congressional_record: CREC-1994-12-20-pt1-PgE
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| CREC-1994-12-20-pt1-PgE | 1994-12-20 | 103 | 2 | E X T E N S I O N O F R E M A R K S | HOUSE | EXTENSIONS | FRONTMATTER | E | E | [{"name": "Fortney Pete Stark", "role": "speaking"}] | 140 Cong. Rec. E | Congressional Record, Volume 140 Issue 150 (Tuesday, December 20, 1994) [Congressional Record Volume 140, Number 150 (Tuesday, December 20, 1994)] [Extensions of Remarks] [Page E] From the Congressional Record Online through the Government Printing Office [www.gpo.gov] [Congressional Record: December 20, 1994] From the Congressional Record Online via GPO Access [wais.access.gpo.gov] E X T E N S I O N O F R E M A R K S MANAGED CARE IN THE DISTRICT OF COLUMBIA: IT MAY BE DANGEROUS TO YOUR HEALTH ______ HON. FORTNEY PETE STARK of california in the house of representatives Tuesday, December 20, 1994 Mr. STARK. Mr. Speaker, in an effort to control Medicaid costs and to use the savings to expand coverage to additional uninsured residents, the Department of Health and Human Services has been granting Medicaid waivers to some States to experiment with various managed care systems. The people being ``experimented'' on are poor people, people who have historically been unable to obtain adequate, dependable, quality health care. One of the waivers which has been granted is to the District of Columbia. Following are some memos I've received from the House District of Columbia Committee Staff members indicating some severe problems with HHS's oversight of and the District government's operation of the D.C. program. It is imperative that HHS give more attention to the operation of the District's program. The new leadership in the District government must take steps to improve the program and to ensure that private contractors are providing quality care to this vulnerable population. The managed care problems in the District of Columbia are also occurring in other jurisdictions. HHS's entire ``waiver'' program needs strong congressional oversight in the 104th Congress. November 7, 1994. To: Pete Stark From: Staff Re: D.C. Medicaid Managed Care Over the last few days I've talked to HCFA, several providers, community groups, and others about the District's new mandatory Medicaid managed care program. There appear to be several serious problems. Five major problems include: 1. Recipients do not know they've been moved into managed care, how it works or that they've been assigned to an HMO. The District's procedures for informing recipients about the managed care program and getting them transferred in are inadequate. The three hospital outpatient clinics I've talked to estimate that 70-80 percent of their patients show up to get care and have no knowledge of the program, or of any choice they were supposed to make about doctors. The District's own data indicates that less that 25 percent of all beneficiaries choose a doctor during the 10-day choice period, while the other 75 percent (a large majority of whom later attempt to change) are assigned one. There are a number of practices that appear to contribute to the problem: letters sent to recipients explaining the program and what the recipient needs to do are unintelligible (I have read them, and without great effort cannot make them out), and are not accompanied by any other efforts to educate recipients about the program; the letters provide misleading and incomplete information; there is no follow up when a letter comes backs indicating an address change, etc; the 10-day ``choice period'' is horribly inadequate and by the time recipients actually get the letter, translates to a 2-3 day choice period; recipients are not being contacted within the required 30-day time frame by the HMO/doctor to whom they've been assigned; and according to counsel for a class action suit being brought against the District\1\ provider lists are not even being sent to many recipients (they should be sent to recipients along with the letter informing them they have 10 days to choose). --------------------------------------------------------------------------- \1\The suit includes six claims--all relating to problems in the District's overall Medicaid eligibility determination process. --------------------------------------------------------------------------- 2. Recipients have great difficulty disenrolling from a plan once they've been assigned to it, or believe they cannot disenroll (recipients should be able to disenroll at any time, without cause, by simply calling the program's ``HelpLine''--the central number that handles all enrollment, disenrollment, eligibility verification, and payment issues). Because such a small percentage of recipients actually select a doctor during the 10 day period they are given to make a selection, this problem affects the large majority of beneficiaries. The problem is apparently caused by a combination of factors: inability to get through to the ``Helpline'' (in a test of the system last Friday, I was on hold for 1 hour and 15 minutes before I hung up); incorrect information given by ``Helpline'' staff to recipients about their ability to change and about what they must do in order to change (a number of recipients have been told they must first call their HMO and discuss with them their reasons for wanting to disenroll); misleading information in letters that implies that recipients are not allowed to disenroll beyond a certain date; and slow processing of disenrollment requests (by law, all disenrollments must be processed within 60 days; many recipients, however, have seen waits of 4-5 months). Although the problem has apparently improved somewhat since a private company called First Health temporarily took over the Helpline, there is concern the problem will continue once the District takes back this responsibility. 3. Recipients have difficulty or are unable to get referrals for needed care. This problem has been particularly evident for pregnant women transferred into the program. It occurs when a patient shows up to see their old doctor and finds out she is now in managed care and has been assigned a new doctor. The recipient wants to keep her old doctor and needs treatment then. In order to get treatment at that time from her previous doctor/clinic, the patient is told--despite internal policy that allows the Helpline staff to approve referrals automatically for pregnant women--that she must first get a signed referral from the new primary care provider. Frequently, the new doctor/HMO refuses to provide the referrals, the patient is unable to get in touch with him/her, or it takes several weeks to get the referral. Apart from the issues of disruption is care and choice, the referral problem is exacerbated by the fact that many pregnant women get assigned to pediatricians, interns, and other doctors who don't even do prenatal care, but are classified under the system as ``primary care providers''. Providence hospital has provided us documentation of 35-40 cases they had in a two week period involving pregnant women receiving prenatal care through their outpatient OB-GYN clinic (many of whom were in their last two weeks of pregnancy when they were shifted into managed care) who were unable to get referrals. Although I don't have documentation of this yet, Prudential is apparently going so far as to (illegally) tell their Medicaid members that they--as a rule--can only refer them to providers within their network. 4. Families are being split up under the program such that family members are being assigned to different HMO's or primary care providers. As far as I can tell, this is caused by the District's ``automatic computerized enrollment'' process that currently can only group and assign recipients on the basis of last name. 5. Medicaid recipients enrolled in certain HMO's appear to have access to only a very limited number of the doctors available to non-Medicaid enrollees in the HMOs. I do not yet have documentation of this, but if it is in fact occurring, such a practice would raise serious questions about access and quality of care, and potential questions about violation of current law. ____ November 10, 1994. To: Pete Stark From: Staff Re: D.C. Medicaid Managed Care: HMO Provider Networks Since my last memo I've received a list of the primary care providers in the Prudential and George Washington HMO's, as well as a list of the providers available to Medicaid members enrolled in these HMO's. In both cases, Medicaid members have access to only a small fraction of the network providers available to non-Medicaid members. In addition to dramatically reducing the total number of primary care doctors available to Medicaid recipients--both in terms of the number that would otherwise be available under the District's managed care program, and in terms of the number that were available prior to managed care--the practice of limiting Medicaid enrollees to a subset of an HMO's providers appears to be prohibited under current law. Information on the Prudential and George Washington networks, as well as a summary of current law and regulation affecting Medicaid member's access to HMO provider networks follows. prudential and george washington networks A comparison of the Prudential plans shows that: (a) While the company's complete HMO network (known as the Prudential HMO of the Mid-Atlantic) consists of 836 primary care providers, its current provider network for Medicaid members consists of 41 primary care providers. (b) 426 of the network's 836 providers are within Prudential's own definition of the Washington DC Metro/ Western Maryland Area (and are thus reasonably accessible, in terms of travel time, to District Medicaid recipients). (c) Of the 42 providers listed in Pru's general HMO network within the District itself, 20 are not available to Medicaid enrollees (making any argument that the network was defined by what Providers are most accessible to District beneficiaries moot). (d) And, perhaps most important, 22 of the providers in the provider network open to Medicaid members are not in Prudential's general HMO network. (suggesting potential serious quality of care/credentialing differences that should be examined) A comparison of the George Washington plans shows that: (a) While the CWU HMO allows its non-Medicaid members to choose between two general delivery options--they can choose to receive care through either a network of participating private practice physicians or through one of six Health Care through a Health Care Center. (b) Of the six Health Care Centers available to non- Medicaid members, five are not available to Medicaid members. Medicaid enrollees are limited to receiving care through only one of these six Centers and through one additional Center which is not availiable to GWU's non-Medicaid members. (c) While the GWU HMO consists of more than 540 primary care doctors, a total of only 44 doctors are available to Medicaid members. (d) Of the 540 doctors in GWU's network, however 135 are within the District itself (again, making any argument that the network has been defined to include those doctors most accessible to Medicaid recipients moot) Statutory and Regulatory Requirements for HMO Medicaid Provider Networks 1. Although there are no District (or federal) laws that specifically address whether panels one companies' various plans must be open, there are two District regulations (both included in the District's ``Regulations for Managed Care Providers that serve AFDC and AFDC-related Medicaid Recipients'') that define requirements for access to providers and integration of Medicaid members into HMO health plans. 41 DCR 1766 (2307.5) states that ``each AFDC and AFDC- related Medicaid recipient enrolled in a pre-paid, capitated provider's plan shall receive service through the same health care providers and facilities that serve non-AFDC and AFDC- related Medicaid enrollees.'' 41 DCR 1766 (2307.6) states that ``each AFDC and AFDC- related Medicaid enrollee shall be fully integrated into the prepaid, capitated provider's plan membership and shall not be treated in a manner different from non--AFDC or AFDC- related Medicaid enrollees.'' 2. Although there are no federal statutory or regulatory requirements that specifically address what providers Medicaid and non-Medicaid members must have access to, there are two federal rules that addresses the scope of beneficiaries' access to providers. One focuses on Medicaid members' freedom of choice within an HMO, and another focusses on equality in access. 42 CFR 434.14 states that ``the HMO must * * * make the services it provides to its Medicaid enrollees as accessible to them (in terms of timeliness, amount, duration, and scope) as those services are to nonenrolled Medicaid recipients within the area served by the HMO.'' 42 CFR 434.29 states that ``the contract [between the state and HMO] must allow each enrolled recipient to choose his or her health provider in the HMO to the extent possible and appropriate.'' According to HCFA, this rule is designed to ensure benficiaries' ability (a) to choose--versus be assigned to--providers within an HMO's network, and (b) to select from among all providers within a HMO that are accepting new patients. ____________________ |