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Health care for neediest faces a ‘tidal wave on horizon’

Henderson County social workers are bracing for a wave of confusion and anxiety from Medicaid recipients who are scheduled to choose managed care plans starting Oct. 1 in place of traditional fee-for-service health coverage. And even if the county weathers the transition, those patients may then confront a severe shortage of doctors willing to treat them, county officials say.


A combination of factors — including the state budget stalemate, the refusal by more than half the state’s Medicaid providers so far to agree to the managed care rates and a predicted work overload on county caseworkers — is setting up the health delivery system for a breakdown, even a crisis, by the end of the year, one county commissioner says.
Jerrie McFalls, the county’s director of social services, and Commissioner Bill Lapsley, who sits on the county Board of Health, reported on the Medicaid transition during a Board of Commissioners meeting earlier this month.
After getting a waiver from the federal government, the state Legislature rewrote the state’s Medicaid law to transition the program from traditional fee-for-service to managed care plans, which policymakers hope will mean more predictable costs and better health outcomes. The state plans to pay managed care companies $30 billion over five years to provide medical care for 1.6 million low-income, disabled or elderly recipients of Medicaid. The first 27 counties are scheduled to go live with the new plans on Nov. 27. Henderson County is expected to start the enrollment process on Oct. 1 and transition to the new coverage in February. Medicaid covers 27,636 adults and children in the county, McFalls, and about 19,000 of those are expected to be shifted into one of four managed care plans the state has authorized.

Providers say no to new rates

If the schedule holds, Medicaid recipients will receive letters notifying them that they have to sign up for the new coverage.
“We expect when they get letters, they will be calling their caseworkers to say, ‘What does this mean? What do I do?’” McFalls said. “We also expect that a lot of the recipients will just come to the office to ask those same questions so during the time that we’re trying to deal with the ACA (Affordable Care Act), caseworkers will have to stop and take those calls.”
Administrators are trying to plan now for how they can “set aside time for caseworkers to return calls to try to help and support Medicaid clients in understanding what they need to do,” she said. The state has hired a broker, called Maximus, that has offered to help counties in the transition.
“The broker is the only people that can help our clients choose one of the four plans,” McFalls said. “Our staff are not qualified to do that and we’re not supposed to do that.”
Provider signup has been slow across the state, another cause for worry.
“There is a hope that most medical providers will sign up for all four health plans, although that’s not a guarantee,” she said. “At this point we’re told that currently there are 89,000 Medicaid providers under the fee-for-service plan but under the managed care plan in the Phase 1 counties, there are only 23,000 across the whole state” that have agreed to accept the coverage.
In Phase 1 counties in the Piedmont, so many providers have declined that “their clients are not able to sign up for health plans because their doctor is not in network in those four plans yet. Less than a third of current providers are signed up to provide Medicaid under the new plans,” McFalls said.
The state has also directed county social services departments to usher Medicaid recipients through a “warm transfer” to the insurance broker.
“We get a call, talk with the client about problem, help them call the broker and help explain what their problem is,” she said. “So you’re talking about time for us to do the interview and then do the warm transfer. It’s a time concern for Medicaid staff who have a lot of duties.”
When open enrollment ends, the broker leaves. Those that are auto assigned will no longer have a broker.

It’s possible Henderson County and others in the Oct. 1 signup period won’t have this problem, at least not right away. The political standoff between Gov. Roy Cooper and the Republican-led Legislature over another health care issue — expanding Medicaid to cover more uninsured North Carolinians — has stalled the 2019-20 state budget. Without a new budget, the state operates on a continuing budget from last year.
“Without the funding they won’t be able to pay the PHPs (prepaid health plan contracts),” McFalls said. “So if there is no budget by late August or early September, this will probably come to a halt because the counties that are in Phase 1 are slated to go live.”

‘Tidal wave on the horizon’

Commissioner Lapsley, who sits on the county Board of Health, is a past chair of the Pardee Board of Directors and current member of the UNC Health Care board in Chapel Hill, emphasized that Medicaid Transformation has no connection to Medicaid expansion.
“This is for current Medicaid recipients — elderly, disabled, children and mothers,” he told commissioners after McFalls completed her report. Although the county does not directly fund Medicaid — the federal government pays about two-thirds of the cost and the state the rest — the impending changes could have dramatic consequences, Lapsley told the board. Given that Medicaid covers nearly a quarter of the county’s residents, a rocky transition could cause a significant disruption in health care for the needy.
“Under this transition program, a significant number of those providers so far have not agreed to provide the service once this transformation takes place,” Lapsley said. If, for instance, only half of the county’s Medicaid providers agreed to the new fee structure, “that’s a significant drop in the number of providers. So the picture that I see is that there 26,000 patients that were being handled as far as I know, OK, adequately, in a timely manner, by the 2,000 doctors. Now a thousand doctors are expected to handle that same number of people. It’s an impossible situation.”
He sketched out a scenario that he said would lead to a breakdown.
“A huge number of these Medicaid patients are going to try to get to a doctor for service and the doctor can’t see them,” he said. “They’re backed up at the front door. They can’t get it. So what’s going to happen? Those patients are going to go to Park Ridge and they’re going to go to the emergency room and Pardee and they’re going to ask for charity care and the system is going to start breaking down.”
Without an adequate number of providers, “we’re going to have a serious problem in the community providing health care to all these people and we could wake up in November, December, next year, and have somewhat of a crisis situation trying to get patients cared for. … I just point out this could be a serious situation, a tidal wave on the horizon, and we all ought to be aware of it. If it does happen, I told you so.”
Chairman Grady Hawkins turned to Lapsley and said: “We were waiting for a solution.”
“I don’t have a solution,” he said. “All I see is a problem.”