Some say it’s normal growing pains. But consumer advocates are raising alarms about the readiness of Pennsylvania’s Department of Public Welfare (DPW) to move some 550,000 Medicaid recipients in Philadelphia and the southeastern part of the state into HMOs.
After a series of delays, Pennsylvania began enrolling recipients in its mandatory managed care program, HealthChoices, on Feb. 1. Non-disabled recipients from Bucks, Delaware, Montgomery, Chester, and Philadelphia counties only have through the month of February to voluntarily choose among four HMOs that have contracted with the state. Those who do not choose a HMO will be automatically assigned to a plan March 1.
Other populations, including SSI Medicaid recipients, many of whom have already begun enrolling in managed care, have until mid-June to pick a health plan. Enrollment in the mandatory program is expected to be completed by July 1.
HCFA has made several stipulations on access, including requiring that there be an "adequate" provider network in place to meet the health needs of special populations prior to implementation and that recipients be afforded "reasonable access to complete, current information" about HMO provider networks so they can choose an appropriate provider for their needs.
AIDS representatives have been the most outspoken critics on access to care under Health Choices. Nan Feyler, executive director of the AIDS Law Project of Pennsylvania, says DPW "is not prepared to implement this for people with special needs" because it has yet to produce an effective analysis to reflect whether there are enough providers with HIV treatment experience in the five counties.
"They have implemented this at the same time that they have been developing policy and they are failing at it. You cannot design and deliver the program at the same time," she says. Some consumer groups think the state should delay enrolling special populations for another year.
Ms. Feyler contends that DPW has repeatedly vowed to develop a list of physicians experienced in treating HIV to help recipients but it has yet to do so. She argues that HMOs have not recruited enough doctors with HIV experience to serve the populations that are being mandated into managed care, particularly in Chester County.
Identifying AIDS providers
DPW HealthChoices Project Manager Patricia Jacobs says the state believes "there is network capacity out there to serve people adequately" and that the state requires plans with an inadequate spread of providers within their network to offer a choice of two providers within "reasonable access." If patients go out of plan for care because there are insufficient specialists in a field, then the plan has to pay for it.
Ms. Jacobs says the state never promised to compile a list of AIDS doctors but has given the state’s Medicaid enrollment broker a list supplied by AIDS representatives in order to help patients as they enroll. Identifying AIDS doctors is difficult mostly because many doctors resist being labeled if they want a general, mixed practice, she says. The federal government doesn’t specifically require that participating specialists be identified with any disease diagnosis, says HCFA. But Ms. Jacobs is trying to work out a compromise with the doctors and the HMOs to address concerns raised by Ms. Feyler’s group and others.
Another consumer beef has been with Benova Inc., the broker hired by Pennsylvania to help recipients select an HMO. Ms. Feyler’s group has written HCFA complaining that Benova violated conditions of the waiver by neglecting to inform people with chronic health problems that they can continue to receive services from their providers who are not part of the HMO networks. Ms. Feyler says that non-English speakers contacting Benova continue to have problems accessing services and have being kept waiting on hold for excessive periods of time.
California’s Medi-Cal program decided this year not to renew a contract with the Portland, OR-based enrollment broker, saying that the firm had failed to educate recipients about their rights, responsibilities, and benefits under managed care. The state also noted that beneficiaries were defaulting into the auto-assignment system for HMOs at excessively high rates rather than choosing their own plan.
It’s too soon to assess whether the same thing is happening in Pennsylvania, but Michael Campbell, a lawyer with the Pennsylvania Health Law Project, acknowledges that "Benova was slow in getting information and there were problems in getting the information out [to recipients] once they had it." Mr. Campbell says he would prefer an enrollment process that was longer and more focused on groups that were having difficulties making up their minds about which plan to join. Once the data on how many recipients were automatically assigned in Phase I are released, Mr. Campbell says he’ll have a better idea of how Benova is doing.
"We’ve heard plenty of complaints about Benova service representatives," says Dennis Gallagher, chief of the Medicaid Operations Branch for HCFA’s Region III, which oversees HealthChoices. Having a broker handle Medicaid enrollment is a good idea but "it’s a difficult one to carry off," he says. "For a company to come in and train new staff and place them in offices and expect them to do it to everyone’s satisfaction is impossible in such a short time frame." Mr. Gallagher believes Benova will continue to improve the quality of its services as it gets experience.
C.J. Jasinski, acting regional director for Benova’s Pennsylvania operations, acknowledges that there have been some wrinkles but says she is working to iron them out. Ms. Jasinski says Benova has 25 employees who are multi-lingual in either Spanish, Russian, Cambodian or Vietnamese and she is "constantly trying to recruit for additional languages." In addition, she says they are using AT&T’s translation services. Although there have been problems with that system she says Benova is trying to reduce the phone waiting time for beneficiaries. Benova also is reaching out to community groups that could provide additional translation services.
Ms. Jasinski says that the next phase of HealthChoices will be more challenging. "We are just now in fact entering the phase where special needs is going to become the dominant scenario" and Benova is doing what it can to train and sensitize staff."
Mr. Gallagher says, despite some problems, Pennsylvania so far has met the terms of the approval letter. "That does not mean that everything that might be happening with the transition is either fine or meets with approval or meets with consumer or providers approval. All of those things have a life of their own."
From HCFA’s perspective, the criticisms are important but don’t necessarily mean the program is in chaos. "I don’t think it’s proper to interpret the complaints as an indication that the program won’t work or can’t work," says Mr. Gallagher. "There is a very positive public purpose on focusing attention to areas that need to be carefully attended to so that the program will work as best as it can."
Contact Ms. Jacobs at 717-772-6292; Ms. Jasinski at 215-988-4469; Mr. Campbell at 215-625-3663; Ms. Feyler at 215 -879-9377; Mr. Gallagher at 215-596 -0324; and the Department of Public Welfare press office at 717-787-4592.