August 8, 2008
BACHRACH SPEAKS
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This Bacharach would never force poor people into HMOs |
After weeks of angry speculation about New York State's plan to force HIV-positive Medicaid recipients into managed care, State Medicaid Director Deborah Bachrach publicly confirmed that mandatory HMO enrollment was in the works. In an interview with the Update this week she said, "We have recommended mandatory enrollment, but the Department of Health has not made a decision. We expect it in the next few weeks."
For the first time, Bachrach also publicly laid out some of the plan's specifics:
- HIV-positive Medicaid recipients will receive a letter explaining that they will lose their exemption to mandatory HMO enrollment, followed by a letter instructing them how to pick a managed care plan. Recipients will be able to enroll in either a standard HMO or one of the state's Special Needs Plans (SNPs), HMOs that specialize in HIV care
- Healthcare providers will receive a letter informing them that their HIV-positive patients are required to select a managed care plan. The letter will ask providers to talk to patients about what plans providers participate in, in order preserve treatment relationships
- Community-based organizations will receive information asking them to help HIV-positive Medicaid recipients transition to an HMO
- HIV-positive recipients of safety net benefits will have 60 days to enroll in an HMO once they receive their instruction letter; HIV-positive of recipients of SSI benefits will have 90 days.
- If recipients don't enroll in an HMO, they will be auto-assigned to one. After auto-assignment, they will have another 90 days to select an HMO plan.
Currently, HIV-positive Medicaid recipients can get health care from fee-for-service insurers, or choose a SNP or standard HMO plan. Mandatory HMO enrollment, which Bachrach says will start in January and gradually roll out over a 12 month period, has Medicaid and AIDS advocates, including Housing Works, up in arms.
First and foremost, advocates are fearful that mandatory HMO enrollment will cause a disruption in care for HIV-positive Medicaid recipients. Diane Spicer, an attorney with the Legal Aid Society's Health Law Unit, says her organization has seen "unending problems" for Medicaid recipients who also receive SSI. (SSI recipients--without other exemptions--were forced into HMOs in 2005.) Those problems include interruptions in home care, failure to notify recipients of their auto-assignment to an HMO, and finding a plan that includes all of the specialists required by people with serious, chronic illnesses.
Bachrach denies that the mandatory enrollment of SSI recipients was a disaster. " We did get calls about a handful [of problems], but in each case we resolved them. People who go to Legal Aid, by definition it means something went wrong. We can't draw conclusions from the people who went to Legal Aid," Bachrach said. She also cites the results of a DOH survey of SSI recipients on Medicaid released last week showing, according to Bachrach, "incredibly favorable" feedback.
Spicer scoffs at the survey, detailed results of which have not been posted on the DOH site, and the idea that Legal Aid cases are isolated. "You'd have to have a 12 th grade reading level and no reading impairment or developmental disability to participate in this survey," Spicer says, referring to the fact that many SSI recipients are severely physically and mentally disabled. "This is the population that didn't understand mandatory enrollment in the first place! I think the problems we're having are representative."
Denise Soffel of Medicaid Matters called Bachrach "a little disingenuous," referring to her speculation that SSI recipient complaints were isolated. "We know that many people are reluctant to complain and especially file formal complaints," she said. "Many people just shake their heads and say, 'I can't fix this.'"
'Not a financial decision'
Some in the AIDS community believe that Bachrach is moving ahead with mandatory enrollment simply to save the state money because HMOs will provide care at a much lower cost than fee-for-service insurers. Bachrach says no way. "This is not a financial decision. We did no financial analysis. The data shows that both managed care plans and SNPs do better than fee-for-service [care]. And the data shows that SNPs and managed care plans have more case managers and specialists," she said referring to a comparison study on HIV-positive Medicaid recipient health services.
New York AIDS Coalition's Matthew Lesieur is skeptical. By the measures of the comparison study, SNPs were the best care providers. "If you're going to rely on the conclusions [of the comparison study], why not enroll everyone in SNPs? If you want to put your money where your mouth is, everyone should be auto-enrolled in SNPs," Lesieur said.
"I find it difficult to believe that they are making decisions without worrying about the financial ramifications. Bachrach's job is to manage Medicaid, which includes controlling costs," said Housing Works President and CEO Charles King, who adds, "The comparison study doesn't show that managed care is that much more effective than regular fee-for-service insurance plans." Lesieur agrees that the comparison study is flawed. "The study tells you about viral load tests, but it doesn't give you health outcomes. What were the viral loads? What were the CD4s? It's widget counting."
Money-related distrust between AIDS groups and Bachrach is a far cry from what was supposed to happen when Gov. Eliot Spitzer was in office and the state's finances weren't looking nearly so grim. "Spitzer's Medicaid reforms were supposed to result in all these savings, which were going to be used to expand care. Now we hear that money is going to fill budget gaps," said King.
Last but not least on the minds of AIDS groups is the fact that Bachrach assured community groups that she would ask for community input on the plan before making any decisions. Bachrach feels that she's kept advocates in the loop all along. "I don't know what to attribute [people's anger] to. This has been under discussion since we rolled out Special Needs Plans four years ago," Bachrach said. Bachrach added that September meetings about enrollment in managed care for HIV-positive Medicaid recipients are in the works.
Responding to the crisis
NYAC, Housing Works, the Legal Aid Society, Medicaid Matters, GMHC and other groups have begun to organize a response to mandatory HMO enrollment. A community sign-on insisting on a meeting with Bachrach to discuss problems with mandatory HMO enrollment will be circulated next week. On September 11, 2008, GMHC will host a meeting for people living with HIV/AIDS, AIDS advocates and others to strategize about mandatory HMO enrollment at 3:30pm in the 12 th Fl cafeteria. Lesieur also says that a coalition of groups will be reaching out to Sen. Tom Duane and Assembly Member Dick Gottfried for help in crafting a response to the state Medicaid changes.
King, who thinks state government has no right to force people into choosing one health care plan over another just because they are poor, said, "The Department of Health should focus on expanding the idea of all-inclusive care. Then they can educate consumers to the benefits that care affords."
Soffel thinks a little well-promoted outreach would go along way. "It's something that the DOH has been inconsistent about, but when they do outreach, the response is always tremendous," she said. "They had a stakeholder meeting upstate and were stunned when 75 people showed up because consumer advocates put the word out. Those kinds of things make a huge difference."