Cloudy
30°
Cloudy
Hi 38° | Lo 28°

As state moves forward with Medicaid Care Management transition, some worry about impact on care

After it was pushed back earlier this year, Step 2 of the state’s Medicaid Care Management program is set to take effect Jan. 1 – but that’s raising questions from families and others who are troubled by what they’ve seen from its implementation so far.

The goal of moving toward a Medicaid Care Management program, state officials have said, is to better coordinate treatment for the state’s Medicaid population by transitioning to a system where care management companies – in this case, Well Sense or New Hampshire Healthy Families – oversee individuals’ health plans.

As described by state Department of Health and Human Services Commissioner Nick Toumpas, the program is designed to facilitate a more holistic approach to health care, to change “the way we pay for and deliver services” and to improve the quality of the medical care being delivered.

It’s “one of the most significant and complex” of the state’s recent undertakings, Toumpas said at this month’s meeting for the state’s Medicaid Care Management Commission. New Hampshire is the 48th state to implement a Medicaid managed care program, as previously reported.

Many moving pieces

What the next phase of implementation will look like in practice is still being finalized, Toumpas and other officials have emphasized. Even the timeline is still flexible, he said, depending on how the next few months of feedback and development proceed.

Caregivers and others who work with individuals in the Medicaid population worry, however, that moving toward this new system will jeopardize the quality and accessibility of treatment, particularly for those with rare or complex medical conditions. Such concerns were voiced at a public forum on the transition to Step 2, held last week and hosted by the State Family Support Council, as well as during the commission meeting. The state began soliciting public input on Step 2 in July and will hold a series of additional input sessions in the months ahead.

Step 1 of the program began last December, at which point some Medicaid recipients were required to enroll in the care management program. Those who were able to “opt out” of the program this year will need to enroll when Step 2 takes effect.

Beginning in April 2015, according to the state’s current timeline, care management companies will start delivering services to those who are enrolled in the Choices for Independence Waiver and those in nursing facilities. At a later date, yet to be determined by the state, the companies will start overseeing care and long-term support services for those with developmental disabilities, with acquired brain disorders and with conditions requiring in-home support.

More than 70 people – in person and via videoconference, from across the state – weighed in on the current and future implementation of the program at last week’s public forum, held at New Hampshire Hospital in Concord. While the individual circumstances varied widely from person to person, their concerns essentially came back to two key issues: Families want to retain as much control as possible over their loved ones’ care, and they don’t want to lose access to the community-based services or other medical treatment they’re currently receiving.

Treatments denied

Many at the forum also said they feared that the care management companies would deny critical prescriptions or treatment options because they lack a full understanding of the patient’s condition. Several reported that they’d already encountered such denials during the current phase of the care management transition.

Deb Scheetz, communications director with Nashua-based Gateways Community Services, spoke at both the public forum and the commission meeting. She highlighted several instances where the care management program has been beneficial: troubleshooting in advance of a colonoscopy for an individual with developmental disabilities, for example, and assisting another young girl with cystic fibrosis who was recently taken into custody by a relative who is unable to drive.

Still, Scheetz said, she wanted officials to understand the potential challenges facing those with “orphan diseases” – the kind of complicated medical conditions that affect only a handful of people in the country – as it moves ahead with Step 2.

“It does a great job if your condition fits a standard box,” Scheetz said, clarifying that all conditions are not so straightforward.

The task of educating an insurance company on the nuances and needs of these conditions is no small feat, she explained, and many families in this category have spent 20 to 30 years doing the same type of work to educate their existing medical providers.

‘We are keenly aware’

These concerns are not lost on the department, Toumpas said at the commission meeting. He and other officials also urged patients who have encountered problems with the managed care transition – such as denials of treatment or prescriptions – to report those issues directly to the department.

“We are keenly aware that every one of those system challenges has an impact on individuals, either those who are sitting in this room or who are not able to make it to a forum,” Toumpas said.

Lorene Reagan, chief of the bureau of developmental services, acknowledged the issues seen during step one at the forum and the commission meeting.

“Has all of this been a perfect transition and worked for everyone? We know the answer to this is no,” Reagan said at the forum.

The goal of the forums, she said, is to make sure the department is adequately hearing out the concerns of those affected by the care management changes before the details of the transition are finalized.

Those who have further questions about Step 2 can email one of the following, the department said: beasmcmstep2@dhhs.state.nh.us, regarding the nursing facilities and the Choices for Independence Program; or for bdsqualitycouncil@dhhs.state.nh.us, regarding the acquired brain disorder, developmental disability or in-home support programs.

(Casey McDermott can be reached at 369-3306 or cmcdermott@cmonitor.com or on Twitter @caseymcdermott.)

Legacy Comments1

There are many questions, within managed care, specific to supports for individuals receiving services necessary for their day to day living. None of these questions, thus far have been answered. However, it does not take a brain surgeon, to recognize that moving into the managed care program spells DISASTER for the population of our most vulnerable citizens. Under the family supports, the individuals' RIGHT TO PURSUIT OF HAPPINESS was a supported goal. Part of services includes an independent vendor or agency to oversee an individuals' benefits, assist with search of most suited health and prescription insurance. In looking at Step 3, I question: WHO WILL OVERSEE THE INDIVIDUALS' BENEFIT ? IF UNDER A MANAGED CARE PLAN, THE MANAGED CARE INS. CARRIER IS TO SEARCH OUT THE MOST SUITED PLAN FOR INDIVIDUALS, WE ARE CLEARLY LOOKING AT A CONFLICT OF INTEREST!!! Further, how would Managed Care implement the HeM-503 Rulings, which, presently allow for individuals, not happy with service delivery, to move their budget to a different agency. Last time, I checked, Managed Care Plans are to be chosen annually. And, of course, there is much, much more !!! Certainly, the present system can be improved, however, not under Managed Care Plans which are intended to provide medical and clinical support and whose employee posted the following question, to a parent of an individual with down syndrome, seeking prior approval for a procedure, as follows: "..and, how long has this individual had this condition?". This is only the forerunner of what's to come, shame on the state of New Hampshire, if it permits for this to proceed. We've already closed the very costly and none effective institutions once, it was not the goal to reopen them and that is exactly what will happen under the Managed Care System, a for-profit institution, they are not designed to address the unique needs persons with Developmental and/or acquired brain injuries and their families face on a daily basis. Stop fitting these services, individuals depend upon, into a Managed Care Plan, start working on improving the service delivery system by creating a competitive vendor market.

Post a Comment

You must be registered to comment on stories. Click here to register.