Dialysis crisis followed shift by Medicaid

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Dialysis crisis followed shift by Medicaid

Monday, February 12, 2007

Susan Jaffe
Plain Dealer Reporter

For the past year, a dialysis machine has been keeping Karletta Edwards' mother alive, substituting for her kidneys to cleanse her blood three times a week.

But in January, shortly after Ohio's Medicaid program transferred her, along with more than 25,000 other low-income people in Northeast Ohio, into an HMO, something went wrong.

The state's contracts with insurance companies are expected to save Medicaid $24 million this year, by the time some 125,000 blind, disabled or older people are placed in privately run managed care plans.

Even though the companies are paid 6.6 percent less, Medicaid's average cost to care for the same population, state officials say the health coverage will remain the same.

The arrangement is also a good deal for the insurance companies expanding into the Medicaid market, state by state. WellCare, one of the companies that will serve Northeast Ohio, reported that revenue for the third quarter of 2006 rose to $1.1 billion, double what it was for the same period a year ago. Its Medicaid membership jumped 46 percent.

The other two companies are Buckeye Community Health Plan and Anthem Blue Cross Blue Shield.

Four weeks ago, Edwards received a desperate call from her mother. The transportation service that picked up Emma Hansen from her East Cleveland home and brought her to the dialysis center didn't show up.

Edwards called Anthem, the company Medicaid is paying to provide her health care.

Edwards learned that the rules had changed and her mother would have to call a day ahead every time to arrange a pickup, and that Anthem provides only 15 round-trips a year, or 30 one-way trips. After five weeks, her mother would be on her own.

"I was so upset I went crazy," said Edwards. "This is a matter of life or death."

She made more than 20 calls, including contacting state legislators, before Anthem put her mother on a list for regular, unlimited transportation to the dialysis center.

She didn't know that she could have called the Cuyahoga County Department of Employment and Family Services (216-987-6640), as director Joe Gauntner explained, which will continue to provide trips for patients whose doctors say they need transportation. The county is fully reimbursed by Medicaid for the service.

There was nothing in the information the state sent to HMO members that explained the 15 trips were in addition to what their county Medicaid offices provide.

A Medicaid spokesman said the agency has no plans to contact Northeast Ohio plan members to clarify the issue, but will make sure plan service representatives and county agencies understand the available transportation options.

The literature members received does explain that they can pick one of two other HMOs (but cannot return to regular Medicaid). Figuring out which is better isn't easy.

"Some plans might have your doctor, hospital and transportation but not your medication," said Susan Childs, the service coordinator at the Musicians Tower seniors building in Cleveland Heights. "So you're going to have to make some choices."

And after March 31, patients are locked into their plans even though the plan can change benefits any time.

But Jon Barley, chief of managed health care in Ohio's Medicaid office, said members get additional benefits they didn't have in regular Medicaid, including an around-the-clock nurse hot line, a directory of participating physicians, and individual care treatment plans for people with diabetes or other chronic diseases that stress prevention.

Keeping patients healthy also avoids the kind of expensive emergency treatment that drives up health-care costs, said J.B. Silvers, a professor of health systems management at Case Western Reserve University's Weatherhead School of Management.

Medicaid pays the HMOs the same amount per member every month, regardless of whether the member is healthy or gets sick. A healthy member costs less and improves profits, so the company has an incentive to control costs.

For patients in traditional Medicaid, the agency just pays their medical bills.

"No one is there to say, 'Maybe five visits to the ER is excessive,' " he said.

"If you can call people up and get them to go to the doctor for asthma care instead of the ER, you can save a lot of money," he said. "The bet is that for the disabled population, the care is so uncoordinated that someone can manage it and still provide high quality care, hold down costs and make money."

If companies can make a profit, that doesn't mean the state is overpaying them or that patients are getting less care, according to Barley, at Ohio's Medicaid office.

It means patients are staying healthy, he said.

"Their care is coordinated, focusing on prevention and that is more effective," he said.

"I think it's a win, win - the beneficiaries benefit and the state benefits."

For more information about Medicaid HMO coverage, call the Managed Care Enrollment Center, at 800-605-3040.

To reach this Plain Dealer reporter:

sjaffe@plaind.com, 216-999-4822

URL: http://www.cleveland.com/news/plaindealer/index.ssf?/base/news/1171273504175720.xml&coll=2