NY Seniors Left To Find Health Care

Oct. 25--A health care company that arrived in the Capital Region in 2008 with ambitions to care for the area's sickest people is pulling out.

Senior Whole Health, a for-profit company based in Massachusetts, is leaving the upstate market, where it has 800 members. It plans to focus its efforts downstate.

"This move is a business decision based on geographical challenges," said Wayne Lowell, chief executive officer at Senior Whole Health. "Our member population is simply not dense enough to provide our high-touch model of care to these upstate counties in a cost -efficient manner."

The company said its nurse managers in Cambridge, Mass., can service multiple members in a day vs. just one a day in Albany.

It raises the question of whether managed long-term care -- something the state is aggressively adopting -- is feasible upstate.

"It's pretty disconcerting that this type of good effort that (Senior Whole Health) made is not financially viable," said Michael Burgess, the former commissioner of the state Office on Aging and a senior policy consultant for the Statewide Senior Action Council. "It doesn't portend well for some of the reforms being considered for long-term managed care."

Senior Whole Health specializes in caring for dual eligibles: seniors and disabled people who qualify for both Medicare and Medicaid. Dual eligibles generally are very poor, sick and costly.

Senior Whole Health was a leader in Massachusetts for caring for this population by offering hands-on, coordinated care ranging from home visits by nurses and adult day care to transportation to doctor's appointments. The model saves taxpayer money by keeping patients out of nursing homes and hospitals.

"They were providing the kinds of things that allowed people to remain living in the community with a lot of support," Burgess said.

New York state has embraced this managed care model and is making it mandatory in many regions. Mandatory enrollment into private managed care plans is expected to begin in New York City in July and spread to other counties over the next several years.

In order for private companies to enter this market, the companies must enroll a high volume of patients to make it profitable. In 2008, Senior Whole Health estimated they needed 1,200 members upstate to make it work. They plateaued at 800 members in 2009 and never budged.

"I can't predict if the model will work for other providers in upstate New York, but what we learned is that for the high-touch model of care that we do ... it wasn't a dense enough population for our company," said Lynne Marshall, spokeswoman for Senior Whole Health.

The company would not comment on why it isn't waiting one year for mandatory enrollment. Senior Whole Health would have likely seen a spike in membership in December 2013 when mandatory enrollment is scheduled to come to Albany. Instead, the company, which was sold to a private equity firm last year, will focus on New York City and the surrounding counties where it currently has less than 50 members.

"It's not a good thing that some of plans that are operating voluntarily are leaving the market," said Joe Baker, president of the Medicare Rights Center, a New York City nonprofit that advocates for Medicare patients. "It's something we all have to look at to say if this a program that can be viable in more rural areas." Baker added that sometimes short-term business goals dictate decisions.

Officials at the Department of Health said business decisions by individual companies are based on a number of factors and are not a reflection of the merits or viability of New York's mandatory long-term care program.

UnitedHealth is also abandoning its plans for dual eligibles, which covered 6,700 people statewide. A UnitedHealth spokeswoman said the company was unable to meet new requirements for state certification.

The loss of the plans means that members are scrambling to find new coverage.

Pat Finlayson, coordinator of the Schenectady County health insurance assistance program, said their hot line is receiving more calls this year. The program helps people enroll in Medicare, Medicaid, managed care or EPIC plans.

"We are laying all the options out to see what works best for them," Finlayson said.

[email protected] --518-454-5348 --@cathleencrowley

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