Managed-care companies to offer own case management

March 13--Two of the three managed-care organizations that have contracted with Iowa to care for the more than 560,000 Medicaid recipients have indicated to the Department of Human Services that they plan to provide the majority of case management services themselves rather than rely on existing agencies.

"That was a service that was done through a wide range of agencies but will now be centralized," said DHS Director Charles Palmer during a Wednesday Council on Human Services meeting in Des Moines. "Is that a good thing or a bad thing? People will argue both sides."

Case managers help assess an individual's needs as well as find and coordinate services, from transportation and meal delivery to home health resources and skilled health care services such as physical or occupational therapy. Furthermore, some elderly and intellectually disabled Medicaid recipients don't have caregivers, experts said, and case managers will serve as advocates and step in to provide necessary help.

DHS said that about 96 percent of the state's 70 case management agencies contracted with at least one managed care organization, 90 percent signed with two and nearly 60 percent signed with all three.

But as the state gets closer to the April 1 start date moving its $5 billion Medicaid program over to the trio of out-of-state managed-care organizations, or MCOs, some are asking what will happen to case management services?

"We've signed contracts with all three (MCOs) with the knowledge that two are likely to be short-term" relationships, said Marcy Murphy, director of Southeast Iowa Case Management, which offers case management services to those with intellectual disabilities and brain injuries as well as the elderly.

And while the agency, which has 36 case managers working with more than 1,050 clients, is doing its best to be ready for life after April 1, Murphy said she has not received "concrete information" on how long the MCOs plan to use its services before transitioning to offer them themselves.

"It makes me sad that (local case management) services are not seen as valuable to some of the MCOs," Murphy said.

Existing case management agencies know their clients' histories and needs, she said, plus clients grow comfortable with their case managers. Some have had relationships with one another for many years, Murphy added, and change can be difficult for the populations who rely on these services.

This shift in services from local agencies to MCOs also potentially could set up conflicts of interest, Murphy said, because the case manager tasked with deciding what services a client is in need of receives a paycheck from the company that's paying for those services.

"I feel like local agencies can better advocate for clients," she said.

What's more, The Gazette reported in December that Eastern Iowa agencies and county departments were losing case managers to the three private insurance companies contracting with the state. The state has not tracked this shift and therefore does not have data on how many case managers have gone to work for MCOs.

But Murphy said she's heard of at least four smaller, rural counties that have stopped offering case management all together.

"MCOs were actively recruiting case managers," she said, explaining representatives would talk to her employees during trainings and call her staff.

MCO Plans

AmeriHealth Caritas Iowa plans to uses a hybrid model, the company said. The MCO has "contracted with nearly every case management agency in the state" in addition to employing its own case managers located across the state "to help support and supplement our contracted case management services."

AmeriHealth said its case managers provide services in-person, by phone and electronically.

"We will work closely with our case management associates and provider partners to ensure our members get the right care in the right place at the right time," the company said via email.

The company added that it's "committed to ensuring a smooth transition" and intends to help each member remain with his or hers existing case manager "whenever possible during the transition period and beyond."

Meanwhile, UnitedHealthcare said it will be offering "care management for individuals and families."

"We have more than three decades of experience in care management and care coordination and we understand not only what will help our members get healthier, but also how we can work with the health care system to improve their experiences and reduce costs," the company said in a statement.

The company said individuals take an initial health risk screening and, based on the results, UnitedHealthcare provides care managers to work off coordinated care plans.

"For example, a pregnant women with a prior high-risk pregnancy would have access to a care manager with OB expertise and for members with complex needs, a multifaceted care plan would be developed that ensures care is coordinated, and that all care givers are in tune to any additional services they may need," the company said.

UnitedHealthcare has hired local care managers and has a team of case managers in place for the April 1 start date, the company said.

"Additionally, and at CMS's request, we will be working with external agencies that are currently supporting individual members," UnitedHealthcare said. "External case managers will transition with their members and we are working with the state to ensure that these case managers have had additional training to ensure that the any transition is beneficial and focused on an individual's overall care needs."

Amerigroup Iowa has hired more than 100 case managers and contracted with the majority of agencies, the company said. To ensure a smooth changeover, the MCO said it will assign an in-house case manager to work with the Medicaid beneficiary's external case manager during the six-month transition period.

"Members will maintain their primary relationship with the case manager of their choice," the company said via email. "With input from stakeholders, Amerigroup will continue to evaluate the extent to which member needs are best served by continued access to external case managers beyond the initial six month period."

At minimum, every member will be contacted by their case manager every month and have a face-to-face visit at least once every 90 days, the company said, and those who require more intensive case management will have additional contact both by phone and in-person, as appropriate.

"Our intention is to remain in close contact with all of our members to ensure they are receiving the care they need," Amerigroup said.

'It's now non-existent'

Kansas shifted about 95 percent of its Medicaid population, including 8,500 developmentally disabled individuals, into managed care in 2013. In the years since, the state's hospitals have had billing disputes with the MCOs, there have been eligibility disputes for some elderly and disabled, and case managers moved from local agencies to work for MCOs, according to Kansas Health Institute, which has done extensive reporting on the state's privatization efforts.

The state contracted with three MCOs -- Amerigroup Kansas, UnitedHealthcare Plan of Kansas and Sunflower Health Plan, a subsidiary of Centene Corp.

During a December Health Policy Oversight Committee meeting in Des Moines, a case manager working for Amerigroup Kansas said case managers left local agencies for more secure and better paying jobs at managed care organizations.

"It was a painful transition -- most case managers went to the MCOs," said Lisa Simon, a service coordinator for Amerigroup Kansas, during that December meeting. "We still saw a lot of the same clients, and I can see the people I need to see. ... Some small agencies decided to not do that service anymore"

But some providers in the state painted a far more dire picture.

"It's now non-existent," said Gayle Taylor-Ford, owner of Therapy Services in Burlington, Kan. The agency provides cognitive and behavior therapy services to individuals with traumatic brain injuries. "Case management has just totally gone away. There are care coordinators now" who work for the managed-care organizations.

Taylor-Ford said "dozens and dozens" of agencies shut down after the Medicaid managed-care transition and MCOs took on the bulk of those responsibilities. She added that under managed care, care coordinators have large case loads, mostly work with patients over the phone rather than in person, and other providers have now had to step in and fill in some of those gaps.

Taylor-Ford recounted a story of a day she went to visit a client, whom she found lying on the floor with a bleeding and infected arm. She had to drive him to the next town and wait with him until he could see a doctor.

Under the old Medicaid system, Taylor-Ford would have called his case manager to help, or it's even likely the case manager would have been by the house and found him sooner than Taylor-Ford did. Instead, she had to take him to the hospital -- a task the MCOs do not reimburse.

What's more, she said, those in most need of services often don't know how to navigate the system and find the things they need, such as transportation to a food bank.

"It was a very difficult transition," she said. "It was really hard in the beginning for" the people who rely on case management services. "They didn't know how to find services."

CMS's letter

In the Center for Medicare and Medicaid Services's Feb. 23 letter to the Iowa Department of Human Services approving the move for April 1, the federal agency listed several terms and conditions relating to case management services to ensure a smooth managed-care transition.

Those conditions included:

--The state must monitor each managed-care organization, contracting with case management agencies and provide CMS a weekly progress report.

--The state must monitor how MCOs train case managers and participate in the training to verify it's adequate. The state must collect evidence that all case managers providing long-term services and supports have been trained before March 15.

--The state must monitor the MCOs' compliance with Iowa Medicaid's contractually established case manager-to-beneficiary ratio

--The state must ensure that beneficiaries are allowed to keep their current case manager until at least Sept. 30, 2016

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