By Clarissa Donnelly-DeRoven
North Carolina’s transition to managed care hasn’t yet proved to be the disaster some feared, nor the panacea others hoped for, according to a new survey from the coalition North Carolina for Better Medicaid. The organization includes two managed care organizations — Healthy Blue and Unitedhealthcare — in addition to community groups, such as the YMCA and Mountain Projects, a community development non-profit that focuses on the western part of the state.
The coalition worked with Health Management Associations, a national health care research and consulting firm, to design and implement the evaluation.
“It’s early days,” said Kathleen Nolan, the regional vice president at HMA who authored the survey. “We wanted to be able to identify progress and places that still needed some work.”
Through interviews with five case managers, one patient advocate, and coalition members — along with a review of public data — the survey found care management teams to be one of the most promising features of the managed care system.
Care management teams
North Carolina’s managed care contracts require that the health plans offer a wide range of services designed to deal with social determinants of health — the non-medical drivers such as access to transportation, housing, nutritious food and other social factors that impact a person’s ability to be healthy. Some options include covering food boxes, in-home therapy for children with substance use disorder, and providing cell phones to help people stay in touch with providers.
It is the job of care managers to tell people they are entitled to these things if they need them and help people obtain them.
While it varies among the managed care organizations (MCOs) that have won contracts with the state, care management teams typically consist of nurses, mental health providers, community health workers and social workers. Their job is to connect with people on the plans who have complex needs and help them access the care — physical, mental and social — they need.
Sometimes care managers reach out based on a person’s diagnosis, other times the plan might notice somebody is going to the doctor over and over, or receive word that they were recently discharged from a stay in the hospital, Nolan explained.
“The health plan will look at that and say, ‘Something’s going on here, so let’s get a case manager on it,’’’ Nolan said. Not everybody on a managed care plan will have a care manager, “but there’s lots of ways that someone can indicate that it might be a good idea for them.”
A care manager from Healthy Blue, whose story is featured in the report, explained that she spoke with a mother who had a child with a swallowing disorder. She was distressed because she couldn’t afford to buy a powder called Thick-It, used to make it safer for people such as her son to swallow without fluid going into his lungs.
“She was quite upset and distressed [and] worried about not being able to purchase this for her son,” the care manager said. “I was able to work with the speech therapist to get her samples until I could coordinate with the provider to get an order sent to the medical supply company.”
Sherée Vodicka, the CEO of the North Carolina Alliance of YMCAs — and a member of the coalition — said she thinks the focus on social determinants of health is one of the most beneficial aspects of the transition.
“There’s such huge potential to serve populations, families that we’ve had less opportunity to serve in the past,” she said. “It just takes people a while to kind of figure out how best to take advantage of the things that have been offered to them, especially when they’re so unusual compared to what normal insurance offers, right?
“I mean who would know that you could call your insurance company and get help with housing, or food, or violence protection?”
While the transition has so far fulfilled its promises around these non-medical health services, it’s possible those achievements could be overshadowed by some of the new administrative burdens of the system, as NC Health News has previously reported.
“Providers are near uniformly having issues with claim denials due to missing taxonomy codes and billing codes,” the report said. “Because the system has shifted from one system to five individual plans, providers are looking to DHHS and plans to create standardized processes and common forms to continue to reduce burden for provider practices.”
Lakajai Harris, a speech language pathologist in rural Beaufort County, said that’s certainly the case for her.
“As a one person company, it’s been a nightmare,” she said. She’s been struggling to get paid.
“I’ve had a few clients whereby [the MCO] reimburses me $0 because they claim that I submitted a claim for $0,” she said. “I tried to do an appeal. Well, it took them seven days to uphold the appeal, so now I have to submit — in writing — another appeal, and that [process] can take up to 30 days.”
Harris also recently went through her claim submissions to figure out which hadn’t been paid yet by the MCOs. She found a handful from September and October that she needed to resubmit, but when she tried she discovered that the MCOs have different claim resubmission guidelines: 120 days for one, 60 days for another.
“Medicaid gave us 365 days,” she said. “Now I’m not able to get reimbursed for some of those claims.”
In the former state-managed Medicaid system, what some are calling Medicaid Direct, she knew that every Wednesday she’d get paid straight into her bank account. Now, checks come seemingly at random — Harris also hasn’t been able to set up direct deposit with two of the four MCOs she contracts with. She said she’ll submit multiple claims on the same day, for one check related to one claim to show up in her mailbox weeks later.
“I work basically from eight o’clock through 5:30. I have clients back to back with maybe just a little bit of travel time. To try to figure out, where are these checks? Why haven’t I received them yet?” she said. “I don’t have time for that.”
The survey also reported that nearly 7,500 people who were supposed to stay on Medicaid Direct were incorrectly switched to a managed care plan, which then required them to navigate the process of moving back, even as many of these people had mental health issues they were also navigating (NC Health News has also reported on this issue.).
Also discussed in the analysis are the particular issues rural people, who already experience provider shortages, have faced in the transition. Many worried about choosing a plan for fear that their doctors wouldn’t be in-network and they’d lose access to care. There were also poor translations — especially in Spanish — of official documents from the state Department of Health and Human Services related to the transition, potentially leading to care disruptions for non-native English speakers.
Nothing “too problematic”
Still, Nolan said these problems are not out of the ordinary during the transition phase.
“I’ve been in the Medicaid space for a long time,” she said. “The idea that we can get to social determinants of health, that we can improve access, that we can do well with integrating care, those are based on experience, not just hope. We’ve certainly seen that work. It is a complex endeavor, and it requires that states and health plans really work together.”
The success of the managed care transition and its focus on improving access to non-medical health services will be analyzed on a population, rather than an individual, level.
“The reason for that is because if you look at it at a population level, then what you’re looking at is the system,” Nolan said. “When you look at a population level, you’re getting at, is the system not giving enough access, such that no one is succeeding in recovery?”
Only time will tell.