T
he 2012 rollout of Medicaid managed care into rural areas and South Texas has been a rough ride for many physicians. And their patients, too. Even after Athens family physician Douglas Curran, MD, finally found an or- thopedic surgeon willing to treat a young Medicaid patient with a growth plate frac- ture, administrative hassles held up that child’s care. During the few days it took the
specialist to get preauthorization from the HMO, the child’s growth plate already began to close and surgery would have been risky. All the doctors can do now is wait for other oppor- tunities to prevent future complications. The HMO networks “are consistently inadequate in our ex-
perience, especially in pediatric subspecialties. And some pa- tients you just can’t see quickly enough without affecting their long-term outcomes significantly,” said Dr. Curran, a member of the Texas Medical Association Board of Trustees. East Texas, part of the 2012 rollout, is new to managed care, and the goal, as he sees it, “doesn’t seem to be to provide care. It seems to be to make it impossible to provide care. It delays care, and it delays the opportunity for care, and it’s ultimately going to cost more money down the road.” Nevertheless, state lawmakers are committed to using it to
reduce costs in a growing program that consumes a quarter of the state budget. Earlier this year, the legislature further expanded the model statewide and made it available to new groups of patients. Meanwhile, TMA, building on its success in the legislative
session, continues to advocate protections for physicians and patients in the shift to managed care that is supposed to save the state millions of dollars and improve health care delivery in the long run. TMA expected the 2013 legislature would push through another round of legislation building on the ex- pansions it authorized in 2011; thus, the association neither opposed nor supported the effort. Meanwhile, TMA-backed Senate Bill 1150 will deliver important protections. Some physicians are not convinced of the state’s promises
that Texas Medicaid is better off under managed care. They report ongoing payment and preauthorization delays and an overall lack of communication by Medicaid HMOs, as well as concerns over network adequacy and lax state enforcement. That’s on top of already low physician payment and partici- pation rates in Medicaid. Other physicians say the move has begun to generate some efficiency in care delivery, and some health plans are making strides in partnering with doctors to incentiv- ize change.
TMA leaders Douglas Curran, MD Stanley Fisch, MD 16 TEXAS MEDICINE October 2013
say more work is needed to boost
access to care in an HMO model that managed 82 percent of the state’s Medicaid patients in 2012, with only a quarter of the state’s physicians fully participating in managed care. (See “TMA Survey Details Physician Unhappiness,” page 19.) Only 32 percent take all Medicaid patients, whether in managed care or fee-for-service.
Physicians understand managed care has the advantage of
providing state budget certainty in the Medicaid program, and some plans have learned from past mistakes, says John Hol- comb, MD, chair of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured. Texas began using Medicaid managed care in urban areas in 1993. With the last expansion into rural Texas and the Lower Rio Grande Valley, however, “there’s still a lot of frustration, and we are now down to a few doctors who are committed to the Medicaid patients they already have and who may be in areas, especially rural areas, where you can’t not see Medicaid pa- tients because that is the most common insurance available,” said Dr. Holcomb, also cochair of TMA’s Physicians Medicaid Congress. “It’s hard to know yet if we are better off because it takes two or three years to make up a lot of the rollout costs, and plans have to be here for the long haul. And I don’t think we can identify poor-quality care as a result of any of this. But the anecdotes are real and have certainly led to delays and lost opportunities for care.” Such shortfalls, he adds, are also concerning in light of the 2013 legislature’s decision to expand Medicaid managed care to cover what he described as “highly vulnerable populations,” namely children and adults with intellectual and developmen- tal disabilities. Done right, however, some doctors say these and other Medicaid patients could benefit from managed care.
MORE EXPANSION Senate Bill 7 by Sen. Jane Nelson (R-Flower Mound) and Rep. Richard Raymond (D-Laredo) aims to save money in Medicaid by expanding Medicaid HMOs to people with long-term care needs, in particular, those with intellectual and developmental disabilities and nursing home residents. STAR+PLUS HMOs, which cover the elderly and people with physical disabilities, will provide services to the new populations. The program will phase in by 2021.
SB 7 establishes a new HMO model, called STAR Kids, for
children with disabilities. Participating managed care plans must demonstrate experience in the care of these children. Because some already do, that program begins sooner — Sept. 1, 2014. To further promote coordination of care for these popula- tions, Senate Bill 58 by Senator Nelson and Rep. John Zerwas, MD (R-Simonton), integrates behavioral and physical health services into Medicaid managed care. The two bills direct the Texas Health and Human Services
Commission (HHSC) to establish several advisory committees to seek input from physicians and providers, people with dis- abilities, patient advocates, and other interested parties on systemic issues in the Medicaid HMO model and on how best to incorporate the new populations and services.
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