Success of State Medicaid Shift for Elderly, Disabled is in the Eye of the Beholder

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As New York State shifts tens of thousands of elderly on Medicaid and Medicare into special HMO’s for long-term care, health officials are giving high marks to themselves and to the private companies they’ve hired to drive down costs and improve care.

But advocates are concerned Albany isn’t monitoring the companies closely and isn’t sharing the right information with people who need it to choose providers – or with the taxpayers who ultimately pay the bills.

The state last month quietly released a 55-page overview about what’s known as managed long-term care. Health Department officials were not available to comment, but in a recent news release, the Department said 38 for-profit and non-profit plans licensed by the state “are providing high-quality services to consumers and helping them maintain or improve critical abilities associated with daily living.”

Among the report’s findings:

  • 85 percent of enrollees rate their plan good or excellent
  • 91 percent would recommend their plan to others.
  • 72 percent received the influenza vaccination in the past year
  • 87 percent were stable or showed improvement in their ability to manage their oral medications

The report has glossy photos of elderly people and care-givers and lists basic information about the plans. But Susan Dooha, from the Center for Independence of the Disabled, said it doesn’t really gauge how they’re performing – and what their basic capacities are.

“If I were joining an HMO, I’d want to know it has enough doctors, and the right kind of doctors in its networks, to take care of me and my healthcare needs,” Dooha said. “I would want to know if I needed an appointment I would be able to get one within 24 hours and not end up in the emergency room for no good reason.”

She said the state wasn’t saying how many people were being diverted from independent living to nursing homes, and how many are falling or have serious skin problems – information it gathers elsewhere but doesn’t readily share.

Much of the information in the report comes from satisfaction surveys, but fewer than a third of people who received surveys responded. And even then, the state very selectively drew upon the results from the survey it commissioned from an outside contractor, according to an advocate from the Coalition to Protect the Rights of New York’s Dually Eligible (for both Medicaid and Medicare – a group of several hundred thousand New Yorkers who are especially poor and unhealthy).

 “This is just a skewed, partial glimpse,” said the advocate, who spoke on condition of anonymity because she was not authorized to speak by her employer. “They leave out the concerning findings.”

New York spent $13.6 billion dollars on long-term care in 2010 – about 26 percent of the Medicaid budget. About 300,000 New Yorkers receive these services at an average cost of $40,000 per person.

Under a reform panel appointed by the Cuomo administration, most of these will eventually be shifted into HMO-type programs, where plans receive a fixed payment to “manage” each individual’s care. The idea is to better integrate and coordinate care, improve health outcomes and reduce costs.

Previously, patients rarely had to go through an intermediary and to a much larger extent could select the care-givers they wanted, in a system called “fee for service.”

Michael Birnbaum, director of the Medicaid Institute at United Hospital Fund, a think tank, said that system has not served users well.

“Delivering community-based long-term care under fee for service has produced uneven quality and poor coordination of care,” Birnbaum said via email.

Whether or not the new system will save money is not clear. The figures in the 2012 report come from 2011, before managed long-term care was mandatory, when many fewer people were enrolled.

Still, the advocate said this report could have been a template for future disclosures, so that when all of the elderly and disabled are enrolled in long-term care HMO’s, the state will be able to say how much money is being spent and on what types of healthcare.

“Where is that money going? We really don’t know from this report whether people are getting the care they need,” the advocate said “There’s nothing about how much services are being given: home care services, adult daycare services, physical therapy, occupational therapy, meals on wheels. We know something about demographics, but we don’t know anything about where the money is going.”