DOs Testify at Medicaid Forums

William J. Burke, DO, and Carl M. Shapiro, DO, represented the profession at Medicaid Managed Care forums sponsored by the Ohio Department of Job & Family Services (ODJFS) in Columbus, August 14, 2008, and in Cincinnati, August 19, 2008.

Each testified about the challenges facing physicians and patients. In particular, they noted the payment system is focused on disease management, and not disease prevention; multiple managed care companies in most counties lead to multiple prescription drug formularies, multiple policies and significant confusion; excessive prior authorization requirements waste precious time for physicians, medical office staff and patients; and inadequate specialist provider panels, and subsequent limited availability of appointments for Medicaid managed care patients, lead to delayed diagnoses and treatment especially in the area of pain management and physical medicine and rehabilitation.

Dr. Burke stressed that the Medical Home Model, as advanced by the Patient Centered Primary Care Collaborative, can provide a regular source of primary care with better health outcomes at lower cost as a result of greater access to needed services, better quality of care, greater focus on prevention, and early identification and management of health problems.

He explained the patient-centered medical home model consists of seven core features:
1.An on-going relationship between the patient and his or her personal physician.
2.Physician-directed medical practice. Team care at the practice level led by the personal physician.
3.Whole-person orientation at all life stages.
4.Coordination and integration of care across the health care system and community.
5.A focus on quality and safety.
6.Enhanced access to medical care when the patient needs it.
7.Appropriate payment for all services delivered.

Additionally, Dr. Shapiro noted the need for a Medicaid Managed Care Report Card. The OOA has drafted a provider survey to lay the groundwork to evaluate the plans from both the primary care physicians and specialists point of view. The survey covers:

• Administrative issues such as time required for verification of consumer eligibility and authorization for referrals;

• Claims processing questions to determine accuracy of payments, and percentage of claims processed within 30 days;

• Health plan member education questions regarding rules, referrals, prior authorizations, benefits, and how much time the provider's staff is required to spend educating consumers about the various plans' benefits;

• Health plan staff's knowledge of requirements and the adequacy of the plans' communication systems and customer service provider relations;

• The helpfulness of the health plan's website for eligibility verification, prior authorization, and claims processing;

• Case management, coordination and implementation of care management activities;

• Adequacy of the specialty provider networks; and

• Credentialing and contracting issues.

Both physicians pledged the OOA would work with Ohio Medicaid to improve access to medical services.

ODJFS is seeking input so that ideas and suggestions presented during the public forums can be taken into consideration when Medicaid initiatives are developed for the upcoming biennial budget for state fiscal year 2010-2011

Ohio's Medicaid Managed Care program recently expanded to every Ohio county, enrolling 1.3 million Medicaid consumers.