The head of the state agency that oversees programs for the developmentally disabled has outlined steps the state will take to assure payments aren't delayed to providers of DD services, if federal officials approve the state's request to include all DD services in KanCare starting next year.
But advocates for the developmentally disabled said the safeguards, described to them in private meetings earlier this week, failed to allay their concerns and instead signaled that administration officials anticipate significant billing problems similar to those experienced by other Medicaid providers after the first phase of KanCare was launched at the beginning of 2013.
"I do believe it's a sincere effort on the part of the state to understand why their contractors can't get their bills paid...but I guess it's part of an all-hands-on-deck strategy since this thing is not working the way they thought it would," said Tom Laing, executive director of Interhab, the association that represents most of the state's 27 Community Developmental Disability Organizations.
Interhab has fought the administration's effort to pull long-term residential services for the developmentally disabled into KanCare, one of the signature initiatives of Gov. Sam Brownback.
KanCare was launched Jan. 1 this year when virtually all the state's 380,000 Medicaid beneficiaries were assigned to managed care plans run by three commercial insurance companies.
Long-term services for the developmentally disabled were excluded from the program in its initial phase after protests from DD advocates and families, but standard medical services for the developmentally disabled have been in KanCare from the outset.
Brownback officials earlier this year submitted a request to federal officials seeking to add the long-term DD services to the program beginning Jan. 1, but federal officials still haven't ruled on the proposal. Public comment on the plan continues through Dec. 24 and no decision from the Centers for Medicare and Medicaid Services is expected before then, which means if approval comes it will only be days or less before the state's planned launch of its expansion.
Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services, also outlined the additional billing safeguards the state is preparing to use today during a public meeting of the KanCare Advisory Council, a reorganized group that last met in May.
Sullivan said the KanCare managed care companies were "putting billing edits in their systems to be ready for Jan. 1," and that the state was devising a monitoring system that would allow state officials to know quickly if payments by the KanCare contractors to some 400 DD service providers dipped significantly below sums historically paid the organizations.
"We are in the process of uploading each provider's average monthly payments from over the last couple of quarters," Sullivan said.
He said state officials could then work with the providers and the KanCare managed care companies to quickly determine the reasons for payment drop-offs should they occur.
Final documentation on the safeguard and flagging processes to be used should be completed within a couple of days, Sullivan said, once state officials have finalized the details with the managed care companies.
The state has been working the past few months with DD service providers in an effort to test the MCO billing systems prior to the tentatively planned Jan. 1 launch of the KanCare expansion.
But all involved with that pilot, or transition program, have acknowledged glitches or problems with the billing of the sort that have been a source of consternation for a wide variety of the service providers pulled into KanCare in its initial phase.
Pharmacists, hospitals, safety net clinics, nursing homes and others have all complained at some point over the past few months about stalled or delayed payments from the KanCare insurance companies. The delays fall particularly hard on smaller organizations that operate on thin margins and without large cash reserves.
Earlier this year, the managed care companies cut "emergency" checks to some of the state's safety net clinics after clinic officials complained to state officials that payment for services was lagging and jeopardizing their operations.
Laing said Sullivan had discussed the possibility of "pre-payments" to DD service providers as a way to assure they would continue to have enough operating cash, but he said it wasn't clear how or if that could be done.
"I can say he articulated several different things they will try to do to make sure the billing flows, which is a clear signal they anticipate the billing issues won't be resolved by January," Laing said.
ACCSES weighs in
Also today, ACCSES, a national association of disability service providers, filed comments with federal officials asking them to deny Kansas' request to include long-term DD services in KanCare.
"We oppose the carving of (the) services into KanCare because we believe that, as proposed, the changes threaten the ability of the LTSS (long-term service and support) system to maintain access to the services and programs for Kansans with intellectual and developmental disabilities," wrote Terry Farmer, the group's chief executive.
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.
Kansas Medicaid officials are preparing for a new phase of KanCare that will target services to the seriously mentally ill.
They will be using a “health home” model that appears to be producing good — though preliminary — results in other states and which will allow Kansas to draw additional federal aid dollars as part of the Affordable Care Act.
Among the goals of federal and state officials in using the model is to reduce emergency room visits and hospital readmissions among Medicaid enrollees.
The Kansas Medicaid program — which was rebranded as KanCare at the beginning of 2013 when virtually all 380,000 enrollees were moved into commercially run managed care plans — is scheduled to begin health home efforts on Jan. 1, 2014, and will direct them at about 36,000 of the state’s seriously mentally ill, though participation is voluntary.
A health home is not so much a place as it is a concept of care delivery built on close coordination among a patient’s various medical providers so that health crises can be prevented or minimized through better management of a person’s conditions.
The mentally ill are disproportionately likely to also suffer other chronic conditions.
“They (federal Medicaid officials) expect fewer emergency room visits, fewer readmissions to inpatient settings and, of course, they also want to see lower costs,” said Becky Ross, Medicaid initiatives director at the Kansas Department of Health and Environment, the state’s chief Medicaid agency. “There are some things they will require all states to measure and then we have some additional things we’ll be measuring.”
Kansas officials are in the process of developing a state Medicaid plan amendment, which Ross said they would formally submit to federal authorities in October after earlier submission of a draft document. And they plan to consult with federal mental health officials on the plan before Aug. 2, Ross said.
Work on the Kansas health home initiative began in April 2012, when a team of state officials began meeting about it. That quickly grew to include a “focus group” of about 70 people who work with the Medicaid program as providers or as association representatives.
And Tuesday, at least 200 people are expected for a forum in Topeka where Ross said state officials hope to collect additional information from potential health home providers so that finishing touches can be put to the state’s plan amendment. An earlier forum was held in April and Ross said Tuesday’s gathering would be the final one.
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.
Gov. Sam Brownback’s Medicaid makeover has been putting a financial squeeze on small Kansas pharmacists and spokespersons for the hometown druggists are calling for the administration to enforce the terms of its contracts with the three KanCare managed care companies.
“I think the simple answer is for the State of Kansas to make sure the MCOs (KanCare managed care companies) are living by their signed contracts and that should have been ready to go Jan. 1 (when KanCare was launched),” said Mike Larkin, executive director of the Kansas Pharmacists Association.
“We understand there will be bumps and hiccups in the implementation of a new program, but I can't help but think that if the shoe was on the other foot and they (the MCOs) were losing money instead of making money, they would have been on this (problem) a lot quicker,” he said.
Pharmacists say the heart of the issue is that the KanCare companies — Amerigroup, UnitedHealthcare and Sunflower State Health Plan — often fail to reimburse the druggists for the costs they incur serving Medicaid enrollees.
“I guess the bottom line is that we were led to believe in the first year (of KanCare) that there would be no changes on reimbursement or anything,” said Ron Booth, owner of the Corner Pharmacy in Leavenworth. “But you see, these (KanCare MCOs) are for-profit companies. They are changing all the rules and no one in Topeka is holding them accountable. I'm speaking out of frustration as a small, locally owned pharmacy. I want to be treated fairly.”
The pharmacists, before and after KanCare, work from rate sheets that list the maximum they will be reimbursed by Medicaid for each of the long list of medications they dispense.
But here is what changed with KanCare, according to pharmacists and others familiar with the business: In the past, the state kept a single list or rate sheet of “maximum allowable costs” and when its reimbursement rates failed to cover a druggists’ costs, it was more or less routine for the pharmacist to appeal and have the rate revised upward. The druggists could then resubmit those claims to the state and be paid enough that they weren’t losing money on the transactions.
With KanCare, each of the state’s contractors — or rather their pharmacy subcontractors — keeps a separate rate sheet, the formulation of which is considered proprietary. Booth and others said getting prices adjusted by the MCOs, so that the pharmacists aren’t losing money on many of their Medicaid claims, has largely been an exercise in futility. And they also are frustrated that they can’t get access to the methods the MCOs use for calculating their reimbursement rates, something obliged of them in their contracts with the state.
Customers turned away
Booth’s pharmacy, which was established in 1871, still has a soda fountain and other small-town amenities of a largely bygone era. It is a hub of activity in the middle of Leavenworth’s historic downtown district and Booth is a proprietor clinging to and clearly relishing his role in the vanishing tradition of local merchant as “pillar of the community,” in daily contact with his customers and their concerns.
Booth said since KanCare started he has served hundreds of his customers at a loss and turned away more than that because he could no longer afford to fill their prescriptions. And he said he has not had a single appeal approved or adjusted upward by any of the KanCare companies since the program started six months ago. He gets form-letter denials, he said, and little or no understanding from the KanCare customer service reps when he calls to complain or ask for assistance.
“My problem is I'm dealing with real people in front of me at the counter,” he said. “They are my friends and neighbors. I actually care about them.”
Reviewing the appeals data
State officials said they were aware of the pharmacists’ concerns with reimbursements (outlined in a May letter from Larkin to KDHE) and were looking into them.
“KDHE has heard provider concerns that fewer MAC (maximum allowable cost) appeals are being approved in KanCare than in fee-for-service Medicaid,” said Kari Bruffett, director of KDHE’s Division of Health Care Finance. “KDHE is in the process of reviewing both KanCare MAC appeals data in aggregate and a sample of denied appeals to ensure compliance with our expectations.”
Meanwhile, Bruffett said, the state’s overall pharmacy spending was up from last year.
“Through the first five full months, overall pharmacy reimbursement is running about 8 percent ahead of the same time period in 2012,” she said in an email to KHI News Service.
“Someone probably is benefiting,” from KanCare, Booth said, but it hasn’t been him.
In fact, you probably shouldn’t get him talking about it unless you have some time to listen.
“At first, we were just absorbing the cost. But I decided I'm not going to do it anymore,” he said. “I'm going to be the squeaky wheel. Someone's got to stand up. I don’t want to subsidize these big MCOs that make millions each year. I work about 70 hours a week. I’m fighting for my life everyday. The big boys don’t need me. They don’t need Ron Booth who gets up in the middle of the night for his patients, sees them at Rotary, sees them at church, goes to the ballgames. I’m part of this community and unfortunately I have a conscience.”
Medicaid services for the disabled in Kansas have been undergoing dramatic changes in the past 18 months and in response many smaller providers of so-called “payroll agent” or “financial management services” for disabled persons who prefer to hire their own care attendants are either changing their business models or simply going out of business.
Some in the business predict major consolidations. Instead of dozens of small firms dotting the landscape, they foresee perhaps four or five large ones.
“There will just be less options for people. More consolidation. The bigger you are, the more likely you are to make a profit on FMS (financial management services),” said Scott Criqui, executive director of Trinity In-Home Care in Lawrence.
Trinity has been in business since 1976. But effective this month, it no longer will provide the administrative services it has offered clients who prefer to “self-direct” their personal care attendants.
Criqui said the nonprofit agency’s decision to stop providing the services was the result of state policy and reimbursement changes that began in November 2011.
“The reimbursement level for FMS is so low we're no longer going to be providing that service,” Criqui said.
For almost 20 years, disabled Kansans who rely on Medicaid for services that allow them to live at home and avoid having to move to a nursing home have had the choice of hiring their own attendants, which is called “self-directed care,” or using those provided by an agency – “agency-directed care.”
'Taken apart piece by piece'
Because personal care workers often provide a number of intimate needs such as helping with bathing, grooming and toileting, many disabled persons or their families have preferred the self-directed option instead of relying upon a person sent by an agency.
But to do that, they need the help of a “payroll agent” to process the timesheets and payments for the personal care attendant.
Now, it seems, many of the state’s 62 payroll agents are shutting their doors or concentrating on other types of services.
Doug Gerdel runs Life Patterns, a Topeka-based agency that serves about 400 self-direct customers in the eastern half of the state,
Historically, Gerdel said, Kansas had “always been way ahead of other states in terms of in-home supports and we were one of the very first states – back in the 1980s – to offer self-directed care.”
But that’s been changing as a result of the new policies.
“People can still self-direct,” he said. “But here in the last 18 months, you can see how that’s being taken apart, piece by piece.”
State officials said despite the changes they think there are enough payroll agent businesses to serve the state’s disabled.
“We currently have more than 60 FMS (Financial Management Service) providers in Kansas, and believe that represents an ample number of choices for consumers,” said Angela de Rocha of the Kansas Department for Aging and Disability Services. “The number of FMS providers fluctuates a bit every month. If there is an apparent consolidation, we are not seeing it yet. We would not be surprised to see some consolidation, but do not at this time anticipate anything too drastic. KDADS has no set optimal number of FMS providers.”
Some agencies, like Trinity in Lawrence, will continue to provide other services. But the agency has already notified more than 90 clients that it no longer will provide payroll agent services.
“It meant I had to quickly find a new payroll agent for my children,” said Shannon Graham, a Lawrence mother who adopted four significantly disabled children and relies on between eight and 10 personal care attendants and nurses to assist her with them. “I think it’s tough on everybody. The people who work and support my children in my home have to be rehired through a different agency.”
Graham said she would now rely on an agency in Olathe, Helpers Inc., for financial services.
KDADS officials said they had “seen no reports on the number of (Medicaid) waiver participants who are shifting agencies in order to continue to self-direct their services.”
'Change, change, change'
Anne Cousin is chief executive at Helpers Inc., which has more than 650 payroll-agent customers across the state. It is one of the larger operators.
“We intend to stay in business,” she said. “But we’re having to work harder than we’ve ever had to work just to stay on top of all the changes that are going on. Everything is change, change, change.”
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.
Advocates for the developmentally disabled held a Statehouse press conference today to praise Gov. Sam Brownback's plan to reduce by 600 the number of disabled Kansans awaiting home- and community-based Medicaid services.
"We think this is a great move by the governor," said Tim Wood, campaign manager for End the Wait, a group pushing for elimination of the waiting lists. "This is a good step in the right direction."
Wood and fellow advocates also urged the Legislature to consider developing a plan to fully eliminate the waiting lists, which have grown over the past decade to include more than 5,000 people with physical or developmental disabilities. About another 1,200 people with developmental disabilities are receiving some of the services but waiting for more.
The governor last week released a budget amendment asking the Legislature to spend an additional $18.5 million to reduce the waiting lists. The recommendation came after state budget forecasters concluded that state spending on Medicaid services would be about $98 million less than previously expected for the fiscal year that ends June 30, including about $37.6 million from the State General Fund.
The governor characterized the reduced costs as "dividends" from the enactment of KanCare, the initiative he launched Jan. 1 that expanded managed care in the state Medicaid system. State budget analysts attributed much of the foregone spending to fewer people receiving Medicaid services. When federal officials approved the administration's KanCare plan, one of the "special terms" of the agreement was that if money were saved, some of it would be used to reduce the waiting lists.
Wood said he and other advocates also would urge lawmakers to aim for equal reductions in the lists for the physically disabled and the developmentally disabled. The governor proposed that the money be split evenly between the two waiting lists but because the cost of caring for the developmentally disabled is higher on average, fewer people could be served.
Wood said ideally that 300 people would come off each the two lists rather than 400 off the physically disabled list and 200 off the developmental disability list.
"While we appreciate the need to bring all people off the waiting lists," he said, "we want the Legislatuare to consider a fair and equitable way to divvy up the dividends."
In related news, spokesmen for Interhab, a group that represents most of the state's Community Developmental Disability Organizations, said more than 1,000 people had signed up to attend a rally scheduled for Wednesday at the Statehouse to urge legislators to exclude long-term DD supports from inclusion in KanCare.
The following video was produced to present to Kansas legislators by the advocacy group End The Wait, which is funded by the Kansas Council on Developmental Disabilities.
People involved with Medicaid services for children say they are hopeful the state’s new KanCare program will someday lead to improved services and health outcomes.
But for now, they report dealing with some of the same problems and frustrations others in the program, which also serves the poor elderly and disabled, have experienced since its launch on Jan. 1: Billing problems, payment delays, concerns about patient access to care and increased administrative complexity.
“There are a lot of bumps in the road; we'll put it that way,” said Dr. Melinda Miner, a Hays Dentist who along with her husband, Dr. Daniel Miner, is one of the leading Medicaid dental providers in her part of the state.
Miner said her clinic just recently began receiving payments for services earlier this year from the KanCare managed care companies and that other dental providers she knows have had the same problem.
“We still have a lot of outstanding claims,” she said. “We never had problems like this when the state ran the program (using two managed care companies). That was the best thing about HealthWave, claims got paid in a timely manner. You didn’t have to worry about them. I think they have that under control now, or at least they’re working hard on it.”
Other Medicaid providers for children also described problems when interviewed by KHI News Service.
“From a provider perspective, it’s been kind of frustrating,” said Dr. Dennis Cooley, a Topeka pediatrician who sees a large number of Medicaid patients, “mostly from dealing with three, brand new MCOs (managed care companies) and each one has their own set of rules.”
'A lot of difficulties'
Cooley, like others dealing with the new system, said “we’ve had a lot of difficulties with prior authorizations,” which are the approvals for payment required from the state’s KanCare contractors before services can be delivered to a patient. “We’ve had difficulty, I think, in getting our patients some of the services, especially like with pharmacy and what meds (the MCOs) are covering. I know at least in our practice it’s been very frustrating and that’s what I’ve heard in talking with other providers, too.”
Cooley said his practice “had good rapport” working with the state’s prior HealthWave managed care companies and that “time would tell,” if the same sort of relationships would develop with the new KanCare contractors: Amerigroup, UnitedHealthcare and Sunflower State Health Plan a subsidiary of Centene.
And here’s an assessment of KanCare’s progress from Tribune, a small town near the Colorado border.
“It’s going OK, we’re just butting up against some billing issues,” said Bonnie Mote, who handles the billing for Greeley County Health Services, a rural health clinic once directed by Dr. Robert Moser, currently secretary of the Kansas Department of Health and Environment, the state’s lead Medicaid agency.
Mote said she thought services for patients had been unaffected by KanCare and that the claims and billing problems would soon be sorted out.
“Dr. Moser contacted us and said they (KDHE) would be contacting the MCOs,” she said.
KanCare moved virtually all the state’s 380,000 Medicaid enrollees into managed care plans run by for-profit insurance companies. But even before the program makeover, the large majority of beneficiaries — more than 280,000 — were children covered by what was then known as HealthWave.
Push is again coming to shove in the struggle over whether the long-term care and support services received by Kansans with developmental disabilities will become part of KanCare or remain outside the control of the private companies hired by the state to manage the Medicaid program.
Advocates pushing for a permanent “carve out” of developmental disability services have circled May 8 on their calendars. That’s the day that the Kansas Legislature is scheduled to return to Topeka to wrap up its 2013 session.
“When you show up in numbers, it makes a difference in the legislative process,” said advocate Tom Laing, speaking last week to approximately 175 parents and advocates at a meeting sponsored by Johnson County Developmental Services.
“A lot of times when politicians do the wrong thing it’s because they haven’t heard from the folks who are the most impacted. If they don’t hear from you, we can’t succeed,” said Laing, executive director of Interhab, an association that represents most of the state's Community Developmental Disability Organizations.
Laing and other advocates said they are hoping that thousands of Kansans with developmental disabilities would turn out with their parents and guardians for a rally on the south steps of the Statehouse and to meet individually with legislators to make their case.
“I’m not a guy who believes in pitch forks and torches. We need to be persuasive, not abrasive,” Laing said.
'Carve in' date approaching
Medical services for the developmentally disabled already are part of KanCare, the reform initiative launched on Jan. 1 by Gov. Sam Brownback. It moved virtually all of the state’s 380,000 Medicaid beneficiaries into managed care plans run by three insurance companies: Amerigroup, United Healthcare and Sunflower State Health Plan, a subsidiary of Centene.
But yielding to pressure from advocates and service providers, the governor and legislators agreed last year to delay the inclusion of long-term, DD support services for a year — until Jan. 1, 2014. With the “carve in” date approaching, advocates are pressing their case again.
“We have to keep these services out of the hands of the profiteers,” said Bridget Murphy, director of the Downs Syndrome Guild of Greater Kansas City.
'Misinformation' fueling concerns
Murphy’s concern that the for-profit managed care companies will disrupt services now generally provided by a network of community-based, non-profit organizations is shared by many parents and advocates.
That frustrates Shawn Sullivan, the secretary of the Kansas Department of Aging and Disability Services, who has spent more than a year meeting with stakeholders to convince them they have nothing to fear from the new managed-care system.
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.
While acknowledging “bumps in the road,” state officials for several weeks have been saying that the launch of KanCare, the state’s new Medicaid program, has been going better than they expected.
But people who work at some of the clinics that specialize in treating poor and uninsured Kansans describe it differently. They say the transition, now entering its third month, has been an ordeal for them and that some of the problems are compromising patient care.
“I went through the tornado in Joplin (in May 2011) and survived,” said Lori Lowrey, chief revenue officer for the Community Health Clinic of Southeast Kansas. “I would equate the anxiety of KanCare with the anxiety I felt following that event. It’s just been an inferno everyday. When you walk through the door, you’re greeted by staff frustrated at every level...nurses, administrators, patients and then trying to communicate with the (KanCare companies) and their contractors, it’s just very taxing. I just don't feel like it’s been accurately portrayed by the people at the state level or the MCOS (managed care companies). It’s been a road full of potholes. It’s not been a few bumps.”
The clinic here serves about 29,000 people a year at its eight sites scattered across the corner of Kansas that generally ranks as the state’s poorest and least healthy. That makes is a key medical provider, particularly when it comes to primary care for the poor. About 35 percent of its patients are on Medicaid, according to clinic officials.
State and KanCare company officials acknowledge there have been problems at the safety net clinics and more so at some of the 16 that are designated as Federally Qualified Health Centers, which includes the Community Health Clinic of Southeast Kansas. The FQHCs together have more than 20 satellite clinics scattered across the state and collectively serve many thousands of the state’s poorer families.
A special meeting that included clinic directors, state officials and KanCare contractors was held privately two weeks ago in Topeka to discuss the situation.
An “issues log” of 86 problems submitted by the clinics to the Kansas Association for the Medically Underserved (KAMU), a group that represents the safety net clinics, was presented at the meeting.
Among the problems cited:
Delayed or stalled payments from the KanCare companies,
Poor communication and misinformation
Troubles getting clinic doctors and other providers included in the KanCare provider networks and patients properly assigned.
Difficulty getting treatments or medications approved for patients.
The list was similar to but longer than the problem tally submitted to state officials a week earlier by the Kansas Medical Society and the Kansas Medical Group Management Association along with a letter asking the state to extend the KanCare transition period to allow more time for smoothing things out.
Kari Bruffett, the director of the Division of Health Care Finance at the Kansas Department of Health and Environment, has been the point person for the administration of Gov. Sam Brownback on much of the KanCare implementation.
Bruffett said state officials determined from the meeting with clinic officials “that while there were some crosscutting issues, there were a lot of issues specific to the individual (clinics), so what we asked the managed care organizations to do with those (clinics) was to work with them individually and basically keep us posted.”
She said she had been assured that many of the problems raised at the meeting were being dealt with and that the chief executives of the KanCare companies have been responsive whenever concerns were brought to their attention.
One result of the meeting, according to some who attended, was an agreement by at least two of the KanCare companies to make “advance payments” to clinics that asked for them to help deal with their cash-flow problems.
“I know of at least one (KanCare MCO) that is in the process of sending out advance payments,” said Cathy Harding, executive director of KAMU, “and another said they would do the same thing.”
She said she expected the third company also would agree to advance or expedited payments.
But in a series of interviews late last week with the KHI News Service, clinic directors from across the state give KanCare what could at best be described as mixed reviews. And those unhappy with the way KanCare is rolling out said they had seen little or no improvement as a result of the meeting.
“In our opinion, it’s kind of going from bad to worse,” said Krista Postai, executive director of the Community Health Clinic of Southeast Kansas. “I have nurses now spending all day on the phone trying to get pre-approvals (for patient medications from the KanCare insurance companies or their subcontractors) and not getting them. A lot of my providers have been doing this for years and they never had anything this absurd on pre-authorizations. I understand that is meant to control costs…but this is costing us a fortune.”
One of the state’s largest assisted-living chains has curtailed its participation in the Kansas Medicaid program.
“Of our 18 facilities, 15 are no longer taking any new Medicaid clients,” said Denise German, senior vice president of Vintage Park, which is headquartered here.
The decision, German said, was driven by a 2012 reduction in Medicaid reimbursements and by concerns that payments would be cut more under KanCare. The three Vintage Park facilities that still accept Medicaid clients are in towns with no other facilities. The company’s local administrators there chose to continue so there would be local options for residents.
KanCare is the name for Gov. Sam Brownback’s Medicaid makeover initiative, which involved the hiring of three managed care companies to run day-to-day operations of the state’s $3.2 billion Medicaid program. The KanCare companies are Amerigroup, UnitedHealthcare and Sunflower State Health Plan, a subsidiary of Centene.
The companies took over Jan. 1.
Looking to cut costs
“These are for-profit companies. We know they’re going to be looking for ways to cut costs and since reimbursement is very minimal already, we’ve elected not to continue to participate in the program,” German said.
Vintage Park began changing its policy a few months after Brownback first announced his KanCare plan in November 2011. Its individual Kansas facilities began making the changes more or less at their own pace. The result has been a major reduction in the number of Medicaid residents. Before this year, German said, Vintage Park facilities in Kansas had been admitting about 100 Medicaid residents annually.
“A year ago, we probably had 250 Medicaid residents in 18 facilities,” she said. “Now, I’d say we’re down to about 120.”
The company, she said, has been doing “fine” without new Medicaid admissions.
Vintage Park won’t ask private-pay residents to leave if they deplete their life savings and end up on Medicaid, she said. But the 15 facilities no longer admit residents already on Medicaid.
Vintage Park is a for-profit company. Most of its facilities are in small and mid-size towns in the eastern third of the state. All 18 facilities passed state inspections the last two years with no deficiencies noted, which generally is taken as an indication of well-run operations.
Not identified as a problem
It’s not clear whether other companies are following Vintage Park’s lead. State officials said they were unaware of the company’s decision and hadn’t seen evidence of a problem.
“We have not heard that assisted living facilities are declining to admit residents who are on Medicaid,” said Angela de Rocha, a spokesperson for the Kansas Department for Aging and Disability Services.
“Assisted living facilities’ refusal to accept residents who are on Medicaid has not been identified as a problem at this point,” she said. “And it is in the financial interest of the (KanCare managed care companies) to keep their members in a community setting instead of admitting them to nursing homes.”
An assisted living facility is considered a community setting.
Others in the industry said they knew too well the pressures cited by Vintage Park officials.
“Our company continues to accept Medicaid,” said Steven Hatlestad, vice president of skilled nursing operations at Americare, another for-profit chain with operations in several states that has 11 nursing homes and six assisted living facilities in Kansas. “But I do not believe that what Vintage Park is doing makes it an outlier. I’m afraid we’ve reached a point where some companies — some really good companies — just can’t afford to do Medicaid anymore.”
Ray Vernon runs Wesley Towers, a large retirement community in Hutchinson that offers in-home care, independent living, congregate living, skilled nursing care, and assisted living. It is a subsidiary of the Kansas West Conference of the United Methodist Church.
Vernon said while reimbursement rates are an issue, his facility won’t refuse to accept residents because they are on Medicaid.
“That would go against our mission,” he said. “But I have to say there’s some validity to what Vintage Park is saying because, in reality, (Medicaid) reimbursement has been flat for quite some time and healthcare inflation runs about twice what it is for the economy at large.”
Jim Klausman, chief executive at Midwest Health, a for-profit operation active in four states and with 24 nursing homes and 11 assisted living facilities in Kansas, said the company shares Vintage Park’s concerns but has a different strategy.
“We understand — and we share — some of the frustrations being expressed by Vintage Park, but we think we have a better shot at changing the system from within rather than pulling out,” he said.
Midwest Health’s nursing homes have signed contracts with all three KanCare companies, he said. But Midwest chose to sign an assisted-living contract with only one: Sunflower State Health Plan.
“We’re still taking Medicaid,” for assisted living, he said, “but you’ll need to be on Sunflower.”
The decision to only sign with one KanCare plan, Klausman said, was meant to strengthen Midwest’s bargaining position.
“We’d rather negotiate with one company than three,” he said.
‘Uncertainty over reimbursement’
Debra Zehr, chief executive with LeadingAge Kansas, a trade group, keeps close tabs on the state’s nonprofit assisted living facilities.
“There’s a lot of uncertainty over reimbursement and the administrative costs that come with having to deal with three payers — the (KanCare) managed care companies — instead of one,” she said. “I don’t know of anybody who thinks they’re breaking even on Medicaid. It’s more of a community service than anything else. You do it because it’s the right thing to do.”
After months of advisory committee haggling over what it should look like, state officials say they are ready to launch the pilot program that will pave the way for including long-term services for the developmentally disabled in the new KanCare program.
Now, all they need to start the pilot are participants.
A recruiting letter went out Friday, seeking organizations and individuals willing to volunteer, but representatives from the state’s developmental disability organizations said doubts remain strong among their members about the pilot in particular and KanCare in general. It seems that nobody, including administration officials, expects a throng of eager participants.
“The advisory committee talked about really wanting, hoping to have a broad representation of providers (in the pilot), including different types of providers,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “I don't know that it’s necessarily as important to have numbers as it is to have different types. I’m hoping to have five providers, at least.”
The administration of Gov. Sam Brownback originally sought to have long-term services for the developmentally disabled included in KanCare when the managed-care program was launched Jan. 1. But groups, including parents, that represent the developmentally disabled, persuaded legislators to postpone that for a year.
KanCare is the governor’s ongoing remake of the state Medicaid program. Since it was launched a few weeks ago, virtually all the state’s 380,000 Medicaid enrollees have been assigned to health plans run by three commercial insurance companies.
The same legislative proviso that delayed the administration’s push to roll long-term developmental disability services into KanCare also called for the pilot program. But disagreement between the administration and advocates for the disabled over what the pilot should try to gauge or accomplish went on for months after the 2012 Legislature adjourned and still hasn’t been fully resolved.
What kind of pilot?
Advocates for the developmentally disabled said they wanted a pilot that would test the administration’s still-unproven theory that the KanCare insurance companies could effectively manage long-term or “non-medical” developmental disability services, producing healthier customers while cutting government costs yet presumably earning profits.
That ambitious set of pledges is something that hasn’t been solidly demonstrated anywhere in the country and sounds “too good to be true,” as Maury Thompson, former director of Johnson County Developmental Supports.
There have been plenty of problems and frustrations. No one denies it.
But as Gov. Sam Brownback’s Medicaid makeover entered its fourth week, administration officials, some legislators and a variety of others involved with KanCare said they thought the massive changes underway in the $3.2 billion program so far have gone smoother than many expected.
KanCare, which launched Jan. 1, moved virtually all the state’s 380,000 Medicaid enrollees into health plans run by three of the nation’s largest managed-care companies: United HealthCare, Amerigroup and Sunflower State Health Plan, a subsidiary of Centene.
“I think we’re in the growing-pains phase,” said Mike Larkin, executive director of the Kansas Pharmacists Association, which months ago began preparing its members for the changes. “Some of our members are getting different answers on things, depending on who they call.”
Because people tend to see their pharmacists more often than other medical providers, pharmacies were among the first to file claims and otherwise deal directly with the new system.
Larkin said he expected to be “inundated” with calls from members dealing with KanCare problems the first week of January.
“I was pleasantly surprised that I wasn’t,” he said. “I think we were more prepared than maybe some other folks for the things that are coming down. There are some stipulations of the contract that the state signed with the MCOs (managed care organizations) that we’re still waiting to see fruition on…but as far as the pharmacies go, there are some frustrations but for the most part, I suppose it could be worse.
“I’m looking at mid-February. I was talking with a legislator and we agreed that if Feb. 15 comes and some things haven’t settled down, then we’ve probably got a problem,” Larkin said.
State officials anticipated there would be difficulties during the transition and took some steps to ease them.
First 90 days
For the first 90 days of KanCare — and in some instances longer — the state is requiring the insurance companies to comply with previously established "plans of care" for Medicaid clients in order to minimize disruptions to the patient's usual or expected services.
Also for the first 90 days, the state is requiring the companies to reimburse Medicaid services given by any medical provider regardless whether the provider has signed a contract joining the companies' service networks.
As the program's launch date approached, state and MCO officials began holding daily 9 a.m. teleconferences with Medicaid providers and beneficiaries to help troubleshoot problems as they arose.
State and insurance company officials answer questions from callers, make note of problems and sometimes post them to their respective online “issues logs," though state officials concede many problems marked "resolved" on the the logs have simply been brought to the attention of someone to work on, rather than fixed.
The most frequent, single response to callers during the daily calls has been “can we get back to you on that?” or words to that affect. But many callers also seem to go away satisfied with the answers they get.
One of those who called in recently was Vicki DeStefano of Fairway. She telephoned on behalf of her 53-year-old brother, Mike, who receives Medicaid-funded assistance after suffering a serious brain injury in a 2006 motorcycle accident that left him mostly unable to move or speak and eating through a tube.
He needs attention around the clock, she told KHI News Service in a later telephone interview, and before November there were six people being paid, not including her, to help care for him at different times of the day or week.
Now there is only one person to help her with her brother. The others left because they stopped getting paid. DeStefano said she is paying the remaining person out of her own pocket because some things she simply cannot do by herself.
She said the agency that handled the payments to the workers told her they weren’t getting reimbursed by the managed care companies. But DeStefano said she was more upset with the intermediary Financial Management Services (FMS) agency (commonly referred to as a “payroll agent”) than she was with United HealthCare, because the company seemed to be trying harder to help her and her brother.
She said her prior experiences with state officials and a succession of its contracting payroll agents had left her exhausted, frustrated and ready for any kind of change in the system.
“We really needed a change,” she said. “Whenever you have the government doing something, it’s a mess. I think we need a change, I just don’t think they did the research to make it go right…The state just dumped it on to all these MCOs and didn’t do anything to help them.”
DeStefano said she was alarmed by how unprepared many of the MCO employees seemed to be, but she said she expected things would only get better. She said she was impressed that the day after she called in to complain about her problems, a United representative called on her to see about fixing them.
Her problems weren’t resolved yet, she said, “but even when they can’t resolve it right away, they’re trying.”
She said she never got quick responses from the state, so the new attention from the MCO was welcome.
Cathy Harding is executive director of the Kansas Association for the Medically Underserved, which represents the state’s safety-net clinics. She also said she was pleased by the responsiveness of the MCOs.
“I think most people expected it wouldn’t be possible to implement a huge program like this without bumps in the road,” Harding said. “The thing I was concerned with (going in) was how responsive would the MCOs be when we bring them problems. In that regard, we have been extremely pleased. All three MCOs, when we bring things to their attention they have literally jumped right on it.”
Harding said there were ongoing transitional problems but that she expected things could be running smoothly within three months.
“This is a guess on my part,” she said, “but given how things are working at this point in terms of addressing issues, I’d be a little surprised if we don’t have all these kinks worked out in three months. Three months for a program of this size is certainly not bad. We’ll see.”
Among the frequent complaints or questions from Medicaid providers during the state’s daily teleconferences have been those about claims rejections or delays in payment from the MCOs.
A week into major changes of the Kansas Medicaid program questions persist about whether a new consumer advocate will have the freedom and the resources to do his job.
Lawrence attorney James Bart was recently hired as the ombudsman for the new KanCare program being implemented by Republican Gov. Sam Brownback. Officials say the Jan. 1 expansion of managed care to include virtually all the state’s Medicaid enrollees is intended to slow the growth in Medicaid costs and improve the care provided to the more than 380,000 low-income, elderly and disabled Kansans in the program.
But some legislators and consumer advocates are questioning whether housing the ombudsman’s office in one of the state agencies responsible for KanCare implementation will hinder Bart’s effectiveness. They also question whether he will have sufficient resources to handle what could initially be large numbers of consumer complaints with the new system.
Bart, the only full-time employee in his office at the Kansas Department for Aging and Disability Services, was asked directly about the adequacy of his resources today during a meeting of the KanCare Specialized Care and Network Issues Workgroup in Topeka.
Sheldon Weigrau, a workgroup member, said if only 1 percent of the state's Medicaid enrollees filed complaints with the ombudsman, that would mean at least 10 complaints or problems a day to handle. He questioned whether Bart would have the resources to deal with that many of them, "otherwise, you're going to be overwhelmed."
Bart said 10 issues landed on his desk during the first working week of KanCare, which ended Jan. 4, and all had been resolved. And he said he had assurances from KDADS Secretary Shawn Sullivan that he could draw on on more of the agency's resources if needed.
"I can't solve every issue," Bart said. "But I can be the grease in the wheels. If it gets to the point where I feel I can't deal with the issues with the resources I've got, then I'll go get more resources."
Question of independence
Sen. Laura Kelly, a Topeka Democrat, is among the legislators asking questions about the ombudsman's office.
“It’s just beyond me to see how someone who is housed in an agency and who is dependent on that agency for the resources they need to do their job can be truly considered to be independent,” Kelly said after the issue was raised at a recent meeting of the Legislature’s Joint Committee on Health Policy Oversight.
A Lawrence man who serves on the Kansas Council on Developmental Disabilities has been hired by the state to be the ombudsman for KanCare enrollees.
James Bart, 50, started the job today. He will office at the Kansas Department for Aging and Disability Services headquarters at 503 S. Kansas Ave. in Topeka.
Bart said he has a law degree from Creighton University but had not practiced law since leaving Nebraska for Kansas about 17 years ago. He is married and the father of a 19-year-old son with developmental disabilities and three younger children.
"I'll make a serious commitment to consumers of Kansas Medicaid to help them in any way I can," Bart said.
Bart said he previously worked in the automotive and insurance industries but preferred to not discuss the details. According to the profile he posted on Linked-in, an online network for business professionals, his employment before this job was as an auto damage appraiser for Crystal Carstar.
Bart said his passion has been advocating for the disabled and that the ombudsman job will allow him to wed his professional experience with his desire to help others.
According to KDADS officials he has worked with ARC of Douglas County, an organization that helps disabled persons and their families in Douglas, Jefferson, Osage and Franklin counties. He completed training in "community-based outreach and graduate network development" with the Kansas Council of Developmental Disabilities and also graduated from a "Special Education Law Boot Camp," conducted by Wrightslaw. He has a bachelors degree in Industrial Relations and Human Resource Management from the University of Iowa.
KDADS officials said Bart would be responsible for assisting Medicaid enrollees with "unresolved access, service and benefit problems," particularly those who receive home- and community-based services or are in long-term care situations. His annual salary will be $62,500.
OLATHE — Workforce shortages prompted by the overhaul of the Kansas Medicaid program are hampering operations at some social service agencies in Johnson County and elsewhere in the state, according to executives at the organizations.
Human Services Director Debbie Collins said since September, her Johnson County agency had lost three of its nine case managers that assist frail elderly Medicaid clients through the Area Agency on Aging.
Collins said the workers all left for similar positions at UnitedHealthcare, one of the three insurance companies hired by the state as part of the new Medicaid program, which the state has dubbed KanCare. Virtually all the state’s 380,000 Medicaid recipients are scheduled transfer into the KanCare managed care plans effective Jan. 1.
The other two KanCare contractors are Amerigroup and Sunflower State Health Plan, a subsidiary of Centene. All three companies have been busy hiring workers for the past few months.
Collins and other agency administrators interviewed for this article said the bright side of losing the workers was knowing that the KanCare companies had hired qualified staff.
They said they didn’t blame their workers for taking the jobs because the employees told them they would get substantially higher pay at the managed care companies.
But the agency leaders said they weren’t sure how KanCare could save the state money, if the contractors will have significantly higher personnel costs.
“We are all befuddled about that,” Collins said.
Savings will come through a focus on patient education, preventive care, and by “ensuring members have access to the right care, at the right place and at the right time,” said Monica Stoneking, a spokeswoman for Sunflower State Health Plan.
Sunflower, she said, was paying “competitive wages in accordance with industry standards.”
Amerigroup spokesperson Maureen McDonnell declined to comment.
Alice Ferreira, a spokesperson for United Healthcare said the company was giving its new hires flexibility so that their former employers wouldn’t be left in the lurch.
“UnitedHealthcare has been working collaboratively with the agencies to provide case managers the work flexibility to ensure they are able to continue to work with the members as appropriate,” she said in an email. “We are committed to ensure members receive the care they need, and anticipate that this partnership will result in a smooth transition.”
She the company also was dedicated to “creating new jobs in Kansas.”
Officials at each of the KanCare contractors have said they would hire as many as 300 people as they prepare for the new program. Each company also has a Kansas headquarters office.
Officials in the administration of Gov. Sam Brownback estimate KanCare will save the state and federal governments $1 billion over the next five years.
Among the various social service and state agencies that have lost workers to the KanCare companies are the state’s Area Agencies on Aging, which, in any event, are seeing their roles change under KanCare.
Though the agencies are handing off case management for the frail elderly to the KanCare companies, they are expected to take on expanded roles in serving individuals with physical disabilities and traumatic brain injuries by assessing their needs for assistance and helping them choose the right KanCare plan, in the event the persons are not content with their state-assigned plans.
Collins said the changes have left her uncertain about what her staffing needs will be after the first of the year.
“We may very well have to expand,” she said. “We really don’t know what the workload will be.”
Other organizations experiencing KanCare-related personnel pinches include the Johnson County Mental Health Center and the Southeast Kansas Area Agency on Aging in Chanute.
Johnson County Mental Health has had 15 staff members take positions with the KanCare companies, according to agency officials, including a senior administrator and a number of clinicians and case managers.
In response, the center has pressed supervisors and everyone else with proper certification and training into service to coordinate care for clients, said Executive Director Maureen Womack.
The main problem, she said, was that clients had lost their connections to workers with whom they felt comfortable dealing.
“What is falling through the cracks,” she said, “is the therapeutic relationship.”
After prodding from local consumer advocates and federal overseers, Kansas officials have made public more details about how they would implement KanCare and say they plan to release more information as quickly as it becomes available.
A federal decision on the state’s plan to remake its Medicaid program is expected any day and the new information is evidence of the back-and-forth in the discussion between the federal Centers for Medicare and Medicaid Services as the administration of Gov. Sam Brownback continues its push for a Jan. 1 launch of the new program.
Brownback officials so far have posted six section 1915c waiver amendments on the KanCare website and also within the last several days have posted six “implementation activities” reports that outline previously undisclosed details about how they expect KanCare to work.
"These are some very specific implementation reports we're submitting to CMS and making available to all of you simultaneously," said Kari Bruffett, director of the division of health care finance at the Kansas Department of Health and Environment, talking last week in a teleconference with Medicaid providers.
Among the things outlined in the reports:
• State officials intend to create an ombudsman position at the Kansas Department for Aging and Disability Services to field complaints and questions about KanCare from Medicaid enrollees and service providers. They began recruiting for the new position Nov. 12 and began interviews last week with the goal of having a person hired by Jan. 1.
• A timeline and plan for communicating the KanCare changes to Medicaid enrollees and providers.
• A plan for following up on “returned” mail, information sent to enrollees that fails to reach the intended recipient.
• Details of how eligibility and enrollment in KanCare will be verified.
• A plan for how the customer call centers will deal with the influx of expected queries from Medicaid enrollees. According to the report, 226 customer-service representatives are “ready to step in as needed.”
Some of the state’s recent actions seem to stem, at least in part, from CMS having heard concerns from some Kansas advocacy groups about the need for more information about KanCare and the creation of an ombudsman position.
Anna Lambertson, executive director of the Kansas Health Consumer Coalition, said she and other advocates met with CMS officials and followed up with a Nov. 13 letter to them outlining their concerns about KanCare. CMS responded 10 days later.
Letter to CMS
“We asked for the state to be more transparent, posting more on line,” Lambertson said. “And we made some very specific requests of the state for an outreach education plan that meets the needs of the various populations and involves the stakeholders.”
Lambertson said she was still reviewing the documents posted subsequent to the group’s letter to CMS. But she said she already had seen enough of the ombudsman plan to know that it fell short of what the consumer groups were seeking.
“We feel very strongly there are certain things that really need to be in place in order for the state to be ready to kick off on Jan. 1, “ she said. “And I personally don’t feel those processes are in place.”
KIOWA — Construction on a new $8.2 million hospital is scheduled to begin early next year in this small, south-central Kansas community.
The project is in response to conditions common in many parts of rural Kansas where an increasingly aging population often is treated in outdated hospital facilities.
A quarter of Kiowa's approximately 1,000 residents are age 65 or older, more than half the town is at least 45 years old, and 80 percent of the critical access hospital's business is from Medicare patients, said Alden Vandeveer, chief executive of the Kiowa District Hospital.
"It's definitely an aging population and we are going to need in the future some pretty good resources for the seniors," he said. "The (hospital) board is real interested in making sure we have the facilities and equipment to serve the community, that the people here have what they need right here at home. We're 20 miles from anywhere."
The current hospital simply wasn't filling the community's needs, he said.
"For example, right now we have shared bathrooms — the old '50s-style bath at the end of the hall, two rooms share one toilet. And the toilet space is so small that if you have a heavy patient, they could get trapped in there — and we have 100-pound nurses who would have trouble getting them out," Vandeveer said.
The hospital's operating room "is unbelievably small — I've never seen one this small. It is the original O.R. — 61 years old," Vandeveer said. "It might be 200 square feet, if you're stretching it."
The new operating room will be 450 square feet, and the entire facility will be 25,500 square feet — about 40 percent larger than the existing hospital. In the new hospital, there will be eight rooms for patients, each equipped with a private restroom.
Hill-Burton era hospitals
Many rural hospitals were built with Hill-Burton Act funds in the 1940s and '50s, said Melissa Hungerford of the Kansas Hospital Association. The 1946 act, part of an initiative by President Harry Truman to improve the nation’s hospital capacity in the aftermath of World War II, provided grants and guaranteed loans for hospital construction.
The majority of Kansas’ 83 critical access hospitals might have been built during that era, Hungerford said, though an exact count is not available.
"There's only so far you can improve on those older structures," Hungerford said. "So many of them have added a wing, remodeled this, changed the front, done those kinds of things over the years. A lot of our hospitals are faced with not being able to just fix what they have. It makes sense that they have to address larger problems like wiring or fire safety."
The need for new wiring, fire sprinklers, accessibility for disabled patients, and sufficient space for modern health care equipment were all behind the construction project now underway at Medicine Lodge Memorial Hospital — another critical access facility 24 miles north of Kiowa — said administrator Kevin White.
Medicine Lodge is renovating half of the existing 36,000 square feet and adding on 17,000 square feet. Some of the new space is aimed at attracting part-time specialists who keep multiple offices around the region.
“We have some areas built in to make it a little more attractive to specialists, for them to have a place to come to for a clinic a day, a month or every two weeks. We had trouble getting that kind of participation,” with the space they have now, White said.
Given the recent recession, the hospital’s board expressed concern about the timing of the project, but decided to move forward after the county’s voters approved a bond to support the project.
"The board always has that fiduciary concern. With things are like they are now, (the concern was) how are you going to pay for it. With the county picking up a big tab, that helps. As long as the critical access cost reimbursement continues for at least a few years, we should be ok,” White said.
Funding for the construction in both Medicine Lodge and Kiowa came, in part, from a $10 million bond approved by Barber County in 2011. About $4 million was slated for Kiowa, and about $6 million for Medicine Lodge. The hospitals are each owned and operated by their respective municipalities, and the bond marks the first funding to come from the county for the hospitals, White said.
“Before that, the hospitals weren't supported by the whole county, they were just supported by their respective districts. Operationally, we still operate from tax support from our local hospital districts,” White said.
In small towns like this across Kansas, hospital administrators are paying close attention to federal deficit-reduction talks in Washington, D.C. that could lead to a 2 percent cut in Medicare spending, starting Jan. 1.
“Two percent may not sound like much,” said Vicki Hahn, who runs the Wichita County Health Center in Leoti. “But we’re a ‘critical access hospital,’ which means we’re reimbursed for 101 percent of our Medicare costs. If 2 percent gets taken away, it would put us in the red on our Medicare patients. That wouldn’t be good.”
Leoti is about 40 miles from Colorado and 110 miles from Oklahoma in a county where about 18 percent of the population is age 65 or older. Total county population is 2,276 people according to most recent U.S. Census estimates.
“We’re a frontier county,” Hahn said.
Medicare patients account for about 78 percent of the patients seen by the publicly owned hospital.
A cut in Medicare reimbursement, Hahn said, would force the hospital to ask the Wichita County Commission for help in offsetting the loss of federal support.
“That would be a big concern,” Hahn said. “If we end up losing revenue that doesn’t get replaced, we would have to come up with a much different business model than the one we have now.”
Many Medicare patients
Wichita County Health Center’s situation is not unique. Because of the disproportionate number of rural and small-town Kansans who are elderly, most of the state’s small hospitals treat a relatively high percentage of Medicare patients. Medicare is the federal health program for persons age 65 and older.
Roger Masse, chief executive officer at Ellsworth County Medical Center, said a 2 percent cut in Medicare reimbursement would result in a $200,000 loss for the public hospital he manages.
“In Ellsworth County, that’s a lot of money,” he said, noting that a three-mill property tax currently generates about $225,000 for the hospital.
“So far, operationally, we’ve been able to just about break even,” Masse said. “We haven’t had to ask the county for more than the three mills. But if we end up taking a $200,000 hit, how long can that be sustained? I don’t know.”
About 55 percent of the hospital’s patients, he said, are on Medicare.
Blaine Miller has a similar story. He runs the Republic County Hospital in Belleville. He said a 2 percent reduction in Medicare reimbursement would lower hospital revenues by about $110,000.
“That would be big for us,” Miller said. “At the same time, our charity care had gone up substantially. Last year, we had about $200,000 in charity care; this year we’re looking at about $300,000.”
Miller attributed the increase to the hospital’s non-Medicare patients either losing or not being able to afford their health insurance.
Kansas has 83 federally designated “critical access” hospitals, the most of any state in the nation.
Among other things, the designation allows the hospitals to bill Medicare for 101 percent of their outpatient, inpatient, laboratory, physical therapy, and post-acute care costs. The hospitals, in turn, agree to have no more than 25 beds, limit their inpatient stays to no more than 96 hours per patient annually, and provide 24-hour emergency room care.
The critical access program was started in 1997 with the goal of ensuring access to emergency, primary and acute care in the nation’s rural areas.
In Kansas, nine counties — Linn, Woodson, Osage, Wabaunsee, Elk, Wallace, Gray, Chase and Doniphan — do not have a hospital.
But 10 counties — Barber, Harper, McPherson, Marion, Dickinson, Washington, Pottawatomie, Nemaha, Brown, Wilson — have two hospitals with 25 beds or less.
A future with fewer hospitals?
“There is so much required of hospitals nowadays, I don’t know that all of them can survive,” said Dennis Franks, chief executive office at Neosho Memorial Regional Medical Center in Chanute. “The requirements are the same for all of us, but our resources for meeting those requirements are different.”
Many of the state’s rural communities, he said, also are having a hard time recruiting medical staff, a situation that’s likely to worsen with implementation of the Affordable Care Act on Jan. 1, 2014, which could mean thousands of additional Kansans gaining access to health insurance either through the new subsidies provided for them to purchase private coverage or perhaps through Medicaid should state policymakers choose to expand the program.
“There simply aren’t enough primary docs to go around,” Franks said.
Top officials in the administration of Gov. Sam Brownback said today that they now have a list they accept as accurate of the 2,197 physically disabled persons who are awaiting home- and community-based Medicaid services.
Armed with the updated information, they said, they are ready to begin providing services to 100 people currently on the list by the end of the year.
"We now have a better handle on the waiting list and wlll be able to make better decisions about how to manage the waiting list and best utilize the funding provided by the Legislature for this program," said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services.
Sullivan, joined at a Statehouse press conference by Lt. Gov. Jeff Colyer, said his agency won't propose additional funding to further decrease the waiting list but would instead wait to see what legislators would appropriate in 2013 to help deal with the problem.
Kansas has drawn attention from federal authorities due to its slow moving and relatively large waiting lists for home- and community-based services, which advocates for the disabled have said puts the state in violation of the federal Americans with Disabilities Act as defined by the U.S. Supreme Court's so-called Olmstead decision.
It wasn't immediately clear if today's announcement would influence the course of the U.S. Justice Department's review of Olmstead complaints filed by disabled Kansans and their advocates.
Feds continue monitoring
“We are continuing to monitor the state’s activities on all issues that may relate to any potential Olmstead violations,” said U.S. Attorney for Kansas Barry Grissom in an email statement to KHI News Service after the press conference
Brownback officials for months have said they doubted the reliability of the lists, particularly the one dealing with the physically disabled. So, today's announcement made clear the administration now has a list it considers fully valid.
As of July, the state's Centers for Independent Living, had reported there were 3,462 people on the list.
Sullivan and Colyer said the state hired Answernet, a firm based in Hays, to start making phone calls in July to check the list. After the company was only able to reach 377 of the people, state officials asked the Centers for Independent Living to double check the list.
That process resulted in 1,226 people being removed from the official backlog after it was found for whatever reason that they no longer needed the services or were not eligible. But it also resulted in another 250 people being added to the list.
Audrey Schremmer-Philip, executive director of 3Rivers, Inc., a center for independent living based in Wamego, said the 250 new names were of people for whom the state's centers for independent living previously had submitted paperwork to the state but for unknown reasons had never made the state's list of people needing services.
Rocky Nichols, executive director of the Disability Rights Center of Kansas, a Topeka-based nonprofit group, was critical of the administration's handling of the waiting list and its review of the backlog.
“We are extremely concerned that the state is creating a self-fulfilling prophecy that is having the net effect of unnecessarily kicking people off the waiting list for services," he said. "The perspective is all wrong here. Not only do you have to wait years to clear the waiting list in Kansas, now the state is saying if they can’t get ahold of you — due to you not having the money to add minutes to your pre-paid cell phone, or you had to move to make ends meet — that they are going to add insult to injury and kick you off services. It makes no sense.”
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.
By the end of this week, officials in the administration of Gov. Sam Brownback are expected to decide if their KanCare Medicaid reforms will move forward on the original timeline of a Jan. 1 launch or whether the program will get pushed to a later, yet-to-be-decided date.
A few things are scheduled to happen over the course of the next five days that will shape that decision, according to Brownback officials. Among them:
Sometime this week, perhaps by Wednesday, completion of the last of the state’s “readiness reviews” of the three managed care companies is due.
Officials have said they will not proceed on schedule unless Amerigroup, United Healthcare and Sunflower State Health Plan, a Centene subsidiary, each has demonstrated it is ready. (The companies had an Oct. 12 deadline for demonstrating that their networks of hospitals, doctors and other service providers were “90 percent adequate,” but administration officials said they wouldn’t make public the status of the companies’ respective network capacities until the end of this week, so it isn’t yet clear how well each company fared with the deadline.)
On Thursday, the day before the administration’s go/no-go decision date, top Kansas health officials are set to meet in Baltimore, Md., with federal officials from the Centers for Medicare and Medicaid Services, the Office of Management and Budget and others.
Reviewing the waiver request
The purpose of the meeting is a review of the state’s so-called Section 1115 waiver application. Much, if not most, of the KanCare plan requires federal approval, either as part of the waiver application, the state’s ongoing Medicaid plan on file with federal officials, or the KanCare contracts and rates. The federal government gets a large say in keeping with the fact that it pays more than half the state’s annual Medicaid costs, which next year are expected to reach $3.2 billion.
Though administration officials have said the launch date for KanCare is contingent upon the various factors still in play as of this week, at the same time they’ve made clear to legislators and others that they have no major fallback plans in place in the event the program is delayed.
“With all those caveats and decision points along the way, we're marching forward for Jan. 1 and all our efforts are for implementation on Jan. 1,” Bruffett told members of the Joint Legislative Budget Committee last week during an update on the KanCare program.
For example, KanCare is expected to supersede HealthWave, the state’s program for providing government subsidized health coverage to children and pregnant women from low- and moderate-income homes. The state’s contracts with the current HealthWave managed care companies, Unicare and Children’s Mercy Family Health Partners (recently purchased by Coventry Health Care), are due to expire Dec. 31. There is no plan to extend those contracts in the event KanCare is delayed.
“We’ve not had any of those kinds of conversations,” Bruffett told KHI News Service.
If necessary, Kansas could continue HealthWave services with the more expensive alternative of paying fees for services instead of relying on managed care contractors, “but that isn’t a good option,” Bruffett said.
As much KanCare as possible
When asked by Sen. Laura Kelly, a Topeka Democrat who serves on the budget committee, what administration officials would do if federal officials do not approve the 1115 waiver on the Brownback timeline, Bruffett said the administration’s intention was to launch as much of KanCare as possible without federal approvals on Jan. 1.
“Everything we have authority to do in the KanCare model, we will do,” she said.
But at this point, it isn’t clear how much of the program could be initiated without the OK from the feds.
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.
State officials are changing the way they determine which in-home Medicaid services are provided to the frail elderly and people who are physically disabled.
The new system will rely on a single agency or organization with a presence in each of the state’s 105 counties to assess what services a person will receive. Currently, there are more than 30 organizations involved with the process. Some assess only the elderly. Others focus solely on the physically disabled.
State officials said their aim is to create a “one-stop shop,” so that services will be determined in the same place regardless of a person’s condition.
“The system we have now is a real mishmash,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “We’ll be going to one that takes more of a no-wrong-door, single-entry approach and implements a conflict-free provision of services.”
About 12,000 Kansans currently rely on the services provided by the system, at an annual cost to taxpayers of about $200 million.
A solicitation to potential contractors interested in managing the new system was put out in February. Bids were due April 3.
Sullivan said he hoped to have the contract awarded sometime next month so that a single, statewide Aging and Disability Resource Center (ADRC) will be up and running by Jan. 1, which also is the scheduled start of KanCare, Gov. Sam Brownback’s plan for letting managed care companies administer the state’s $2.9 billion Medicaid program. KanCare remains contingent upon federal approvals.
The resource center, according to Sullivan, would be in charge of measuring the needs of an elderly, physically disabled or brain-injured person. It also would do preliminary screening for Medicaid eligibility and help the person choose the managed care company best suited to meet the person’s needs.
Today, the assessments are handled by 11 area agencies on aging, 10 centers for independent living and about a dozen home health agencies that specialize in caring for the brain-injured.
“When you have this many systems in place, it can be confusing as to who to turn to for assistance,” Sullivan said. “With the ADRC, we’ll be going to one database, one information source and one hotline for people to call.”
The change, he said, was driven by a federal initiative aimed at increasing efforts to help Medicaid beneficiaries live in community settings rather than nursing homes and a concern among state officials that not enough was being done to prevent the centers for independent living from inflating their assessments in ways that generated more work — and therefore more revenue —- for their case management and home-health programs.
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.
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.”
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.
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.
A company that is among the five bidding on the state’s Medicaid managed care contract has agreed to pay $137.5 million to settle claims it defrauded Medicaid programs in nine states.
The U.S. Department of Justice announced the settlement with WellCare Health Plans Inc. last week.
It was the second settlement the company agreed to after federal prosecutors in 2006 launched criminal and civil investigations stemming from complaints filed by whistleblowers.
In 2009, the company entered a deferred prosecution agreement and paid $40 million in restitution and forfeited another $40 million. WellCare’s former chief executive, Todd Farha, is scheduled to go to trial in January.
The settlement announced last week will be divided among the federal government and the Medicaid programs in Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Missouri, New York and Ohio.
Sean Hellein, a former financial analyst with WellCare, will collect more than $20 million, federal officials said. He filed the initial whistleblower claim that prompted the investigation.
WellCare officials said the settlement wiped the slate clean for the company.
“The company acted swiftly upon learning of the wrongdoing in 2007, took action to separate the individuals involved, and cooperated fully with state and federal authorities in their investigations. These matters are now resolved and a new leadership team has been put into place,” WellCare spokeswoman Denise Malecki told KHI News Service.
She said the company would bring high standards to its Kansas operations if it wins a contract to help implement KanCare, Gov. Sam Brownback’s Medicaid makeover plan.
“Today, WellCare's commitment to transparency and ethical behavior will be unparalleled in providing quality, cost-effective health care to the members of the KanCare program,” she wrote in an email.
As part of the settlement with the Justice Department, WellCare agreed to enter a corporate integrity agreement that allows the U.S. Department of Health and Human Services' Office of the Inspector General to oversee its “rehabilitation” for three years.
Sherriene Jones-Sontag, a Brownback spokesperson, said the qualifications of WellCare and other KanCare bidders would be thoroughly reviewed by the administration.
“The state conducts thorough evaluations to ensure the selection of qualified bidders who meet the requirements of the KanCare program, including financial sustainability,” she wrote in an email. “The contracts for the KanCare program will include mechanisms such as performance bonds and parent corporation guarantees as well as significant reporting requirements and ongoing reviews of the financial conditions of KanCare contractors.”
WellCare isn’t the only KanCare bidder that has been ensnared in a federal whistleblower lawsuit.
Amerigroup paid $144 million in damages and $190 milllion in fines after losing a whistleblower case in Illinois in 2008.
Wall Street analysts remained bullish on WellCare after last week’s announcement.
“It's conceivable that the company could double its revenues in the next couple of years," Tom Carroll, an analyst at Stifel Nicolaus, told Florida Health News, a partner of KHI News Service.
According to financial analysts, the company had $6.1 billion in revenue last year and has more than $300 million in cash on hand.
But the claims raised against WellCare in the lawsuit were alarming to some in Kansas who already have concerns about the governor’s Medicaid plans.
“I am deeply troubled and shocked by the contents of this settlement agreement, and I believe it underscores the need to slow down the process of implementing KanCare,” Shannon Cotsoradis, chief executive of the advocacy group Kansas Action for Children, wrote in an email to KHI News Service. “Thoroughly vetting potential contractors is a critical component of the implementation process and it must happen to protect the children and families in our state. I don't think this is the kind of Medicaid ‘reform’ we are looking for.”
Among the things cited in the case, WellCare:
• Created a wholly owned reinsurance subsidiary that inflated the company’s premiums in a way that made profits look like expenses;
• Hid information that would have caused the company to send money back to the Illinois Medicaid and Florida Healthy Kids programs;
• Falsified encounter and performance data;
• Rewarded physicians and clinics for referring healthy, low-cost patients to WellCare and sending sick, high-cost patients to competing health plans;
• Engaged in marketing and enrollment practices that discriminated against patients with chronic illnesses;
• Collected premiums on patients who were dead; and
• Operated a “sham” special investigations unit that allowed the company to “seek excessive reimbursement from the providers.”
The fraudulent activity was alleged to have occurred between 2002 and 2007.
County officials across Kansas are raising doubts about KanCare, Gov. Sam Brownback's plan for letting insurance companies manage the state's $2.8 billion Medicaid program.
"Before the administration gets to the point of signing contracts with these companies, it should let the Legislature, a special committee or the public know what's in them so we can have the professionals on the ground tell us where the potholes are. We shouldn't be putting our vulnerable populations at risk," said Ed Eilert, a Republican member of the Johnson County Commission and a former Overland Park mayor, a post he held 24 years.
Johnson County is Kansas' most heavily populated county. Eilert said he expected the commission there soon would pass a resolution urging the governor to "carve out," or exclude from KanCare, the long-term care services Medicaid provides for people with a developmental disability.
According to local officials contacted by KHI News Service, at least 20 counties have passed similar resolutions asking the governor to reconsider the reach of KanCare. At least three more are considering a resolution.
The first resolution was jointly endorsed March 5 by commissioners in Marion and Harvey counties. The Topeka-based Kansas Association of Counties later distributed copies of the document to the state's other 103 counties. Within a month, 18 other counties approved their own resolutions and more are expected to follow.
It's not clear if the resolutions will change the administration's approach. When the Legislature returns April 25 for its wrap-up session, lawmakers are expected to debate a proposal that would exclude long-term services for the developmentally disabled from KanCare.
An effort to debate the measure on the House floor was stymied by a procedural move at the end of the regular session, but supporters have pledged to bring it up again.
→ Continue reading at khi.org.
The House Appropriations Committee today passed a bill to create a joint legislative committee to oversee KanCare, Gov. Sam Brownback’s plan to move virtually all the state's Medicaid beneficiaries into managed care plans.
The Senate Ways and Means Committee passed a similar bill Tuesday.
The primary difference between the two bills is that Senate Bill 459 would let the Senate president pick the oversight committee’s first chair; House Bill 2789 would let the House speaker choose the chair.
The proposed committee would include six members from the House and five from the Senate.
Rep. Brenda Landwehr, a Wichita Republican and chair of the House Health and Human Services Committee, testified in favor of the House bill.
“I was very, very pleased to see that we turned in 79 signatures in bipartisan support of this bill,” she said. “The House has taken the lead on this and it would be my preference for House leadership to appoint the chair.”
Landwehr, chief sponsor of the bill in the House, said the oversight committee would not have the authority to “stop or delay” KanCare but would monitor the initiative’s implementation.
Afterward, Landwehr told KHI News Service that she hoped to be named chair of the proposed committee.
Landwehr is a former chair of the House Social Services Budget Committee. She currently chairs the Joint Committee on Health Policy Oversight.
She said she’s opposed to a resolution urging the governor to delay KanCare’s start by six months.
“I’m not sure there’s a way to satisfy those who oppose KanCare,” Landwehr said. “It’s like every time the administration has answered their objections, they come up with a new objection.”
Administration officials, she said, have said they will not launch KanCare on Jan. 1, 2013, if it’s not ready.
“I have a lot of confidence in Dr. Moser,” she said, referring to Kansas Department of Health and Environment Secretary Robert Moser. “He’s a physician and he’s been intimately involved in the KanCare process. If the process comes to a point where he feels it should not go forward, he has the latitude to make that decision.
“I would rather have him make that decision than individuals who either haven’t had the time or haven’t taken the time to get the details on what’s happening,” Landwehr said. “I think Dr. Moser and (Department on Aging Secretary) Shawn Sullivan have answered every single question to the extent that they can without violating the procurement process. They’ve been very open, very transparent.”
Earlier this month, 22 senators signed a resolution in support of starting KanCare on July 1, 2013, rather than Jan. 1, 2013.
A similar initiative is underway in the House.
“Maybe we should have co-chairs?” for the proposed committee, said Sen. Dick Kelsey, a Goodard Republican who introduced the resolution to postpone KanCare in the Senate.
Last week, the Governor’s Office announced that it had started a 20-member KanCare Advisory Committee consisting of four legislators and 16 consumers and advocates.
→ Read more about the KanCare proposal in KHI's story "Brownback Medicaid makeover an ambitious plan."
Gov. Sam Brownback’s Medicaid reform plan, KanCare, has spawned one of the biggest, busiest and -some say- most confusing courtships in state history.
“I feel like I’m the pretty girl in high school and it’s two weeks before prom,” said Krista Postai, who runs the Community Health Center of Southeast Kansas, a multisite safety-net clinic headquartered in Pittsburg. “I have lots of offers.”
Postai and other Medicaid providers – a group that includes doctors, hospitals, pharmacies, home health agencies, nursing homes, mental health centers and community-based programs for the developmentally disabled – are being wooed by the five companies that have submitted bids to manage the state’s $2.8 billion Medicaid program.
“They all want to do something different and they’re all saying it’s going to be great,” Postai said. “The sales pitches are phenomenal, but I’m thinking they’re like the cute guys with the blue eyes who sell computer software. You want to believe them, but it never works the way they said it would.”
State officials have said they plan to award contracts to three of the companies this summer. An exact date has not been announced.
Meanwhile, each of the five bidders - Centene, Coventry, Amerigroup, WellCare, and United Healthcare - has until March 30 to show that it has assembled at least half of the statewide provider network needed in order to secure a contract award.
“We’re being barraged” by solicitations from the companies, said Deborah Zehr, executive director at LeadingAge Kansas, an association that represents the state’s nonprofit nursing homes. “It’s been pretty confusing because nobody knows who’s going to win the contracts, and yet we’re being encouraged to go ahead and commit to a company that may or may not be selected."
Zehr said that struck her as odd since providers also are being told that any willing provider can sign with any or all managed care networks after the contracts have been awarded.
Administration officials have said they want to launch KanCare on Jan. 1, 2013. But that would come after each of the three selected companies sometime this fall has been “auto-assigned” a third of the state’s Medicaid beneficiaries of which currently there are about 383,000.
The initial contracts are to be for three years.
Some providers said they plan to wait until the companies have state contracts before signing with any of them.
Janet Splitter is executive director at ElderCare, a nonprofit meals and home-health program based in Great Bend.
“We’ve heard from all five companies,” she said. “But we’re taking a wait-and-see approach because it doesn’t make a lot of sense to fill out the forms for a company that’s not going to get the contract.”
Some of the forms, Splitter said, were 40 pages long and would require several hours to complete.
Initially, most of the managed care companies asked providers to sign letters of interest or intent, expressing a willingness to work with them if they were awarded one of the contracts.
But in recent weeks, some of the companies have begun pressing providers to enter contractual agreements. And many program directors told KHI News Service they were uncomfortable with that more aggressive push.
“I don’t have teams of lawyers and accountants who know all the ins and outs of a managed care contract, but these companies do,” said Lori Feldkamp, executive director at Big Lakes Developmental Center in Manhattan. “I find that disconcerting.”
Big Lakes serves about 200 developmentally disabled adults in Riley, Geary, Clay and Pottawatomie counties.
Felkamp said Big Lakes has yet to align itself with any of the contractors.
“We’re waiting,” she said. “I have a lot of questions. I don’t have very many answers and, frankly, I don’t know that the answers are there to be had.”
Still time for contracts
Kari Bruffett, an assistant secretary at the Kansas Department of Health and Environment, said the KanCare bidders recently were told that simple letters of intent from providers would be sufficient to for determining each company's potential network capacity.
"The most common question we have heard from providers is whether the bidders need to secure contracts or letters of intent to demonstrate the extent of their network development on March 30," Bruffett wrote in an email to KHI News Service. "We have clarified that letters of intent are acceptable at this time."
KDHE, she wrote, would review standard provider contract and subcontract provisions before they can be executed with providers. She added that all providers who sign with a network would be assured payment for services at least equal to what they currently are paid after incentives are counted.
"Per the RFP (request for proposal), all in-network providers will receive 100 percent of the (current) fee for service as the floor, inclusive of incentives for quality and outcomes," she said.
In recent weeks, administration officials have offered repeated assurances that KanCare is designed to improve healthcare outcomes and “bend the cost curve of Medicaid” without cutting provider rates, reducing eligibility or restricting access to services.
A single "front door" for billing
Brownback last week asked legislators to approve spending an additional $3.4 million on a “robust communication and education program about changes taking place with KanCare” and to updates the state's Medicaid billing system so that it would give providers “a single billing front door.”
That proposed bill streamlining was in response to concerns raised by some providers that KanCare would add administrative complexity to the Medicaid program.
→ Continue reading on khi.org.
The Senate Ways and Means Committee has introduced a bill that would create a new joint committee to oversee implementation of Gov. Sam Brownback's KanCare Medicaid makeover plan.
Administration officials today welcomed the development and also told lawmakers there would be a "rigorous readiness review," before KanCare is launched. If the managed care companies hired to implement the plan fail the reviews, officials said, then KanCare's Jan. 1, 2013 launch date would be pushed out.
SB 459 would create an 11-member oversight committee for the program, including six House representatives and five senators. It also would create a new fund in which would be deposited dollars saved from moving Medicaid beneficiaries from nursing homes to private homes or community settings. The secretaries of the Kansas Department of Social and Rehabilitation Services and the Department on Aging would each provide quarterly reports to the Legisalture on the status of the savings fund. The same bill will be introduced in the House, according to administration officials and Rep. Brenda Landwehr, a Wichita Republican who is a sponsor.
The oversight committee would be charged with examining the program's progress, watching to assure access to Medicaid services doesn't suffer and that quality-of-care benchmarks are met.
“Legislative oversight will be key in accomplishing the objectives of KanCare that lead to improved delivery of health care to Medicaid consumers," said Lt. Gov. Jeff Colyer in a prepared statement endorsing the bills. Colyer has been point man on the governor's plan to remake Medicaid.
KanCare would move virtually all of the state's Medicaid clients into fixed-cost, managed-care plans, including the elderly, disabled and mentally ill receiving long-term care services.
The plan has met resistance and some lawmakers have faulted the administration for moving too quickly with its plan, which still needs federal approvals.
A resolution was introduced in the Senate urging the administration to delay KanCare's start until July 1, 2013. A hearing on it was held today in the Senate Public Health and Welfare Committee.
In the House, there is a bill that would require the administration to exclude or "carve-out" from KanCare the long-term Medicaid services provided to the developmentally disabled.
That bill was the subject of hearings Wednesday and again today in the House Health and Human Services Committee.
At Wednesday's hearing, various advocates for the developmentally disabled spoke in favor of House Bill 2457, which was introduced by Rep. Jim Ward, a Wichita Democrat.
Administration weighs in
Today, Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, and Secretary Shawn Sullivan of the Department on Aging, made the administration's argument for moving forward with KanCare without delay and with long-term services for the developmentally disabled included in the plan.
Sullivan said, as he has in other legislative hearings and public forums, that the administration aims for as little disruption as possible to Medicaid clients. He said the state's contracts with the managed care companies will require that they use existing Medicaid providers and that the roles of the state's 27 Community Developmental Disablity Organizations (CDDOs) would remain intact.
He said the governor and other top officials, including himself considered it "very important to maintain the structure, infrastructure and the integrity of the current (developmental disability) system.
He said many of the state's developmentally disabled are served by small organizations that might have only five clients and that KanCare would be particularly beneficial to those in their care because it would bring "much more robust coordination (of services) for all the client's needs," whether the client had diabetes, mental illness or another chronic medical condition.
Moser also said the main focus of KanCare would be improved coordination of care with the goal of preventing illnesses leading to costly hospitalizations.
He assured the committee that KanCare would not move forward on Jan. 1, 2013 unless everything was in place to do it effectively.
"If this is not ready and robust, we will not move forward," he said.
Kari Bruffett, a KDHE assistant secretary, gave similar assurances Thursday to the Senate Public Health and Welfare Committee.
'On the right track'
Several of the House committee members indicated they were in support of the KanCare plan.
"I continue to feel we're on the right track," said Rep. Jim Denning, an Overland Park Republican.
Landwehr, the committee chair, closed the hearing delivering something of a lecture to those in the room who were opposing the administration's initiative.
She urged Medicaid providers to work with the managed care companies as they try to develop their networks and she told opponents that instead of "fighting or opposing" the administration plan they should work with Brownback officials to come up with something that would work.
"It doesn't take a brainiac to figure out something needs to change," she said. "The status quo is not going to be acceptable. It's not going to work. The money's not there."
→ Continue reading on khi.org.
Advocates for better long-term care for elders gave sometimes emotional testimony today as they asked a Senate committee to consider raising minimum staffing levels at nursing homes.
"We realize what we're asking for is a significant change," said Mitzi McFatrich, executive director of Kansas Advocates for Better Care. "But we believe it is reasonable to set a minimum standard for direct nursing care at the beginning of a major overhaul to the Medicaid system."
The administration of Gov. Sam Brownback is working to expand managed care to all currently on Medicaid, including those in nursing homes. The governor's KanCare plan is scheduled to start Jan. 1, 2013, contingent upon federal approval.
In Kansas, nursing homes are required to give direct staff care for at least 1.85 hours per resident per day, and to average at least 2.0 hours per day throughout the week. The minimum staffing level is one qualified employee per 30 residents, which translates to 2.06 hours per resident per day.
Qualifying staff are registered professional nurses, licensed practical nurses, nurse aides, nurse aide trainees, medication aides and paid nutrition assistants.
Several people who testified cited a 2002 study by the Centers for Medicare & Medicaid Services that recommended at least 4.85 hours of combined staff time per resident per day. Maren Turner, director of AARP Kansas, said legislators should consider raising the state minimum to at least that level.
"Residents in facilities that fell below the minimum staffing thresholds (recommended by CMS) were at a significantly greater risk of hospitalization for potentially avoidable causes, lack of functional improvement, incidence of pressure sores and skin trauma ... and weight loss," Turner said.
Committee members also heard several personal stories, including one from Barbara Braa, whose mother lives in a nursing home.
"If you cared for a child in your home and only gave them two hours of care a day, somebody would be at your door taking them away. And that's all we provide," for the elderly, Braa said, fighting back tears.
A report is expected in the next few weeks from the Legislative Division of Post Audit on how increased staffing levels at nursing homes would affect state spending.
Turner and others asked committee members to consider scheduling an interim hearing on the issue after the report is available.
There are 342 nursing homes in Kansas. McFatrich said that all facilities averaged 3.59 hours per resident per day in 2010. But the averages for individual nursing homes ranged from 1.4 hours to 5.7 hours. She said 151 nursing homes fell below the state average.
Senate Bill 184 would incrementally raise the minimum staffing levels to 4.44 hours per day. The bill was introduced last year but no action has been taken on it.
→ More from today's committee meeting at khi.org.
Companies also among those vying for Kansas Medicaid business
Centene and Coventry, two of the five major managed care companies seeking a contract with the Kansas Medicaid program, have landed awards from the state of Missouri, officials there announced today.
Today also was the deadline for bids on Gov. Sam Brownback's KanCare proposal and administration officials confirmed Centene, Coventry and three other companies had met the deadline. Centene is seeking the KanCare award through its wholly owned subsidiary, Sunflower State Health Plan.
The KanCare plan was announced by administration officials in November 2011 and most of the nation's large managed care companies expressed early interest in bidding on it.
The Governor's Office released a statement this afternoon saying the five companies that submitted bids were:
• Centene, which is headquartered in suburban St. Louis, but its subsidiary has opened a Topeka office,
• Wellcare of Kansas, which is based in Tampa, Fla.,
• United Health Care of Minneapolis, Minn.,
• Coventry Health Care of Kansas, which is headquartered locally in Wichita and nationally in Bethesda, Md., and
• Amerigroup, which is based in Virginia Beach, Va.
Aetna, which also scored a Missouri award, had shown early interest in the Kansas proposal but was not among those submitting bids by today's deadline. It wasn't immediately clear why the company did not offer a KanCare bid.
KanCare would extend managed care to virtually all Kansas Medicaid beneficiaries, including the elderly and disabled.
Zane Yates, Centene vice president of regulatory and government affairs, today told members of the Kansas Mental Health Coalition that the company also had won a recent award from Washington state. He said the Clayton, Mo.-based company also has a bid pending with New Hampshire and that this morning he had delivered the company's "final response" to the Kansas request for approval.
Kansas is one of several states that have recently expanded or plan to expand managed care within their Medicaid programs.
Centene, Coventry and Wellcare were the three companies chosen last year to implement Kentucky's managed care expansion, which began Nov. 1, 2011.
The Kentucky plan got off to a rocky start. Its implementation was delayed a month and complaints from pharmacists, hospitals and other providers sparked a round of legislative hearings last week after a co-chairman of the Program Review and Investigations Committee earlier in the month threatened to subpoena information from the companies.
The Kentucky health care providers said they were having problems getting timely payments from the managed care companies, and independent pharmacists complained they were losing money after some of the companies cut the prescribing fees the pharmacists were paid.
Kentucky Gov. Steve Beshears ushered in the changes, which officials there have projected could save the state $375 million over three years.
Brownback officials have predicted KanCare will save the state and federal governments about $850 million over five years.
Administration officials here have said they hope to have the KanCare contracts finalized by summer and intend to choose three companies to divide Medicaid services statewide.
The Kansas Medicaid program costs about $2.8 billion a year and serves more than 350,000 Kansans.
→ Continue reading about the companies bidding for KanCare contracts, including coverage of the rocky start for managed care in Kentucky at khi.org.
Brownback administration, state's top insurer see potential savings in patient-centered model.
Larry Rahn had never heard of a "patient-centered medical home," though his doctor's practice here is one of a handful certified in Kansas.
Nonetheless, the 49-year-old John Deere mechanic said he had noticed something different about Dr. Jerad Widman's approach to medicine and that his health has improved in seven years under Widman's care.
"He goes the extra mile. He's been working on my bad cholesterol for two years and finally has it where he wants it," Rahn said. "He kept hammering on trying to eat right. After a couple years, I finally paid attention. You actually do feel better."
For Widman, the patient-centered medical home approach is about "proactively taking care of the whole patient, not just their chief complaint," he said.
"When people are sick enough to actually come into the doctor, the great majority of the time there's more than just a cold going on," he said. "Patients present with complaints. But most patients don't even know what all needs to be managed. If we leave it to them to tell us what to take care of, we don't take care of enough."
Widman said electronic health records are essential to the way he runs his practice, which is certified by the National Committee for Quality Assurance at Level 3, the highest level.
He said having and maintaining an electronic health record for each patient is the foundation of coordinated care.
He also uses the system to track and organize the care his patients receive outside his practice, which helps him minimize redundant treatments. The digital records also help his staff prepare for patient visits and deliver care at "the top level of their training," he said.
For example, his aides can perform a routine foot exam on a diabetic patient or update a patient's vaccinations even though the appointment initially was scheduled to check blood pressure — all before the doctor enters the exam room.
Proponents of patient-centered medical homes say that coordinating care through a single primary care provider will improve patient health and efficiency of delivery and reduce costs systemwide. Better management of chronic diseases and other preventive care will lead to fewer costly hospitalizations, they say.
Among medical home proponents are officials in the administration of Gov. Sam Brownback. They've indicated that medical homes will be central to their plan to overhaul Medicaid.
If every American had access to a medical home, national health care spending would drop by 5.5 percent, or $67 billion per year, according to estimates by the American Academy of Family Physicians.
Widman said he had no doubt medical homes would yield significant savings as more providers adopt the concept. But so far, he said, there is very little financial incentive for doctors to do so. Doctors make more money the more patients they see — and less money if they spend more time with each patient, he said.
"My only incentive has been top-notch, quality care for my patients. It has actually been to my financial detriment to do it," Widman said. "It's easily cut my take-home pay by 25 percent. That would be a conservative estimate."
As long as doctors are primarily paid for services — not outcomes — Widman said he doesn't foresee the medical home concept catching on.
"My hope is that the reimbursement structure is going to change to incentivize the comprehensive approach as opposed to the volume approach," he said.
A three-year pilot project under way in Kansas ultimately may lead to the state's largest private insurer changing its reimbursement structure.
The Patient Centered Medical Home Initiative — launched last summer by a coalition of the state's leading medical societies with underwriting from three Kansas health foundations — is intended to help eight practices overhaul their offices into certified medical homes.
The practices are working with web-based TransforMED to complete "mini-quality-improvement projects" with the goal of becoming certified at the top level, said Carolyn Gaughan, executive director of the Kansas Academy of Family Physicians.
TransforMED is a subsidiary of the American Academy of Family Physicians devoted to helping doctors get their practices certified as medical homes.
Getting a practice certified as a medical home is not easy, Gaughan said.
"They can't just close the practice and become a patient-centered medical home — that isn't how it works," Gaughan said. "It's stressful, and they're pretty brave to be dedicated to doing this. They're the laboratory in Kansas."
As part of the project, Blue Cross Blue Shield of Kansas is paying the eight pilot practices for implementing various patient-centered medical home practices.
Blue Cross spokeswoman Mary Beth Chambers said data gathered during and after the project would help guide how the company reimburses health care providers in the future.
"We feel fairly confident that there needs to be a move away from the fee-for-service model if we're going to — as a state — get control of health care costs," Chambers said. "The purpose of the pilot is to see whether this sort of model will provide better coordinated quality care that will ultimately lower the cost of health care. If you put more emphasis on the front-end care, prevention and wellness, does that save money over time?"
Last month, Blue Cross affiliate Wellpoint Inc. announced it would begin raising reimbursements for primary care providers who implement certain medical home practices, and even more for those who demonstrate savings. Most qualifying providers in the 14 states Wellpoint serves will see a 10 percent payment increase, and some could earn up to 50 percent more.
Chambers said that while there is a good deal of sharing data and best practices amongst members of the Blue Cross and Blue Shield Association, she could not say how Wellpoint’s move might affect Blue Cross of Kansas’ planning.
“Ultimately it’s up to each independent Blue plan to make the decisions that are best for their service area,” she said.
Verdict is out
Tina Davis is the director of four rural health clinics that — along with the county hospital — comprise the Ellsworth County Medical Center, one of the eight pilot sites.
She said "the verdict is out" on whether medical homes will lower the overall cost of health care.
"If we do our job well, it will reduce the number of in-patient stays and ER (emergency room) visits, so obviously our revenue from the hospital side will decrease. But on the outpatient side, because we're doing a better job maintaining those patients ... our revenue should be greater," Davis said.
Dr. Jennifer Brull's practice in Plainville is another pilot site. She said she's working toward medical home certification solely to improve patient care. But she said the bottom-line benefit of doing so is a question of when, not if.
"I think that people who are smart are going to say, 'I see it coming' — I see more money coming from (operating a patient-centered medical home) and I'm going to jump on that. But you got to have faith so you can be there when the money comes. Otherwise you're going to be playing catch-up," Brull said. "Blue Cross is putting their money where their mouth is; they are actually trying to pay to improve care."
KanCare and medical homes
Using medical or health homes to coordinate care and ultimately lower costs is part of Gov. Sam Brownback's Medicaid makeover, called KanCare. At the Feb. 3 announcement of KanCare's executive reorganization order, Cabinet member Shawn Sullivan said health homes were a major component of the plan to move all those on Medicaid into managed care.
→ Continue reading about Gov. Brownback's plans for health homes in Kansas — and find links to resources cited in this story — at khi.org/pcmh.