September 5, 2008
MANAGING ANSWERS
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Looking for answers on mandatory managed care |
On Wednesday, the State Department of Health met with community-based organizations to provide details about the impending roll-out of mandatory managed care for Medicaid recipients living with HIV and the elimination of fee-for-service care at Designated AIDS Centers. The meeting, attended by some 90 people, brought more questions than answers. Despite specifics about the plan to implement the changes, and the DOH's call for community input, looming questions remain.
The state hasn't set an official date for the roll-out and has yet to receive approval from the Centers for Medicare & Medicaid Services (CMS) or Gov. David Paterson. It's also unclear how people who are unstably housed will be reached, and if HIV special needs plans (SNPs) are going to be prepared for an influx in patients.
State officials were careful to reinforce their position that mandatory managed care is not a budget belt-tightening move. Director of the DOH's division of managed care, Jay Laudato said. "We have not proposed cost savings to the [New York State] Division of the Budget. FOIL us, sue us, do what you have to do."
There are currently 27,500 HIV-positive Medicaid beneficiaries in New York City whose only known exemption from managed care is their HIV status. 9,375 beneficiaries are enrolled in managed care, 3300 in SNPs. Because managed care insurers charge less than fee-for-service insurers, many advocates believe that the state is eyeing the savings to be gained by moving thousands of people living with HIV into managed care.
The Wednesday gathering at St. John's University was intended for CBOs and was invitation-only, but a group of a dozen Medicaid recipients living with HIV/AIDS protesting outside the meeting held up signs reading "Don't force people with AIDS into substandard care." That prompted AIDS Institute director Humberto Cruz to invite them into the meeting to ask questions. Props to Cruz for doing so. While the State has already met with health care plans, Designated AIDS Care Centers and CBOs, it has yet to meet actual Medicaid recipients affected by the policy shift. The State DOH consumer meeting on October 29 and 30 (locations to be determined).
Here are the most critical questions that were asked, and analysis of the answers the State provided.
What is the rationale for mandatory managed care?
"Why do we have to move to managed care at all?" asked a Housing Works client at the meeting. Laudato responded that unlike in managed care, the state has no way of evaluating fee-for-service patients, which means "a lot of people fall into the cracks." Laudato also noted that the three-systems study of Fee-for-Service, Mainstream Managed Care and HIV Special Needs Plans (SNPs) showed better results for managed care than fee-for-service. SNPs had the highest quality of care. He acknowledged that one study is slender justification but said it couldn't be ignored.
As noted in an Update piece by Director of Shubert Botein Policy Associates Ginny Shubert, the three-system study was deeply flawed (and full of its own enigmas). It doesn't look at quality analysis data outcomes, and mostly looks at if services were performed, not at the patient's health outcomes. For example, the study shows if a person is prescribed for ARVs, but not if he is adhering to meds. "Whether or not you billed for that procedure isn't a measure of providing quality care," Housing Works President and CEO King told the Update.
How will the plan roll out?
The State has not decided when the roll-out will begin in New York City and if the process will proceed borough by borough or at random, nor the process for the rest of the state. Jennifer Dean, assistant director of Bureau Planning and Implementation at the Division of Managed Care, explained that about 2,500 Medicaid recipients a months and their providers will receive notices about the new policy. Recipients will have 60 days to choose a plan, and then a three-month grace period before being locked into a plan. HASA case workers, COBRA case managers New York Medicaid CHOICE workers and other providers will be trained to help with the process. Then participants will only be allowed to change plans for nine months if they have a "good cause reason." One such reason, which earned praise from advocates at the meeting, is switching from a mainstream plan to a SNP.
People in homeless shelters will be exempt from choosing a plan, but those in SROs and unstably housed people are not exempt. If someone doesn't receive a letter, then the letter is to be forwarded to the Human Resources Administration, which will try to find an up-to-date address. The clock on the period of time for people to be assigned won't be started until people receive their letters.
Audience participants questioned the short-time period for enrollment. "Why not give six months or some more generous window?" asked Sean Cahill, director of public policy at GMHC. Dean explained, "We've found that after 60 days of not choosing people tend to forget." Still, Cahill told the Update, "I don't understand what the rush is. Unstably house people and people in SROs will not be able to be reached by letters in that time frame."
What about people who can't access SNPs
"We can't make a SNP a mainstream plan, and we can't make a mainstream plan a SNP," said AIDS Institute Deputy Director Ira Feldman, noting that SNPs are held to more rigid standards than mainstream plans. There are currently only three SNPs serving 3,300 people in New York State. And it is unlikely that SNPs could handle the massive rollout of patients. People in Staten Island don't qualify for SNPs unless they work in another one of the four boroughs—pretty unlikely for most people who qualify for Medicaid, a provider from the borough noted. "People in Staten Island can't join a SNP even if they wanted to," he said. "We can't say one-size-fits-all when there are disparities between neighborhoods."
What about 'intelligent assignment?'
People who don't respond to a plan within 60 days will be auto-assigned to a plan, which means that people can easily be assigned into plans that don't include their current doctors or care providers. In the past, patients have been auto-assigned into the highest-rated plans, but DOH is toying with the idea of "intelligent assignment," which, based on a patient's current doctors, would try to fit the patient into the best plan. "We're not sure we can do that, but we'll try," Laudato said. He also noted that because so many people with HIV currently see COBRA case managers, HASA case workers or other people who can help with the shift, "we're hoping to minimize auto assignment, but it's a difficult process."
The Legal AIDS Society staff attorney Diane Spicer told the Update that if "intelligent enrollment" actually works, "it would be a huge improvement," compared to the disaster stories when the state shifted SSI recipients to mandatory managed care. "But we have to continue knocking on the door to make sure this happens," she said.
The Update will keep you posted on news of the roll-out and the consumer meetings on October 29 and 30.