Managed Care Year One: For Edbergs, finding a primary care doctor was harder than expected

Jeff Edberg has had fears and concerns over his son's health care since last October.

That's about the time conversation was reaching a fever pitch over Gov. Terry Branstad's decision to hand over the state's $5 billion Medicaid program to three private, out-of-state insurance companies.

'I'm a worrier, but I'll tell you this — it got a little too real for me on Monday,' said Edberg, who lives in Iowa City.

That was three days after the switch from fee-for-service to a managed-care system took place.

Edberg's 13-year-old son, Colin, has developmental and physical disabilities. He lives at Hills and Dales, an intermediate care facility in Dubuque that provides 24-hour skilled nursing care to about 40 other medically fragile children and young adults.

In a managed-care system, the state contracts with multiple managed-care organizations, or MCOs. Those MCOs then contract with Medicaid providers, from doctors and hospitals to community-based services and transportation agencies. Providers can sign with any combination of the MCOs.

That makes choosing an MCO for a person like Colin very difficult, Edberg said. Colin has about a dozen providers — from specialists at the University of Iowa Hospitals and Clinics to speech therapists and psychiatrists.

Confused by how the new Medicaid system works?

We're here to help. Click the image above to check out an interactive explanation of Iowa's new Medicaid managed care system.

'He sees so many providers, it's not likely that we'd find (an MCO) where all of the providers picked one MCO,' he said.

For example, UIHC has opted to sign with all three MCOs, while Hills and Dales only has signed with two. Hills and Dales is Colin's most important provider, Edberg said, so he initially selected Amerigroup, which had contracted with that facility.

Then over the weekend, Edberg received the instructional packet and forms from Amerigroup, his selected MCO, to fill out. The forms required the family to select a family doctor, or primary care physician, for Colin, Edberg said.

Read Part 1 in the Managed Care Year One series where we introduce the Edbergs.

But when he logged onto the MCO's site to look at his selections, he was extremely unhappy to find that within a 25-mile radius of Hills and Dales there were only four primary care providers listed — Crescent Community Health Center, a nurse practitioner and two located in Galena, Ill.

'The literature and announcements from Iowa Health link before April 1 said we can keep our own doctor — the doctor that Colin has been seeing, who knows him and can help him,' he said. 'He is non-verbal, so it takes years of experience to understand how to help this child.'

In the end, he decided to move Colin from Amerigroup to AmeriHealth Caritas — coverage that will begin on May 1. AmeriHealth was able to contract with one of the larger doctor's groups in the city, Edberg said, but he's still more than a little concerned.

'This system is worse than my fears of what it would be,' he said.

A Gazette search this past Thursday afternoon of the Dubuque provider network on the three MCO websites found:

• AmeriHealth is the only MCO to contract with both area hospitals — Finley Hospital and Mercy Medical Center

• AmeriHealth has contracted with primary care providers from Medical Associates and the Crescent Community Health Center

• UnitedHealthcare has contracted with primary care providers from Dubuque Family Practice and Crescent Community Health Center

• Amerigroup has contracted with primary care providers from Crescent Community Health Center.

'Dubuque has an inadequate provider network — Medical Associates has signed a contract with AmeriHealth, but there are plenty of clinics that have not signed yet,' said Senate President Pam Jochum, D-Dubuque.

Jochum has been an outspoken critic of the privatization plan and has pushed hard for legislative oversight.

'There are still gaps,' she said. 'The number of medical doctors available are few and far between.'

The provider network is critical, Jochum said, because without it the state cannot expect to provide care or improve health outcomes.

But Branstad's office believes the provider network is adequate, saying Thursday that the switch to managed care 'means more doctors than ever before'

According to the state, under fee-for-service Medicaid contracted with 7,512 physicians, 2,526 nurses, and 900 occupational and physical therapists. Now under managed care, MCOs have contracted with 16,821 physicians, 5,054 nurses, and 2,024 occupational and physical therapists.

But Jochum expressed caution over those numbers, saying the state is counting contracts and not people.

'For instance, Medical Associates has five satellite clinics,' she said. 'If I'm a doctor working there, they're counting me six times even though I'm one human being.'

Similar questions arose in February, when Branstad announced the three MCOs 'signed contracts with more than 8,600, 12,200 and 14,600 doctors respectively' despite there being only 6,828 active physicians with work addresses in Iowa, according to the Iowa Board of Medicine.

Department of Human Services spokeswoman Amy McCoy said at the time that DHS data is collected based on provider billing numbers — meaning some providers could file claims under several unique numbers such as multiple clinics where they see patients as well as at the hospital where they have privileges.

'DHS data reports are based on these billing arrangements, not medical licenses,' she said. 'And they are compared to the unique numbers used under the fee-for-service network to get the most accurate counts possible.'

Jochum said the MCOs still have a long way to go.

'I want them to give me the names of people who have signed contracts,' she said. 'Then I'll decide if the network is adequate.'

McCoy said Thursday that the state is working hard to get problems solved and it's important for Medicaid recipients to let DHS know when difficulties occur.