Saturday, November 30, 2013

Oregon's Medicaid Leaves Many in the Cold: No Spinal Surgery, Back Pain or Allergy Treatment

The Oregonian's Brent Hunsberger reports that Oregon's one-size-fits-all Medicaid will cover childhood dental care for elderly people with no children. Also, if you are a smoker or obese, you will get treatment and counseling.  But, tough luck if you have severe spinal problems, back pain or allergies. A panel decides what gets covered and what doesn't. Hunsberger sets up a silver lining assessment:
Their [older people with no children at home] concerns about the Oregon Health Plan [Oregon's Medicaid] might be slightly misplaced. It offers the same 10 essential health benefits that private insurance does – preventive care, mental health services and childhood dental care among them.
. . .

The plan also has prioritized health services that it can afford to cover.
But, the cloud is still there.
A panel of providers determines [covered treatment], based on prevalence of the disease and other factors. If your condition isn't on it, the plan won't cover it. Spinal surgeries and treatments for allergies and back pain, for instance, aren't covered, [Christine Senz of Tuality Health Alliance] said.

"Sometimes it seems really, really arbitrary," Senz says. "But it's all based on science and outcomes and actuarial outcomes."
Maybe it seems arbitrary because it doesn't conform to normal American needs. Webmd says 55% in the U.S. have allergies. Less than 2/3rds that number (36%) are obese. 116 million Americans have chronic back pain. Only about 1/3rd that number (43.8 million) use tobacco.  But, of course, you can die from the effects of tobacco, whereas you will only have severe daily suffering if you have chronic back pain.

Even Medicaid's one-size-fits-all treatment is iffy. It is only available if you can find a doctor/medical facility in your area to treat you. Since Medicaid pays only a third of what standard insurance pays, it can be a challenge* to find anyone in your area who will provide your "10 essential health benefits".
Access might be another issue. Medicaid pays doctors about one-third what commercial insurance pays for the same services, said Christine Senz, chief operating officer of Tuality Health Alliance, a Hillsboro-based provider network that includes Tuality Community Hospital. So, to make sure they bring in enough revenue, doctors often limit the number of Medicaid patients they'll take.

"They often close to Medicaid or Medicare patients before they close to commercial patients," Senz said. "Certainly access is a problem."
What a deal: ten essential health benefits (which may or may not cover what you need most) coupled with difficulty in finding someone to actually treat you. Showing up at the emergency room when you have problems does not sound like such a bad alternative.
*From a 2010 study:
Sixty-six percent of those who mentioned Medicaid-CHIP (Children’s Health Insurance Program) were denied appointments, compared with 11 percent who said they had private insurance, according to an article being published Thursday in The New England Journal of Medicine.

In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was an average of 22 days longer.
From a New York Times article published Thursday:
. . . [I]n just five weeks, millions of additional Americans will be covered by [Medicaid], many of them older people with an array of health problems. The Congressional Budget Office predicts that nine million people will gain coverage through Medicaid next year alone. In many of the 26 states expanding the program, the newly eligible have been flocking to sign up.
But, doctors are not accepting lots of new patients. Specialists are especially difficult to schedule.
On top of that, only about 57 percent of doctors in California accept new Medicaid patients, according to a study published last year in the journal Health Affairs — the second-lowest rate in the nation after New Jersey. Payment rates for Medicaid, known in California as Medi-Cal, are also low here compared with most states, and are being cut by an additional 10 percent in some cases just as the expansion begins.
. . .
Dr. Paul Urrea, an ophthalmologist in Monterey Park, said he was skeptical of “blue-sky scenarios” suggesting that all new enrollees would have access to care. “Having been in the trenches with Medi-Cal patients who have serious eye problems,” he said, “I can tell you it’s very, very hard to get them in to see those specialists.”

Dr. Urrea said that when he recently tried to refer a Medicaid patient with a cornea infection to another eye specialist, he was initially informed that the specialist could not see the patient until February. “And this is a potentially blinding condition,” he added.


MAX Redline said...

Dr. Paul Urrea really should have been a urologist.

Anyway...there are a couple of things that Brent rather conveniently overlooked: if you receive services under medicaid, the governments will attempt to recoup any costs from your estate. Of course, if you're on medicaid, in many cases you won't have an especially large estate, so they'll simply take everything and leave your children with nothing.

If your spouse survives you, they won't go after your estate until she dies as well. Then, however, all bets are off.

As well - at 61, are you going to need "well baby" care, pediatric dentistry, or a "free" breast pump? No? Then why are you being forced to buy them?

T. D. said...

Max, thanks for the information. I did not know that about Medicaid.

The people not wanting to go on it probably don't know either. They just have pride in themselves and their ability to take care of themselves, and do not want to receive public aid they don't need. Bedrock Americans.

Another example of having to have outside help to get a true picture of an Oregonian story. Sigh.

MAX Redline said...

More info, TD: Oregon Health Plan (medicaid) issued a new policy statement, which I just noticed - if you sign up for OHP after Oct. 1 2013, they will not pursue estate recovery unless you enter long-term care. They state that services such as ltc aren't strictly medical and therefore aren't covered under OHP.

T. D. said...

Thanks for the update, Max! You're my reporter "of record".

MAX Redline said...

Lollers, TD. But hey, the Oregonian noticed the new OHP statement yesterday!

The Oregon Health Authority, which oversees the plan, said last week it would change its asset-recovery policy. Starting Oct. 1, anyone applying for coverage under the plan won't be subject to asset recovery rules meant for those receiving long-term care, the agency said.

The agency also plans to remove the alarming fine print in Cover Oregon's application.

"We are not going to be implementing the state recovery for people receiving just the Oregon Health Plan," said health authority spokeswoman Patty Wentz. "(Recovery) will remain in effect for long-term care services and connected medical costs."

Good to see that they got around to it, finally....

T. D. said...

Max, since this is an administrative change, I assume it can also be changed back at any time.

T. D. said...

Oh, and you scooped the Oregonian again! :-)

MAX Redline said...

That's a good observation regarding the nature of the change, TD - i.e., administrative. It was, however a result of pushback from a number of folks who read the fine print and understood it (correctly) to mean that if they allowed themselves to be pushed into OHP, they could conceivably lose all of their assets.

Because of that, I suspect they'd be unlikely to change it back. Nonetheless, it's still a potential landmine should long-term care be needed, so I'm guessing they'll tweak that part as well, eventually. It all kind of reminds me of Portland City Council's multiple tweaks to their "arts tax" - which took so many weird turns that Steve Novick finally advocated trashing the whole thing and starting over.

Heh - yes, the Oregonian's a little slow on the uptake, sometimes. ;-)

I'm not sure if they just miss stuff when they're reading, or whether they simply decide that there's more important stories out there, or what. Some of them don't seem to be especially accomplished at journalism, though.

T. D. said...

It looks like commenters helped Hunsberger identify the issue.

One hopes that Hunsberger's missing the recovery of assets part of Medicaid was due to ignorance and not consciously leaving out an important factor. But, it doesn't say much for a reporter who gives financial advice to miss estate recovery in his original financial "tips" article published only two days earlier.

Another commenter asked about an important issue Hunsberger has not yet addressed. What about people with fluctuating incomes? Will they have to pay the Medicaid money back if they go over the $15,860 limit since 2014 income is based on an estimate?

MAX Redline said...

Yes, I found the link on OHP's change of plans over the weekend, until then I'd been a bit concerned over the asset recovery program. Actually, more like appalled, as it affects OHP participants prior to Oct.1 of this year - they've been going after assets after death (unless a spouse is still alive) for any participant who received services, and it wasn't limited to ltc.

That's the change that they've just implemented, effective for new enrollees from Oct 1 onward:

They'l apply asset recovery only for service rendered if a participant enters long term care. In any case, they don't care about any kids; the spousal-only exception remains in effect.

It seems odd that the writer didn't mention the important details in his "tips" column. And you're right, another comment raised the issue of fluctuating income; an issue that hadn't even occurred to me (nor, apparently, to the Oregonian writer). But then, I'm not publishing "tips" in a newspaper.

I'll go out on the proverbial limb, here, and guess that yes, they'd have to reimburse.

T. D. said...

I noticed the Oct 1 onward exemption too. Puts the pre-Oct 1 people in a bad fix. As you point out most of them are in for long term care.

I think you're right on reimbursing. Everything about this is so slipshod and unsure. I wonder if Oregon will actually throw the rascals out who voted for this. Probably not Blumenauer.

MAX Redline said...

The correct spelling, I believe, is "Bluemanure".

Anonymous said...

Thank you for sharing this informative post.One of the nice information about spine pain you give here.

T. D. said...

Mike, sounds like you know a little something about spinal surgery.