About 60 people attended the second pre-bid conference for the
Kansas Medicaid managed care contracts. The event was held Nov. 30
in a conference room at the Eisenhower State Office Building. Pictured
in front of the blackboard is Steve Schramm, an actuarial consultant
hired by the administration of Gov. Sam Brownback to help explain
the state's request for proposal. (Photo by Mike Shields)
TOPEKA — Kansas isn’t the only state doing it.
When Gov. Sam Brownback announced his administration would seek bids from private companies to manage the care of virtually every person enrolled in the state’s Medicaid program, Kansas became part of what has been a rapidly accelerating trend since Medicaid managed care companies came on the national scene in the 1990s.
"Virginia, Florida, Texas, Illinois, New York, California … especially California and Texas and Florida. They certainly have a lot of people that are eligible for Medicaid," said Michael McCue, a professor at Virginia Commonwealth University and co-author of a recent national study of Medicaid managed care operations.
Looking to cut budgets
"States are looking for ways to manage those populations and cut their budgets, and typically 20 to 30 percent of state budgets are going to Medicaid. With the recession, states are looking for ways to manage that cost," he said.
In 2000, according to the federal Centers for Medicare and Medicaid Services, 18.8 million enrollees — or 55 percent of the nation’s Medicaid population — were covered by various managed care arrangements. By 2009, CMS reported that the number of enrollees receiving services covered by managed care plans had nearly doubled to 36 million, or 72 percent of the Medicaid population.
The agency also reported the nation now has 225 full-service Medicaid health plans that each have at least 5,000 members enrolled.
But the business is increasingly dominated by a handful of major, for-profit insurance companies that are positioning themselves to manage the care of the 16 million more Americans expected to become eligible for Medicaid once the federal health reform law fully kicks in on Jan. 1, 2014.
"With enrollment in employer-sponsored health insurance steadily declining and more Americans falling into the Medicaid safety net, health insurance companies are going where the growth is — the Medicaid managed care market," wrote Emily Berry in a recent article titled "Mining for Medicaid Gold" that appeared in American Medical News, a trade journal for doctors.
Most of the nation's major managed care companies have shown interest in securing one of the three contracts that Brownback officials have said they intend to sign. The contracts are each expected to be in the range of $300 million to $400 million a year.
"Small state, big contract," a representative of one of the major companies told KHI News Service, acknowledging his firm likely wouldn’t show interest in a contract here worth only $100 million.
The governor’s plan is a high-stakes affair for Kansans and for some of the insurance companies.
"Health system reform, in combination with economic factors, is expected to speed consolidation of health insurers," wrote Ron Sommer, an independent stock analyst who writes the blog Measured Approach.
Mergers and acquisitions
"The prospect for mergers and acquisitions throughout the industry is high due to pending reform initiatives and greater access to financing. In addition, there are tax incentives for privately held companies to sell now when capital gains taxes are relatively low. There is an incentive for health care insurers to be very large to realize economies of scale and efficiency. Instead of mega-mergers among the big companies, we expect to see the majors buy up the smaller regional providers," Sommer wrote.
Evidence of that already is available in Kansas. In late October, a few days before the governor announced preliminary details of his Medicaid makeover plan, Coventry Health Care, a publicly traded national player, announced it had reached agreement to buy the nonprofit Children’s Mercy Family Health Partners. Children’s Mercy currently is the state’s largest Medicaid managed care company, providing services to about 155,000 women and children enrolled in the Kansas HealthWave program.
Coventry is one of the major national companies interested in securing a Kansas Medicaid contract.
Quick schedule for expansion
The governor’s plan would expand the state’s more limited use of Medicaid managed care for HealthWave beneficiaries to also include the elderly, disabled and mentally ill. Though more and more states are moving to managed care, Kansas, under the Brownback plan, still would be one of the very few to bring all those groups — generally the most expensive to treat — under the wing of managed care.
Also unusual is the relatively quick schedule the Brownback administration has set for itself and its goal of rolling out the new, expanded program statewide on Jan. 1, 2013. Other states that have included all those subpopulations in their managed care contracts have done so incrementally and at a slower pace. And even with that, there have been problems.
For example, New Mexico began its move to Medicaid managed care in 1997 but only recently phased it in for nursing home residents. Now, two managed care companies oversee nursing home care statewide, creating a host of problems for nursing homes, according to Linda Sechovec, executive director of the New Mexico Health Care Association, a long-term care trade group.
Sechovec said the state Medicaid program wasn’t paying the facilities enough to cover their costs before moving to managed care and that problem was made worse by the introduction of "third parties" that are slow to pay and impossible to negotiate with when it comes to setting payment rates.
Buying a "broke" system
“It’s just not a model that is well-served by pinching every penny to the point that service is inadequate,” she said. “In my state, providers haven’t had a rate increase since 2007. They have staff members who have gone without raises for three years or more, and we are pleading with our legislature and administration to address the chronic underfunding that existed not only before managed care but is now exacerbated.
“It was a broke system,” Sechovec said. “But the managed care companies came in and they bought it. They bought it and they didn’t fix it. That’s exactly where we’re at.”
Cindy Luxem, Sechovec’s counterpart at the Kansas Health Care Association, said she was well aware of the problems in New Mexico and other states where managed care has been extended to Medicaid’s long-term care populations. She said her group’s members are worried the same problems could emerge here.
“We're concerned about things like timely claims processing, the prompt-pay issue,” Luxem said. “Kansas had done a pretty good job historically of getting providers paid in a timely way, and I can't necessarily say that is the case in all the states I visit with, so that prompt-pay piece is really important for us.”
Brownback officials have said they expect the managed care companies to maintain advisory councils made of up providers and their representatives so that concerns — such as those about prompt payment — can be voiced and addressed. The administration’s contract proposal also would allow bonus payments to companies that meet various performance standards, including prompt payment of provider claims.
Introducing the profit motive
But the concerns of some in the state’s provider network are more deep-seated. They view with alarm the introduction of the profit motive to a segment of the social service system that deals with some of the state’s most seriously disabled.
Tom Laing, executive director of Interhab, an association that represents most of the community groups that provide services to the state’s developmentally disabled, said Kansas has a long-standing structure for providing those services that has worked well without including a profit-seeking insurance company in the driver’s seat.
“We provide many aspects of a managed-care model currently,” he said. “We have capitated rates where we assume the risk. We have annual review and assessment … and as a result we’ve been able to save the state millions and millions of dollars. Our costs per person served are slightly less than they were 15 years ago. We've already done the transition to managed care to the extent you can for our population.”
Laing said the Brownback administration signaled early that it intended to expand managed care.
“Going into this conversation, we understood this would be the administration’s goal,” he said. “They said it from the beginning. And we’ve said from the beginning that we don’t think it is a good fit for the developmentally disabled community, and we’ll continue to advise them and the Legislature accordingly. There is so much here that is experimental that somebody’s got to be looking at it.”
Brownback officials have said many of the providers’ concerns are misplaced.
The contracts, they said, will require the managed care companies to produce savings for the state of 8 percent to 10 percent over five years without cutting benefits or services. Furthermore, the companies will be expected to improve health outcomes for those on Medicaid.
Better services at reduced costs?
Improving coordination and eliminating duplicated or unneeded treatment will result in better services at reduced costs, officials said.
"My view on integrated care was that I was probably a skeptic when we started this conversation several months ago," said Shawn Sullivan, secretary of the Kansas Department on Aging, which will be called the Department for Aging and Human Services after assuming oversight of programs for the mentally ill and disabled currently managed by the Kansas Department of Social and Rehabilitation Services.
"But that changed after I reviewed what had been done in eight or 10 other states and talked with some of my colleagues there about what worked. Some of the policy changes we’re building into the integrated care system will have a substantial (beneficial) impact on those we serve," he said.
Sullivan also predicted the administration will find major Medicaid savings by increasing the use of home- and community-based services and thereby decreasing the number of people who enter long-term care facilities where services are costlier to taxpayers.
Though Sullivan was persuaded by what he learned of other states' operations, the jury is still out on what expanded managed care will mean for Kansas and the nation with regard to taxpayer expense and care for Medicaid clients.
Studies of other states' programs have been mixed regarding the cost savings achieved by managed care.
The Lewin Group reported that Medicaid managed care saved New Mexico about $44 million in fiscal 2006 and that quality and provider-satisfaction ratings were better than national averages. The Lewin Group is owned by a major insurance company and often is commissioned to do studies for the industry.
But a New Mexico Human Services Department evaluation for fiscal year 2010 that focused solely on the long-term care program within Medicaid concluded that the "costs far outpaced original projections and continue to increase. … The program’s structure and oversight needs streamlining to assure future affordability."
The evaluators also reported "the estimated savings from using a managed care model were insufficient to cover the new managed care organization administration, profit and taxes, and increased program costs by an estimated $68 million."
A Georgetown University study of Medicaid managed care programs in Florida concluded there was "no clear evidence" the programs were saving money or that health outcomes for clients had been improved.
Average effect -zero
Perhaps the most comprehensive recent study, which included data from all 50 states, concluded: "Our baseline estimates suggest that the average effect on Medicaid spending of shifting recipients from (fee for service) to managed care is close to zero."
That report by the National Bureau of Economic Research also found that savings were more difficult to achieve in states that already had relatively low Medicaid provider rates. In those instances, researchers concluded, managed care contracting generally "seems to increase Medicaid spending."
The Commonwealth Fund study co-authored by McCue found that publicly traded insurance companies that focused on Medicaid managed care had significantly higher administrative costs than any other type of Medicaid managed care organization and the lowest medical costs. The researchers said both could be a result of more cost-effective care or reduced care and lower rates paid to providers.
The study also found that publicly traded companies performed "significantly worse" than others on measures of clinical quality dealing with preventive or chronic illness care.