The New York State Department of Health has asked the Health Care Finan cing Administration (HCFA) to delay its readiness review of Medicaid managed care implementation in the boroughs of Brooklyn, Manhattan and Staten Island in New York City, by waiting to mail notification letters until at least the end of 1998.
"We experienced delays in contracting with our enrollment broker," said Frances Tarlton, spokeswoman for the Health Department, "and thought it would be best to hold the review in mid-October."
Tom McGraw, vice president for managed care of MAXIMUS, Inc., the McLean, VA, company that will provide benefits education and enrollment services, said the firm had experienced delays in leasing and renovating office space but would be ready to operate as of Sept. 21. MAXIMUS originally had planned to be operational Sept. 2.
Sue Kelly, the Medicaid associate regional administrator in HCFA Region 2, said the HCFA review will examine adequacy of the provider networks among plans in the ZIP code areas that will first implement the mandatory program — Brooklyn, Manhattan and all of Staten Island — with an estimated 240,000 people to be enrolled. The review also will examine marketing, education and outreach to beneficiaries, enrollment systems, quality monitoring systems, the complaints process and the mechanism for excluding or exempting beneficiaries.
"The whole point of the readiness review is to ensure that people will be making informed choices for their health care," Ms. Kelly said.
Judy Wessler, policy coordinator for the Commission on the Public’s Health System, praised the decision to move cautiously. "There will be a lot of people with serious illnesses pushed into Medicaid managed care," she said. "We need to be sure that what is needed is in place when the program starts."
One of the biggest concerns raised about Medicaid managed care in New York City has been adequacy of provider networks for those who must participate. Ms. Kelly said while HCFA will look at each geographic area as a site with its own unique needs, the agency has some idea of what it wants to see in terms of the number of enrollees each primary care physician can reasonably be expected to be responsible for.
"Some studies have been done, both nationally and locally," she reported. "The City of New York commissioned New York University to research the situation in the initial ZIP code areas, and they gave us their independent assessment. We also make use of analyses done nationally regarding level of capacity that is appropriate."
While the New York University study looked at ratios of 900-1,500 to 1, the ratio chosen was 1,500 enrollees per primary care physician, said Daniel Walsky, HCFA’s New York branch director. That is a "fairly standard ratio nationally," he said.
Ms. Wessler, the consumer advocate, said many consumer organizations had been "actively involved in recommending changes to the program and are pleased that some of their recommendations were accepted." She said the consumer groups had raised concerns that the proposed ratio of primary care providers to enrollees was too high and patients would not be able to get appointments, and state and city officials had agreed to lower the ratio.
Leslie Moran, senior vice president of the HMO Council and Conference of New York, said plans have been committed to the program since its inception because they believe it is the "right approach for providing health care services to this population and will offer better access and higher quality."
"Plans are working extremely hard to ensure that the provider panels are adequate," she said. "You can’t move forward without sufficient capacity. The process is probably slower than many people would like, but we don’t want to go ahead and then see people not being well-served because too many people came in too quickly."
A second major concern has been over the work to be provided by MAXIMUS, the benefits broker with a two-year, $24 million contract to provide education, outreach and enrollment services. Mr. McGraw said while finalizing office space, his firm has screened more than 1,000 resumes and hired more than 300 people for initial start-up at the end of September. More people will be added as the mandatory program moves into full swing, he said. Ms. Wessler said it appears MAXIMUS has hired "some good people who have a community and consumer perspective."
MAXIMUS is responsible for providing information on managed care plans and their provider networks to recipients, for staffing a city- and statewide help line, and for working with managed care plans to assist callers with their health care questions and issues. The contract includes incentives for in-person benefits counseling and presentations.
Mr. McGraw said MAXIMUS has completed drafts of policy and procedures manuals, a training curriculum and client enrollment and educational materials for city and state approval. Much of the system programming has been done, he said, and capabilities for interchanging files with the state have been tested.
With the delay of the HCFA readiness review, Mr. McGraw said MAXIMUS would be operational for voluntary enrollments with managed care plans until approval of the Section 1115 waiver. He noted that the enrollment packets are similar for both voluntary and mandatory enrollment, varying only in the cover letter. And the call center will be available to help those interested in enrolling voluntarily.
Mr. McGraw said plans call for an initial mailing of enrollment letters with two follow-up mailings if needed. A third follow-up mailing would be for mandatory assignment to a primary care provider if the recipient hasn’t chosen one. Mailings will be complemented by a media campaign based on radio advertisements and billboards. There also will be outreach efforts through a wide variety of community-based agencies and organizations.
While there are no plans for a concentrated phone follow-up of those who do not respond, phone calls will go to those who start the process but whose paperwork is not completed. MAXIMUS also will do phone follow-up for those recipients who enroll through a health plan.
Ms. Tarlton, the spokeswoman for the Department of Health, said the goal is to enroll 20,000 people a month as the program is phased in over a three-year period.
Contact Ms. Kelly at (212) 264-2058; Ms. Tarlton at (518) 474-5422; Mr. McGraw at (212) 290-2211; Ms. Wessler at (212) 749-1227; and Ms. Moran at (518) 462-2293. n
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