Wednesday, September 17, 2008

Evaluating Medicaid Managed Services




In January, 1994 the Board of Directors and the Health Care Policy and Practice Network of the New York City Chapter held a think tank for leading health and mental health social workers to discuss their experiences with the development of managed care for clients enrolled in the Medicaid program. Out of the think tank, a work group was formed to analyze the implementation of managed care and to make suggestions for impromvement. Click the link to read the report.




40 comments:

Kristie said...

I am so glad this article pointed out the limitations and evaluations that some people have when it comes to accessing healthcare. Even those on medicare and medicaid are facing barriers to treatment, especially as far as mental health is concerned. It is nice to see something empirical which openly displays the flaws within the current health care system. While it is good for those who are well insured, those who are not are often left to face health care alone.

Linda B said...

Working as a Patient 1st Care Coordinator, I assist many Medicaid patients that are attempting to navigate the Patient 1st/Medicaid system. I know how difficult obtaining adequate services can be, due to the limited number of medical, dental, and mental health providers available to the Medicaid population. It is important for organizations such as the NASW to evaluate services provided to the Medicaid population, and identify weaknesses and barriers in the health care system.

Linda B said...

Addressing Kristie's comment,I agree that there are huge barriers for Medicaid patients in accessing mental health services, in Alabama as well as New York. I have had numerous clients that waited months to be evaluated by the psychiatrist at the local mental health center, which is the only local psychiatrist that accepts Medicaid payment. One of these clients, a very unstable bi-polar female with 3 small children, spent months seeing only a therapist, before being scheduled to see the psychiatrist, and receiving adequate psychotropic medication. This is a very difficult situation for patients and families that are in dire need of mental health treatment.

Tiffiney Brittingham said...

This was a very interesting article. I want to practice in a healthcare setting. The article gave a general idea of how a program should function properly. The article also gave a general idea of what to do and what not to do in a managed care position. This is very important for graduate students getting ready to take on a management position in a health or mental health setting.

Tiffiney Brittingham

Tiffiney Brittingham said...

Commenting on Linda B's response...I recently completed a paper about the time limits and procedures the mentally ill go through before being seen by the right professionals. Linda is correct it takes months to receive service. It is very important to evaluate programs such as medicaid.

Stu J. said...

Interesting to note the age of article and the challenges that remain thirteen long years later. As Susan shared in class, money is a motivating force behind many policy decisions. Is Medicare intentionally difficult to use in order to lessen expenses to the government?

Stu J. said...

In reply to Linda's comment, it is a crime that it is so difficult to access Medicaid services for too many clients.

Stu J. said...

In reply to Kristie's comment, the gap in availability of mental health coverage is another one of those odd injustices. Why is mental illness not as protected a right as physical health needs? Money, lack of respect for the importance of mental health as compared to physical health, inadequate stakeholder support?

Anonymous said...

I was glad to see this article. One of the strongest points made was regarding the waiting times. They should be monitored and made as a component of quality assurance. I have also tried to refer clients to the MHC who had Medicaid it would takes weeks or months to get them an appointment.
Donna A

Anonymous said...

In response to Linda's comment, I too have seen how slow the system works for some especially in the mental health care system. Donna A.

scarlett holt said...

I found this article interesting as it raised many points of concern that I have had in practice, particularly regarding the homeless population. Though as social workers we cannot expect those in the general population or even in the medical profession to understand and empathise with every argument the we present, it is pleasing to see printed material that allowed for concerns to be expressed, and sent the message that at least some compromises may be considered.
Scarlett H.

scarlett holt said...

Re: Stu J.
Yes, the fact that the same issues are present after a thirteen year time period is ridiculous! I have also questioned the barriers to services regarding Medicare/Medicaid being an issue of cost to the govenment. Some would argue "it's all about the money."
Scarlett H.

jefN gadsden said...

That is an excellent example of social workers advocating for their clients and advocating for the profession. We have to inform, and sometimes remind, people how important and cost effective social workers are.

jefN gadsden said...

Great point Stu, 13 years later and Linda is still witnessing difficulty in obtaining adequate services for Medicaid patients.

SWilliams said...

Linda B, you are right about the Mental Health System today in Alabama addressing the needs of Medicaid patients. Just today in a meeting at work we were discussing the Medicaid system and the lack of counselors that will take Medicaid. One of the only places in my area that takes Medicaid is the local Mental Health Center. While there is along wait for the adolescents, there is even a longer wait for adults. Many times the adults are only able to see a psychiatrist or counselor if they are in crisis or recently released from a hospitalization. Adolescents are seen for the initial consultation within 3 days of discharge, and then they can wait for weeks to see a counselor or psychiatrist, while adults can wait longer. The local MHC here will not even consider seeing a client that has an IQ of 70 or below. More needs to be done to reform the system. The clients who are using the Mental Health System are not likely to be heard by the lawmakers that can reform the system, so someone needs to stand up for them. Way to go NASW of NY, maybe the political leaders will listen and begin making changes.

Anonymous said...

RESPONSE
This is in response to several comments regarding the barriers that patients with mental illness & Medicaid in particular face. As we all know there are multiple barriers for receiving adequate mental health care; one of these that there seems to be a lack of private psychiatrists that take on Medicaid patients in the arena of mental health. I have had some luck with finding local physicians by going to the Medicaid site which lists local providers. I know of a couple psychiatrists in our area that work in the hospital setting and have a private practice on the side.
In terms of wait times to see a psychiatrist in a local mental health agency, it can be a long process for a variety of reasons: in most mental health agencies there are a variety of services, some being more or less intensive. A day program meeting 5 days a week will have more access to a psychiatrist than a person that sees a therapist x1 month on an outpatient basis. If the symptoms/need/Dx is appropriate when a new client comes in for service or a new treatment episode, they are offered the more intense program in order to be seen quicker by the psychiatrist and meet their mental health needs. Sometimes clients do not relay this information to the referring agency. They may not want to commit to the demands of the more intense program either by choice or some other restrictions such as work or childcare.

In the local mental health setting, a client must be involved in program there in order to receive services from the psychiatrist. This is for the safety of the client and the doctor. Many of the meds need observation by clinical staff and occasional blood work to insure no physical damage is being done to the body. Sometimes people just want a prescription and not have to participate in any form of therapy.

I know at our local mental health center, they will mandate that a client keep several appointments with the therapist before access is granted to see the psychiatrist. The staff has been burned in the past by non-compliance and clients just seeking meds. Sometimes specific clients have a history of this kind of behavior. There must be rules in place to make sure the services and medications are not abused. If not, there can be dire health and legal consequences. We must also keep in mind that medications are not a quick fix, magic bullet to solving problems. It can be a necessary component of treatment, but it must be incorporated with therapy and leaning coping skills.

Often times, there is a crisis real or perceived in the life of a client. However, if one is compliant with treatment, meds, and applying coping skills it makes it more manageable. If one has not been attending treatment, etc… the client needs to be held accountable. They cannot just show up out of the blue and expect people to drop everything and attend to their needs when they have not been compliant. There are always several sides to the story. There needs to be good communication between the treating and referring agencies

Another reality is the caseloads are extremely high, which can be a barrier for new clients getting in.
Matt G. (Gadsden)

Anonymous said...

Original Post
I don’t have any experience working with Managed Care, but I hear that
it is challenging. I know on the state level, Medicaid performs audits occasionally for
quality assurance and to prevent fraud. Most agencies have some for of internal audits/quality control that originate internally. I wonder why there are not more frequent audits by Medicaid. In the article it is interesting that it mentions that in the past, Social Workers were not made available as a means to provide services mentioned in the article. I wonder what profession they were relying on to perform those jobs since Social Workers apparently provide about 85 % of mental health services from what I read.
Matt G. (Gadsden)

Kim B. said...

I enjoyed this article because I have worked with many families who receive medicaid and medicare benefits and have often listened to them voice their frustrations with the rules and regulations of medicaid benefits. Although, medicaid and medicare is a wonder resource for families it can be frustrating for them because of their lack of understanding of the full range of services available.

I think this article is both beneficial for me as a professional and the client. Gaining understanding of medicaid and medicare will assist me in helping families to understand what is available for them.

Kim B. said...

Commenting on Tiffany B's response..... I agree that it is important for up and coming social workers to learn all they can about medical benefits to better assist families. I have never worked in the medical or mental health field directly; however, I would be opened to learn all I can to possibly work at an agency that addresses those needs in the future.

Teresa D. / Gadsden Center said...

Managed Health Care has many flaws that are brought out in this study. But there is good news, as the study also points out. Social Workers are the perfect professionals to make this system function better. Many people who have health problems, especially major health problems, also have psychological and social problems and we all know that these issues have a tremendous affect on the healing process. Great job NASW!!

Teresa D. / Gadsden Center said...

RE: linda b
I totally agree with you Linda. I worked in Foster Care at DHR and found that the wait time for appointments, even for ESPDT screenings, was getting longer and longer. I also agree in regards to the importance of this study. I only hope that Medicaid heads the warnings and takes the well thought out advice of NASW.

Tysie Baker said...

It is sad that after so many years our government still has not perfected equality. My hope is that when people are seriously ill, they do not have to wait for long periods of time before they can get the help they need. I can only say that since private insurance companies have so many problems that is probably the reason why state funded insurance companies have problems as well.

Tysie Baker said...

In response to Scarlet. I must agree, I am happy that they are finally investigating the problems more, in hopes that people will be able to receive quality healthcare in a timely manner.

R.A.Montgomery said...

An Evaluation of Medicaid Managed Care:
Social Work Issues and Recommendations and the Social Work Role in Managed Care

This is a good idea but it is sad that it comes after a major Medicaid fraud case that was in the news last month. Some Los Angeles hospital used homeless people to fraud the government out of millions. Therefore, now Medicaid is cracking down on other facilities to recapture some of the funds that were loss due to fraud.
LOS ANGELES—for hundreds of homeless people, posing as phony hospital patients provided them a clean bed and cash. For the hospitals that processed them, it meant a full patient-load and a paycheck from the government. Now some of those allegedly involved in what authorities say was a massive scheme have been charged with billing government programs for millions of dollars in unnecessary health services.
MY RESPONSE”
Linda B, I agree with you 100%. I remember when I worked for a local nursing home's rehabilitation unit. It was a chaos attempting to advocate for my consumers. I would tell my consumers to be prepared to be turned down for services, and to bring their denial letters to me so that I could resubmit their information with whatever form Medicaid wanted this week. Two the main issues with Medicaid is that they have long wait period for services, and Medicaid is very slow in paying invoices to professionals will provide Medicaid services to populations at risk.

Anonymous said...

I thought that all of the areas of concern were right on target and should be addressed in all states. Some of the most important issues were making sure that patients are aware of their medical coverage, addressing patient's aggravation due to the gap in time of sickness and an appointment date, and the low standard of healthcare. I am a firm believer that everyone should have access to quality medical care.

LDW

Anonymous said...

I agree with Kristie, it's encouraging to know that poor healthcare issues are being identified; my hope is that positive change will follow.

LDW

Anonymous said...

Having worked in the medical field, I find the Medicaid system in Alabama is very time consuming and frustrating. Think about the nursing home Medicaid paperwork. It is a ten page appliciation where most elderly people don't even know where to begin. There is a maze of unknowns because Mediciaid seems to always be changing their rules and not keeping everyone informed. I was once told by an AL Medicaid Rep. that each state decides what services Medicaid will cover. Why not have uniformity between the states and streamline the necessary paperwork? Social workers need to be aware of insurances such as Medicaid so that they can help educate their clients and assist as needed. Lastly, social workers who work with Medicaid need to make friends with someone at their local Medicaid office-makes life easier at times
Angel P.

Anonymous said...

Re: JefN in Gadsden
Totally agree with your blog. It is more cost effective to utilize social workers, but when is everyone going to get on the bandwagon? This is when, in the aging population, geriatric case managers can work with families, doctors, Medicaid, etc and would save someone a whole lot of money. Most people just need someone to help them through this web we call healthcare. The same principle can be used with any population, ie mental health, children, etc.
Angel P.

ojwashington said...

Re: Linda B

I have also have experienced the difficulties to obtaining and identifying adequate services for patient with Medicaid. I have found that the barriers have been the limited number of providers that accept Medicaid. Also another barrier has been the limited days that these providers will only see Medicaid patients.

ojwashington said...

My job as a Patient 1st Care Coordinator, allows me to work with people with Medicaid to assist them with locating and scheduling appointments with healthcare providers. I have noted several barriers faced by this population such as the limited number of providers that accept Medicaid/Medicare. Another barrier faced by this population is the limited number of days that the providers will actually provide services to Medicaid patients. Another issue faced by Latino Medicaid patients is that some of the providers who accept Medicaid don’t provide interpreters to translate during the services which are provided. It should also be noted that Medicaid Policy states that if providers are going to accept Medicaid patients then they must accommodate these patients which includes providing interpreters.

bekkah_s said...

Most Americans would agree that there is definitely a gap in health care services for all populations-not just Medicaid and Meidcare recipients. I liked several points within the articls. Issue #8 was my favorite! I don't think that very many people view social workers as those that can assist in a healthcare setting. MOst think of doctors, nurses, specialists, etc. The idea of validating our services by inclusion into the managed health care system is fantastic. I believe that although social workers have come a long way, many still view us as the "welfare" or "baby snatchers". To include social work services would be to say that a physical exam has as much value as a social worker's assessment.

Maybe my next comment is due to my inexperience with the healthcare setting, but I was a little confused by Issue #2 regarding the homeless. Why would they not be eligible for services due to becoming homeless and why would they need a fee for service?

bekkah_s said...

I agree with jeffn's comment regarding social workers' value. The workers that helped make this plan were forward thinking and saw a way to advocate for their clients and themselves!

Gina Smith said...

swilliams: I understand where you are coming from with issues surrounding mental health and Medicaid. My county has a mental health center, but only has one therapist. My clients whether foster care or protective service, does good to see her 30 minutes per month. Though her agency bills Medicaid directly, I find that many times the children and families that I work with need more than 30 minutes per month. It appears that it is in their best interest to see a private therapist that bills DHR and then DHR get reimbursed from Medicaid.
For example: I recently had a protective service family wherein we received concerns from the school that the 14 year old son was cutting himself. Mental health was contacted, the situation was explained and due to their schedule, the child was unable to receive an appointment for 3 weeks, October 6 to be exact. I advocated for a private therapist to do crisis intervention until the child could be seen by mental health; however, I was unable to get this approved by my supervisor. However, last week, the child had to be admitted to inpatient treatment as his father walked into his bedroom and found him with a sword, contemplating killing himself, either by falling on the sword or my attempting to chop his head off. I agree there is a definite need for more providers that will directly bill Medicaid and provide some much needed and more expedient services.

T M Morgan said...

This article definately highlighted some important issues as far as connecting our clients to the appropriate services. While they are waiting for their spot in the assembly line they are lacking the tools to live a full and funtional life. I have clients who are unable to get on medication for their mental illness and meanwhile their children are the ones who suffer as their caretaker is unable to function and effectively parent them.

T M Morgan said...

I agree with Matt and wonder why Medicaid itself is not audited. They love to audit other agencies but I would be willing to bet that they have enough waste within their own agency to pay for all kinds of wonderful programs.

nikkig said...

Nice to see these concerns being addressed. I took my mom to the emergency room the other night, and while she was checking out, I noticed a pamphlet for patients receiving medicaid, and it was just so sad to me. The pamphlet was actually telling these patients when to come to the emergency room and when not to. What was funny about it is that the list of when NOT to come was longer than the list of when to get services. Go figure. Something has got to be done so that people are able to receive necessary healthcare services regardless of the provider.

nikkig said...

In response to Linda B,
Your post reminds me of the BCBS commercial that is aimed at Medicaid recipients, telling them that they have services that will help them better than their Medicaid because the Medicaid plans are so difficult to navigate.

bekkah_s said...

The health care system within our country is in dire need of repair. With the amount of wealth in our country and being one of the leading world powers, I don't understand why every American is not ensured. Even those that are covered under a plan are sometimes forced to file for bankruptcy if a catastrophic or chronic illness occurs. Most often these people are those that are living paycheck to paycheck and are categorized as the "working poor".
I am glad to see that people are discussing different options and plans of action to address some of the limitations of the system. I am pleased to see that not only provision of services, but the quality of services (waiting times, etc) are being considered.
I have not had much experience with Medicaid directly and maybe someone with more experience could clarify. One thing that confused me is the services for the homeless. Why would their services end when this population has one of the highest rates for costly emergency room visits?

bekkah_s said...

In response to jefn

I totally agree with your comment regarding the cost effectiveness of social workers. Our society is made up of multiple band-aids. If we could spend a little bit of time with our clients to understand their needs, cost, overused services, frustration, etc. could be greatly reduced.

Debbie Walker said...

The social workers who offered recommendations in this evaluation of Medicaid Managed Care programs talked about the difficulty that consumers experience when trying to access needed services. It is the social worker’s responsibility to keep abreast of all Medicaid services available to consumers and the standards required for delivery of the services. We should be willing to search out and assist our clients with accessing the services they need.