The head of the National Association of Insurance Commissioners and two members met today with President Obama to discuss the troubled rollout of the Affordable Care Act.
Kansas Insurance Commissioner Sandy Praeger, a moderate Republican who has generally supported the law, was invited but chose not to attend. NAIC President Jim Donelon, the Republican insurance commissioner from Louisiana, organized the meeting.
Praeger said she wasn’t trying to distance herself from the controversy surrounding the law’s problem-plagued rollout.
But she said the meeting was “premature” because the NAIC had not worked with its members to develop consensus on how to address remaining problems with the law’s implementation.
“It’s a huge honor to be invited to the White House,” Praeger told KHI News Service. “But I want to make sure that we use the president’s time wisely and that we are really able to have some constructive and meaningful dialogue.”
Praeger said the NAIC typically has been a “consensus organization.”
“As a past president of this organization, I think we have a real responsibility to communicate with the leadership and make sure that when we have a meeting that it’s not just representing a single point of view, but it's representing a consensus point of view that’s been arrived at through a vetting process,” she said.
In a joint email sent to their counterparts late Tuesday, Praeger and other commissioners who decided not to attend the meeting said they had “serious reservations about both the process and the policy issues surrounding such an important meeting.”
Adam Hamm, the Republican insurance commissioner from North Dakota, gave similar reasons for skipping the meeting in a statement to the New York Times.
“Because the topic for the meeting (Affordable Care Act) is so delicate and potentially divisive among the nation’s insurance commissioners, a meaningful discussion between all the commissioners needs to take place before a meeting with the president,” said Hamm, who like Praeger is a former president of NAIC. “Unfortunately, that did not happen so I had to respectfully decline to participate in today’s meeting.”
Bob Hanson, a spokesperson for the insurance department, said Praeger also wanted to remain in the state so that she could continue to work with Kansas insurers attempting to comply with President Obama’s recent request that the companies allow customers to temporarily keep policies that don’t meet the ACA’s minimum coverage requirements.
“The Commissioner and her department personnel are in the middle of conferring with companies on how the president's changes might be implemented,” Hanson said in an email. “Those business and regulatory discussions are keeping the commissioner here in Kansas to make sure any details are hammered out in the best interest of our citizens.”
Blue Cross Blue Shield of Kansas, the state’s largest health insurer, announced Tuesday that it would comply with the president’s request and work to reverse approximately 10,000 policy cancellations already in process, allowing policyholders to keep their nonconforming plans another year.
“This governmental change will allow many of our members to keep the benefit plan they already have and like, while still allowing them to consider new plans that they may be able to purchase with the help of a tax subsidy or small business tax credit,” the company said in a news release.
Praeger said reversing the cancellations likely would be costly to BCBS-KS and other insurers and could lead to premium increases. The main reason, she said, was that companies had based their rates on the assumption that many young, healthy people who had nonconforming policies would purchase more comprehensive plans thereby broadening the insurance pool. If significant numbers of those people decide to hang on to their current plans, the mix of policyholders enrolled in more comprehensive plans will be older and less healthy, Praeger said.
“If you’re going to let these healthier folks stay out of the mix for another year, there’s going to be a (cost) impact,” she said.
There are a lot claims circulating online and in the media about Obama's campaign pledge "If you've got a health care plan that you like, you can keep it" ... many of those claims miss the mark. So here's the lowdown:
If you bought your insurance plan before Obamacare was signed into law (March 23, 2010) your plan is grandfathered, and so long as you keep renewing it, you can keep it indefinitely.
Otherwise, your plan is not grandfathered. Some of those plans purchased after March 23, 2010 do not meet the law's requirement to cover "essential health benefits" (that includes covering childbirth and basic preventive care, for example). If you have one of those plans, you are one of the roughly 5% of Americans who received a letter saying you will have to update coverage to a plan offering the essential health benefits.
The state's largest insurer — Blue Cross Blue Shield of Kansas — has said that about 65% of people who purchase its individual plans (vs group or employer coverage) have grandfathered plans. Many of the remaining 35% already have plans that include most — if not all — of the essential health benefits and so their coverage and premiums will not change dramatically. Nevertheless, they may receive a letter notifying them of their options to update their coverage to comply with the law. Again, this only applies to people who enrolled in their current plan after March 23, 2010.
Of those people required to update their plans, some may see their total premiums go up.
However, many will now qualify for tax credits to buy updated insurance plans via the new marketplace — and so the amount they actually pay could be slashed dramatically. Those with incomes between 100% and 400% of the poverty level will qualify for tax credits. For example, a family of four earning between $23,050 and $92,200 will qualify for tax credits. Until HealthCare.gov is working properly, you can go to InsureKS.org to see how much tax-credit assistance you qualify for.
→ More coverage of Obamacare at khi.org/healthreform.
Kansans frustrated by their inability to shop for health insurance coverage on the federal marketplace website can now do much of the legwork on the state insurance department’s updated website, InsureKS.org.
Late Friday afternoon the department upgraded the site first launched in early September so that consumers in any county can access a list of the health plans available in the federal marketplace along with their prices.
“We’re pretty excited because if somebody goes on our website they can find out whether they qualify for a tax credit and they can take that information and look at the rates and plans and come pretty close to figuring out which plan they're interested in when they’re able to get on the (federal) marketplace. So, hopefully it will give them a little bit of a head start,” said Linda Sheppard, director of health care policy and analysis at the insurance department.
Consumers can do about everything on the insurance department website that they could do on the official federal site – if it were working – except finalize a purchase.
The marketplace website operated by the U.S. Department of Health and Human Services — HealthCare.gov — has been plagued by problems and has been mostly inoperable since its launch Oct. 1, though there were indications of progress Friday.
Officials with a consortium of nonprofit organizations training and deploying navigators to help consumers shop for plans said that, by day's end, five Kansans had managed to purchase coverage using the federal marketplace.
Sheppard said Kansas officials didn’t seek federal approval to add the work-around tools to the state site, which also includes a feature allowing users to locate navigators and marketplace-certified agents nearest them.
Kansas is one of 36 states that opted to have the federal government design and operate its marketplace rather than building its own.
Republican Gov. Sam Brownback returned a $31.5 million federal grant that Insurance Commissioner Sandy Praeger had obtained to build a state-based marketplace, sometimes called an "exchange."
Sheppard said Kansans she's talked to at meetings across the state haven’t been angry about their inability to use the marketplace, but they have been frustrated by their inability to get information about the coverage options available to them.
“They don’t seem angry about it, they just generally say something like, ‘Yeah, that’s what I expected,’” she said.
A new report finds some 78,000 Kansans are among those not poor enough for Medicaid but too poor to qualify for tax subsidies under the Affordable Care Act
About 78,000 Kansans are among 5.2 million poor, uninsured adults who will fall into the “coverage gap,” created by 26 states choosing not to expand Medicaid under the federal health reform law next year, according to a study released today by the Kaiser Family Foundation.
These people are projected to have incomes too high to qualify for their state’s existing Medicaid programs, but below the federal poverty level (nearly $11,500 for an individual) required to be eligible for tax subsidies to buy private coverage on the new insurance marketplaces set up by the Affordable Care Act, or ACA. Medicaid is the state-federal health insurance program for the poor.
“Millions of adults will remain outside the reach of the ACA and continue to have limited, if any, options for health coverage,” the study concludes.
The law provides full federal funding for three years to states that expand Medicaid to cover residents under 138 percent of the poverty level (or just under $15,900 for an individual).
But the Supreme Court made that requirement effectively optional for states, and most Republican led-states have opted against expanding the program.
There is no deadline by which states must opt to expand Medicaid, and a few states are still considering it.
Nearly half of the uninsured in the coverage gap live in Texas (1 million), Florida (763,980) and Georgia (409,350) — largely because those states have the most uninsured and limited Medicaid eligibility today.
Kansas among states with coverage gaps
In Kansas, about 78,000 adults will fall into the coverage gap, according to the report.
Alabama, Mississippi and Louisiana also will be especially hard hit, with more than a third of their uninsured adults falling into the coverage gap next year, the study shows.
In Kansas, 29 percent of uninsured adults fall into the coverage gap.
These states will feel the pinch because they have higher rates of poor uninsured adults and their existing Medicaid programs have some of the nation’s the tightest eligibility rules.
In Kansas, adults with children are eligible for Medicaid coverage if they earn less than $7,421 (for a family of three). Childless Kansans are not eligible regardless of income level.
Gov. Sam Brownback and the Legislature have shown no desire to expand Medicaid and seem unlikely to approve it this year.
Federal officials have said they have little ability to address the coverage gap, given the Supreme Court's ruling. The only way to fix that would be for Congress to modify the health reform law.
A new pilot program aimed at improving billing and collections at local health departments is beginning at a critical time — just as tens of thousands of Kansans are expected to get insurance coverage under the Affordable Care Act (ACA).
Currently, billing mistakes are costing many local health departments when it comes to collecting from private insurance companies and the Medicaid program. But that cost isn’t as significant as it could be because many of those now being served by departments are uninsured and so pay their bills directly.
The payer mix is expected to change as more Kansans obtain private coverage through the new online marketplace healthcare.gov, provided federal officials are able to solve technical problems that have plagued the website since its Oct. 1st launch.
A decision by Gov. Sam Brownback and the Republican-controlled legislature to expand eligibility for the state’s Medicaid program – known as KanCare – also would substantially increase the pressure on local health departments to improve their billing procedures. However, neither appear poised to authorize that expansion soon.
The pilot — spearheaded by the Kansas Foundation for Medical Care (KMFC), a Quality Improvement Organization — is beginning in this month in Douglas, Harper, Reno and Sumner counties.
Each of the four local health departments (LHDs) will receive up to $1,360 to train staff members on billing techniques that will maximize reimbursement for services provided to privately insured clients, said Stephanie Lambert-Barth, manager for KFMC's Immunization Billing Project.
“Training of LHD billing staff will streamline the billing processes and improve billing outcomes, resulting in a return on the training investment. Demonstrating this return on investment may help other Kansas LHDs make the case to fund training for their billing staff,” she said.
The Lawrence-Douglas County health department is one of the largest and best funded in the state. Nevertheless it only has one office assistant working two days a week on billing, said director Dan Partridge.
"For us billing has been a challenge because our capacity to dedicate and train staff has been limited," Partridge said.
Currently about 3/4 of his department's revenue comes from clients who pay their bills directly. The agency has an 85 percent collection rate among those clients. However, it collects only 57 percent of the amount it bills to Medicaid and only 20 percent of what it bills to clients covered by private insurance.
"Most of it is coding errors," Partridge said. "We feel confident our participation (in the pilot) will lead to improved collection rates. We also want to be prepared for whatever shift the ACA will create within our revenue streams as private insurance coverage increases."
KFMC’s Lambert-Barth said that, while the project is focused on improving reimbursement rates for immunization services, the plan is to evaluate all claims billed by the health department, including family planning services, for example.
"Our project's final product is a strategic plan report, which will include recommendations for how to move forward. It is not yet clear what those specific recommendations will be, but if the pilot goes well then expansion (of the pilot) would make sense,” she said.
The pilot project’s website contains links to billing resources, tools, project updates and other related information.
State lawmakers' resistance to expanding Medicaid “just makes no sense,” Kansas Insurance Commissioner Sandy Praeger said Thursday, speaking at a meeting of safety-net clinic officials.
Many legislators, she said, “really don't understand” the consequences of not expanding Medicaid because there was “almost no discussion of the Affordable Care Act” during this year's legislative session.
Praeger, who has been hosting a series of informational forums on the health reform law for the past three weeks, said legislators will have a hard time not addressing Medicaid expansion in 2014.
“People are starting to understand what the lack of Medicaid expansion means,” she said. “And I think legislators are starting to hear from them.”
Currently in Kansas, non-disabled adults with children are eligible for Medicaid if their incomes fall below 32 percent of the federal poverty level, roughly $6,250 a year for a family of three.
“Let me put that in perspective for you,” said Health Reform Resource Project Director Sheldon Weisgrau, who also spoke at the annual conference of the Kansas Association for the Medically Underserved. “That means that a mother with two kids who works a minimum-wage job half-time makes too much money to be on Medicaid,” though the children would qualify.
Childless, non-disabled adults, are not eligible for Medicaid “under any circumstances,” he said.
Under the Affordable Care Act, commonly known as Obamacare, the federal government will cover all or most of the costs of expanding Medicaid to include adults whose incomes fall below 138 percent of the poverty level. However, expansion is optional and up to the political leaders in each state.
Low-income children and pregnant women already are covered under Medicaid.
In Kansas, Medicaid expansion would insure about 130,000 adults who are currently uninsured, according to various estimates.
Gov. Sam Brownback and the Republican majorities in both the House and Senate have shelved the Medicaid-expansion debate, saying they doubt the federal government will be able to keep its promise to cover most of the costs.
Cost of expansion
If adopted, Medicaid expansion would cost the state about $625 million over 10 years, according to a projection by the Brownback administration.
“To put that number into context, last year the State of Kansas spent $1.2 billion in state money on Medicaid,” Weisgrau said. “This increase of $625 million is over 10 years, but the Legislature decided we could not afford that.”
The administration's calculation, he said, did not include the offsetting costs to local programs — county health departments, safety-net clinics, hospitals — for covering the needs of the uninsured.
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.
Advocates pushing Kansas officials to expand Medicaid acknowledge it is unlikely they will achieve their goal this year.
But they said they remain hopeful they can convince Gov. Sam Brownback and legislators next year to make more Kansans eligible for the program.
“If it’s not going to happen the first year, we’ll continue to build grassroots support. We’re not giving up,” said Anna Lambertson, director of the Kansas Health Consumer Coalition, one of the groups pushing for expansion.
Medicaid, known in Kansas as KanCare, currently provides medical and long-term living assistance services for about 380,000 poor, disabled and elderly Kansans. Expansion could increase enrollment in the program by as many as 240,000, according to various projections.
The federal Affordable Care Act initially required states to expand Medicaid eligibility. However, the U.S. Supreme Court decision that upheld the law made expansion optional for states.
Expansion would have a bigger impact in Kansas than in many other states. That’s because the state’s current eligibility criteria exclude all but the poorest adults. Only those with children and incomes less than 32 percent of the federal poverty level — about $6,000 a year for a family of four — can qualify. Implementing expansion would mean that adults in that same family of four could make more than $31,000 a year and qualify.
The Brownback administration has estimated that expanding eligibility for the $3.2 billion program would cost the state an additional $600 million over 10 years.
Door still open
Whenever asked about expansion, Brownback says things that suggest he’s more likely to say “no” than “yes” to it. But advocates said they remain encouraged by the fact he hasn’t rejected the idea.
“If he’s really looking at the options with an open mind — as he himself has said he’s doing — then I see him taking his time (to decide) as beneficial,” Lambertson said. “I’d rather that he take his time than just say ‘no’.”
Last week, Brownback again expressed doubts that the federal government could afford to keep its promise to cover all the costs of expansion for the first three years and no less than 90 percent thereafter. Despite his misgivings, he said, he continues to have “active conversations” with expansion advocates and legislators on the topic.
“It’s in the legislative process,” Brownback said. “Expansion would have to be addressed by the Legislature. They would have to budget it.”
Brownback’s requirement that legislators budget for it before he would sign off on it has advocates convinced a decision won’t be made this year.
Members of the House-Senate conference committee negotiating a final version of the fiscal 2014-15 budgets are scheduled to return to the bargaining table early next month when the Legislature returns to Topeka for what leaders hope will be a brief wrap-up session.
The first 90 days of KanCare have passed, which means the transition period during which the state's 380,000 Medicaid beneficiaries could switch managed-care health plans this year is over.
That is important — for among other reasons — because many KanCare enrollees may find themselves in situations where the medical providers they are accustomed to using are not in the network of the KanCare plan to which they were assigned or chose themselves before the changeover period ended April 4.
And as the 90th day was marked last week, many Medicaid providers continued to report persistent problems with the program that was rolled out Jan. 1 by the administration of Gov. Sam Brownback.
'Number of issues'
"We still have a number of issues that pharmacists have to deal with," said Michael Larkin, executive secretary of the Kansas Pharmacists Association. "In the big picture, our number one concern is assuring that the managed care organizations adhere to the contracts signed (with the state) back in June."
Larkin said the contracts called for the KanCare companies to use a "transparent" process for determining the reimbursement rates for pharmacy services. In the association's view, he said, those contract provisions have been ignored by the KanCare companies "across the board."
"And also the managed care organizations when they do change their pricing are supposed to notify us, let it be known to everyone that the pricing has changed. I don't know that they're doing that either," Larkin said.
He said a meeting was held last month with KanCare company representatives to try to resolve the concerns but that the problems continue apparently because "the wrong people were in the room to discuss that."
Larkin said he was trying to set up another meeting that also would include state officials.
Association members also are reporting reduced or delayed payments from the KanCare companies for durable medical equipment.
"They're having trouble getting proper reimbursement and knowing, if in fact, they will be reimbursed before the equipment goes out the door," Larkin said.
Administration officials acknowledged some ongoing problems but said on whole they are pleased with the program's progress.
"It's been very workmanlike," Lt. Gov. Jeff Colyer said of the transition.
He also repeated what administration officials have said since the first month of KanCare: "There haven't been as many bumps in the road as we expected. Everybody's been very committed to working with people who are having issues."
Larkin said from the pharmacists' perspective the problems have been "something in between a bump in the road and grave concern."
"We're hopeful things will turn out for us. So far, it hasn't happened," Larkin said.
After months of trying to dance around the politically charged issue, the administration of Gov. Sam Brownback has openly acknowledged that the $139 million Medicaid enrollment system that it is building will be interconnected with the online health insurance exchange required by the Affordable Care Act, and that the system will be ready to go by the Oct. 1 federal deadline.
“It's just a connectivity kind of a thing,” said Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, which is spearheading the project to overhaul the 26-year-old, paper-based system to a modern online one.
“I certainly appreciate the concerns that are tied to the political angst, but this program was well on its way when I came on board and my job is to make sure it gets completed successfully,” he said.
Entangled with the exchange
Overhauling the state’s antiquated Medicaid enrollment system has been in the works since at least 2009, when the project was called K-MED.
The project stalled briefly in August 2011, when Brownback returned a $31.5 million federal grant, most of which had been earmarked for developing the state’s new Medicaid enrollment system. Brownback said he was returning the grant because it was tied to the Affordable Care Act — which he he had pledged he would not implement prior to the U.S. Supreme Court ruling on the law, and later until after the 2012 federal elections.
Then that same month, administration officials announced a new contract with Accenture to develop the Kansas Eligibility and Enforcement System (KEES), using $118 million in federal funds to pay for the $139 million projected cost. K-MED became KEES.
A key condition of the federal funding was that the KEES system would have to be “interoperable” with the coming health insurance exchange — an online marketplace scheduled to launch Oct. 1 where consumers can compare and buy coverage that will begin Jan. 1, 2014.
In Kansas and the 25 other states that elected not to run their own health insurance exchanges, the federal government will build and operate them.
Moser said interoperability of KEES and the exchange means that — for consumers — there will be a single entry point for enrolling in private health insurance or in Medicaid, the state-federal health care program for low-income, elderly and disabled persons. Medicaid in Kansas is known as KanCare.
“You enter in some information, most of it is going to be yes/no. If you're eligible for Medicaid then it would pop up the KEES patient portal,” Moser said. “If it shows that your income level is such that you don't qualify for Medicaid…it's going to push your information over to the federal exchange. So those two systems literally will be handing back and forth inquiries.”
Moser said the fact KEES would interface with the insurance exchange was no different than integration with other federal computer systems, such as Homeland Security or the Internal Revenue Service.
“It doesn't really have that significant of an implication in my mind. But then again, I'm a physician and a little bit more patient-centered and look at the convenience factor. If that person is in a hospital setting and I think they need admitted, but they're worried about the cost because they don't have coverage, I'd like to be able to determine at that point in time 'Are they eligible for coverage' and use that as leverage to get them in to the hospital,” Moser said.
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.”
A study released today by the Kansas Hospital Association says that expanding Medicaid eligibility to levels called for in the federal health reform law would pump more than $3 billion into the state’s economy and create 4,000 new jobs by 2020.
The study, done for the association by the Center for Health Policy Research at George Washington University and Regional Economic Models, Inc., also shows that expansion would save the state more than it would cost.
Tom Bell, the association’s chief executive, said the projected economic benefits were too significant to be ignored by Gov. Sam Brownback and legislative leaders as they consider whether or not to expand eligibility for the healthcare program that serves poor, elderly and disabled Kansans.
Brownback has been a vocal opponent of the Affordable Care Act but has not made a decision on Medicaid expansion, which was made optional for states as the result of last year’s U.S. Supreme Court decision upholding the law.
“I think from our perspective, it’s not unlike the state landing a huge federal contract,” Bell said.
The impact of the expansion on the Kansas economy could rival that of the National Bio and Agro-Defense Facility in Manhattan, Bell said.
“That’s the way we look at it, as an opportunity for our state,” he said.
Bigger impact in Kansas
Since Jan. 1 in Kansas, the Medicaid program has operated under the name of KanCare. Three health insurance companies are under contract with the state administer it.
The health reform law requires that the federal government cover state costs of expanding Medicaid for three years. After that, the federal share would recede gradually until it reaches 90 percent, where it would remain.
Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level (FPF) — currently $5,900 a year for a family of four.
Because those numbers are so low, expanding Medicaid would have a bigger impact in Kansas than in many other states by making all Kansans who earn up to 133 percent of FPL — $30,660 for a family of four — eligible for the program.
Various estimates suggest that expansion could add between 226,000 and 240,000 Kansans to the 380,000 now enrolled in Medicaid.
Net benefit to the state
A Kansas Department of Health and Environment report released last week estimated Medicaid costs would climb by $513 million over 10 years regardless of whether the state expanded eligibility for the program. That’s because heightened attention surrounding the expansion issue is expected to prompt many people who already are eligible but not enrolled to sign up.
Covering only those who are made eligible by the expansion would cost another $600 million over 10 years, the KDHE report said. Even so, the hospital association report said that expanding Medicaid would produce a net savings to the state of $82 million from 2014 to 2020.
“That’s front loaded into those first three years, but it’s still a substantial net benefit,” Bell said.
Brownback has not ruled out expansion but neither has his administration shown much, if any, enthusiasm for the idea. Reacting to the KDHE cost estimate, Sherriene Jones-Sontag, the governor’s chief spokesperson, said expanding Medicaid would affect the state’s ability to fund other “core responsibilities.” The impact would be even greater “if the federal government fails to keep its promise to pay for its part of the expansion,” she said.
Bell said administrators at the association’s 126 member hospitals understand Brownback’s concerns, which are shared by many legislators. But he said they believe the Medicaid expansion dollars are needed to offset the anticipated loss of other federal funds that hospitals have used to cover the cost of caring for the uninsured.
“From an economic perspective for our members — especially those that treat a higher number of uninsured — they think it makes great sense to take a serious look this and see if we can make it work,” Bell said.
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.
The state health department earlier this month stopped analyzing HIV tests for many of the state's medium and small counties and also stopped providing rapid or oral test kits, which is creating a new burden for cash-strapped health departments and creating some uncertainty whether they can continue testing for the disease in some rural locations around Kansas.
Compounding the problem, some local department heads said, was the short notice they received that the services previously provided free to them by the state were being terminated.
Notification letters from the Kansas Department of Health and Environment went out in late November, they said, giving them only about five weeks, including the holidays, to make alternate arrangements in time for Jan. 1, when the new policy kicked in.
"It's another nail," said Julia Hulsey, director of the Reno County Health Department in Hutchinson.
Kansas routinely ranks low nationally in its support for public health agencies.
New cost for patients
Hulsey said her department was able to contract with a laboratory in Wichita that agreed to provide the testing supplies for free (though it will charge for the lab work) and so her agency plans to continue the tests but will start charging patients for them probably by Feb. 1, once she has a clear picture of her agency's new, added costs.
"I don't have that whole cost figured out yet," Hulsey said, "but, of course, it will be more than KDHE because they didn't charge for it."
She said her goal would be to price the tests as low as possible to not discourage people from getting them. She said the department historically has performed about 220 tests a year.
Dan Partridge, director of the Lawrence-Douglas County Health Department, said Lawrence Memorial Hospital agreed to help with the testing after KDHE withdrew the services, so it will only cost his agency about $9,000 a year to continue the testing instead of about $18,000. But he said the new obligation signals another state retreat from support for local health departments.
Urged to continue
State officials, in their November letter, urged the local departments to try to continue the services on their own.
KDHE "would like to encourage your agency to continue to provide HIV testing to clients requesting an HIV test, especially those reporting high-risk behaviors," the letter stated. "However, any test conducted at your agency beginning January 1, 2013, and continuing thereafter will need to be paid for by either your agency or by the client through insurance, public assistance programs, or out-of-pocket."
But a spokesperson for the state's local health departments said it would be difficult or impossible for some smaller departments to pay for the tests on their own.
"I suspect there will be some health departments in some areas that won't be able to find a workaround like Douglas County," said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. "I couldn't give you a firm number, but in some of those rural areas they may not have another option for testing."
The state’s letter also included some cost-comparison information to help the local departments shop for testing materials, lab work and other necessities of the program.
Hulsey in Reno County said she ended up considering four or five outside laboratories between the time she got the letter and Jan. 1 when the state assistance stopped.
"We got very short notice on this," she said. "And then having to go negotiate for ourselves...you never know if you're getting the best price."
State officials said they had to reduce the services because of cutbacks in a federal testing program administered by the Centers for Disease Control and Prevention that has been reconfigured to focus on areas where the incidence of HIV/AIDS is greatest.
In the past, according to state officials, 40 local health departments received the free services. That number has been trimmed to 10, according to Ralph Wilmoth, director of the HIV/AIDS program at KDHE. The 10 county health departments that will continue to get the aid include Johnson, Sedgwick, Wyandotte and Shawnee, the state’s most heavily populated, and also Crawford, Pratt, Riley, Saline, Thomas and Trego counties.
The state also will provide the testing services to various organizations other than health departments in about a dozen counties. For example, in Douglas County the services will be continued for the Douglas County Aids Project, a non-profit group. In Reno County, the services will continue for the state prison in Hutchinson.
Wilmoth said the CDC made the program changes in anticipation of the full-scale implementation of the Affordable Care Act, which begins Jan. 1, 2014. Millions of Americans are expected to become newly eligible for Medicaid then and HIV testing is among the health services covered by Medicaid.
Linked to Medicaid expansion
But when the U.S. Supreme Court ruled on the health reform law, it concluded that each state had the option to not expand its Medicaid eligibility and Gov. Sam Brownback nor the Kansas Legislature have yet determined whether Kansas will broaden access to its program, which is known as KanCare.
Many Kansas hospital officials say they are worried that if state policymakers choose not to expand eligibility for the state’s Medicaid program, the hospitals will see a significant drop in the money they receive to help care for patients who can’t or won’t pay their medical bills.
Currently, 64 of the state’s 127 hospitals divide about $51.3 million a year in what are called Medicaid disproportionate share payments.
They use the money, a mix of federal and state dollars, to offset some of the costs of caring for the uninsured.
“It’s a significant amount of funding for us,” said Bruce Witt, director of governmental relations at Via Christi Health in Wichita.
In the current fiscal year, Via Christi Health is expected to receive almost $13 million from the disproportionate share payments, the most of any health care provider in the state.
Under the Affordable Care Act, also known as Obamacare, those payments are to be significantly reduced, starting in October.
“We’re being told that ‘disproportionate share’ won’t be completely phased out, but that roughly 50 percent will be going away,” said Tom Bell, chief executive of the Kansas Hospital Association. “It may end up being somewhere between 50 and 75 percent. We don’t know at this point.”
Though Via Christi could expect to lose the most dollars, the smaller, rural hospitals likely would be the hardest hit proportionately based on an analysis done for the KHI News Service by its parent organization, the Kansas Health Institute. The analysis calculated the likely revenue hit on each Kansas hospital based on recent payment histories, bed counts and inpatient stays.
State option on Medicaid
The law’s design, Bell said, preceded the U.S. Supreme Court’s June 28, 2012 ruling that gives states the option of choosing to not expand their Medicaid coverage to include non-disabled, childless adults whose incomes fall below 133 percent of the federal poverty level.
Since the ruling, governors in at least 10 states – Alabama, Georgia, Idaho, Louisiana, Maine, Mississippi, South Carolina, South Dakota, Oklahoma, and Texas - have said they will not expand Medicaid eligibility.
“Our lieutenant governor is saying he’s not sure that DSH (disproportionate share) is going away because the (U.S.) Supreme Court has said the federal government can’t penalize states for not going along with the Medicaid expansion,” said Shawn Rossi, a vice president with the Mississippi Hospital Association.
“We don’t know if that’s a correct assumption,” Rossi said, “but we are for sure telling our legislators that if DSH goes away, we’re definitely going to need something to take its place. We see a very large number of people who are uninsured.”
Brownback looking it over
Kansas’ Gov. Sam Brownback has been an outspoken opponent of the Affordable Care Act, has not yet decided whether to implement the Medicaid expansion.
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.
The Brownback administration has not ruled out implementing the Medicaid expansion called for in the federal health reform law.
But a spokesman today told members of the Legislature’s Joint Committee on Health Policy Oversight that prior to making a decision administration officials want to develop their own estimate of how many Kansans are likely to sign up for the health care program and how much the expansion would cost the state.
“We’re continuing to study the issue,” said Mark Dugan, chief of staff for Lt. Gov. Jeff Colyer. “We would like to come to you with our own numbers.”
Currently, there are several competing estimates of how the expansion would affect Medicaid enrollment and the cost of the program. The latest, released earlier this month by the Kansas Health Institute indicated that approximately 240,000 additional low-income, disabled and elderly Kansans would enroll in a program that currently serves about 380,000. According to the KHI analysis, expanding Medicaid would cost the state an additional $519 million between its implementation in 2014 and 2020.
The KHI projections are higher than those in a 2010 report prepared for the now defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis done in 2010 by the Kaiser Family Foundation. However, they considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act.
The KHI News Service is an editorially independent program of KHI.
Currently, Kansas’ Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and only then if they earn less than 32 percent of the Federal Poverty Level — $5,900 a year for a family of four.
The ACA expansion would have a bigger impact in Kansas than many states. It would raise the eligibility threshold for all Kansans to 133 percent of FPL — $30,660 for a family of four.
Two of the four legislators who braved inclement weather to attend Thursday’s meeting of the 12-member committee made it clear that they favored the expansion.
Rep. Don Hill, a moderate Republican from Emporia, said that virtually all legislators regardless of party and ideology agree that the current health care system is broken and in need of reform to lower costs and reduce the number of people who are either uninsured and under-insured.
He said while the ACA is far from perfect, “it has some redeeming elements.” One of those, he said, is the Medicaid expansion because of its potential to extend coverage to many of the state’s 365,000 uninsured.
Citing the federal government’s promise to shoulder the cost of serving all those made eligible by the expansion for the first three years, Sen. David Haley, a Kansas City Democrat, asked, “Why can’t we cover more Kansans and why shouldn’t we?”
“I think we’re going to take a good look at it,” Dugan answered.
But, Dugan said, a factor that must be considered is whether or not the cash-strapped federal government can be counted on to keep its funding promise. After paying all of the costs of the expansion for three years, the federal government would gradually reduce its commitment until it reached 90 percent, where it would be maintained.
“He (Gov. Brownback) doesn’t have a high degree of confidence in the federal government maintaining that 90 percent commitment over the long term,” Dugan said.
Dugan said the federal government missed an opportunity to negotiate a compromise with Republican governors skeptical of the expansion when it rejected the idea of allowing states to increase eligibility to only 100 percent of FPL.
“That was an opportunity for middle ground that was lost,” he said.
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.”
Like Kansas Gov. Sam Brownback, Bob Laszewski is a staunch opponent of the Affordable Care Act.
Despite that, the Washington, D.C. consultant said at a meeting here today that Brownback is making a mistake by refusing to partner with the federal government to run the Kansas health insurance purchasing exchange that the law requires to be operational by 2014.
“Do the partnership. That is a no-brainer,” Laszewski said to about 100 legislators, lobbyists and health care providers at a meeting sponsored by the Kansas Health Institute, the parent organization of the KHI News Service.
Laszewski, whose client list consists mostly of health insurance companies, said it’s time for opponents of the law to stop fighting it and start doing what they can to ensure that it is implemented in a way that does the least harm to the industry and consumers. One way to do that, he said, would be to implement exchanges – new online marketplaces – that encourage competition among insurance companies rather than rely on regulations to moderate increases in premiums.
“Putting the insurance exchange up doesn’t mean you support the thing (the reform law), it means you are trying to minimize the damage,” Laszewski said, predicting that premiums in the individual and small-group markets would go up no matter who runs the exchanges.
Brownback last year blocked Kansas Insurance Commissioner Sandy Praeger’s attempts to establish a state-operated exchange, returning a $31.5 million federal grant in the process. Last month, the governor told Praeger, who also is a Republican, that he would not support her efforts to partner with the federal government to operate and fund the Kansas exchange.
“Kansans feel Obamacare is an overreach by Washington and have rejected the state’s participation in this federal program," Brownback said, explaining his decision.
Praeger, who also spoke at the KHI meeting, said she would try once more before a Feb. 15 federal deadline to convince the governor and legislators that partnering on an exchange would be better than allowing the federal government to run it. Federal officials recently extended the deadline in an effort to accommodate states where governors had opposed or held out on state participation pending the outcome of the November national elections.
“There is still some opportunity for us to retain some control,” Praeger said. “Our department looks forward to working with the Legislature and the governor to see if that still is an option. The decision really rests with them.”
Praeger said partnering with the federal government would allow her department to retain authority to approve the plans marketed in the exchange and manage consumer protection efforts. She said it might also prevent federal officials from over-regulating the exchange.
The ACA calls on states to expand Medicaid eligibility to include adults earning up to 138 percent of the federal poverty level — $30,660 a year for a family of four. But the U.S. Supreme Court decision earlier this year that upheld the law also made the program expansion optional for states.
Implementing the expansion in Kansas would make more than 300,000 additional adults eligible for a program that today serves approximately 380,000 Kansans – mainly women, children, seniors in nursing homes and people with disabilities.
A KHI analysis handed out at the meeting estimated that about 240,000 additional Kansans would enroll in Medicaid if the expansion were implemented in 2014, including 122,185 adults and 117,886 children. According to the analysis, expanding Medicaid would cost the state an additional $519 million between 2014 and 2020.
The projected cost and enrollment figures in the KHI analysis are higher than those in a 2010 report prepared for the now-defunct Kansas Health Policy Authority and also higher than those in a state-by-state analysis prepared in 2010 by the Kaiser Family Foundation. But the costs projected in the KHI analysis were considerably less than those estimated in 2011 by the Kansas Policy Institute, a conservative think-tank based in Wichita, which has opposed the Affordable Care Act and its implementation. The Kansas Policy Institute also projected the program’s cost through 2023.
Currently, the state’s Medicaid eligibility criteria for adults are among the most restrictive in the nation. Only those with children are eligible and then only if they earn less than 32 percent of FPL – $5,900 a year for a family of four.
Brownback hasn’t said whether he plans to implement or recommend the expansion for Kansas. But he has said that he doubts the federal government would keep its promise to initially pay 100 percent of the cost of serving all those newly made eligible by the Medicaid expansion. Under current law, the federal commitment would be good for the first three years, drop to 95 percent in 2017 and then to 90 percent in 2020, where it would remain.
Laszewski said covering currently uninsured Kansans in Medicaid would be significantly cheaper for taxpayers than providing them with tax credits to purchase private coverage in the exchange. And he said by agreeing to the expansion, Brownback and other Republican governors might be able to get federal officials to agree to their long-standing request to convert the program to block grants to states with fewer restrictions on how the money is spent.
“Put up or shut up, that’s what I say to Republican governors,” Laszewski said. “It gives you leverage to get what you’ve always said you wanted — autonomy. Go to the Obama administration and say, ‘OK, we’ll expand Medicaid but we’re not going to do it your way.’”
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.
About 100 people rallied outside the Kansas Statehouse Nov. 9, urging state officials to expand Medicaid eligiblity as provided for in the federal health reform law.
A Lawrence pastor cast the expansion as a Christian imperative during a call-and-response exercise with the crowd.
“If Jesus was up in the Capitol would he make a choice to keep 130,000 people without care?” said the Rev. Joshua Longbottom, associate pastor at Plymouth Congregational Church in Lawrence.
"No," the crowd shouted.
“If Jesus was up in the Capitol, would he tell families that they just need to get better jobs so that they could afford to take care of themselves?” Longbottom asked.
Again, the answer was "no."
“Did Jesus say, ‘I’m sorry you can’t get to the well, Mr. Leper, but you need to cultivate some self-reliance’?” Longbottom said.
“No,” the crowd yelled.
“So I ask the question, Gov. Brownback, ‘What would Jesus do?” Longbottom said. “I thought the mark of his ministry was caring for the ill, caring for the sick, caring for the dispossessed, caring for the marginalized, caring the first for the least.”
Longbottom said he hoped the governor wasn’t a “…politician who puts on his Christianity like it’s a cardigan (sweater), using it to gain access to a constituency.”
Brownback, a conservative Republican, has been outspoken about his Christianity and penned a spiritual autobiography titled "From Power to Purpose."
He's been a consistent political foe of the Affordable Care Act, also known as ObamaCare, first in the U.S. Senate and later as governor.
He has said repeatedly that the majority of Kansans are opposed to the reform law and cites the success of the law's opponents in recent state elections as the proof.
Expansion not ruled out
Last week, the governor announced that he would block the state’s participation in a state-federal insurance exchange, one of the hallmarks of the new law. But unlike some Republican governors, he hasn't ruled out the possibility he would support some sort of Medicaid expansion.
"The Medicaid expansion is a separate issue" from the insurance exchange, said chief Brownback spokesperson Sherriene Jones-Sontag in an email Friday to KHI News Service in response to a question asking if the governor would oppose opening up the program.
"We are continuing to discuss options and alternatives with like-minded states and with our legislative partners in Kansas," she said.
The U.S. Supreme Court has upheld the Affordable Care Act, but said the law couldn't oblige states to expand their Medicaid programs. The law gives states the option of expanding their Medicaid programs to include adults earning up to 133 percent of federal poverty guidelines.
Detailed spending proposals for the coming fiscal year prepared by officials at the state’s three top health agencies outline how Gov. Sam Brownback’s administration is planning to cap or cut spending on a broad range of health-related programs.
The governor’s formal budget recommendations for fiscal year 2014, which begins July 1, 2013, won’t be delivered to the Legislature until January when its new session begins. But agency chiefs were told as early as August by the governor to keep spending in check and to present alternatives for cutting 10 percent from each department’s upcoming state general fund budget.
The documents presented by the Kansas Department of Health and Environment, the Kansas Department for Children and Families, and the Kansas Department for Aging and Disability Services to the state budget office as part of the governor’s budget building process were obtained by KHI News Service and are made available here.
Administration officials declined to answer questions about their spending plans.
“We will not comment on the budget proposal at this time,” said Angela de Rocha, spokesperson for the Kansas Department for Aging and Disability Services and the Kansas Department for Children and Families.
Fading state aid
But there is abundant comment contained in the budget documents themselves and representatives of many, if not all, the organizations and programs that rely upon state health dollars have been advised informally within the past couple of weeks by administration officials of the planned spending limits and possible cuts. However, none of the representatives interviewed by KHI News Service had been given the full details laid out in the documents.
“We actually had a meeting with the secretary (Shawn Sullivan of the Kansas Department for Aging and Disability Services) but he didn’t give us any numbers,” said Cindy Luxem, chief executive of the Kansas Health Care Association, which represents for-profit nursing homes and some of the state’s providers of home and community-based services for the elderly.
“The providers at this stage of the game are not getting any kind of bump in the rates (for Medicaid services). The intention of the state is to keep the rates flat, essentially for the next two years, is what he told us,” she said.
Michelle Ponce, executive director of the Kansas Association of Local Health Departments, said she was alerted that the “reduced resources” budget proposed by the Kansas Department of Health and Environment could mean a cut in state aid to the local health agencies.
If adopted as outlined in the agency’s budget plan, 40 local health departments would see their state grants cut with the biggest decreases falling on the state’s largest local agencies.
“It’s maybe too early to tell you exactly what it would all mean,” Ponce said. “But it is unlikely all those agencies could absorb those cuts and maintain current services.”
Ponce said state support for local public health agencies hadn’t increased in years despite the added costs of inflation so any cuts would fall all the harder on the departments. She said association research had showed that since at least 1984, local governments have been stuck with absorbing the growing costs of health department programs as state aid has faded.
Health and Environment
Throughout the budget documents, officials note the need to hold down spending, though sometimes the notes are accompanied by caveats that seem to argue against some of the possible reductions.
At KDHE, officials said “that in recognition of the reality we find ourselves in as a state agency in the current budget environment, the (agency) will not be asking for budget enhancements” in fiscal 2014.
In fact, agency officials proposed total state general fund spending of about $1 million less than for fiscal 2013. About 80 percent of the agency’s $2.6 billion annual budget comes from fees, grants or federal aid as opposed to state tax dollars.
As part of the agency’s “reduced resources” options for cutting 10 percent from the state general fund portion of its budget, officials said they would trim administrative costs by almost 34 percent as a way to forestall more cuts to direct services.
A Kansas health consumer group is planning a post-election rally at the Statehouse in support of expanding the state’s Medicaid program.
Meanwhile, Lt. Gov. Jeff Colyer today headlined an event in Overland Park that was sponsored by a conservative think tank that opposes broadening the Medicaid program. Colyer, however, didn't make explicit what intentions, if any, the administration of Gov. Sam Brownback might have with respect to the issue.
Anna Lambertson, executive director of the Kansas Health Consumer Coalition, said the group "wants to get the dialogue started," on the potential benefits for Kansans, if policymakers here decide they will open up eligibility to include adults earning up to 133 percent of federal poverty guidelines.
Currently, the state's Medicaid program is mostly restricted to poor children, pregnant women, the disabled and the elderly. A non-disabled adult rearing children is currently eligible for Medicaid, if his or her income is below 32 percent of the poverty level – about $5,200 a year for a young mother with two children.
Kansas’ eligibility threshold is among the lowest in the nation.
Affordable Care Act
Under the federal Affordable Care Act, commonly referred to as Obamacare, states would have the option of expanding their Medicaid programs to include adults with incomes at or below 133 percent of federal poverty guidelines or about $30,700 a year for a parent in a four-person household or about $14,900 a year for a childless adult.
Brownback, an outspoken critic of the health reform law, has said he won't consider any aspect of the health reform law's implementation, including a possible Medicaid expansion, until after the Nov. 6 election.
Republican presidential candidate Mitt Romney has pledged to repeal the law, if elected.
Governors in at least six states – Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas – have said they will reject the expansion, citing concerns that it would prove to be too expensive and would expand – rather than shrink – the role of government.
Governors in at least 13 states have said they will expand the program.
According to a preliminary estimate by analysts at the Kansas Health Institute, if the expansion is approved here it could add 130,000 people to Kansas Medicaid by 2019.
Colyer was the main speaker at a Kansas Policy Institute (KPI) meeting today in Overland Park that drew about 60 people. He confined his remarks to describing the administration's rationale and goals for its KanCare Medicaid reforms.
He didn't offer new information, but instead repeated points he and other administration officials have made in various venues since unveiling their plan about a year ago. He didn't touch on the question of Medicaid expansion and did not take queries from the audience before leaving for another engagement.
But earlier in the two-hour event, KPI President Dave Trabert said that expanding Medicaid in the state could increase the program's enrollment by 254,000 people by 2023 and increase state general fund spending on Medicaid by $4.7 billion within a decade.
Under the law, the federal government, starting Jan. 1, 2014, would finance 100 percent of the costs of covering the newly eligible Medicaid enrollees for three years: 2014, 2015, and 2016.
The federal match would drop to 95 percent in 2017; 94 percent in 2018; 93 percent in 2019; and 90 percent in 2020 and beyond.
Currently, the federal government picks up about 57 percent of the state’s Medicaid cost. The state pays the remainder.
Kansas has done a good job the past couple of years covering more children with health insurance.
In 2009, 8.2 per cent of children in Kansas were uninsured, according to a new report from the Georgetown Center on Children and Families. Two years later, the figure was down to 6.4 percent.
That 1.8 percentage point change was the seventh best improvement among states over the period, according to the report. Oregon and Texas improved the most, at 3.1 percentage points each. Missouri — which improved coverage by .2 percentage points — was among the bottom 10 states in reducing the percentage of its uninsured children.
Much of Kansas' increase in coverage for children is attributable to the state's Healthwave program — which insures children whose families earn a little too much to qualify for Medicaid — said Suzanne Wikle, director of policy and research for the non-profit advocacy group, Kansas Action for Children.
“In 2010, the eligibility level for our Healthwave program was increased to account for the fastest-growing group of uninsured children, who were just above the eligibility line at that point. So we made the program available to many more uninsured children in the state. That’s had a very big impact,” Wikle said.
Wikle said the state has also done a better job of marketing the Healthwave program. She's worried, though, that when Healthwave is incorporated into KanCare the name change may confuse some families and cause them to miss out on coverage they’re eligible for.
KanCare is Gov. Sam Brownback's plan to move most of the state's 380,000 Medicaid enrollees into managed care plans operated by three insurance companies.
Currently, large managed care companies only provide services to children and pregnant women from low-income families through HealthWave.
The authors of the Georgetown report say full implementation of the Affordable Care Act is the next opportunity to make substantial progress on insuring children.
If policies proposed by GOP presidential candidate Mitt Romney and his running mate, Paul Ryan, were put in place, among the results would be deep cuts in federal Medicaid spending in Kansas and other states, according to a new report from the Kaiser Commission on Medicaid and the Uninsured.
Nationwide, federal Medicaid spending would drop $1.7 trillion between 2013 and 2022, according to the analysis. Of that, $932 billion would come from repealing the Affordable Care Act. The other $810 billion would come from reductions or savings realized by converting Medicaid to a block grant program for states, capping the amount of federal aid each state could receive.
Romney's Medicaid and budget proposals already have been approved twice in the Republican-dominated U.S. House but were not advanced due to opposition from the Democrats who control the U.S. Senate and the White House.
Romney once again voiced his support for Medicaid block grants and his vow to repeal Obamacare before a national audience during the third presidential debate on Monday night. Romney said the block grants had been successfully tried in Rhode Island and Arizona.
Kansas Gov. Sam Brownback, a Republican, also has championed Medicaid block grants and has asked federal officials to grant one to Kansas as part of a Medicaid waiver application his administration submitted with his plan to put virtually all Kansas Medicaid enrollees into managed care plans run by private insurance companies.
That request is still pending.
Supporters of the Romney Medicaid and budget proposals say they are needed to help cut the federal budget deficit. Critics say they would mean certain cuts in services to Medicaid patients and reduced payments to hospitals and other medical providers.
The Kaiser report, a more detailed reprise of one published in 2011, offered new information by breaking down the projected reductions in federal Medicaid spending in each state, should the Romney proposals be enacted.
Kansas would see a 36 percent reduction in federal Medicaid dollars over the 2013-2022 period, or about $12 billion, according to the report.
Kansas is expected to spend about $3.2 billion on Medicaid next year, with the federal government picking up about 57 percent of that cost.
The analysis drew on estimates prepared earlier by the Congressional Budget Office.
The projected reductions in spending from repealing Obamacare were based on an assumption that each state would expand the number of people eligible for Medicaid services under the law. The U.S. Supreme Court ruled earlier this year that states could not be obliged under the law to expand Medicaid eligibility.
Some Republican governors have signaled that their states would not add people to Medicaid, should the health reform law stay on the books.
Brownback has been a vocal opponent of the Affordable Care Act, but has not yet said whether he would propose expanding the program in Kansas. He has said he expects the reform law to be repealed.
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.
Author and economist John Goodman is scheduled to talk about his ideas for reforming the U.S. health care system at an appearance next week at the University of Kansas Dole Institute of Politics.
Goodman sometimes is called "the father of health savings accounts," and has a new book: "Priceless: Curing the Healthcare Crisis." He co-wrote the 1992 book "Patient Power: Solving America's Healthcare Crisis."
He also developed the Health Care Contract with America, a five-point plan for reforming health care, which has been cited by the Congressional Health Care Caucus, a study group for Republican congresspersons and members of their staffs.
In his new book, among other things, Goodman calls for abolishing Medicaid and moving the program's beneficiaries into private insurance plans. Medicaid enrollees, under his plan, would instead get a $2,000 per person tax credit or refund that they could apply toward the purchase of private health insurance.
He also recommends replacing much of Medicaid outpatient spending for those who are not elderly or disabled with a "health stamp" system modeled on the food stamp program. Beneficiaries would be given the stamps and allowed to spend them as they saw fit for medical care. He also favors abolishing the Children's Health Insurance Program.
The main point of his book is that the current health system has neutered the function of pricing in the health care market, thereby driving up costs. Consumers, he argues, don't pay the real costs of medicine and largely are unaware of them. Providers aren't reimbursed for their true costs but instead take whatever the insurance companies and government are willing to pay.
"So, the overall conclusion of the book is that when we take prices out of the system we create perverse incentives," which have led to higher costs and inefficiencies, Goodman said in an interview with KHI News Service.
Officials at the Kansas Department of Health and Environment said today that they had released additional information from the state's Medicaid managed care contracts sought in an Open Records request filed last week by the Johnson County Commission.
That information followed an earlier release requested by county officials of cost proposals submitted to the state by Amerigroup, Sunflower State Health Plan and United Healthcare, the insurance companies that signed KanCare contracts with the state. State officials said they sent the earlier information to the county officials on Friday. Johnson County officials confirmed Monday that they received that information and were still looking through it on Tuesday.
Some of that insurance company information had been marked "confidential" trade secrets but a KDHE spokesperson said none of the companies had objected to release of the documents.
No objection from companies
Miranda Steele of KDHE said officials at the department of administration had advised the managed care companies that the state had received an Open Records request for the cost proposals, which the state intended to honor.
"According to D of A, none of the MCOs objected at the time. So in our opinion, we did not need to ask the MCOs for consent to send the cost proposal information," to Johnson County, Steele said in an email to KHI News Service.
The state's public disclosure laws include exemptions for trade secrets and some other insurance company financial filings. According to Johnson County officials, they were informed verbally last week that their second information request would be denied because of that exemption. The county then filed a formal written request for the information, which was approved today by Michael G. Smith, associate chief counsel at KDHE's division of health care finance.
The information sent to Johnson County officials this afternoon also was given to KHI News Service upon request and has been posted as attachments to this article.
The newly released documents show some changes in the signed contracts with the companies versus the final cost proposals the firms submitted in May during negotiations with state officials.
Johnson County commissioners have hit a wall in their effort to learn how much the three insurance companies that have signed contracts to run the Kansas Medicaid program will collect in profit or administrative fees.
State officials told them they would not share the requested financial information because it was “proprietary and confidential,” according to Maury Thompson, director of Johnson County Developmental Supports, a county agency that provides services to the disabled and which initiated the information request.
“The county’s opinion is that they are public documents and should be disclosed,” Thompson said. “Once any contract is signed by the board of county commissioners, it is a public document. We're very curious to learn on what legal grounds they think they cannot disclose a signed, legal governmental contract.”
Portions of the state’s KanCare contracts with the three managed-care organizations (MCOs) have been posted on a state website. But not included with those postings were contract attachments A and B, which is where Thompson said commissioners believe the information they seek could be found.
“The underlying intent of obtaining this financial information is to determine what the administrative charge will be to the state for their services and what their medical loss ratio or profit will be from this business,” Thompson said. “What sort of money are we pulling out of the system to pay these three MCOs?”
Kansas is expected to spend about $3.2 billion on Medicaid services in the coming year, or, on average, about $641 per beneficiary per month. Most of that money would go to the insurance companies and their service providers, assuming federal authorities sign off on Gov. Sam Brownback’s plan to implement KanCare starting Jan. 1.
$1 billion in savings pledged
Brownback officials have said they expect the new system to save the state and federal governments $1 billion over the next five years without cutting services and while improving outcomes for Medicaid patients. The claims have been met with some skepticism by county commissioners and legislative critics because details of how the savings might be realized have not been clearly explained. Administration officials have said the savings will come from better coordination of care.
Johnson County officials filed their disclosure request on Thursday and are awaiting the formal denial from state officials so they can file a counter response, Thompson said. Meanwhile, the matter rests in the hands of the county’s lawyers and could lead to a showdown between the local and state officials over the correct interpretation of the state’s Open Records laws.
Thompson said state officials had agreed to release MCO cost proposal information sought in a separate and earlier information request by the county. That information is expected to the commission early this week, but it won’t include the figures commissioners most want to see, he said.
Kansas’ open records laws were intended to make most state and local governmental affairs readily available to public scrutiny. But they include a fairly lengthy list of disclosure exemptions, including some specific to insurance company financial documents, particularly those filed with the Kansas Insurance Department.
There also is a broader exemption in the law for trade secrets. That exemption already has been successfully invoked at least once by one of the managed care companies when the contracts were still being negotiated.
The insurance department rejected a request in April by KHI News Service for financial projections filed by Amerigroup, one of the later successful bidders, after the company asked that the information not be released.
William Sneed, an attorney representing Amerigroup, delivered an April 11 letter to Ken Abitz, director of the insurance department’s financial surveillance unit, citing the trade secrets exemption.
Under that provision of the law, insurance department officials were barred from disclosing the information without the company’s permission.
Laws and practices slow to catch up
Profit-driven Medicaid managed care companies have become some of the nation’s fastest growing and most sophisticated business enterprises.
Directly or indirectly through subcontractors they employ hundreds of thousands of people, report billions of dollars in annual revenues and now, according to federal statistics, have about half the country’s 62 million Medicaid patients enrolled in their plans.
But federal and state laws and practices in some important ways haven’t kept pace with the growth of the managed care companies, which exist in a regulatory and legal space different from that occupied by commercial health insurers, those that provide plans to employers and other private purchasers.
A range of political and economic uncertainties are hindering the ability of hospital officials to plan for the future, according to a report released today by the Kansas Hospital Association.
"The 2012 election has moved the health care debate to the forefront, which is good," the association's chief executive Tom Bell wrote in an editorial accompanying the report. "However, the ongoing nature of the debate complicates hospitals’ ability to make investments."
Among the unknowns cited in the 16-page report:
• The impact of the 2012 election on Medicare reform and on implementation of the Affordable Care Act,
• The uncertain future for federal disproportionate share payments, which compensate hospitals for treating uninsured patients who do not pay, and
• Whether Kansas will expand Medicaid eligibility as provided for under the ACA.
"Cuts to entitlements, especially significant federal cuts to Medicare, could jeopardize hospitals and physicians — limiting access to care," Bell said. "The state’s pending decisions about Medicaid expansion also will have a substantial impact, at a time when hospitals have already surrendered significant Medicare revenue through the ACA with the expectation of expanded coverage."
Under the health reform law, about 130,000 additional Kansans are expected to become eligible for Medicaid in 2014. The state currently has about 350,000 people directly benefiting from Medicaid services. In anticipation that hospitals would be providing less uncompensated care to uninsured patients because of expanded Medicaid eligibility, the ACA also reduced the disproportionate share payments.
While the U.S. Supreme Court ruled much of the health reform law constitutional, its decision granted states leeway to decide if they will expand eligibility.
If Kansas opts not to expand its Medicaid coverage, Bell has said, the state’s hospitals would be put in a position of still having to care for thousands of uninsured people in their emergency rooms while losing millions of dollars in federal disproportionate share payments.
Kansas Gov. Sam Brownback has reiterated his opposition to the Affordable Care Act in statements since the ruling, but he has stopped short of saying the state won’t implement the Medicaid expansion on schedule in 2014.
"Decisions regarding the expansion of Medicaid under Obamacare will not be made until after the November elections. The Brownback administration does not speculate on hypotheticals," according to a statement issued by the Governor's Office.
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.
Talk of repealing the Affordable Care Act is partisan bluster that won’t come to pass even if Republicans sweep the November elections, a top Obama administration health care official predicted at a forum here today.
“Even those people who are talking about repealing, privately, they acknowledge that no, the law is here to stay,” said Jay Angoff, director of the U.S. Health and Human Services Department region that includes Missouri, Kansas, Nebraska and Iowa.
Angoff said that even if Republicans control the White House and U.S. House following the election, they would not have a large enough majority in the Senate to push through legislation to overturn the law. Senate rules require 60 votes to advance most legislation.
Angoff is a former Missouri insurance commissioner and has served as an advisor to Health and Human Services Secretary Kathleen Sebelius on health insurance cost and coverage issues. The forum, organized by the Health Care Foundation of Greater Kansas City, drew an audience of about 50 people.
'When the dust settles'
Kansas State Rep. Jim Denning, an Overland Park Republican, disputed Angoff’s comments, including taking issue with the director’s analysis of the potential congressional repeal. Denning is the retired chief executive of Discover Vision Centers, which has eight locations in Missouri and Kansas.
Angoff also predicted that states eventually would go along with the expansion of Medicaid eligibility included in the Affordable Care Act.
“When the dust settles,” he said, “states are going to realize what a terrific deal this is.”
In its June 28 ruling on the reform law, the U.S. Supreme Court left it up to the states to decide if they want to participate in the expanded Medicaid program.
Under the law, the federal government would pay 100 percent of the costs of the newly eligible Medicaid enrollees when the provision takes effect in 2014, gradually reducing its share to 90 percent by 2020.
The expanded eligibility would take in low-income residents under the age of 65 who earn up to 138 percent of the federal poverty level.
Kansas currently covers more than 350,000 individuals under its Medicaid program. Preliminary estimates project the state’s enrollment could increase by about 130,000 individuals under the health law expansion.
The Kansas Medicaid program costs about $2.8 billion a year. The federal government currently covers about 60 percent of the cost.
Good for small business
Angoff also said the Affordable Care Act was a great deal for small businesses, despite the fact that the National Federation of Independent Businesses was a lead challenger of the law in the suit before the Supreme Court.
He noted a provision that provides tax credits to businesses with 25 or fewer workers that offer health insurance to their workers.
Roughly 360,000 small businesses have already received assistance under that program, Angoff said, and more than 1 million more are eligible.
“We think it’s a great victory for the American public,” Angoff said of the Supreme Court decision.
Denning said it wouldn’t take a 60-vote majority in the Senate to repeal the Affordable Care Act.
He said the Senate could overturn the act with a simple majority through the budget process, much the way the law was passed in the first place.
He also disagreed that the Medicaid expansion was a good deal.
“This is not free money,” Denning said. “The federal government has no money.”
He said the federal government would have to run up its debt to pay for the Medicaid expansion.
He also said he was concerned that the federal government would pay for the expansion the first few years but then would pull back, leaving states to pick up more and more of the tab.
Denning also said the tax credit program for small businesses has not been nearly as popular as Angoff made it seem.
“He’s just talking sound bite stuff there,” Denning said of Angoff's remarks.
The tax credit program was complicated and resulted in costly plans that insurance brokers had little luck in pushing with their business customers, he said.
The chief executive officer of one of the private insurance companies that recently signed Medicaid managed care contracts with the state of Kansas said today that states shouldn’t refuse the offer of additional federal money to expand their programs.
James Carlson, CEO of Amerigroup, made the comment during a discussion with Wall Street analysts about his company’s potential sale to insurance giant WellPoint.
“When you step back from this, there are billions of dollars of federal money that are going to flow into states,” Carlson said in a report published by Politico. “We think the states are going to need to take it.”
Kansas insurance officials are evaluating WellPoint’s bid for Amerigroup, which is one of three companies selected by the state to manage care provided to the approximately 350,000 poor, elderly and disabled Kansans enrolled in Medicaid. The other two are United Healthcare of the Midwest, a subsidiary of United Healthcare, and Sunflower State Health Plan, a subsidiary of Centene.
Several Republican governors have said they don’t intend to expand eligibility for their Medicaid programs now that the U.S. Supreme Court has ruled that the federal government can’t withhold its share of funding for the program in states that decline to do so.
Kansas Gov. Sam Brownback has reiterated his opposition to the Affordable Care Act in statements since the ruling, but he has stopped short of saying the state won’t implement the Medicaid expansion on schedule in 2014.
Brownback spokesperson Sherriene Jones-Sontag said the governor still favors repeal of the health reform law and has urged voters to reject it at the polls in November by voting against President Obama’s re-election.
The expansion would result in a more dramatic increase in Medicaid eligibility in Kansas compared to other states. Currently, Kansas adults with dependent children can’t qualify for the program unless they earn less than 27 percent of the federal poverty threshold – about $6,000 for a family of four. Adults without children aren’t eligible for Medicaid unless they are disabled.
The ACA expansion would make everyone who earns less than 133 percent of the poverty threshold eligible for Medicaid. That means a family of four could earn up to about $30,000 and still qualify.
If implemented, the expansion could add as many as 150,000 Kansans to Medicaid rolls.
Related coverage on KHI.org:
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.”
In Pittsburg, the community health center so desperately needed more space that last year staff converted closets and a bathroom into offices.
But next year the number of patients the center sees is expected to grow 24 percent, said Krista Postai, chief executive of the Community Health Center of Southeast Kansas.
"And I have no place to put them," she said. "This building is totally and completely at capacity."
That should soon change.
By December 2014, using a $4.7 million federal grant, the center will nearly triple its space from 15,000 to 40,000 square feet.
The grant was announced today by the U.S. Department of Health and Human Services. It is part of more than $21.6 million awarded to five Kansas community health centers.
About 40,000 new patients will gain access to care thanks to the construction and renovation projects funded by the grants, according to HHS.
The funding stems from the Affordable Care Act, which authorized $9.5 billion to expand health services over five years and $1.5 billion for construction and renovation at community health centers.
“For many Americans, community health centers are the major source of care that ranges from prevention to treatment of chronic diseases," HHS Secretary Kathleen Sebelius said in a prepared statement. "This investment will expand our ability to provide high-quality care to millions of people while supporting good paying jobs in communities across the country.”
The grant amounts for the other Kansas health centers were:
■ $2.7 million for the Salina Family Healthcare Center in Salina.
■ $4.6 million for Hunter Health Clinic in Wichita.
■ $4.5 million for Konza Prairie Community Health Center in Junction City.
■ $5 million for PrairieStar Health Center in Hutchinson.
The grant funds were disbursed directly to the health centers, which are private, nonprofit organizations.
In Pittsburg, the new construction is set to begin in July and finish by December 2014, Postai said.
The center will then be able to expand most existing services as well as add optometry, physical therapy and speech therapy services. An estimated 8,200 additional patients will be able to access the center.
Plans are to add 42 positions at an average salary of $45,700 as a result of the expansion, center officials said.
The waiting room has been at capacity for years with more demand on it after one of the area's biggest employers was shuttered at the end of 2008. The wheel maker Superior closed as the auto industry crashed and the number of people near Pittsburg without insurance shot up from 12 percent in 2009 to nearly 18 percent in 2010.
"From the time we open, it is wall-to-wall people. We need space," Postai said. "You can only be open so many hours and you can only schedule so creatively. And our efficiency has been impacted by our lack of space."