Early reports to the state's largest newspaper resemble tales from the days of Medicaid transitions in other states. While managed care may be better for accountability measures over the long haul, in state after state, large-scale transitions prove difficult.
On April 4, 2016, Governor Terry Branstad declared Iowa Medicaid’s transition to managed care “smooth,” saying the process, then on Day 3, had gone off without “major disruptions” to patients or providers.
Based on the history in other states, waiting for a month or more before declaring “mission accomplished” may have been wise.
Iowa’s largest newspaper, The Des Moines Register, published an editorial Sunday outlining a list of early run-ins that Medicaid enrollees, family members, or providers have had with contractors. And more may becoming, since the newspaper published an email address for readers to forward stories of their experiences with managed care.
The move to managed care was delayed twice from its original January 1, 2016, start date, after CMS found Iowa was not ready to make the transition. The year ahead of the move has been marked by intense partisan battling over the change, which did not let up even after CMS gave the green light. Among other things, the famed Mayo Clinic across the border in Minnesota declined to reach agreement with the contractors Iowa selected to run manage healthcare.
Stories in Iowa are similar to those in other states that taken a head-first dive into Medicaid managed care. While many states ultimately find things settle down and they see savings, the early going has been rough in Kentucky, Ohio, Illinois, and other places.
In Kentucky, low reimbursements in Medicaid managed care have been blamed for provider shortages in some rural pockets. Early snags during Ohio’s transition left some longtime home health care aides without paychecks for weeks. Some had no choice but to take other jobs, leaving clients they had been with for years without care.
Iowa Medicaid Director Mikki Stier told skeptical lawmakers April 13, 2016, that the state had not seen any widespread system failures across the $4.2 billion program that serves 560,000 clients. But according to the Register editorial, there are plenty of anecdotes:
· A physician’s assistant posted on social media her frustration with a contractor over its requirement to use an out-of-state specialty pharmacy to order a client’s medication for schizophrenia. The client could not figure out how to navigate the system, and the assistant provided samples of medication to cover a gap while she waits more than a week for the prescription to come from Florida.
· A mother who has handled care for her 28-year-old “nonverbal” daughter for a decade said while her guardianship was always acknowledged under the old system, the contractor refused to do so and sent a consent order for her daughter to sign. Except there’s one problem: her daughter can’t legally sign anything.
· Another enrollee said he never received his insurance card or a booklet of participating providers from his managed care contractor and wasn’t billed when he went to a doctor’s appointment after the April 1, 2016, start date. Instead, the materials went to the person handling his financial affairs. More than a week later, he received a bill for $233 for the office visit.
In August 2013, when The American Journal of Managed Care talked to Kentucky Medicaid Commissioner Larry Kissner about his state’s challenging transition, he said the main issue was the speed of the transfer, and the fact that it was done within the context of finding budget savings.
Over the long haul, Kissner said, managed care companies are better-suited for accountability measures like making sure Medicaid enrollees receive cancer screenings or have their blood sugar check. The problem is that the transitions are rough.
“The managed care companies do a much better job of care coordination than we did with fee-for-service,” Kissner said at the time.