Move to managed care involves a steep learning curve, patients and providers tell Noelle Hunter of The Morehead News

Patients and providers are "ascending a steep learning curve as they implement Medicaid managed care," reports Noelle Hunter in a two-part series in The Morehead News. Even for a proactive patient, the changeover has its challenges, and vulnerable populations are at risk of falling through the cracks, providers say. For health administrators, it means getting accustomed to three new systems, all of which require pre-authorization before treatment can begin.

The move to managed care, which took place Nov. 1, was intended to fill a $166 million shortfall in the Medicaid budget. Gov. Steve Beshear pushed hard for the switch and estimates it will save the state $1.3 billion in the next three years. Managed care will be handled by four organizations — Kentucky Spirit, CoventryCares, WellCare and Passport — across the state. Passport was already handling the Louisville region.

When the switch took place, Medicaid recipient Mary Jo Long discovered "45 percent of Medicaid recipients were automatically enrolled in Kentucky Spirit," Hunter reports. "None of the doctors (in Rowan County) take Kentucky Spirit," Long said. Discovering this, she waited on hold 30 minutes before being switched to CoventryCares and doesn't "anticipate any problems from here," she said.

While Long was able to navigate the challenge, many patients, particularly those with mental or behavioral health issues, might find it difficult, said Kimberly McClanahan, CEO of Pathways, Inc., a drug or alcohol rehabilitation center. "A lot of our patients are seriously mentally ill and they don't or cannot always pay attention to the information they are getting in the mail about the change," she said. "When they got their first letter about the changes, it was seven pages long. A lot of our consumers just threw it in the trash."

Health administrators are likewise dealing with lengthy forms from managed care organizations. "We've essentially gone from a one-page document to a sometimes 25-30 page document that has to be faxed to the MCOs before any care can be given," said G.R. "Sonny" Jones, chief financial officer at St. Claire Regional Medical Center.

The paper overload stems from the fact that Medicaid patients must be pre-authorized before they can receive any treatment, the likely key to savings in such a system. "I was talking to a case manager who said she spent an hour and 45 minutes on the telephone trying to obtain a pre-authorization," said Charlotte Walker, administrative director for clinical operations at St. Claire.

Moreover, the existing network of providers is not extensive enough, in part because the move to managed care happened in just 120 days, as per the state's directive, "when it usually takes a year or two to develop a satisfactory network," Jones said.

Behavioral health organizations and pharmacies are also experiencing challenges, with some patients not able to access their prescriptions "because each MCO has different prescription formularies," Hunter reports.

Whether the move will indeed save money remains to be seen, administrators say. "In the long run, the financial incentives are there to pay hospitals and providers less," Jones said. "It will make it more difficult for us."

An op-ed piece in the Lexington Herald-Leader indicated likewise. "There will now be four bureaucracies, with each sopping up Medicaid money to pay for the bureaucrats needed to keep track of everything," writes Edward L. Smith, a charter member of Northern Kentucky's Mental Health/Substance Abuse Regional Planning Council. "Where will the money for the bureaucrats come from? From services, of course." (Read more)

To read Part 1 of Noelle Hunter's series Mandatory Medicine, click here. For Part 2, click here.