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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.”
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.
Sixty officials from a variety of disciplines and from around the state gathered here today to grade Kansas' public health system by collectively answering a battery of 600 questions as part of the National Public Health Performance Standards Program.
Kansas is one of 23 states to conduct the evaluation and first did so in 2008, a year after the program was started by the federal Centers for Disease Control and Prevention. Four years ago, however, only officials from the Kansas Department of Health and Environment participated, said Brenda Nickel, director of KDHE's Center for Performance Management.
"The intent at the time was to also conduct it with our external partners statewide. But in 2008, the recession was going on and that opportunity was never fully realized," she said. "What's going on here today with our external stateholders, I think is going to provide a richer report because we actually have those individuals with boots on the ground in communities, as well as state-level partners, who are helping answer these questions."
Participants split into three groups to each grade the state's public health system on 200 questions, such as:
• Does the state public health system commit financial resources to workforce development efforts?
• Does the system utilize the leadership of the state public health agency in planning and policy development?
• Does the system have the professional expertise to carry out effective health communications?
The quantity of questions to be answered in a single day left little time for discussion of each question before the group voted on a grade.
The pace of the evaluation helped keep the group focused and moving along, said participant Michelle Ponce, director of the Kansas Association of Local Health Departments.
"We don't have time to get caught up in the weeds or thinking through every single in and out — we have to limit ourselves to the big picture and stay focused on the larger system. It doesn't give you time to get mired down into who does what and who's responsibility exactly is it. We're focused on the system — what is everybody's responsibility, what do we do well, and what are the gaps," Ponce said.
For years, poor patients in this southeast Kansas community have relied on a free health clinic that operates on Thursday afternoons out of a Bible school classroom.
In its heyday, the Parsons Community Clinic could count on about a dozen primary care physicians and an equal number of nurses to volunteer at the First Assembly of God building at North 16th Street and Dirr Avenue. It still treats about 35 to 45 patients each week for everything from rashes to diabetes.
But now, with the volunteers getting up in years, the clinic faces an uncertain future — and local medical leaders essentially are trying to put it out of business.
“That is our hope, yes,” said Dr. Stephen Miller, a retired surgeon who helped found the clinic 15 years ago.
n its place, though, members of the Southeast Kansas Healthcare Collaborative are proposing a model that, at least according the group’s research, does not exist anywhere else in the country.
The plan is to create a rural health network that would connect providers via computer to create a “virtual” federally qualified health center, or FQHC, serving Labette, Neosho and Wilson counties. FQHCs typically are bricks-and-mortar facilities offering primary care services in underserved communities.
Led by Labette Health, the hospital in Parsons, and its Chief Executive Officer Jodi Schmidt, collaborative members hope the idea is unique enough to earn funding through the new Health Care Innovation program administered by the federal Centers for Medicare and Medicaid Services.
They have an $11.4 million grant request pending before the agency that would allow them to develop and implement the plan.
The collaborative is targeting an area with about 50,500 residents in a corner of the state that has some of the worst health outcomes among Kansas’ 105 counties, according to the County Health Rankings from the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation. This year’s ranks are Labette (91), Wilson (87) and Neosho (83).
Members of the collaborative are striving to achieve the “triple aim” of better individual care, better population health and lower per capita health care costs.
The virtual health center plan
Under the plan, organizers would establish a nonprofit organization – overseen by a 21-member board – to manage the virtual community health center. The center would contract with primary care physicians and midlevel providers at hospitals in the three counties.