CHARLESTON (AP) - West Virginia is looking at changing the way Medicaid provides health care to some of its sickest people, and advocates for those who rely on this government program are questioning the move.
The state Department of Health and Human Resources seeks to improve care for people who are 65 or older or are so disabled that they have rarely or never been able to work, said spokesman John Law. As a result of their conditions, these low-income people also receive help through the federal Supplemental Security Income program.
"It's generally the people who are the sickest and need the most care," Law said Friday.
The department's Bureau of Medical Services aims to shift these people to managed care, starting in December in the more populous counties that have more of the needed services, Law said. Managed care is similar to health maintenance organizations, or HMOs, found in private insurance. It's an alternative to the traditional route of paying a fee for each doctor visit, medical test or procedure.
Bureau officials are expected to discuss this plan Monday during a meeting of a House-Senate interim study panel, the Legislative Oversight Commission on Health and Human Resources Accountability.
Among other provisions, managed care requires each patient to choose or be assigned a primary care physician. They then have access to services from a network of health care providers and facilities, with their main doctor referring them to specialists. These patients must secure prior approval before receiving certain testing and procedures, or if they wish to seek services outside of the provider network.
But these sorts of rules concern such advocates as Deborah Weston, a lawyer with Mountain State Justice. The public interest law firm often represents people on Medicaid. Among other concerns, Weston questioned how managed care would provide behavioral health services, which can be a significant need for these people, or medical specialists who are already in short supply in West Virginia.
Law said the primary goal is better health. Managed care could help these people make sure they're making their appointments, taking prescriptions, and checking their blood sugar and blood pressure, he said. Costs are also an issue, Law said.
The rising cost of health care, and the increasing number of people who are eligible for Medicaid, has become a major driver behind the West Virginia state budget. One sign of this: the state is counting on $65 million in surplus general tax revenues this budget year to ensure sufficient Medicaid funding during the next one. At Gov. Earl Ray Tomblin's request, the Legislature budgeted an additional $132 million for Medicaid to that new spending plan, which begins July 1.
West Virginia is not alone. States generally are facing unsustainable cost growth in Medicaid, putting pressure on budgets, said Neva Kaye, an official with the National Academy for State Health Policy, during a recent online forum hosted by the National Conference of State Legislatures. As a result, all but three states had steered people on Medicaid into managed care as of 2010. One of the holdout states, New Hampshire, has since begun to enter that fold, Kaye said.
An estimated 71 percent of the 65 million on Medicaid nationally have received at least some services through managed care.
"I've seen it grow from a cautious use of a voluntary program in a few states to becoming the dominant delivery system in Medicaid," Kaye said during the April 20 forum, which focused on managed care.
West Virginia's Medicaid managed care program traces its origins to 1996 and now covers more than 170,000 people. Known as Mountain Health Trust, its share of the state Medicaid population includes those who receive federal Aid to Families with Dependent Children. It provides coverage through three companies with overlapping territory in West Virginia: Carelink Health Plans, the Health Plan of the Upper Ohio Valley, and Unicare.