KentuckyOne Health, CoventryCares in Dispute

Business First by David A. Mann, Reporter

Date: Thursday, August 16, 2012, 2:59pm EDT

 

KentuckyOne Health, a statewide health care system, was formed by the Jan. 1 merger of Jewish Hospital & St. Mary’s HealthCare Inc. and Saint Joseph Health System.

 

The largest health care provider in the state is terminating contracts with CoventryCares, one of the state’s four Medicaid managed care organizations, .

KentuckyOne Health stated in a news release that it has sent a notice of termination of all contracts. These terminations will be effective for the former Saint Joseph Health System facilities on Dec. 1, and for the former Jewish Hospital & St. Mary’s HealthCare Inc. facilities on Nov. 1.

Officials with CoventryCares could not immediately be reached for comment.

KentuckyOne Health will continue to be contracted to participate with Kentucky’s three other Medicaid managed-care providers: Spirit Health Plan, Wellcare of Kentucky and Passport Health Plan.

On April 27, Our Lady of Peace, a KentuckyOne facility, received a letter of termination, effective July 18, from CoventryCares. Additionally, CoventryCares terminated the contract with another KentuckyOne facility, Taylor Regional Hospital, without cause, the release said.

“KentuckyOne leadership strongly believes that Medicaid recipients in the commonwealth should have access to quality health care via a comprehensive network of provider and community organizations in order to achieve improved health outcomes,” the release said. “We feel CoventryCare’s actions will ultimately hinder and prevent the care our communities need and deserve.”

Louisville-based Jewish Hospital & St. Mary’s HealthCare Inc. and Lexington-based Saint Joseph Health System merged earlier this year to form KentuckyOne Health. The merged system has more than 13,000 employees and $1.8 billion in annual revenue.

Diabetes in Appalachia: “Just give me a pill”

Wednesday, Aug 8, 2012 07:45 AM EDT

 

In Appalachia, fighting diabetes means battling a culture where even vegetables tend to be covered in bacon fat

By This is the first of a three-part series on the challenges of rural health-care in some of the country’s poorest areas. The second and third parts will run Thursday and Friday.

PRESTONBURG, Ky. — Here in the heart of Appalachian coal mining country, where black lung disease and TB used to be major killers of men, a new epidemic is sweeping through the dogwood-dappled hollows that’s even deadlier than coal dust. The new threat is diabetes. Ads for diabetes counseling and testing clinics have replaced supermarkets as a major revenue source in local papers. Billboards urging middle-aged people to get tested appear almost everywhere there’s a straight stretch of highway.

Nationwide, diabetes affects 15 percent of all Americans; more than a quarter of all people over 65 are diabetic, while half are borderline. But in Kentucky and across the broad Appalachian region, a third of the population is believed to be diabetic, and health workers here believe that most diabetics don’t know it. Gilbert Friedell, who spent his life as a nationally known cancer specialist before founding a statewide health reform committee in Kentucky, however, rejects the conventional wisdom that diabetes prevention and care is a “health” problem.

“We used to say with cancer control in eastern Kentucky that if we were to apply what we now know about cancer, we could cut mortality by half in 10 to 15 years. The same thing is true with diabetes. We know what we have to do to prevent Type II diabetes and how to maintain a reasonable level of personal performance. We know these things. But, if we’re so smart, how come we haven’t fixed the diabetes problem? The answer is we’re still relying on individual approaches where it really requires community action and support.”

That insight led Friedell and the 25-member citizens committee that bears his name deep into the hollows of Kentucky, where strip miners have bulldozed off the tops of the mountains, and where earlier this year, a fierce tornado laid waste to thick forests of trees, blocked roadways and shredded the walls and roofs of gas stations, barns and mobile homes. That’s where the Friedell Citizens Committee launched the Tri-County Diabetes Partnership, drawing together an alliance of doctors, nurses, dietitians, teachers, church people, local health departments and even USDA farm extension agents.

Just above a branch of the Big Sandy River, Lora Hamilton coordinates the Floyd County diabetes program. She guesses that 15,000 of the county’s 45,000 people are diabetic. A few weeks ago she went to the Stumbo elementary school to talk about diabetes to the eighth graders. “The first question I asked was, how many of you have diabetes in your family. Ninety percent raised their hands. They knew there was diabetes in their families.”

Hamilton wasn’t surprised. With estimates that 50 percent of the mountain population will be diabetic in a quarter-century if current trends continue, she says most people are resigned — and believe there’s nothing they can do. “They tell me, ‘I’ve got diabetes or I’m going to get it. I’m just gonna have to live with it. My granddad lost a leg. My grandmother was on dialysis.’ And what I say is, ‘Well, you know you can keep that from happening by taking care of yourself.’”

Next door in neighboring Magoffin County, the USDA county home agent Brooke Jenkins-Howard provides family counseling.

“We have so many people who are diabetic. They go to the doctor and get the diagnosis and then they come to me for the practical side of things. They want to know what they can eat. They want recipes. We [in the Extension Service] have our roots in food, and people know us for that. A lot of times when you’re in the community and you have a reputation for doing these things for people you’re maybe easier to talk to than those medical folks who might be intimidating.”

Jenkins tells the story of a man who came to see her after having visited the county dietitian. The dietitian outlined appropriate food types he should eat, measured by grams of sugar and other carbohydrates and what each day’s total calorie count should be. “He took it home to his wife,” Jenkins-Howard said, “but she didn’t know how to put that information together into meal plans.” Part of the problem, as food anthropologists have long noted, is that changing diets is one of the hardest behavioral adjustments for any traditional population. More pointed is a misunderstanding of what it means to be diabetic.

“A common misperception people here have is, ‘I have diabetes; I can’t have sugar.’ That’s all they focus on. We try to concentrate on carbohydrates in the context of your entire meal plan. Breads are a big thing. Sweets are big. And people still want to fry food.”

“Fried foods. Absolutely! They want that bad!” Bertie Salyers broke in. Salyers recently retired as the Magoffin County health director in order to attend to health problems, including diabetes, in her own family.

Fried beans. Fried peas. Fried corn. “Killed” lettuce and onions in which hot bacon fat is drizzled over leaf lettuce and other greens. These are staples throughout the American South — and especially in the Appalachian region.

An equal barrier to controlling diabetes, Salyers says, is a deep-seated fatalism about both health and poverty.  “They come in and say, ‘It runs in the family. I’ve known I’m going to get it. Just give me a pill.’”

Recently Jenkins and the farm extension office initiated a weekly class on the local cable television network aimed both at diet and self-examination for diabetic symptoms. “We talk about food and diet habits. We can send out written materials to go with the lessons related to diet. We talk about screening for A1c [hemoglobin blood] levels, making your own foot exams [for neuropathy] and eye care [for signs of retinitis].” The object is to encourage diabetics or borderline diabetics to look for signs of the problems that can lead to amputations and blindness; the cable-TV lessons reach about 6,000 people, or half the population of the county.

And that’s good, says former health director Bertie Salyers, except for one additional problem: “So many people do not have access to that local channel. There’s a section of our county that has totally no access, and there are different spots that have no access.” Needless to say, she adds, almost no one in the south end of the county has access to high-speed Internet to take advantage of emerging “health home” monitoring online.

That same barrier plagues rural residents throughout Appalachia — and indeed in much of rural America — as does lack of high-speed Internet and home-diagnosis and monitoring kits for a variety of chronic diseases. But, says Salyers, the blanket of pessimism concerning diabetes and all the complications that go with it has also kept the majority from taking advantage of the screening and counseling programs that do exist.

“The resources are here, but a very small percentage of the people take advantage of [the screening and the classes],” she said at a recent gathering of health nurses and diabetes counselors at the Hope clinic in Salyersville.

Angie Conley, a nurse and diabetic counselor at Hope, offers free classes to talk about diabetes prevention and self-management, but she says few people come, even though they know how prevalent the disease is in their families. “They’re open to anybody,” she said, shrugging her shoulders. “It’s in the newspapers. It’s on the radio. But they don’t come,” Conley says.

The reason, Conley believes, is the general attitude toward pills and illness. “You’ve got to get them at the [clinic] door,” she continued. “If you don’t, they’re not going to come back for the classes. We’ve learned that.  You sit ‘em down and talk to them about diabetes and then they listen.”

One part of the reason, she and Salyers believe, is the cost. Though the Hope clinic is a FQHC (Federally Qualified Health Center), where a visit only costs $25, that’s a lot of money for most of the clinic’s clients, even if the clinic foots the bill for lab work that can cost thousands of dollars. Drugs for pre-diabetic or borderline patients who aren’t covered by Medicaid or Medicare can run another $75 to $100. Put those bills together with $4 a gallon gasoline to drive back over the ridges into town, and it’s more than they can afford.

“Our people,” she says, “have a disconnect between cause and effect, what the consequences are of what they do. Many people have been in poverty so long they’ve never practiced delayed gratification. It’s like I want it now — whether it’s a piece of pie or a new television. It doesn’t matter if I have to pay extra (on a credit card). It’s a cultural kind of thing. Any good results [from waiting] are so far out there they don’t matter. We’re so present-oriented that’s too hard to see.”

Nonetheless, nurse Kathry Hembry does see incremental progress among some patients.

“The number of people who come in [to the clinic] now versus 15 years ago is a whole lot better — the people who come in to get their eyes checked. Take the number of people in our community that’ve lost their legs due to diabetes. Ten years ago I could list you five people I knew personally; I can’t think of one right now. We are making progress; it’s just that we’re not making enough progress.”

Back to the east over the big mountain ridge in Floyd County, diabetes educator Cheryl Younce is running through her standard diet class for people newly diagnosed with the disease. After an hour and a half of rundowns on carb and calorie counting — all of it aimed at illustrating how people can control diabetes — the four clients who had showed up began to talk.

Maxine R., whose family was full of diabetics, thought she was healthy until last year, just after she turned 61. “The minute they told me I saw my mom with the needles stuck in her.” And then she went on, “I had a brother-in-law that had his legs amputated. He was sitting at the table one day eating a whole lemon pie. I remember he said, ‘Oh, my blood sugar is 900′ (normal is between 70 and 100 units). Then they amputated his legs, and even so gangrene set in. Then he died. Yesterday my sister-in-law collapsed even though she was on insulin. They took her to a hospital in Lexington and told her she had to go on dialysis. She weighs 400 pounds.”

Debbie G. has known she’s been diabetic for more than 10 years. “The last five years,” she said, “my job was real stressful and the way I’d deal with it was to eat. And the thing is I can’t remember to take my medicine. I get distracted, but when you get past 60, you start to realize you could die.”

David B., who’s 39, weighed 300 pounds when he went to his doctor last year unable to sleep. He always felt thirsty and found himself going to the bathroom every hour or two. “I went to my doctor and he lectured me like I hadn’t been lectured since I was 10 years old.” In six months he lost 80 pounds, but despite that he’s still diabetic, taking oral medicine and wondering if he can drive the disease back.

Tim D., who’s “in his early 50s,” has had diabetes for 14 years and “never paid attention to sugar. One day the air conditioning went out and I was drinking two quarts of juice a day — thirsty all the time. I didn’t pay attention to my meds and now I’m a full diabetic and have had 10 [arterial] stents inserted.”

Younce, the dietitian, acknowledges that far more diabetic patients could have shown up for her after-work class, but she says the public response in the Tri-County area has clearly improved. With as many as 22,000 residents either already diagnosed or borderline diabetics, and with advertisements for diabetic screening and treatment plastered everywhere, the epidemic is no longer hidden.

It’s still far from the vision Gilbert Friedell and his citizen corps hope for, but little by little, he and Bertie Salyers and the others want to believe they’ve begun to make a difference.

On the surface, argues Friedell, it’s all about nutrition, exercise and cutting overeating. “If you lose 7-8 percent of your weight and exercise strenuously 150 minutes a week, you can bring diabetes under control.” But to get there, he insists, requires real community action. “It can’t be top-down lecturing. The whole community has to be involved to bring about the difference in each individual.

“What we need is a comprehensive, coordinated health system in this country, which so far we do not have.”

Partial support for this story provided by the Henry J. Kaiser Family Foundation.

Close

Healthcare in Appalachia:Dying for a Ride

Salon Series

No matter what changes we make to healthcare, in rural America, simply getting to the doctor is a big problem

By

This is the second in a three-part series on rural health-care challenges. Part one, on diabetes in Appalachia, can be read here. Part three will run Friday.

LOUISVILLE, Ky. — Fausta Luchini’s client was obese and suffered from hypertension. “David,” a middle-aged man, came from a farming family but wanted to make it on his own. And the clinical psychologist is still frustrated by the way the medical system failed him. All for the want of a ride to the clinic.

“David really wanted to work. He didn’t want to spend all his time in the rehab program or on [his family’s] farm, either,” she says. “But he couldn’t get a job because he didn’t have a car — or a driver’s license. Then he got a job at a fast-food restaurant. For a while he was coming into our center, [picked up by] Medicaid, and then he would leave around 10:30 in the morning. He was going over [to the restaurant] for the lunch shift and then coming back in time for a ride back home — which was resourceful.”

And it violated Medicaid rules.

Mental patients can only use Medicaid-funded transportation to come to a treatment center. When the taxis that held Medicaid contracts found out, Luchini said, they blew the whistle — which gets to the core of a major problem for rural patients who count on Medicaid. Behavioral rehabilitation formally aims to reinsert patients into family or community life. But clinicians who work in rural America say the absence of public transportation makes getting back into a normal community almost impossible.

Most of the Seven Counties clients live in rural towns and villages east and south of Louisville. Nearly all are poor and, says Seven Counties executive director Anthony Zipple, suffer from multiple illnesses that the Medicaid system doesn’t address. And too many of them can’t get to clinics on their own.

“These folks are at far higher risk than the general population for chronic, expensive, life-threatening medical problems,” he said. “The way we have [medical care] structured in the United States, and particularly in Kentucky, doesn’t make a lot of sense.” The central dilemma, say mental health specialists, is the categorization of care into separate compartments — and they say it’s not at all clear that even the reforms proposed under Obamacare address those divisions.

For example, a key part of the ongoing healthcare reform efforts requires patients to declare a “medical home,” much as it does in most European healthcare systems, in order to control costs and coordinate care through an “accountable care organization.” Zipple argues that the pieces of the system are not linked together in a way that makes sense. “The divide between behavioral health and the rest of medicine is substantial,” and that divide leaves his clients worse off than other poor people.

Medical care, public or private, he and his staff say, separates physical illness from medical treatment — not only in the way Medicaid and private insurance pay for care, but also with the research models governing pharmacological research into drug efficacy and side effects. “A lot of the medications we use, particularly the anti-psychotics, have side effects that induce all kinds of metabolic problems. It’s well-known that people on these kinds of drugs are at higher risk for weight gain, diabetes and increased cholesterol levels — all of which result in shorter life expectancy.”

Three recent morbidity and mortality studies in Maine, Massachusetts and Ohio showed variously 50 to 300 percent higher death rates for patients diagnosed with mental/behavioral problems compared to the same age groups in the general population.

“People with serious mental illness in this country die 25 years earlier than the rest of the population,” Zipple says. Roughly two-thirds of those conditions are generally preventable through a combination of dietary control, individualized medication and physical activity. And, Zipple says, life expectancy among mental patients has continued to decline as treatments have grown more expensive. “Life expectancy for people with serious mental illness has actually gotten shorter over the last decade.”

Much of that has to do with buses and taxis.

“Transportation is the biggest thing,” says psychologist Laura Escobar-Ratliff. Escobar-Ratliff works with the Seven Counties group in the rolling farmland of Shelby County, 40 minutes east of Louisville. Shelby County has no bus or taxi service to take people shopping, to fill prescriptions or to work, she says. Medicaid-reimbursed vans can pick up patients to come to her office — but only for rehabilitation treatment programs.

“But,” she adds, “there are caveats. If there’s a car registered to your address, you can’t use the service — even if the car doesn’t run.” Yes, she admits, patients can get written waivers from the Medicaid authorities in Frankfort, the Kentucky state capital, but only if the client pays a state-certified mechanic to fill out a form, and often the clients can’t afford the cost. If there is a car that the wife (or husband) has to use to go to work, a waiver can also be granted through formal application, but, says Luchini, “They don’t want to do that because they don’t want the boss to know her husband comes to Seven Counties [for mental health care].”

“And,” adds Escobar-Ratliff, “it will have to be repeated every year … so she has to go back to her boss to say that her husband’s [mental)[ condition isn’t a temporary thing — it’s chronic.”

“These are real barriers,” says Luchini. “But then if you get the [Medicaid] transportation, you may get picked up late, so you miss the appointment, and when they get you here we’re seeing somebody else — and you have to wait ’til the next time.”

Often, they said, figuring out transportation leaves mentally disturbed or retarded clients so lost or confused that they quit coming to Seven Counties — even though they believe that many, even a majority of their clients, could reenter their communities if Medicaid and state rules were redesigned. Often they say they are told that financial constraints don’t permit such changes. But Michael Ringswald, a Louisville banker who sits on the Seven Counties board of directors, insists that more flexible policies would actually save Kentucky’s Medicaid program money.

Ringswald cites a new report from a watchdog group, Kentucky Voices for Health, showing that the state spends nearly twice as much of its Medicaid money on institutional — or nursing home — facilities as it does on independent living support, exceeded only by Michigan, Alabama and Mississippi. Another report from AARP scored the state 46th in the nation in the quality of its long-term care. The same report estimated that more than 1,400 nursing home residents could be supported far more cheaply if the state and federal Medicaid systems redirected their policies and programs toward independent living for clients.

But the overwhelming majority of institutionalized behavioral care clients do not go into nursing homes. Instead they are sent to so-called Personal Care Homes, which are often abandoned hospitals or motels that, in Ringswald’s view, are simply “warehousing” institutions that take mentally ill people directly from the state’s psychiatric hospital, feed them, provide bathing facilities and administer anti-psychotic drugs — at a cost of $1,158 per month to the state.

Redirecting Medicaid behavioral care toward job-holding and independent living, he maintains, not only is better for the clients, “it drops the costs dramatically. Once you start warehousing them in personal care institutions, you’re always going to have to warehouse them.”

Partial support for this story provided by the Henry J. Kaiser Family Foundation.

Close

Frank Browning reported for nearly 30 years for NPR on sex, science and farming. He is the author of, among other books, “A Queer Geography” and “Apples.” More Frank Browning.

 

 

Kentucky Agency Asks Judge to Drop Contempt Order over Medicaid Lawsuit

Kentucky Agency Asks Judge to Drop Contempt Order over Medicaid Lawsuit

 

The Kentucky Cabinet for Health and Family Services has apologized to a federal judge and is asking him to drop a contempt order against the agency. U.S. Senior Judge Karl Forester held the agency in contempt last month after ruling that the cabinet did not comply with his order to process thousands of requests from Appalachian Regional Healthcare patients who wanted to switch Medicaid managed-care companies.

The issue stems from a lawsuit ARH filed against Coventry Cares, a Medicaid managed-care company that has decided to cut ties with the ARH system.

The Lexington Herald-Leader reports an attorney for the state agency filed a motion on Friday that said the judge’s order wasn’t clear and specific and the cabinet’s failure to abide by it was “inadvertent.”

Kentucky advertises for Medicaid insurance proposals in Passport area

Kentucky advertises for Medicaid insurance proposals in Passport area

4:03 PM, Jun 20, 2012   |  
 
Tom Loftus
The Courier-Journal
 
FRANKFORT, KY. — Kentucky began the process this week of contracting with multiple companies to provide Medicaid services in the region that for the past 15 years has been served exclusively by Passport Health Plan.

On Tuesday the state began advertising for proposals from insurance companies to provide “managed care” services for Medicaid in Jefferson and 15 surrounding counties.

Bidders have until July 24 to respond.

Jill Midkiff, spokeswoman for the Kentucky Cabinet for Health and Family Services, said the state intends to select at least two companies that will begin providing Medicaid services in the region beginning Jan. 1.

Last year federal officials decided Medicaid beneficiaries in the region must be given a choice of managed care organizations. They did not extend beyond this year a waiver that has allowed Passport to be the exclusive Medicaid provider in the region.

That action came amid Kentucky’s decision last year to contract with three companies that now compete to manage health care for Medicaid recipients in Kentucky’s other 104 counties.

Mark Carter, chief executive of Passport, said it will bid to continue serving the region.

“With the track record we have, we think we’ll be able to make a very competitive proposal,” Carter said.

Because the transition to managed care in the rest of the state has been marked with complaints by providers and patients alike, some are concerned about what the pending change will mean for the 171,000 Medicaid beneficiaries in the region.

“We don’t feel that having multiple managed care contracts really supports the efforts of quality improvement and member satisfaction over time,” said Jodi Mitchell, of Kentucky Voices for Health, a health-care advocacy coalition.

Mitchell said that the federal government’s requirement of choice of managed care organizations may result in less choice of providers for Medicaid beneficiaries.

Currently a Medicaid beneficiary in the region can go to any provider because all work with Passport. “I’m not so sure that will be the same situation when you bring these for-profit companies in,” Mitchell said.

Passport was sharply criticized in late 2010 in a report by then-Auditor Crit Luallen that revealed wasteful spending and improper transfers of profits to the provider groups represented on its board. Passport responded by instituting reforms, restructuring its board and replacing all of its executives with a new team headed by Carter.

Reporter Tom Loftus can be reached at (502) 875-5136.

Medicaid Regulations No Match for Rural Roads

 

The dispute between an Eastern Kentucky hospital chain and private Medicaid operators has lawyers arguing distance versus drive time. Under state regulations, a private Medicaid operator cannot sign up a patient unless it has a doctor or hospital within 60 miles of that patient’s home. But that distance is measured as the crow flies and the state doesn’t take into account narrow and winding Appalachian roads. For many patients, it may be faster to visit a doctor that’s 70 miles away than it is to visit one that’s 50 miles away.That’s prompted the Appalachian Regional Healthcare hospital chain to argue against the 60-mile rule.

ARH says it has hospitals that are easier to get to for Eastern Kentucky patients, therefore no private operator could have a proper healthcare network without a contract with ARH. The state and private operators disagree.

“I think they do realize there is an issue there it’s just a question of how’s that’s been interpreted,” says Anne Hadreas with the Kentucky Equal Justice Center.

State regulations also say providers within a one-hour drive are in a patient’s network, but Hardreas says that isn’t often enforced.

“It definitely puts more of a burden on the consumer and we’re talking about Medicaid patients here who are by definition are low income and it means that they will have to travel farther to get the same amount of care,” she says.

Kentucky AG recovers nearly $2.3M in Medicaid case

June 6, 2012 12:00 PM

 

From CBS Moneywatch

Kentucky AG recovers nearly $2.3M in Medicaid case

FRANKFORT, Ky. — Attorney General Jack Conway has recovered nearly $2.3 million for the Kentucky Medicaid program in a settlement with Aventis Pharmaceuticals Inc. and Aventis Behring LLC.

Conway announced the settlement on Tuesday.

It was the latest in 17 settlements in lawsuits against some of the nation’s largest pharmaceutical companies in a dispute over whether the firms overcharged the Medicaid program for prescription drugs for the state’s elderly, poor and disabled.

Since 2008, the attorney general’s office has recovered nearly $235 million in legal settlements for the state and federal Medicaid programs.

Coventry sends out letters alerting Medicaid patients

Coventry sends out letters alerting Medicaid patients their physicians have left E. Ky. practices … except they haven’t

By Terry Boyd | Published: May 23, 2012

 

Click to enlarge.

How do Medicaid managed care insurers give the ol’ heave-ho to physicians who might have too many high-risk Medicaid patients in Kentucky’s poorest counties?

Apparently, they send out letters to members announcing those physicians no longer work at their respective practices, even though the doctors are still very much in place.

For example, last Friday, insiders started telling Insider Louisville that Medicaid managed care members in Eastern Kentucky were getting letters from Bethesda, Md.-based Coventry Health stating their physicians were no longer at Big Sandy Health Care.

Big Sandy is a private, non-profit corporation based in Prestonsburg that operates medical clinics, dental clinics and women’s practices  in various parts of southeastern Kentucky including Pikeville.

Big Sandy CEO Ancil Lewis confirmed yesterday his system’s Medicaid patients have received letters from Coventry stating certain doctors are no longer with the health care system.

Whether they were sent to deceive Medicaid members into leaving Big Sandy and possibly shifting them ultimately to one of the other two Medicaid managed care contractors isn’t clear, Lewis said. “Those letters are in error. I can’t say whether it’s a ploy or incompetence. But the letters are in error.

“The doctors named in the letters are still with Big Sandy.”

Other sources say Medicaid patients in Eastern Kentucky received similar letters from Coventry notifying them their doctor is no longer employed at their clinics, or their pharmacy was no longer covered under Coventry.

The common denominator in the moves is the doctors, clinics and pharmacies all have large numbers of high-risk patients, our sources say.

This latest issue arises after Coventry ended up with a disproportionate share of high-risk patients for several reasons including the insurer waiving drug co-pays during the initial open enrollment period.

Matt Eyles, vice president of Public Affairs and Policy at Coventry’s headquarters in Bethesda, Md. initially asked for time to research the issue, but did not get back to Insider Louisville.

Circulating inaccurate information is only one issue Big Sandy is having with Coventry. Coventry’s reimbursement methods make it impossible for Big Sandy’s accounting system to document whether the system is getting properly reimbursed for services.

“Their accounting is very different” from the previous system, Lewis said. “We don’t know exactly what we’re being reimbursed for, or whether we’re being reimbursed the correct amounts.”

The letters and other problems are the latest round of breakdowns as Kentucky shifted to a Medicaid managed care system from a fee for services system starting last November.

Insider Louisville, the Herald-Leader in Lexington and newspapers out in the state have documented the problems, ranging from suits accusing the MCO of not paying health care providers such as Appalachian Regional Healthcare to a decision – later rescinded – that Coventry would stop covering an opiate-withdrawal drug to notifying Louisville-based Baptist Healthcare System that Coventry intends to renegotiate for more favorable reimbursement rates and other changes.

The back story on Medicaid changes in Kentucky: In April, 2011, state officials asked health insurers to submit managed-care proposals for the $6 billion worth of care 800,000 poor and elderly Kentuckians receive annually under the federal/state Medicaid program. At the time, Gov. Steve Beshear touted the switch to managed care from fee-for-services as saving the state $375 million over the life of the initial three-year contracts. Insiders said officials in other states such as Georgia took as long as 18 months to make the change while Kentucky tried to do it in less than six months.

Ky. hospital chain takes Medicaid dispute to court

from the Washington Examiner

May 02, 2012 — 11:05 AM
 
 
The Associated Press

FRANKFORT, Ky. (AP) — An eastern Kentucky hospital chain has asked a federal judge to intervene in a dispute with one of three companies the state picked to administer Medicaid when it changed the program last year.

Attorneys for Appalachian Regional Healthcare say patient care will be disrupted and workers will be laid off unless the judge issues an emergency order forcing Coventry Cares to allow its members to continue receiving care at its facilities. The Lexington Herald-Leader (http://bit.ly/IFS28F) reports attorneys filed a request Tuesday seeking the injunction against Coventry.

If Coventry terminates its contract with Appalachian Regional Healthcare on Friday, it would affect about 25,000 people in the state’s poorest region. The healthcare system includes eight hospitals and several clinics and home-health agencies.

The state decided last year to switch Medicaid to a managed-care program as a way to save money, but problems have arisen during its implementation. Coventry was one of three companies the state chose to manage health care services for Medicaid patients in most of the state.

Coventry has said it needs to pull out of the contract because of decisions made by the state. The company said in court papers that another Medicaid contractor was allowed to not include ARH in its network, which meant it got more high-risk and high-cost patients. It also said that the state doesn’t effectively assess risks to assure managed care providers with more high-risk patients are adequately compensated.

Jill Midkiff, spokeswoman for the Cabinet for Health and Family Services, said the contractors agreed to the state’s risk-adjustment plan when it bid to become a provider.

Rick King, chief legal officer for the hospital chain, says patients are facing long travel times to get to other facilities approved by Coventry.

“We’re talking about 25,000 or more people who are going to be scrambling around trying to find health care in places where they’ve never been, trying to buy gas that they can’t afford,” King said Tuesday at a public meeting over the issue in Harlan.

ARH spokeswoman Hollie Harris said it would also mean job cuts of up to 400 workers.

“This is an issue that is going to have a devastating impact on southeastern Kentucky,” said Dan Stone, CEO of the ARH hospital in Harlan.

Coventry spokesman Matthew Eyles said the company would continue coverage for a few ARH patients, including some pregnant women, some cancer patients and follow-up appointments for people who have had recent surgeries.

Kerri Richardson, spokeswoman for Gov. Steve Beshear, said he is aware of the dispute, and that state officials have encouraged Coventry and ARH to continue talks.

Kentucky hospital chain in dispute with Medicaid contractor

From the C-J

 FRANKFORT, KY. — An eastern Kentucky

hospital chain has asked a federal judge to
intervene in a dispute with a Medicaid

contractor.

Attorneys for Appalachian Regional
Healthcare say patient care will be
disrupted and workers will be laid off
unless the judge issues an emergency
order forcing Coventry Cares to allow its
members to continue receiving care at its
facilities.

The Lexington Herald-Leader reports
attorneys filed a request Tuesday seeking
the injunction against Coventry.

If Coventry terminates its contract with
Appalachian Regional Healthcare, it would
affect about 25,000 people in the state’s
poorest region. The healthcare system
includes eight hospitals and several clinics
and home-health agencies.

The state decided last year to switch
Medicaid to a managed-care program as a
way to save money, but problems have
arisen during its implementation.