The Future of Managed Care in Medicaid and the Fear of the Unknown
The unknown. No one likes the unknown. Especially people, like me, who try so desperately to maintain control over our lives.
But the future of Medicaid in North Carolina is unknown. We have all heard Governor McCrory talk about expanding managed care to all Medicaid services, not just behavioral health care, but for all medical services. Here in NC, our experience with managed care organizations (MCOs) has not been all sunshine and roses. So, when we hear…let’s expand the MCO system to all Medicaid services, I am reminded of the feeling I had this past Saturday as I stood on the side of the Wells Fargo building, 30-stories up, facing background, with a harness and a helmet on, when the rappel guy said, “Ok…now lean back and let go…”
OK….so is anyone wondering how I managed rappelling down the 30-story Wells Fargo building downtown Raleigh this past Saturday in the name of Special Olympics North Carolina?
Answer: I DID NOT MANAGE WELL!!!
I do not kid you when I say that I thought that I would enjoy rappelling. I envisioned myself bouncing off the side of the building, laughing, and doing straddle jumps. I envisioned myself getting to the bottom with an adrenaline rush and an immediate need to sign-up for next year’s Over The Edge charity event.
So, what actually happened? Picture this:
I am standing on the edge of a 30-story building. I have 20 pounds of equipment attached all around my body. I am donning a helmet and gloves. I have never seen any of the equipment that is wrapped around my body. The pro-rappellers are saying things like “rigger,” “descenders,” and “carabiners.” They are obviously all hard-core, banging rapellers, which I, most certainly, am not.
In order to get on the ledge of the building, you have to climb up onto the ledge…as in, take your 2 arms and hoist your body up onto the ledge…sit down on your bum with your back to the 30-story view…and, then, completely stand up…. on a ledge… in order to lean back and jump off the building.
If you can envision preparing yourself for a jump off a 30-story building without your heart racing, then you are way cooler than I.
Ever heard the saying, “The first step is the hardest?” Whoever said that had, obviously, rappelled off the Wells Fargo building. Just prior to actually going over the edge, not only did my body have to battle the physical issues (shaking, breathing, and sweating), but my brain kicked into high gear. I wanted to cry. I cussed at the nice rappellers trying to comfort me. My brain told me to give up and descend as we are meant to…via elevators.
The rappeller-volunteer said, “Lean back and let go!”
I cussed. I screamed, “Get me off this building!!” to the nice rappeller-volunteers. But, eventually (and, definitely, NOT gracefully) I started the descent down the building. The entire way down, which, by the way, takes at least 15 minutes, I panicked; I hyperventilated; I prayed; I cussed; I tried to not spin; I made a very weak attempt of actually using the lever attached to my rope to make myself go down (No, I do not know the term for the apparatus); my muscles failed me….for 15 minutes.
Why?? Fear of the unknown. I was in a completely new situation, and one in which I had no control.
Similarly, the unknowns of the future of Medicaid terrify providers, recipients, and advocates alike. “Just lean back and let go!”
I am currently at the Association for Home and Hospice Care of North Carolina (AHHC) Leadership Convention in Wrightsville Beach. (Which, BTW, is a great association). The morning speaker, Scott Carbonara was fantastic. He spoke about engaging fully in life, work, and family.
During lunch, I ended up sitting next to another attorney (unbeknownst to me at the time of sitting), who works for the National Council on Medicaid.
Another person who wants to talk about Medicaid sitting next to me during lunch? I felt like I drew the lucky straw.
Then she said that she helps implement managed care throughout the country. She may as well have said that she teaches medical providers to refuse Medicaid and provide horrible services to Medicaid recipients.
You have to understand, if you have read my blogs, my opinion as to MCOs and mental health.
She must’ve read my horror on my face. She said…”Oh, I know. Most people do not have positive reactions when I explain my job.”
Me? I felt like I was standing on edge of the ledge with an unknown rappeller telling me to, “Lean back and let go!” Trust me…
We proceeded to have a rather lengthy conversation. I explained the effects of the MCOs on Medicaid recipients and behavioral health care providers here in NC.
I explained to her that some MCOs are denying medically necessary assertive community treatment team services (ACTT) (a highly intense, 24-hour/day service for the most severely mentally ill) even when the recipients meet the continued stay criteria and do not meet discharge criteria. I explained that the recipients who were undergoing discharge from ACTT were becoming hospitalized, incarcerated, homeless, and sometimes all of the above.
She was horrified.
“Why would the MCOs deny ACTT services if discharge criteria is not met?” She said. “It ends up costing more money, with the hospitalizations and incarcerations, than it would cost if the MCO actually authorized the mental health care needed.” In other words, providing medically necessary services saves money, if you look at the totality of circumstances.
“Where is CMS?”
You win a prize! Ding! Ding! Ding!
I explained that our management of Medicaid services is bifurcated. The MCOs are only in charge of behavioral health, not the total patient care. The monetary incentive for the MCOs in NC is to provide the least expensive services to the least amount of Medicaid recipients through the least amount of Medicaid providers.
She said, “Well, the providers can choose to deal with the MCOs, right?”
Not in NC. As the MCOs are jurisdictional, if the MCO in one county says that you cannot see your patients, another MCO in a different MCO may say otherwise.
She explained that her MCOs work completely differently. (Here I was on the edge of the Wells Fargo building again). We are just supposed to trust that other MCOs would act differently?
Then she told me why her MCOs would not act like our current MCOs.
In her MCO world, the MCOs manage ALL Medicaid services. If a recipient suffers high blood pressure, diabetes, and schizophrenia, the MCO handles all the recipients’ medical issues. That MCO is in charge of the totality of the recipient’s care. If the MCO denies ACTT services and the recipient is hospitalized, then the MCO has the burden of paying for that more expensive ER visit. If the MCO denies ACTT services and the recipient is incarcerated without the proper care and medication, then that MCO has the burden of paying for all crisis care for the recipient that may occur from not receiving necessary services. It costs less to provide proper care rather than let the recipient decompress and pay higher emergency costs.
She wanted to get a representative of one her MCOs to listen to my horror stories. She tried to convince me that the MCOs she has worked with would approve all necessary services. It’s just cheaper in the long run.
But, to me, there is fear of the unknown.
What if the MCOs she has worked with do NOT authorize services like she is describing??
How do we know that a new system would be better? I mean, we’ve all seen how great the new billing system NCTracks is…New is not always better. Change is unknown, and the unknown is scary.
I guess we all have to ask ourselves: Is the current NC MCO system bad enough to warrant a change to the unknown?
When you are standing on top the 30-story building, and are told to “Lean back and let go…”
Or do you take the elevators?
Posted on October 7, 2013, in ACTT Services, AHHC, Behavioral health, CMS, DHHS, Division of Medical Assistance, Health Care Providers and Services, Home Health Services, Hospice, Hospitals, MCO, Medicaid, Medicaid Advocate, Medicaid Recipients, Medicaid Reform, Mental Health, Mental Health Problems, Mental Illness, NC, NCTracks, North Carolina and tagged AHHC, Behavioral health, Centers for Medicare and Medicaid Services, DHHS, Division of Medical Assistance, Health care, Health care provider, Home Health Services, Hospice, Managed care, Managed Care Organizations, McCrory, MCO, Medicaid, Medicaid recipients, Medicaid Reform, Mental disorder, Mental health, NCTracks, North Carolina, Pat McCrory. Bookmark the permalink. 10 Comments.