Some Linn County health providers say Medicaid payment changes not sustainable long term
Changes to the home- and community-based services waiver -- which affects approximately 5,000 Iowans who have traumatic brain injuries, developmental or intellectual disabilities -- moved the payment model from a fee-for-service model to a tiered rate system, effective
While
Bringing you multiple perspectives:
In reporting this story, we talked with individuals on all sides of the issue. Here are their views:
Officials behind the change: "Previously these services were reimbursed using about 5,000 individual rates, exceptions to policy, and old county contract rates not necessarily tied to the individuals' severity of disability. This was not an effective way to appropriately reimburse providers to meet individuals' needs. It was very complex and unjustifiable."
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Providers impacted by the change: Say they are seeing a significant decrease in their Medicaid payments for services. One
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Members impacted by the change: Are worried their services might be cut by providers in light of these payment reductions.
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Sturtz, of
Sturtz added that losing his long-term case manager leaves her concerned that her brother might struggle to find long-term support in the years to come.
"What if Jake was kicked out, where would he go?" she said.
Instead of receiving a fee for services performed,
Tier one is the lesser amount of reimbursement, and tier six the greatest.
Medicaid enrollees covered the waiver were placed in one of these tiers based on his or her level of need.
Highland said the goal of the tiered rates was to stabilize payments to providers by reimbursing more for services to individuals with more-severe disabilities and less to individuals with relatively less-severe disabilities.
"Previously these services were reimbursed using about 5,000 individual rates, exceptions to policy and old county contract rates not necessarily tied to the individuals' severity of disability," Highland said in an email to The Gazette. "This was not an effective way to appropriately reimburse providers to meet individuals' needs.
"It was very complex and unjustifiable."
But the payments -- coupled with client shifts to managed-care organization case management -- has been a factor in the closure of
No Longer Sustainable
The new tiered reimbursement rate system implemented in December by the
"
The shift of clients from independent providers to in-house services provided by managed-care organizations also has taken a toll on some case-management organizations.
UnitedHealthcare of the
UnitedHealthcare ended its agreement with
"Those agreements concluded as UnitedHealthcare added approximately 300 new employees to continue to meet the health care needs of our members," Harris said in an email to The Gazette.
That number dipped to 787 in fiscal 2017, and in January of this year -- as the county's contract with UnitedHealthcare neared its close -- clients had dropped to about 350 people.
Staffing at the county case management department also reduced, from 37 full-time employees in fiscal 2015 to 25 in fiscal 2017. Earlier this year, the department was down to 15 case managers and its coordinator,
With client numbers shrinking and the county's case-management department struggling to pay the bills,
In late January, the board voted 4-1, with Supervisor
"I learned a long time ago in a different career that there are three management phases in a business," Supervisor
With that vote, the remaining clients with
Much of the department's former staff members have found new county positions. Services Coordinator
The Consistent Person
Read more
Case Study: Small provider funding cut in half by Medicaid change
The role of a case manager is to be an advocate for an individual's needs.
Beavers said some case managers have been with the county as long as 30 years. Beavers herself has been a case manager for about 40 years.
"For a lot of individuals, the case managers have been a consistent person in their life," Beavers said. "There are a lot of people we work with, a lot of the families that it is very difficult to be looking at making changes to having somebody new.
"It's not that consistent person anymore."
It was
Hagen "is very knowledgeable in what she does," Sturtz said. "I think the social workers that are assigned these (clients), it's invaluable the knowledge that they have. I'm not saying it's not valuable with privatized case management, but going forward, if someone comes into the middle of something like that, it could have fallen apart."
No More Tiers?
Because of the waiver change, other providers are looking at their own budgets with apprehension.
Under the previous fee-for-service system, the
Nowadays, Linn County Options Director
"Just in the first month, we were down about
Other area providers have seen a similar shift in payments due to the new system, including
"It's been challenging," said
Although the possibility of switching to tiered rates had been introduced a year ago, Fox said providers only had 18 days' notice before the switch took place in the middle of the fiscal year.
Officials at local providers, including Fox, also have raised concerns to the state and managed-care organizations at the accuracy of the assessment that placed individuals in respective tiers.
"In tier three alone, I have one individual who has a competitive job and is doing very well in that job and another individual who's in a wheelchair that needs total assistance to get through the day. They are in the same tier," Fox said.
However, Westhoff said cost-cutting initiatives ultimately may come down to more extreme measures.
"We serve people who need 24/7 support. How do we change that?" Westhoff said. "It may force us to consider who we can't serve."
No white horses
In January, before the
"I would like to see us at least give the Legislature a chance to do their process and figure out if something can happen at the state legislature that can reverse some of these travesties that are happening with the clients that we're serving. Not only through managed care, but also through fee-for-service," Houser said.
However, the remaining four supervisors had much less faith in state lawmakers.
"I don't expect the legislature to come riding in on a white horse and save our fee-for-service dilemma that we have," Supervisor Harris said.
Duplicate bills -- House File 2451 and Senate Study Bill 3185 -- aim to relocate some programs and services -- including services such as long-term living and community support services for people with disabilities 18 years old or older -- under the purview of the
That would include case-management services.
While the
The proposed bill does not specifically address whether a tiered system would be maintained, or if the
"Most people in the disability or aging arena, they're not going to get well, they're not going to get cured.
"It's a different perspective than the insurance model, which is what Medicaid is, it's a health insurance model," Miller said. "You need to figure out what that person needs to maintain their lifestyle."
However, Miller said simply passing the services -- and simultaneously the clients -- to a new department needs to be handled delicately.
"You would be instituting another new change in the system. Some people would feel it's a change for the better, but others would feel it's for the worse," she said. "It would be again another transition to another contract, to another company, to a different case manager."
"The whole goal is to have the right service for the right patient at the right time ... at the right cost," Miller added. "That's not an easy thing to do in the long-term care situation.
l Comments: (319) 368-8536, [email protected]; (319) 339-3175, [email protected].
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