Sunday, September 18, 2016

Too quick for our own good?

Cedar Rapids-Iowa City Gazette “On Topic” column from March 13, 2016

Gov. Terry Branstad always and forever, it seems, has branded himself as pro-business.
Back in 2010 when he campaigned to retake Terrace Hill from then-Gov. Chet Culver, Branstad won the endorsement of the Iowa Association of Business and Industry’s political action committee. The organization at the time represented 1,400 businesses in the state.
When he got that nod from the PAC, Branstad vowed to be a “pro-business, pro-growth governor who will reduce taxes and not increase debt.” He resolved, in a Gazette story reported by James Q. Lynch at the time, to “make government more efficient and work day in and day out to encourage job creation.”
So you have to wonder what thought Gov. Branstad gave, with that pro-business mindset, to the many health care providers, large and small, when he set in motion his lickety-split rush to managed care.

The difficulty, uncertainty, turmoil — use what word you like — that was set loose by this hurried push is hard for an objective observer — as well as the governor’s political adversaries — to deny.
The tsunami-like effect has been felt not only by Iowa’s large hospitals and small clinics, case workers, nurses and other professionals. Also affected are the three private, out-of-state managed-care organizations that began to set up shop here last year — all on the promise that Iowa would be ready for the transition by Jan. 1. Which it wasn’t.
They’ve lost time and they’ve lost money. In the meantime, they’ve disconcerted their client base — Iowa’s Medicaid recipients.
None of this makes for good business.
To recap: Iowa’s Medicaid price tag soared from $2.4 billion in fiscal year 2004 to $4.9 billion in FY 2015, according to the state’s Department of Human Services
In an understandable effort to want to get a grip on these mounting costs, Gov. Branstad announced in February 2015 a shift from a program in which providers are reimbursed by the state for services to a managed-care system. (The DHS has claimed Iowa would save some $51 million in six months alone.) Start date: New Year’s Day 2016.
Three — well, four at first, but that’s a long story — managed-care companies signed contracts to take over the approximately $5 billion program that works with 560,000 enrollees. They began to take on nurses, case workers and other professionals — some hired away from existing agencies and hospitals in the state.
In early November, the Iowa Hospital Association and 11 hospitals called for a delay. Things were moving too fast, they said.
And in mid-December, after on-site reviews and expressing ongoing concerns over 16 separate issues relating to the provider network, the Centers for Medicare and Medicaid Services — aka, the feds — agreed, and pressed the pause button. The start got pushed back to March 1.
During all this, some Medicaid beneficiaries continued to protest that they’d yet to even get their hands on an information packet from their state-selected managed-care organization, let alone try to figure out what they wanted to do. They also worried — and still do — that insurance coverage and services would be cut back under the private, for-profit companies.
They repeatedly said they couldn’t get straight answers from the managed-care organizations or from the state.
Frustration reigned. As Jeff Edberg of Iowa City, father of two Medicaid beneficiaries, told Gazette health care reporter Chelsea Keenan last month, he’s spent roughly 10 hours a week on the phone with the DHS and elected officials trying to obtain information.
“I’d love to be wrong, to come back in three, four, seven months and say, ‘Gee, I was being an overprotective dad and the governor really had my son’s best interests at heart,’” Edberg said.
The managed-care organizations, meanwhile, weren’t — and still aren’t — making back any their financial outlay. Anthem, parent of Amerigroup, one of the three companies picked for Iowa, offered an example of how much money we’re talking about, during its 2015 fourth-quarter investors conference call in late January, and as reported by, the Des Moines Register and others:
Anthem’s CFO, Wayne DeVeydt, said that the company anticipated a “few hundred-million-dollar headwind” in various states’ managed-care programs where the company was involved, and that about 25 percent of that potential loss could be tied to the “delay of two months” in Iowa in 2016. So if that “few” hundred million dollars is, let’s say, $200 million, at minimum, a quarter of that would be $50 million. (You can listen to that conference call at
Not to be left out, Senate Democrats put together a bill to ensure oversight and, they said, to better protect both the beneficiaries and the health care providers. Culver reappeared on the public scene, calling for accountability.
Branstad responded by suggesting Culver and the hospitals were attempting to “scare” patients — that’s the word the governor used on Iowa Public Television’s “Iowa Press.”
All along the governor said everything has been moving along quite well, by golly, and the state was ready, providers were ready and he was ready.
On Feb. 23, the CMS finally OK’d the managed-care handover — but again slid back its debut, to April 1.
Messy, right?
More important, though, this has been more than partisan politics as usual, as Branstad has suggested. This dash also seems to have given little concern to the providers, companies and enrollees.
Which brings the big question: What’s the rush?
Sure, it’s true 39 other states have gone to managed care. But most made their transition with bigger windows — some up to 18 months. Remember, Iowa’s DHS didn’t sign contracts with the managed-care organizations until October 2015 — just two months before the initially planned start date.
Also, only about five states have moved as many Medicaid recipients to managed care as Iowa wants to slide over. The significant majority of states shifted much smaller amounts of their population to managed care.
State Sen. Liz Mathis, D-Robins, pointed out to The Gazette in mid-October that Kansas moved toward managed care with a similarly short time frame, and that was a “disaster.”
Indeed, according to the KHI News Service, part of the Kansas Health Institute, the three companies that handled Medicaid for that state lost $110 million in 2013, the first year of managed care there.
As Mathis said, Iowa’s unnecessary haste “is not good for patients, and it’s not good” for the managed-care organizations.
Time will tell how managed care unfolds in Iowa in the months and years to come, assuming the transition does go through in a few weeks.
But surely a little more time to work things out wouldn’t have hurt. That’s just good business.

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