Under Idaho Medicaid law, doctors warn kids’ access to primary care is at risk

Idaho providers warn that a new state law meant to overhaul the way the state manages care for Medicaid patients risks stripping away primary care access for those patients — many of whom are children.

Lawmakers this year passed House Bill 345, which transitions the state to a new Medicaid management system in the hopes of cutting down costs to the state. But the bill also ends a program that helped health care providers pay for the costs of taking Medicaid patients, raising questions among providers about whether they could afford to continue such care.

House Bill 345 transitions the state Medicaid program to a managed care system, which means private companies direct patients to what they deem to be the appropriate level of care and keep costs down. That is, the companies would try to route minor conditions to primary care providers rather than specialists or the emergency room.

But as part of the bill, lawmakers told the Idaho Statesman they unintentionally set the program, Healthy Connections, to expire before the new managed care kicks in. Without those payments, providers may have to limit the number of Medicaid patients they can see — or stop seeing those patients altogether — when the program sunsets in January, providers told the Statesman.

More than one out of three children in Idaho are on Medicaid, according to Families USA, a Washington, D.C.-based nonpartisan nonprofit. That means the loss of Healthy Connections places a significant burden on pediatricians, said Brian Birch, who owns the Treasure Valley Children’s Clinic in Meridian. There’s no plan to replace the program.

Lawmakers cut Healthy Connections because it will no longer be needed, since managed care companies will now offer that case management, said Rep. Jordan Redman, R-Coeur d’Alene, who cosponsored House Bill 345. Redman told the Statesman that lawmakers didn’t realize how long it would take to implement the new system until officials from the Department of Health and Welfare told them, in a June committee meeting.

Sen. Kevin Cook, R-Idaho Falls, in a late-July op-ed said lawmakers had “overlooked” the program in the bill to overhaul Medicaid.

“I think a lot of us had anticipated the managed care organization coming into effect sooner than 2029, so I think that’s probably where there’s a little bit of misunderstanding,” Redman told the Statesman.

From providers’ perspective, Medicaid is just like any other insurance company: A doctor provides care and bills the patient’s insurance company, whether that’s Medicaid, funded by the federal and state government, or a private insurance company like Aetna.

For providers, the key difference is that Medicaid reimburses that care at a lower rate than private companies do. Healthy Connections payments had helped to bridge that gap and decrease the hit providers took when they saw Medicaid patients.

The halt in payments may mean staffing cuts. Many practices fund care coordinator positions based on those payments, Birch said.

Birch told the Statesman he thinks his practice can weather the loss of funding and continue to provide the same level of case management, in part because only 25% of its patients are on Medicaid — a relatively small number compared with other clinics in the state. But in other states with low rates of reimbursement for Medicaid coverage, private practices capped the number of Medicaid patients they could see or stopped seeing them altogether, he said.

A leader of the Idaho chapter of the American Academy of Pediatrics, Birch told the Statesman he tried to bring this issue to lawmakers’ attention during this year’s legislative session to no avail.

From a survey of 12 Idaho private pediatric practices Birch conducted this year, four said they were at risk of being forced to close their clinic. All but one said they were considering limiting care to Medicaid patients, while half said they may stop taking Medicaid patients altogether.

The program helped increase all patients’ access to care — not just kids’ — but the impact of its loss is greater for pediatricians because so many children in Idaho are on Medicaid. The effect on pediatricians “cannot be ignored,” Birch said.

Redman said lawmakers understood the need to at least temporarily reinstate that funding. They plan to discuss it at a September meeting of the Medicaid Review Panel, a legislative committee focused on the implementation of House Bill 345, he said.

“If this was a mistake, then help us fix it,” Birch said, directing his message to lawmakers. “And reassure us that it’s going to get fixed so that we don’t have to make these really difficult decisions.”

Birch recounted a common scenario: A child wakes up his mother in the middle of the night complaining of an ear infection, and she has a choice to make. If she waits until morning to call her son’s doctor, it could take hours to get an appointment. Or she could take her son to the emergency room, which would be expensive and probably excessive, but quick.

Pediatric practices like Birch’s have worked to make it easier to access care outside the emergency room, he said. With extra staffing and care coordinators funded by Healthy Connections payments, they can offer initiatives like a daily “Quick Sick” clinic, which lets parents bring kids in for walk-in appointments, so that mother can get her child in and out, with a confirmed diagnosis and medication, before anyone misses work or school.

For patients on Medicaid, practices like these save the state money. They divert families away from unnecessary emergency room care, which costs the state about 10 times more than being seen in a primary care facility, Birch estimated. For more complex cases, they help parents determine whether their child’s problem can be addressed through primary care, rather than a pricier visit to a specialist.

“We want to be the center of medical care for the patient,” Birch said.

The Healthy Connections program costs the state about $24 million a year — “budget dust” compared with the state’s $5 billion Medicaid budget, Birch argued. And by focusing on proactive outreach and preventative care, it keeps kids from developing more serious conditions.

Kids from low-income families and kids with medically complex conditions are on Medicaid. In rural areas, children with serious conditions need the case management Healthy Connections provides, said Jennifer Jorgensen, a co-owner of Frontier Pediatrics in Twin Falls. Twin Falls has few specialists, she said, so her clinic often must send kids to Boise for treatment. Healthy Connections funds the staff members that coordinate those referrals, she said. Without Healthy Connections funds, she’s not sure what her clinic will do.

“I think that’s the scariest part,” Jorgensen told the Statesman. “Things are getting gutted, but we don’t necessarily have a solution for how to replace them.”

Senate Minority Leader Melissa Wintrow, a Boise Democrat serving on the Medicaid committee, said confusion about what was in House Bill 345 prompted her to vote against it. The bill was “rammed through” the Legislature, she told the Statesman. It was introduced Feb. 28 and signed into law on March 20.

“When you have a bill that big getting slammed through that quick, it’s easy to miss things,” she said. “I don’t think many folks that I know really understood” the implications of the bill for Healthy Connections.

But if there’s a problem with the bill that lawmakers didn’t catch, “it is our responsibility to fix it,” she said. “It’s our responsibility now to take care of business and make sure that these providers don’t start rejecting Medicaid patients.”

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