Archive for Thursday, December 5, 2013

Health advocates say KanCare causing numerous problems

December 5, 2013


— Advocates for those with disabilities and chronic health conditions said Thursday that Gov. Sam Brownback's privatization of Medicaid, called KanCare, has produced numerous problems.

On a related issue, the advocates vowed to step up efforts to persuade Brownback and the Republican-dominated Legislature to expand Medicaid under the Affordable Care Act.

Finn Bullers, left, speaks Thursday during a meeting of the National Council on Disability. Shawn Sullivan, who is secretary of the Kansas Department for Aging and Disability, and state Rep. Jim Ward, D-Wichita, listen as Bullers describes problems he has had with KanCare, the state's privatized version of Medicaid.

Finn Bullers, left, speaks Thursday during a meeting of the National Council on Disability. Shawn Sullivan, who is secretary of the Kansas Department for Aging and Disability, and state Rep. Jim Ward, D-Wichita, listen as Bullers describes problems he has had with KanCare, the state's privatized version of Medicaid.

The issues were discussed during a meeting of the National Council on Disability, an independent federal agency that makes recommendations to the president and Congress.

The council holds four meetings per year and tries to hold two of those outside of the Washington D.C. area. Members had expressed an interest in hearing more about the managed care model under KanCare, and one of the council's members, Gary Blumenthal, is a former Kansas legislator who represented Merriam.

Brownback administration officials defended the nearly one-year old KanCare system, saying it was containing health care costs and delivering superior services. They said they expected to slow the increase in Medicaid costs by $1 billion over five years.

Under KanCare, three private insurance companies handle the health care services for nearly 400,000 Medicaid recipients.

"We have been able to expand services," while not decreasing payments to health care providers, said Kansas Medicaid Director Dr. Susan Mosier. KanCare now covers heart and lung transplants, bariatric surgeries and dental care for adults, which the old Medicaid system didn't, she said.

But critics cited numerous problems and reiterated their opposition to the state's plan to place long-term care for those with developmental and intellectual disabilities under the system. That plan is set to take effect Jan. 1 pending approval from the federal government.

Consumer sees reduced services

Finn Bullers, of Prairie Village, who is 49 and suffering from Muscular Dystrophy, said before KanCare he received in-home care around-the-clock, but under KanCare, the private insurance company reduced that to 40 hours per week. He said his doctors say that cut is unrealistic.

"There is no consistency. And if it's happening to me, it's happening to thousands of Kansans," Bullers said.

Kansas Department for Aging and Disability Services Secretary Shawn Sullivan said he couldn't speak about Bullers' case, but said under the state's old Medicaid system was flawed because organizations could propose a care plan and then provide those services. That produced conflicts of interest and resulted in some people getting more services than they needed, he said.

But Rocky Nichols, executive director of the Disability Rights Center for Kansas, said complaints to his office about services have increased 50 percent since KanCare took effect.

And, he added, many people needing in-home services wait up to 12 years.

"We believe the state is not upholding its end of the bargain," he said.

State Rep. Jim Ward, a Democrat, said hospitals in his hometown of Wichita were reporting lengthy and costly legal disputes with the private insurance companies over getting reimbursed for health care services.

Tom Laing, executive director of InterHab Inc., said the primary goal of managed care systems was to reduce costs.

"This is a way to balance the budget where tax cuts empty the treasury and then programs are pointed at as the problem. It's a little bit of a game and the loser in the game tend to be the people who are not at the table," he said.

Debate of expansion of Medicaid

The advocates also called for expansion of Medicaid. Under the federal health reform law, states can expand the income eligibility limits for Medicaid.

Twenty-six states have expanded, but most states headed by Republican governors, such as Kansas, haven't.

Under the reform law, the federal government would pay for the expansion for three years, and no less than 90 percent after that.

But Brownback's spokeswoman Sara Belfry said the governor doubted the federal promise. "That sounds a lot like, 'if you like your insurance plan, you can keep your insurance plan,'" Belfry said, referring to the President Barack Obama's earlier statement about certain insurance plans.

Expanding Medicaid eligibility would provided $350 million in federal funds for health care and cover 160,000 Kansans, Ward said.

Ward said if Brownback would push for Medicaid expansion among his GOP allies, the governor would also find support from legislators who generally oppose him on other issues.

"It really is on his desk and we await his decision," Ward said.


Barbara Gordon 4 years, 6 months ago

In Finn Buller's case, my understanding is that KanCare decided that he only needed care when his wife was at work. Apparently she doesn't sleep or shop for groceries, and their kids get to raise themselves.

John Graham 4 years, 6 months ago

First, I am NOT stating the reduction in home care is appropriate. Only someone who is a specialist in home care can make that determination. Typically that specialist is NOT a doctor rather it typically is a nurse with experience in managing/evaluating home care needs. Your reference article indicates a care coordinator (typically a nurse with experience in managing/evaluating catastrophic cases) interviewed the patient in his home. Typically such an interview would include an inspection of the home to determine how the patient and his home interact. For example are there stairs, can a wheelchair fit through doors and into the bathroom etc. The interview typically also looks at what resources are available to the family, for example family that can help provide care. The interview typically is not a five minute process, it is quite lengthy and detailed as to the patient' nursing care needs as well as what can be reasonably provided by family.

This article indicates three separate companies were involved in making these determinations. So it does not sound like this was a lightly regarded process.

There is a major discrepancy from the reference article to the above article. The article above states home care was reduced from 24/7 to 40 per week total. The reference article states United Healthcare reduced home care by 10 hours per day, meaning care was still provided 14 hours per day which is 98 hours per week. This is substantially more than the 40 hours total in the above article. Both articles can not be correct.

Lastly one has to keep in mind even in a hospital ICU a patient does not have a nurse in the room 24 hours per day. Often an ICU nurse will be assigned two patients unless the patient is extremely critical. While this patient on a blower needs someone available at all times to respond to a ventilator disconnect alarm there are periods of hours when he will not need direct care. He needs periods of care with periods of someone simply available to respond if an emergency occurs. The reference article indicates he has care while his wife is away for work as well as a caregiver sleeping in the house to provide some care during the night as well as respond to emergencies. Apparently the family will be expected to provide some care as well as be available for periods to respond in case of emergency. That is not uncommon. 24/7 home care is rather unusual as the family is typically expected to provide some of the care and monitoring of the patient. If anyone thinks insurance is going to provide 24/7 total care with no responsibility falling onto the family they will be surprised if they come to that need. If the patient truly needs 24/7 care and the family can't provide any of it, there are nursing homes for those situations.

John Graham 4 years, 6 months ago

Yes some of the above sounds harsh if that is your family member, but reality is insurance expects the family to provide a reasonable portion of the patient's home health needs. And yes family members can be taught how to do enteral feedings as well as care for pulmonary toilet, dressing changes and ostomies among other things. It happens all the time.

Julius Nolan 4 years, 6 months ago

Did I miss something? It said his provider reduced support to 40 hours a week. No where was it stated 3 different companies made this determination. The only way these companies make money is by reducing costs, therefore that means reducing services provided. Further it appears that they also delay and deny payments for provided services. Look at what is happening to hospitals and their billings. Yes, you can save money by denying claims, that is exactly what is happening.

John Graham 4 years, 6 months ago

Please see the link in Barb G's entry above. It is an article referencing the patient and his situation.

Insurance companies in the old days could be quite slow in paying without any real fear of consequence. Several years ago a law was passed that held insurance companies responsible for paying bills in a timely manner. Once a correctly filled out bill is submitted to the insurance company they have a specified time frame (I can't remember if it is 30 or 60 days) to pay the bill. If they do not pay within that time frame they must pay a penalty which is a specified rate of interest in addition to the contracted fee payment. So it does not benefit the insurance company to withhold or delay payments. Occasionally additional documentation is required before the bill can be considered but that is not common. The main reason for a delay in payment is the bill was not submitted correctly or to the correct location.

Despite the common complaint that insurance companies make money by denying payment that is not a common problem with medical insurance particularly it is uncommon with Medicare and Medicaid. Like most govt programs Medicare and Medicaid are full of govt regulations. These regulations typically spell out quite completely what services are covered and what diagnosis codes justify which procedures codes. A hospital submits a bill that includes diagnosis codes. Those codes are what Medicare and Medicaid use to determine if the hospitalization is justified. If the hospitalization is justified then a preset fee is paid based on the primary diagnosis and any additional diagnosis documented. Occasionally someone may get admitted to the hospital with a diagnosis that by the guidelines does not justify the hospitalization. The bill is denied and the hospital is left to find another diagnosis documented in the chart that does justify the hospitalization. If they do not have a diagnosis to justify the hospitalization (which is unlikely as the utilization review nurse is very good in finding diagnosis to justify someone already in the hospital) then the hospital can appeal the denied payment. A similar process is used for procedures in a doctors office or in a hospital. The guidelines clearly spell out which diagnosis codes justify which procedures. If the doctor or hospital bills for a procedure but the diagnosis listed does not justify the procedure then payment will be denied. The doctor or the hospital can see if they can change the diagnosis to one that justifies the procedure and rebill. So if a doctor or hospital is not documenting the correct diagnosis codes that will result in denied payments that must be rebilled which results in delays. But once the bill is correctly submitted the bills are typically paid promptly. The article does not specify why the hospitals are feeling the bills are slow to be paid. It may well be their own fault. Medicaid's side of the story was not provided. So no one knows what the real truth is.

John Graham 4 years, 6 months ago

While the above sounds rather complicated, the guidelines for Medicare and Medicaid are spelled out rather well and quite completely. Precerts are typically not needed unlike most regular insurance. All in all Medicare and Medicaid work quite well even if the amount they pay for services is not very much particularly Medicaid.

John Graham 4 years, 6 months ago

If a Medicare or Medicaid bill is denied a good medical biller in the doctor's office or the hospital should know the bill will be denied prior to submitting it in almost all occasions. There are even parts of most medical billing software that will flag the bill as inconsistent diagnosis and procedure codes. Having been involved in medical billing for the last 20 years it is my experience that the overwhelming number of problems with getting paid in a timely manner are with the people submitting the bills and not the insurance companies particularly Medicare and Medicaid. Since the timely payment law was enacted the insurance companies have been dramatically better in paying as they are contracted to.

John Graham 4 years, 6 months ago

Lastly with a recent law that limits healthcare companies in that they must spend at least 80% of premiums collected to pay medical claims. If they spend less than 80% on medical claims they must refund the insured. So denying claims does not allow the insurance company to keep more money for itself.

Kate Rogge 4 years, 6 months ago

It was always about eliminating public services to create profit for private companies.

Michael LoBurgio 4 years, 6 months ago

States Opting Out Of Medicaid Expansion Will Lose Billions

States not expanding Medicaid under Obamacare will be collectively lose more than $35 billion in federal funds in 2022 alone, according to a new report from the Commonwealth Fund.

Texas ($9.2 billion), Florida ($5 billion), Georgia ($2.9 billion), Virginia ($2.8 billion) and North Carolina ($2.6 billion) will be the biggest losers, according to the organization, which supports Obamacare. The study's projections of the budget impact nearly a decade out relied on estimates of Medicaid expansion eligibility and spending in 2022 from the Urban Institute to reach its conclusion.

The report covered 20 states, all with Republican governors and/or state legislatures that refused to expand Medicaid under the health care reform law after the U.S. Supreme Court made it optional in June. It did not include several states (such as Pennsylvania and New Hampshire) where expansion is not yet finalized, but state officials are working toward it.

Michael LoBurgio 4 years, 6 months ago

Ready for I/DD care

The privatization of long-term care of Kansans with intellectual and developmental disabilities launches in less than a month and is getting national attention. Here’s hoping the experiment goes well – unlike what some other Kansans and providers have experienced this year.

The National Council on Disability will hold hearings and panel discussions Wednesday and Thursday at the Statehouse in Topeka. A big focus will be long-term I/DD care, which shifts to KanCare starting Jan. 1.

This shift was strongly opposed by parents and other advocates for the disabled. They worry that the three private insurance companies that manage KanCare aren’t experienced with these services and may put profit before proper care.

Only two other states, Michigan and Vermont, use a form of managed care for long-term I/DD services, the Washington Post reported. And Kansas is the only state to turn exclusively to national managed-care companies. “No state has ever taken a developmental disability population and placed it in an arrangement like this, with an out-of-state managed-care system, all at once,” Rocky Nichols, executive director of the Disability Rights Center of Kansas, told Kaiser Health News. “It’s almost like throwing everyone into the deep end of the pool.”

Read more here:

Michael LoBurgio 4 years, 6 months ago

Did you know medicare and federal medicaid charges 4%

to administer our public health insurance program, while private insurers charge 15% to 30% for theirs?

Privatization Equals Corruption

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