In Laconia, Medicaid Commission hears downside of managed care, a blizzard of paperwork

LACONIA — When the Governor's Commission on Medicaid Management, the panel convened to oversee the introduction of managed care of the state's Medicaid program, met here last week commissioners for the first time heard from providers of the administrative burdens and clinical issues arising from the transition.

Since December 1, when the managed care program began, 110,526 Medicaid patients have enrolled in one of three managed care organizations (MCOs) — Well Sense, N.H. Healthy Families and Meridian. The enrollment includes those receiving physical and mental health benefits. The program is scheduled to be extended to those receiving long-term care — the developmentally disabled and elderly — and those treated for substance abuse in December, 2014, though the target is unlikely to be met.

The commission began meeting in May, well in advance of the start of program, but Katie Dunn, director of the Medicaid program at the New Hampshire Department of Health and Human Services (DHHS), said that the concerns expressed were the first the commissioners had encountered.

Ken Norton, executive director of NAMI (National Alliance on Mental Illness)-NH, agreed that two months into the program "some of the real life problems are coming to the surface."

Christine Thompson, a nurse at Genesis Behavioral Health in Laconia, described managed care as "the most time cumbersome and time-consuming process ever." In particular, she said that she spent some two hours on the telephone, much of it on hold, when seeking prior authorization for a specific medication only to have an unhelpful three-minute conversation with a representative of the MCO. "it's getting to be ridiculous," she said. "We're not giving our clients what was promised."

Maggie Pritchard , executive director of Genesis, said that because the MCOs are not familiar with the treatment plan of clients, they require excessive documentation for granting prior authorization for medications and services, including in the case of one patient 32 pages of records. Such requirements may lead to delays in providing clients with the medications they need, compromising their care, as well as impose burdens on staff. Pritchard feared the MCOs may require prior authorization for every contact with clients, which she said would "reduce care and increase paperwork."

Eugene Friedman, the chief financial officer of Genesis, said that as a result of such incidents the agency not only incurs an unnecessary cost but also forgoes a valuable revenue. He explained that that when clinical staff are engaged in resolving operational problems they are not providing the clinical services, for which the agency is reimbursed.

Prior to managed care, Friedman explained, Genesis billed New Hampshire Medicaid, but since must also bill the three MCOs, each with a different billing procedure. Moreover, reimbursements have not been timely, placing pressure on the agencies cash flow. He advised other providers to "have your line of credit in order."

Noting that reimbursement rates have not risen but fallen, Pritchard added that Genesis "has drawn on its credit line more than ever" since the advent of managed care.

Clyde Terry , chief executive officer of Granite State Independent Living, echoed Friedman's concerns about the increased administrative overheads managed care imposes on the already strapped budgets of providers. Likewise, as a provider of long-term care to the developmentally disabled he feared that the MCOs may question the necessity of many of the services his agency provides. He urged the commission expand the definition of "medical necessity" to include those personal services that enable the developmentally disabled to live with independence and dignity.

Two parents of autistic children told the commission of their ordeals in securing medications. Denise Colby recalled she spent eight weeks getting approval from Well Sense for an oral steroid that costs $450 a month out-of-pocket. Meanwhile, it took the MCO nearly as long to approve an appointment with an specialist to address her son's eating disorder. "I have a 5-year-old son who weighs 32 pounds and only eats Goldfish crackers," she said, "and he could not get the help he needed. It has been one headache and heartache after another."

Another man said that he encountered similar obstacles in seeking authorization for medications for his autistic daughter, whose mood swings, he remarked with a mix of empathy and levity that drew laughter from his listeners, placed a strain on the household.

Mary Vallier-Kaplan, former vice-president of the New Hampshire Endowment for Health who chairs the commission, and Donald Shumway, chief executive officer of Crotched Mountain Rehabilitation Center, the co-chair, urged anyone, — providers, parents and patients — with similar experiences to share them with the commission and call the hotline at DHHS (1-800-852-3344, extension 4344).