It is often called the safety net.
For 47-year-old Coy Olsen of Reno, however, the conflict between Medicaid’s managed care programs and local healthcare providers is causing patients such as herself to fall through its torn seams.
As someone who suffers from several health conditions such as sleep apnea and chronic back issues, Olsen requires ongoing care. That care was placed in doubt, however, after she received a letter from her medical provider.
Last week, Saint Mary’s Health Network informed Olsen that it will stop accepting her Medicaid coverage through Health Plan of Nevada on July 18. It’s a decision that will impact 37,000 Health Plan of Nevada members on Medicaid in Northern Nevada. Saint Mary’s cited a failure by Health Plan of Nevada to uphold contract terms. The care provider is also dropping Amerigroup’s Medicaid managed care plan, citing the same reasons.
The news felt like a punch to the gut for Olsen. Olsen says she has a great relationship with her Saint Mary’s physician — a doctor she credits for preventing serious damage to her heart by diagnosing a critical health issue at an early stage.
“I love her, she’s a great doctor,” Olsen said. “She literally saved my life.”
Just as devastating for Olsen is the notion of playing the familiar and frustrating game of medical roulette once again. With Saint Mary’s dropping her plan, Olsen is desperately looking for a new doctor.
This isn’t the first time this has happened to Olsen. She fears it won’t be the last.
Through the years, Olsen has found herself searching for new physicians as more and more healthcare providers stop accepting Medicaid managed care plans. Each time, the search for a new physician gets tougher and tougher. One big reason is the ever narrowing pool of places to go. Renown Health, for example, does not take Olsen’s Medicaid insurance from Health Plan of Nevada except for obstetrics and pediatric care.
For some of the places that take her plan, there can be limits to the type of service or care she can receive. As someone who requires opioids to treat her pain, Olsen’s options for acquiring a prescription pain medication are limited to certain primary care providers. The recent investigation by authorities of an alleged prescription painkiller drug ring in Reno combined with the arrest of local physician Dr. Robert Rand also cast a spotlight on opioids.
Olsen, however, says the Medicaid coverage issues are worse for patients than the recent Reno drug bust.
“They made a big deal of Dr. Rand’s office being shut down but that’s just one doctor,” Olsen said. “(Deciding to stop accepting Medicaid plans) is like having 30 doctors shut down and then some for the patients who are affected.”
A huge access problem
The problems involving Medicaid managed care coverage could not have come at a worse time.
In 2013, Nevada had about 323,000 residents on Medicaid. Fast forward to the present and that number has ballooned to more than 600,000.
A big reason is the one-two punch from an increasing population and the implementation of the Affordable Care Act. Also known as “Obamacare,” the ACA expanded eligibility for Medicaid to a large number of people, granting coverage to many Nevadans in need but also adding new patients to an already strained healthcare system
“Our Medicaid population doubled but our provider population did not,” said Marta Jensen, acting administrator of the Nevada Department of Health and Human Services’ health care financing and policy division. “Everybody’s struggling with access at this point — it’s a nationwide problem.”
Saint Mary’s echoed Jensen’s assessment about the scope of the Medicaid issue.
“Saint Mary’s understands that Medicaid patients statewide are challenged with access to open networks and therefore, have limited provider options through their health plans,” said spokeswoman Jamii Uboldi. “As a local provider, this issue reaches beyond our region and state, and we support a collaborative approach to ensuring Medicaid patients in Nevada can access care.”
The decision by Saint Mary’s came as a surprise to Health Plan of Nevada. Health Plan of Nevada just renewed its contract with saint Mary’s parent company Prime Healthcare in March, a contract that was supposed to run through 2019.
“As far as we’re concerned, (Health Plan of Nevada) has a contract with Prime Health,” said HPN spokesman Trevor Hayes. “We’re taking all the steps we can to ensure that Prime and Saint Mary’s fulfills its contractual commitment.”
If Saint Mary’s goes ahead with its plans to drop Health Plan of Nevada and Amerigroup’s Medicaid managed care programs, it would further curtail already limited options for patients. Renown still accepts Amerigroup’s Medicaid plan but provides limited services for Health Plan of Nevada’s Medicaid program. This would leave Northern Nevada Medical Center as the only major hospital in Reno-Sparks that fully accepts both managed care Medicaid plans.
One thing state and health officials stressed is that the issue at hand only affects the managed care portion of Medicaid delivered through entities such as Health Plan of Nevada and Amerigroup. It does not affect the traditional fee-for-service or “straight” Medicaid coverage typically used to cover populations such as the elderly and disabled. The issue is also limited to outpatient services and does not impact inpatient hospital service or emergency room visits.
Just like Renown provides exceptions for accepting obstetrics and pediatric patients for Health Plan of Nevada’s managed care Medicaid program, Saint Mary’s says it will continue to accept the managed care plans for disciplines such as oncology and obstetrics. Reno’s two federally qualified health centers, Northern Nevada HOPES and Community Health Alliance, will continue to accept both Medicaid managed care plans as well.
For patients such as Olsen who are not covered by fee-for-service Medicaid or don’t fall under the exceptions, however, the decision by key primary care providers to drop their plans is a serious problem.
Although Northern Nevada HOPES and Community Health Alliance offer a range of services , Olsen says the centers can’t prescribe her opioids. Olsen tried to get into the Family Medicine Center at the University of Nevada, Reno but wait times for new patients are at three months and her current supply of pain medications would be long gone by then, she said. Olsen also offered to pay in cash to get service from three doctors’ offices that did not take her Medicaid plan. All three refused to take her cash payment, saying it could be seen as fraud since she was a Medicaid patient.
“I have no way now to get my prescriptions come end of July,” Olsen said. “I have nowhere else to go.”
Playing hardball
At the governor’s office, there’s serious concern about picking up the patient load should Saint Mary’s decide to get out of the Medicaid managed care market, said Mike Willden, chief of staff to Gov. Brian Sandoval.
For the last two months, Sandoval’s office has been in constant communication with Saint Mary’s as well as Renown to come up with potential solutions to the Medicaid managed care crisis. So far, the issue is proving to be a bigger problem in Northern Nevada. Reno-Sparks, for example, only has three major hospitals.
“It hasn’t risen to the governor’s office as an issue in the south and that’s probably because they have 24 hospitals so (the problem) isn’t as confined,” Willden said. “They can spread the Medicaid load much wider in Las Vegas.”
Saint Mary’s and Renown gave different reasons for their current situation with Medicaid managed care organizations.
Renown says it is working on better options for patients impacted by healthcare access problems, including Medicaid patients. During an event on Tuesday announcing a new partnership for high-level care between Renown and several Stanford University entities, Renown president and CEO Tony Slonim told the Reno Gazette-Journal that a new approach should also be considered for improving the Medicaid managed care system.
“This is about figuring out who our patients are and creating innovative solutions for them,” Slonim said. “We believe we have partners with local, county and state government and we’re working aggressively with those partners to ensure we’re providing healthcare to all of Northern Nevada that’s better and drives innovation.”
Saint Mary’s did not specifically cite what contract terms were allegedly broken by Health Plan of Nevada and Amerigroup in its response to the Reno Gazette-Journal. The governor’s office, however, indicated that the issues involved late payment, underpayment and lack of payment.
The claims led to an analysis by the state of Medicaid data but it found no conclusive evidence concerning issues with the Medicaid fee schedule and payments, Willden said. This includes cases where Medicaid denied payment for services rendered, with the denial rate at less than 5 percent, according to Willden. Whether Medicaid pays a high enough amount, however, is a different question.
“Can hospitals say that Medicaid is not their best paying source?” Willden said. “That’s a true statement … but user denial rates are very, very low.”
To help address complaints about Medicaid paying less than other insurance, Willden says the governor’s office regularly picks two or three specialties each legislative session and try to get them pay raises. As far as potential issues with Medicaid managed care in general, however, the state can’t identify one single problem that it can consider “absolutely broken,” Willden said.
Health Plan of Nevada, meanwhile, says it is still trying to make sense of Saint Mary’s decision. Just last week, it agreed to enter into mediated negotiations with Prime Healthcare to resolve any alleged issues although mediation has yet to start.
“Saint Mary’s should not be putting members in the middle and creating confusion about where they can receive care,” Health Plan of Nevada’s Hayes said. “They remain a contracted facility in the HPN Medicaid network until otherwise noted and we hope the hospital will continue to support the state Medicaid program.”
The state is also hopeful that a solution can be reached before July 18. Ultimately, however, this is a contract negotiation between different parties and there’s a limit to what the state can do, according to Willden.
“We have the power to bring people together to talk and help them through the process,” Willden said. “The ultimate solution is between the hospitals and their contractual relationship with (Health Plan of Nevada and Amerigroup).”
In addition to continuing negotiations, both impacted managed care organizations are also looking at potential solutions should they fail to come to an agreement with Saint Mary’s.
“Amerigroup Nevada hopes to come to a quick resolution with Saint Mary’s to ensure that there aren’t any gaps in care for our Medicaid members in Washoe County,” said spokeswoman Olga Gallardo. “We are putting alternative solutions in place and are actively working with our members to ensure that they have access to health care services.”
For those caught in the middle the Medicaid issue is a source of much stress and anguish. Olsen says it’s ironic that she can actually get the prescriptions she needs by telling providers she does not have insurance and just paying with cash. Olsen, however, says she shouldn’t have to lie to get the care that she needs.
“Why?” a tearful Olsen said. “I don’t understand, I just don’t get it.
“I live on the edge anyway but this just rocks my world.”
MEDICAID INFORMATION: For assistance or questions regarding Medicaid, contact the Reno Medicaid District Office at 775-687-1900.