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March 4, 2013
PITTSBURG While acknowledging “bumps in the road,” state officials for several weeks have been saying that the launch of KanCare, the state’s new Medicaid program, has been going better than they expected.
But people who work at some of the clinics that specialize in treating poor and uninsured Kansans describe it differently. They say the transition, now entering its third month, has been an ordeal for them and that some of the problems are compromising patient care.
“I went through the tornado in Joplin (in May 2011) and survived,” said Lori Lowrey, chief revenue officer for the Community Health Clinic of Southeast Kansas. “I would equate the anxiety of KanCare with the anxiety I felt following that event. It’s just been an inferno everyday. When you walk through the door, you’re greeted by staff frustrated at every level...nurses, administrators, patients and then trying to communicate with the (KanCare companies) and their contractors, it’s just very taxing. I just don't feel like it’s been accurately portrayed by the people at the state level or the MCOS (managed care companies). It’s been a road full of potholes. It’s not been a few bumps.”
The clinic here serves about 29,000 people a year at its eight sites scattered across the corner of Kansas that generally ranks as the state’s poorest and least healthy. That makes it a key medical provider, particularly when it comes to primary care for the poor. About 35 percent of its patients are on Medicaid, according to clinic officials.
According to KDHE, 40,176 of the state's more than 370,000 Medicaid beneficiaries had changed KanCare plans by February. Here are enrollment numbers for each plan:
Amerigroup: 119,645 people or 32.4 percent of enrollees.
Sunflower State Health Plan, a subsidiary of Centene: 131,852 people or 35.7 percent of enrollees.
UnitedHealthcare: 117,960 people or 31.9 percent of enrollees.
State and KanCare company officials acknowledge there have been problems at the safety net clinics and more so at some of the 16 that are designated as Federally Qualified Health Centers, which includes the Community Health Clinic of Southeast Kansas. The FQHCs together have more than 20 satellite clinics scattered across the state and collectively serve many thousands of the state’s poorer families.
A special meeting that included clinic directors, state officials and KanCare contractors was held privately two weeks ago in Topeka to discuss the situation.
An “issues log” of 86 problems submitted by the clinics to the Kansas Association for the Medically Underserved (KAMU), a group that represents the safety net clinics, was presented at the meeting.
Among the problems cited:
The list was similar to but longer than the problem tally submitted to state officials a week earlier by the Kansas Medical Society and the Kansas Medical Group Management Association along with a letter asking the state to extend the KanCare transition period to allow more time for smoothing things out.
Kari Bruffett, the director of the Division of Health Care Finance at the Kansas Department of Health and Environment, has been the point person for the administration of Gov. Sam Brownback on much of the KanCare implementation.
Bruffett said state officials determined from the meeting with clinic officials “that while there were some crosscutting issues, there were a lot of issues specific to the individual (clinics), so what we asked the managed care organizations to do with those (clinics) was to work with them individually and basically keep us posted.”
She said she had been assured that many of the problems raised at the meeting were being dealt with and that the chief executives of the KanCare companies have been responsive whenever concerns were brought to their attention.
According to KDHE, payments to Medicaid providers in January 2013, the first month of KanCare, lagged payments made in January of 2012 by almost 6 percent. Payments from all sources to providers in January 2012 were about $210.6 million. Payments from all sources in January 2013 were $198.2 million. Agency officials said they expect total payments will be up for February, but those figures won't be made publicly available until later this month.
One result of the meeting, according to some who attended, was an agreement by at least two of the KanCare companies to make “advance payments” to clinics that asked for them to help deal with their cash-flow problems.
“I know of at least one (KanCare MCO) that is in the process of sending out advance payments,” said Cathy Harding, executive director of KAMU, “and another said they would do the same thing.”
She said she expected the third company also would agree to advance or expedited payments.
But in a series of interviews late last week with the KHI News Service, clinic directors from across the state give KanCare what could at best be described as mixed reviews. And those unhappy with the way KanCare is rolling out said they had seen little or no improvement as a result of the meeting.
“In our opinion, it’s kind of going from bad to worse,” said Krista Postai, executive director of the Community Health Clinic of Southeast Kansas. “I have nurses now spending all day on the phone trying to get pre-approvals (for patient medications from the KanCare insurance companies or their subcontractors) and not getting them. A lot of my providers have been doing this for years and they never had anything this absurd on pre-authorizations. I understand that is meant to control costs…but this is costing us a fortune.”
Grace Med in Wichita is one of the state’s biggest safety net operations and the problems there have been manageable from the start, said David Sanford, the chief executive.
“We knew there might be a cash-flow problem based upon the lack of knowledge of our patients and the three MCOs getting up to speed,” he said, “so we had cash reserves to help cover payroll” during the opening weeks of KanCare.
He said payments from the KanCare companies were now coming in.
“I'm encouraged they've about caught up with us anyway,” he said.
Sanford said the KanCare companies generally had been responsive when alerted to problems encountered by the clinic.
“My general feeling is that with any transition of this magnitude, you know you're going to have some challenges along the way,” he said.
The clinic early on “established strong ties” with the managed care companies, Sanford said, and “I feel very positive that the concerns we've had connected with Grace Med, that they (the KanCare companies) have been fairly responsive.”
Dr. Robert Freelove, chief executive of Salina Family Health Care Center, a safety net clinic in Salina that sees about 10,000 patients a year, said there had been a number of problems there since the KanCare launch though not as many as some other clinics are having. Chief among them, he said, was the increased number of pre-authorizations required by the managed care companies, especially for the clinic’s dental services.
“A lot of things we could do before and just order, we now have to call and get prior authorizations for,” Freelove said. “I can say that I hope it’s a transition issue but I honestly don't know. I've got a sense that it’s going to be an ongoing problem, just something we’re going to have to deal with from now on. It will certainly take more staff time and ultimately could lead to more staffing, particularly in our dental clinic.”
Freelove said the Salina clinic had “been lucky” to be spared many of the troubles he’s aware of at fellow safety-net clinics in other parts of the state, including cash-flow problems due to stalled or denied KanCare payments. Some clinics have had to cash in bank CDs or draw on lines of credit to cover expenses.
On a scale of 1 to 10, with 1 being “swell” and 10 being “meltdown,” he said he would rate the KanCare implementation so far someplace in the middle.
“I'd probably give it about a 5 when you consider the vast scope of change and everything that possibly could go wrong,” he said. “We're a far cry away from 10. But that's for us, individually. I know some places would easily say 8 or 9, we're just fortunate to not have some of the problems other places have had from a financial standpoint. If we were having a cash-flow problem, then that would be a 9. Pittsburg is a 9.”
Freelove said about 35 percent of the clinic's patient are on Medicaid.
Bryan Brady, chief executive of First Care Clinic in Hays, said the complications experienced there were “all minor stuff. We’re not having to do anything drastic to make payroll or anything. We're getting paid...and some of it’s been timelier than the prior system.”
Brady said First Care sees about 6,000 patients a year, about 20 percent of which are on Medicaid.
Brett Middleton, chief executive of the Heart of Kansas clinic in Great Bend, said a relatively low percentage of its patients (10-12 percent) were on Medicaid, so the payment problems with the KanCare companies weren’t yet crippling its operations.
“Through what I would call some good management, we're in a cash position that we can get by and meet our obligations and we have other payer sources that are still paying regular,” he said. “While (the delay in Medicaid payments) concerns me, it hasn't really caused us any problems short term. Certainly, it would be a long-term problem,” if things don’t improve.
“I believe the stated aims of KanCare are good,” said Jason Wesco, chief executive of Health Partnership Clinic of Johnson County in Overland Park. “Integrating care and care coordination and delivering more primary care, I completely support it. The problem is, I think, is that the stated aims are the state's stated aims and the people implementing the program don't work for the state. I think there's just some breakdown. I believe the governor and Dr. (Robert)Moser at KDHE, I think they absolutely believe in integrated care and believe this is the best way to do it. But at the end of the day, we're at mercy of the managed care companies.
“We’ve just had a terrible time trying to get appropriately credentialed with the MCOs, though we started working on it in October (2012),” Wesco said. “We received payment last week for the first time. The basic things we need are inclusion in (the KanCare provider directories) and payment in a timely manner. Those are two of our biggest issues.”
Managers at two smaller, non-federally designated safety net clinics said they have been able to deal OK with the KanCare problems.
“Our experience with KanCare is limited because we are still small, so KanCare hasn't impacted us yet like it has the much bigger clinics,” said Jon Stewart, chief executive of Heartland Community Health Center in Lawrence. “That is gradually changing as we grow. But even in our limited experience we have had mixed reviews. Overall, I am optimistic that this will work out well.”
Chrysanne Grund at the Greeley County Health Services in far west Kansas also said the transition problems had so far been manageable. Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, the state’s lead Medicaid agency, once ran Greeley County Health Services, where between 8 percent and 10 percent of the patients seen are on Medicaid.
“We're not off to a bad start,” Grund said. “We're signed up with all three of the (KanCare) companies. We've had a few delays in some payments, but largely we're getting along OK. It’s not a flawless process...but it’s not like the payments totally stopped.”
→ KDADS chief describes lessons learned with KanCare (12/5/13)
→ Other states watching Kansas as it implements ‘unprecedented’ Medicaid model (12/5/13)
→ KanCare reimbursement problems continue for providers (11/25/13)
→ Kansas dental program for children on hold because of KanCare MCO (11/11/13)
→ Kansas Medicaid providers complain to oversight committee (10/7/13)
→ Wichita hospital execs describe problems with KanCare (8/29/13)
→ KanCare to adopt “health home” model for treating mentally ill (7/22/13)
→ Kentucky’s rush into Medicaid managed care: A cautionary tale for other states (7/18/13)
→ DD groups largely reconciled to KanCare carve-in (7/15/13)
→ Advocates urge more government oversight of Medicaid managed care (7/8/13)
→ Independent pharmacists push for KanCare contract enforcement (7/1/13)
→ Payroll agents for the disabled on Medicaid say they are struggling under KanCare (6/3/13)
→ Personal Care Attendants: KanCare's unheralded workers (5/20/13)
→ House GOP leaders pen letter backing DD supports in KanCare (5/17/13)
→ More than 1,000 rally at Statehouse for DD carve-out (5/8/13)
→ Nothing to be done about coverage gap in states not expanding Medicaid, feds say (4/29/13)
→ As KanCare continuity of care period ends, problems persist; legislators starting to hear about it (4/8/13)
→ Advocates raise concerns over possible reductions in KanCare services (3/28/13)
→ Conferees agree on KanCare oversight committee (3/28/13)
→ DD advocates push to extend KanCare "carve-out" (3/20/13)
→ Safety-net clinics struggling with KanCare (3/4/13)
→ Major medical provider groups ask for longer KanCare transition (2/13/13)
→ Lawmakers and providers assess KanCare transition (1/28/13)
→ Five-part series: "Lower cost and better care: Can KanCare deliver?" (1/14/13)
→ Independence of KanCare ombudsman questioned (1/7/13)
→ KanCare special terms and conditions spelled out by CMS in a document (12/28/12)
→ KanCare workforce shift hampering local agencies (12/10/12)
→ Governor announces KanCare approval by feds (12/7/12)
→ More KanCare implementation details outlined (12/3/12)
→ Federal officials say they hope to act soon on KanCare waiver request (11/28/12)
→ New KanCare info included on state website (11/20/12)
→ Groups call for KanCare delay (11/8/12)
→ Go/no-go date looms this week for KanCare (10/15/12)
→ KanCare benefit packages outlined (9/26/12)
→ Provider groups nervous about lack of KanCare details (9/13/12)
→ KanCare Confidential (9/10/12)
→ KanCare contracts awarded (6/27/12)
→ KanCare plan panned again at public hearing (6/20/12)
→ Wichita KanCare forum draws more than 200 (6/19/12)
→ Medicaid makeover: Can Kansas learn from Kentucky? (6/11/12)
→ Hundreds protest inclusion of disability services in KanCare (4/25/12)
→ Counties weighing in on KanCare (4/9/12)
→ Hospital administrator to chair KanCare Advisory Council (3/29/12)
→ Brownback Medicaid makeover an “ambitious” plan (3/28/12)
→ KanCare bidders heavily courting Medicaid providers (3/19/12)
→ Legislators push to delay KanCare start (3/7/12)
→ Brownback announces managed care for all in Medicaid (11/8/11)
→ Kansas Medicaid makeover in the works (3/7/11)
→ Full Medicaid and KanCare coverage
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