WellCommons

In Lawrence, Shannon Graham talks on the phone while nurse Kiran Sarai, center, helps six-year-old Max. Graham has five adopted children, four of whom have significant disabilities. The family relies on the weekly assistance of between eight and 10 personal care attendants and nurses. Pictured in the foreground, left to right are Carli, 24, Taegan, 5, and Cheyenne, 15. by KHI News Service

LAWRENCE—Every day a small army of Kansans — officials estimate there are about 16,000 of them — are at work helping some of the state’s neediest cope with the demands of daily life so that they can remain in their own homes rather than nursing homes or state institutions.

The personal care attendants or PCAs, as they are called, do all sorts of things to help: They clean house, fix meals, line out doses of medications, change adult or infant diapers, scour feeding tubes, lift people on and off toilets and in and out of beds, bathtubs and wheelchairs. They advance the pieces on a board game so a child can play with a younger brother. They let the dog out. Sometimes they are small but tough women presented impromptu tasks that would intimidate others, such as calming a large, shouting man made erratic by a brain injury.

They are people like Cydney Bunner, a University of Kansas graduate student who helps a Lawrence family that has four significantly disabled children.

Or Sally Fronsman-Cecil, one of two personal care attendants for an 85-year-old Topeka woman who is diabetic, had a lung removed and is beginning to show signs of dementia but is still in her own home.

Or Fred Miller, a grown-up farm kid, who does the heavy lifting for a young woman robbed of self- locomotion by muscular dystrophy and a litany of accompanying ailments.

They usually are paid between $9 and $10 an hour, generally without benefits such as health insurance, vacation or paid time off to deal with their own illnesses or problems. Collectively, they care for about 20,000 Kansas Medicaid beneficiaries any given month.

Some are employed by agencies, others are hired directly by the people or families they help. Either way, it is Medicaid that pays for their labors.

“Without the personal care attendants and the nurses in my house, I would not be able to have the children that I have,” said Shannon Graham, a Lawrence woman who became a foster mother about 15 years ago and then ended up adopting five of the children in her care. Four of the five are seriously disabled. “It can be very intimate support that is provided. They become a part of your family at that level.”

‘Not even considered providers’

Graham said any given week she has between eight and 10 care attendants and nurses in her home helping with the children. She hires and trains most of them herself, she said, placing ads at the University of Kansas to be seen by prospective nursing students.

One of Graham’s sons, six-year-old Max, relies on a wheelchair. He is developmentally disabled and prone to serious epileptic seizures.

Max requires “a special diet because of his horrible epilepsy,” Graham said.

“He has a nurse with him all the time at school,” she said. “These people (the care attendants) have to be trained to learn to look at him and know when he might need oxygen. If he has a seizure, there's a protocol they need to follow and these people are getting paid 9 to 10 bucks an hour.”

Because they mostly help people in their homes, the work of the personal care attendant is largely unseen by the public and they often are overlooked by policymakers. Many, if not most, are exempt from wage-and-hour laws.

→ Continue reading this story and others in our ongoing series on the transition to KanCare.

Lawrence call center expected to add positions to handle insurance exchange calls.

Four states that have snubbed the federal health law by defaulting to the federal government to build new online insurance marketplaces and not agreeing to expand Medicaid are getting new jobs at call centers that will help consumers understand their new coverage options this fall. Kansas is one of the four states.

Up to 9,000 jobs are expected to be created at call centers to support the new federally run marketplaces. A U.S. Department of Health and Human Services spokeswoman said some of them will be added to existing Medicare call centers in Phoenix, Chester, Va., Lawrence, Kan., and Tampa, Fla. — all states with Republican leaders who oppose the law.

A fifth center in Coralville, Iowa and a sixth in Corbin, Ky., will also be expanded, she said. Plans are still being finalized for other locations, she said.

Of those states, only Kentucky is setting up its own online insurance marketplace that will help people shop for individual or small employer coverage. Iowa, will run its exchange in partnership with the federal government. The other states are relying entirely on the federal government.

Of the six states getting call centers, only Kentucky has committed to expanding Medicaid in 2014, even though governors in Florida and Arizona say they support it. So far, 22 states have agreed to expand Medicaid.

The jobs are through Vangent, a General Dynamics Information Technology subsidiary, which was awarded a $530 million one-year contract by the federal government to set up call centers to answer inquiries related to the insurance marketplaces in 34 states where they will be run in whole or part by the federal government.

The government estimates that next October, when the marketplaces go live, the call centers will be open seven days of the week, 24 hours a day, handling 6.1 million phone calls and 23,000 e-mails. The contract could be renewed for up to nine more years, making it potentially worth more than $5 billion.

States running their own marketplaces will have their own call centers.

The marketplaces are expected to expand health coverage to about 27 million people by 2016. Under the federal contract awarded to Fairfax, Va.-based Vangent, the company will also field inquiries about Medicare, Medicare Advantage and “other relevant programs,” the award announcement stated.

→ More info on health reform and the coming Kansas health insurance exchange on khi.org.

A screenshot from "What Are You Waiting For?" a video produced to present to Kansas legislators by the advocacy group End The Wait, which is funded by the Kansas Council on Developmental Disabilities. by KHI News Service

Advocates for the developmentally disabled held a Statehouse press conference today to praise Gov. Sam Brownback's plan to reduce by 600 the number of disabled Kansans awaiting home- and community-based Medicaid services.

"We think this is a great move by the governor," said Tim Wood, campaign manager for End the Wait, a group pushing for elimination of the waiting lists. "This is a good step in the right direction."

Wood and fellow advocates also urged the Legislature to consider developing a plan to fully eliminate the waiting lists, which have grown over the past decade to include more than 5,000 people with physical or developmental disabilities. About another 1,200 people with developmental disabilities are receiving some of the services but waiting for more.

The governor last week released a budget amendment asking the Legislature to spend an additional $18.5 million to reduce the waiting lists. The recommendation came after state budget forecasters concluded that state spending on Medicaid services would be about $98 million less than previously expected for the fiscal year that ends June 30, including about $37.6 million from the State General Fund.

The governor characterized the reduced costs as "dividends" from the enactment of KanCare, the initiative he launched Jan. 1 that expanded managed care in the state Medicaid system. State budget analysts attributed much of the foregone spending to fewer people receiving Medicaid services. When federal officials approved the administration's KanCare plan, one of the "special terms" of the agreement was that if money were saved, some of it would be used to reduce the waiting lists.

Wood said he and other advocates also would urge lawmakers to aim for equal reductions in the lists for the physically disabled and the developmentally disabled. The governor proposed that the money be split evenly between the two waiting lists but because the cost of caring for the developmentally disabled is higher on average, fewer people could be served.

Wood said ideally that 300 people would come off each the two lists rather than 400 off the physically disabled list and 200 off the developmental disability list.

"While we appreciate the need to bring all people off the waiting lists," he said, "we want the Legislatuare to consider a fair and equitable way to divvy up the dividends."

In related news, spokesmen for Interhab, a group that represents most of the state's Community Developmental Disability Organizations, said more than 1,000 people had signed up to attend a rally scheduled for Wednesday at the Statehouse to urge legislators to exclude long-term DD supports from inclusion in KanCare.

Related story

→ In wake of Olmstead investigation, governor's claim of waiting list progress challenged

The following video was produced to present to Kansas legislators by the advocacy group End The Wait, which is funded by the Kansas Council on Developmental Disabilities.

Dr. Dennis Cooley visits with April Yarger during her son Peyton's first check-up. by KHI News Service

People involved with Medicaid services for children say they are hopeful the state’s new KanCare program will someday lead to improved services and health outcomes.

But for now, they report dealing with some of the same problems and frustrations others in the program, which also serves the poor elderly and disabled, have experienced since its launch on Jan. 1: Billing problems, payment delays, concerns about patient access to care and increased administrative complexity.

“There are a lot of bumps in the road; we'll put it that way,” said Dr. Melinda Miner, a Hays Dentist who along with her husband, Dr. Daniel Miner, is one of the leading Medicaid dental providers in her part of the state.

Miner said her clinic just recently began receiving payments for services earlier this year from the KanCare managed care companies and that other dental providers she knows have had the same problem.

“We still have a lot of outstanding claims,” she said. “We never had problems like this when the state ran the program (using two managed care companies). That was the best thing about HealthWave, claims got paid in a timely manner. You didn’t have to worry about them. I think they have that under control now, or at least they’re working hard on it.”

Other Medicaid providers for children also described problems when interviewed by KHI News Service.

“From a provider perspective, it’s been kind of frustrating,” said Dr. Dennis Cooley, a Topeka pediatrician who sees a large number of Medicaid patients, “mostly from dealing with three, brand new MCOs (managed care companies) and each one has their own set of rules.”

'A lot of difficulties'

Cooley, like others dealing with the new system, said “we’ve had a lot of difficulties with prior authorizations,” which are the approvals for payment required from the state’s KanCare contractors before services can be delivered to a patient. “We’ve had difficulty, I think, in getting our patients some of the services, especially like with pharmacy and what meds (the MCOs) are covering. I know at least in our practice it’s been very frustrating and that’s what I’ve heard in talking with other providers, too.”

Cooley said his practice “had good rapport” working with the state’s prior HealthWave managed care companies and that “time would tell,” if the same sort of relationships would develop with the new KanCare contractors: Amerigroup, UnitedHealthcare and Sunflower State Health Plan a subsidiary of Centene.

And here’s an assessment of KanCare’s progress from Tribune, a small town near the Colorado border.

“It’s going OK, we’re just butting up against some billing issues,” said Bonnie Mote, who handles the billing for Greeley County Health Services, a rural health clinic once directed by Dr. Robert Moser, currently secretary of the Kansas Department of Health and Environment, the state’s lead Medicaid agency.

Mote said she thought services for patients had been unaffected by KanCare and that the claims and billing problems would soon be sorted out.

“Dr. Moser contacted us and said they (KDHE) would be contacting the MCOs,” she said.

Healthwave

KanCare moved virtually all the state’s 380,000 Medicaid enrollees into managed care plans run by for-profit insurance companies. But even before the program makeover, the large majority of beneficiaries — more than 280,000 — were children covered by what was then known as HealthWave.

→ Continue reading on khi.org.

Tom Laing, executive director of Interhab, speaking to parents of developmentally disabled children and advocates at a recent town-hall meeting in Overland Park. by KHI News Service

Push is again coming to shove in the struggle over whether the long-term care and support services received by Kansans with developmental disabilities will become part of KanCare or remain outside the control of the private companies hired by the state to manage the Medicaid program.

Advocates pushing for a permanent “carve out” of developmental disability services have circled May 8 on their calendars. That’s the day that the Kansas Legislature is scheduled to return to Topeka to wrap up its 2013 session.

“When you show up in numbers, it makes a difference in the legislative process,” said advocate Tom Laing, speaking last week to approximately 175 parents and advocates at a meeting sponsored by Johnson County Developmental Services.

“A lot of times when politicians do the wrong thing it’s because they haven’t heard from the folks who are the most impacted. If they don’t hear from you, we can’t succeed,” said Laing, executive director of Interhab, an association that represents most of the state's Community Developmental Disability Organizations.

Laing and other advocates said they are hoping that thousands of Kansans with developmental disabilities would turn out with their parents and guardians for a rally on the south steps of the Statehouse and to meet individually with legislators to make their case.

“I’m not a guy who believes in pitch forks and torches. We need to be persuasive, not abrasive,” Laing said.

'Carve in' date approaching

Medical services for the developmentally disabled already are part of KanCare, the reform initiative launched on Jan. 1 by Gov. Sam Brownback. It moved virtually all of the state’s 380,000 Medicaid beneficiaries into managed care plans run by three insurance companies: Amerigroup, United Healthcare and Sunflower State Health Plan, a subsidiary of Centene.

But yielding to pressure from advocates and service providers, the governor and legislators agreed last year to delay the inclusion of long-term, DD support services for a year — until Jan. 1, 2014. With the “carve in” date approaching, advocates are pressing their case again.

“We have to keep these services out of the hands of the profiteers,” said Bridget Murphy, director of the Downs Syndrome Guild of Greater Kansas City.

'Misinformation' fueling concerns

Murphy’s concern that the for-profit managed care companies will disrupt services now generally provided by a network of community-based, non-profit organizations is shared by many parents and advocates.

That frustrates Shawn Sullivan, the secretary of the Kansas Department of Aging and Disability Services, who has spent more than a year meeting with stakeholders to convince them they have nothing to fear from the new managed-care system.

→ Continue reading on khi.org.

Gov. Sam Brownback talking with Anna Lambertson of the Kansas Medicaid Access Coalition last month at the Statehouse. The coalition delivered a petition with more than 2,700 signatures urging expansion of the state Medicaid program, which currently has among the tightest restrictions in the nation. by KHI News Service

Advocates pushing Kansas officials to expand Medicaid acknowledge it is unlikely they will achieve their goal this year.

But they said they remain hopeful they can convince Gov. Sam Brownback and legislators next year to make more Kansans eligible for the program.

“If it’s not going to happen the first year, we’ll continue to build grassroots support. We’re not giving up,” said Anna Lambertson, director of the Kansas Health Consumer Coalition, one of the groups pushing for expansion.

Medicaid, known in Kansas as KanCare, currently provides medical and long-term living assistance services for about 380,000 poor, disabled and elderly Kansans. Expansion could increase enrollment in the program by as many as 240,000, according to various projections.

The federal Affordable Care Act initially required states to expand Medicaid eligibility. However, the U.S. Supreme Court decision that upheld the law made expansion optional for states.

Expansion would have a bigger impact in Kansas than in many other states. That’s because the state’s current eligibility criteria exclude all but the poorest adults. Only those with children and incomes less than 32 percent of the federal poverty level — about $6,000 a year for a family of four — can qualify. Implementing expansion would mean that adults in that same family of four could make more than $31,000 a year and qualify.

The Brownback administration has estimated that expanding eligibility for the $3.2 billion program would cost the state an additional $600 million over 10 years.

Door still open

Whenever asked about expansion, Brownback says things that suggest he’s more likely to say “no” than “yes” to it. But advocates said they remain encouraged by the fact he hasn’t rejected the idea.

“If he’s really looking at the options with an open mind — as he himself has said he’s doing — then I see him taking his time (to decide) as beneficial,” Lambertson said. “I’d rather that he take his time than just say ‘no’.”

Last week, Brownback again expressed doubts that the federal government could afford to keep its promise to cover all the costs of expansion for the first three years and no less than 90 percent thereafter. Despite his misgivings, he said, he continues to have “active conversations” with expansion advocates and legislators on the topic.

“It’s in the legislative process,” Brownback said. “Expansion would have to be addressed by the Legislature. They would have to budget it.”

Brownback’s requirement that legislators budget for it before he would sign off on it has advocates convinced a decision won’t be made this year.

Budget negotiations

Members of the House-Senate conference committee negotiating a final version of the fiscal 2014-15 budgets are scheduled to return to the bargaining table early next month when the Legislature returns to Topeka for what leaders hope will be a brief wrap-up session.

→ Continue reading on khi.org.

Lt. Gov. Jeff Colyer, who spearheaded KanCare — the overhaul of the state's Medicaid program by the administration of Gov. Sam Brownback. by KHI News Service

The first 90 days of KanCare have passed, which means the transition period during which the state's 380,000 Medicaid beneficiaries could switch managed-care health plans this year is over.

That is important — for among other reasons — because many KanCare enrollees may find themselves in situations where the medical providers they are accustomed to using are not in the network of the KanCare plan to which they were assigned or chose themselves before the changeover period ended April 4.

And as the 90th day was marked last week, many Medicaid providers continued to report persistent problems with the program that was rolled out Jan. 1 by the administration of Gov. Sam Brownback.

'Number of issues'

"We still have a number of issues that pharmacists have to deal with," said Michael Larkin, executive secretary of the Kansas Pharmacists Association. "In the big picture, our number one concern is assuring that the managed care organizations adhere to the contracts signed (with the state) back in June."

Larkin said the contracts called for the KanCare companies to use a "transparent" process for determining the reimbursement rates for pharmacy services. In the association's view, he said, those contract provisions have been ignored by the KanCare companies "across the board."

"And also the managed care organizations when they do change their pricing are supposed to notify us, let it be known to everyone that the pricing has changed. I don't know that they're doing that either," Larkin said.

He said a meeting was held last month with KanCare company representatives to try to resolve the concerns but that the problems continue apparently because "the wrong people were in the room to discuss that."

Larkin said he was trying to set up another meeting that also would include state officials.

Association members also are reporting reduced or delayed payments from the KanCare companies for durable medical equipment.

"They're having trouble getting proper reimbursement and knowing, if in fact, they will be reimbursed before the equipment goes out the door," Larkin said.

'Workmanlike'

Administration officials acknowledged some ongoing problems but said on whole they are pleased with the program's progress.

"It's been very workmanlike," Lt. Gov. Jeff Colyer said of the transition.

He also repeated what administration officials have said since the first month of KanCare: "There haven't been as many bumps in the road as we expected. Everybody's been very committed to working with people who are having issues."

Larkin said from the pharmacists' perspective the problems have been "something in between a bump in the road and grave concern."

"We're hopeful things will turn out for us. So far, it hasn't happened," Larkin said.

→ Continue reading on khi.org.

The first personally meaningful information many Americans receive about the Affordable Care Act could come as they sit down with tax preparers. H&R Block is routinely telling its clients about subsidies or tax penalties that may lay in store for them while preparing their customers 2013 tax returns. by KHI News Service

With the filing deadline approaching, the nation’s largest tax preparation company is letting its customers know how they are likely to be affected by the Affordable Care Act.

“After the ACA was upheld by the Supreme Court in 2011, we did some focus groups and some surveys to try and measure the public’s understanding of what all is in the ACA,” said Meg Sutton, senior advisor for tax and health care services at H&R Block. “It became pretty clear that there needed to be a process for educating our clients.”

Sutton called the 2010 federal health reform law the “biggest tax-code change in the past 20 years.”

The company’s tax preparers, she said, have been calling their customers’ attention to the ACA’s penalties for not having health insurance and to the subsidies that will be available to low- and modest-income families.

The information also is available on an H&R Block website.

“Client reaction has been very positive,” Sutton said.

The company’s surveys, she said, had found that 77 percent of its clientele didn’t realize their 2013 tax returns would be used to determine their eligibility for health insurance subsidies and that 44 percent of those between ages 18 and 34 were unaware of the penalties for being uninsured.

Sutton said the company’s tax preparers do not tell their customers to buy - or not to buy – health insurance. Instead, she said, customers are “informed of their options” based on the information in their 2013 tax returns.

The ACA’s mandate that almost all Americans either have health insurance or pay a penalty takes effect Jan. 1, 2014.

Marvin Lawton has been a tax preparer at the H&R Block office in Topeka for the past eight years.

“I’ve found there to be quite a cross section in the way people react – all the way from being OK with it to being dismayed by it,” he said. “Some are OK with it because they already have insurance and won’t be affected by it, some are bewildered over how they’re going to afford it and some wonder why they have to pay a penalty if everybody in their family is healthy."

Most of his customers with little or no health insurance have seemed pleased to hear about the subsidies, he said.

“I’ve had a lot of people who used to have insurance through their job but ended up getting laid off in the past year,” he said. “They know how expensive health insurance is. So when I tell them about penalties, they say ‘But I can’t afford it.’ Then, when I tell them about the subsidies and how they’ll be able to buy it through the exchange and be part of a larger pool, they’re OK with it. They say they’re OK with it if it’s affordable. And I say that’s the intent, that’s why it’s called the Affordable Care Act.”

H&R Block customers have the option of signing up for email alerts on changes in the new health reform law.

Sutton said, H&R Block appears to be the only national tax preparation firm helping its customers predict the law’s effect on their 2014 taxes.

Surveys have shown that about 60 percent of the nation’s taxpayers use tax preparation companies. H&R Block accounts for almost 20 percent of the tax-preparation market.

Kansas Health Consumer Coalition Executive Director Anna Lambertson said she welcomed the company’s initiative.

“I think it’s great,” Lambertson said. “I give them high marks.”

The coalition, she said, has been looking for ways to launch a similar informational campaign in Kansas.

“We can’t do it alone,” she said. “And H&R Block can’t do it alone. It’s going to take everybody getting involved.”

Sheldon Weisgrau, a spokesman for the Health Reform Resource Project, also praised the company.

“I assume they’re hoping this will lead to more people coming to them to have their taxes done,” he said. “But that’s fine. Anytime you’ve got someone providing accurate information it’s a positive.

Weisgrau said federal officials have announced plans for launching a major outreach campaign in June.

“They don’t want to start too early, which makes sense,” he said. “The exchange won’t be up and running until October.”

Mary McBain, chief executive of the Kansas Society of Certified Public Accountants CEO said the H&R Block initiative had not gone unnoticed.

“The major accounting firms have definitely been ramping up for this,” she said. “Some of the bigger firms have hired people just to work on ACA – that’s all they do.”

MacBain said her organization was committed to providing its members with accurate information about the law.

“All of us, I think, need to take a deep breath and not get caught up in all the emotion that’s comes with health care reform,” she said. “We need to be informed because, frankly, there’s a lot of misinformation out there.”

→ Find more information on health insurance exchanges and other health reform topics at khi.org/healthreform.

Sen. Laura Kelly, a Topeka Democrat. by KHI News Service

The Senate has tentatively approved a bill that could lead to some school districts holding back first graders who fail a reading test.

The measure was based on Gov. Sam Brownback’s proposal for improving fourth grade reading scores by holding back third graders known to be having trouble reading.

“We need to be getting to these kids as early as we can,” said Sen. Laura Kelly, a Topeka Democrat, who proposed changing the focus of Senate Substitute for House Bill 2140 from third graders to first graders.

Kelly’s amendment was endorsed by Sen. Steve Abrams, an Arkansas City Republican and chair of the Senate Education Committee.

“It’s fairly well known that through the third grade children are learning to read,” he said. “After the third grade, they’re reading to learn.”

Abrams said he considered Kelly’s amendment to be “friendly.”

The Senate endorsed the bill on a voice vote shortly before 8 p.m. Tuesday. A formal final action vote is set for Wednesday morning.

Abrams said an earlier version of the bill had stalled in the education committee after several members argued that it constituted a mandate and was likely to do more harm than good.

Those concerns were resolved, he said, by adoption of a number of amendments in the committee and during the floor debate aimed at exempting students in special education or English-as-a-Second-Language classes, allowing students to take the test more than once, limiting the mandate to school districts with below-average reading scores, and giving parents the final say in whether their children were promoted.

“The concern that what was initially proposed did not include parental involvement ended up being resolved in this bill,” Kelly said.

The amended bill also would allow teachers to declare whether students who fail the test should be allowed to advance.

It wasn't immediately clear how many first graders might be affected by the bill or what the cost might be for school districts. Neither question was raised during the debate.

Child advocates had testified against the initial bill, arguing that state resources would be better spent on early childhood development programs, many of which have long waiting lists.

Shannon Cotsoradis, chief executive for the advocacy group Kansas Action for Children, welcomed the changes to the bill.

“Tonight’s floor debate in the Senate underscores the commitment to early intervention and to investments in early learning programs as a path to literacy,” she said. “The amendments will also provide the flexibility to act in the best interests of individual students rather than mandating a one-size-fits-all approach.”

The bill calls for spending $10 million — $5 million a year for two years — on a grant program aimed at helping children learn to read.

It also would set aside $1 million a year for two years to reward school districts with the most improved reading scores.

If the bill passes on final action, as expected, it would be sent to the House, where it’s likely to be referred to a conference committee.

Related stories on khi.org
→ Brownback reading initiative questioned by education experts
→ Governor's office restates support for reading initiative

Senate President Susan Wagle, a Wichita Republican. It’s that time in the legislative session when the rubber begins to meet the road on major issues such as budget, taxes, education spending, KanCare and perhaps Medicaid expansion. Over the next few days, KHI News Service will publish a series of profiles on a few key lawmakers and the roles they play in the process. by KHI News Service

Susan Wagle, already distinct in history as the first woman elected president of the Kansas Senate, said there are other things for which she would prefer to be remembered:

“A fiscal conservative, a social conservative, a mom, a businesswoman and a schoolteacher . . . that’s pretty diverse,” she said.

This is her 23rd year in the Legislature — 10 in the House, 13 in the Senate.

Her tenure has been punctuated by causes she took on when broader interest among legislators was not always apparent and which brought her statewide, sometimes national, attention.

“I’m a second-born of six children — two boys and four girls - and you know how second-borns are,” she said. “I was a challenge for my parents and I can be a challenge up here (at the Statehouse) if it’s an issue I care about.”

The 59-year-old Wichita resident was at the forefront of a conservative Republican takeover of the Senate in the November 2012 general elections.

She was elected the chamber’s leader in December and in January presided over a major rules change that barred any floor amendments that would add costs to spending bills. That so-called ‘pay-go’ provision, championed by conservative Republicans, was adopted 28-11, mimicking one already in force in the House.

‘Dancing not dating’

Despite that and other changes, she is regarded by some as “old school.”

“In many respects, I believe Susan is kind of old school in terms of her appreciation of the political process and the exchange of ideas,” said Senate Minority Leader Anthony Hensley, a Topeka Democrat.

ln 2002, he said, she worked with Democrats on a Senate redistricting map that was adopted despite opposition from Republican moderates, then the majority in the GOP caucus.

He also credited her with putting together a coalition of GOP conservatives and Democrats to break a 2007 budget deadlock.

“Just because she’s of a different political stripe doesn’t mean we can’t work with her,” Hensley said. “We’ve always had an understanding that we’re only dancing, we’re not dating.”

Health policy background

Wagle has had more experience with health policy issues than has been the norm for those who have risen to the Senate presidency.

From 2001 to 2007, she was chair of the chamber’s Health Care Strategies Committee. It was a period in which the Legislature was unusually active in its consideration of potentially far reaching state Medicaid and other health reforms.

She also had an unsuccessful run at statewide office before becoming president, which is a bit uncommon in that top legislative leaders often aren’t that well known to general voters outside their own districts.

In 2006, she ran for lieutenant governor on the ticket with GOP gubernatorial nominee Jim Barnett of Emporia, a physician and fellow senator who since has retired from politics. The pair was handily defeated in the general election by Democrat Kathleen Sebelius and her running mate Mark Parkinson.

Legislative causes

In 2000, Wagle launched an investigation of how then- Kansas Attorney General Carla Stovall, a fellow Republican, had hired her former law firm to represent the state in the lawsuit that led to the master settlement agreement with the nation’s tobacco companies. Stovall’s former firm collected $27 million for its role. The state's ongoing share in the settlement has been earmarked mostly for children’s programs.

Three years later during debate on the Senate floor, Wagle accused a professor at the Kansas University School of Social Welfare of showing pornographic videos, condoning pedophilia, and using foul language in a popular class he taught on human sexuality. Her move to cut funding for the school was vetoed by Sebelius.

A subsequent university investigation and report on the allegations exonerated the professor.

In 2011, as chair of the Senate Commerce Committee, Wagle held several contentious hearings on allegations that the chief executive at the Kansas Bioscience Authority had mishandled or misrepresented the agency’s activities. The executive resigned and took a job out of state.

“You want her on your side,” said Tim Shallenburger, a former Kansas House speaker who now serves as Gov. Sam Brownback’s chief legislative liaison. “Not so much because she’s president of the Senate but because of the passion she brings to an issue. She’s very hard working.”

‘Smaller government’

Wagle says her political energies are now focused on improving the economy.

“Clearly, the state of Kansas is in the midst of an economic downturn, followed by long-term stagnation that, I believe, has been caused by a lack of leadership at the federal level,” she said. “We’re at a turning point. If we don’t get control of federal spending, this country and this state will take a turn for the worse and the opportunities I had growing up will not be the same as those that my children will have.”

The best way to stimulate the state’s economy, she said, was “…through lower taxes, smaller government, and less regulation.”

She said she shares that view with Gov. Sam Brownback, a confidante for many years, and House Speaker Ray Merrick.

“We are unified on that goal, although we may have to take different paths to get there,” Wagle said.

Wagle, a former elementary school teacher, said her readiness to cut taxes dated to 1986 when a statewide reappraisal tripled the property taxes on some commercial property that she and her husband owned.

“Our taxes went from $5,000 a year to $15,000 a year,” she said. “I was shocked.”

Four years later, she ran for the House and won.

Abortion

Wagle, who grew up in east Wichita, also is well known for her opposition to abortion.

“I didn’t start out pro-life,” she said. “I graduated from (Wichita) Southeast (High School) in 1972, which was about the time that Dr. (George) Tiller started his practice. I had friends — young girls — who saw the clinic as a form of birth control and who later suffered emotional consequences. But we were young and I didn’t think that much about it.”

→ Continue reading on khi.org.

Workers at the state's Medicaid eligibility clearinghouse shown at the sorting tables where mailed and paper application forms are processed and then scanned for entry to the state's computerized enrollment and eligibility system. The front end of the new KEES system is already being used for some sign-ups, foregoing the need for the paper shuffling. by KHI News Service

After months of trying to dance around the politically charged issue, the administration of Gov. Sam Brownback has openly acknowledged that the $139 million Medicaid enrollment system that it is building will be interconnected with the online health insurance exchange required by the Affordable Care Act, and that the system will be ready to go by the Oct. 1 federal deadline.

“It's just a connectivity kind of a thing,” said Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, which is spearheading the project to overhaul the 26-year-old, paper-based system to a modern online one.

“I certainly appreciate the concerns that are tied to the political angst, but this program was well on its way when I came on board and my job is to make sure it gets completed successfully,” he said.

Entangled with the exchange

Overhauling the state’s antiquated Medicaid enrollment system has been in the works since at least 2009, when the project was called K-MED.

The project stalled briefly in August 2011, when Brownback returned a $31.5 million federal grant, most of which had been earmarked for developing the state’s new Medicaid enrollment system. Brownback said he was returning the grant because it was tied to the Affordable Care Act — which he he had pledged he would not implement prior to the U.S. Supreme Court ruling on the law, and later until after the 2012 federal elections.

Then that same month, administration officials announced a new contract with Accenture to develop the Kansas Eligibility and Enforcement System (KEES), using $118 million in federal funds to pay for the $139 million projected cost. K-MED became KEES.

A key condition of the federal funding was that the KEES system would have to be “interoperable” with the coming health insurance exchange — an online marketplace scheduled to launch Oct. 1 where consumers can compare and buy coverage that will begin Jan. 1, 2014.

In Kansas and the 25 other states that elected not to run their own health insurance exchanges, the federal government will build and operate them.

Political sensitivity

Moser said interoperability of KEES and the exchange means that — for consumers — there will be a single entry point for enrolling in private health insurance or in Medicaid, the state-federal health care program for low-income, elderly and disabled persons. Medicaid in Kansas is known as KanCare.

“You enter in some information, most of it is going to be yes/no. If you're eligible for Medicaid then it would pop up the KEES patient portal,” Moser said. “If it shows that your income level is such that you don't qualify for Medicaid…it's going to push your information over to the federal exchange. So those two systems literally will be handing back and forth inquiries.”

Moser said the fact KEES would interface with the insurance exchange was no different than integration with other federal computer systems, such as Homeland Security or the Internal Revenue Service.

“It doesn't really have that significant of an implication in my mind. But then again, I'm a physician and a little bit more patient-centered and look at the convenience factor. If that person is in a hospital setting and I think they need admitted, but they're worried about the cost because they don't have coverage, I'd like to be able to determine at that point in time 'Are they eligible for coverage' and use that as leverage to get them in to the hospital,” Moser said.

→ Continue reading this story on khi.org

Related stories

→ Kansas frustrations with exchange development common among states

→ KEES ‘will be the envy’ of states, says Colorado IT guru

Charlene Robinson waits for her appointment at the Community Health Center of Southeast Kansas clinic in Coffeyville. To help alleviate patient confusion regarding their healthcare providers through the new KanCare program, CHC/SEK clinics have posted banners to inform patients that they may receive their healthcare services through CHC/SEK. by KHI News Service

While acknowledging “bumps in the road,” state officials for several weeks have been saying that the launch of KanCare, the state’s new Medicaid program, has been going better than they expected.

But people who work at some of the clinics that specialize in treating poor and uninsured Kansans describe it differently. They say the transition, now entering its third month, has been an ordeal for them and that some of the problems are compromising patient care.

“I went through the tornado in Joplin (in May 2011) and survived,” said Lori Lowrey, chief revenue officer for the Community Health Clinic of Southeast Kansas. “I would equate the anxiety of KanCare with the anxiety I felt following that event. It’s just been an inferno everyday. When you walk through the door, you’re greeted by staff frustrated at every level...nurses, administrators, patients and then trying to communicate with the (KanCare companies) and their contractors, it’s just very taxing. I just don't feel like it’s been accurately portrayed by the people at the state level or the MCOS (managed care companies). It’s been a road full of potholes. It’s not been a few bumps.”

The clinic here serves about 29,000 people a year at its eight sites scattered across the corner of Kansas that generally ranks as the state’s poorest and least healthy. That makes is a key medical provider, particularly when it comes to primary care for the poor. About 35 percent of its patients are on Medicaid, according to clinic officials.

State and KanCare company officials acknowledge there have been problems at the safety net clinics and more so at some of the 16 that are designated as Federally Qualified Health Centers, which includes the Community Health Clinic of Southeast Kansas. The FQHCs together have more than 20 satellite clinics scattered across the state and collectively serve many thousands of the state’s poorer families.

A special meeting that included clinic directors, state officials and KanCare contractors was held privately two weeks ago in Topeka to discuss the situation.

Issues identified

An “issues log” of 86 problems submitted by the clinics to the Kansas Association for the Medically Underserved (KAMU), a group that represents the safety net clinics, was presented at the meeting.

Among the problems cited:

• Delayed or stalled payments from the KanCare companies,

• Poor communication and misinformation

• Troubles getting clinic doctors and other providers included in the KanCare provider networks and patients properly assigned.

• Difficulty getting treatments or medications approved for patients.

The list was similar to but longer than the problem tally submitted to state officials a week earlier by the Kansas Medical Society and the Kansas Medical Group Management Association along with a letter asking the state to extend the KanCare transition period to allow more time for smoothing things out.

Kari Bruffett, the director of the Division of Health Care Finance at the Kansas Department of Health and Environment, has been the point person for the administration of Gov. Sam Brownback on much of the KanCare implementation.

Bruffett said state officials determined from the meeting with clinic officials “that while there were some crosscutting issues, there were a lot of issues specific to the individual (clinics), so what we asked the managed care organizations to do with those (clinics) was to work with them individually and basically keep us posted.”

She said she had been assured that many of the problems raised at the meeting were being dealt with and that the chief executives of the KanCare companies have been responsive whenever concerns were brought to their attention.

One result of the meeting, according to some who attended, was an agreement by at least two of the KanCare companies to make “advance payments” to clinics that asked for them to help deal with their cash-flow problems.

“I know of at least one (KanCare MCO) that is in the process of sending out advance payments,” said Cathy Harding, executive director of KAMU, “and another said they would do the same thing.”

She said she expected the third company also would agree to advance or expedited payments.

But in a series of interviews late last week with the KHI News Service, clinic directors from across the state give KanCare what could at best be described as mixed reviews. And those unhappy with the way KanCare is rolling out said they had seen little or no improvement as a result of the meeting.

“In our opinion, it’s kind of going from bad to worse,” said Krista Postai, executive director of the Community Health Clinic of Southeast Kansas. “I have nurses now spending all day on the phone trying to get pre-approvals (for patient medications from the KanCare insurance companies or their subcontractors) and not getting them. A lot of my providers have been doing this for years and they never had anything this absurd on pre-authorizations. I understand that is meant to control costs…but this is costing us a fortune.”

→ Continue reading about problems reported from clinics in Wichita, Johnson County and others around the state.

Betty Spalsburg, a resident at the Vintage Park assisted living facility in Tonganoxie, enjoys a recent musical program put on by children from The Learning Center, a local child care center. Children shown, left to right, are Thatcher Page, Miley White and Sam Chelbi. by KHI News Service

One of the state’s largest assisted-living chains has curtailed its participation in the Kansas Medicaid program.

“Of our 18 facilities, 15 are no longer taking any new Medicaid clients,” said Denise German, senior vice president of Vintage Park, which is headquartered here.

The decision, German said, was driven by a 2012 reduction in Medicaid reimbursements and by concerns that payments would be cut more under KanCare. The three Vintage Park facilities that still accept Medicaid clients are in towns with no other facilities. The company’s local administrators there chose to continue so there would be local options for residents.

KanCare is the name for Gov. Sam Brownback’s Medicaid makeover initiative, which involved the hiring of three managed care companies to run day-to-day operations of the state’s $3.2 billion Medicaid program. The KanCare companies are Amerigroup, UnitedHealthcare and Sunflower State Health Plan, a subsidiary of Centene.

The companies took over Jan. 1.

Looking to cut costs

“These are for-profit companies. We know they’re going to be looking for ways to cut costs and since reimbursement is very minimal already, we’ve elected not to continue to participate in the program,” German said.

Vintage Park began changing its policy a few months after Brownback first announced his KanCare plan in November 2011. Its individual Kansas facilities began making the changes more or less at their own pace. The result has been a major reduction in the number of Medicaid residents. Before this year, German said, Vintage Park facilities in Kansas had been admitting about 100 Medicaid residents annually.

“A year ago, we probably had 250 Medicaid residents in 18 facilities,” she said. “Now, I’d say we’re down to about 120.”

The company, she said, has been doing “fine” without new Medicaid admissions.

Vintage Park won’t ask private-pay residents to leave if they deplete their life savings and end up on Medicaid, she said. But the 15 facilities no longer admit residents already on Medicaid.

Vintage Park is a for-profit company. Most of its facilities are in small and mid-size towns in the eastern third of the state. All 18 facilities passed state inspections the last two years with no deficiencies noted, which generally is taken as an indication of well-run operations.

Not identified as a problem

It’s not clear whether other companies are following Vintage Park’s lead. State officials said they were unaware of the company’s decision and hadn’t seen evidence of a problem.

“We have not heard that assisted living facilities are declining to admit residents who are on Medicaid,” said Angela de Rocha, a spokesperson for the Kansas Department for Aging and Disability Services.

“Assisted living facilities’ refusal to accept residents who are on Medicaid has not been identified as a problem at this point,” she said. “And it is in the financial interest of the (KanCare managed care companies) to keep their members in a community setting instead of admitting them to nursing homes.”

An assisted living facility is considered a community setting.

Others in the industry said they knew too well the pressures cited by Vintage Park officials.

“Our company continues to accept Medicaid,” said Steven Hatlestad, vice president of skilled nursing operations at Americare, another for-profit chain with operations in several states that has 11 nursing homes and six assisted living facilities in Kansas. “But I do not believe that what Vintage Park is doing makes it an outlier. I’m afraid we’ve reached a point where some companies — some really good companies — just can’t afford to do Medicaid anymore.”

Ray Vernon runs Wesley Towers, a large retirement community in Hutchinson that offers in-home care, independent living, congregate living, skilled nursing care, and assisted living. It is a subsidiary of the Kansas West Conference of the United Methodist Church.

Vernon said while reimbursement rates are an issue, his facility won’t refuse to accept residents because they are on Medicaid.

“That would go against our mission,” he said. “But I have to say there’s some validity to what Vintage Park is saying because, in reality, (Medicaid) reimbursement has been flat for quite some time and healthcare inflation runs about twice what it is for the economy at large.”

Shared frustrations

Jim Klausman, chief executive at Midwest Health, a for-profit operation active in four states and with 24 nursing homes and 11 assisted living facilities in Kansas, said the company shares Vintage Park’s concerns but has a different strategy.

“We understand — and we share — some of the frustrations being expressed by Vintage Park, but we think we have a better shot at changing the system from within rather than pulling out,” he said.

Midwest Health’s nursing homes have signed contracts with all three KanCare companies, he said. But Midwest chose to sign an assisted-living contract with only one: Sunflower State Health Plan.

“We’re still taking Medicaid,” for assisted living, he said, “but you’ll need to be on Sunflower.”

The decision to only sign with one KanCare plan, Klausman said, was meant to strengthen Midwest’s bargaining position.

“We’d rather negotiate with one company than three,” he said.

‘Uncertainty over reimbursement’

Debra Zehr, chief executive with LeadingAge Kansas, a trade group, keeps close tabs on the state’s nonprofit assisted living facilities.

“There’s a lot of uncertainty over reimbursement and the administrative costs that come with having to deal with three payers — the (KanCare) managed care companies — instead of one,” she said. “I don’t know of anybody who thinks they’re breaking even on Medicaid. It’s more of a community service than anything else. You do it because it’s the right thing to do.”

→ Continue reading on khi.org.

Projected job creation due to Medicaid expansion, according to a report issued by the Kansas Hospital Association. by KHI News Service

A study released today by the Kansas Hospital Association says that expanding Medicaid eligibility to levels called for in the federal health reform law would pump more than $3 billion into the state’s economy and create 4,000 new jobs by 2020.

The study, done for the association by the Center for Health Policy Research at George Washington University and Regional Economic Models, Inc., also shows that expansion would save the state more than it would cost.

Tom Bell, the association’s chief executive, said the projected economic benefits were too significant to be ignored by Gov. Sam Brownback and legislative leaders as they consider whether or not to expand eligibility for the healthcare program that serves poor, elderly and disabled Kansans.

Brownback has been a vocal opponent of the Affordable Care Act but has not made a decision on Medicaid expansion, which was made optional for states as the result of last year’s U.S. Supreme Court decision upholding the law.

“I think from our perspective, it’s not unlike the state landing a huge federal contract,” Bell said.

The impact of the expansion on the Kansas economy could rival that of the National Bio and Agro-Defense Facility in Manhattan, Bell said.

“That’s the way we look at it, as an opportunity for our state,” he said.

Bigger impact in Kansas

Since Jan. 1 in Kansas, the Medicaid program has operated under the name of KanCare. Three health insurance companies are under contract with the state administer it.

The health reform law requires that the federal government cover state costs of expanding Medicaid for three years. After that, the federal share would recede gradually until it reaches 90 percent, where it would remain.

Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level (FPF) — currently $5,900 a year for a family of four.

Because those numbers are so low, expanding Medicaid would have a bigger impact in Kansas than in many other states by making all Kansans who earn up to 133 percent of FPL — $30,660 for a family of four — eligible for the program.

Various estimates suggest that expansion could add between 226,000 and 240,000 Kansans to the 380,000 now enrolled in Medicaid.

Net benefit to the state

A Kansas Department of Health and Environment report released last week estimated Medicaid costs would climb by $513 million over 10 years regardless of whether the state expanded eligibility for the program. That’s because heightened attention surrounding the expansion issue is expected to prompt many people who already are eligible but not enrolled to sign up.

Covering only those who are made eligible by the expansion would cost another $600 million over 10 years, the KDHE report said. Even so, the hospital association report said that expanding Medicaid would produce a net savings to the state of $82 million from 2014 to 2020.

“That’s front loaded into those first three years, but it’s still a substantial net benefit,” Bell said.

Governor undecided

Brownback has not ruled out expansion but neither has his administration shown much, if any, enthusiasm for the idea. Reacting to the KDHE cost estimate, Sherriene Jones-Sontag, the governor’s chief spokesperson, said expanding Medicaid would affect the state’s ability to fund other “core responsibilities.” The impact would be even greater “if the federal government fails to keep its promise to pay for its part of the expansion,” she said.

Bell said administrators at the association’s 126 member hospitals understand Brownback’s concerns, which are shared by many legislators. But he said they believe the Medicaid expansion dollars are needed to offset the anticipated loss of other federal funds that hospitals have used to cover the cost of caring for the uninsured.

“From an economic perspective for our members — especially those that treat a higher number of uninsured — they think it makes great sense to take a serious look this and see if we can make it work,” Bell said.

→ Find the various cost estimates of Medicaid expansion in Kansas, as well as archived coverage of the issue, here.

During the 2012 session, a bipartisan group of representatives and senators introduced a resolution attempting to delay the Jan. 1, 2013 launch of KanCare. The resolution failed, but lawmakers succeeded in persuading the Brownback administration to hold off a year on including in the program long-term services for the developmentally disabled. DD advocates say they will ask this year's Legislature to extend or make permanent that temporary "carve-out." Given the large numbers of new legislators following the 2012 elections and the administration's push to expand KanCare, it remains to be seen what will happen. Of the eight legislators shown in this file photo, only three are still serving. by KHI News Service

After months of advisory committee haggling over what it should look like, state officials say they are ready to launch the pilot program that will pave the way for including long-term services for the developmentally disabled in the new KanCare program.

Now, all they need to start the pilot are participants.

A recruiting letter went out Friday, seeking organizations and individuals willing to volunteer, but representatives from the state’s developmental disability organizations said doubts remain strong among their members about the pilot in particular and KanCare in general. It seems that nobody, including administration officials, expects a throng of eager participants.

“The advisory committee talked about really wanting, hoping to have a broad representation of providers (in the pilot), including different types of providers,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “I don't know that it’s necessarily as important to have numbers as it is to have different types. I’m hoping to have five providers, at least.”

The administration of Gov. Sam Brownback originally sought to have long-term services for the developmentally disabled included in KanCare when the managed-care program was launched Jan. 1. But groups, including parents, that represent the developmentally disabled, persuaded legislators to postpone that for a year.

KanCare is the governor’s ongoing remake of the state Medicaid program. Since it was launched a few weeks ago, virtually all the state’s 380,000 Medicaid enrollees have been assigned to health plans run by three commercial insurance companies.

The same legislative proviso that delayed the administration’s push to roll long-term developmental disability services into KanCare also called for the pilot program. But disagreement between the administration and advocates for the disabled over what the pilot should try to gauge or accomplish went on for months after the 2012 Legislature adjourned and still hasn’t been fully resolved.

What kind of pilot?

Advocates for the developmentally disabled said they wanted a pilot that would test the administration’s still-unproven theory that the KanCare insurance companies could effectively manage long-term or “non-medical” developmental disability services, producing healthier customers while cutting government costs yet presumably earning profits.

That ambitious set of pledges is something that hasn’t been solidly demonstrated anywhere in the country and sounds “too good to be true,” as Maury Thompson, former director of Johnson County Developmental Supports.

→ Continue reading on khi.org.

Melissa Ranson reads to children at the Topeka-Shawnee County Public Library. Experts say youngsters benefit from early exposure to books and reading. "She enjoys it," Ranson said of her three-year-old daughter, Landry, right. by KHI News Service

Some experts at Kansas universities are questioning Gov. Sam Brownback’s plan to cut spending on established early childhood development programs in order to fund a proposed new initiative aimed at improving the reading scores of the state’s fourth-graders.

Though the governor hasn’t yet provided much detail on how the new Kansas Reads to Succeed program would work, he has said he favors requiring third graders to pass a reading test before being advanced to the fourth grade.

‘Irresponsible and cruel’

“Passing children up the grade ladder when we know they can’t read is irresponsible and cruel,” Brownback said in his State of the State speech to the Legislature last month.

But reading specialists at two Kansas universities said research has shown that holding children back a year often does more harm than good.

“Children who are retained, typically, are more likely to not graduate from high school,” said Suzanne DeWeese, a reading recovery specialist with the Jones Institute for Education Excellence at Emporia State University. The university trains many of the state’s K-12 teachers.

“Children who aren’t learning to read need better instruction, not a repeat of a curriculum that’s already failed them,” she said. “And the sooner they have access to that instruction, the better.”

Early intervention

Diane Nielsen, an associate professor of education at the University of Kansas, said waiting until students were in third or fourth grade to address reading deficiencies was shortsighted.

“To do what it appears the governor wants to do, it would need to be done in the grades below fourth, beginning with support in preschool,” said Nielsen, a specialist in reading instruction.

“The emphasis should not be on a single year’s test results,” she said. “It should be on early intervention because there are so many things that need to be in place before a child reaches the fourth grade. Reading is not the simple process that people tend to think it is. It can be very complicated.”

Brownback, who campaigned for governor promising to boost 4th grade reading skills, told KHI News Service that he has been disappointed by the proficiency ratings.

“They’ve been fairly level for a long time,” he said. “We need to do better.”

Sherriene Jones-Sontag, the governor’s chief spokesperson, said details of Brownback’s new initiative would be made public in a bill that would be introduced by a legislative committee probably sometime this week.

“We reviewed models for potential legislation from several other states, including Florida,” she said. “Some aspects will be similar, some will be different and some completely unique to what other states have done to help struggling readers.”

‘Soup-to-nuts’

The governor’s plan has been endorsed by the Kansas Policy Institute, a conservative think tank based in Wichita.

“What we’ve seen in places like Florida, which has had practices like this in place for over a decade, is that when you set up the (reading) test in third grade, the (school) districts and teachers see the significance and start building in interventions early on,” said James Franko, the institute’s director of policy.

“So instead of waiting for students to reach the third grade, they’re taking a soup-to-nuts look at how they do reading for (kindergarten) through third grade, identifying those students who are struggling, and getting them the help they need so there isn’t this rude awakening when, all of a sudden, they get to the third grade and can’t read with their peers,” Franko said.

→ Continue reading on khi.org.

An Amerigroup billboard in Lawrence advertises the number of providers the managed care company has in its network. Some legislators and others say the KanCare transition is going smoother than expected. But others say the jury is still out on the effectiveness of the program's implementation. The state contracted with three managed-care companies. The other two are Sunflower State Health Plan and United Healthcare. by KHI News Service

There have been plenty of problems and frustrations. No one denies it.

But as Gov. Sam Brownback’s Medicaid makeover entered its fourth week, administration officials, some legislators and a variety of others involved with KanCare said they thought the massive changes underway in the $3.2 billion program so far have gone smoother than many expected.

KanCare, which launched Jan. 1, moved virtually all the state’s 380,000 Medicaid enrollees into health plans run by three of the nation’s largest managed-care companies: United HealthCare, Amerigroup and Sunflower State Health Plan, a subsidiary of Centene.

"Growing pains"

“I think we’re in the growing-pains phase,” said Mike Larkin, executive director of the Kansas Pharmacists Association, which months ago began preparing its members for the changes. “Some of our members are getting different answers on things, depending on who they call.”

Because people tend to see their pharmacists more often than other medical providers, pharmacies were among the first to file claims and otherwise deal directly with the new system.

Larkin said he expected to be “inundated” with calls from members dealing with KanCare problems the first week of January.

“I was pleasantly surprised that I wasn’t,” he said. “I think we were more prepared than maybe some other folks for the things that are coming down. There are some stipulations of the contract that the state signed with the MCOs (managed care organizations) that we’re still waiting to see fruition on…but as far as the pharmacies go, there are some frustrations but for the most part, I suppose it could be worse.

“I’m looking at mid-February. I was talking with a legislator and we agreed that if Feb. 15 comes and some things haven’t settled down, then we’ve probably got a problem,” Larkin said.

State officials anticipated there would be difficulties during the transition and took some steps to ease them.

First 90 days

For the first 90 days of KanCare — and in some instances longer — the state is requiring the insurance companies to comply with previously established "plans of care" for Medicaid clients in order to minimize disruptions to the patient's usual or expected services.

Also for the first 90 days, the state is requiring the companies to reimburse Medicaid services given by any medical provider regardless whether the provider has signed a contract joining the companies' service networks.

As the program's launch date approached, state and MCO officials began holding daily 9 a.m. teleconferences with Medicaid providers and beneficiaries to help troubleshoot problems as they arose.

State and insurance company officials answer questions from callers, make note of problems and sometimes post them to their respective online “issues logs," though state officials concede many problems marked "resolved" on the the logs have simply been brought to the attention of someone to work on, rather than fixed.

The most frequent, single response to callers during the daily calls has been “can we get back to you on that?” or words to that affect. But many callers also seem to go away satisfied with the answers they get.

“They’re trying”

One of those who called in recently was Vicki DeStefano of Fairway. She telephoned on behalf of her 53-year-old brother, Mike, who receives Medicaid-funded assistance after suffering a serious brain injury in a 2006 motorcycle accident that left him mostly unable to move or speak and eating through a tube.

He needs attention around the clock, she told KHI News Service in a later telephone interview, and before November there were six people being paid, not including her, to help care for him at different times of the day or week.

Now there is only one person to help her with her brother. The others left because they stopped getting paid. DeStefano said she is paying the remaining person out of her own pocket because some things she simply cannot do by herself.

She said the agency that handled the payments to the workers told her they weren’t getting reimbursed by the managed care companies. But DeStefano said she was more upset with the intermediary Financial Management Services (FMS) agency (commonly referred to as a “payroll agent”) than she was with United HealthCare, because the company seemed to be trying harder to help her and her brother.

She said her prior experiences with state officials and a succession of its contracting payroll agents had left her exhausted, frustrated and ready for any kind of change in the system.

“We really needed a change,” she said. “Whenever you have the government doing something, it’s a mess. I think we need a change, I just don’t think they did the research to make it go right…The state just dumped it on to all these MCOs and didn’t do anything to help them.”

DeStefano said she was alarmed by how unprepared many of the MCO employees seemed to be, but she said she expected things would only get better. She said she was impressed that the day after she called in to complain about her problems, a United representative called on her to see about fixing them.

Her problems weren’t resolved yet, she said, “but even when they can’t resolve it right away, they’re trying.”

She said she never got quick responses from the state, so the new attention from the MCO was welcome.

“Extremely pleased”

Cathy Harding is executive director of the Kansas Association for the Medically Underserved, which represents the state’s safety-net clinics. She also said she was pleased by the responsiveness of the MCOs.

“I think most people expected it wouldn’t be possible to implement a huge program like this without bumps in the road,” Harding said. “The thing I was concerned with (going in) was how responsive would the MCOs be when we bring them problems. In that regard, we have been extremely pleased. All three MCOs, when we bring things to their attention they have literally jumped right on it.”

Harding said there were ongoing transitional problems but that she expected things could be running smoothly within three months.

“This is a guess on my part,” she said, “but given how things are working at this point in terms of addressing issues, I’d be a little surprised if we don’t have all these kinks worked out in three months. Three months for a program of this size is certainly not bad. We’ll see.”

Slow payments

Among the frequent complaints or questions from Medicaid providers during the state’s daily teleconferences have been those about claims rejections or delays in payment from the MCOs.

→ Continue reading on khi.org.

In the current fiscal year, Via Christi Health — which includes this hospital on St. Francis in Wichita — is expected to receive almost $13 million from the disproportionate share payments, the most of any health care provider in the state. Hospitals use the money, a mix of federal and state dollars, to offset some of the costs of caring for the uninsured. Under the Affordable Care Act, also known as Obamacare, those payments are to be significantly reduced in anticipation of more people being covered by Medicaid. However, the U.S. Supreme Court ruling gave states the option to not expand Medicaid — meaning if Kansas chooses not to expand its Medicaid program, the state's hospitals face the loss of significant funding and may have to cut staff or services, officials said. by KHI News Service

Many Kansas hospital officials say they are worried that if state policymakers choose not to expand eligibility for the state’s Medicaid program, the hospitals will see a significant drop in the money they receive to help care for patients who can’t or won’t pay their medical bills.

Currently, 64 of the state’s 127 hospitals divide about $51.3 million a year in what are called Medicaid disproportionate share payments.

They use the money, a mix of federal and state dollars, to offset some of the costs of caring for the uninsured.

“It’s a significant amount of funding for us,” said Bruce Witt, director of governmental relations at Via Christi Health in Wichita.

In the current fiscal year, Via Christi Health is expected to receive almost $13 million from the disproportionate share payments, the most of any health care provider in the state.

Under the Affordable Care Act, also known as Obamacare, those payments are to be significantly reduced, starting in October.

“We’re being told that ‘disproportionate share’ won’t be completely phased out, but that roughly 50 percent will be going away,” said Tom Bell, chief executive of the Kansas Hospital Association. “It may end up being somewhere between 50 and 75 percent. We don’t know at this point.”

Though Via Christi could expect to lose the most dollars, the smaller, rural hospitals likely would be the hardest hit proportionately based on an analysis done for the KHI News Service by its parent organization, the Kansas Health Institute. The analysis calculated the likely revenue hit on each Kansas hospital based on recent payment histories, bed counts and inpatient stays.

State option on Medicaid

The law’s design, Bell said, preceded the U.S. Supreme Court’s June 28, 2012 ruling that gives states the option of choosing to not expand their Medicaid coverage to include non-disabled, childless adults whose incomes fall below 133 percent of the federal poverty level.

Since the ruling, governors in at least 10 states – Alabama, Georgia, Idaho, Louisiana, Maine, Mississippi, South Carolina, South Dakota, Oklahoma, and Texas - have said they will not expand Medicaid eligibility.

“Our lieutenant governor is saying he’s not sure that DSH (disproportionate share) is going away because the (U.S.) Supreme Court has said the federal government can’t penalize states for not going along with the Medicaid expansion,” said Shawn Rossi, a vice president with the Mississippi Hospital Association.

“We don’t know if that’s a correct assumption,” Rossi said, “but we are for sure telling our legislators that if DSH goes away, we’re definitely going to need something to take its place. We see a very large number of people who are uninsured.”

Brownback looking it over

Kansas’ Gov. Sam Brownback has been an outspoken opponent of the Affordable Care Act, has not yet decided whether to implement the Medicaid expansion.

→ Continue reading on khi.org.

KanCare ombudsman, James Bart. by KHI News Service

A week into major changes of the Kansas Medicaid program questions persist about whether a new consumer advocate will have the freedom and the resources to do his job.

Lawrence attorney James Bart was recently hired as the ombudsman for the new KanCare program being implemented by Republican Gov. Sam Brownback. Officials say the Jan. 1 expansion of managed care to include virtually all the state’s Medicaid enrollees is intended to slow the growth in Medicaid costs and improve the care provided to the more than 380,000 low-income, elderly and disabled Kansans in the program.

But some legislators and consumer advocates are questioning whether housing the ombudsman’s office in one of the state agencies responsible for KanCare implementation will hinder Bart’s effectiveness. They also question whether he will have sufficient resources to handle what could initially be large numbers of consumer complaints with the new system.

Bart, the only full-time employee in his office at the Kansas Department for Aging and Disability Services, was asked directly about the adequacy of his resources today during a meeting of the KanCare Specialized Care and Network Issues Workgroup in Topeka.

Sheldon Weigrau, a workgroup member, said if only 1 percent of the state's Medicaid enrollees filed complaints with the ombudsman, that would mean at least 10 complaints or problems a day to handle. He questioned whether Bart would have the resources to deal with that many of them, "otherwise, you're going to be overwhelmed."

Bart said 10 issues landed on his desk during the first working week of KanCare, which ended Jan. 4, and all had been resolved. And he said he had assurances from KDADS Secretary Shawn Sullivan that he could draw on on more of the agency's resources if needed.

"I can't solve every issue," Bart said. "But I can be the grease in the wheels. If it gets to the point where I feel I can't deal with the issues with the resources I've got, then I'll go get more resources."

Question of independence

Sen. Laura Kelly, a Topeka Democrat, is among the legislators asking questions about the ombudsman's office.

“It’s just beyond me to see how someone who is housed in an agency and who is dependent on that agency for the resources they need to do their job can be truly considered to be independent,” Kelly said after the issue was raised at a recent meeting of the Legislature’s Joint Committee on Health Policy Oversight.

→ Continue reading on khi.org.

Mark Dugan, (right) chief of staff for Lt. Gov. Jeff Colyer, and KanCare ombudsman, James Bart. by KHI News Service

The Brownback administration has not ruled out implementing the Medicaid expansion called for in the federal health reform law.

But a spokesman today told members of the Legislature’s Joint Committee on Health Policy Oversight that prior to making a decision administration officials want to develop their own estimate of how many Kansans are likely to sign up for the health care program and how much the expansion would cost the state.

“We’re continuing to study the issue,” said Mark Dugan, chief of staff for Lt. Gov. Jeff Colyer. “We would like to come to you with our own numbers.”

Currently, there are several competing estimates of how the expansion would affect Medicaid enrollment and the cost of the program. The latest, released earlier this month by the Kansas Health Institute indicated that approximately 240,000 additional low-income, disabled and elderly Kansans would enroll in a program that currently serves about 380,000. According to the KHI analysis, expanding Medicaid would cost the state an additional $519 million between its implementation in 2014 and 2020.

The KHI projections are higher than those in a 2010 report prepared for the now defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis done in 2010 by the Kaiser Family Foundation. However, they considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act.

The KHI News Service is an editorially independent program of KHI.

Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level — $5,900 a year for a family of four.

The ACA expansion would have a bigger impact in Kansas than many states. It would raise the eligibility threshold for all Kansans to 133 percent of FPL — $30,660 for a family of four.

Two of the four legislators who braved inclement weather to attend Thursday’s meeting of the 12-member committee made it clear that they favored the expansion.

Rep. Don Hill, a moderate Republican from Emporia, said that virtually all legislators regardless of party and ideology agree that the current health care system is broken and in need of reform to lower costs and reduce the number of people who are either uninsured and under-insured.

He said while the ACA is far from perfect, “it has some redeeming elements.” One of those, he said, is the Medicaid expansion because of its potential to extend coverage to many of the state’s 365,000 uninsured.

Citing the federal government’s promise to shoulder the cost of serving all those made eligible by the expansion for the first three years, Sen. David Haley, a Kansas City Democrat, asked, “Why can’t we cover more Kansans and why shouldn’t we?”

“I think we’re going to take a good look at it,” Dugan answered.

But, Dugan said, a factor that must be considered is whether or not the cash-strapped federal government can be counted on to keep its funding promise. After paying all of the costs of the expansion for three years, the federal government would gradually reduce its commitment until it reached 90 percent, where it would be maintained.

“He (Gov. Brownback) doesn’t have a high degree of confidence in the federal government maintaining that 90 percent commitment over the long term,” Dugan said.

Dugan said the federal government missed an opportunity to negotiate a compromise with Republican governors skeptical of the expansion when it rejected the idea of allowing states to increase eligibility to only 100 percent of FPL.

“That was an opportunity for middle ground that was lost,” he said.

→ Download the various cost estimates of expanding Medicaid in Kansas at khi.org.

James Bart of Lawrence has been hired to be the KanCare ombudsman. by KHI News Service

A Lawrence man who serves on the Kansas Council on Developmental Disabilities has been hired by the state to be the ombudsman for KanCare enrollees.

James Bart, 50, started the job today. He will office at the Kansas Department for Aging and Disability Services headquarters at 503 S. Kansas Ave. in Topeka.

Bart said he has a law degree from Creighton University but had not practiced law since leaving Nebraska for Kansas about 17 years ago. He is married and the father of a 19-year-old son with developmental disabilities and three younger children.

"I'll make a serious commitment to consumers of Kansas Medicaid to help them in any way I can," Bart said.

Bart said he previously worked in the automotive and insurance industries but preferred to not discuss the details. According to the profile he posted on Linked-in, an online network for business professionals, his employment before this job was as an auto damage appraiser for Crystal Carstar.

Bart said his passion has been advocating for the disabled and that the ombudsman job will allow him to wed his professional experience with his desire to help others.

According to KDADS officials he has worked with ARC of Douglas County, an organization that helps disabled persons and their families in Douglas, Jefferson, Osage and Franklin counties. He completed training in "community-based outreach and graduate network development" with the Kansas Council of Developmental Disabilities and also graduated from a "Special Education Law Boot Camp," conducted by Wrightslaw. He has a bachelors degree in Industrial Relations and Human Resource Management from the University of Iowa.

KDADS officials said Bart would be responsible for assisting Medicaid enrollees with "unresolved access, service and benefit problems," particularly those who receive home- and community-based services or are in long-term care situations. His annual salary will be $62,500.

→ Continue reading on khi.org.

Monica Anderson, right, a case manager with the Johnson County Area Agency on Aging, goes over some paperwork with client Patti Rogers. The two have worked together for seven years, and Rogers said she’s sorry she has to change case managers because of the overhaul of the Kansas Medicaid program. by KHI News Service

OLATHE — Workforce shortages prompted by the overhaul of the Kansas Medicaid program are hampering operations at some social service agencies in Johnson County and elsewhere in the state, according to executives at the organizations.

Human Services Director Debbie Collins said since September, her Johnson County agency had lost three of its nine case managers that assist frail elderly Medicaid clients through the Area Agency on Aging.

Collins said the workers all left for similar positions at UnitedHealthcare, one of the three insurance companies hired by the state as part of the new Medicaid program, which the state has dubbed KanCare. Virtually all the state’s 380,000 Medicaid recipients are scheduled transfer into the KanCare managed care plans effective Jan. 1.

The other two KanCare contractors are Amerigroup and Sunflower State Health Plan, a subsidiary of Centene. All three companies have been busy hiring workers for the past few months.

Collins and other agency administrators interviewed for this article said the bright side of losing the workers was knowing that the KanCare companies had hired qualified staff.

They said they didn’t blame their workers for taking the jobs because the employees told them they would get substantially higher pay at the managed care companies.

But the agency leaders said they weren’t sure how KanCare could save the state money, if the contractors will have significantly higher personnel costs.

“We are all befuddled about that,” Collins said.

Projected savings

Savings will come through a focus on patient education, preventive care, and by “ensuring members have access to the right care, at the right place and at the right time,” said Monica Stoneking, a spokeswoman for Sunflower State Health Plan.

Sunflower, she said, was paying “competitive wages in accordance with industry standards.”

Amerigroup spokesperson Maureen McDonnell declined to comment.

Alice Ferreira, a spokesperson for United Healthcare said the company was giving its new hires flexibility so that their former employers wouldn’t be left in the lurch.

“UnitedHealthcare has been working collaboratively with the agencies to provide case managers the work flexibility to ensure they are able to continue to work with the members as appropriate,” she said in an email. “We are committed to ensure members receive the care they need, and anticipate that this partnership will result in a smooth transition.”

She the company also was dedicated to “creating new jobs in Kansas.”

Officials at each of the KanCare contractors have said they would hire as many as 300 people as they prepare for the new program. Each company also has a Kansas headquarters office.

Changing roles

Officials in the administration of Gov. Sam Brownback estimate KanCare will save the state and federal governments $1 billion over the next five years.

Among the various social service and state agencies that have lost workers to the KanCare companies are the state’s Area Agencies on Aging, which, in any event, are seeing their roles change under KanCare.

Though the agencies are handing off case management for the frail elderly to the KanCare companies, they are expected to take on expanded roles in serving individuals with physical disabilities and traumatic brain injuries by assessing their needs for assistance and helping them choose the right KanCare plan, in the event the persons are not content with their state-assigned plans.

Collins said the changes have left her uncertain about what her staffing needs will be after the first of the year.

“We may very well have to expand,” she said. “We really don’t know what the workload will be.”

Lost connections

Other organizations experiencing KanCare-related personnel pinches include the Johnson County Mental Health Center and the Southeast Kansas Area Agency on Aging in Chanute.

Johnson County Mental Health has had 15 staff members take positions with the KanCare companies, according to agency officials, including a senior administrator and a number of clinicians and case managers.

In response, the center has pressed supervisors and everyone else with proper certification and training into service to coordinate care for clients, said Executive Director Maureen Womack.

The main problem, she said, was that clients had lost their connections to workers with whom they felt comfortable dealing.

“What is falling through the cracks,” she said, “is the therapeutic relationship.”

→ Continue reading on khi.org.

Robert Laszewski — a nationally renowned expert on health reform and president of Health Policy and Strategy Associates in Washington, D.C. by KHI News Service

→ Watch video below

Like Kansas Gov. Sam Brownback, Bob Laszewski is a staunch opponent of the Affordable Care Act.

Despite that, the Washington, D.C. consultant said at a meeting here today that Brownback is making a mistake by refusing to partner with the federal government to run the Kansas health insurance purchasing exchange that the law requires to be operational by 2014.

“Do the partnership. That is a no-brainer,” Laszewski said to about 100 legislators, lobbyists and health care providers at a meeting sponsored by the Kansas Health Institute, the parent organization of the KHI News Service.

Laszewski, whose client list consists mostly of health insurance companies, said it’s time for opponents of the law to stop fighting it and start doing what they can to ensure that it is implemented in a way that does the least harm to the industry and consumers. One way to do that, he said, would be to implement exchanges – new online marketplaces – that encourage competition among insurance companies rather than rely on regulations to moderate increases in premiums.

“Putting the insurance exchange up doesn’t mean you support the thing (the reform law), it means you are trying to minimize the damage,” Laszewski said, predicting that premiums in the individual and small-group markets would go up no matter who runs the exchanges.

Brownback last year blocked Kansas Insurance Commissioner Sandy Praeger’s attempts to establish a state-operated exchange, returning a $31.5 million federal grant in the process. Last month, the governor told Praeger, who also is a Republican, that he would not support her efforts to partner with the federal government to operate and fund the Kansas exchange.

“Kansans feel Obamacare is an overreach by Washington and have rejected the state’s participation in this federal program," Brownback said, explaining his decision.

Try again

Praeger, who also spoke at the KHI meeting, said she would try once more before a Feb. 15 federal deadline to convince the governor and legislators that partnering on an exchange would be better than allowing the federal government to run it. Federal officials recently extended the deadline in an effort to accommodate states where governors had opposed or held out on state participation pending the outcome of the November national elections.

“There is still some opportunity for us to retain some control,” Praeger said. “Our department looks forward to working with the Legislature and the governor to see if that still is an option. The decision really rests with them.”

Praeger said partnering with the federal government would allow her department to retain authority to approve the plans marketed in the exchange and manage consumer protection efforts. She said it might also prevent federal officials from over-regulating the exchange.

The ACA calls on states to expand Medicaid eligibility to include adults earning up to 138 percent of the federal poverty level — $30,660 a year for a family of four. But the U.S. Supreme Court decision earlier this year that upheld the law also made the program expansion optional for states.

Implementing the expansion in Kansas would make more than 300,000 additional adults eligible for a program that today serves approximately 380,000 Kansans – mainly women, children, seniors in nursing homes and people with disabilities.

A KHI analysis handed out at the meeting estimated that about 240,000 additional Kansans would enroll in Medicaid if the expansion were implemented in 2014, including 122,185 adults and 117,886 children. According to the analysis, expanding Medicaid would cost the state an additional $519 million between 2014 and 2020.

The projected cost and enrollment figures in the KHI analysis are higher than those in a 2010 report prepared for the now-defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis prepared in 2010 by the Kaiser Family Foundation. But the costs projected in the KHI analysis were considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act and its implementation. The Kansas Policy Institute also projected the program’s cost through 2023.

Currently, the state’s Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and then only if they earn less than 32 percent of FPL – $5,900 a year for a family of four.

Brownback hasn’t said whether he plans to implement or recommend the expansion for Kansas. But he has said that he doubts the federal government would keep its promise to initially pay 100 percent of the cost of serving all those newly made eligible by the Medicaid expansion. Under current law, the federal commitment would be good for the first three years, drop to 95 percent in 2017 and then to 90 percent in 2020, where it would remain.

Medicaid leverage

Laszewski said covering currently uninsured Kansans in Medicaid would be significantly cheaper for taxpayers than providing them with tax credits to purchase private coverage in the exchange. And he said by agreeing to the expansion, Brownback and other Republican governors might be able to get federal officials to agree to their long-standing request to convert the program to block grants to states with fewer restrictions on how the money is spent.

“Put up or shut up, that’s what I say to Republican governors,” Laszewski said. “It gives you leverage to get what you’ve always said you wanted — autonomy. Go to the Obama administration and say, ‘OK, we’ll expand Medicaid but we’re not going to do it your way.’”

→ Continue reading on khi.org.

Dr. Dennis Cooley visits with April Yarger during her son Peyton's first check-up. The Topeka doctor has signed contracts with all three managed care organizations that are scheduled to begin administering Medicaid services in the state starting Jan. 1, the planned launch date for KanCare. by KHI News Service

After prodding from local consumer advocates and federal overseers, Kansas officials have made public more details about how they would implement KanCare and say they plan to release more information as quickly as it becomes available.

A federal decision on the state’s plan to remake its Medicaid program is expected any day and the new information is evidence of the back-and-forth in the discussion between the federal Centers for Medicare and Medicaid Services as the administration of Gov. Sam Brownback continues its push for a Jan. 1 launch of the new program.

'Implementation Activities'

Brownback officials so far have posted six section 1915c waiver amendments on the KanCare website and also within the last several days have posted six “implementation activities” reports that outline previously undisclosed details about how they expect KanCare to work.

"These are some very specific implementation reports we're submitting to CMS and making available to all of you simultaneously," said Kari Bruffett, director of the division of health care finance at the Kansas Department of Health and Environment, talking last week in a teleconference with Medicaid providers.

Among the things outlined in the reports:

• State officials intend to create an ombudsman position at the Kansas Department for Aging and Disability Services to field complaints and questions about KanCare from Medicaid enrollees and service providers. They began recruiting for the new position Nov. 12 and began interviews last week with the goal of having a person hired by Jan. 1.

• A timeline and plan for communicating the KanCare changes to Medicaid enrollees and providers.

• A plan for following up on “returned” mail, information sent to enrollees that fails to reach the intended recipient.

• Details of how eligibility and enrollment in KanCare will be verified.

• A plan for how the customer call centers will deal with the influx of expected queries from Medicaid enrollees. According to the report, 226 customer-service representatives are “ready to step in as needed.”

Some of the state’s recent actions seem to stem, at least in part, from CMS having heard concerns from some Kansas advocacy groups about the need for more information about KanCare and the creation of an ombudsman position.

Anna Lambertson, executive director of the Kansas Health Consumer Coalition, said she and other advocates met with CMS officials and followed up with a Nov. 13 letter to them outlining their concerns about KanCare. CMS responded 10 days later.

Letter to CMS

“We asked for the state to be more transparent, posting more on line,” Lambertson said. “And we made some very specific requests of the state for an outreach education plan that meets the needs of the various populations and involves the stakeholders.”

Lambertson said she was still reviewing the documents posted subsequent to the group’s letter to CMS. But she said she already had seen enough of the ombudsman plan to know that it fell short of what the consumer groups were seeking.

“We feel very strongly there are certain things that really need to be in place in order for the state to be ready to kick off on Jan. 1, “ she said. “And I personally don’t feel those processes are in place.”

→ Continue reading this story — and ongoing KanCare coverage — on khi.org.

Shannon Cotsoradis of Kansas Action for Children by KHI News Service

A child advocacy organization is criticizing Gov. Sam Brownback for restricting access to some programs that help low-income Kansans while more children and families are slipping into poverty.

Shannon Cotsoradis, chief executive of Kansas Action for Children, said recent changes made by the Brownback administration to tighten eligibility criteria for cash and child-care assistance programs are making it harder for some struggling families.

Cotsoradis cited data in 2012 KIDS COUNT report released on Thursday. It showed that the numbers of Kansas children enrolled in Medicaid and receiving food stamps had gone up significantly while the numbers receiving cash and child-care subsidies had gone down.

“You see this huge discrepancy in the data,” Cotsoradis said. “It just doesn’t make a lot of sense.”

Angela de Rocha, a spokesperson for the Kansas Department of Children and Families, defended the administration’s policy changes as efforts to encourage people to become more self-reliant.

“I think we should be praised, not criticized,” she said.

According to the new KIDS COUNT report, 21 percent of Kansas children are living in poverty, up from 18 percent in 2007. The average number of children enrolled in the Supplemental Nutritional Assistance (food stamp) Program rose to more than 136,000 in 2011 – an increase of nearly 40,000 since 2007.

Also, nearly half of all school-aged children in Kansas – 48.6 percent – qualified for free or federally subsidized lunches this year. That is an increase of almost 10 percentage points in four years.

Over the same period, the report shows that the number of families receiving cash-assistance through the Temporary Assistance for Needy Families program has been trending down. In 2011, there were 25,981 families that received assistance, down from 26,633 in 2007. Families receiving child-care assistance decreased to 19,735 in 2011 from 21,025 in 2007.

Officials at the Kansas Department of Children and Families anticipate that the TANF numbers will continue to drop. The official caseload estimate released earlier this month by the Kansas Legislative Research Department says the agency anticipates spending $2.4 million less from the state general fund to support the program in the 2014 budget year “due to the continuation of recent changes in policies.”

Cotsoradis said that explanation “confirms that they (administration officials) are creating barriers to those programs.”

But de Rocha said the declining numbers of families receiving cash and child-care assistance isn’t necessarily the result of the policy changes. She said it could mean that many have gotten full-time jobs because of the department’s insistence that they comply with job-search, training and part-time work requirements.

“It is either people who got a job or who don’t want to cooperate with the job-search and work requirements,” she said. “All we’re saying is ‘we’re happy to help you get back on your feet, but you need to find a job.’”

Cotsoradis said the changes to the assistance programs seemed at odds with Brownback’s campaign promise to make reducing childhood poverty one of his administration’s top priorities.

On Wednesday, the governor appointed a 12-member task force and charged its members to report back with “concrete ideas” on reducing childhood poverty.

“All too often in our state, children who are living in poverty today become tomorrow’s poor parents,” Brownback said. “Intergenerational poverty such as this affects our state’s long-term productivity and wellbeing. We need concrete ideas on how to change this pattern.”

The first task force meeting is scheduled for 10 a.m. Monday in the Kansas Board of Regents Conference Room on the 5th floor of the Curtis State Office Building in Topeka.

→ Continue reading about recent policy changes mentioned in this story on khi.org.

Former State Rep. Carolyn Weinhold was among those who gathered at the Statehouse on Friday in support of expanding the state's Medicaid program. In the 1990s, Weinhold was a Democrat representing a Salina district. She now works for the Kansas Disability Rights Center in Topeka. by KHI News Service

About 100 people rallied outside the Kansas Statehouse Nov. 9, urging state officials to expand Medicaid eligiblity as provided for in the federal health reform law.

A Lawrence pastor cast the expansion as a Christian imperative during a call-and-response exercise with the crowd.

“If Jesus was up in the Capitol would he make a choice to keep 130,000 people without care?” said the Rev. Joshua Longbottom, associate pastor at Plymouth Congregational Church in Lawrence.

"No," the crowd shouted.

“If Jesus was up in the Capitol, would he tell families that they just need to get better jobs so that they could afford to take care of themselves?” Longbottom asked.

Again, the answer was "no."

“Did Jesus say, ‘I’m sorry you can’t get to the well, Mr. Leper, but you need to cultivate some self-reliance’?” Longbottom said.

“No,” the crowd yelled.

“So I ask the question, Gov. Brownback, ‘What would Jesus do?” Longbottom said. “I thought the mark of his ministry was caring for the ill, caring for the sick, caring for the dispossessed, caring for the marginalized, caring the first for the least.”

Longbottom said he hoped the governor wasn’t a “…politician who puts on his Christianity like it’s a cardigan (sweater), using it to gain access to a constituency.”

Brownback, a conservative Republican, has been outspoken about his Christianity and penned a spiritual autobiography titled "From Power to Purpose."

He's been a consistent political foe of the Affordable Care Act, also known as ObamaCare, first in the U.S. Senate and later as governor.

He has said repeatedly that the majority of Kansans are opposed to the reform law and cites the success of the law's opponents in recent state elections as the proof.

Expansion not ruled out

Last week, the governor announced that he would block the state’s participation in a state-federal insurance exchange, one of the hallmarks of the new law. But unlike some Republican governors, he hasn't ruled out the possibility he would support some sort of Medicaid expansion.

"The Medicaid expansion is a separate issue" from the insurance exchange, said chief Brownback spokesperson Sherriene Jones-Sontag in an email Friday to KHI News Service in response to a question asking if the governor would oppose opening up the program.

"We are continuing to discuss options and alternatives with like-minded states and with our legislative partners in Kansas," she said.

The U.S. Supreme Court has upheld the Affordable Care Act, but said the law couldn't oblige states to expand their Medicaid programs. The law gives states the option of expanding their Medicaid programs to include adults earning up to 133 percent of federal poverty guidelines.

→ Continue reading on khi.org.

Kansas Insurance Commissioner Sandy Praeger. by KHI News Service

Kansas Insurance Commissioner Sandy Praeger said today that she wants to meet this week with Gov. Sam Brownback about how to move forward with implementation of the federal health reform law.

Specifically, Praeger said she wants to talk to Brownback about the state partnering with the federal government on a health insurance purchasing exchange. Kansas no longer has the option of designing its own online insurance marketplace but it can still partner on one with federal officials, if it acts quickly, she said.

Praeger said partnering with the federal government on an exchange would allow the state to maintain its authority to review and license insurance plans.

Praeger, a moderate Republican who supports the reform law, said she must let federal officials know by Friday, Nov. 16 whether the state intends to partner on an exchange. But she said she needs the governor’s blessing on that and a grant application her department has prepared, which must be submitted by Thursday, Nov. 15.

“The governor needs to agree that he won’t oppose us applying for the grant,” Praeger said. “He doesn’t have to give tacit approval necessarily, but just indicate it’s OK if we want to move forward on this.”

Brownback, a conservative Republican, voted against the Affordable Care Act as a member of the U.S. Senate and as governor has tried to block its implementation pending the outcome of a U.S. Supreme Court ruling on the law and then later the outcome of the presidential race.

Brownback in August 2011 rejected a $31.5 million federal grant intended to help Kansas develop an exchange as part of a program to develop models for other states to use.

Praeger said President Obama’s re-election means that the reform law won’t be repealed. It also means that states that have been slow to act will have to play catch up to meet approaching implementation deadlines.

Under the law, each state is to have an exchange operational by Jan. 2014.

“It’s time to stop resisting,” Praeger said.

→ Continue reading on khi.org.

Savannah Johnson, 4, waits with her grandmother, Joyce Corwin, for a WIC visit with Lawrence-Douglas County Health Department. They live in Baldwin City. Budget plans being considered by the administration of Gov. Sam Brownback could mean cuts in state aid to local health departments. by KHI News Service

Detailed spending proposals for the coming fiscal year prepared by officials at the state’s three top health agencies outline how Gov. Sam Brownback’s administration is planning to cap or cut spending on a broad range of health-related programs.

The governor’s formal budget recommendations for fiscal year 2014, which begins July 1, 2013, won’t be delivered to the Legislature until January when its new session begins. But agency chiefs were told as early as August by the governor to keep spending in check and to present alternatives for cutting 10 percent from each department’s upcoming state general fund budget.

The documents presented by the Kansas Department of Health and Environment, the Kansas Department for Children and Families, and the Kansas Department for Aging and Disability Services to the state budget office as part of the governor’s budget building process were obtained by KHI News Service and are made available here.

Administration officials declined to answer questions about their spending plans.

“We will not comment on the budget proposal at this time,” said Angela de Rocha, spokesperson for the Kansas Department for Aging and Disability Services and the Kansas Department for Children and Families.

Fading state aid

But there is abundant comment contained in the budget documents themselves and representatives of many, if not all, the organizations and programs that rely upon state health dollars have been advised informally within the past couple of weeks by administration officials of the planned spending limits and possible cuts. However, none of the representatives interviewed by KHI News Service had been given the full details laid out in the documents.

“We actually had a meeting with the secretary (Shawn Sullivan of the Kansas Department for Aging and Disability Services) but he didn’t give us any numbers,” said Cindy Luxem, chief executive of the Kansas Health Care Association, which represents for-profit nursing homes and some of the state’s providers of home and community-based services for the elderly.

“The providers at this stage of the game are not getting any kind of bump in the rates (for Medicaid services). The intention of the state is to keep the rates flat, essentially for the next two years, is what he told us,” she said.

Michelle Ponce, executive director of the Kansas Association of Local Health Departments, said she was alerted that the “reduced resources” budget proposed by the Kansas Department of Health and Environment could mean a cut in state aid to the local health agencies.

If adopted as outlined in the agency’s budget plan, 40 local health departments would see their state grants cut with the biggest decreases falling on the state’s largest local agencies.

“It’s maybe too early to tell you exactly what it would all mean,” Ponce said. “But it is unlikely all those agencies could absorb those cuts and maintain current services.”

Ponce said state support for local public health agencies hadn’t increased in years despite the added costs of inflation so any cuts would fall all the harder on the departments. She said association research had showed that since at least 1984, local governments have been stuck with absorbing the growing costs of health department programs as state aid has faded.

Health and Environment

Throughout the budget documents, officials note the need to hold down spending, though sometimes the notes are accompanied by caveats that seem to argue against some of the possible reductions.

At KDHE, officials said “that in recognition of the reality we find ourselves in as a state agency in the current budget environment, the (agency) will not be asking for budget enhancements” in fiscal 2014.

In fact, agency officials proposed total state general fund spending of about $1 million less than for fiscal 2013. About 80 percent of the agency’s $2.6 billion annual budget comes from fees, grants or federal aid as opposed to state tax dollars.

As part of the agency’s “reduced resources” options for cutting 10 percent from the state general fund portion of its budget, officials said they would trim administrative costs by almost 34 percent as a way to forestall more cuts to direct services.

→ Continue reading on khi.org

Lt. Gov. Jeff Colyer — a point man for Gov. Sam Brownback's plan to remake the state's Medicaid program — speaking about the proposed KanCare reforms at a public event in Overland Park on Thursday. by KHI News Service

A Kansas health consumer group is planning a post-election rally at the Statehouse in support of expanding the state’s Medicaid program.

Meanwhile, Lt. Gov. Jeff Colyer today headlined an event in Overland Park that was sponsored by a conservative think tank that opposes broadening the Medicaid program. Colyer, however, didn't make explicit what intentions, if any, the administration of Gov. Sam Brownback might have with respect to the issue.

Anna Lambertson, executive director of the Kansas Health Consumer Coalition, said the group "wants to get the dialogue started," on the potential benefits for Kansans, if policymakers here decide they will open up eligibility to include adults earning up to 133 percent of federal poverty guidelines.

Currently, the state's Medicaid program is mostly restricted to poor children, pregnant women, the disabled and the elderly. A non-disabled adult rearing children is currently eligible for Medicaid, if his or her income is below 32 percent of the poverty level – about $5,200 a year for a young mother with two children.

Kansas’ eligibility threshold is among the lowest in the nation.

Affordable Care Act

Under the federal Affordable Care Act, commonly referred to as Obamacare, states would have the option of expanding their Medicaid programs to include adults with incomes at or below 133 percent of federal poverty guidelines or about $30,700 a year for a parent in a four-person household or about $14,900 a year for a childless adult.

Brownback, an outspoken critic of the health reform law, has said he won't consider any aspect of the health reform law's implementation, including a possible Medicaid expansion, until after the Nov. 6 election.

Republican presidential candidate Mitt Romney has pledged to repeal the law, if elected.

Governors in at least six states – Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas – have said they will reject the expansion, citing concerns that it would prove to be too expensive and would expand – rather than shrink – the role of government.

Governors in at least 13 states have said they will expand the program.

According to a preliminary estimate by analysts at the Kansas Health Institute, if the expansion is approved here it could add 130,000 people to Kansas Medicaid by 2019.

Colyer was the main speaker at a Kansas Policy Institute (KPI) meeting today in Overland Park that drew about 60 people. He confined his remarks to describing the administration's rationale and goals for its KanCare Medicaid reforms.

He didn't offer new information, but instead repeated points he and other administration officials have made in various venues since unveiling their plan about a year ago. He didn't touch on the question of Medicaid expansion and did not take queries from the audience before leaving for another engagement.

'Crowd out'

But earlier in the two-hour event, KPI President Dave Trabert said that expanding Medicaid in the state could increase the program's enrollment by 254,000 people by 2023 and increase state general fund spending on Medicaid by $4.7 billion within a decade.

Under the law, the federal government, starting Jan. 1, 2014, would finance 100 percent of the costs of covering the newly eligible Medicaid enrollees for three years: 2014, 2015, and 2016.

The federal match would drop to 95 percent in 2017; 94 percent in 2018; 93 percent in 2019; and 90 percent in 2020 and beyond.

Currently, the federal government picks up about 57 percent of the state’s Medicaid cost. The state pays the remainder.

→ Continue reading on khi.org.

Top welfare officials from the administration of Gov. Sam Brownback during an April press conference about the state's 1115 waiver application. From left: Dr. Robert Moser, secretary of the Kansas Department of Health and Environment; Lt. Gov. Jeff Colyer, also a physician; and Dr. Susan Mosier, state Medicaid director. by KHI News Service

By the end of this week, officials in the administration of Gov. Sam Brownback are expected to decide if their KanCare Medicaid reforms will move forward on the original timeline of a Jan. 1 launch or whether the program will get pushed to a later, yet-to-be-decided date.

A few things are scheduled to happen over the course of the next five days that will shape that decision, according to Brownback officials. Among them:

Sometime this week, perhaps by Wednesday, completion of the last of the state’s “readiness reviews” of the three managed care companies is due.

Officials have said they will not proceed on schedule unless Amerigroup, United Healthcare and Sunflower State Health Plan, a Centene subsidiary, each has demonstrated it is ready. (The companies had an Oct. 12 deadline for demonstrating that their networks of hospitals, doctors and other service providers were “90 percent adequate,” but administration officials said they wouldn’t make public the status of the companies’ respective network capacities until the end of this week, so it isn’t yet clear how well each company fared with the deadline.)

On Thursday, the day before the administration’s go/no-go decision date, top Kansas health officials are set to meet in Baltimore, Md., with federal officials from the Centers for Medicare and Medicaid Services, the Office of Management and Budget and others.

Reviewing the waiver request

The purpose of the meeting is a review of the state’s so-called Section 1115 waiver application. Much, if not most, of the KanCare plan requires federal approval, either as part of the waiver application, the state’s ongoing Medicaid plan on file with federal officials, or the KanCare contracts and rates. The federal government gets a large say in keeping with the fact that it pays more than half the state’s annual Medicaid costs, which next year are expected to reach $3.2 billion.

Though administration officials have said the launch date for KanCare is contingent upon the various factors still in play as of this week, at the same time they’ve made clear to legislators and others that they have no major fallback plans in place in the event the program is delayed.

“With all those caveats and decision points along the way, we're marching forward for Jan. 1 and all our efforts are for implementation on Jan. 1,” Bruffett told members of the Joint Legislative Budget Committee last week during an update on the KanCare program.

For example, KanCare is expected to supersede HealthWave, the state’s program for providing government subsidized health coverage to children and pregnant women from low- and moderate-income homes. The state’s contracts with the current HealthWave managed care companies, Unicare and Children’s Mercy Family Health Partners (recently purchased by Coventry Health Care), are due to expire Dec. 31. There is no plan to extend those contracts in the event KanCare is delayed.

“We’ve not had any of those kinds of conversations,” Bruffett told KHI News Service.

If necessary, Kansas could continue HealthWave services with the more expensive alternative of paying fees for services instead of relying on managed care contractors, “but that isn’t a good option,” Bruffett said.

As much KanCare as possible

When asked by Sen. Laura Kelly, a Topeka Democrat who serves on the budget committee, what administration officials would do if federal officials do not approve the 1115 waiver on the Brownback timeline, Bruffett said the administration’s intention was to launch as much of KanCare as possible without federal approvals on Jan. 1.

“Everything we have authority to do in the KanCare model, we will do,” she said.

But at this point, it isn’t clear how much of the program could be initiated without the OK from the feds.

→ Continue reading on khi.org/kancare-deadlines.

Children's Cabinet chair Amanda Adkins (left) and cabinet member Shannon Cotsoradis (right). by KHI News Service

The Children's Cabinet should start planning to receive as little as $12 million in tobacco dollars — or $44 million less than current funding — for programs in fiscal 2014, said chair Amanda Adkins at a cabinet meeting today.

Adkins was relaying an estimate from Attorney General Derek Schmidt of "the absolute worst-case scenario" if an arbitration panel rules against Kansas and other states in a dispute with tobacco companies.

"We could have to pay back or be on the hook for as much as $42 million, which means in fiscal year 2014 our tobacco settlement dollars could be as low as ... $12 million. That is just the hard reality in which we find ourselves right now," Adkins said. "If we're really committed to the work that's being done by everybody in this room, we have to plan for the worst-case scenario."

The Children's Cabinet oversees the Children's Initiatives Fund, or CIF, which gets its money from tobacco settlement payments that Kansas and 45 other states negotiated in 1998 with four major tobacco companies. Among the 20 or so CIF programs are Early Head Start, child care and services that assist at-risk families, such as those with disabled children.

Kansas received $56 million in fiscal year 2013 and has received $761 million in total since 1999. However, tens of millions of those funds could be reclaimed out of future payments if an arbitration panel agrees with tobacco companies, which claim Kansas and 31 other states haven't upheld their end of the settlement. The panel is expected to issue its ruling in June.

Cabinet member Sen. Laura Kelly, D-Topeka, said she would like more information on how the attorney general's office arrived at its projection.

"I think it's important to be prepared for disaster, but I'm not convinced we have a disaster on the way," Kelly told KHI News Service, noting that that last year the attorney general projected $40 million in tobacco receipts and the state ultimately received $56 million.

When asked how officials arrived at the $12 million figure, a spokesman for the attorney general declined to comment.

"As this matter is in arbitration we decline comment," Jeff Wagaman wrote in an email today.

Preparing for the worst

Adkins said cabinet members should start planning for the worst-case scenario by seeking funding from additional sources, including businesses, charitable organizations and the state.

→ Continue reading at khi.org.

by KHI News Service

Officials at the Kansas Department of Health and Environment said today that they had released additional information from the state's Medicaid managed care contracts sought in an Open Records request filed last week by the Johnson County Commission.

That information followed an earlier release requested by county officials of cost proposals submitted to the state by Amerigroup, Sunflower State Health Plan and United Healthcare, the insurance companies that signed KanCare contracts with the state. State officials said they sent the earlier information to the county officials on Friday. Johnson County officials confirmed Monday that they received that information and were still looking through it on Tuesday.

Some of that insurance company information had been marked "confidential" trade secrets but a KDHE spokesperson said none of the companies had objected to release of the documents.

No objection from companies

Miranda Steele of KDHE said officials at the department of administration had advised the managed care companies that the state had received an Open Records request for the cost proposals, which the state intended to honor.

"According to D of A, none of the MCOs objected at the time. So in our opinion, we did not need to ask the MCOs for consent to send the cost proposal information," to Johnson County, Steele said in an email to KHI News Service.

The state's public disclosure laws include exemptions for trade secrets and some other insurance company financial filings. According to Johnson County officials, they were informed verbally last week that their second information request would be denied because of that exemption. The county then filed a formal written request for the information, which was approved today by Michael G. Smith, associate chief counsel at KDHE's division of health care finance.

The information sent to Johnson County officials this afternoon also was given to KHI News Service upon request and has been posted as attachments to this article.

Some changes

The newly released documents show some changes in the signed contracts with the companies versus the final cost proposals the firms submitted in May during negotiations with state officials.

→ Download documents and continue reading on khi.org.

Johnson County officials are trying to get financial information regarding the three KanCare contractors hired to run the state's Medicaid program but could be stymied by exceptions to the state's Open Records law, which allow nondisclosure of "trade secrets" and various insurance company financial filings. by KHI News Service

Johnson County commissioners have hit a wall in their effort to learn how much the three insurance companies that have signed contracts to run the Kansas Medicaid program will collect in profit or administrative fees.

State officials told them they would not share the requested financial information because it was “proprietary and confidential,” according to Maury Thompson, director of Johnson County Developmental Supports, a county agency that provides services to the disabled and which initiated the information request.

'Very curious'

“The county’s opinion is that they are public documents and should be disclosed,” Thompson said. “Once any contract is signed by the board of county commissioners, it is a public document. We're very curious to learn on what legal grounds they think they cannot disclose a signed, legal governmental contract.”

Portions of the state’s KanCare contracts with the three managed-care organizations (MCOs) have been posted on a state website. But not included with those postings were contract attachments A and B, which is where Thompson said commissioners believe the information they seek could be found.

“The underlying intent of obtaining this financial information is to determine what the administrative charge will be to the state for their services and what their medical loss ratio or profit will be from this business,” Thompson said. “What sort of money are we pulling out of the system to pay these three MCOs?”

Kansas is expected to spend about $3.2 billion on Medicaid services in the coming year, or, on average, about $641 per beneficiary per month. Most of that money would go to the insurance companies and their service providers, assuming federal authorities sign off on Gov. Sam Brownback’s plan to implement KanCare starting Jan. 1.

$1 billion in savings pledged

Brownback officials have said they expect the new system to save the state and federal governments $1 billion over the next five years without cutting services and while improving outcomes for Medicaid patients. The claims have been met with some skepticism by county commissioners and legislative critics because details of how the savings might be realized have not been clearly explained. Administration officials have said the savings will come from better coordination of care.

Johnson County officials filed their disclosure request on Thursday and are awaiting the formal denial from state officials so they can file a counter response, Thompson said. Meanwhile, the matter rests in the hands of the county’s lawyers and could lead to a showdown between the local and state officials over the correct interpretation of the state’s Open Records laws.

Thompson said state officials had agreed to release MCO cost proposal information sought in a separate and earlier information request by the county. That information is expected to the commission early this week, but it won’t include the figures commissioners most want to see, he said.

Disclosure exemptions

Kansas’ open records laws were intended to make most state and local governmental affairs readily available to public scrutiny. But they include a fairly lengthy list of disclosure exemptions, including some specific to insurance company financial documents, particularly those filed with the Kansas Insurance Department.

There also is a broader exemption in the law for trade secrets. That exemption already has been successfully invoked at least once by one of the managed care companies when the contracts were still being negotiated.

The insurance department rejected a request in April by KHI News Service for financial projections filed by Amerigroup, one of the later successful bidders, after the company asked that the information not be released.

William Sneed, an attorney representing Amerigroup, delivered an April 11 letter to Ken Abitz, director of the insurance department’s financial surveillance unit, citing the trade secrets exemption.

Under that provision of the law, insurance department officials were barred from disclosing the information without the company’s permission.

Laws and practices slow to catch up

Profit-driven Medicaid managed care companies have become some of the nation’s fastest growing and most sophisticated business enterprises.

Directly or indirectly through subcontractors they employ hundreds of thousands of people, report billions of dollars in annual revenues and now, according to federal statistics, have about half the country’s 62 million Medicaid patients enrolled in their plans.

But federal and state laws and practices in some important ways haven’t kept pace with the growth of the managed care companies, which exist in a regulatory and legal space different from that occupied by commercial health insurers, those that provide plans to employers and other private purchasers.

→ Continue reading on khi.org.

Gov. Sam Brownback addresses about 225 health workers, government officials, and members of the Governor's Council on Fitness at the 2012 Kansas Summit on Obesity. by KHI News Service

In his opening remarks today at the Kansas Summit on Obesity, Gov. Sam Brownback focused on what it takes for a person to lose weight.

"It's the two E's: eating and exercise. It's not really complicated in my estimation," Brownback told about 225 health workers, government officials and members of the Governor's Council on Fitness, who gathered for the first time in four years to discuss one of the state's top health concerns.

Then, after six hours of presentations and discussion on the latest approaches to reducing obesity, the governor used his closing remarks to issue a new directive to the state's top health officer, Dr. Robert Moser, secretary of the Kansas Department of Health and Environment.

"I got a couple things out of this today that I want to address already. I'm going to assign Bob Moser to assess all the state facilities and our cafeterias for healthier lifestyle options — food and healthy activity," Brownback said, sparking applause and cheers.

"In the CDC's assessment they said they needed to lead by example," Brownback said referring to a presentation by Dr. William Dietz, former director of nutrition, physical activity and obesity at the Centers for Disease Control and Prevention. "Well, we need to lead by example. I don't think we've focused on it. We look at the numbers and we say this is terrible, but then we don't lead by example. It's time we do."

The governor also said by the first of the year his administration would be announcing an incentive-based walking program to encourage teams across the state to form and participate.

And Brownback accepted a challenge from Blue Cross Blue Shield of Kansas chief executive Andrew Corbin to walk five miles with him on a state trail of the governor's choice in exchange for a Blue Cross donation for the trail's maintenance.

"That's the sort of thing I want to see us do," Brownback said. "Let's get out and let's have some fun, get people active and get their blood going."

High costs of obesity

The statistics on obesity were laid out in detail by Dietz:

• 64 percent of Kansas adults are overweight or obese,

• 30 percent of Kansas adults are obese,

• Obesity costs the U.S. nearly $150 billion annually — or 9 percent of medical costs,

• In Kansas, $1.3 billion per year is spent on obesity-related ailments such as Type II diabetes, heart disease and other complications, and

• Obesity accounts for nearly 80 percent of preventable deaths, the second leading cause in the state behind tobacco.

"Virtually every system in the body is affected by obesity," Dietz said. "And these costs don't show the personal costs of obesity — the discrimination of obesity, the painfulness of obesity, the under-performance at work, the increased absenteeism at work. There are estimates that suggest those costs are at least as much as the direct costs of obesity."

→ Continue reading about the summit attendees' recommendations for reducing obesity at khi.org.

Tom Bell, president and CEO of the Kansas Hospital Association. by KHI News Service

A range of political and economic uncertainties are hindering the ability of hospital officials to plan for the future, according to a report released today by the Kansas Hospital Association.

"The 2012 election has moved the health care debate to the forefront, which is good," the association's chief executive Tom Bell wrote in an editorial accompanying the report. "However, the ongoing nature of the debate complicates hospitals’ ability to make investments."

Among the unknowns cited in the 16-page report:

• The impact of the 2012 election on Medicare reform and on implementation of the Affordable Care Act,

• The uncertain future for federal disproportionate share payments, which compensate hospitals for treating uninsured patients who do not pay, and

• Whether Kansas will expand Medicaid eligibility as provided for under the ACA.

"Cuts to entitlements, especially significant federal cuts to Medicare, could jeopardize hospitals and physicians — limiting access to care," Bell said. "The state’s pending decisions about Medicaid expansion also will have a substantial impact, at a time when hospitals have already surrendered significant Medicare revenue through the ACA with the expectation of expanded coverage."

Under the health reform law, about 130,000 additional Kansans are expected to become eligible for Medicaid in 2014. The state currently has about 350,000 people directly benefiting from Medicaid services. In anticipation that hospitals would be providing less uncompensated care to uninsured patients because of expanded Medicaid eligibility, the ACA also reduced the disproportionate share payments.

While the U.S. Supreme Court ruled much of the health reform law constitutional, its decision granted states leeway to decide if they will expand eligibility.

If Kansas opts not to expand its Medicaid coverage, Bell has said, the state’s hospitals would be put in a position of still having to care for thousands of uninsured people in their emergency rooms while losing millions of dollars in federal disproportionate share payments.

Kansas Gov. Sam Brownback has reiterated his opposition to the Affordable Care Act in statements since the ruling, but he has stopped short of saying the state won’t implement the Medicaid expansion on schedule in 2014.

"Decisions regarding the expansion of Medicaid under Obamacare will not be made until after the November elections. The Brownback administration does not speculate on hypotheticals," according to a statement issued by the Governor's Office.

→ Download the full report at khi.org.

Federal officials have set a Sept. 30 deadline for hearing from governors on their “benchmark” plan choices for basic benefits to be available through the new online purchasing exchanges. The benchmark plans and exchanges are set forth by the federal health reform law, which Gov. Sam Brownback has pledged to have no part of until after the November presidential election. by KHI News Service

State insurance regulators are preparing a recommendation for Gov. Sam Brownback on what basic benefits should be available to Kansans who seek health insurance through the new online purchasing exchange that federal officials expect to be operational here within about 16 months.

A three-hour hearing to collect public input on what should constitute the state’s “essential health benefits” benchmark plan is scheduled for Wednesday. It is set to start at 9 a.m. in Shawnee Room A at the Maner Conference Center, which is next to the Capitol Plaza Hotel in Topeka.

“Our plan is to get some summary information (including a recommendation) over to the governor within a week or so after the hearing is over, and at that point it will be up to him to decide if he wants to make an election,” said Linda Sheppard, director of the accident and health division at the Kansas Insurance Department. Sheppard also is the agency’s project manager for matters dealing with implementation of the Affordable Care Act, the controversial federal health reform law that Brownback has pledged to have no part of until after the November presidential election.

Brownback, like other conservative Republicans, opposed the Affordable Care Act, first as a U.S. senator and then when he campaigned for governor in 2010. In August 2011, under pressure from GOP party activists, he spurned a $31.5 million federal “innovator” grant to Kansas to help the state create a health insurance exchange model for use here and possibly in other states.

He then said his administration would have nothing to do with “Obamacare” until after the U.S. Supreme Court ruled on the reform’s constitutionality. After the court largely upheld the law in June, he said he would do nothing to implement it until after the election.

Republican presidential nominee Mitt Romney and most Republicans running for Congress have vowed to repeal the law as a first order of business, if elected. In Kansas, conservative Republicans continued to use the reform law to bludgeon more moderate opponents in the party’s August primaries and were mostly successful with the tactic.

Insurance Commissioner Sandy Praeger is a moderate Republican who helped craft portions of the Affordable Care Act as part of her work on behalf of the National Association of Insurance Commissioners. She has consistently said that the law has shortcomings but allows flexibility to states in how it is implemented in some areas, and that Kansas should exercise those options in order to have programs more in tune with the state’s needs and desires.

The health reform law stipulates that the federal government will run the insurance exchanges in states that choose not to create their own and will have them up and running by Jan. 1, 2014. Likewise, in states where governors decline to choose the models for “essential benefits” offered through the exchanges, the federal government will do so.

Sheppard said if the federal government chooses the benchmark plan for Kansas, it could be one that is less affordable than a plan selected by those more familiar with the Kansas market.

Spokesmen for Brownback this week said they were unable to say whether the governor would pass on making a recommendation regarding essential benefits as he did on returning the exchange grant.

According to Sheppard, federal officials have set a Sept. 30 deadline for hearing from governors on their benchmark plan choices.

→ Continue reading on khi.org.

Mary Barker, a case manager with the Jayhawk Area Agency on Aging, reassesses the needs of Vivian Glessner, a 91-year-old resident at Briarcliff Care Center in Topeka. Barker meets with Glessner every 11 months to make sure she’s receiving the appropriate level of Medicaid-funded services. An association representing the state’s area agencies on aging has bid on a contract that would have case managers for the frail elderly also assess the needs of people who are physically disabled or have traumatic brain injuries. by KHI News Service

State officials are changing the way they determine which in-home Medicaid services are provided to the frail elderly and people who are physically disabled.

The new system will rely on a single agency or organization with a presence in each of the state’s 105 counties to assess what services a person will receive. Currently, there are more than 30 organizations involved with the process. Some assess only the elderly. Others focus solely on the physically disabled.

State officials said their aim is to create a “one-stop shop,” so that services will be determined in the same place regardless of a person’s condition.

'Mishmash'

“The system we have now is a real mishmash,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “We’ll be going to one that takes more of a no-wrong-door, single-entry approach and implements a conflict-free provision of services.”

About 12,000 Kansans currently rely on the services provided by the system, at an annual cost to taxpayers of about $200 million.

A solicitation to potential contractors interested in managing the new system was put out in February. Bids were due April 3.

Sullivan said he hoped to have the contract awarded sometime next month so that a single, statewide Aging and Disability Resource Center (ADRC) will be up and running by Jan. 1, which also is the scheduled start of KanCare, Gov. Sam Brownback’s plan for letting managed care companies administer the state’s $2.9 billion Medicaid program. KanCare remains contingent upon federal approvals.

The resource center, according to Sullivan, would be in charge of measuring the needs of an elderly, physically disabled or brain-injured person. It also would do preliminary screening for Medicaid eligibility and help the person choose the managed care company best suited to meet the person’s needs.

Today, the assessments are handled by 11 area agencies on aging, 10 centers for independent living and about a dozen home health agencies that specialize in caring for the brain-injured.

“When you have this many systems in place, it can be confusing as to who to turn to for assistance,” Sullivan said. “With the ADRC, we’ll be going to one database, one information source and one hotline for people to call.”

Federal initiative

The change, he said, was driven by a federal initiative aimed at increasing efforts to help Medicaid beneficiaries live in community settings rather than nursing homes and a concern among state officials that not enough was being done to prevent the centers for independent living from inflating their assessments in ways that generated more work — and therefore more revenue —- for their case management and home-health programs.

→ Continue reading at khi.org.

Pictured in the foreground, Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services, prepares to deliver remarks to a group of about 350 Medicaid providers who gathered Monday in Topeka to hear more about KanCare. About 350 people attended the afternoon meeting in Topeka and about 150 attended a similar and simultaneous session held in Garden City. Evening informational meetings also were held for Medicaid beneficiaries. Administration officials have more "education" sessions scheduled in other cities this week. by KHI News Service

Representatives of hospitals, doctor practices and other Medicaid providers turned out in relatively large numbers today for the beginning of a series of meetings aimed at answering questions about KanCare, Gov. Sam Brownback's plan to remake the state Medicaid program.

State officials said they still hadn't resubmitted their application for the federal waivers needed to launch the administration's Medicaid makeover plan but intend to refile that paperwork "very soon" and meanwhile are moving forward with their desired Jan. 1 start date for the new program. Federal approval is necessary for the administration to advance its plan of moving virtually all of the state's 383,000 Medicaid beneficiaries into fixed-cost managed care plans run by insurance companies.

"KanCare will start in January," Gary Haulmark, commissioner for community services and programs at the Kansas Department for Aging and Disabilities Services told the crowd.

Simultaneous "education" sessions on the new program were held in Topeka and Garden City on Monday and additional sessions are scheduled this week in Wichita, Leavenworth, Salina, Hays, Fort Scott, and Overland Park.

About 350 people filled an auditorium to near capacity on the campus of Washburn University in Topeka and about 150 people attended the afternoon session in Garden City, state officials there said. Evening meetings with presentations intended for Medicaid beneficiaries also were scheduled in each of the tour cities. About 150 Medicaid beneficiaries and others attended the evening session at Washburn.

In the Topeka sessions, the KanCare plan was described by Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services and by Haulmark. They were joined by representatives of the three managed care companies newly under contract with the state. Those companies are the local subsidiaries of UnitedHealthCare, Amerigroup and Centene, each of which is a large company that has Medicaid business in multiple states.

Company representatives also spoke at the Garden City meeting, which was led by Dr. Robert Moser, secretary of the Kansas Department of Health and Environment.

The Topeka meeting for providers was scheduled for three hours, but broke up after about two had passed. Officials fielded about two dozen questions from the audience. They said they would post the full list of questions and answers on the state's KanCare information website by sometime next week.

Officials also collected questions put on notecards from beneficiaries during the evening session and pledged that all the answers, even those they couldn't get to Monday, would be posted on the KanCare webpage. Officials also talked about the additional services that will be made available to all or some Medicaid patients, including some preventive dental services for adults, which currently aren't covered by the program.

Some participants said they weren't sure what all questions they needed to be asking at this stage of the process.

"I would say the administration has been consistent in their optimism," said Amy Campbell, a representative of the Kansas Mental Health Coalition who attended both Monday sessions in Topeka. "How can they offer all these value-added services but pay them (the MCOs) less? I'm very glad they're having these meetings. But it seems like a lot of information to put together between now and December. We've never been through this before. What are we supposed to say?"

For beneficiaries, KanCare was described with a series of examples of fictional program clients with various needs and how their services or Medicaid experience might change.

In each example, the only changes were the possibility of more services and dealings with a care coordinator.

More informational meetings will be held in various locations throughout the state in September and again in October, officials said.

Here is a sampling of the questions and answers:

Q: Will any savings from KanCare be used to reduce the waiting lists for home and community based services?

A: Sullivan told the audience that state officials do not expect to cut Medicaid spending but they expect to slow the annual increase in cost of the program by about 1 percent a year for the next five years. That is expected to save the state and federal governments $1 billion over that period, he said.

"I'm not able to stand up here and say all the waiting lists will be gone in three or five years, " he said. "What we think is that this gives us more funds (available) to allocate toward them," should the governor and Legislature decide they want to reduce the waiting lists.

Q: What if a managed care company wants to pay me less than the current Medicaid fee-for-service rate?

A: Haulmark said the state's contracts with the insurance companies would prohibit them for paying less than the current rate.

"That cannot happen," he said. "The MCO (managed care organization) must pay you at least the fee-for-service rate," that is effective on Nov. 9, 2012.

Q: Will we have to switch pharmacies?

A: Kelley Melton, pharmacy program manager at the Kansas Department of Health and Environment, said the state was urging the signing of contracts between the managed care companies and the pharmacies currently doing Medicaid business with the state.

"Our goal is to have as many of the currently contracting pharmacies as possible contracted with the MCOs," she said.

Each of the KanCare MCOs is working with a pharmacy benefits subcontractor to administer its drug benefits, officials said.

Amerigroup is working with CVS/Caremark, United is working with OptumRX, formerly known as Prescription Solutions; and Centene is working with U.S. Script.

Melton said those companies would manage the pharmacy benefits but that nursing homes, hospitals, and individual Medicaid beneficiaries could continue to use their customary pharmacies, if the pharmacies join the MCO networks.

Q: Will a KanCare enrollee be allowed to change plans at any time?

A: No. Plan changes will be allowed once annually but a change in doctor or other provider will be allowed at any time, Haulmark said.

Meeting schedule

The events are open to the public but are aimed primarily at Medicaid service providers and people enrolled in Medicaid. The afternoon events are geared for providers. The evening events are directed at beneficiaries.

Tuesday in Leavenworth: From 1 p.m. to 4 p.m. at the Riverfront Community Center, Riverview Room, 123 S. Esplanade St. And from 6 p.m. to 8 p.m. at the same location.

Thursday in Overland Park: From 1 p.m. to 4 p.m. at the Tomahawk Ridge Community Center, Pinnacle and Summit Rooms, 11902 Lowell. And from 6 p.m. to 8 p.m. at the same location.

→ More meeting times around the state, the presentation slides from the tour, and information on KanCare at khi.org.

Moise Brutus is a 22-year-old Florida Medicaid beneficiary who became a triple-amputee as the result of a motorcycle crash in 2010. Brutus hadn't had any experience with Medicaid or other government programs until after the wreck, which left him unable to work or afford private health coverage. by KHI News Service

Kansas is part of a new wave of states moving to expand managed care to higher numbers of their Medicaid patients.

Gov. Sam Brownback’s KanCare plan, unveiled in November, would begin moving virtually all the state’s 380,000 Medicaid enrollees into managed care plans on Jan. 1.

Nationally, the first wave into Medicaid managed care began in the early 1990s. By 2008, more than 70 percent of Medicaid beneficiaries nationwide were enrolled, largely as the result of state or local government mandates.

There are fewer studies than one might expect of the effectiveness of Medicaid managed care, experts say. And those that have been done have shown mostly mixed results with respect to health outcomes and cost savings. A working paper released in July 2011 by the nonpartisan National Bureau of Economic Research apparently was the first study to examine Medicaid managed care costs over an extended period from all 50 states.

The authors reported that the 13 years of data they reviewed suggested “shifting Medicaid recipients into managed care plans did not reduce Medicaid spending in the typical state.”

Despite the uncertain or uneven results reported by researchers, states have forged ahead with managed care.

Generally left out of the first wave of managed care plans were Medicaid recipients who were elderly or disabled and required long-term services. They tend to be the most needy and thus most costly beneficiaries, and the new wave of expansions, including KanCare, would bring more of them into the plans.

State officials, here and elsewhere, have concluded or hope that including them in managed care will offer new opportunities for savings or at least assure more predictable costs.

KHI News Service reporters have been closely following developments surrounding the KanCare plan. As part of our reporting over the past few months, we have interviewed dozens of people involved in various ways with Medicaid managed care expansions across the nation.

What follows are various perspectives gleaned from some of those interviews.

A Florida perspective

Moise Brutus is a 22-year-old Miami, Fla., man who became a triple-amputee as the result of a motorcycle crash in 2010.

Brutus said he was working as an assistant manager at an auto dealership before the accident and didn't have any experience with Medicaid or other government programs until after the wreck, which left him unable to work or afford private health coverage.

After a few months on Medicaid, while he was still in the early stages of recovery, the state of Florida sent him a letter saying he needed to enroll in a managed care plan. He ignored the letter and subsequently was “auto assigned” by the state to a plan run by WellCare.

Florida incrementally has been moving more of its Medicaid beneficiaries into managed care, and 85 percent of them are expected to be in managed care plans by 2014.

Brutus said WellCare assigned him a case manager. He spurned her initial efforts to contact him by telephone because he was experiencing profound depression that led him to consider suicide after he had sought “stump revision” surgery through traditional Medicaid and was denied.

“I was lost,” he said. “At that point I was still in a lot of pain physically and emotionally.”

Ultimately, his mother responded to the case manager’s calls and the woman was able to connect with Brutus.

“She took it on herself — kind of like she was on a mission to save the world,” Brutus said of the case manager. “She got me in touch with the doctors I needed, got me the medication I needed, because some of the medications I was taking Medicaid didn't cover. So, she pretty much had to get me an override so I could get the medications, and I went in and did the stump revision. WellCare took care of that.”

He said the case manager also arranged for him to get an additional month of physical rehabilitation sessions.

“To sort of make a long story short, I'm not on any medication at all. I'm walking. They took care of all my prosthetics, my rehab, teaching me how to walk. They got me a new bionic hand. I'm actually the first person to get that approved from Medicaid,” Brutus said.

“I can honestly say I wouldn't be here if it wasn't for WellCare and (the case manager). They're not perfect, but they certainly have helped me a lot. Now, I’m going back to school and I’m pretty much done with rehab. I’m doing some occupational therapy and I’m walking on my own with no assistive device,” he said.

WellCare experiences

“Would I actually recommend (Medicaid managed care) to anyone? From my experience I would, but speaking logically I'm sure not every story has as happy an ending as mine,” Brutus said.

In June 2011, Brutus was among those who testified at a public hearing on Florida’s Medicaid managed care makeover. His comments for this article were from a March 21 telephone interview with KHI News Service.

A WellCare employee helped arrange the interview.

“A lady actually called me (from WellCare prior to the interview) and spoke with me and she pretty much told me to just tell it how it is, that if I feel like I don't agree with something to definitely let you know,” he said.

→ Continue reading on khi.org.

Or jump to...

→ A Texas perspective

→ A national perspective

→ A Georgia perspective

→ A Kentucky perspective

→ A Indiana perspective

by KHI News Service

Gov. Sam Brownback's plan to remake the state Medicaid program got a chilly reception Monday at the first of two scheduled public forums on KanCare.

There were nearly two hours of comments and questions from a crowd of more than 200 people gathered at a Wichita State University auditorium. Most of the response was negative.

There were 40 comments — officially capped at three minutes each, though many went much longer. Most came from relatives of the elderly, disabled and mentally ill or from medical providers who cater to those groups.

They would be the groups most affected by the administration's KanCare plan, which aims to expand fixed-cost managed care to include virtually all the 380,000 Kansans currently on Medicaid.

The comments mostly touched on one or more common concerns:

The timeline to implement the plan in January was too fast Fear that patients' existing providers couldn't be kept under the plan That managed care would result in loss of services, Some people also expressed worries that the Brownback administration was setting up Kansas for problems experienced by other states under managed care.

'Soft science' Commenter Richard Harris said attempts to reform Medicaid have been based on "soft science and limited evidence."

"The concerns I have boil down to the evidence. Most managed care operations cut services and do not significantly cut expenses," he said. "I challenge the governor and lieutenant governor to name for us any state in which the system you are proposing has worked and has provided a higher level of service across the board at a lower cost to the state."

For the most part, comments and questions were accepted without direct answers from the Brownback administration. Officials present included: Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, the agency which administers Medicaid through its Health Care Finance division; Health Care Finance Director Kari Bruffett; Kansas Department on Aging Secretary Shawn Sullivan; and Gary Haulmark, deputy secretary at the Kansas Department of Social and Rehabilitation Services. At least three legislators also attended: Sen. Dick Kelsey, a Goddard Republican, Sen. Oletha Faust-Goudeau, a Wichita Democrat, and Rep. Steve Alford, a Ulysses Republican.

During two, 15-minute presentations before the comment period, Moser and Sullivan attempted to address common concerns they said they already had heard. Sullivan said the alternative to KanCare was not the status quo.

'Huge cuts looming' "The alternatives to the changes we're making are continued cost increases, the risk of reimbursement rates to providers that threaten the quality of care provided, (and) huge cuts for Medicaid that are looming at the federal level probably to the tune of hundreds of millions of dollars," he said.

"The one thing we are not doing that often gets reported...is that we're turning this Medicaid system over to private contractors. That's not our intent at all. We already have 73 percent of those we serve in Medicaid on a managed-care type system," Sullivan said.

"We have not turned over the contracting of Medicaid to those vendors to just do whatever they want. We have extremely stringent performance standards, pay-for-performance measures, there will be very distinct outcome and accountability measures that the state will build into this. This will be a partnership between the state and vendors."

→ Continue reading on khi.org.

by KHI News Service

Kentucky already has done what Kansas is getting ready to do: It hired three managed care companies to run most of its Medicaid system.

Medicaid is the state and federal program that provides health coverage for the poor and disabled. In Kentucky, there are about 885,000 people enrolled in it. In Kansas, there are about 380,000.

Kentucky Gov. Steve Beshear, a Democrat elected to his second term in 2010, said the for-profit companies’ business-like approaches would save the state and federal governments hundreds of millions of dollars over a three-year period. At the same time, he said, the state’s health outcomes would improve.

Kansas Gov. Sam Brownback, a Republican, said much the same when he announced KanCare, his plan to remake the state Medicaid program.

But Kentucky's transition to a fixed-rate managed care system, which began only a few days before Brownback announced his plan in November, has been plagued by problems during its first seven months of operations.

More states have been shifting to fixed-rate Medicaid managed care plans as policymakers look for ways to contain growing program costs. Kentucky has had more trouble than most. One observer called it "the poster child for managed care growing pains."

Learning from mistakes

Adam Edelen, the Kentucky state auditor, told KHI News Service that Kansas officials should pay close attention to what has happened in his state to perhaps learn from its mistakes.

“Shortly after I came into office (in January), I started getting phone calls from (Medicaid) patients who were frustrated because they couldn’t get in to see the doctors they were used to seeing,” Edelen said. “Then I started hearing from providers who’d gone 90 days without being paid. Kentucky is much like Kansas. We’re a small, rural state, and many of our practitioners and family practices are like small businesses. When their accounts receivable are 90 days in arrears, they’re in a real cash crunch.”

Edelen said when the problems began, he called a “very respected” banker friend to find out if small-town doctors truly were having to borrow money to keep their doors open.

“He said, ‘Adam, that’s all that bankers in Kentucky are talking about.’”

Edelen’s office, Auditor of Public Accounts, is an executive branch agency independent of the governor’s office and the state legislature. Edelen, also a Democrat, launched a quick review of the policies governing the new Medicaid system.

He said he soon learned that the new system relied on telephones, fax machines and paper copies. It was meant to be slow.

“I don’t have a problem with managed care,” he said. “But I have real problem with a system designed to create logjams in order to slow payment (to medical providers). The notion that (payment) authorizations could be denied via the mail is absurd.”

He also found that between November 2011 and February 2012, the managed care companies had “taken $708 million from taxpayers and paid (providers) $420 million. That’s not acceptable.”

Edelen put together a list of 10 recommendations to improve the new system and in February announced that “sweeping audits” of the managed care companies would be completed by year’s end.

There are other reasons Kansas officials might want to closely watch Kentucky’s Medicaid experience.

The three insurance companies brought in to run Kentucky’s Medicaid program – WellCare, Centene and Coventry – are among the five bidding on the Kansas Medicaid contracts, which were let in November and are scheduled to be signed by July.

The Brownback administration's plan is to hire three of the companies to operate statewide, providing services to virtually all of the state's Medicaid clients, including long-term services for the elderly, physically disabled and ultimately the developmentally disabled. Those three Medicaid subgroups generally are considered the most expensive and problematic to include in managed care. They were left out of Kentucky's new managed care system.

Some tips

Edelen said he had several bits of advice for Kansas policymakers:

• “Slow down until you know you have it right, because the gaps you have in your system at the time of a premature rollout will only be exacerbated – I promise you that.” He said Kentucky spent less than six months assembling its reform package. In hindsight, it should have spent a year to 18 months.

• “Like President Reagan used to say: Trust but verify.”

• “Unless you have elected representatives who are in a position to provide vigilant oversight, things will get out of control. In fact, it’s their very nature to get out of control.”

→ Continue reading on khi.org/kentucky.

by KHI News Service

As part of its effort to remake the Kansas Medicaid program, the administration of Gov. Sam Brownback has completed its 1115 Medicaid waiver application.

Lt. Gov. Jeff Colyer and other top administration officials fielded questions about it today during an hour-long Statehouse press conference.

The application was posted Thursday without fanfare to the website of the Kansas Department of Health and Environment and also submitted to the federal Centers for Medicare and Medicaid Services.

"We sincerely appreciate the accessibility and candidness of CMS throughout this application process," Colyer said.

The administration earlier this year gave federal officials a concept paper roughly outlining what would be in the full waiver application. Brownback officials need the waiver approved in order to move forward with their plan to shift the state's 350,000 Medicaid beneficiaries into managed care plans operated by three insurance companies.

The administration currently is reviewing bids from five companies. According to the timeline attached to the waiver application, administration officials intend to have the final three companies chosen by May with contracts signed by June. State officials said they expected CMS to approve the contracts sometime in August.

Town hall meetings to inform Medicaid clients and providers about how the plan would work are scheduled to begin in July.

The new program would be launched Jan. 1, 2013, assuming the federal approvals are secured and the managed care companies have been certified ready to go.

The waiver application included information about the administration's recent agreement to postpone until January 2014 the inclusion in KanCare of long-term services for the developmentally disabled.

The greatest opposition to the KanCare plan has been from families of the developmentally disabled and their service providers.

Had the administration not submitted its application by today, it would have been required to meet new federal regulations regarding public input on 1115 waiver applications.

Colyer said the application wasn't submitted to meet that deadline and that administration officials felt they met most of the new requirements anyway because of the various forums and public meetings they have attended or held while developing their Medicaid makeover plan.

The new requirements, effective today, would require that state officials hold at least two public hearings and allow comment on an application 30 days prior to submitting it for federal review.

Federal officials now will allow a 45-day public comment period before acting on the application.

Among those planning to comment to federal officials is Kansas Action for Children, a Topeka-based advocacy group.

Shannon Cotsoradis, the organization's chief executive, said KAC has several concerns about the KanCare plan, including the fact that it doesn't spell out how those currently enrolled in the state's HealthWave program will be moved into KanCare.

HealthWave provides medical services to low- and moderate-income children and pregnant women who are eligible for Medicaid or the Children's Health Insurance Program.

"We have 238,000 Kansas children that rely on HealthWave and there doesn't seem to be a clear and transparent process for transitioning them to KanCare," Cotsoradis said.

Under KanCare, Medicaid clients would be automatically assigned to one of the three managed care companies. The clients then would have 45 days to decide if they wanted to be enrolled with another company.

Cotsoradis said she feared the "auto assigning" of clients could disrupt relationships some children or families have developed with doctors or other Medicaid providers, if it turns out that the providers are in the network of a company other than the one to which the family has been auto assigned by the state.

She said many families likely wouldn't learn that they had been put in a new plan until they tried to go to the doctor and that might not happen within the 45 day window for choosing a different plan.

"So all that work that's been done over years to see that that kid has a medical home could be disrupted by the auto assignment," she said. "That can be a huge thing for those with special health care needs. Disruption in the relationship can be very problematic."

Administration officials have said they intend to auto assign equal thirds of the state's Medicaid population to each of the three managed care companies to assure that each company has enough clients to sustain a statewide operation. The KanCare plan requires that each of the companies provide services statewide, as opposed to operating in a specific region of the state or city. Officials have said that component of their plan is essential to assuring quality services in all parts of the state, including the more remote, rural counties.

→ Download a PDF of the Medicaid waiver application and find related stories on the KanCare plan at khi.org.

by KHI News Service

Services for developmentally disabled wouldn't be included in KanCare until 2014.

House Majority Leader Arlen Siegfreid is preparing a budget proviso that would "carve out" until 2014 long-term services for the developmentally disabled from Gov. Sam Brownback's Medicaid makeover plan.

The proviso has been cleared with the Governor's Office, according to sources in the Legislature and the administration, which means it likely will move through the Legislature with little or no opposition.

A large number of legislators, including a majority in the Senate, already have signaled their desire to see the planned Jan. 1 launch of KanCare delayed until July 1, 2013. It is unlikely many will oppose delaying until 2014 what has been the most controversial part of the governor's plan.

It would be the first major change to the governor's KanCare proposal since it was announced in November. The inclusion of non-medical, long-term services for developmentally disabled Medicaid clients has produced the biggest opposition to the governor's plan at the Statehouse and in county seats across Kansas.

For example, Johnson County commissioners today joined their counterparts from more than 30 other counties in approving a resolution asking the governor to exclude the developmental disability services from the plan. Earlier this week, Jim Rice, chairman of the Seward County Commission, published an open letter in the Liberal newspaper taking the Brownback administration to task on the issue, comparing KanCare to Obamacare.

Word of the pending proviso traveled fast after Siegfreid discussed it with Rep. Bob Bethell, an Alden Republican who chairs the House Aging and Long-term Care Committee. Bethell said Siegfreid told him he could share the news with other legislators. Word spread from there.

→ Continue reading on khi.org.

by KHI News Service

A company that is among the five bidding on the state’s Medicaid managed care contract has agreed to pay $137.5 million to settle claims it defrauded Medicaid programs in nine states.

The U.S. Department of Justice announced the settlement with WellCare Health Plans Inc. last week.

It was the second settlement the company agreed to after federal prosecutors in 2006 launched criminal and civil investigations stemming from complaints filed by whistleblowers.

In 2009, the company entered a deferred prosecution agreement and paid $40 million in restitution and forfeited another $40 million. WellCare’s former chief executive, Todd Farha, is scheduled to go to trial in January.

The settlement announced last week will be divided among the federal government and the Medicaid programs in Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Missouri, New York and Ohio.

Sean Hellein, a former financial analyst with WellCare, will collect more than $20 million, federal officials said. He filed the initial whistleblower claim that prompted the investigation.

WellCare officials said the settlement wiped the slate clean for the company.

“The company acted swiftly upon learning of the wrongdoing in 2007, took action to separate the individuals involved, and cooperated fully with state and federal authorities in their investigations. These matters are now resolved and a new leadership team has been put into place,” WellCare spokeswoman Denise Malecki told KHI News Service.

She said the company would bring high standards to its Kansas operations if it wins a contract to help implement KanCare, Gov. Sam Brownback’s Medicaid makeover plan.

“Today, WellCare's commitment to transparency and ethical behavior will be unparalleled in providing quality, cost-effective health care to the members of the KanCare program,” she wrote in an email.

As part of the settlement with the Justice Department, WellCare agreed to enter a corporate integrity agreement that allows the U.S. Department of Health and Human Services' Office of the Inspector General to oversee its “rehabilitation” for three years.

Sherriene Jones-Sontag, a Brownback spokesperson, said the qualifications of WellCare and other KanCare bidders would be thoroughly reviewed by the administration.

“The state conducts thorough evaluations to ensure the selection of qualified bidders who meet the requirements of the KanCare program, including financial sustainability,” she wrote in an email. “The contracts for the KanCare program will include mechanisms such as performance bonds and parent corporation guarantees as well as significant reporting requirements and ongoing reviews of the financial conditions of KanCare contractors.”

WellCare isn’t the only KanCare bidder that has been ensnared in a federal whistleblower lawsuit.

Amerigroup paid $144 million in damages and $190 milllion in fines after losing a whistleblower case in Illinois in 2008.

Wall Street analysts remained bullish on WellCare after last week’s announcement.

“It's conceivable that the company could double its revenues in the next couple of years," Tom Carroll, an analyst at Stifel Nicolaus, told Florida Health News, a partner of KHI News Service.

According to financial analysts, the company had $6.1 billion in revenue last year and has more than $300 million in cash on hand.

But the claims raised against WellCare in the lawsuit were alarming to some in Kansas who already have concerns about the governor’s Medicaid plans.

“I am deeply troubled and shocked by the contents of this settlement agreement, and I believe it underscores the need to slow down the process of implementing KanCare,” Shannon Cotsoradis, chief executive of the advocacy group Kansas Action for Children, wrote in an email to KHI News Service. “Thoroughly vetting potential contractors is a critical component of the implementation process and it must happen to protect the children and families in our state. I don't think this is the kind of Medicaid ‘reform’ we are looking for.”

Among the things cited in the case, WellCare:

• Created a wholly owned reinsurance subsidiary that inflated the company’s premiums in a way that made profits look like expenses;

• Hid information that would have caused the company to send money back to the Illinois Medicaid and Florida Healthy Kids programs;

• Falsified encounter and performance data;

• Rewarded physicians and clinics for referring healthy, low-cost patients to WellCare and sending sick, high-cost patients to competing health plans;

• Engaged in marketing and enrollment practices that discriminated against patients with chronic illnesses;

• Collected premiums on patients who were dead; and

• Operated a “sham” special investigations unit that allowed the company to “seek excessive reimbursement from the providers.”

The fraudulent activity was alleged to have occurred between 2002 and 2007.

→ Find the latest coverage of KanCare, including Brownback's agency reorganization announcement today, at khi.org.

by KHI News Service

County officials across Kansas are raising doubts about KanCare, Gov. Sam Brownback's plan for letting insurance companies manage the state's $2.8 billion Medicaid program.

"Before the administration gets to the point of signing contracts with these companies, it should let the Legislature, a special committee or the public know what's in them so we can have the professionals on the ground tell us where the potholes are. We shouldn't be putting our vulnerable populations at risk," said Ed Eilert, a Republican member of the Johnson County Commission and a former Overland Park mayor, a post he held 24 years.

Johnson County is Kansas' most heavily populated county. Eilert said he expected the commission there soon would pass a resolution urging the governor to "carve out," or exclude from KanCare, the long-term care services Medicaid provides for people with a developmental disability.

According to local officials contacted by KHI News Service, at least 20 counties have passed similar resolutions asking the governor to reconsider the reach of KanCare. At least three more are considering a resolution.

The first resolution was jointly endorsed March 5 by commissioners in Marion and Harvey counties. The Topeka-based Kansas Association of Counties later distributed copies of the document to the state's other 103 counties. Within a month, 18 other counties approved their own resolutions and more are expected to follow.

It's not clear if the resolutions will change the administration's approach. When the Legislature returns April 25 for its wrap-up session, lawmakers are expected to debate a proposal that would exclude long-term services for the developmentally disabled from KanCare.

An effort to debate the measure on the House floor was stymied by a procedural move at the end of the regular session, but supporters have pledged to bring it up again.

→ Continue reading at khi.org.

by KHI News Service

The House Appropriations Committee today passed a bill to create a joint legislative committee to oversee KanCare, Gov. Sam Brownback’s plan to move virtually all the state's Medicaid beneficiaries into managed care plans.

The Senate Ways and Means Committee passed a similar bill Tuesday.

The primary difference between the two bills is that Senate Bill 459 would let the Senate president pick the oversight committee’s first chair; House Bill 2789 would let the House speaker choose the chair.

The proposed committee would include six members from the House and five from the Senate.

Rep. Brenda Landwehr, a Wichita Republican and chair of the House Health and Human Services Committee, testified in favor of the House bill.

“I was very, very pleased to see that we turned in 79 signatures in bipartisan support of this bill,” she said. “The House has taken the lead on this and it would be my preference for House leadership to appoint the chair.”

Landwehr, chief sponsor of the bill in the House, said the oversight committee would not have the authority to “stop or delay” KanCare but would monitor the initiative’s implementation.

Afterward, Landwehr told KHI News Service that she hoped to be named chair of the proposed committee.

Landwehr is a former chair of the House Social Services Budget Committee. She currently chairs the Joint Committee on Health Policy Oversight.

She said she’s opposed to a resolution urging the governor to delay KanCare’s start by six months.

“I’m not sure there’s a way to satisfy those who oppose KanCare,” Landwehr said. “It’s like every time the administration has answered their objections, they come up with a new objection.”

Administration officials, she said, have said they will not launch KanCare on Jan. 1, 2013, if it’s not ready.

“I have a lot of confidence in Dr. Moser,” she said, referring to Kansas Department of Health and Environment Secretary Robert Moser. “He’s a physician and he’s been intimately involved in the KanCare process. If the process comes to a point where he feels it should not go forward, he has the latitude to make that decision.

“I would rather have him make that decision than individuals who either haven’t had the time or haven’t taken the time to get the details on what’s happening,” Landwehr said. “I think Dr. Moser and (Department on Aging Secretary) Shawn Sullivan have answered every single question to the extent that they can without violating the procurement process. They’ve been very open, very transparent.”

Earlier this month, 22 senators signed a resolution in support of starting KanCare on July 1, 2013, rather than Jan. 1, 2013.

A similar initiative is underway in the House.

“Maybe we should have co-chairs?” for the proposed committee, said Sen. Dick Kelsey, a Goodard Republican who introduced the resolution to postpone KanCare in the Senate.

Last week, the Governor’s Office announced that it had started a 20-member KanCare Advisory Committee consisting of four legislators and 16 consumers and advocates.

→ Read more about the KanCare proposal in KHI's story "Brownback Medicaid makeover an ambitious plan."

by KHI News Service

Gov. Sam Brownback’s Medicaid reform plan, KanCare, has spawned one of the biggest, busiest and -some say- most confusing courtships in state history.

“I feel like I’m the pretty girl in high school and it’s two weeks before prom,” said Krista Postai, who runs the Community Health Center of Southeast Kansas, a multisite safety-net clinic headquartered in Pittsburg. “I have lots of offers.”

Postai and other Medicaid providers – a group that includes doctors, hospitals, pharmacies, home health agencies, nursing homes, mental health centers and community-based programs for the developmentally disabled – are being wooed by the five companies that have submitted bids to manage the state’s $2.8 billion Medicaid program.

“They all want to do something different and they’re all saying it’s going to be great,” Postai said. “The sales pitches are phenomenal, but I’m thinking they’re like the cute guys with the blue eyes who sell computer software. You want to believe them, but it never works the way they said it would.”

State officials have said they plan to award contracts to three of the companies this summer. An exact date has not been announced.

Meanwhile, each of the five bidders - Centene, Coventry, Amerigroup, WellCare, and United Healthcare - has until March 30 to show that it has assembled at least half of the statewide provider network needed in order to secure a contract award.

“We’re being barraged” by solicitations from the companies, said Deborah Zehr, executive director at LeadingAge Kansas, an association that represents the state’s nonprofit nursing homes. “It’s been pretty confusing because nobody knows who’s going to win the contracts, and yet we’re being encouraged to go ahead and commit to a company that may or may not be selected."

Zehr said that struck her as odd since providers also are being told that any willing provider can sign with any or all managed care networks after the contracts have been awarded.

Administration officials have said they want to launch KanCare on Jan. 1, 2013. But that would come after each of the three selected companies sometime this fall has been “auto-assigned” a third of the state’s Medicaid beneficiaries of which currently there are about 383,000.

The initial contracts are to be for three years.

Holding off

Some providers said they plan to wait until the companies have state contracts before signing with any of them.

Janet Splitter is executive director at ElderCare, a nonprofit meals and home-health program based in Great Bend.

“We’ve heard from all five companies,” she said. “But we’re taking a wait-and-see approach because it doesn’t make a lot of sense to fill out the forms for a company that’s not going to get the contract.”

Some of the forms, Splitter said, were 40 pages long and would require several hours to complete.

Initially, most of the managed care companies asked providers to sign letters of interest or intent, expressing a willingness to work with them if they were awarded one of the contracts.

But in recent weeks, some of the companies have begun pressing providers to enter contractual agreements. And many program directors told KHI News Service they were uncomfortable with that more aggressive push.

“I don’t have teams of lawyers and accountants who know all the ins and outs of a managed care contract, but these companies do,” said Lori Feldkamp, executive director at Big Lakes Developmental Center in Manhattan. “I find that disconcerting.”

Big Lakes serves about 200 developmentally disabled adults in Riley, Geary, Clay and Pottawatomie counties.

Felkamp said Big Lakes has yet to align itself with any of the contractors.

“We’re waiting,” she said. “I have a lot of questions. I don’t have very many answers and, frankly, I don’t know that the answers are there to be had.”

Still time for contracts

Kari Bruffett, an assistant secretary at the Kansas Department of Health and Environment, said the KanCare bidders recently were told that simple letters of intent from providers would be sufficient to for determining each company's potential network capacity.

"The most common question we have heard from providers is whether the bidders need to secure contracts or letters of intent to demonstrate the extent of their network development on March 30," Bruffett wrote in an email to KHI News Service. "We have clarified that letters of intent are acceptable at this time."

KDHE, she wrote, would review standard provider contract and subcontract provisions before they can be executed with providers. She added that all providers who sign with a network would be assured payment for services at least equal to what they currently are paid after incentives are counted.

"Per the RFP (request for proposal), all in-network providers will receive 100 percent of the (current) fee for service as the floor, inclusive of incentives for quality and outcomes," she said.

In recent weeks, administration officials have offered repeated assurances that KanCare is designed to improve healthcare outcomes and “bend the cost curve of Medicaid” without cutting provider rates, reducing eligibility or restricting access to services.

A single "front door" for billing

Brownback last week asked legislators to approve spending an additional $3.4 million on a “robust communication and education program about changes taking place with KanCare” and to updates the state's Medicaid billing system so that it would give providers “a single billing front door.”

That proposed bill streamlining was in response to concerns raised by some providers that KanCare would add administrative complexity to the Medicaid program.

→ Continue reading on khi.org.

by KHI News Service

The Senate Ways and Means Committee has introduced a bill that would create a new joint committee to oversee implementation of Gov. Sam Brownback's KanCare Medicaid makeover plan.

Administration officials today welcomed the development and also told lawmakers there would be a "rigorous readiness review," before KanCare is launched. If the managed care companies hired to implement the plan fail the reviews, officials said, then KanCare's Jan. 1, 2013 launch date would be pushed out.

SB 459 would create an 11-member oversight committee for the program, including six House representatives and five senators. It also would create a new fund in which would be deposited dollars saved from moving Medicaid beneficiaries from nursing homes to private homes or community settings. The secretaries of the Kansas Department of Social and Rehabilitation Services and the Department on Aging would each provide quarterly reports to the Legisalture on the status of the savings fund. The same bill will be introduced in the House, according to administration officials and Rep. Brenda Landwehr, a Wichita Republican who is a sponsor.

The oversight committee would be charged with examining the program's progress, watching to assure access to Medicaid services doesn't suffer and that quality-of-care benchmarks are met.

Oversight key

“Legislative oversight will be key in accomplishing the objectives of KanCare that lead to improved delivery of health care to Medicaid consumers," said Lt. Gov. Jeff Colyer in a prepared statement endorsing the bills. Colyer has been point man on the governor's plan to remake Medicaid.

KanCare would move virtually all of the state's Medicaid clients into fixed-cost, managed-care plans, including the elderly, disabled and mentally ill receiving long-term care services.

The plan has met resistance and some lawmakers have faulted the administration for moving too quickly with its plan, which still needs federal approvals.

A resolution was introduced in the Senate urging the administration to delay KanCare's start until July 1, 2013. A hearing on it was held today in the Senate Public Health and Welfare Committee.

In the House, there is a bill that would require the administration to exclude or "carve-out" from KanCare the long-term Medicaid services provided to the developmentally disabled.

That bill was the subject of hearings Wednesday and again today in the House Health and Human Services Committee.

At Wednesday's hearing, various advocates for the developmentally disabled spoke in favor of House Bill 2457, which was introduced by Rep. Jim Ward, a Wichita Democrat.

Administration weighs in

Today, Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, and Secretary Shawn Sullivan of the Department on Aging, made the administration's argument for moving forward with KanCare without delay and with long-term services for the developmentally disabled included in the plan.

Sullivan said, as he has in other legislative hearings and public forums, that the administration aims for as little disruption as possible to Medicaid clients. He said the state's contracts with the managed care companies will require that they use existing Medicaid providers and that the roles of the state's 27 Community Developmental Disablity Organizations (CDDOs) would remain intact.

He said the governor and other top officials, including himself considered it "very important to maintain the structure, infrastructure and the integrity of the current (developmental disability) system.

He said many of the state's developmentally disabled are served by small organizations that might have only five clients and that KanCare would be particularly beneficial to those in their care because it would bring "much more robust coordination (of services) for all the client's needs," whether the client had diabetes, mental illness or another chronic medical condition.

Moser also said the main focus of KanCare would be improved coordination of care with the goal of preventing illnesses leading to costly hospitalizations.

He assured the committee that KanCare would not move forward on Jan. 1, 2013 unless everything was in place to do it effectively.

"If this is not ready and robust, we will not move forward," he said.

Kari Bruffett, a KDHE assistant secretary, gave similar assurances Thursday to the Senate Public Health and Welfare Committee.

'On the right track'

Several of the House committee members indicated they were in support of the KanCare plan.

"I continue to feel we're on the right track," said Rep. Jim Denning, an Overland Park Republican.

Landwehr, the committee chair, closed the hearing delivering something of a lecture to those in the room who were opposing the administration's initiative.

She urged Medicaid providers to work with the managed care companies as they try to develop their networks and she told opponents that instead of "fighting or opposing" the administration plan they should work with Brownback officials to come up with something that would work.

"It doesn't take a brainiac to figure out something needs to change," she said. "The status quo is not going to be acceptable. It's not going to work. The money's not there."

→ Continue reading on khi.org.

by KHI News Service

Companies also among those vying for Kansas Medicaid business

Centene and Coventry, two of the five major managed care companies seeking a contract with the Kansas Medicaid program, have landed awards from the state of Missouri, officials there announced today.

Today also was the deadline for bids on Gov. Sam Brownback's KanCare proposal and administration officials confirmed Centene, Coventry and three other companies had met the deadline. Centene is seeking the KanCare award through its wholly owned subsidiary, Sunflower State Health Plan.

The KanCare plan was announced by administration officials in November 2011 and most of the nation's large managed care companies expressed early interest in bidding on it.

The Governor's Office released a statement this afternoon saying the five companies that submitted bids were:

• Centene, which is headquartered in suburban St. Louis, but its subsidiary has opened a Topeka office,

• Wellcare of Kansas, which is based in Tampa, Fla.,

• United Health Care of Minneapolis, Minn.,

• Coventry Health Care of Kansas, which is headquartered locally in Wichita and nationally in Bethesda, Md., and

• Amerigroup, which is based in Virginia Beach, Va.

Aetna, which also scored a Missouri award, had shown early interest in the Kansas proposal but was not among those submitting bids by today's deadline. It wasn't immediately clear why the company did not offer a KanCare bid.

KanCare would extend managed care to virtually all Kansas Medicaid beneficiaries, including the elderly and disabled.

Zane Yates, Centene vice president of regulatory and government affairs, today told members of the Kansas Mental Health Coalition that the company also had won a recent award from Washington state. He said the Clayton, Mo.-based company also has a bid pending with New Hampshire and that this morning he had delivered the company's "final response" to the Kansas request for approval.

Kansas is one of several states that have recently expanded or plan to expand managed care within their Medicaid programs.

Centene, Coventry and Wellcare were the three companies chosen last year to implement Kentucky's managed care expansion, which began Nov. 1, 2011.

The Kentucky plan got off to a rocky start. Its implementation was delayed a month and complaints from pharmacists, hospitals and other providers sparked a round of legislative hearings last week after a co-chairman of the Program Review and Investigations Committee earlier in the month threatened to subpoena information from the companies.

The Kentucky health care providers said they were having problems getting timely payments from the managed care companies, and independent pharmacists complained they were losing money after some of the companies cut the prescribing fees the pharmacists were paid.

Kentucky Gov. Steve Beshears ushered in the changes, which officials there have projected could save the state $375 million over three years.

Brownback officials have predicted KanCare will save the state and federal governments about $850 million over five years.

Administration officials here have said they hope to have the KanCare contracts finalized by summer and intend to choose three companies to divide Medicaid services statewide.

The Kansas Medicaid program costs about $2.8 billion a year and serves more than 350,000 Kansans.

→ Continue reading about the companies bidding for KanCare contracts, including coverage of the rocky start for managed care in Kentucky at khi.org.

by KHI News Service

Brownback administration, state's top insurer see potential savings in patient-centered model.

Larry Rahn had never heard of a "patient-centered medical home," though his doctor's practice here is one of a handful certified in Kansas.

Nonetheless, the 49-year-old John Deere mechanic said he had noticed something different about Dr. Jerad Widman's approach to medicine and that his health has improved in seven years under Widman's care.

"He goes the extra mile. He's been working on my bad cholesterol for two years and finally has it where he wants it," Rahn said. "He kept hammering on trying to eat right. After a couple years, I finally paid attention. You actually do feel better."

For Widman, the patient-centered medical home approach is about "proactively taking care of the whole patient, not just their chief complaint," he said.

"When people are sick enough to actually come into the doctor, the great majority of the time there's more than just a cold going on," he said. "Patients present with complaints. But most patients don't even know what all needs to be managed. If we leave it to them to tell us what to take care of, we don't take care of enough."

Little incentive

Widman said electronic health records are essential to the way he runs his practice, which is certified by the National Committee for Quality Assurance at Level 3, the highest level.

He said having and maintaining an electronic health record for each patient is the foundation of coordinated care.

He also uses the system to track and organize the care his patients receive outside his practice, which helps him minimize redundant treatments. The digital records also help his staff prepare for patient visits and deliver care at "the top level of their training," he said.

by KHI News Service

For example, his aides can perform a routine foot exam on a diabetic patient or update a patient's vaccinations even though the appointment initially was scheduled to check blood pressure — all before the doctor enters the exam room.

Proponents of patient-centered medical homes say that coordinating care through a single primary care provider will improve patient health and efficiency of delivery and reduce costs systemwide. Better management of chronic diseases and other preventive care will lead to fewer costly hospitalizations, they say.

Among medical home proponents are officials in the administration of Gov. Sam Brownback. They've indicated that medical homes will be central to their plan to overhaul Medicaid.

If every American had access to a medical home, national health care spending would drop by 5.5 percent, or $67 billion per year, according to estimates by the American Academy of Family Physicians.

Widman said he had no doubt medical homes would yield significant savings as more providers adopt the concept. But so far, he said, there is very little financial incentive for doctors to do so. Doctors make more money the more patients they see — and less money if they spend more time with each patient, he said.

"My only incentive has been top-notch, quality care for my patients. It has actually been to my financial detriment to do it," Widman said. "It's easily cut my take-home pay by 25 percent. That would be a conservative estimate."

As long as doctors are primarily paid for services — not outcomes — Widman said he doesn't foresee the medical home concept catching on.

"My hope is that the reimbursement structure is going to change to incentivize the comprehensive approach as opposed to the volume approach," he said.

Kansas initiative

A three-year pilot project under way in Kansas ultimately may lead to the state's largest private insurer changing its reimbursement structure.

The Patient Centered Medical Home Initiative — launched last summer by a coalition of the state's leading medical societies with underwriting from three Kansas health foundations — is intended to help eight practices overhaul their offices into certified medical homes.

The practices are working with web-based TransforMED to complete "mini-quality-improvement projects" with the goal of becoming certified at the top level, said Carolyn Gaughan, executive director of the Kansas Academy of Family Physicians.

TransforMED is a subsidiary of the American Academy of Family Physicians devoted to helping doctors get their practices certified as medical homes.

Getting a practice certified as a medical home is not easy, Gaughan said.

"They can't just close the practice and become a patient-centered medical home — that isn't how it works," Gaughan said. "It's stressful, and they're pretty brave to be dedicated to doing this. They're the laboratory in Kansas."

As part of the project, Blue Cross Blue Shield of Kansas is paying the eight pilot practices for implementing various patient-centered medical home practices.

Blue Cross spokeswoman Mary Beth Chambers said data gathered during and after the project would help guide how the company reimburses health care providers in the future.

"We feel fairly confident that there needs to be a move away from the fee-for-service model if we're going to — as a state — get control of health care costs," Chambers said. "The purpose of the pilot is to see whether this sort of model will provide better coordinated quality care that will ultimately lower the cost of health care. If you put more emphasis on the front-end care, prevention and wellness, does that save money over time?"

Last month, Blue Cross affiliate Wellpoint Inc. announced it would begin raising reimbursements for primary care providers who implement certain medical home practices, and even more for those who demonstrate savings. Most qualifying providers in the 14 states Wellpoint serves will see a 10 percent payment increase, and some could earn up to 50 percent more.

Chambers said that while there is a good deal of sharing data and best practices amongst members of the Blue Cross and Blue Shield Association, she could not say how Wellpoint’s move might affect Blue Cross of Kansas’ planning.

“Ultimately it’s up to each independent Blue plan to make the decisions that are best for their service area,” she said.

Verdict is out

Tina Davis is the director of four rural health clinics that — along with the county hospital — comprise the Ellsworth County Medical Center, one of the eight pilot sites.

She said "the verdict is out" on whether medical homes will lower the overall cost of health care.

"If we do our job well, it will reduce the number of in-patient stays and ER (emergency room) visits, so obviously our revenue from the hospital side will decrease. But on the outpatient side, because we're doing a better job maintaining those patients ... our revenue should be greater," Davis said.

by KHI News Service

Dr. Jennifer Brull's practice in Plainville is another pilot site. She said she's working toward medical home certification solely to improve patient care. But she said the bottom-line benefit of doing so is a question of when, not if.

"I think that people who are smart are going to say, 'I see it coming' — I see more money coming from (operating a patient-centered medical home) and I'm going to jump on that. But you got to have faith so you can be there when the money comes. Otherwise you're going to be playing catch-up," Brull said. "Blue Cross is putting their money where their mouth is; they are actually trying to pay to improve care."

KanCare and medical homes

Using medical or health homes to coordinate care and ultimately lower costs is part of Gov. Sam Brownback's Medicaid makeover, called KanCare. At the Feb. 3 announcement of KanCare's executive reorganization order, Cabinet member Shawn Sullivan said health homes were a major component of the plan to move all those on Medicaid into managed care.

→ Continue reading about Gov. Brownback's plans for health homes in Kansas — and find links to resources cited in this story — at khi.org/pcmh.