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A Baltimore-based advocacy organization for children and youth says a qualitative study of parents and pediatric offices shows that a significant number of children are having trouble accessing the health care services they are entitled to under Maryland’s HealthChoice Medicaid managed care program.
In particular, says Advocates for Children and Youth (ACY), Maryland is not following federal law in the way it covers newborns. Children face long delays before they can see pediatric specialists, and thousands of children risk losing their traditional doctors because of the way managed care organizations auto-assign children to specific doctors.
Carol Fanconi, health policy director for ACY, tells State Health Watch that the organization used three focus groups made up of parents and interviewed pediatric office managers at 34 practices with a combined staff of 121 doctors to obtain the data presented in its qualitative report. Because of the nature of the research, she says, the organization cannot estimate the extent of the concerns raised.
However, every concern included in the report had been voiced enough times to convince researchers that it was a systemic problem and not isolated to a particular patient, physician practice, or managed care organization. Ms. Fanconi says a research advisory group approved the nature and methodology of the work.
Debbie Chang, deputy secretary for health care financing with the Maryland State Department of Health and Mental Hygiene, tells State Health Watch that the report’s backers interviewed "a select group of providers and families who were solicited to talk about their problems."
She says the researchers who prepared the report talked with six providers, 31 office managers, and 42 parents from Baltimore; the program has approximately 400,000 members and more than 54,000 providers.
"The information in the report is not representative of the program as a whole and shouldn’t be generalized to the program as a whole," Ms. Chang says.
Although state officials say those surveyed only were asked to discuss problems and never asked about any positive aspects of the program, Ms. Fanconi says the questionnaire used with the pediatric office managers specifically asked participants to first list improvements that had taken place during the three-year history of the program. "
The office managers had a difficult time identifying things that had improved. The start-up year was chaotic, and they think it’s still pretty much chaotic," she says.
The report’s findings look at general concerns voiced by parents and office managers and then at specific problems relating to these issues:
• auto-assignment and continuity of care;
• eligibility verification;
• provider directories;
• interruption of care;
• newborn eligibility;
• appointment scheduling;
• testing and lab work;
• dental and vision care;
• access to specialists;
• equipment and supplies;
• restrictions on medication choices;
• children with special health needs;
• foster children;
• consumer complaint resolution;
• billing, payment, and reimbursement issues.
Many of the concerns are illustrated by descriptions of real situations with the names of the clients disguised. Ms. Chang says the department has asked for information on the real-life cases so they could be reviewed and help could be provided, but ACY has refused to release the information.
"We think that’s unfortunate because we could be much more help," she says.
A key concern of both parents and providers was that children frequently are auto-assigned by managed care organizations to practices that are inconveniently located and have no prior history with the children or their families. Parents reported that sometimes children in the same family were assigned to different managed care organizations and primary care providers.
Office managers complained about cumbersome eligibility verification processes that need to be followed every time a child comes to the office. They also said managed care plan directories showing pediatric specialists often are not accurate, listing doctors who are not participating with the plan or not taking new HealthChoice patients.
Continuing interruptions in coverage and service were reported, which often did not come up until the time a patient was in the physician’s office or trying to fill a prescription.
ACY officials complain that while managed care organizations may be following a state policy in denying services for newborns who do not have their own HealthChoice ID number, their actions are contrary to federal law, which requires plans to reimburse under a mother’s name for up to one year.
"Many practices said they feared that parents were not bringing their newborns in for services because they believed babies were not insured until they had their own numbers and that the families would have to pay for such services," the report states. "In addition, office managers said that they have great difficulty securing services from third parties, including pharmacists, specialists, and medical equipment suppliers, who were not willing to provide free services."
There were complaints from parents about long waits for appointments and being sent for lab work to facilities that were difficult to travel to. Parents also said there were not enough dental providers or pediatric specialists. Office managers complained about overly restrictive and rapidly changing pharmacy formularies and requirements that parents obtain all equipment and supplies from managed care organization subcontractors rather than from doctors or nearby providers.
Practices said that too few children qualified for the Rare and Expensive Case Management program, a fee-for-service system for children with severe, complex, or unusual medical conditions. They also said that primary care providers were not being included in development or implementation of case management plans for the children with special needs who remain in HealthChoice.
Ms. Chang says the department already is implementing many of the changes that ACY called for. Providers directories are being revised and will be put on-line, she says, and hospitals are being required to submit newborn eligibility forms within 24 hours. She says they want to implement a single form for specialists to use in communicating with primary care providers and want to have more regular involvement with the foster care system.
Regarding concerns about the assignment of newborns, Ms. Chang says the state is following a procedure that is acceptable under federal law. She says ACY wants newborns auto-assigned to the managed care organization that cares for their siblings instead of the mother’s plan. Usually, parents and children are in the same plan, Ms. Chang says. But if they are different, assignment is made to the mother’s plan because that is the one responsible for the birth outcome of the newborn and thus has an interest in providing high-quality care.
Ms. Fanconi says ACY recognizes that because of the complicated nature of implementing Medicaid managed care, no single one-time correction can solve all the problems. So its key recommendation is that Maryland initiate a continuous improvement process modeled after the Massachusetts Health Access Networks.
"The Massachusetts concept is built on a no-fault philosophy that recognizes that all players want to do a good job of delivering health care, but each is isolated from important information held by other stakeholders. Such a process could promote ongoing communication between providers, MCOs, and local health agencies, as well as advocates and consumers," Ms. Fanconi says.
The group recommends that the Department of Health and Mental Hygiene hold regular meetings that include all stakeholders, perhaps 10 such meetings a year in each of five regions.
Ms. Chang counters that her agency has a number of advisory groups already functioning, makes use of representative focus groups, and has other means to hear about problems and obtain recommendations. There also is a complaint-and-grievance process, she says, that federal authorities have said is a model for the nation. In addition, there will be a comprehensive evaluation of the three-year-old program in preparation for the application to renew its waiver. With all of that, she says, they are studying the Massachusetts system to see if there is anything they want to import to Maryland.
ACY provided 16 key recommendations and additional supporting recommendations for specific changes in program design and practice, including:
• a new auto-assignment algorithm that assigns to a child’s historic doctor and managed care organization;
• reimbursement for services to newborns under their mother’s ID for up to one year;
• corrections to provider directories to ensure they reflect what physicians are in the network and are accepting new patients;
• a requirement for all MCOs to have a 24-hour automated eligibility verification hotline;
• a guarantee of eligibility for HealthChoice for 12 months at a time to reduce interruptions in care;
• enforcement of the requirement that well-child visits be scheduled within 30 days of a parent’s request;
• a requirement for MCOs to reimburse clinics, hospitals, and physician offices for tests and lab work as long as the facilities are certified.
"The bottom line," Ms. Fanconi tells State Health Watch, "is that we believe Medicaid is a good program with good benefits. We just want to be sure that people can access the program and its benefits and that we are able to improve outcomes."
[Contact Ms. Fanconi at (410) 547-9200 and Ms. Chang at (410) 767-4664.]