March 7, 2012

Inhumanity of mismanaged care

Even Gov. Steve Beshear’s critics concede that he’s good at managing natural disasters — such as last Friday’s twisters. He’s had more than his fair share.

He’s been less adept at managing a bureaucratic disaster that began last November, when the state implemented managed care for 560,000 Medicaid recipients beyond the Jefferson County region.

We thought we’d heard the worst horror stories imaginable — from belatedly paid providers, mistreated patients and agitated advocates — until last Wednesday. That’s when Senate Health and Welfare Committee hearings on the managed-care mess climaxed with the testimony of two Lexington psychiatrists whose clients include children and adolescents who’ve been abused and exposed to domestic violence, and who struggle not to injure themselves or others.

They were duly exasperated. “The biggest and most egregious issue,” said Dr. Vince Blanch, “is that these children — who’ve been stable on medications for long periods of time — are not getting the medications they need to remain stable.”

Providers spend precious time applying for medications that often are denied. “I can accept that,” Blanch said, “because then I can call and speak to someone directly and try to argue this, which takes another 20 to 30 minutes per patient.” That’s if he’s lucky. Routinely, there’s no timely reply. Families “assume everything’s OK, and then they go to the pharmacy and they’re disappointed.”

Dr. Fred Kinnicutt interjected that physicians are contractually prohibited from disparaging managed care organizations, “but every time an MCO (falsely) tells a family that I have not … filled out a form, that’s disparaging.”

Blanch agreed: “Your MCO tells you one thing, your physician tells you another, and your children are suffering in the meantime.” The confusion and frustration undermines the trust vital to the doctor-patient relationship. “Parents normally will pull these children from treatment — even if they’re doing well — if there are breaks in treatment,” Blanch added.

It further complicates matters that folks on Medicaid — a program that serves the indigent, elderly and disabled — are ill equipped to battle, much less beat, the bureaucracy. “They don’t receive information that is clear, concise and easy to follow,” Blanch testified. “All of these issues lead to delay of treatment, less effective treatment and more expensive treatment.”

But it gets worse. One MCO, WellCare of Kentucky, has blocked access to an entire class of medication — anti-psychotics — often “used to treat schizophrenia, bipolar-affective disorder and also, significantly, for excessive, extreme physical aggression,” according to Blanch.

Mike Ridenour of WellCare replied, “I just got told by our folks that nothing is not available through appeal.”

But time is of the essence, Blanch rebutted. “Children who are stabilized on these medications will not last” and some will get “involved with the juvenile justice system because of issues of aggression or anger.”

Dr. Kinnicutt quoted a Jan. 16 letter from MCO Kentucky Spirit pledging that, as of Feb. 1, a waiver would be granted through the end of the year for “all behavioral health medications currently being prescribed.”

“It’s Feb. 29, and it still hasn’t happened,” Kinnicutt said. “I’m filling out multiple authorizations for my kids.”

A representative of Kentucky Spirit asked for specifics about the patients in question, saying he would follow up on those cases. Sen. Julie Denton, R-36, who chairs the committee, had heard enough. “As you address the specific case, make the global fix so that we don’t keep having to come back” to help kids who are “falling through the cracks.”

Then Kelly Gunning, spitfire of the National Alliance on Mental Illness, testified, “This is happening with adults also. It’s unacceptable.

“We have taken the doctor-patient relationship and we have farmed it out to a third party that has no vested interest (in these) very fragile individuals. A prior authorization that takes two or three days can be the difference between two and three years for a son or a child getting back into the system of care ... The public defenders can tell you where these people are showing up — and I damn guarantee you, it’s not the hospital.”

She exhorted the panel to “trust our physicians to do their job and please help us, as parents and citizens, do our job” by exempting behavioral health from managed care. A vulnerable population remains at risk. Governor, for the sake of common decency, public health and safety, clean up this mess. 

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