Its a program for lowincome and disadvantaged people. It covers children, the elderly, the handicapped and so on. I was born with a rare medical syndrome, and im going to need those services because my syndromes not going to go away and its not going to be healed, so i really want to learn more about this topic. I hope you do, too, because on april 1st, iowa joined 39 other states and the district of columbia by switching from a gov delivering Healthcare Services to more than half a million. I think its 580,000 iowans to private management care. Thats called an mco, and well learn more about that in a minute. Governor branstads plan and its implementatio n was said by many newspapers and different advocates to be a very aggressive plan and happening rapidly compared to some of the other branstad said in his first report on it that it was going smoothly and that he hoped things would continue to run smoothly while we saved taxpayers money, which is a great idea. However, a majority of iowans in medicaid seem to disagree with that view including some legislators. Were hearing good reports, and were hearing not so good reports. Them are covered, their voices arent really heard according to what ive read. The Des Moines Register said this, and i quote, that the governor dismissed public opposition, disregarded concerns raised by essentially everyone, ignored problems in other states and moved forward with his plan. Now his constituents are paying the price, end quote. That doesnt tell me much about whats happening. We have us more of whats happening in our own community. What does medicaid and mco look like in our county, in our towns . To explore this question, id like to introduce you to our panelists. Seated next to me is sofia mehaffey, director of Community Health and nutrition programs at horizons. Welcome sofia. Sofia thank you. Martha good to have you here. Next to sofia is tim charles, of Mercy Medical center. Tim, im glad youre a part of our panel, too. Tim good to be here. Martha nice to have you. To round out our panel is advocate and medicaid beneficiary herself, rhonda shouse. Ive hoped i said that correctly. Rhonda yeah. Thank you. Martha lets get on the same page. Theres so many terms being bantered about and so many misconception s when we talk about government plans and describe what medicaid is and whats happening when they say the word privatization and mco . Tim, youre the ceo, lets start with you. Tim sure. Martha explain some of those terms to us, please. Tim very simply, what a mco is is a managed care organization. Its a private insurance product or offering thats designed, in this case, for the medicaid population. Its intended to provide services as is designed within mentioned, its also intended to result in another objective, which is the objective of the state, and thats to save a substantial amount of money. Martha thats always good when i hear my taxes are being saved, but im curious when i hear that the programs may not be working when they went to privatization. Rhonda, do you know what that is privatization compared to what it was in the past . Youve difference is that it was Feefor Service before. Youd go into the doctor and the doctors office, from my understandin g, they would get paid for treating you for that service. Now, managed Care Organizations are providing money to the providers, and its not done on a Feefor Service basis. The one thing that i really want to point out about this and how iowa differs from a lot of the other states is iowa has included their disabled population in managed care, which a lot of other states have not. Rhonda correct. Martha its existing now with the changes. Rhonda correct, with the new program. About 20 of the medicaid population in iowa from the latest figures according to dhs is a disabled population. Yet the majority of the cost is from this population, so the cost savings is going to be a balance because. For instance, i have friends who are quadriplegics. Thats not something thats going to get better by being theres a lot of concerns about the way its being managed. Martha is a goal of managed care to heal and then to dismiss . Im not understanding when you say thats not going to be covered. Tim i think its important to put this into context. Martha sure. Tim there are three different layers to this in my mind. The first is that we have a National Initiative underway. Its the Affordable Care act. By design, the intenti care act was to expand the access that individuals had to some form of insured service. In the state of iowa when the decision was made to expand medicaid, it literally tripled the number of individuals who become eligible for that resource. Prior to that, many of these individuals might to go to the free clinic for their care. Some of service. The question thats at hand is how will this approach of using private insurance organizations to manage the overall implementatio n of the plan in iowa, how will that play out . That has impacts for organizations, such as mercy. It certainly has impacts for organizations such as horizon. But it also has a very, very human impact. Part of the reason im here ton i think, sofia, that you might align with what tims saying about the human impact. You want to tell us a little bit about what you do and how this fits in with some of these defining examples weve heard so far . Sofia absolutely. Im director of Community Health and nutrition at horizons, which means that one of the programs i oversee is meals on wheels. Some of our meals on dollars. The human face on it is we have seniors in our community who are receiving meals using this funding. They need those meals. It has been written out for them by their physician saying that they need them, so when we are or not being funded properly, it has a huge impact on what were able to do for the people in our community. Martha sure. Have you seen a change in how thats funded or how thats possible to feed these meals on wheels clients . Sofia initially we had some challenges in terms of. We transition. Obviously, thats idealistic. Martha yeah, sure. Sofia it didnt turn out exactly how we had hoped, and we did have some hiccups along the way in terms of making sure that we were funded at the right reimbursemen t rates and making sure that we were funded in a timely manner. I know that for some smaller organizations its been a challenge to maintain the service in lieu of these funds that theyre waiting for and in limbo waiting for. Weve been able to sustain, but i know that its been a says their moneys not coming. Her paychecks arent equal to the hours shes put in, and shes having trouble feeding her family. Its trickling down, but its a major change and change is hard and takes transition. In the meantime, like you said, people have to be fed and medical has to be given, and its a to the disabled population, im part of that. I think why that in particular is concerning for me is the fact that the Chronic Health issues and the complexity of the Health Issues that this population has is some that cannot wait days or weeks for prior authorization s or for appeals to take place. Thats a real concern especially as were talking about payments beneficiary, does that mean providers are going to end up backing out of the program . Will i have less providers to go to . Thats a real fear for me. Martha or are the providers being spread more thin . I did some research for tonight. I went after cardiologists. I dont know why. That was early in the alphabet that popped up on the reports from the managed Care Organizations. Now this isnt always happening, but their basic leve there is one cardiologist within 90 miles of your home, thats basic standard service. Now most of them were 18 miles away or 15, so the reality didnt match. I was kind of surprised by that. Ninety miles away is acceptable for somebody who needs a cardiologist to get there. If theyre elderly or disabled or cant drive, everythings compounded. Tim i think that speaks to the complexity of the more urban experience particularly for a population that already is challenged by transportatio n issues. Martha Health Issues. Tim . Health issues, other socioeconomic issues. Just to reflect upon the concern with regard to providers and their continuing to serve patients in this population, unfortunately i can tell you that there are providers today that are beginning to close their doors to this population. Now, whats difficult organization such as mercy, which by virtue of its mission is committed to caring for the sick and improving the health of the community we serve and literally having within that a commitment to care for everyone who crosses our threshold, we are trying to understand what our role needs to be through this transition period, as well as to understand as it is today, actually becomes worse . What happens if one of these three players drops out . What happens if we discover. Martha one of the mcos, you mean . Tim . One of the mcos. Martha the three that are. Okay. Tim . Determines that they can no longer continue to incur the losses that theyre incurring today. Martha which is happening. Tim . Which is significant . They are, today theyre receiving for the care thats being delivered. How do we begin to design a system that actually does care for the individuals who are disabled but also takes care of this new and expanded population . Honestly, im beginning to focus more down the road in terms of two or three years out. How do we ensure that were in a expanded, better educated population that now understands how to access the resources . Martha its a real conundrum. I dont know how you even can count whats available to be provided as the population for the needs grow because one of the things that was documented this week is that the statistics say for iowa the number of doctors and Healthcare Providers and providers you see concerns in that area. Then they had documentatio n of one doctor was counted five times because he goes to five clinics, so thats not five doctors. That poor doctor is being spread thin by going to five clinics which might have funding problems to serve patients when he used to have one clinic, and hes the way that dhs has counted them. I know my doctor is through mercy physicians clinic or physicians network. I was told by my mco when i called to declare that doctor as my primary that that person practices closer to where i live than where i was going, and thats not accurate. When i got to doing research, they told me five different addresses this person practices. Martha we might have read the same program. Rhonda well, this was personal. Thi tried to convince me it was closer to me. Having individuals working outside the state of iowa when im calling pennsylvania and theyre trying to tell me something is closer to me than what it is or their offering me services in iowa city when i live in cedar rapids and dont have a car, we have issues. Martha how do we address some of these issues . How do we talk about feeding seniors that are nutritionally deficient and need meals such as youre offering and people are that are handicap such as you conversation s happening in iowa or in counties to get the Service Providers with those who are requiring services, the beneficiaries, the participants . Is there any crossconversation . Tim perhaps one of the unfortunate consequences of this transition is that those conversation s were underway. I can tell you that prior to the Hospital Community was working with the state collaborative ly to focus on taking advantage of the fact that we are traditionally a lowcost provider in the us, delivering very high quality care, and we were committed to continuing that process. What were all spending a great deal of time and energy now is trying to figure out how to administer our services through time, energy, and resources. Martha on implementatio n. Tim . On the implementatio n of it. Martha . Tim even though to your question, even while all of that is happening, we are taking steps to address the needs of this population. For example, we have a clinic that is immediately adjacent to the hospital that a wonderful physician of ours, monica meeker, is staffing. Shes caring for individuals who have no resources, individuals who have medicaid, individuals that have community from other countries that are just learning how to navigate our system. Its that kind of role that we think is necessary for us to take, but for this to work on an ongoing basis and to be sustained, we have to come together and do. Martha ive been with organizations that do a lot of work before theres change. They do excellent work and all change happens and the implementation, every implementation has snags, they dont do the followup after conversation s of work. Then they live on old behaviors that dont fit the new paradigm, and it doesnt work. It doesnt work, but, like you said, theres just so much time. How do people give feedback . Are you just filling out forms, or do you get to call . Do you have a role in the stake and providers or individuals give feedback . Sofia we have bn dont mean as a. Because i know you are really busy people. Sofia we have been talking with each of the mcos individual and trying to assess client needs, to fill this communication gap that were seeing with some of the mcos and throughout the process. I think that initially part of the benefit of switching to privatized managed care was supposed to be that it would provide the clients with the ability to choose who they worked provide was. As were seeing more and more providers needing to close their doors because theyre not getting funding or to have to turn away clients who are on medicaid, having been a previous beneficiary of medicaid, i can say that they were already doors that were closed to me. Now, with the implementatio n of the mcos as well and more doors being closed, what im seeing is less and less choice for those people. So we really need to communication gap in order to serve those clients the best that we can and remain solvent as organizations. Martha guys, i dont know how you all sleep at night whether you need benefits or youre providers of benefits because this seems like a tangled. Wheres it all heading . How do you plan for the future if youre a provider while trying as a person whos involved get . Tim ill speak to that. First of all, what we important level we have a system that is not affordable and not sustainable in and of itself. As a result of that we are in a position where we have to find alternative solutions to that. Because even for those who are fortunate enough to well insured, health care is becoming less and le be worked on in a significant way. Tere are many, many experiments that are going on across the country. Some are working. Some are not. I would claim that what iowa is involved in right now is one those experiments. Im very concerned that the experiment is not going to go well because of the human impact that it obviously is having. The thing we cant do is spend all of our time just arguing coming together and trying to devise what that future system is going to look like. There is that possibility, but those kinds of forms have yet to be initiated. Martha that kind of thinking encourages me and im excited to hear that, but i cant imagine all providers that are also trying to do their job while theyre trying to manage this. On the same hand, those who are recipients of services to be able to have Adequate Health care or have your needs met while youre trying to figure out how to get through the system, too. Rhonda as a beneficiary. Martha its coming from both ends, isnt it . Rhonda . Theres an is a potential medical need. For me to look forward and to see what this program will look like in two years is almost impossible to do because im having to worry about my Health Issues for this week and next week or next month, so thats the real human impact. I think its important to point out that, for me, as far as feedback, the mcos do have appeals process and grievance processes. Again, those take time, and those of us with complex Health Issues, we dont nec true, too, that i heard that the three mcos plus the state of iowa have hired people just to take concerns and complaints and appeals, so theyve developed a new whole level to the Healthcare System for people that are receiving medicaid benefits . Do you know anything about that . Rhonda if so, i have not heard that. Martha i dont want to speak to. Tim i havent heard that, but i suspect that thats true. Martha theyve had to hire more people to handle the feedback. Tim only because, keep that theyre going to be able to continue with a renewed contract after the initial term is up. The way in which that will occur is that theyll be able to demonstrate that the system is working, that services are being delivered. Theyll be able to demonstrate that theres satisfaction on the part of the recipients that are receiving that care. Then thirdly, and we cant lose sight of this, theyre going to need to demonstrate that the dont fully understand and appreciate yet. I think, as messy as this has been, this has been somewhat of a grace period because when the mcos are losing the amount of money that they claim that theyre losing. Its very, very difficult to sort out whats real and whats theyve already saved roughly 22 million from this transition from what they would have expected to spend on the Medicaid Program going foward. At the end of day, how do you save those dollars . Well, you save those dollars either by restricting services, shaving days off of inhome care that individuals are eligible for. You save dollars by paying your providers less, which may compound the phenomena were beginning to see where providers are saying, i just cant afford to do this. Martha and thats the door closing. Tim or you save dollars by just creating so many hurdles that individuals become frustrated and they begin not using the system for which it was intended, which was to ensure that they have access particularly to good primary care. Martha its tangled. Im she pronounces her name is ragan of mason city. Shes the co chair of the committee overseeing this for the state. She said in late august that this system right now and this privatization is a threelegged stool and all three legs are broken, but shes willing to stay with it and to ask the hard questions and to work it through. Im thankful that people are trying. Im thankful that people are looking at from the care view, from the services view, and hopefully we have more people like you, rhonda, advocacy for those w