AJC Article on CMO/Medicaid

July 28, 2007

Do HMOs work for Medicaid?By Andy The Atlanta Journal-ConstitutionPublished on: 07/28/07

Judith McNeely of Suwanee has tried for months to get an HMO to approve speech therapy for her twins, 4 years old, who are developmentally delayed.

The struggle, she says, "has been an absolute nightmare."

The twins' speech therapist, Brook Todd, echoes that frustration in seeking to get WellCare, the HMO, to pay for their visits. The boys' speech problems, so severe that the two are only understood by their family, must be addressed before they reach kindergarten, Todd says.

A WellCare spokeswoman said the company is looking into the situation.

Last year, twins Dawson and Smyth and more than 900,000 other Georgians — most of them children — moved into one of three HMOs serving Medicaid, the health program for the poor and disabled, and PeachCare, which covers uninsured children. The goal was to curb Medicaid's steadily rising costs.

A year later, Gov. Sonny Perdue's signature health care program has delivered sizable savings to the state: $78 million in the last fiscal year, according to state officials.

But the HMO switch has also continued to generate complaints from doctors, hospitals and other health care providers, while raising questions about whether patients, especially children, are getting needed and timely medical services.

Consumer health advocate Lowe said, "There are widespread reports of children with serious conditions being denied therapies while their medical providers jump through arbitrary authorization hoops."

Georgia officials, Lowe added, "need to take a careful look to see if patients, providers and the state are getting a good deal" with the HMOs.

Perdue himself asked for an audit of unpaid medical claims owed to Children's Healthcare of Atlanta — and the state is running a broader audit of payments to other medical providers.

Meanwhile, the three HMOs serving Medicaid and PeachCare recently reported financial figures showing their Georgia profits are small — if they're making money at all.

One HMO has shaken up its Georgia leadership team after getting fined $3.7 million by the state for delays in authorizing treatment.

So far, there's been no comprehensive review of patient care under the HMO system. The state is just now receiving key data to make such an assessment. "We don't know about quality," said Dr. s, president of the Georgia chapter of the American Academy of Pediatrics. "The jury is still out.''

The HMOs say patients are getting the services they need, and that problems are addressed when they arise.

In June 2006, Perdue launched his HMO plan, called the biggest change in Georgia Medicaid history. Instead of allowing patients to go to any doctor who would accept them, the HMOs would connect them to a primary-care doctor who would guide their care.

The health plan would closely monitor patient care, and encourage members to use their doctors instead of emergency rooms for routine medical care, thus reducing costs. At the time, Medicaid's percentage cost increases were running in the double digits annually.

The state believed the HMOs "could do a better job managing the care of our members" and save taxpayers money, said Kathy Driggers, chief of managed care and quality for the Department of Community Health, which runs PeachCare and Medicaid in Georgia.

Medicaid, during the same time, has tightened eligibility rules, while PeachCare imposed a four-month enrollment freeze as it fought to maintain funding. The result is lower-than-expected membership in the HMOs.

Since the HMO startup, a number of doctors, aggravated by what they call slow and reduced pay from HMOs, have limited the number of patients they will accept from the government programs. Dr. Wagner, a Sandy Springs pediatrician, is one who has cut his Medicaid/PeachCare patient load. The HMO experience, he said, "has been a mess.''

And based on lower fees and more administrative hassles, Dr. Mark Ritz, a Homerville dentist, says he and other dentists are re-evaluating their participation in the government programs.

A lingering problem involves gaps in the HMOs' doctor networks. Beth Sullivan, a family doctor in Commerce, said a 5-year-old patient had to be driven more than 100 miles to Augusta for an orthopedist willing to treat his broken wrist under his HMO. State officials and HMOs, however, say pediatric specialists are difficult to find for all children, not just those in the government insurance programs.

For their part, the HMOs — Amerigroup, WellCare and Peach State — each assert they have a high rate of payments to medical providers.

"Our No. 1 priority is for our members to get the care they need and deserve," said Kent , spokesman for Virginia-based Amerigroup, who acknowledges the company lost money in Georgia in the first quarter this year. Amerigroup's medical costs in Georgia decreased in the second quarter, but still are running higher than the company's average, said Wednesday.

Cotton, WellCare's chief operating officer in Georgia, declined to comment on the company's Georgia financial figures. He said the company, based in Florida, "feels confident that members are receiving [needed] services.''

Peach State, run by Missouri-based Centene, was fined $3.7 million in May for delays in authorizing requests for services. Since then, its Georgia CEO and medical director have departed. The parent company declined to discuss the moves, saying that the authorization problem has been resolved. Centene is appealing the Georgia fines.

"Even with 290,000 members and 11,000 physicians, Peach State considers it unacceptable when even one member has an issue with health care services," the company said in a statement. "We vigorously examine such issues and take corrective action when necessary."

Still, much friction between families and insurers has come over denials of speech, physical and occupational therapies for children.

Leanne Manning of Suwanee says her two children, 12 and 10, who both have developmental disabilities, are no longer getting occupational or physical therapy services because the therapists say they can't get paid by the HMOs for those visits. "I'm trying to do the things at home, but it's not the same," she said. Her oldest daughter "has regressed physically," and the younger one "is "struggling to reach her potential," Manning said. "If they get the help, they'll be very productive, tax-paying citizens."

The HMOs have scrutinized this therapy care more than old-style Medicaid, Driggers explained. State officials say they're working with the insurers to streamline the approval process for therapy services.

Adding to the chorus of criticism are complaints from many hospitals that say they're losing money on the government programs. "It has been an administrative nightmare," said Tish Towns, vice president of government relations for financially strapped Grady Health System, which operates Grady Memorial Hospital in Atlanta. "I think there's a tremendous amount of work to do to get this right.''

Nothing has frustrated hospitals more than being paid a $50 "triage fee" when the insurer views an emergency room visit as a non-emergency. "In many cases, we're doing thousands of dollars in tests," said Laster, chief operating officer of Regional Hospital in Hawkinsville, near Macon.

The Georgia Hospital Association says most of its member hospitals are frustrated by payment and other problems — and that the $50 payments show up more often now than under the old Medicaid program.

"Several rural hospitals have faced near-failure to make payroll, and most rural hospitals are in a cash-flow crisis" because of reimbursement problems, said Jimmy , CEO of HomeTown Health, an organization of rural hospitals.

Asked to give a one-year grade on HMOs' performance, Driggers of Community Health declined, saying, "As with most organizations, there are frequently opportunities for improvement.''

July 28, 2007

I am so glad there is an article on this because the system is ridulous--the medicaid HMOs. my kids have Peachstate and I finally got approval for my sons speech therapy, which there was an obvious need for. They kept denying until my speech therapist gave them a piece of her mind about how they were not doing their job to provide needed services. She came out, without pay, anyway because he really needed it and bought interactive toys for him. I have never known anyone who has gone out of their way like that for my son. i am grateful. She told me if they had continued denying approval she would donate her time every week to provide the therapy. For a long time i felt many providers were more worried about getting you in and out of their office so they could scoot in the next person. Its a shame because its supposed to be about providing care not making or saving money. The medicaid system is worse with the HMOs,

worse for us because they want to save money. and yet you get denied for many services because you are deemed not needing services when you are in dire need. Thank you for forwarding this article.loriemancuso@... wrote: Do HMOs work for Medicaid?By Andy The Atlanta Journal-ConstitutionPublished on: 07/28/07 Judith

McNeely of Suwanee has tried for months to get an HMO to approve speech therapy for her twins, 4 years old, who are developmentally delayed. The struggle, she says, "has been an absolute nightmare." The twins' speech therapist, Brook Todd, echoes that frustration in seeking to get WellCare, the HMO, to pay for their visits. The boys' speech problems, so severe that the two are only understood by their family, must be addressed before they reach kindergarten, Todd says. A WellCare spokeswoman said the company is looking into the situation. Last year, twins Dawson and Smyth and more than 900,000 other Georgians — most of them children — moved into one of three HMOs serving Medicaid, the health program for the poor and disabled, and PeachCare, which

covers uninsured children. The goal was to curb Medicaid's steadily rising costs. A year later, Gov. Sonny Perdue's signature health care program has delivered sizable savings to the state: $78 million in the last fiscal year, according to state officials. But the HMO switch has also continued to generate complaints from doctors, hospitals and other health care providers, while raising questions about whether patients, especially children, are getting needed and timely medical services. Consumer health advocate Lowe said, "There are widespread reports of children with serious conditions being denied therapies while their medical providers jump through arbitrary authorization hoops." Georgia officials, Lowe added, "need to take a careful look to see if patients, providers and the state are getting a good deal" with the HMOs. Perdue himself asked for an audit of unpaid medical claims owed to Children's

Healthcare of Atlanta — and the state is running a broader audit of payments to other medical providers. Meanwhile, the three HMOs serving Medicaid and PeachCare recently reported financial figures showing their Georgia profits are small — if they're making money at all. One HMO has shaken up its Georgia leadership team after getting fined $3.7 million by the state for delays in authorizing treatment. So far, there's been no comprehensive review of patient care under the HMO system. The state is just now receiving key data to make such an assessment. "We don't know about quality," said Dr. s, president of the Georgia chapter of the American Academy of Pediatrics. "The jury is still out.'' The HMOs say patients are getting the services they need, and that problems are addressed when they arise. In June 2006, Perdue launched his HMO plan, called the biggest change in Georgia Medicaid history. Instead

of allowing patients to go to any doctor who would accept them, the HMOs would connect them to a primary-care doctor who would guide their care. The health plan would closely monitor patient care, and encourage members to use their doctors instead of emergency rooms for routine medical care, thus reducing costs. At the time, Medicaid's percentage cost increases were running in the double digits annually. The state believed the HMOs "could do a better job managing the care of our members" and save taxpayers money, said Kathy Driggers, chief of managed care and quality for the Department of Community Health, which runs PeachCare and Medicaid in Georgia. Medicaid, during the same time, has tightened eligibility rules, while PeachCare imposed a four-month enrollment freeze as it fought to maintain funding. The result is lower-than-expected membership in the HMOs. Since the HMO startup, a number of doctors, aggravated by what they

call slow and reduced pay from HMOs, have limited the number of patients they will accept from the government programs. Dr. Wagner, a Sandy Springs pediatrician, is one who has cut his Medicaid/PeachCare patient load. The HMO experience, he said, "has been a mess.'' And based on lower fees and more administrative hassles, Dr. Mark Ritz, a Homerville dentist, says he and other dentists are re-evaluating their participation in the government programs. A lingering problem involves gaps in the HMOs' doctor networks. Beth Sullivan, a family doctor in Commerce, said a 5-year-old patient had to be driven more than 100 miles to Augusta for an orthopedist willing to treat his broken wrist under his HMO. State officials and HMOs, however, say pediatric specialists are difficult to find for all children, not just those in the government insurance programs. For their part, the HMOs — Amerigroup, WellCare and Peach State — each assert they

have a high rate of payments to medical providers. "Our No. 1 priority is for our members to get the care they need and deserve," said Kent , spokesman for Virginia-based Amerigroup, who acknowledges the company lost money in Georgia in the first quarter this year. Amerigroup's medical costs in Georgia decreased in the second quarter, but still are running higher than the company's average, said Wednesday. Cotton, WellCare's chief operating officer in Georgia, declined to comment on the company's Georgia financial figures. He said the company, based in Florida, "feels confident that members are receiving [needed] services.'' Peach State, run by Missouri-based Centene, was fined $3.7 million in May for delays in authorizing requests for services. Since then, its Georgia CEO and medical director have departed. The parent company declined to discuss the moves, saying that the authorization problem has been resolved.

Centene is appealing the Georgia fines. "Even with 290,000 members and 11,000 physicians, Peach State considers it unacceptable when even one member has an issue with health care services," the company said in a statement. "We vigorously examine such issues and take corrective action when necessary." Still, much friction between families and insurers has come over denials of speech, physical and occupational therapies for children. Leanne Manning of Suwanee says her two children, 12 and 10, who both have developmental disabilities, are no longer getting occupational or physical therapy services because the therapists say they can't get paid by the HMOs for those visits. "I'm trying to do the things at home, but it's not the same," she said. Her oldest daughter "has regressed physically," and the younger one "is "struggling to reach her potential," Manning said. "If they get the help, they'll be very productive, tax-paying

citizens." The HMOs have scrutinized this therapy care more than old-style Medicaid, Driggers explained. State officials say they're working with the insurers to streamline the approval process for therapy services. Adding to the chorus of criticism are complaints from many hospitals that say they're losing money on the government programs. "It has been an administrative nightmare," said Tish Towns, vice president of government relations for financially strapped Grady Health System, which operates Grady Memorial Hospital in Atlanta. "I think there's a tremendous amount of work to do to get this right.'' Nothing has frustrated hospitals more than being paid a $50 "triage fee" when the insurer views an emergency room visit as a non-emergency. "In many cases, we're doing thousands of dollars in tests," said Laster, chief operating officer of Regional Hospital in Hawkinsville, near Macon. The Georgia Hospital

Association says most of its member hospitals are frustrated by payment and other problems — and that the $50 payments show up more often now than under the old Medicaid program. "Several rural hospitals have faced near-failure to make payroll, and most rural hospitals are in a cash-flow crisis" because of reimbursement problems, said Jimmy , CEO of HomeTown Health, an organization of rural hospitals. Asked to give a one-year grade on HMOs' performance, Driggers of Community Health declined, saying, "As with most organizations, there are frequently opportunities for improvement.'' www.ourchurch.com/member/b/amyangel/ Fight Spam! Click Here!

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July 28, 2007