“MEDICINE IS A PERSONAL BUSINESS, AND WE DEAL WITH OUR PATIENTS ON A PERSONAL BASIS. IT WOULD BE NICE TO DEAL WITH THESE [HMOs] ON A PERSONAL BASIS.”
challenges. “We take very seriously our role as the oversight agency,” Mr. Traylor said, adding that the commission specifi- cally asked the legislature for the payment rate protections in SB 7.
If an HMO does not timely respond to complaints or pay physicians on time, for example, the agency assesses fines and sanctions to bring the companies into compliance, doing so on almost a quarterly basis since the last rollout. That includes a $2.9 million fine against Molina — the largest fine the agency has levied thus far against a health plan — for an inadequate network and for not resolving client complaints fast enough. In the first year, health plans in South Texas improved by
increasing their networks, according to state officials. HHSC receives fewer complaints from patients, and the HMOs paid most claims within the required 30-day period and within 14 days on average.
As for network adequacy, Mr. Traylor says the agency en-
forces Texas Department of Insurance standards at minimum and conducts a “readiness review” before any rollout, barring insufficient HMO networks from going live.
But the issue of having enough specialists available is not unique to Medicaid managed care or to Texas, as the state in general faces physician shortages. “We will continue to be challenged with that,” he said, adding the state is taking steps to incentivize better Medicaid participation and reforms through the Medicaid 1115 Transformation Waiver program (See “Medicaid Makeover,” Texas Medicine, March 2013, pages 12–18.).
The commission already holds health plans to high stan-
dards, “but it’s an area where we’re always looking to improve,” Mr. Traylor said, referring to the new provider protection plan under SB 1150. “We are dealing with a client base for whom health care services are essential, and we want to make sure as a state that the rollout goes as smoothly as possible and providers continue to participate in the program. At the end of the day, the goal for the state, the managed care organizations, and providers is and should be serving people enrolled in the Medicaid program.”
MAKING PROGRESS Meanwhile, some physicians and HMOs point to signs of early successes in reducing utilization, improving care coordination, and financially incentivizing physicians for bettering quality of care in some of the expansion areas.
20 TEXAS MEDICINE October 2013
Before Medicaid man-
aged care landed in South Texas, Dr. Fisch says, the PCCM model was not ef- fective overseeing utiliza- tion for certain services. HMOs, on the other hand, have done a better job, which may save the state money.
“In the past, it was hard to say no to parents who
wanted their kids to have physical therapy because their toes pointed inward or occupational therapy to learn social skills when there was no scientific evidence to support it. Now, HMOs are saying no when there is no medical necessity, which helps take the onus off us [physicians].” Dr. Fisch also sees an advantage in expanding Medicaid
managed care to include adults and children with more com- plex needs not necessarily covered by traditional fee-for-ser- vice Medicaid plans. STAR Kids, for example, would allow HMOs to work with doctors on a fee schedule that recognizes the extra time and effort required to treat children with intellectual and develop- mental disabilities. “And if that’s the case, then the program is definitely moving in the right direction.” The same goes for the incentive payment program that Driscoll initiated to financially reward practices like his for quality improvements. So far, that HMO is the only one he works with to do so, although the managed care expansion legislation envisions that all Medicaid HMOs will eventually incorporate quality-based payment initiatives. Mary Dale Peterson, MD, Driscoll’s president and chief ex- ecutive officer, says that besides rewarding physicians for their hard work, the key to the improvements she has seen under managed care is “establishing relationships and meeting fre- quently with your network of doctors.” She is a member of TMA’s select Medicaid committee. That relationship-building is effective, she says. In Hidalgo
County, most physicians keep their clinics open after hours — one of Driscoll’s financial incentive drivers — which helped reduce emergency department visits and hospital admissions by 50 percent and 30 percent, respectively. In Nueces County, the plan’s partnerships with the obstetric community and out- reach to pregnant women helped lower pre-term birth rates in Driscoll’s Medicaid population. Care coordination offered through managed care is a big factor in those improvements, as is the HMO’s ability to share with physicians what Dr. Peterson described as big-picture data on patient utilization. Physicians don’t typically get that seeing patients one visit at a time in traditional fee-for-service plans.
“Some of the things the state struggled with on overutiliza-
tion we’ve been able to ameliorate, and we are building on our strengths. So [Medicaid managed care] can work, and it is working,” Dr. Peterson said.
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