Health Care Reform and Confusion

It should be so easy: a patient should receive his or her needed and entitled health care.  Medicaid should be the conduit that connects the patient and the physician, and then pays the physicin or other health care provider for services rendered.

Furthermore, if Medicaid contracts with a for-profit Managed Care Organization (MCO) to provide care to patients, there should be adequate state oversight to ensure the safety and well-being of these patients. As the 2016 Conference Report for the Health and Human Services, passed this week by the Iowa House and Senate, states, “the primary focus of the general assembly in moving to Medicaid managed care is to improve the quality of care and outcomes for Medicaid members.”

Instead of being easy, the transition to Medicaid managed care has been confusing in both negative and positive ways. As I said in the first post on this blog this year, I will spend this year highlighting my experience with how Medicaid managed care works with my patients in my family medicine practice.

Medicaid managed care in Iowa started April 1, 2016, when 550,000 patients assigned to three for-profit MCOs began to have their care provided by these MCOs.

Two patients: Mindy (fictional name) is a young adult with a chronic, inherited intestinal illness which requires periodic visits for medication and IV fluids. She has been through several major medical workups and no medical regime has been found to correct her condition. She has been to multiple medical facilities including the Mayo Clinic. She has been treated so many times that she has no peripheral veins available in which to place intravenous lines. She recently had a port,  which is a site underneath her skin, placed in her chest. The port allows for intravenous access. Mindy has been on Medicaid but often becomes confused about the need for the required reporting necessary to continue her Medicaid status. She received a letter from the Iowa Department of Human Services which said, “Confirmation of your MCO Coverage-Beginning April 1, 2016.” The letter also said that she, her son, and husband had been placed in a named Medicaid MCO. Mindy was seen this week in my clinic with her usual gastrointestinal symptoms and sought medication and IV fluids. Unfortunately, my clinic could not verify her Medicaid status and subsequently, found out that she does not currently have Medicaid. According to the Iowa Department of Human Services, over a thousand individuals were erroneously notified that they had Medicaid when, in truth, they did not have Medicaid coverage. This was a confusing and costly mistake for both my patient and my clinic.

My second patient is Joan (fictional name) who has chronic passage of kidney stones and sees me at least once a week for that reason. She goes to the Mayo Clinic yearly for follow-up of her condition. She is on disability for this condition and has Medicaid coverage. Despite published reports that none of the MCOs had contracts with the Mayo Clinic, Joan, through a prior authorization process, was able to obtain an appointment with her Mayo Clinic specialist. This was a confusing but positive development.

Regarding ombudsmen to hear complaints from Medicaid patients, I have now learned that regular Medicaid patients can access ombudsman services in the office of the long-term care Medicaid ombudsman. Confusing? Yes. The good news is that the bill passed in the legislature increased the number of ombudsmen that will be available to assist Medicaid patients if Governor Branstad does not line item veto this increase.

Finally, my very able head nurse has been severely stressed with the prior authorization requirements of all three MCOs. Referencing the judicial system, the phrase, “Justice delayed is justice denied” is used. In medicine it is accurate to say, “Medical care delayed (by prior authorization complications) can be life denied.” The complicated prior authorization processes  need to be fully evaluated by entities designated by the Iowa Legislature for Medicaid managed care oversight such as the Medicaid Assistance Advisory Council (MAAC) of which I am a member. In the 2016 Conference Report that I referenced previously, I am pleased to report that the MAAC will be one of the entities, which “shall submit executive summaries of pertinent information regarding their deliberations during the prior year relating to Medicaid managed care…no later than November 15, annually”…if Governor Branstad does not line item veto this part of the bill.

We will continue to watch this too often confusing process unfold. My goal will now be the phrase used by the General Assembly of Iowa: “to improve the quality of care and outcomes for the Medicaid members.” For me, they will always be considered patients, not “members,” especially when the MAAC presents its executive summary on November 15 each year.