi with a limit of 32 physician office visits per year while the most restrictive state was Wyoming which offers coverage for only 12 visits annually.

Since our state does not have considerations in our office visit limit policy to account for the needs of specialized patient populations, our practice has had to make some difficult decisions to ensure our patients can continue receiving care. Alabama Medicaid Agency guidance recommends that when one of our patients has exceeded their visit limit, we provide them with education on where they can go to receive continued care. This education includes the following recommendations:

• Visit your County Health Department website to receive covered primary care through your nearest Family Health Service location; and

• For affordable specialized care, visit your nearest Federally Qualified Health Center or Rural Hospital to receive federally subsidized indigent care with a sliding scale for out-of-pocket payments.

While these recommendations may work for the otherwise healthy patient populations within Alabama Medicaid, our care team has encountered several obstacles for cancer patients that they do not account for. When a patient is diagnosed with cancer their oncologist essentially becomes their primary care provider. Providers that are not trained in oncology related illnesses are not equipped to diagnose and treat complications that could be an externality of cancer treatment. Thus, a common practice has developed where primary care providers automatically refer cancer patients with acute symptoms back to their oncologist in case the symptoms are related to their medications or their disease state. Family Health Services are therefore unable to treat our patients so, unfortunately, we are unable to refer them there for appropriate care coordination.

We are not aware of any Federally Qualified Health Centers or subsidized rural hospitals in our state that maintain an oncologist on staff or have the full resources to treat a cancer patient. We are unable to refer our patients to continue to receive affordable care through these sites of service as they are immediately referred back to us. This leaves us with only two options that could ensure our patients still receive care:

A. We work with the patient and our team of billing staff to find patient assistance programs, charitable donations, and available practice funds from our own reserves to cover the patient’s out of pocket costs.

B. In the event we are unable to secure additional financial resources for our Medicaid patients, we call around to our contacts at all the for-profit hospitals in the region to see if they are willing to take referrals for Medicaid enrolled cancer patients needing indigent care (which they sometimes refuse to do).

At our practice we believe that taking a team-based approach is essential to providing high quality cancer care- so we do everything in our power to preserve the relationships that our care team has formed with our patients. We always start with the former option for our Medicaid patients; however, there are limitations to patient assistance programs. Our ability to secure additional funding or manufacturer supplied drugs is dependent on patient eligibility and manufacturer funding availability. For those patients where we are unable to cover in-office medical service costs, we must interrupt their treatment plans to find them a new care team in a higher cost hospital setting. By the time they are settled in with their new care team their disease may have progressed and their treatment needs could have become more burdensome on their caregivers as well as on the health care system. Additionally, shifting the patient to the hospital setting does not resolve their financial burden. Instead of working with their community care team to create an affordable payment plan, they are now vulnerable to higher costs at the hospital system.

According to numerous studies, the cost of care for patients receiving treatment in a community oncology clinic is consistently lower compared with the hospital outpatient setting for relatively every treatment we provide3. Since the physician office visit limit policy diverts patients away from our site of service and the federally subsidized sites are not an option, the actual effect of this policy is that patients are being steered toward the highest cost options. This means that Alabama Medicaid patients with cancer are costing the Agency significantly more money by going to hospital-based systems than they would if the office visit limit policy did not apply. For the benefit of the financial health of the state and the benefit of our patients here at SCC, we recommend the Agency revise their physician visit limit policy.

We at Southern Cancer Center look forward to the opportunity of working with you to improve the policy and find a solution that benefits both the program and its cancer patients long term. We look forward to hearing from you with available dates to meet and discuss further. Thank you for your consideration.

On Behalf of the Physicians at Southern Cancer Center,

Lauren Pettis, MSN, RN

Executive Director Southern Cancer Center (SCC)


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