Missouri lawmakers began to put their own Medicaid plans on the table this week as a House committee continued to churn through witnesses testifying on the state's current program and areas of possible reform.
During two days of hearings, Tuesday evening and all day Wednesday, the committee discussed ways to involve beneficiaries more directly in their health care decisions as well as the pros and cons of expanding managed care plans, which put private companies in charge of developing a network of providers to serve the Medicaid population. The state pays the managed care company, which is responsible for reimbursing providers.
Republican Reps. Chris Molendorp of Belton, Keith Frederick of Rolla and Sue Allen of Town and Country, all testified as they presented their own ideas and plans for reforming Medicaid. Committee Chair Jay Barnes, R-Jefferson City, also shared more specifics of his plan.
Molendorp talked about blunting the cost curve by providing incentives that promoted good personal health maintenance. He mentioned group insurance plans that offer gym memberships or access to a
wellness coach. He pointed to the incentive of charging copays for regular doctor's visits but none for visits to the emergency room and said he would like to see that flipped.
He said he also wanted to include "wrap-around services," which help cover nontraditional services such as transportation and day care that make it possible for patients to receive other types of care.
"If we are going to offer someone dialysis, if we don't offer wrap-around, it does not mean that much," Molendorp said. "It's not relevant because they cannot get to the dialysis clinic."
Frederick, who is an orthopedic surgeon, said he wants a pilot program that shifts a portion of current Medicaid recipients onto health savings account plans. Each participant would have an account that the state paid into each year from which they could pay for health care services. At the end of the year, if any money was left in the account, part of the remainder would rollover or go back to the state, but the Medicaid participant would also share in a cut of the savings.
"At every point, the patient is considering the cost-benefit analysis of treatments being offered," Frederick said of his plan. "Let's restore that relationship between providers of services and consumer of services at each point along the way of care."
Rep. Chris Kelly, D-Columbia, challenged Frederick's plan, arguing it would only work if the federal government implemented significant changes to the new health care law, a point Frederick conceded.
"Your proposal is intellectually interesting, but it requires the Congress of the U.S. to revisit and change the Affordable Care Act in a fundamental way ... and we've seen no appetite in the Congress for changing anything," Kelly said.
Barnes includes a smaller health savings account in his plan but focuses primarily on providing a menu of plans from which beneficiaries could choose. The plans would be part of an expanded managed care program.
He said there might be a short window of time when the state could receive a waiver from the federal government for an experimental plan because he sensed some "desperation" on the part of the administration for getting states to expand.
"It would be a huge mistake to miss that window of opportunity for being a real laboratory of democracy and come up with a Medicaid program that actually saves money," Barnes said. "(There is) a short window of time when states are going to be really free to do what they want."
But not all Republicans are as interested as Barnes in seeking a federal waiver, which would depend on the state expanding eligibility to 138 percent of the federal poverty line. Allen, Frederick and others said it is folly to expand a program that is not working as well as it should. They also argued that increased Medicaid funding would add to the nation's debt and be passed on to future generations.
"Rather than spending millions of dollars to give free medical care to able-bodied adults, first of all we should provide care to those who need the resources the most," Allen said. "They are currently underserved with the existing Medicaid coverage that we have."
Managed care
Under the current Medicaid system, more than 50 counties are a part of managed care plans. The plans cover children, parents and pregnant women - a total of more than 400,000 Medicaid beneficiaries across the state.
The state contracts with managed care companies, setting parameters for specific outcomes of specific groups. The companies are responsible for developing a network of providers and defining when certain services are deemed medically necessary.
"Managed care is the vehicle that states are using to make the Medicaid programs better," said Vern Smith, a national consultant with more than 30 years of experience with Medicaid programs. "Medicaid has the market power to really make a difference in the standard of care across the state."
Barnes said the fundamental problem with current Medicaid is that the beneficiaries are not cognizant of the costs of their care because the state is acting as a third-party payer.
"The person who receives the services doesn't care about the cost and isn't the purchaser. ... No one is watching the store," Barnes said. "Managed care companies are watching the store."
Jo Anne Morrow, who works with Medicaid recipients as a legal aide, said she encounters the challenges of dealing with managed care plans on a daily basis. She told the committee about a recent experience helping a mother find a pediatrician for her son who had just broken his arm. Morrow said they found a list of 38 pediatricians on the plan's website. But after calling the numbers, only two were actually pediatricians who could treat her son. The other numbers included billing offices or doctors who only treated infants.
"What we find with the list of providers is it doesn't necessarily get a child to a doctor," Morrow said.
As the Wednesday hearing dragged well past 4 p.m. Wednesday, a queue of mental health counselors and psychiatrists waited to address the committee. They said they have had difficulty dealing with the state managed care providers and asked that mental health services be carved out of any expanded managed care system.
"We turn away children every day because they are in a managed care area and their symptoms aren't covered for inpatient treatment," Elizabeth Mendenhall, the director of clinical services at Lakeland Behavioral Health System in Springfield, said.