The Kansas Medicaid program seems to be catching up with the rest of the nation when it comes to dental care for children.
In the past dozen years the state has doubled the number of Medicaid children receiving dental services, said Kamyar Nasseh, an economist from the American Dental Association. Nasseh spoke at the Oral Health Kansas conference held here last week.
Nasseh said about 20 percent of Kansas children on Medicaid logged a dental visit in 2000. But in 2012, that figure was up to 40 percent, he said, citing statistics from the federal Centers for Medicare and Medicaid Services.
One explanation for the greater percentage of Kansas Medicaid children seeing a dentist could be the state’s school-based screening and sealant program, said Jennifer Ferguson, manager of the Kansas Children’s Oral Health Program. The program targets low-income students.
The program screened approximately 154,000 students during the 2012-2013 school year, more than double the number served just three years prior, according to a presentation by Ferguson.
But despite the improvements, the Kansas percentage remains slightly below the national average, Nasseh said.
Yesterday, KHI News Service reported that Kansas’ Medicaid-reform program, known as KanCare, had effectively shut down a grant-funded initiative that provided Medicaid dental services to children in Head Start programs.
Nasseh gave the keynote speech at the two-day conference, which drew about 160 people. It was held at Johnson County Community College.
Nasseh cited other Kansas figures:
Approximately 49 percent of low-income adults saw a dentist in 2010, down from about 53 percent in 2002. There was a similar decline in the national percentage.
Assuming full implementation of the federal health-reform law, approximately 545,000 Kansas children would have dental benefits by 2018, a roughly 16 percent increase over 2010. A key requirement of the law is that private health insurance plans must include pediatric dental and vision benefits starting next year.
The Medicaid reimbursement rate for dental services is less than half (46.9 percent) the commercial payment rate, which is about in line with the national average of 50.3 percent.
And he described a national survey by the dental association that found that more than a third of dentists reported they were not busy enough and could accept more patients.
Conference presentations are available online, along with the first-ever county-by-county oral health snapshot of the state, which was produced by Oral Health Kansas and released at the conference.
90 percent of counties short on dental providers
Tanya Dorf Brunner, executive director of Oral Health Kansas, said she was surprised to hear that given that 95 of Kansas’ 105 counties do not have enough dental providers.
Members of an oral health task force established by the Kansas Board of Regents recommended last year that the state open a dental school to help address the shortage.
The disconnect between the findings in the dental association survey and the Kansas statistics could boil down to differences among safety-net providers and private-practice dentists.
If state-run Medicaid had its problems, one part that was working well in Kansas was providing oral health care to kids through programs such as Kansas Cavity Free Kids, Head Start officials say.
By the fifth year of the pilot program, which began in 2007, more than 7,000 children in 41 rural counties had received regular cleanings, fluoride varnishes and sealants from dental hygienists in Head Start classrooms.
It worked so well that program officials planned to expand it to other areas of the state where access to dental care is chronically limited.
But the program was effectively shut down after the launch of KanCare on Jan. 1, when day-to-day management of the state's Medicaid program was turned over to three for-profit managed care companies.
UnitedHealthcare, one of the state’s three KanCare contractors, chose to not authorize payment for teeth cleanings performed at Head Start, a decision that effectively put the entire program on ice.
"United does not recognize (a hygienist's) services if she's working under Head Start for doing cleanings for kids or for pregnant women," said Kathy Hunt, the Head Start official who coordinated Kansas Cavity Free Kids.
The other two KanCare companies — Amerigroup and Sunflower State Health Plan, a Centene subsidiary — continued the previous state policy of allowing dental care performed at Head Start facilities to be billed under Medicaid.
But Hunt said the program could not continue serving children covered by those companies while turning away others covered by United.
"Quite frankly, we have not provided services since" KanCare began, Hunt said. "We can't say 'I'm going to provide services for this child and not for this child.'"
Hunt also serves on the board of directors for Oral Health Kansas. She testified about the problem last month at the first meeting of the Legislature’s KanCare oversight committee.
A month later, she hadn’t had any response from legislators, state officials or representatives of UnitedHealthcare.
A state senator says he’s working on a bill that would give some foster parents more say in the legal process for determining whether children in their care should be returned to their biological parents or put up for adoption.
“It seems to me that foster parents are the ones who spend the most time with these kids, but they have no authority, no power,” said Sen. Forrest Knox, an Altoona Republican. “They’re just babysitters.”
Knox said he plans to propose creating a “new tier” of foster parents who would be allowed to participate in the decision-making process in exchange for being better trained and taking on more difficult children.
“We’d expect a lot more out of them, but we’d pay them a lot more, too,” he said.
Knox and his wife, Renee, have nine biological children, two of whom still live at home. The couple adopted four brothers — then ages 5, 7, 8 and 13 — two years ago after caring for them two years as foster parents.
Too little say
Knox said he thought more “good people” would agree to become foster parents if they knew they “would be given the tools to make a difference in kids’ lives.”
Many compassionate adults, he said, don't become foster parents because they know they would have little or no say in what happens to the children placed in their care.
“The kids get jerked out of their homes and they’re not told why,” Knox said. “They have no standing. They’re just a place to put kids.”
Knox said his proposal would not increase overall costs.
“I’m looking at spending less money total,” he said, “but spending it more effectively.”
In Kansas, foster-care decisions are the subject of court proceedings during which a judge rules on evidence presented by attorneys representing the state, the children, and the biological parents.
Foster parents are allowed to file written reports with the court, letting the judge know how the children in their care are faring. But they are not considered an ‘interested party’ with legal standing in the case.
Decisions affecting the services children receive while in foster care are made by the Kansas Department for Children and Families, which contracts for services with two nonprofits: KVC Behavioral Health and St. Francis Community Services.
St. Francis and KVC, in turn, each have networks of licensed foster homes. They also rely on networks developed by other charitable organizations.
'A lot of inefficiencies'
Kansas privatized most if it’s foster care responsibilities in 1996.
“I haven’t seen (privatization) really work,” Knox said. “I see a lot of inefficiencies.”
According to the latest reports on the DCF website, 5,780 children were in the state’s foster care system last month. Currently, the system includes 2,546 licensed foster parents.
Knox said he hoped his proposal would be the subject of a pilot project somewhere in the state next year.
Bruce Linhos, executive director with the Children’s Alliance of Kansas, an advocacy group that helps train foster parents, said similar proposals similar have been tried in the past with varying degrees of success.
All of the foster care contractors and subcontractors, he said, have foster parents who have more training than most and who are willing to take on children with especially difficult behaviors.
“That kind of family has always been around and they’re of huge value,” he said.
Still, Linhos said, Knox’s proposal appears to be “entirely plausible” in light of an ongoing effort to lessen the state’s reliance on residential facilities for mentally ill children. He said it might also complement a recent Office of Judicial Administration initiative aimed at helping parents and children better navigate the foster care system.
Marcia Allen, who runs Kansas Family Advisory Network, a Wichita-based group that advocates for parents whose children are in state custody, said Knox’s proposal would raise several issues that have proven to be contentious in the past.
“I fully support more training for foster parents and I understand that they want more say in the process," she said. "But is that to say they should have more say than the birth parents? Should they have more say than the children? And what about grandparents? Shouldn't they have a say? Everybody wants more say in the process. And you know what? They all probably deserve more say.”
Perhaps it is a case of could-have-been.
Two years ago, Gov. Sam Brownback rejected a $31.5 million federal grant to set up a health insurance marketplace tailored for Kansas — defaulting instead to the federally run exchange that was launched Oct. 1 but which continues to be beset by problems.
Gary Schneider — the technology expert who was poised to lead Kansas' marketplace development until Brownback opted against it — left instead for Colorado, one of 16 states that chose to run their own marketplace. He now is the IT project manager for the Colorado Health Benefit Exchange.
In Colorado, so far, things are going smoothly, Schneider said.
More than 700 people have enrolled in insurance plans using Connect for Health Colorado, the state’s marketplace. And more than 30,000 people have created accounts on the website allowing them to compare plan options and see if they qualify for tax subsidies.
"We had some bumps in the road with our system when we first turned it on, but most of those have been resolved," Schneider said.
Like the federal marketplace, Colorado's website initially was overwhelmed with traffic.
"Until you turn a system like this on ‘live’ and experience a real load, you can't be sure how it's going to react," Schneider said. "That was the first couple days, but things got pretty stable pretty quick."
CGI, the contractor that built the Colorado marketplace, also built the federal exchange. But Schneider said the fact that so many states went the way of Kansas — opting to use the federal marketplace, HealthCare.gov — greatly complicated the task for the national government.
"If they had anticipated 35 or so states being in the federal marketplace, I'm sure they would have done some things differently,” he said. “But that just panned out in the last 18 months, where states made these decisions to opt out. I don't think they anticipated more than a handful of states to be in the federal marketplace.”
Schneider said he wasn't surprised that the federal marketplace is off to a rocky start “given the tight deadline and the fact that so many states opted to not have a state-based marketplace. That made their task extremely challenging...because there are business rules that apply to different states."
President Obama today held a press conference to reassure those frustrated with HealthCare.gov, saying that "nobody is more frustrated by (the glitches) than I am."
But, said Obama, "even with all the problems at HealthCare.gov, the website is still working for a lot of people, just not as quick or efficient or consistent as we want."
That complexity has been the federal marketplace’s undoing so far, said Timothy Jost, an expert on the health reform law and a professor at Washington and Lee University School of Law.
"The main culprit is just a very, very complex system that must be established to enroll millions of people in hundreds of different health plans," Jost said. "The fact that 36 states refused to participate I think was completely unexpected. And Congress has not appropriated funds — since the initial appropriation, that I know of — for the federal exchange," he said, referring to the federal marketplace.
"Instead Congress has held numerous hearings that have tied up key government officials and kept them from getting their job done. So I think Congress is probably more to blame than anybody else."
Jost also laid blame on "the states that have opposed implementation, including Kansas."
“The states' decisions to not run their own exchanges has had a very serious effect,” he said. “States that are running their exchanges are showing a lot of success.”
States including Hawaii, California and Colorado experienced problems in the opening days of their marketplaces, but according to most reports those have now been largely resolved.
Switching to a state-based marketplace
Should Kansas change direction and decide to run its own insurance marketplace — which for now seems unlikely given the opposition to Obamacare among the state’s Republican leaders — it could have the option of implementing proven software, such as that running Colorado's marketplace.
Schneider said he is in talks with several other states about using the system Colorado built, but Kansas isn't among them.
A new pilot program aimed at improving billing and collections at local health departments is beginning at a critical time — just as tens of thousands of Kansans are expected to get insurance coverage under the Affordable Care Act (ACA).
Currently, billing mistakes are costing many local health departments when it comes to collecting from private insurance companies and the Medicaid program. But that cost isn’t as significant as it could be because many of those now being served by departments are uninsured and so pay their bills directly.
The payer mix is expected to change as more Kansans obtain private coverage through the new online marketplace healthcare.gov, provided federal officials are able to solve technical problems that have plagued the website since its Oct. 1st launch.
A decision by Gov. Sam Brownback and the Republican-controlled legislature to expand eligibility for the state’s Medicaid program – known as KanCare – also would substantially increase the pressure on local health departments to improve their billing procedures. However, neither appear poised to authorize that expansion soon.
The pilot — spearheaded by the Kansas Foundation for Medical Care (KMFC), a Quality Improvement Organization — is beginning in this month in Douglas, Harper, Reno and Sumner counties.
Each of the four local health departments (LHDs) will receive up to $1,360 to train staff members on billing techniques that will maximize reimbursement for services provided to privately insured clients, said Stephanie Lambert-Barth, manager for KFMC's Immunization Billing Project.
“Training of LHD billing staff will streamline the billing processes and improve billing outcomes, resulting in a return on the training investment. Demonstrating this return on investment may help other Kansas LHDs make the case to fund training for their billing staff,” she said.
The Lawrence-Douglas County health department is one of the largest and best funded in the state. Nevertheless it only has one office assistant working two days a week on billing, said director Dan Partridge.
"For us billing has been a challenge because our capacity to dedicate and train staff has been limited," Partridge said.
Currently about 3/4 of his department's revenue comes from clients who pay their bills directly. The agency has an 85 percent collection rate among those clients. However, it collects only 57 percent of the amount it bills to Medicaid and only 20 percent of what it bills to clients covered by private insurance.
"Most of it is coding errors," Partridge said. "We feel confident our participation (in the pilot) will lead to improved collection rates. We also want to be prepared for whatever shift the ACA will create within our revenue streams as private insurance coverage increases."
KFMC’s Lambert-Barth said that, while the project is focused on improving reimbursement rates for immunization services, the plan is to evaluate all claims billed by the health department, including family planning services, for example.
"Our project's final product is a strategic plan report, which will include recommendations for how to move forward. It is not yet clear what those specific recommendations will be, but if the pilot goes well then expansion (of the pilot) would make sense,” she said.
The pilot project’s website contains links to billing resources, tools, project updates and other related information.
Some 27,000 people in Wyandotte County have no health insurance. Health officials are hoping Obamacare and the new insurance marketplace expected to be operating soon in Kansas can help change that.
“We assume quite a few (of the 27,000) are going to be able to qualify” for subsidies through the marketplace, said Joe Connor, director of the Unified Government of Wyandotte County Health Department.
The marketplace, which federal officials have pledged will be ready to launch on schedule Oct. 1, is aimed at making affordable health coverage available to thousands of Kansans who otherwise might not have it.
Nationally, the state marketplaces — also sometimes called insurance exchanges — are expected to serve millions of Americans and are a key component of the Affordable Care Act, which became law in 2010.
‘Misinformation and polarization’
Officials here have a task force that earlier this month began planning ways to get the word out about the exchange to some of the people considered most likely to benefit from it.
The panel is part of the Healthy Communities Wyandotte initiative and is chaired by former Kansas Medicaid Director Barb Langner. She now works at the University of Kansas Medical Center but is working on the initiative as a volunteer.
Langner said the group doesn’t want to duplicate public-awareness work that will be done by others, including the federal government and the Kansas Insurance Department, but that a local touch is needed if everyone in the county is to be reached.
“This is a county that's used to creating some local solutions,” Langner said. “I think the statewide (public outreach) effort will be all well and good, but there are some pockets of people you will not reach unless you have local involvement. A lot of people are not going to go to a public meeting about this. It has to be a little more user friendly.”
Langner said the task force hopes to provide easily understandable information about the exchange to people who already are trusted in the neighborhoods so they can disseminate it to likely exchange users.
“I think because of the misinformation and uncertainty and sort of the polarization on this topic, it’s going to take someone who is trusted to explain it. And you're going to be dealing people that most likely don't have a lot of familiarity with insurance products, so I think personal contact with someone they trust will be important,” Langner said.
“Our role is to get whatever information has been produced to the people who have the contacts in the community. The logical places are churches, perhaps daycares, schools, small businesses, salons. We’re still in the planning phase right now,” she said.
Little time left
Whatever the group does will need to happen soon, because Oct. 1 is looming. The coverage plans offered through the marketplace become effective starting Jan. 1, which isn’t too distant in time, either.
WICHITA — After opposing the move for nearly two years, many providers of long-term services for the developmentally disabled say they now are largely resigned to the state’s plan to fully include their system in KanCare. But that doesn’t mean all the questions and worries about the proposed changes have gone away.
Chief among them seems to be this: How will the whole thing work?
“There was that whole debate this past (legislative) session and last year’s session about whether it’s good for people with DD to be in this (KanCare), but that debate is behind us now,” said Jerry Michaud, president of Developmental Services of Northwest Kansas, Inc., (DSNWK) a nonprofit Community Developmental Disability Organization that serves about 500 developmentally disabled, or DD, people in the state’s 18 northwestern-most counties.
“And so now, it’s how do we set up a system that's going to work and not wait until the first day to realize there are some major hiccups,” Michaud said.
State officials this week are holding two public hearings on an application they plan to file with federal authorities, probably in mid or late August, seeking approval for the KanCare expansion and some other Medicaid program changes.
The second of the two public comment sessions is set for 10 a.m. Tuesday in the Madison Ballroom at the Downtown Ramada Inn in Topeka (map).
However, state officials said they believe they already have all the authority they need for the so-called “DD carve-in” as a result of the initial federal sign-off on KanCare in December 2012, just days before the KanCare initiative was launched on Jan. 1.
Kansas officials said federal officials have been urging states to broaden their Medicaid managed care programs so that various services can be better coordinated. And key spokespersons for the state's developmentally disabled service groups said they don’t expect the federal Centers for Medicare and Medicaid Services to block the expansion once they receive the state’s Medicaid waiver request.
But there are a number of key questions about how the changes scheduled to begin Jan. 1 will be accomplished and whether or not some of the problems experienced by KanCare providers in the past few months will have been smoothed out so that the new expansion is relatively easy or seamless for the developmentally disabled and those who assist them.
State officials have said for two years that they intend to leave the current, time-honored service delivery system in place. But the nature of the working relationship the providers will have with the state’s three KanCare contractors and their myriad subcontractors is still being sorted out.
“We are meeting two times a week with the MCOs (the KanCare managed care companies) and the different provider work groups to make sure we get this correct and to make sure we have this exactly correct the first time out,” said Aquila Jordan, director of Home and Community Based Services for the Kansas Department for Aging and Disability Services (KDADS), the agency that oversees the state’s Medicaid DD programs.
The big push by federal officials to get the word out in the next few months about the Affordable Care Act mostly will bypass Kansas, but even in this generally anti-Obama red state there are organizations and community groups gearing up to inform the public about the new health insurance exchange scheduled to launch on Oct. 1.
“I think that there's a lot of misunderstanding about what the Affordable Care Act is and how it works and there's so much noise from a political perspective that people can't really focus on what it is they need to know” about it, said Roberta Riportella, a professor of community health at the Kansas State University Extension. “What we're going to try to do is cut through that noise.”
Riportella has been on the job at K-State for about three months and for at least the next several will be spearheading an effort to use county extension agents and faculty members to inform the Kansas public about the federal health reform law, particularly the new insurance exchange through which millions of Americans and hundreds of thousands of Kansans are expected to purchase their health coverage.
The extension is a long-trusted K-State institution with agents working in all 105 counties. They do all sorts of things to help people, ranging from counseling on best farming practices to helping seniors enroll in Medicare Part D drug programs. They teach 4-H kids to make jelly and other skills, give parents tips on home economics, and are the state’s most persistent crusaders against musk thistle and other noxious pests.
Over the next several weeks, including as part of their annual training sessions in August in Manhattan at the K-State campus, the agents will be learning details of the Affordable Care Act and how to communicate its meaning to the people intended to benefit from it.
In at least one county, (Shawnee, home of Topeka), there will be as many as three extension agents working to get out the word.
They and their colleagues across the state will be trying to inform a public that still knows relatively little about the law three years after it was passed. A recent poll by the Kaiser Family Foundation showed that most Americans still don’t know much about the law commonly referred to as Obamacare.
“I think it will take a big educational effort and I don't expect everybody to get it by the deadline,” said Cindy Evans, a K-State extension agent who works in Shawnee County. “We'll just have to keep working at it and hopefully, if it turns out to be a good thing, people will tell their friends and family about it. It won't be just an agency like (extension) carrying the message. You’ll need community connections, churches and other groups letting people know.”
Each year for the past six, Evans said, she has worked one on one with seniors to help them enroll or re-enroll in the Medicare prescription drug program. But she said it would be impossible to work individually like that with people on the Affordable Care Act simply because of the thousands expected to use the insurance exchange.
'Keep politics out'
Sue Peterson has served for years as K-State liaison to the Kansas Legislature and she knows very well the revulsion the state’s elected conservative Republicans have for Obamacare. Gov. Sam Brownback campaigned for the job pledging to fight the law "every step of the way.”
“It was envisioned by the United States Congress when they passed the Hatch Act and Smith Lever acts, (that) research and extension would provide information to the public who needed or wanted information. The university, and research and extension provide unbiased scientific research findings or information to the public at large around the state,” Peterson told KHI New Service in an email when asked if she expected the university to face political repercussions at the Statehouse because of extension agents doing their jobs.
Evans said she didn’t want her efforts to be misconstrued as political.
“I think extension's role is going to be what it always been — education,” she said. “I don't want to be political at all on this. I just want to keep politics out. People have feelings on both sides on whether they think it will work or cost the system too much. It’s not my role in extension to be political. My role in health literacy and senior health counseling, is to just accurately help people understand the law as it is today.
“I’m not trying to take a stand whether it’s good or bad,” Evans said. “My major area is family finance and people spend a lot of money on insurance and health care and I want to help. My role in family finance is to help them make a good financial decision and not be political.”
Federal officials are preparing for a major public awareness campaign to be most evident in August and September that in some ways has already started. Today, for example, the U.S. Department of Health and Human Services announced a new website and a telephone call center in anticipation of the Oct. 1 exchange launch.
But the major focus of the marketing blitz by the feds and national health consumer groups is expected to be in states with high numbers of people without health coverage, including California and Texas.
Kansas is among the states where federal officials will run the new health insurance exchange but the state’s top insurance regulators said they hope to inject a local flavor.
Insurance Commissioner Sandy Praeger said her agency has been in discussion with the feds about having some of the more complex calls to the exchange’s toll-free helpline roll over to her department so that Kansas consumers come in touch quickly with local people more familiar with the Kansas insurance plans offered in the exchange and the governing regulations.
“We’re discussing how we can make a quick, relatively seamless transfer,” of appropriate calls to the Kansas Insurance Department, Praeger told KHI News Service.
“Our expectation is if you call the 800 number and if you have really simple questions like ‘I don't think I have the proper web address for the exchange or my password isn't working,’ a very operational question, they would handle it,” said Linda Sheppard, the insurance department’s director of health care policy and analysis. “But if it’s questions specifically related to anyone's benefits or coverage, those would be forwarded to us.”
The department already routinely fields calls from consumers with complaints about denials of insurance claims or delays in processing, so it only makes sense to carry that practice forward with implementation of the Affordable Care Act, Praeger said.
The exchange or marketplace is scheduled to be operational in each state by Oct. 1 with coverage purchased through the exchange effective Jan. 1.
'Hiccups along the way'
Some Republican officials have questioned whether the exchanges will be up and running by Oct. 1. Praeger, who has been generally supportive of the new law, is not among them. But she predicted it wouldn’t be a smooth start.
“Oh, I think they'll be up and running,” she said. “There will be some hiccups along the way. That's putting it mildly, especially if you look at how the Medicare prescription drug program rolled out in the Bush administration and this is much more complicated.”
→ Related story: Kansas insurers gearing up to market new plans on exchange
School administrators here say they are alarmed and confounded by the looming, new costs they face with the implementation of the Affordable Care Act.
“We've been talking about it (in anticipation) the last two years. I wish there was somebody smarter than me to find a solution,” said Chris Hipp, director of the North Central Kansas Special Education Cooperative Interlocal 636.
“We are not built to pay full health benefits for non-certified folks who work a little over 1,000 hours a year. I've spent hours and hours running every possible scenario. We can't pay for any of them, so it’s all kind of an academic effort really," he said.
As part of the federal health reform law, commonly referred to as Obamacare, larger employers across the country have a new set of insurance coverage obligations and fees they must pay. The new rules apply to commercial enterprises with 50 workers or more but also to public employers such as cities, school districts and the state of Kansas.
Kansas officials estimate the new fees alone will cost the State Employees’ Health Benefit Plan at least $4.7 million in 2014, or about $63 per worker. That’s without reckoning the added costs of the law’s new coverage requirements, much of which the plan already is absorbing.
For many businesses and larger governmental units, the new obligations are unwelcome but not unmanageable because they can be passed through either to customers or, at least partially, to health plan policyholders.
And for some governmental units, the expected costs represent a small percentage of overall spending. Lawrence officials, for example, estimate the new Obamacare fees will cost the city $137,200 in 2014, which could be considerably less than the potential costs of complying with a new conceal-carry firearm law passed earlier this year by state lawmakers.
Rural school districts
But the new health reform rules are particularly challenging for rural school districts and special education cooperatives, where officials say they have little or no place to turn for additional money, especially since state school aid has been held flat or reduced and more often than not the so-called “local option” school budget authority already has been maxed out.
“A lot of the districts and co-ops are looking at various options, including the option of getting out of offering health insurance and acknowledging that the most economical step for them is to pay the penalty and have their employees go to the exchange and get what's available through the marketplace. But a lot have not made that decision yet,” said David Shriver, assistant executive director for insurance services at the Kansas Association of School Boards.
The situation at the Phillipsburg special education cooperative offers a stark example of the complications many Kansas schools are facing, Shriver said.
The interlocal co-op is funded by 11 participating school districts that together cover an area of about 4,500 square miles spanning eight rural counties slightly west of the geographic center of the conterminous United States. It is square in the heart of the heartland. The districts collectively serve about 3,700 students, of which about 670 are in the special education program.
Hipp said NCKSEC Interlocal 636 has about 85 “certified” employees (mostly teachers) but also employs about twice that many people as “non-certified” teacher assistants or “paras” and other support staff.
Those workers, earning close to minimum wage, also are offered health benefits by the co-op. But about 100 of them don’t take it because it is too costly for them. The imbalance between their wages and their health insurance costs is so pronounced, Hipp said, that some of the para-educators who use the co-op’s health plan end up writing checks to the co-op two or three times a year just to cover their share of the benefits.
Under the health reform law, Hipp said, the interlocal must offer health coverage that meets the federal standard of affordability or pay a penalty for each employee that gets insurance through the subsidized federal exchange. The exchange — sometimes called a marketplace — is scheduled to be in operation by Oct. 1, with the coverage effective for policyholders beginning Jan. 1, 2014.
Here’s the dilemma for the co-op and similar organizations: On one hand, they can’t afford to pay their “non-certified” workers enough to make premium costs an affordable percentage of their incomes. But nor can the organizations afford to maintain a health plan and pay the annual penalties that must be paid by employers that have workers who opt for coverage through the insurance exchange.
Kansas insurance companies are preparing to sell a range of health plans on a new, online exchange being created by the federal government in an effort to make coverage more available to the thousands of people who have struggled to obtain it.
The Affordable Care Act, often called “Obamacare,” requires the new health insurance marketplaces to be up and running in every state by October, with the coverage sold through them effective on Jan. 1. But large numbers of Americans who stand to benefit most from the exchanges still know little to nothing about the law or how it will affect them, according to a recent poll by the Kaiser Family Foundation.
Anyone will be able to use the online marketplaces to purchase health coverage, but they are being created mostly to make private coverage more affordable for the uninsured and individual policies more widely available to those who don’t have access to group coverage through an employer.
“It’s going to create new opportunities for people who don’t have any insurance at all,” said Andy Corbin, chief executive of Blue Cross Blue Shield of Kansas, the state’s largest private health insurer. “And for those who don’t make much money, it may save them some dollars.”
Corbin said that plans offered on the exchange will “probably be more expensive” than the individual and small-group policies the company now sells. But he said in many cases the amount that consumers actually pay would be lower because of federal subsidies.
The exchange, or marketplace, also will give small businesses — those with fewer than 50 employees — new options. Rather than purchasing group insurance, they will be able to select a plan on the exchange and allow their workers to purchase individual policies. The businesses will have the option of helping their employees pay for the coverage, or not.
At least three insurance companies will sell multiple plans on the Kansas exchange, which will be operated by the federal government because Gov. Sam Brownback, a Republican opponent of the health reform law, declined to establish a state-run exchange. The companies are Blue Cross Blue Shield of Kansas, Coventry Health Care of Kansas and Blue Cross Blue Shield of Kansas City, which does business in two Kansas counties, Johnson and Wyandotte.
Subsidies to blunt higher premiums
Ron Rowe, a vice president for BCBS of Kansas City, predicted the cost of premiums for new, non-group policies would trend higher.
“Some people’s rates are going to go down and some are going to go up, but in aggregate it’s going to be about a 30 to 35 percent increase for that entire block of business,” he said.
But those increased costs could be mitigated for many. People who already have individual policies can keep them. And those who qualify for federal subsidies could end up paying less for more expensive and more complete coverage.
“Many people who are going to see big, high rate increases are going to qualify for a subsidy,” Rowe said. “And the amount that they’re going to pay out-of-pocket, net with the subsidy next year, will be less than they’re paying today even if the premium is significantly higher.”
For example, a person with annual earnings equal to 150 percent of the federal poverty level — $17,235 — would pay about $460 a year for a $5,000 policy, according to a cost-estimating tool developed by the Kansas Insurance Department. Federal tax credits paid directly to the insurance company would cover the remaining $4,540.
The credits, available only through the exchange, will be calculated on a sliding scale up to 400 percent of federal poverty guidelines, or annual earnings of $45,960 for an individual. But at that top level, the subsidy would amount to only about $630 leaving the consumer responsible for the remaining $4,370.
Despite the likelihood that many consumers purchasing through the exchange could pay less, both Corbin and Rowe said they anticipated a backlash from those forced to pay more.
“We’re trying to get out in front of the negative that’s going to come,” Corbin said.
To do that, he said, the company planned to do as much as it could to educate consumers about the exchange, the subsidies available and why some coverage would cost more.
Higher risks mean higher costs
Premiums are expected to rise because the reform law prohibits insurance companies from continuing practices they have historically used to reduce their risks. Those practices include denying or limiting coverage for high-cost individuals or capping their benefits. Going forward, the companies must sell policies to anyone regardless how sick they might be.
Kansas Insurance Commissioner Sandy Praeger, a Republican who has bucked the party line in supporting the law, said the old system often denied affordable coverage to people who needed it most.
“If you had any kind of pre-existing condition, you probably couldn’t buy (insurance) at all,” Praeger said. “You could be denied coverage because of allergies.”
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.
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.
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.
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.
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.
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.
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.
Is the whirl of hospital revolving doors slowing?
Federal health officials are now reporting that the rate of preventable and costly hospital readmissions is down for the first time in more than five years, which meant about 70,000 fewer hospital returns nationally in 2012 for the Medicare program alone.
With a strong push from the federal health reform law, scores of medical and social service workers around Kansas — like thousands of their counterparts in other states — are working together on projects that officials say show promise for reducing avoidable readmissions.
If they succeed, hospitals could be spared some of the Affordable Care Act penalties they face in the form of reduced Medicare payments and federal health care spending could be trimmed $8.2 billion by 2019, if projections from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) prove accurate.
Starting in October 2012, almost 30 of the 46 non-exempt Kansas hospitals were punished for relatively high readmission rates in the first year of the ACA program, according to information from CMS compiled by Kaiser Health News, a partner of KHI News Service.
Because of the potential financial sting attached, nobody wants to be on that penalty list when it’s redrawn for this year, especially since last year’s maximum penalty of a 1 percent reduction will grow to a maximum 2 percent and then 3 percent for 2014.
“Almost every hospital is looking at this, because they stand to gain or lose,” said Ken Mishler, chief executive of the Kansas Foundation for Medical Care, a Topeka-based, non-profit organization that is the federal government’s sole designated contractor in Kansas for improving health care quality. In federal parlance, the foundation is known as a Quality Improvement Organization or QIO.
Mishler’s group was directly involved with organizing projects in four locations - Hays, Topeka, Kansas City and Wichita – but there are others underway, too, including one by the Kansas Healthcare Collaborative, a 2008 creation of the Kansas Hospital Association and the Kansas Medical Society.
There is evidence the various efforts, some of which predate the ACA, may be working. The readmission rate in Kansas was already lower than the national average, but recent numbers show even that somewhat lower rate has dropped.
According to the Kansas Foundation for Medical Care there were 49.4 per 1,000 Medicare fee-for-service patients readmitted to Kansas hospitals within 30 days in 2011 versus 52.5 in 2010. That compares favorably to the national average of 56.8 per 1,000 in 2011 and 58.2 per 1,000 in 2010. Foundation officials say the ultimate goal is a 20 percent reduction.
The efforts to make that happen in Kansas vary place to place but among the things they have in common is the involvement of multiple types of medical and social service providers or agencies, not just hospitals.
The reason for that, experts say, is that one of the best ways to reduce readmissions is to make sure that patients get proper follow-up care or attention after they are discharged whether they leave the hospital to live alone at home - where they may receive limited assistance from a variety of outside sources - or a skilled nursing facility where they get more-or-less 24-hour attention.
‘A community problem’
“It’s not just a hospital problem. It’s a community problem and you have to get all the providers together. It’s not easy work. It’s hard work,” said Laura Sanchez, the project director for the Kansas Foundation for Medical Care.
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.
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.
About 30 dental hygienists from around the state were in Topeka this week to ask their legislators to approve the licensing of mid-level dental providers.
A bill to license so-called registered dental practitioners was introduced last week. If it becomes law, it would allow hygienists with 18-months additional training to, among other things:
• permanently fill teeth,
• extract teeth,
• repair dentures, and
• temporarily crown teeth.
The Kansas Health Consumer Coalition, Kansas Action for Children, the Kansas Health Foundation — a major funder of the Kansas Health Institute — and other groups have supported the licensing of mid-level dental practitioners in Kansas, and organized today's visits by the hygienists.
Heidi Lowry and Tammi Engel were among those who traveled the farthest. They are from Atwood — a town in the northwest corner of the state, which is designated a "dental desert."
According to a 2011 report, at least 57,000 Kansans live in "dental deserts," areas where the closest dental office is at least a half-hour drive from the resident's home.
Lowry and Engel met with Sen. Ralph Ostmeyer, a Grinnell Republican, to tell him how licensing the dental practitioners would improve oral health in Rawlins County and others like it.
"It's not just access" to care, said Lowry, a trained hygienist who now spends most of her time as director of the Rawlins County Dental Clinic.
"With the current economic climate on the state and federal level, we're going to have to look at ways to be self-sustaining. Being able to use (practitioners) is going to go a long ways toward being able to provide those services and do it in an economic manner. That's just more fiscally responsible with our Medicaid dollars, and all the way around," Lowry said. "When you're just talking economics, a (practitioner) is not going to make the same wage as a dentist. And when we're a safety net clinic and write off a significant portion of services every year, it's going to make the safety net clinics more sustainable without state, federal or grant dollars. That's huge. We can continue to see those who don't have insurance and not tax emergency rooms."
Ostmeyer asked the women if dentists were any less opposed to the idea than they were several years ago when licensing dental practitioners was first proposed.
"Are you able to sit down with the Kansas Dental Association?" Ostmeyer asked.
The dental association opposes the measure, saying there are better ways to increase access to oral health care — including its Kansas Initiative for New Dentists, which would offer loan repayment and scholarships to dentists and students who agree to serve for at least two years in a dental desert. The dental association has scheduled an event at the Statehouse tomorrow to announce the first four recipients of awards under the program.
"I've talked with several dentists in our area and we don't have near as much fight back. I don't think they'd publicly say 'I support this' in front of the dental association, but they see the need," Lowry said.
It's not easy to recruit and keep a dentist in rural areas, Lowry said.
Before she and her supervising dentist arrived in Rawlins County in 2008, citizens there had been trying to lure a dentist for 10 years, she said.
"When you live in that rural of an area, there's things you just don't think about," Lowry told KHI News Service after her talk with Ostmeyer. "If you have to see a medical specialist, you're driving to Denver. There's concern with (obstetrics) care, if (a potential recruit is) young wanting to start a family," she said.
"We're 30 miles from the closest Walmart, shopping is not really available, there's no fast food per se...our movie theater is open Saturdays and Sundays. During the summer they show on Fridays but as soon as sports start up, they close," Lowry said. "You have to really want a rural, community-minded area."
One of the two dentists the community recruited using a school loan repayment program is leaving soon, she said.
"She's coming back to the city, to Kansas City. So we're going to be down to one, which is going to be difficult," Lowry said.
A different mindset
She said if practitioners were licensed, the needs of Rawlins County could be met with two of them in addition to the current three hygienists and dentist.
Among the needs that would be most immediately met: fillings in the baby teeth of children the clinic serves in schools using portable equipment. Currently the closest dentist who accepts Medicaid referrals is 60 miles away in Norton and only handles "extreme" cases.
Ostmeyer asked why it was difficult to get dentists to see Medicaid patients.
Lowry said Medicaid doesn't pay as well and "that's compounded by the fact that there's just a shortage of dentists in general, so their schedules are full seeing (patients who have) private insurance."
She said practitioners also would fill a need for caring for the developmentally disabled children and adults her staff treats.
"What we've found is that if we can see them on site, they don't have to have as much valium or other things to make them chemically relax, they don't have to be restrained. So if we could bring services to them, it would be much better," Lowry said.
"I've just found that the mindset of a hygienist, generally it's just a little bit different personality than dentists — one's a little bit more willing to go do the on-site, portable dentistry," she said.
Alaska was the first state to sanction licensing of mid-level dental providers in 2006, and only Minnesota has done so since.
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.
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.
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.
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.
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.’”
LAWRENCE — About 60 community organizers from eight states are meeting here this week to collaborate on their efforts to license mid-level dental providers in their respective states.
In each state, proposals for licensing the new position are intended to address long-standing shortages of dentists, especially in rural areas where other approaches — such as loan repayment incentives — have been unsuccessful, said Dr. Albert Yee of Community Catalyst, the Massachusetts-based organization spearheading the effort nationally.
Representatives of Kansas, Ohio, New Mexico, Vermont, Washington, Colorado, Michigan, and Minnesota are attending the three-day, semi-annual meeting coordinated by Community Catalyst.
A mid-level dental provider's training places them between a regular dentist and a dental hygienist — able to fill cavities and perform simple extractions of teeth. Alaska was the first state to sanction mid-levels in 2006, and only Minnesota has done so since.
Opposition from dentists has so far blocked proposed legislation to license mid-levels in Kansas and in other states.
Similar to nurse practitioners
Yee said the dentists' criticisms of mid-level dental providers — that they're undertrained or provide second-rate care — is unwarranted. He pointed to a recent report on 26 nations and territories’ experiences with mid-level dental therapists, which found that they provide good quality, cost-effective care.
"The evidence that's out there, the studies have shown that it's not a lower level of care. It's exactly the same quality of care that the dentists provide for the same procedures," said Yee, who also works with the Kellogg Foundation, which commissioned the report he cited. "There's really no study to the contrary, no evidence whatsoever that they provide second-rate care."
Yee said the opposition to mid-level practitioners — sometimes called dental therapists, registered dental practitioner, or RDPs — remind him of his experience as an internist in the 1980s and early 1990s, when similar opposition was aimed at nurse practitioners by doctors.
"Obviously nurse practitioners and physicians' assistants 25 years later are basically a normal part of the landscape. So with that, I saw the potential for dental therapy having that benefit in the dental profession in improving access to care for underserved populations," Yee said.
In Kansas, at least 57,000 people live in so-called dental deserts, where there are no dental services and where the closest dental office is at least a half-hour drive from the resident's home, according to a 2011 report.
Many more Kansans lack dental insurance and cannot afford routine preventive care, much less restorative care, said Suzanne Wikle of Kansas Action for Children, which is part of the effort to license mid-level practitioners in the state. The Kansas Health Foundation — a major funder of the Kansas Health Institute — is also part of that effort.
Wikle said lack of access to dental care leads to 17,500 hospital emergency room visits for dental care each year.
"The number one reason is cavities," she said.
The average cost for dental care in the ER is $400 to 600 per visit, Yee said.
"And they're not equipped (in emergency rooms) to provide dental care. They're only getting a prescription, they still need to get the care. Whereas the average dental visit could cost between $70 and $80," Yee said.
'Not the solution'
But Kevin Robertson, director of the Kansas Dental Association, has said the solution to that problem is not licensing mid-level practitioners.
Robertson said the bills introduced in the last two legislative sessions by supporters of the new licensing went too far by proposing that the practitioners be allowed to perform procedures which are, by definition, considered surgery — that is, anything that includes the cutting of the hard surfaces of teeth.
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.
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.
Hays dentist Melinda Miner is one of a handful in her profession who publicly support licensing a new type of mid-level dental provider as a way to increase Kansans' access to oral health care.
She's also among the relative few who will see Medicaid patients.
"Only 25 percent of us see the problems," Miner said. "Most dentists live in a different world. Their patients pay cash and can afford the expensive treatments. They don't see the dental decay and the problems in people who can't pay."
Miner was among about 25 people who met Tuesday in Topeka as part of the Kansas Dental Project, a coalition of advocacy groups seeking to improve dental care for children, the elderly and the medically underserved.
The group was formed in 2010 to urge Kansas policymakers to approve the licensing of mid-level practitioners as a way to help address the state's dental workforce shortage. Currently only Alaska and Minnesota license the mid-level caregivers.
Bills to authorize the licensing of "registered dental practitioners" in Kansas were put before lawmakers in each of the past two sessions of the Legislature. However, they did not make it to a vote in either chamber because of stiff opposition from the Kansas Dental Association, which represents about 75 percent of the state's approximately 1,400 dentists.
Kansas Dental Project members said they plan to propose a simliar bill again this year.
Miner was asked how more dentists could be won over to support the legislation.
"There are only 1,400 dentists in this state. I don't know that they need to be won over," Miner said. "Reaching out to the communities for support is probably a better avenue...seeking support from the people who see the problems."
Miner also suggested that supporters of the proposal stress the potential economic benefits of licensing mid-level providers.
For example, she said she would hire two mid-level practitioners as soon as it was possible and at least one other full-time employee to handle their appointments. She said she felt sure many dentists would do the same as soon as mid-levels are sanctioned.
"I don't see how the economic impact could be anything but positive," Miner said.
Jill Gottschamer, president of the state dental hygienist association, said she agreed with that approach. She said while only 28 new dentists were licensed in the state this year, there were 124 new hygienists licensed, some of whom cannot find work.
"I personally know three hygienists who can't find jobs," Gottschamer said. "We can't get dentists, but we've got a massive amount of hygienists in the state. So we have an extremely large workforce ready to fill the need."
Dentists acknowledge the workforce shortage, but say that licensing mid-level practitioners would not solve the problem.
Kevin Robertson — director of the Kansas Dental Association — has said 99.9 percent of the state's dentists do not support licensing mid-level dental providers because doing so would endanger patients.
He said extending Medicaid dental coverage to include adults would be a better way to improve access to care.
"Patients who cannot afford dental care from a dentist will not be able to afford treatment from a (mid-level provider) either without adult Medicaid," Robertson said.
Miner and her husband Daniel are two of 13 dentists in Ellis County and they are the only ones who will treat children on Medicaid, she said. Medicaid patients account for about 30 percent of those seen by her and her husband. And she said many of the approximately 7,000 appointments the couple schedule each year are for residents of nearby Trego and Ness counties, which have no dentists.
Access to oral health care in rural areas of the state is being squeezed even for those with dental insurance, Miner said.
"We have 110 people on our waiting list for new patients, and not just people on Medicaid," she said. "We're not meeting the needs of our community."
Miner estimated that each mid-level practitioner would enable her practice to schedule 2,000 to 3,000 more appointments per year, in part by opening satellite clinics in Wakeeney and Ness City for preventive and other basic dental services.
With the legislation proposed by the dental project, mid-level practitioners would be allowed to perform about 30 routine services and procedures — such as filling cavities, performing simple tooth extractions or administering local anesthetic — that currently are limited to dentists.
The practitioners, similar to a nurse practitioner, would be required to work under a dentist's "general" supervision, though the dentist would not be required at the technician's side or necessarily present in the same office.
Spokespersons for the dental association have argued that routine procedures quickly can turn dangerous and that allowing lesser-trained practitioners to do what dentists now do could put patients at risk.
But Miner said supervising dentists would be able to limit the procedures the mid-level practitioner's could perform commensurate to their experience.
"It's no different than a nurse practitioner," she said. "In Victoria, Kansas, right next door to us, there's an entire clinic that's only run by nurse practitioners. The doctors are overseeing it, but they're not there — and that's very common out in our area. And we all trust those nurse practitioners and we know they know what they're doing.
"To me, it's the same thing. I trust my hygienists now, but the law says I have to go check her, so I go check her work and talk to the patient. But I don't know that I've ever really disagreed with her. I feel like with a little more training this would be a natural transition."
There's little dispute that there is a pressing need to increase access to oral health care in Kansas.
At least 57,000 Kansans live in dental deserts, where there are no dental services and where the closest dental office is at least a half-hour drive from the resident's home.
Amid national concerns that the seriously mentally ill are dying from preventable diseases, a leading Kansas healthcare philanthropy is about to make a down payment on a multi-year initiative aimed at integrating physical and mental health services for safety-net patients.
Within the next couple weeks, the Sunflower Foundation expects to open a competitive grant program that Chief Executive Billie Hall said likely would provide more than $1 million in funds to selected health providers focusing on integrated patient care. Foundation officials expect to award the grants by March.
“When we made the decision to get into this particular area,” Hall said, “we knew it would be a long horizon. We know we are in for five, maybe 10 years, depending on how things go in our state.”
The foundation’s board chose the initiative as a major priority about 18 months ago.
To date, Hall said, the foundation has spent about $50,000 sending some providers from different Kansas clinics to visit Cherokee Health Systems in Tennessee, which has 43 clinical sites in that state and a history of melding medical and mental health services.
Integration can mean having mental health and primary medical care agencies housed in the same building, said Melody Martin, a program officer with the foundation. But that is not the only way to do it, she said.
For instance, community health centers in Lawrence and Newton now have social workers or behavioral health specialists who work alongside the clinics’ medical teams.
At Heartland Community Health Center in Lawrence, behavioral health specialist Karin Denes-Collar technically is employed by Bert Nash Community Mental Health Center, which is located several blocks to the west of the clinic. But her office is at Heartland, where she consults daily with the medical staff about the conditions of various patients.
For example, she said, a patient with diabetes might also suffer depression in ways that could hinder the treatments for the underlying medical conditions. A homeless man with a chronic physical malady likely also struggles with a range of other problems that compound the illness. Assistance with those problems might best come from a social worker.
Reconnecting kinds of care
Area providers and national experts alike say that better coordination of care is essential to proper treatment for the mentally ill.
In an April 2009 paper, the National Council for Community Behavioral Healthcare said that persons with serious mental illness were dying 25 years earlier than the rest of the population largely because treatable conditions — such as diabetes and cardiovascular disease — had gone unmanaged.
“The bottom line is that the mind and body are connected,” said Tim DeWeese, director of clinical services at the Johnson County Mental Health Center in Mission. “And so the more physically healthy you are, the more mentally healthy you are going to be and vice versa. I think it’s really just reconnecting the two things. I don’t know where we got off base.”
The Sunflower Foundation is building upon a pilot project started two years ago by a subsidiary of the Association of Community Mental Health Centers of Kansas in collaboration with the Kansas Association for the Medically Underserved (KAMU)
Providers from nearly a dozen communities, including Heartland in Lawrence, were part of the pilot, said Connie Hubbell, director of governmental affairs at KAMU. The participants collected data for about a year starting in early 2011.
Undertaken with little funding, Hubbell said the pilot yielded results that were encouraging nonetheless. For instance, data compiled on 81 patients indicated an 8 percent reduction in monthly expenses per patient.
“So we know it’s out there,” she said. “We know it can happen. The integrated model is cost effective, it does save money, and it’s much more appropriate for the patient.”
Integration in action
One of the biggest challenges, Hubbell said, is successfully melding the consultative atmosphere of mental health with the often-frenetic pace that goes with providing primary care in a safety-net clinic.
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.
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.
Kansas has done a good job the past couple of years covering more children with health insurance.
In 2009, 8.2 per cent of children in Kansas were uninsured, according to a new report from the Georgetown Center on Children and Families. Two years later, the figure was down to 6.4 percent.
That 1.8 percentage point change was the seventh best improvement among states over the period, according to the report. Oregon and Texas improved the most, at 3.1 percentage points each. Missouri — which improved coverage by .2 percentage points — was among the bottom 10 states in reducing the percentage of its uninsured children.
Much of Kansas' increase in coverage for children is attributable to the state's Healthwave program — which insures children whose families earn a little too much to qualify for Medicaid — said Suzanne Wikle, director of policy and research for the non-profit advocacy group, Kansas Action for Children.
“In 2010, the eligibility level for our Healthwave program was increased to account for the fastest-growing group of uninsured children, who were just above the eligibility line at that point. So we made the program available to many more uninsured children in the state. That’s had a very big impact,” Wikle said.
Wikle said the state has also done a better job of marketing the Healthwave program. She's worried, though, that when Healthwave is incorporated into KanCare the name change may confuse some families and cause them to miss out on coverage they’re eligible for.
KanCare is Gov. Sam Brownback's plan to move most of the state's 380,000 Medicaid enrollees into managed care plans operated by three insurance companies.
Currently, large managed care companies only provide services to children and pregnant women from low-income families through HealthWave.
The authors of the Georgetown report say full implementation of the Affordable Care Act is the next opportunity to make substantial progress on insuring children.
In what could be a first for the state, if it is chosen, Kansas officials are considering contracting with an out-of-state organization to provide services for children in foster care.
Since the state privatized its foster care program in 1997, it has relied on a group of Kansas-based, non-profit organizations to manage the care provided to children who have been deemed wards of the state due to parental abuse or neglect.
Typically, there are about 6,000 children in the state’s foster care system at any given time. The state's lead foster care contractors collectively employ about 800 people.
Each of the organizations that have secured the state’s foster care contracts since the privatization initiative 15 years ago has been active for decades in Kansas child welfare services and are well known by the state’s foster care parents, welfare workers, and court and law enforcement officials.
The current contract holders are: TFI formerly known as The Farm, Inc., which has offices in Emporia and Topeka; KVC Behavioral Healthcare, Olathe; United Methodist Youthville, Wichita; and St. Francis Community Services, Salina.
Now, they face a potential, nonprofit competitor from Florida that provides similar services in multiple states: Florida, Louisiana, Texas, Iowa, North Carolina and Vermont.
“A large part of what we do is very similar to the work that’s being done in Kansas,” said David Dennis, chief executive of Eckerd, which was one of six organizations that met the state’s Sept. 20 deadline for submitting contract proposals.
Eckerd was founded in 1968 by Jack and Ruth Eckerd. The couple, now deceased, also started the Eckerd drug store chain in the 1950s.
In Florida, Dennis said, Eckerd manages the state’s foster care contracts in Pinellas, Pasco, and Hillsborough counties.
“It’s pretty much the Tampa Bay area,” he said, noting the contracts there involve more than 6,100 children.
The State of Florida pays Eckerd about $120 million a year for its services. Kansas spends about $140 million a year on its foster care program, not counting about $10 million spent on family preservation programs.
“Our piece of what’s going on in Florida is larger than the (foster care) systems in 14 other states and the District of Columbia,” Dennis said.
Florida privatized most of its foster care system in the late 1990s and early 2000s.
Another new entry
Another new entry to the contract competition is Olathe-based Kids TLC. The nonprofit organization has a history of providing child welfare services as a subcontractor, but has never before bid on a lead Kansas foster care contract.
The group seeks to provide services in the region that includes Atchison, Douglas, Johnson, Leavenworth, and Wyandotte counties.
“We’re known for having the largest PRTF (psychiatric residential treatment facility) in the state of Kansas,” said Jeremy Brenneman, the organization’s marketing and public relations coordinator. “But we also have a foster care program, an outreach program that goes out and looks for homeless and runaway kids, and a case management program that helps families that are at risk.”
Most of the program’s current services, Brenneman said, are provided in Douglas, Johnson, and Wyandotte counties.
Kids TLC is ready to expand its reach, he said, noting that its bid for the foster care work “really fits in with what we want to do.”
With the new contracts, which are expected to become effective July 1, 2013, the state is reducing its five foster care service regions to four. The new contracts are for four-year terms with two, optional, two-year extensions.
Organizations are allowed to bid on providing services in more than one of the four regions.
Author and economist John Goodman is scheduled to talk about his ideas for reforming the U.S. health care system at an appearance next week at the University of Kansas Dole Institute of Politics.
Goodman sometimes is called "the father of health savings accounts," and has a new book: "Priceless: Curing the Healthcare Crisis." He co-wrote the 1992 book "Patient Power: Solving America's Healthcare Crisis."
He also developed the Health Care Contract with America, a five-point plan for reforming health care, which has been cited by the Congressional Health Care Caucus, a study group for Republican congresspersons and members of their staffs.
In his new book, among other things, Goodman calls for abolishing Medicaid and moving the program's beneficiaries into private insurance plans. Medicaid enrollees, under his plan, would instead get a $2,000 per person tax credit or refund that they could apply toward the purchase of private health insurance.
He also recommends replacing much of Medicaid outpatient spending for those who are not elderly or disabled with a "health stamp" system modeled on the food stamp program. Beneficiaries would be given the stamps and allowed to spend them as they saw fit for medical care. He also favors abolishing the Children's Health Insurance Program.
The main point of his book is that the current health system has neutered the function of pricing in the health care market, thereby driving up costs. Consumers, he argues, don't pay the real costs of medicine and largely are unaware of them. Providers aren't reimbursed for their true costs but instead take whatever the insurance companies and government are willing to pay.
"So, the overall conclusion of the book is that when we take prices out of the system we create perverse incentives," which have led to higher costs and inefficiencies, Goodman said in an interview with 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.
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.
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.
“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.
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.
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.
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.
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.
Talk of repealing the Affordable Care Act is partisan bluster that won’t come to pass even if Republicans sweep the November elections, a top Obama administration health care official predicted at a forum here today.
“Even those people who are talking about repealing, privately, they acknowledge that no, the law is here to stay,” said Jay Angoff, director of the U.S. Health and Human Services Department region that includes Missouri, Kansas, Nebraska and Iowa.
Angoff said that even if Republicans control the White House and U.S. House following the election, they would not have a large enough majority in the Senate to push through legislation to overturn the law. Senate rules require 60 votes to advance most legislation.
Angoff is a former Missouri insurance commissioner and has served as an advisor to Health and Human Services Secretary Kathleen Sebelius on health insurance cost and coverage issues. The forum, organized by the Health Care Foundation of Greater Kansas City, drew an audience of about 50 people.
'When the dust settles'
Kansas State Rep. Jim Denning, an Overland Park Republican, disputed Angoff’s comments, including taking issue with the director’s analysis of the potential congressional repeal. Denning is the retired chief executive of Discover Vision Centers, which has eight locations in Missouri and Kansas.
Angoff also predicted that states eventually would go along with the expansion of Medicaid eligibility included in the Affordable Care Act.
“When the dust settles,” he said, “states are going to realize what a terrific deal this is.”
In its June 28 ruling on the reform law, the U.S. Supreme Court left it up to the states to decide if they want to participate in the expanded Medicaid program.
Under the law, the federal government would pay 100 percent of the costs of the newly eligible Medicaid enrollees when the provision takes effect in 2014, gradually reducing its share to 90 percent by 2020.
The expanded eligibility would take in low-income residents under the age of 65 who earn up to 138 percent of the federal poverty level.
Kansas currently covers more than 350,000 individuals under its Medicaid program. Preliminary estimates project the state’s enrollment could increase by about 130,000 individuals under the health law expansion.
The Kansas Medicaid program costs about $2.8 billion a year. The federal government currently covers about 60 percent of the cost.
Good for small business
Angoff also said the Affordable Care Act was a great deal for small businesses, despite the fact that the National Federation of Independent Businesses was a lead challenger of the law in the suit before the Supreme Court.
He noted a provision that provides tax credits to businesses with 25 or fewer workers that offer health insurance to their workers.
Roughly 360,000 small businesses have already received assistance under that program, Angoff said, and more than 1 million more are eligible.
“We think it’s a great victory for the American public,” Angoff said of the Supreme Court decision.
Denning said it wouldn’t take a 60-vote majority in the Senate to repeal the Affordable Care Act.
He said the Senate could overturn the act with a simple majority through the budget process, much the way the law was passed in the first place.
He also disagreed that the Medicaid expansion was a good deal.
“This is not free money,” Denning said. “The federal government has no money.”
He said the federal government would have to run up its debt to pay for the Medicaid expansion.
He also said he was concerned that the federal government would pay for the expansion the first few years but then would pull back, leaving states to pick up more and more of the tab.
Denning also said the tax credit program for small businesses has not been nearly as popular as Angoff made it seem.
“He’s just talking sound bite stuff there,” Denning said of Angoff's remarks.
The tax credit program was complicated and resulted in costly plans that insurance brokers had little luck in pushing with their business customers, he said.
The chief executive officer of one of the private insurance companies that recently signed Medicaid managed care contracts with the state of Kansas said today that states shouldn’t refuse the offer of additional federal money to expand their programs.
James Carlson, CEO of Amerigroup, made the comment during a discussion with Wall Street analysts about his company’s potential sale to insurance giant WellPoint.
“When you step back from this, there are billions of dollars of federal money that are going to flow into states,” Carlson said in a report published by Politico. “We think the states are going to need to take it.”
Kansas insurance officials are evaluating WellPoint’s bid for Amerigroup, which is one of three companies selected by the state to manage care provided to the approximately 350,000 poor, elderly and disabled Kansans enrolled in Medicaid. The other two are United Healthcare of the Midwest, a subsidiary of United Healthcare, and Sunflower State Health Plan, a subsidiary of Centene.
Several Republican governors have said they don’t intend to expand eligibility for their Medicaid programs now that the U.S. Supreme Court has ruled that the federal government can’t withhold its share of funding for the program in states that decline to do so.
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.
Brownback spokesperson Sherriene Jones-Sontag said the governor still favors repeal of the health reform law and has urged voters to reject it at the polls in November by voting against President Obama’s re-election.
The expansion would result in a more dramatic increase in Medicaid eligibility in Kansas compared to other states. Currently, Kansas adults with dependent children can’t qualify for the program unless they earn less than 27 percent of the federal poverty threshold – about $6,000 for a family of four. Adults without children aren’t eligible for Medicaid unless they are disabled.
The ACA expansion would make everyone who earns less than 133 percent of the poverty threshold eligible for Medicaid. That means a family of four could earn up to about $30,000 and still qualify.
If implemented, the expansion could add as many as 150,000 Kansans to Medicaid rolls.
Related coverage on KHI.org:
Republicans are working still to repeal it, but even before the U.S. Supreme Court ruled that the Affordable Care Act was constitutional, many of its major changes were under way for Kansas hospitals, doctors and other medical providers.
In fact, some representatives of doctor and hospital groups in Kansas and nationally say that many key requirements of the law were inevitable or bound to happen with or without the law, simply because the status quo of the health care industry was unsustainable because of its costs.
In 1965, U.S. health care spending accounted for about 6 percent of the gross domestic product; by 2009, it represented about 17 percent. One culprit for the rising cost, experts say, has been payment systems that reimburse providers more for the volume of their services than for the quality or effectiveness of the care.
“I don't want to downplay the significance of the (Supreme Court) ruling,” said Tom Bell, chief executive of the Kansas Hospital Association, “but I think it’s been clear for some time that a lot of the ways that the system is changing - the movement away from fee-for-service, value-based purchasing, those sorts of things - those things were going to continue whether this law was struck down or upheld. ... So from that perspective, (the decision) was maybe not quite as momentous as we’ve been hearing on the cable news networks.”
A report on the ACA by the national Physicians Foundation published soon after the law was passed in 2010 generally was negative about the reform’s anticipated consequences, particularly for the 32 percent of the nation’s doctors working in individual, private practices of one or two physicians. For them, the authors concluded, the law almost certainly means that their forms of practice “will be largely, though not uniformly, replaced” by new arrangements that will make many of them salaried employees of hospitals or larger group practices.
Nonetheless, the report concluded, “health reform was necessary and inevitable. The impetus of informal reform would likely have spurred many of the changes (required by the ACA) independent of formal reform.”
Quietly moving forward
So as politicians continue to fight over the law, forward-looking hospitals and doctors for at least the past two years quietly have been preparing for and adopting its various provisions.
“The Supreme Court’s ruling keeps in place improved access to health care through expanded insurance coverage and important insurance reforms, which were key elements of the Affordable Care Act,” said Jeff Korsmo, chief executive of Via Christi Health, a Catholic-affiliated system that is the largest private provider of health services in Kansas. “The way we deliver health care has been changing since the Affordable Care Act took effect two years ago, and it will need to change even more dramatically in the years ahead.
“The growth in the cost of health care in the United States is simply unsustainable,” Korsmo said after the court ruling, “and it’s going to get worse because 10,000 baby boomers a day are reaching Medicare age. Those costs, combined with our federal and state governments’ fiscal challenges, all call for major change in health care.”
The head of the Kansas Hospital Association said today that most of the group's member hospitals have accepted the U.S. Supreme Court decision to uphold the Affordable Care Act and are ready to embrace reform.
“The number one thing I’m hearing from my people is, ‘Oh my gosh, are we going to have to go through this health reform political debate again?’” said Tom Bell, noting that he and other health care officials had hoped the ruling would give them a clearer picture of the future.
So far, he said, that’s not happened.
“I’m not so sure that – because of our political environment – we have any more certainty today than we did last week,” he said. “It’s hard to plan.”
Bell spoke during a Kansas Health Institute-sponsored panel discussion on the court’s ruling. Also participating on the panel were:
• Bill Rich, professor of constitutional law at Washburn University School of Law.
• Kansas Insurance Commissioner Sandy Praeger.
• Jay Angoff, director of the U.S. Health and Human Services regional office in Kansas City.
Angoff told the audience that over time “cooler heads are going to prevail” as the public learns more about the law’s benefits and costs.
The court's decision left intact the law's requirement that everyone who can afford health insurance buy it or pay a penalty. But the ruling also made the law's planned Medicaid expansion optional for states. Several Republican governors already have said they do not intend to expand Medicaid eligibility in their states. Gov. Sam Brownback hasn't said yet what his intentions might be with respect to the expansion, which could mean as many as 130,000 additional Kansans would gain eligibility.
Brownback has said he would take no steps to implement the Affordable Care Act until after the November elections, based on the assumption that Republicans will prevail in their bid for control of the White House and Congress and then repeal the law.
If Kansas opts not to expand its Medicaid coverage, Bell 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.
Currently, the disproportionate share payments are meant to help hospitals offset the costs of caring for the uninsured.
Under the Affordable Care Act, Bell said, the payments would be phased out because it assumes the vast majority of the hospitals’ patients will be insured under Medicaid or otherwise by 2014, when the law's major coverage provisions are scheduled to kick in.
“There are a lot of things that really need to be looked at closely,” Bell said.
A Wichita legislator who attended the event said he thought fellow lawmakers would act in the 2013 legislative session to authorize Kansas' participation in the Medicaid expansion.
“If you’re a legislator and the hospitals’ (profit) margins in your district are tied to their DSH (disproportionate share) payments, how do you vote against giving them more patients with insurance through a Medicaid expansion if you know there isn’t going to be anything to replace the DSH payments with?” said Rep. Jim Ward, a Wichita Democrat who serves on the House Health and Services Committee. “At what point does ideology get by the practical reality?”
→ Related story: States balk at expanding Medicaid
In the wake of today's U.S. Supreme Court ruling, Kansas could still avoid ceding total control of its health insurance exchange to the federal government if it moves quickly, Insurance Commissioner Sandy Praeger said.
“That’s probably the best-case scenario now from an exchange standpoint,” Praeger said.
But that would require a meeting of the minds between Praeger and Gov. Sam Brownback and meeting a mid-November deadline for alerting federal officials to the state's intentions.
Last year, Brownback returned a $31.5 million federal grant that would have helped the state develop its own exchange. And today, after the court's decision, the governor vowed he would do nothing to implement the Affordable Care Act's provisions until after the November elections.
“Stopping ObamaCare is now in the hands of the American people," Brownback said. "It begins with electing a new president this fall.”
Opposition from Brownback and Republican legislative leaders resulted in Kansas missing deadlines for establishing its own exchange. Under the federal law, each state must have an operational exchange by Jan. 1, 2014, with plans for it certified by Jan. 1, 2013. States that choose not to implement an exchange on their own would cede that authority to federal officials.
Kansas missed the cutoff for developing its own exchange but could still partner with the federal government on one, an arrangement that Praeger said would allow state officials to set rules for insurance company participation in the online marketplace and direct consumer assistance efforts.
“Plan management and consumer assistance are two functions that our industry and our agent community are most concerned about. So, I think they would like us to retain control,” Praeger said.
Praeger said federal officials have told her that she doesn’t need explicit authorization from Brownback to proceed. She could sign the letter declaring the state’s intention to partner with the federal government on an exchange.
Despite those assurances, Praeger, a moderate Republican who supports the health reform law, said she doesn’t want to circumvent Brownback, a conservative Republican who continues to fight the law.
“Even if I’m allowed to sign the letter, I’m not going to do that unless the governor at least agrees they won’t try to block our efforts,” Praeger said. “After the dust settles, I think we (Praeger and Brownback) will have a conversation and we’ll sort through all of the issues.”
As outlined in the Affordable Care Act, individuals, small-business owners and people whose incomes qualify them for federal subsidies and tax credits would shop for policies using the exchange websites that would help the shoppers sort through coverage and price options. The exchange also could be used to determine eligibility for the Medicaid program, eligibility for which would be expanded under the law where states choose to do so.
→ More in-depth coverage of the Supreme Court's ruling on health reform and its implications for Kansas at khi.org/aca-ruling.
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.
“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.
Or jump to...
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."
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.
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.”
To help Kansans better understand the health reform law, the problems it was intended to address and the issues that prompted Kansas and 25 other states to challenge it in court, the Kansas Health Institute recently talked to several experts. Excerpts from those conversations are featured in this collection of short videos. Each offers an informed perspective on the law and the controversy that surrounds it as the U.S. Supreme Court prepares to rule on its constitutionality this month.
Maynard Oliverius, CEO, Stormont-Vail HealthCare Topeka
Oliverius, a longtime hospital administrator, provides a historical viewpoint on health reform and its ultimate goal of improving access to health care for all Americans. “The Affordable Care Act is really a continuation of a public health policy that was formulated really back in the 1940s,” he says. As part of the health reform law passed in 2010, he says, hospitals agreed to forgo $155 billion in Medicare compensation with the expectation that 32 million Americans who now are uninsured will gain coverage through Medicaid or the insurance exchanges.
Oliverius acknowledges that the health reform law has flaws but says, “What I would hope is that Congress would look at the law, tweak, fix those things that need to be adjusted and fixed, and try to move away from the political ideology war that seems to be going on today.”
This is the first of six short videos. Click here to watch the next video, or jump to others in the series below...
The population of Stevens County is less than 5,800, but its health department has more than 7,000 patients, and it's out of space.
Many of those patients are so-called Low German Mennonites, or Mexican Mennonites, said Paula Rowden, administrator of the health department in the southwest corner of the state. They typically have come to Kansas from Mexico, looking for jobs in agriculture or livestock.
"They seem to be at the greatest risk. They're the ones that are utilizing the emergency room for medical care," Rowden said.
She said the Mennonites present a unique challenge because of their culturally restricted level of education.
"They don't typically educate children beyond sixth grade," Rowden said. "So you talk about people that really have difficulty comprehending complex health issues — this is a group that needs help."
According to a 2007 estimate by the Kansas Statewide Farmworker Health Program, there are likely 3,000 to 5,000 Low German Mennonites in southwest Kansas.
Rowden said what's needed are health education programs that address the education and language barriers. Examples would include classes that explain the importance of being vaccinated or how to manage chronic disease, such as diabetes or hypertension.
However, her 5,000-square-foot facility is out of room. "We certainly don't have enough space to provide all the services we would like to," Rowden said.
But by year's end, the health department will have twice the space thanks to a county-funded renovation project.
New space, more services
The $265,000 project to renovate an 11,000-square-foot building owned by the county is scheduled to start June 1.
The space being renovated for the health department is a soon-to-be-vacated 54-bed nursing home. On May 23, its clients will be moved to a new 80-bed nursing home.
The old nursing home has two wings, one of which is being renovated.
"We need this to capitalize on that prevention and health promotion piece that is so critical in people understanding how to take care of themselves," Rowden said.
Federal officials have not responded to Gov. Sam Brownback’s assertions that his administration is in full compliance with the Americans with Disabilities Act.
But advocates for the physically disabled say the governor’s recent open letter to federal officials asserting his administration is doing enough to help people with physical disabilities live in community settings should not go unchallenged.
“The state’s own numbers don’t support the governor’s position,” said Shannon Jones, executive director of the Statewide Independent Living Council of Kansas. “If you go back three years and look, there were 7,200 (physically disabled) people receiving services. Today there are 6,100. That’s not an increase, it’s a decrease.”
Jones’ group has been at the forefront of the state’s ADA-compliance issue, encouraging hundreds of disabled people to file complaints with federal authorities over a prolonged waiting list for services that has been growing since at least 2008.
Officials at the U.S. Department of Health and Human Services responded to the complaints in 2009 by opening an investigation.
Then last month, Leon Rodriquez, director of the HHS Office of Civil Rights, announced that efforts to get the Brownback administration to reduce the waiting list for home- and community-based services had stalled and that the case had been turned over to the U.S. Department of Justice.
The decision increased the likelihood the state would be sued in federal court, similar to actions that the Justice Department has taken in other states with growing frequency under the administration of President Barack Obama.
Brownback responded to Rodriguez with a public letter expressing disappointment with the agency’s decision.
Underlying the dispute is a 1999 decision in a U.S. Supreme Court case, Olmstead v. L.C., which found that states have an obligation to ensure that Medicaid-funded services for people with physical and mental disabilities are provided in the most integrated settings appropriate to their needs.
Subsequent rulings involving other states have found that stalled or slow-moving waiting lists constitute violations of the ADA, which became national law in 1990 in large part thanks to then-U.S. Sen. Bob Dole of Kansas, who was left disabled for life by serious wounds suffered in World War II.
In his letter to Rodriguez, Brownback, a Republican, argued that his administration had inherited the waiting list from former Gov. Kathleen Sebelius, who in December 2008 “implemented a freeze on new beneficiaries” and in March 2009 amended the policy to allow one person to begin receiving in-home services for every two who exited the program.
Sebelius, a Democrat, left Kansas to become HHS secretary in April 2009.
Brownback noted that in May 2009, HHS informed Sebelius’ successor, then-Gov. Mark Parkinson, also a Democrat, that the agency had started investigating the waiting list complaints.
“Effectively, Secretary Sebelius decided upon joining the Obama Administration that Governor Sebelius and her policies were in violation of federal law,” Brownback wrote.
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.
Proponents in at least 15 states including Kansas are pushing their legislatures to license mid-level dental providers as a way to extend basic oral health care access to thousands who have none.
But those efforts are running up against a common obstacle: opposition from dentists.
Mid-level dental care was the topic today of a panel discussion at the Association of Health Care Journalists' annual conference in Atlanta.
Fear of the unknown is likely behind most dentists' opposition to mid-level providers, said panelist Michael Helgeson, a dentist in Minnesota. Alaska and Minnesota are the only two states that currently license mid-level dental providers.
"I think the fear that dentists have is that (mid-level providers) are going to be independent, they're going to get in deep and try to pull teeth that they're not able and licensed to pull, that they're going to get into lots of trouble. That's the fear that a lot of dentists have," Helgeson said.
He said licensing of mid-level dental providers in Minnesota ensures that doesn't happen. The key is oversight of their work by dentists, he said, which is required by the legislation passed in that state in 2009.
"They're not hanging up their own separate shingle. They don't on the nursing side either," Helgeson said of nurse practitioners, now commonplace in the U.S. since licensing began for them in the 1960s. "You can scour the literature and you won't find stories of people who went in for a throat culture and the nurse practitioner decided to do a tonsillectomy."
In Minnesota, dental therapists are required to have a management agreement with a dentist who oversees their work at remote sites sometimes via video telehealth connections. They are only allowed to practice in state-designated underserved areas, and their scope of work is limited. Further, Helgeson said, the dental therapists receive much of the same training as dentists, taking many classes side-by-side.
"I'm 100 percent confident that our dental therapists at Apple Tree know how far they can go, and when they're in a gray area we have telehealth," said Helgeson, whose nonprofit organization employs two registered dental therapists, as they're called in Minnesota. So far, there are 15 licensed in the state, he said.
Kevin Robertson, chief executive of the Kansas Dental Association, said dentists do not support the mid-level provider model simply because it would lower the standard of care to all patients.
"Why should the U.S. (or) Kansas lower the standard of care for oral care that is the gold standard for the world?" Robertson said.
Dealing with dental deserts
There's little dispute between dentists and advocates for mid-level providers that there is a pressing need to increase access to oral health care in Kansas.
At least 57,000 Kansans live in dental deserts, where there are no dental services and where the closest dental office is at least a half-hour drive from the resident's home, according to a report published last fall by the Kansas Department of Health and Environment and the University of Kansas Medical Center. KDHE officials project that number to increase as more dentists retire.
→ Continue reading at khi.org/midlevels.
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.
The Kansas Department on Aging has put together a list of 800 nursing home residents who officials believe might be able to move to less expensive, less institutional settings.
The agency has asked the state’s Area Agencies on Aging and Centers for Independent Living to have their case managers meet with each of the 800 residents to see if they are able and willing to move.
The effort is part of Aging Secretary Shawn Sullivan's ongoing effort to reduce the number of people in nursing homes. Kansas, with its disproportionately elderly population, has a higher percentage of people in full-care nursing homes than all but a handful of other states.
KDoA officials have pledged to pay the case manager’s employer $2,000 for each Medicaid-funded nursing home resident who is able to move out of the nursing home and stay out for at least 90 days.
KDoA Secretary Shawn Sullivan said the payments were designed to offset some of the uncompensated case management costs that hamstrung earlier efforts to reduce the state’s nursing home population.
But the notion of rewarding someone for helping people move out of nursing homes has upset the state’s nursing home lobby.
“It’s a bounty. There’s no other word for it,” said Cindy Luxem, executive director of the Kansas Health Care Association, which represents most of the state’s for-profit nursing homes. “If a nursing home paid a case manager a bonus for every resident they got to move there from another nursing home – that’s a felony,” Luxem said. “It’s illegal, but here we have the state paying bonuses to case managers who are essentially doing the same thing. They’re being rewarded for getting people to move out.”
She also said it seemed unfair that nursing homes aren’t paid $2,000 when their social workers help residents return home or move to community-based settings.
“For us, this is just beyond belief,” Luxem said of the agency’s new policy.
But Sullivan said the nursing home industry was mischaracterizing the payments, which have not started because the policy is so new.
“It’s not a bounty,” Sullivan said. “It’s an attempt to cover some of the administrative costs that haven’t been covered in the past.”
In recent years, KDoA stopped reimbursing Agencies on Aging for their case managers’ mileage and travel time.
The Kansas Department of Social and Rehabilitation Services has never covered the so-called “windshield time” incurred by case managers with the Centers for Independent Living.
Nor does either of the state agencies cover the costs of required training for the case managers.
The Area Agencies on Aging and Centers for Independent Living are the local agencies charged with assessing current or potential nursing home residents to determine what level of assistance each may need.
More independence, less cost
Sullivan said no one who’s living in a nursing home would be forced to move as a result of the new policy.
The initiative, he said, is designed to give the 800 residents and their family members information on services that could be made available to them in their communities. The result could be more independence for the beneficiaries and their families, and savings for the Medicaid program.
Sullivan said the $2,000 payments would be state-funded and come from the department’s administrative budget. Each payment will be made in three installments.