Low Medicare reimbursements in Sonoma County — blamed for helping drive physicians out of the county or out of private practice — could be fixed by legislation pending in Congress.
The House on Friday approved language that would bring a higher Medicare reimbursement rate to more than a dozen California counties currently designated as rural areas, including Sonoma County.
That “rural” designation has meant that Sonoma County doctors get a lower reimbursement rate than doctors in counties designated as “urban,” such as Napa, Marin and San Francisco. Local doctors say their counterparts in Napa and Marin get Medicare payments that are 10 to 15 percent higher than what they receive.
The change could have an impact far beyond Medicare billings, because most private insurers base their reimbursements in large part on Medicare rates.
“This fix isn’t about paying certain doctors more, it’s about paying all doctors fairly,” said Congressman Sam Farr, D-Carmel, who authored the language that would dump California counties’ “rural” designation.
“When doctors start to turn away elderly patients, something is drastically wrong,” he said. “Medicare is around for a reason, and this reimbursement problem is chipping away at its value.”
Under the legislative fix, Sonoma County would be newly classified as a metropolitan statistical area, which it already is by the Census Bureau, and thus qualify for a higher reimbursement rate.
The language is part of a larger bill approved Friday, HR 4213, that seeks to extend unemployment benefits as well as delay a 21 percent cut in Medicare reimbursements for doctors across the country.
The Senate broke for the Memorial Day recess before taking up the bill. The 21 percent cut takes effect June 1.
“We are very pleased that the House voted positively on HR4213 — this is a major step in being able to provide health care to our Medicare patients,” said Dr. Catherine Gutfreund, the incoming president of the Sonoma County Medical Association.
“However, it’s deplorable that the Senate did not act upon this before leaving for Memorial Day vacation,” she said. “In Sonoma County, physicians are already reimbursed at a low rate. If an additional 21 percent is withheld that makes it extremely difficult to keep your practice open.”
Farr said he had “wished” the Senate had taken action this week, but “I’m hoping they’ll pass the bill as soon as possible.”
The Centers for Medicare and Medicaid Services announced Friday that it would delay processing claims for two weeks while awaiting Congressional action.
Medicare reimbursement rates are calculated using a formula known as the Geographic Practice Cost Index, or GPCI (pronounced Gypsy). The index adjusts Medicare rates based on local geographic market conditions, such as the cost of staff, office rent and malpractice premiums.
Tom Mentzer, Farr’s spokesman, said the GPCI “fix” would direct $400 million to California doctors, with almost $7 million annually going to Sonoma County.
The GPCI fix would move Sonoma County and 13 other counties out of the rural status. Marin County, though already designated as an “urban” area under Medicare, would see its Medicare rates increase because it would become part of San Francisco’s MSA.
Congressman Mike Thompson, D-St. Helena, said Sonoma County’s rural designation has made it difficult to attract and retain doctors, because most private insurance providers base their rates on Medicare.
“Sonoma County will be reimbursed at a more appropriate rate,” Thompson said Friday evening. “We’ve been getting a reimbursement rate as a rural area. In fact we’re more of a metropolitan area.”
The other counties that would benefit are El Dorado, Monterey, Placer, Riverside, Sacramento, San Benito, San Bernardino, San Diego, San Joaquin, San Luis Obispo, Santa Barbara, Santa Cruz and Yolo.
The earliest the Senate is expected to take up the legislation is June 7 and any changes made to the bill will go back to the House.