Maryland’s Early & Periodic Screening, Diagnosis, and Treatment Program is lowering rates paid to providers of private duty nursing. The EPSDT program is Medicaid’s child health component which provides comprehensive and preventative health care to individuals under the age of twenty-one. Many Maryland children have care needs so complex, it requires the assistance of an aide or nurse for specified periods of time during treatment. The Omnibus Budget Reconciliation Act Act of 1989 ensures the accessibilty to care services for recipients. In order for health care providers to bill for services rendered to the EPSDT recipient, they must enroll in Medicaid as a certified provider. Once certified, providers can provide private duty nursing services to children with medical need.
Provider reimbursement rates have always been low and regulations have always been comprehensive, to say the least. Many providers never make it through the process of becoming certified due to the high standards. However, those who become certified can then market to Medicaid recipients and bill for those services provided. Considering reimbursement rates were already low and the state had already issued a rate increase in the past year, it begs the question: How will providers be able to provide the same level of care with less money?
Private duty nursing is a heavily regulated practice in the State of Maryland. Supervision of EPSDT recipient cases is intense. In order to attract quality nurses and an experienced registered nurse supervisor, providers must budget properly and that’s no easy task. Consider this; in 2009, the reimbursement rate for one unit (15 minutes) of nursing was 7.91(yes, you read it right). The average cost of supervision is $50.00 per month/per case. Compliance-related paper work accounts for another 1% and marketing accounts for 10% of the provider’s budget. The average licensed practical nurse makes $22.00 an hour in Maryland. With the 2009 reimbursement rate of 31.64 an hour, you can see a provider’s profit is a mere $3.00 an hour. Now, from that $3.00, a provider must pay an RN to supervise the care. Again the average for an RN supevervisor on a EPSDT case is $50.00 per visit. This monthly supervision is mandated but not reimbursed by the state. Throw in another 2% for overhead costs and what becomes obvious is a financial loss for the provider. But we’re not done. In 2010, a .03% reduction in reimbursement rates was issued by the state and the latest reduction takes affect October 31, 2011 (Maryland Register, 10/2011). How will providers make up the difference without sacrificing care goals?
We’re already witnessing what can happen when providers and pharmaceutical companies feel the squeeze from public health programs. We are experiencing the worst drug shortage in recent history. Manuafcturers are no longer willing to produce generic drugs for low reimbursement rates. Likewise, some provider practices are no longer accepting Medicaid and Medicare patients while others refuse to accept new patients. Home care is a growth industry. We are finding new ways of delivering care in the home setting with good results. The lowering of reimbursement rates paid to good providers may have a negative impact on the public’s health. Fraud is already at an all-time high. Will a rate reduction cause some providers to engage in practices they would normally never consider? If providers are forced to lower rates paid to licensed care givers, can patients expect to see a lower quality of care delivery? Given the current climate, it may be unavoidable. Smaller providers may not be able to survive in the reform market. Some may need to consider merging with larger operations or finding other ways to draw revenue. If quality of care is lowered, hospital re-admissions will increase. When all variable are weighed, it may not be a question of whether or not providers can afford a rate decrease. A better question may be, can Maryland’s health care system afford it?
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