Medicaid managed care not working
by STEVE LeMASTER
As members of the Medical Staff Leadership Council for the hospitals that comprise the Appalachian Regional Healthcare (ARH) system, we want to make you aware of the hardships that threaten both our patients and our ability to adequately operate practices and provide timely care since the Kentucky Medicaid program was switched on Nov. 1, 2011, to the current Medicaid managed-care system.
Since the managed-care system went into effect, we now must juggle our responsibility to provide care to our region’s most vulnerable citizens while restructuring the operation of our practices to accommodate lengthy wait times for our patients brought on by complicated, time-consuming pre-approval processes for routine procedures. Collectively, we are now seeing a significant increase in denied patient claims, delays in payments in excess of 90 days, and increases in unpaid accounts receivables amounting to millions of dollars.
Many of our patients are very ill and have sadly been taken on an emotional roller coaster ride as the Managed Care Organizations (MCOs) administering the Medicaid plan have negotiated contracts with providers only to sever those agreements just months into the contracts. This has forced our patients to endure additional worry as they have had to go through the process of changing their MCO plans multiple times just to be able to continue to receive care from their longstanding provider located within their local community.
When the state changed to the managed-care system, it was under the condition that the three MCOs chosen to administer the Medicaid program would provide members with local access to care through an adequate patient care network of providers. Unfortunately, due to these broken contracts with area providers our patients have now been assigned to managed-care plans that do not have adequate networks to provide the healthcare services needed.
Two years ago, a Medicaid patient could go to any hospital in the state for treatment. Today, a Medicaid patient in Eastern Kentucky is lucky if there is even a hospital in their county or a neighboring county where their Medicaid managed-care plan will authorize them for needed treatment.
When you call for precertification authorizations you are calling a call center and most of the time they don’t understand healthcare or care about the patient. The process is time consuming and lengthy, it requires one member of your staff to deal with these issues only. At ARH alone, authorizations are often taking as long as two days for MCOs to approve a procedure as simple as an X-ray.
The truth is the majority of the time you get a denial or additional information is needed. This may require the patient to have to come back on another day which results in delays and additional problems.
Our patients are having to sit in our waiting rooms longer and sometimes must be told to go back home until we can get authorization from their MCO to perform the procedure they need. These patients have limited financial resources and issues with transportation already. If the patient has to make arrangements with one of the area’s few public transportation companies for a return appointment, they may not be able to get transportation on the day needed, which creates an additional hardship on the patient and the doctor. Sadly, many of these patients do not make the trip back to our office, but rather wait until their medical condition worsens to the point that they must receive emergency care in a hospital setting. These hardships do not disappear after the patient is treated.
Prescribing the medications they need has also become an increasingly difficult process. In the beginning, a list of medications covered by the MCOs was provided, but since the time most of those medications have been deleted, resulting in doctors having to substitute medications with something that is covered or a generic. We as physicians should be able to treat our patients and prescribe the medications they need to get better. We do not want a call center making these decisions for us.
Unfortunately, the Medicaid managed-care plan in Kentucky is not working and is simply unfair to the poor and disabled patients it was created to protect. The patients that are affected by these changes are among our region’s most vulnerable - they are very ill or do not have the financial means to travel out of their community to find an MCO-approved provider. Most importantly, they should not be expected to carry a larger burden than patients with the same conditions who are fortunate to have jobs providing commercial insurance.
Our patients need timely medical care not delays. We encourage the state of Kentucky and the Centers for Medicare and Medicaid Services to take a step back and re-evaluate the current state of the Kentucky Medicaid program to ease our patients’ ability to receive care and to bring about a timely process for authorization and payment to the providers who work diligently to keep these patients healthy.
The Appalachian Regional Healthcare Medical Staff Leadership Council and other members of the Eastern Kentucky medical community:
Syamala HK Reddy, MD, Ophthalmology, Hazard ARH Regional Medical Center
Bradley Moore, DO, Family Practice, McDowell ARH Hospital and the Family Care Clinic – Wheelright
Maria Hortillosa, MD, Anesthesiology/Family Practice, Middlesboro ARH Hospital
Bethany Lucas,MD, Family Practice, Morgan County ARH Hospital
Sandesh R. Patil, MD, Cardiology,Whitesburg ARH Hospital
Roy Varghese, MD, Emergency Medicine/Internal Medicine, Mary Breckinridge ARH
JD Miller, MD, Internal Medicine, Mary Breckinridge ARH
Fares J. Khater MD, Internal Medicine, Whitesburg
Mansoor Mahmood, MD, Internal Medicine, South Williamson
Charles E. Johnson, MD, Pediatrics, Williamson ARH Hospital
Jose M. Echeverria, MD, Internal Medicine, Harlan ARH Hospital
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