It has been a year of change for people on Medicaid and providers. A new survey examines the good and the bad so far.
By Clarissa Donnelly-DeRoven
North Carolina Health News
North Carolina’s transition to managed care has yet to turn out to be the disaster some feared, nor the panacea others hoped for, according to a new survey of the coalition North Carolina for better Medicaid. The organization includes two managed care organizations – Healthy Blue and Unitedhealthcare – in addition to community groups, such as the YMCA and Mountain projectsa non-profit community development organization that focuses on the western part of the state.
The coalition worked with Health Management Associationsa national health care research and consulting firm, to design and implement the evaluation.
“This is just the beginning,” said Kathleen Nolan, regional vice president of HMA, author of the survey. “We wanted to be able to identify progress and areas that still needed work.”
Through interviews with five case managers, a patient advocate and coalition members – as well as a review of public data – the survey found that care management teams were one of the most promise of the managed care system.
Care management teams
North Carolina managed care contracts require health plans to provide a broad range of services designed to address the social determinants of health – the non-medical factors such as access to transportation, housing, food nutritional and other social factors that affect a person’s ability to be healthy. Some options include covering food boxes, home therapy for children with substance use disorders, and providing cell phones to help people stay in touch with providers.
It’s the job of care managers to tell people they have a right to these things if they need them and to help people get them.
Although it varies among managed care organizations (MCOs) that have won state contracts, care management teams typically consist of nurses, mental health care providers, community health workers and social workers. Their job is to connect people on plans with complex needs and help them access the care — physical, mental and social — they need.
Sometimes care managers contact based on a person’s diagnosis, other times the plan might notice someone going to the doctor repeatedly, or getting word they just got out of a hospital stay,” Nolan explained.
“The health plan will look at this and say, ‘There’s something going on here, so let’s hire a case manager,'” Nolan said. Not everyone on a managed care plan will have a care manager, “but there are lots of ways for someone to indicate that it might be a good idea for them.”
A Healthy Blue care manager, whose story is featured in the report, explained that she spoke with a mother who had a child with a swallowing disorder. She was upset because she couldn’t afford a powder called Thick-It, which is used to make it safer for people like her son to ingest without liquid entering his lungs.
“She was quite upset and distressed [and] worried that she won’t be able to buy it for her son,” the care manager said. “I was able to work with the speech therapist to get his samples until I could coordinate with the supplier to get an order sent to the medical supply company.”
Sherée Vodicka, CEO of the North Carolina Alliance of YMCAs – and a member of the coalition – said she believed the focus on the social determinants of health was one of the most beneficial aspects of the transition.
“There is such huge potential to serve people, families that we have had less opportunity to serve in the past,” she said. “It just takes people a while to figure out how to get the most out of the things that have been offered to them, especially when they are so unusual compared to what normal insurance offers, right?
“I mean, who knew you could call your insurance company and get help with housing, food, or protection from violence?”
Although the transition has so far delivered on these non-medical health services, these achievements may be overshadowed by some of the new administrative burdens on the system, such as North Carolina Health News at Previously reported.
“Vendors almost uniformly experience claim denial issues due to missing taxonomy codes and billing codes,” the report said. “Because the system has grown from a system of five individual plans, providers are looking to DHHS and planning to create standardized processes and common forms to continue to reduce provider practice burden.”
Lakajai Harris, a speech therapist in rural Beaufort County, said that was certainly the case for her.
“As a one-man business, it’s been a nightmare,” she said. She struggles to get paid.
“I had a few clients for whom [the MCO] refund me $0 because they claim I submitted a claim for $0,” she said. “I tried to appeal. Well, it took them seven days to maintain the appeal, so now I have to submit – in writing – another appeal, and that [process] may take up to 30 days.
Harris also recently reviewed its claims to determine which ones had not yet been paid by the MCOs. She found a handful of September and October that she had to resubmit, but when she tried, she found that the MCOs had different guidelines for resubmitting applications: 120 days for one, 60 days for the other.
“Medicaid gave us 365 days,” she said. “Now I can’t get reimbursed for some of those claims.”
In the old state-run Medicaid system, what some call Medicaid Direct, she knew that every Wednesday she would be paid directly into her bank account. Now the checks are seemingly coming in randomly — Harris also hasn’t been able to set up direct deposit with two of the four MCOs she has a contract with. She said she would submit multiple claims on the same day, only to have a claim-related check appear in her mailbox weeks later.
“I basically work 8am to 5:30pm. I have clients back to back with maybe just a bit of travel time. To try to understand, where are these checks? Why haven’t I received them yet? ” she says. “I don’t have time for that.”
The survey also reported that nearly 7,500 people who were supposed to stay on Medicaid Direct were wrongly switched to a managed care plan, which then forced them to navigate the return process, even though many of those people had mental health issues, they were also browsing (NC Health News has also reported about this question.).
The analysis also addresses the particular problems that rural populations, who already experience provider shortages, have faced during the transition. Many feared choosing a plan for fear that their doctors would not be networked and they would lose access to care. There were also poor translations — especially into Spanish — of official state Department of Health and Human Services documents related to the transition, which could lead to disruptions in care for non-native English speakers.
Nothing “too problematic”
Still, Nolan said these issues aren’t out of the ordinary during the transition phase.
“I’ve been in the Medicaid space for a long time,” she said. “The idea that we can get to the social determinants of health, that we can improve access, that we can succeed in integrating care, is based on experience, not just on hope. . We have certainly seen this work. It’s a complex undertaking, and it requires states and health plans to really work together.
The success of the transition from managed care and the focus on improving access to non-medical health services will be analyzed at the population level rather than the individual level.
“The reason is that if you look at it at the population level, then what you’re looking at is the system,” Nolan said. “When you look at a level of population, you get there, doesn’t the system give enough access so that no one is able to recover?”
Only time will tell.