Regulators Unhappy With Mayo Memo on Prioritizing Patients

April 25, 2017

The state of Minnesota is not satisfied with the Mayo Clinic's explanation of what its CEO meant when he asked staff last year to prioritize commercially insured patients over publicly insured patients when they're referred for the same problem.

"I remain concerned that Mayo has yet to offer the community a strong, clear position on the equal treatment of patients on Medicaid," said Nathan Moracco, assistant commissioner of the Minnesota Department of Human Services (DHS), in an April 14 letter to John Noseworthy, MD, Mayo's president and CEO.

The Star Tribune in Minneapolis, Minnesota, reported excerpts of Dr Noseworthy's videotaped speech in March. "We're asking...if the patient has commercial insurance, or they're Medicaid or Medicare patients and they're equal, that we prioritize the commercial insured patients enough so...we can be financially strong at the end of the year to continue to advance, advance our mission," Dr Noseworthy is quoted as saying.

"If we don't grow the commercially insured patients, we won't have income at the end of the year to pay our staff, pay the pensions, and so on, so we're looking for a really mild or modest shift of a couple percentage points to shift that balance."

Dr John Noseworthy

The clinic later said that it had no intention of delaying appointments for Minnesota Medicaid patients to book commercially insured patients sooner.

The brouhaha at the Mayo Clinic about prioritizing patients has some of its roots in the Affordable Care Act (ACA). Like 30 other states, Minnesota expanded Medicaid eligibility under the ACA, which brought an additional 223,000 residents into the program as of March 2016, according to the Kaiser Family Foundation. In his speech to employees last year, Dr Noseworthy said that a recent 3.7% increase in Medicaid patients at the Mayo Clinic was a "tipping point" for the need to rebalance the organization's payer mix.

Dr Noseworthy's comments prompted Minnesota DHS Commissioner Emily Piper to dash off a letter of "dismay" to the Mayo Clinic about unequal treatment for enrollees in the state's Medicaid program, called Minnesota Health Care. Her assistant, Nathan Moracco, followed up with a letter posing a pageful of questions about the new policy Dr Noseworthy was apparently describing in his speech to employees.

What new policy? Dr Noseworthy essentially replied.

"Minnesota Medicaid patients continue to have the same access to appointments at Mayo Clinic as commercially insured patients," he wrote DHS, noting that medical need is the primary factor in booking a visit. "There has been no internal procedural or operational change that affects Minnesotans with Minnesota Health Care Program coverage."

In a more detailed response to the state's questions, a Mayo exec in its Medicaid operation expanded on Dr Noseworthy's assertion, saying that his organization continues to comply with DHS mandates for scheduling and caring for Medicaid patients. "Minnesota Medicaid patients will not experience delays in the order they are seen or provided care," wrote Ronald Grousky, Mayo's authorized provider representative for Medicaid enrollment.

"We Have to Make the Numbers Work"

In a reply to Dr Noseworthy shared with Medscape Medical News, Nathan Moracco at Minnesota DHS said Mayo needed to explain its patient appointment policies in "precise and clear terms."

The equal access to appointments that Mayo promises to Medicaid patients, Moracco said, is not the same as equal treatment. He also noted that Dr Noseworthy spoke of medical need as the primary factor in making an appointment, but "left out secondary factors that may be used to distinguish treatment for Medicaid clients."

In a statement issued to Medscape Medical News, DHS said it appreciated Dr Noseworthy's timely and open response, but "some uncertainty remained." The department was waiting to receive the clinic's follow-up response.

Medscape Medical News asked to interview Dr Noseworthy or someone else in the Mayo Clinic about Moracco's letter and the meaning of the CEO's exhortation to prioritize commercially insured patients. The media affairs department once again pointed to a statement by Dr Noseworthy that was provided to Medscape Medical News last month.

"In an internal discussion I used the word prioritized and I regret this has caused concerns that the Mayo Clinic will not serve patients with government insurance," Dr Noseworthy said. "Nothing could be further from the truth."

Half of the total services provided by the clinic, he said, are for people who have government insurance. Although discussions about the "fiscal sustainability in healthcare" are uncomfortable, "they are critical for us to be able to meet the needs of our patients."

The Mayo Clinic also referred to a speech that Dr Noseworthy gave to the Economic Club of Minnesota on March 22. He revealed that Medicaid and Medicare reimbursement covers less than 50% of the cost of delivering services to these patients at the Mayo Clinic, leaving more than $2.3 billion in annual costs unpaid. "And yet we have to make the numbers work at the end of the year to support our mission," he said, adding that the mix of fully funded and partially funded patients challenges every healthcare organization.

Many Healthcare Professionals Sympathize With Mayo

Dr Noseworthy's call to prioritize commercially insured patients set off alarm bells at the Minnesota DHS, but many Medscape readers sympathize with Mayo's predicament, judging by their comments on an earlier story about the issue. To be sure, some readers castigated the clinic for enacting what they called a greedy policy, and tarnishing its reputation in the process. Several others claimed that favoring commercially insured patients over those in Medicare constituted age discrimination.

However, Dr Noseworthy's critics were outnumbered by defenders. A common thread ran through their comments: Dr Noseworthy was saying out loud what every other healthcare executive was saying in private about gaining more commercially insured patients to stay in business, given the stinginess of government reimbursement rates.

"Punished for simply stating a fact?" asked one family physician. "Yep."

"It's funny that when Dr Noseworthy speaks the truth, the PC crowd fall(s) all over itself in rebuke," said another physician. "Dr Noseworthy instinctively understands that unless Mayo Clinic succeeds financially, its skill set will be lost to both the rich and the poor."

One physician boiled down his opinion to a healthcare proverb: "No margin, no mission."

Follow Robert Lowes on Twitter @LowesRobert


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