Managed Care Year One: Some beneficiaries, providers still face real challenges

July 03--It's been three months since Iowa handed over its $5 billion Medicaid program to three private insurance companies.

In the months leading up to that transition, opponents -- including Iowa Senate Democrats and many beneficiaries and providers -- loudly asked if the timeline was too crunched, if the provider network was ready and if services would be cut to achieve any potential savings.

The switch was twice delayed by the federal government, the state tossed out a contract with one managed-care organization (MCO) and a group of Iowa hospitals even filed an injunction in district court to stop the move.

See also: 5 things you need to know about Medicaid managed care

But April 1 has now come and gone -- Medicaid managed care is here to stay. So how successful has the move been?

The answer depends on whom you ask.

Gov. Terry Branstad has said the transition gives Medicaid patients a choice among three new health plans that will offer better access and quality of care as well as create a more predictable and sustainable Medicaid program.

Confused by how the new Medicaid system works?

We're here to help. Click the image above to check out an interactive explanation of Iowa's new Medicaid managed care system.

"Medicaid modernization means more doctors than ever before serving Medicaid patients," Branstad said in mid-June. "It also means better care, more access to services and improved accountability and oversight."

As of May 31, according to the Department of Human Services's most recent figures:

-- More than 180,000 people were enrolled with Amerigroup Iowa

-- More than 204,290 were enrolled with AmeriHealth Caritas Iowa

-- More than 171,300 were enrolled with UnitedHealthcare of the River Valley

In addition, about 97 percent of the state's 22,000 active Medicaid providers have signed with at least one MCO, about 76 percent with two MCOs and about 70 percent with all three.

The state's call center has seen more than a 50 percent drop in calls -- there were about 7,000 the week of June 13 to 17 compared with 15,000 April 4 to 8, the Department of Human Services said, and more than 2.25 million provider claims have been processed.

Beneficiary concerns

Over the past three months, The Gazette has reported on a variety of beneficiary issues. One Cedar Rapids woman has struggled to be listed as the guardian of her adult physically dependent son -- despite being his guardian for 13 years -- while others have run into issues obtaining specialty medications, insulin pumps and getting hearing aids approved. "The Titanic has left the dock," Jeff Edberg said.

Edberg, a commercial Realtor in Iowa City, has a 14-year-old son, Colin, who has physical and mental disabilities. Colin lives in an intermediate care facility in Dubuque with other medically fragile children.

The Edbergs ran into several headaches in the first few months of managed care. They struggled to find a primary-care physician for Colin in Dubuque, which still was building its provider network after the April 1 switch. That caused them to switch MCOs but meant Colin was without a doctor for a month until the new coverage kicked in.

Since those initial issues, things have calmed down considerably, Jeff Edberg said, though he still fought with the MCO over providing a specialty drug for his other son, Liam -- a drug the family has relied on for five years.

"I'm happy it was finally approved," he said. "But I expect this (fight) will happen again."

Edberg keeps a folder to log the dates, times, names of people he speaks with and detailed notes of conversations. He does this, he said, so he can advocate for his children and ensure the health care promised to them remains intact.

"If I'm not doing it, it won't get done," he said. "For Liam, a mistake can be disastrous. For Colin, it would be fatal."

The main take-away for Rhonda Shouse, a Medicaid recipient, is that the state was not ready on April 1, despite the state's stance that it was ready to go on Jan. 1.

"There haven't been any main catastrophes, but we are on borrowed time if things continue this way," said Shouse, who also is an administrator of the MCO Watchdog Facebook group -- a group with more than 1,800 Medicaid providers, caregivers and beneficiaries.

She pointed to snafus reported in that Facebook group with prior authorizations and provider reimbursements -- problems that, if not fixed quickly, could persuade physicians and others to accept fewer Medicaid patients or work with fewer MCOs, and ultimately restrict access.

"People are worn down," she said. "There still is a high level of distrust" with the MCOs and state.

Billing issues

State Sen. Liz Mathis, D-Cedar Rapids, said she's receiving the same number of calls and emails from constituents at the end of June as she did in early April. They range from a father trying to get a hearing aid for his disabled daughter to home health care providers seeing a drop in approved hours for clients.

"I can't get to them all," she said, adding she sends many requests for help along to DHS. "It feels like one big circle. DHS calls and does their customer service, but there's still no resolution.

"I'm not saying things are different from fee-for-service (with the former, state-run Medicaid), there were always issues. This just seems to be in larger volumes."

Looking back on the past three months, she said she would have liked to see more answers for beneficiaries and more proper payments for providers. These problems are a result of a rushed transition that needed more time, she said.

"I wish we would have rolled the waiver programs in one at a time," she added. "So we could have tested one -- work out the kinks and complications."

Mathis -- a staunch opponent to the privatization plan from the start -- said she's been frustrated by Branstad's view on the transition, saying his office is not acknowledging real problems.

She and other Senate democrats are holding listening posts throughout the summer to give enrollees and beneficiaries a chance to discuss any unresolved problems.

Mathis held the first meeting of the series in Marion at the end of May. More than 65 people attended and asked questions of representatives of the state and MCOs for more than two hours.

The second meeting, hosted by Sen. Chris Brase, D-Muscatine, took place Tuesday in Muscatine. Brase said the MCOs were invited to attend his listening post but ultimately decided to not come.

He heard from more than a dozen individuals, including a representative from a pediatric clinic in Southeast Iowa that has not received any payments from one MCO since May.

"They're taking out a loan just to make payroll," he said. "They may have to turn down clients if they don't get paid. And they're feeling like the bad guy."

Providers from rehabilitation therapists to Horizon's Meals on Wheels have reported that they have run into major billing issues -- with inaccurate, unpaid or denied claims. A Dubuque-based outpatient therapy clinic estimates it is owed $80,000 from two MCOs that have paid it incorrect amounts sine the transition.

To see the full visualization, click here.

Oversight

The start of the new fiscal year on Friday also means Medicaid managed care oversight has kicked in.

The Iowa Senate passed an expansive oversight bill in early March that included provisions to enhance the role and responsibilities of the Health Policy Oversight Committee, execute a comprehensive review of program integrity and create a special fund to finance system improvements and support for recipients.

The bill failed to make it through the Iowa House, however legislators were able to reach a compromise and appropriate oversight funding through the health and human services budget.

The oversight includes additionally funds for a managed-care ombudsman, external quality reports and expanded duties for the Medical Assistance Advisory Council, among other items.

DHS said it's in the process of collecting data and anticipates monthly reports to be available this summer. In addition, a quarterly report will be available in the fall and will include more comprehensive data, analysis and trends.

Mathis, chairwoman of the Senate Human Resources committee, plans to hold her one allotted out-of-session committee meeting at the end of July to discuss the available data.

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