“I don’t think we had any expectation the further rollout of Medicaid managed care wouldn’t happen. It was a matter of understanding reality and finding the best way to deal with it.”
tive Commissioner Tom Suehs and oth- ers from HHSC “trying to get in there early with our concerns and questions.” He says HHSC was very responsive to those concerns, including retaining one statewide drug formulary under the Medicaid HMO model instead of multi- ple ones and establishing a single claims clearinghouse.
But physicians in the Rio Grande Val- ley still have many questions about how the transition to managed care will work. “The fear and loathing is the issue we have to overcome,” Dr. Holcomb said.
to provide STAR and STAR+PLUS HMO services in the Rio Grande Valley: United Healthcare Community Plan, Superior Healthplan Network, Molina Healthcare of Texas, Driscoll Children’s, and Health Spring (STAR+PLUS only). In addition, HHSC divided 166 of the affected rural counties into three servic- es areas. Amerigroup, Superior, and First Care will cover West Texas. Contracts for Central Texas went to Amerigroup, Su- perior, and Scott & White. Amerigroup and Superior received the Northeast Texas contracts. The remainder of the 202 counties in the Medicaid HMO ex- pansion will be added in existing urban services areas.
Fear and loathing
John R. Holcomb, MD
TMA did not sup- port the Medicaid managed care ex- pansion, but it did not oppose it as it did in previous leg- islative sessions. “The medical
54 TEXAS MEDICINE October 2011
professional societies realize the prob- lems associated with Medicaid fund- ing, especially in a cyclical downturn as we’re in right now,” Dr. Holcomb said. “I don’t think we had any expectation the further rollout of Medicaid managed care wouldn’t happen. It was a matter of understanding reality and finding the best way to deal with it.” Helen Kent Davis, director of TMA’s Office of Governmental Affairs, says phy- sicians realized even before the 2011 leg- islative session started that lawmakers would have to find savings in the Medic- aid program to balance the budget. Had TMA opposed the managed care expan- sion, that $600 billion in savings likely would have come out of physician and other provider payments.
TMA officials met several times with physicians from the affected county medical societies before the 2011 ses- sion to discuss the HMO model and the ramifications of opposing it. Harlingen pediatrician Stanley Fisch, MD, says the Cameron-Willacy County Medical Society began discussing Med- icaid managed care last fall with Execu-
“We’ve been down this road before with Texas Medicaid. We’ve done conversions from fee for service to Medicaid man- aged care in the past.” There were many problems when Medicaid managed care was introduced to the large urban areas a decade or more ago. For example, children from the same family often were assigned to different HMOs. And many patients or their parents didn’t understand that they had to choose a primary care physician from their HMO’s network. Dr. Holcomb hopes many of those is- sues will be avoided this time around. “The state made promises to the medi- cal community that they, in fact, have learned from past rollouts and will im- plement those lessons learned from past rollouts,” he said. Still, Dr. Fisch and others expect there will be some initial confusion among pa- tients. He says patients in the Valley are used to having to choose a primary care physician under the Primary Care Case Management model. “But what they’re not used to is the fact that HMOs will probably enforce that much more stringently and not be so forgiving when they do go to some- body else or if they go to the ER a lot,” Dr. Fisch said.
Physicians in the Valley also are con- cerned that having five different plans running Medicaid managed care in the area could increase administrative bur- dens on their practices.
“My concerns for my practice are how many HMOs will we have to deal with? Do we have to enroll with each and ev- ery one? Are we going to have to bill through five different clearinghouses
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