NYC Medicaid mandatory managed care rollout hits a few speed bumps
NYC Medicaid mandatory managed care rollout hits a few speed bumps in enrollment
The first rollout of Medicaid managed care in New York City has had its problems — enrollment materials not available in the many languages needed, exempt people receiving enrollment packets, providers telling people they must enroll to continue receiving services — but the issue dividing government agencies and consumer advocates is whether the problems are temporary bumps in the road or a warning of bigger problems to come.
"Things have gone quite well," says Sandra Mullen, a spokeswoman for the city’s Department of Health, which shares responsibility with the state Health Department for the program. "Obviously, there are kinks involved in any kind of start-up. But we’re very pleased that from Aug. 9 to Oct. 1, there were 12,000 enrollments processed. We’re moving at a very good pace."
That assessment is shared by the state Health Department’s spokesman Rob Kenney, who says the rollout is "going well" with benefits education and enrollment contractor Maximus "meeting all the contract requirements for enrollment and processing."
But consumer advocates are less sanguine, fearing that the "kinks" seen by Ms. Mullen are only the tip of the iceberg of massive problems caused by lack of adequate planning and preparation for the Aug. 9 launch.
Mandatory managed care ultimately will cover 1.5 million people in New York City. Phase I mandatory enrollment started Aug. 9 for 382,000 Medicaid recipients in Manhattan, Brooklyn, and Staten Island. They are given 60 days to choose from among 18 health plans that have a total of 6,576 participating primary care physicians and 20,152 specialists. Those who do not choose a plan within 60 days are automatically assigned to a plan. Participants have 90 days from the date of their initial enrollment to change plans without cause; after that they are locked in until 12 months after enrollment.
Mandatory managed care excludes Medicaid recipients in institutions or foster care and exempts those with HIV/AIDS, serious mental illness, developmental disabilities, or language barriers. Individuals who are exempted still may enroll voluntarily if they wish.
One of the major problems advocates see is that outreach educational materials were not available in the many languages needed when the first mailings went out. They also complain that community groups and even providers have not had sufficient information and understanding to be able to help Medicaid beneficiaries decide what is best for them.
"There were a number of problems that we felt should have been addressed in planning that are now appearing in implementation," says Susan Dooha, director of health care access for Gay Men’s Health Crisis. "For one thing, the state’s data system doesn’t recognize that some Medicaid beneficiaries are exempt from managed care. The state had said that no one with HIV or AIDS would be asked to enroll or be mandatorily assigned. But many in this group are receiving enrollment packets.
"We also had asked for adequate resources to educate AIDS provider agencies so they could help their clients. But there were no presentations and no materials, and the agency people don’t know the basics of enrollment, exemption, or how health care may change for those who choose to enroll," she adds.
"We see problems now with kids with AIDS being enrolled in mandatory managed care even though they are exempt. Their families want to disenroll them, but it’s difficult to accomplish and they are at risk of having their care disrupted. These kids are medically fragile and may need urgent care at any time. While the incidence hasn’t been great yet, we’ve only just gotten started, and I’m concerned about what we may see as we go on," Dooha says.
Another major area of concern is the lack of printed materials in many different languages. Ms. Mullen acknowledges that only English-language materials were ready Aug. 9, with the Spanish version coming several weeks later. She says materials in Haitian-Creole, Russian, Chinese, and Arabic are being rushed into production.
State spokesman Mr. Kenney notes that the Health Care Financing Administration (HCFA) requires only English and Spanish materials, based on the percentage of population in the target area, but the state and city are taking extra steps in producing materials in other languages as well.
The city tried to overcome the lack of brochures in various languages with a notice in 18 languages on the back of the envelope holding the enrollment mailing, says Judy Wessler, policy coordinator for the Commission on the Public Health System. The notice gives a telephone number for a translation service operated by Maximus.
"But they’re not getting many calls for help," she concedes. "The language on the envelope may not have been strong enough so people understand there can be major changes in the way they receive health care and they need to know what is happening." Ms. Dooha reports that providers say they are seeing Russian, Chinese, and other patients who are very confused about the enrollment materials they received.
"Those are the fortunate ones," she says, "because they’re well-enough connected to come in and ask for help. What about all the others who are confused but are not asking anyone?"
She also said that those who do not speak English can have difficulty with the telephone help line because they listen to a series of baffling voice mail messages in English until the system finally hangs up on them.
The program is "moving too quickly without adequate plans in place for a major disruption" in health care services, says Chris Molnar, director of the Medicaid Managed Care Education Project of the Community Services Society. Because the city and state have refused to adequately involve community agencies in the outreach work, Ms. Molnar says, "people have been clueless. They are very vulnerable to misleading marketing pitches. People are enrolling without understanding what it means to enroll, without understanding that they have choices, without understanding that they may not have to enroll at all."
The first auto-assignment figures — due before the end of October — will suggest to advocates how well enrollees understand their options. A high level of auto-assignment into managed care plans indicates to advocates that outreach and counseling efforts need to be stepped up.
Some of the concerns are driven by the experience of 12 upstate counties where mandatory Medicaid managed care already is under way. "We’ve heard from upstate that auto-assignment can be high," Ms. Dooha says, "and that there can be disparities among communities or populations. We understand, for instance, that the black auto-assignment rate is significantly higher than for whites. That suggests that outreach plans were not developed in an effective way and that the government agencies don’t have good connections with community leaders and groups. It alarms me that this could be happening in upstate communities.
"Despite us raising this issue with HCFA and begging for their scrutiny of the city’s outreach plans, now we’re learning of problems here after enrollment has begun."
Another area of concern being voiced deals with questionable marketing practices by some HMOs and providers. "Many providers are disseminating inaccurate information to their client base," Ms. Molnar says, telling clients they will not be able to receive service unless they sign up with a particular HMO. "There’s a question of who’s watching the shop as everyone tries to gain market share. It’s important that the city and state put the monitoring forces on the street that they said they would."
Some enrollees receiving mental health services are being told they must sign up with a particular HMO to continue to receive care, says Ms. Wessler with the Commission on the Public Health System. Government agencies take action in response to advocates’ marketing concerns, she says, but usually on a case-by-case basis rather than systemically. "I think they need to make an example of an organization that’s been doing things incorrectly and hand out some punishment to send a message that this shouldn’t be happening," she says.
Problems also have been reported with special populations such as the hearing-impaired (a hearing person must call Maximus and ask to have the special telephone connected for the hearing-impaired person), the blind (no Braille materials available), and the homeless. The case of the homeless could prove particularly interesting because although they are supposed to be exempt, they are not coded that way in the computer system and so have been sent enrollment mailings. There is the potential for a significant auto-assignment of people who were specifically supposed to be protected from the mandatory managed care program, says David Wunch, a policy analyst with Care for the Homeless.
To complicate the task, he says, homeless people who want to opt out of managed care must telephone and ask that an exemption form be mailed to them — city and state policy doesn’t allow community groups to distribute such exemption forms. But because the homeless often move among the city’s homeless shelters, the mailed form may never reach them.
The system puts the homeless at risk for a break in the continuity of care, says Care for the Homeless assistant executive director Bobby Watts. A homeless person who has been unwittingly auto-enrolled in an HMO may turn up ineligible for coverage at his or her conventional Medicaid provider, he says.
Governmental agencies may be willing to wait for problems to cause harm rather than proactively thinking of what problems there can be and working to prevent them, says Ms. Dooha.
"We should extend the managed care concept to the way change is handled as well as to the actual medical care," she declares. "I don’t know how bad the problems have to get before action is taken to slow down and review what’s happening. I don’t want to see children with AIDS in a medical crisis because their families haven’t gotten good information. I don’t want to see people enrolled in managed care and then clueless about how to get the care they need.
"What level of civil rights violations is needed before things slow down and are reviewed or federal money is withdrawn? We haven’t gotten an answer for how bad it has to get and how HCFA sees its role." (HCFA officials declined an interview for this article.)
"I’ll grant that some progress has been made, but I’m still very disturbed. I think these early problems should be a wake-up call. I think the advocacy groups have been constructive. We’ve been raising issues and making suggestions to avoid problems, but we haven’t been heeded. It’s difficult to keep faith with so many obstacles in the way, but we’re still amenable to continuing to work things out. We haven’t yet given up on the idea that we can make a difference in this process."
Contact Sandra Mullen at (212) 788-5290, Susan Dooha at (212) 367-1228, Rob Kenney at (518) 474-7354, Judy Wessler at (212) 749-1227, Chris Molnar at (212) 614-5401, and David Wunch and Bobby Watts at (212) 366-4459.
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