Managed Care Changeover: Bad Rx?
The city has finally begun the long-awaited task of assigning medicaid recipients to managed care plans. But, in the midst of the chaotic process that will change the way hundreds of thousands of people get health care, some on medicaid are being enrolled in HMOs even though, by law, they shouldn't be. On December 1, most medicaid recipients in Brooklyn, Staten Island, and a handful in Manhattan below 96th Street will be automatically enrolled in an HMO if they haven't already chosen one. (Joining an HMO has been an option, though not a requirement, since 1991.) But state law allows certain groups, including the seriously mentally ill, the homeless, and those with chronic medical problems, not to participate in this otherwise mandatory process. While most of those entitled to opt out of the HMO system are automatically exempt, many are slipping through the cracks and being wrongly asked to sign on with HMOs, according to advocates for the medicaid population. And, though the state can give permission to people who feel they shouldn't be forced to join an HMO, so far it has granted only 59 such exemptions.
The switch into managed care may be more than an annoyance for some patients. "If you have AIDS, getting thrown into a randomly chosen HMO which may or may not include your current doctor could immediately make your care unstable," says Michael Kink, legislative director for the AIDS service organization Housing Works. "That's a life-and-death issue."
Indeed, in light of such concerns, state law allows people with HIV to be automatically exempt from the HMO requirement. Yet, because the state isn't aware of all the medicaid recipients who have HIV, many are being asked to sign up anyway. While Kink puts the number of HIV-positive people being swept up into medicaid HMOs in the thousands, the state has granted only five exemptions for people with chronic conditions of any kind including HIV, according to Rob Kenny, a spokesman for the State Department of Health. Kenny says the department will readily grant exemptions for people with HIV, but has only received a few requests so far.
A similar pattern is taking place among the city's homeless and severely mentally ill, most of whom are also supposed to be automatically exempt from mandatory managed care. "These are people who don't understand the implications [of joining an HMO]," says Julia Stewart, associate executive director of managed care at The Bridge, an agency that serves the homeless, severely mentally ill people, and people living with HIV or AIDS.
Yet Stewart says many of her clients have unwittingly signed up for managed care plans in the waiting rooms of doctors' offices. "They're sitting there, waiting to be called in, and a marketing person comes in and says if you want to keep coming here, you better sign up for this managed care plan. But they don't understand their choices. A lot of them can't even read. And once they're signed up, it's a tremendous hassle to disenroll them."
Language barriers may also contribute to the problem. The initial medicaid managed care mailing went out only in English. And while the state says it now has its main brochure translated into five languages, many forms are available only in English.
At the same time, while state regulations say that people can opt out of mandatory managed care because of language barriers, only one exemption based on language has been requested and that has been denied, according to the state department of health. (The exemption form, it should be noted, is available only in English and Spanish.)
Currently, managed care plans are considered adequate for non-English-speakers if they employ at least three doctors who speak a certain language (or if those doctors have three staff people who speak that language). Maximus, the company that is handling the medicaid managed care enrollment process, has also set up a telephone translation service to help non-English-speakers. In light of such efforts, the city is "comfortable that some of the early issues in the enrollment process around language and distribution have been resolved," according tocity health department spokesperson Sandra Mullin.
But some see the latest problems as more than bumps. Noting that the English word angina (the heart condition) sounds deceptively like the Russian ahn-jeen-ah, which means strep throat, Gregory Myzur, who works at the American Brotherhood for Russian Disabled, says that poor communication with one's doctor can be dangerous.
Several other immigrants' rights groups agree, which is why they are filing a civil rights complaint against the state for not sending out enrollment materials in appropriate languages. "People have the right to info about how this program will affect them and that info just wasn't available," says Chris Molnar, the director of managed care education at the Community Service Society. "There's a real sense that these communities are not the priority for the state."
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