[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.

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