Editor’s note: This is the first of a two-part report on Kentucky’s Medicaid managed care program. Next week’s story will profile two bills currently making their way through the Kentucky General Assembly to address issues mentioned in the following report.
HAZARD — Kentucky’s Medicaid managed care program has given both providers and patients a run for their money — sometimes literally — in the last few years, now, however, some doctors say they are standing up and giving a voice to those Medicaid patients who may not feel like they have a voice to begin with.
Dr. Syamala Reddy, an ophthalmologist at the Hazard ARH, knows all too well about the silence of Medicaid patients; 30 percent of patients he sees are Medicaid patients, who, since 2011, have had to contend with managed care organizations (MCOs) to be seen or heard by a physician.
Reddy, who has been a provider to some of his patients for over 30 years, said one of the main issues with the MCOs is the pre-certification process and wait time. Before any Medicaid patient can be seen, or procedure or test can be started, even something as simple as a check-up, the patient must be pre-authorized and certified to ensure that their care will be covered by their MCO.
The average wait time for a pre-certification is around 48 hours, Reddy said, and that is not adding in the amount of time it could take to get through to the company to start the pre-certification process.
“Imagine the hardship the patient goes through when they come in for a check-up, and I send a request for a pre-cert, come back after two days to hear a response,” Reddy said. “On average, it takes seven minutes of my time to get any telephone call to talk to somebody. Not to count the number of hours my staff has taken.”
Reddy said he has allocated one staff member, Keila Pigman, solely for the job of handling all Medicaid calls and pre-certifications because it is too much of a hassle to have everyone on staff trying to add that to their workload.
“You fight tooth and nail and stay on the phone for four hours for them to tell you that they’re not going to approve it. It’s not worth it,” Pigman said. “They don’t care about the patients’ health; they just care about how much money it’s going to cost them.”
Reddy said he has also had issues with what medicines the MCOs will cover for his patients. Fourth-generation antibiotics and medicines, which are the newest and strongest medicines in the field right now, are not being covered most of the time. MCOs will only cover older generations of medicine, Reddy said, and he has even been denied coverage for a first-generation medicine, Neosporin, an over-the-counter antiseptic costing anywhere from $2-5.
Dr. J.D. Miller, ARH’s vice president of medical affairs, said the problems with the new system are making everything difficult for everyone involved in the process.
“Even if you did provide care, if they can’t get their medicines and can’t do the other things, they’re still not going to get the kind of care they need,” Miller said.
Reddy explained that he and other doctors are unable to prescribe any brand name medicine if there is a substitute or generic version available. He said most substitutes and generic versions of medicines are cheaper because the quality is much lower, and thinks the MCOs should not compromise their patient’s care just to save a few dollars that could have to be spent anyway if the patient lets their condition worsen due to frustration with the system.
One out of every six patients Reddy sees, he claimed, drops out of his care because they are frustrated with wait times or non-coverage.
Miller said the new system has been causing the process of getting patients treated to slow down, so much so sometimes that patients will often not return to be treated after waiting to be pre-certified.
Miller said, “Truly, I think the name of the game is to make it harder to receive services because that costs less.”
Reddy attended all of the introductory sessions with the new MCOs when it was announced the changes to the system would happen, and at each one he was told providers would be looking at very minimal changes to the way they handled Medicaid, if any at all. Now, Reddy said the organizations have not kept their promises.
He said with the previous Medicaid system, providers knew who they were talking to when they called the Medicaid office in Frankfort for assistance or pre-authorization for their patients. Now, however, the Medicaid MCOs each have their own separate call centers, which he said do not communicate with each other.
“Things were pretty clear, what we can expect, where we don’t have coverage, where we have coverage, what kind of coverage we have. Today, the three managed care companies we call, we don’t know whom we’re talking to; these call centers could be just anywhere on the planet,” Reddy said.
Reddy and Miller are members of the Medical Staff Leadership Council for the ARH hospitals. Those members from the Kentucky River area, including Reddy and Miller, came together last week and wrote and signed a letter to the editor addressing some of their concerns with the Medicaid system.
Calls seeking comment from the Medicaid managed care program in Frankfort were not returned this week, while calls made to the three MCOs, Kentucky Spirit, CoventryCares, and WellCare, were also unsuccessful.
Reddy, who suggested writing the letter, said he hopes this gives his patients the voice that they might not think they have.