KHI News Service

Backlog means cash crunch at safety-net clinics

A workable solution is in sight, officials say, coming in 2012

By Dave Ranney | December 06, 2010

Many Kansas safety-net clinics are having money troubles because it is taking the state so long to approve their patients for HealthWave, the government’s health insurance program for low-income children and pregnant women.

That leaves the charity clinics, at least temporarily, footing the bills for the services they provide, creating cash-flow problems for enterprises usually short on cash.

“It’s a huge issue,” said Lee Wolf, chief executive at the Konza Community Health Center in Junction City. “All of the community health centers are not-for-profits, but we all have bottom lines, too. We depend on those dollars coming in. When they don’t come in, it’s a problem for us and it’s a problem for our patients because if they don’t know if they’re covered they tend to put off their health care and we end up with a lot of emergencies.”

Audio clip

Jim McLean's KPR story: The HealthWave backlog

In limbo

According to the latest numbers, Kansas Health Policy Authority officials had more than 17,700 HealthWave applications and renewals in limbo for at least 45 days due to the processing backlog that has been a problem for the state off and on for more than two years.

The backlog began with a change in federal law requiring that applicants provide proof of citizenship.

It grew again when the recession brought a spike in applications coupled with agency staff and budget cuts.

Another factor was the change earlier this year in the contractors running the day-to-day operations of the application clearinghouse, which is in Topeka.

The result, according to clinic officials, is that some of their patients have been waiting four, five or six months to get state medical cards.

KHI News Service

Kansas legislators sign in before taking a tour of the Medicaid eligibility clearinghouse. At the counter is Rep. Bob Bethell, R-Alden, chairman of the Home and Community Based Services Oversight Committee.

View larger photo

“Everybody loses”

“I have people who’ve been left hanging for months,” said Chrysanne Grund, project director with Greeley County Health Services in Tribune. “They get to a point where they need specialty care, but there aren’t any specialists who will see them if they don’t have a HeathWave card, so they end up having to go to the hospital and now they’re in all kinds of debt and the hospital, in all probability, isn’t going to get paid. It doesn’t make sense, everybody loses.”

The health policy authority recently streamlined processes at the clearinghouse for determining HealthWave eligibility.

Agency officials predict the backlog will be eliminated by early spring.

Making progress

“The clearinghouse is processing a lot more applications now than they were earlier in the year,” said Peter Hancock, an agency spokesman. “They’re making progress. We believe we’re on course to have this taken care of by March.”

Meanwhile, the delays are discouraging some from even applying.

“There are lot of rumors and misperceptions out there about HealthWave and how difficult it is to get approved,” Wolf said. “It’s a barrier we’ve had to tear down.”

Dealing with the problem

Earlier this year, in an effort to ease the problem, the health policy authority put outreach workers in 12 of the state’s 39 safety-net clinics.

Underwritten by the first money from a five-year, $40.3 million federal grant that is intended to modernize the state’s Medicaid and HealthWave application system, the workers help low-income families gather the paperwork they need to apply for HealthWave – birth certificates, pay stubs, proof of residence.

They’re able to expedite the approval process.

Wolf said his outreach worker’s “average turnaround time is 12 days.”

Presumptive eligibility

There’s also a program that has greatly diminished the cash-flow problems for three of the state’s busiest safety-net clinics. Officials said it works well enough they would like to see it expanded to include all the clinics.

Called “presumptive eligibility,” it allows clinics to be paid for the care they provide women and children determined most likely eligible for HealthWave.

The three clinics that have the program are:

“We have a screening process that we go through, and if it looks like (a patient) would be eligible for HealthWave, we’re allowed to issue them a temporary card that gives them access to health service immediately,” said Dave Sanford, executive director at GraceMed.

Sanford last month was named as the newest member of the Kansas Health Policy Authority. His appointment awaits confirmation by the Kansas Senate.

Helping cash flow

The clinics make sure the patient applies for HealthWave and if the patient later is found to be ineligible, the coverage stops with that determination.

“As long as we act in good faith, we’ll be reimbursed for the services we provide while the application is being processed,” Sanford said.

The clinics are not expected to pay back reimbursements they receive for patients later deemed ineligible.

GraceMed and Hunter Health Clinic have had presumptive eligibility since 2008 and Community Health Center since September.

“This has already impacted our cash flow in a very positive way,” said Krista Postai, executive director at the Community Health Center.

“Since the middle of September, we’ve gotten about 600 HealthWave applications in and approved,” using the presumptive eligibility standards, she said. “We’ve noticed that parents — once they know they’re covered — are bringing their kids in earlier than they used to. It’s such a relief. My staff has been getting hugs. Some of these people have been waiting for months.”

Most prove eligible

Most of those applying for HealthWave through the clinic are eligible, she said.

“The question, really, isn’t whether they’re eligible, it’s whether they’ve been in limbo for so long that they’ve given up,” she said. “We’ve had very, very few people go through the presumptive eligibility process who weren’t eligible. Almost none.”

Sanford said since March, 2 percent of the GraceMed patients presumed eligible for HealthWave later were found not to be.

The health policy authority has similar presumptive eligibility projects at Via Christi Hospital on St. Francis in Wichita and Children’s Mercy Hospital in Kansas City, Mo., which sees many low-income Kansas patients.

Hospitals onboard

The program also is popular with the hospitals.

“Presumptive eligibility presents a wonderful opportunity for families that may be uninsured or underinsured to get the care they need and for the hospital to get paid for the services it provides,” said Cindy Samuelson, a spokeswoman for the Kansas Hospital Association. “It also opens a dialogue with the patient about the cost of care and how HealthWave is there to help. It’s peace of mind for both sides.”

KHI News file photo

Cathy Harding, executive director of the Kansas Association for the Medically Underserved.

View larger photo

Advocates for the uninsured say presumptive eligibility should be available throughout the state.

“We would love to see that,” said Cathy Harding, executive director of the Kansas Association for the Medically Underserved. “It would make for a better cash flow for the safety-net clinics but more importantly people wouldn’t have to wait so long to get coverage.”

Statewide in 2012

The health policy authority plans to have a statewide, presumptive-eligibility system in place by summer 2012.

“The plan is to have presumptive eligibility programs in locations throughout the state, in hospitals, schools, safety-net clinics,” said Hancock, the KHPA spokesman. “Wherever you are, there will be a place close to you.”

That expansion also is being underwritten by the federal grant, which also will pay for a new state computer system that will allow people to apply for HealthWave or Medicaid online.

For now, hard copies of applications must be mailed to the Topeka clearinghouse.

A trade-off

The grant money will come in installments as the new system is developed.

“The funding for training becomes available in the spring of 2012, for deployment in the summer of 2012,” Hancock said.

With barriers to HealthWave enrollment eased, the number of people using the program is expected to increase. That will raise the state’s costs for the public health coverage.

“Unfortunately, that’s part of the trade-off,” Hancock said. “Getting people enrolled is important because we know people with coverage are more likely to get the care they need when they need it rather than waiting until their conditions are really serious and much more expensive to treat. It’s also good for hospitals, clinics and other providers because it means they’re giving out less uncompensated care.”