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March 5, 2012
TOPEKA A panel of four Medicaid experts today talked with a crowd of about 120 people who gathered at the Topeka library to hear more about Gov. Sam Brownback's KanCare plan.
Among the concerns voiced by audience members as the event concluded:
Some in the crowd also said long-term care services for the elderly and disabled should not be included in KanCare, at least not until other elements of the governor's plan have been put in place and proven successful.
"We've already seen from this administration that they give no thought to consequences in the field," said Shannon Jones, executive director of Statewide Independent Living Centers of Kansas.
The state's independent living centers have faced a wave of other policy changes under the Brownback administration that have left them struggling.
Under KanCare, virtually all the state's Medicaid beneficiaries would be moved into a managed care plan overseen by one of three competing companies. State officials currently are reviewing the contract proposals tendered by five companies. According to the governor's plan, three of the five will be selected and each will be expected to operate statewide using current Medicaid providers but in new networks affiliated with the managed care companies.
Joan Alker, a featured speaker and one of the four forum panelists, said the Brownback plan was complex, far reaching and unlikely to gain full or quick approval from federal authorities. Alker is co-director of the Georgetown Center for Children and Families and a research associate professor at the Georgetown University Health Policy Institute.
She began her talk by questioning some of the assumptions about the Medicaid program's costs. She said the current cost of Kansas Medicaid is slightly smaller as a percentage of total state spending (9.1 percent) than the national average (11.3 percent) spent by states on Medicaid and that the Kansas percentage was smaller even when compared to other Plains states.
Brownback officials have said their reform plan is necessary because without it the state's Medicaid spending would remain on an unsustainable upward trajectory, essentially taking money needed for education, public safety and other essential state services.
No need for waivers
Alker said the goals of better coordinated care sought by Kansas also could be pursued or accomplished without federal approval of a Medicaid waiver. She cited North Carolina and Alabama as states that have in place or are moving forward with Medicaid case management of the sort proposed in KanCare. But neither of those states sought or needed waiver approval to do it, she said.
A managed care pilot program in Florida similar to what Kansas officials propose to do statewide had been "fairly chaotic" because Medicaid beneficiaries were confused about their managed care plans and how to use them, she said. And extending managed care to include long-term services for the elderly and disabled, both relatively high-cost groups to serve, was a largely untested proposition.
"Managed care can be a good approach when done well," she said. "But I think when you're talking about vulnerable populations, you have to be very, very careful."
Furthermore, she said, research hasn't clearly shown that managed care saves money when applied to Medicaid.
"We don't have a great deal of evidence that managed care has saved money in Medicaid," she said.
Also, the KanCare plan seems to assume that there are a lot of duplicated or wasted services, she said. But from a national perspective, "there's not a lot of evidence of over-use in the Medicaid program. More often you see under-use."
If that is the case in Kansas, then it will be difficult to save money in the way the administration has outlined.
"I think a targeted and specific discussion about that would be helpful," she said.
Jodi Mitchell, executive director of Kentucky Voices for Health, a consumer advocacy group, was another featured speaker.
Late last year, Kentucky expanded its Medicaid managed care to include all the state's counties. Mitchell said there had been significant problems implementing the changes, in part because the new plans were put in place so quickly. She said the Kentucky managed care contracts were bid, awarded and implemented in a relatively short span of eight months.
"We had a very expedited timeline," she said.
The three managed care companies selected in Kentucky are among the five vying for Kansas contracts: Coventry, Centene and WellCare.
Mitchell said having three companies involved meant a choice for some Medicaid providers in Kentucky but not necessarily for Medicaid consumers because many providers, particularly in rural areas, had chosen to work with a single managed care company. That left many consumers no real choice but to go with the provider and plan offered in their area.
She said the changes in Kentucky had sparked complaints about restricted access to some types of mental health drugs.
The main problems, however, had been "member confusion because of very quick implementation," insufficient provider networks and inadequate payments to providers, which she described as "a huge issue."
She praised a program called Community Connect that had been implemented by WellCare because it provided consumers an accessible database of all services locally available to them.
"I like to give credit where credit is due," she said. "They (WellCare) hope to take this model to all the states where they operate."
Also appearing at the forum as panelists were Scott Brunner, a former Kansas Medicaid director now working as a senior analyst at the Kansas Health Institute, and Jean Hall, director of the Institute for Health and Disability Policy Studies at the University of Kansas.
The forum was sponsored by the Kansas Health Consumer Coalition. Anna Lambertson, the group's executive director, said Brownback officials had been invited to participate, but none attended.
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