Kaiser quits taking first-time Medicaid enrollees
CINDY ELLEN RUSSELL / CRUSSELL@STARADVERTISER.COM
Nam Huynh, 63, signed Medicaid application papers with the assistance of eligibility worker Hue Nettrour at the Kalihi-Palama Health Center on Friday. The process can take anywhere from one to 10 weeks, with pregnant women receiving priority in the process, Nettrour said.
Kaiser Permanente Hawaii has stopped accepting new Medicaid patients, making it more difficult for those on the government-backed health insurance program to find doctors willing to admit them.
The state’s largest health maintenance organization — both a medical provider and insurer — serves approximately 31,500 members enrolled in Quest, the state’s version of Medicaid, on Oahu and Maui.
Medicaid is one of Hawaii’s largest government programs, with an annual budget of $2 billion and 345,000 members, but doctors have long complained that Quest doesn’t fully reimburse them for the cost of caring for low-income patients, the aged, blind or disabled.
“If a government payer doesn’t pay enough, people can only take on so many of those patients,” said Kaiser spokeswoman Laura Lott. “We do that for the same reason providers (doctors) do it. A doctor in the community can’t have all Quest patients because they don’t pay him enough per patient.
“It’s part of our mission to improve the health of the communities we serve, and that includes taking care of those who are most vulnerable,” Lott added. “But we couldn’t take every one of them because that’s not sustainable for us.”
To stay in business, providers must strike a balance with higher-paying privately insured patients to offset the lower Medicaid reimbursements. That means new Quest enrollees have difficulty finding primary care providers.
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“It’s hard for all patients, even privately insured patients these days, to find a doctor,” said Dr. David Derauf, executive director of Kokua Kalihi Valley Comprehensive Family Services, a federally qualified health center that serves mostly Medicaid patients. “We have a shortage of primary care physicians, so it’s no surprise to us that people who are on Medicaid … have a much greater challenge getting access to care. It’s hard to recruit and retain capable physicians, so the fact that that Kaiser’s not accepting these people, that will further exacerbate it.”
Emmanuel Kintu, CEO and executive director of Kalihi- Palama Health Center, said community health centers play a critical role in filling the gaps when other providers simply cannot.
“You will not find a community health center that says, ‘We are not taking additional Quest patients,‘” Kintu said.
Kaiser said it has more than 700 physicians and providers in more than 60 specialties to serve its more than 240,000 members.
“In the Kaiser Permanente integrated model, all our patients are treated equally and receive the same high-quality care (despite lower payments for Quest),” Lott said, adding that existing Kaiser members who switch to Quest can retain their coverage.
Kaiser, rated the top Medicaid plan in the country based on quality and patient satisfaction by the National Committee for Quality Assurance, has closed enrollment before — several years ago, she said.
Kaiser has a limit of 25,000 Medicaid enrollees, but it increased capacity during open enrollment under the federal Affordable Care Act, also known as Obamacare, from November through January, said Keopu Reelitz, spokeswoman for the state Department of Human Services, which administers the Medicaid program. The increased capacity allowed those enrolled in Obama-care who might have had a change in circumstances, and now qualify for Medicaid, to have the option of choosing Kaiser’s Quest plan, she said.
Hawaii Medical Service Association, ‘Ohana Health Plan, UnitedHealthcare Community Plan and AlohaCare also enroll Medicaid recipients.
HMSA said that more than 800 primary care doctors in its network care for Quest patients and that almost 500 of these physicians are accepting new enrollment.
“HMSA and our physician partners agree that it’s important to care for all Hawaii residents, regardless of their financial situation,” said HMSA spokeswoman Elisa Yadao in a statement. “Having a healthy community benefits all of us, and HMSA is committed to doing all we can to make that happen.”
Reelitz said the Department of Human Resources doesn’t track Medicaid doctors.
“We do not currently have information on how many providers accept Medicaid or are open to new Medicaid (patients). We contract with each health plan to ensure enrollees have access to an adequate provider network,” Reelitz said. “It will take us at least a week or two to compile and analyze the information.”
Hawaii needs an additional 450 primary care doctors to meet its residents’ needs, according to the Hawaii/Pacific Basin Area Health Education Center.
“In a perfect world all doctors would take all patients and not have to ask about insurance type,” said Dr. Kelley Withy, director of the center. “Medicaid and MedQuest patients are often the patients with greatest health care needs, and yet reimbursement for caring for them is lower than most other insurances. This makes it very difficult for patients with Medicaid and MedQuest to find providers.”
48 responses to “Kaiser quits taking first-time Medicaid enrollees”
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Obamacare, what a joke.
Fals hopes,to those that were not covered and used the ER services? With false hopes current enrollee are led to believe that they are enrolled and yet find doctors unwilling to accept these types of patient. In the meantime enrollee like me who has had coverage for over 50 years now suffer as we are subsdizing the previously unrolled . The annual rate of increases in premiums were very nominal pre-Obama care and now has increased disproportionately. Auwe.
Are you a Democrat voter?…then you and the rest of these misguided Gruber subjectss deserve what is coming.
Why are medical premiums so high? Democrats cause that, too? I wish the simple solution was to put Republicans in power, but we’ve seen how well that worked for us.
According to the article, it isn’t about Obamacare … it is about Kaisercare. Or, Kaiser no care. How can a hospital say … “We are the best! BUT, only if you can pay!”
Read the article again….Obamacare is contributing as to why Kaiser not accepting new social program health care applicant. You must be one of the Gruber subject who ate up Obama’s words when he said you can keep your insurance or your doctor cRap.
Read the article, Kaiser takes care of over 31,000 already. How many do you take care of?
Now, MAUI hospital, about to be taken over by KAISER ? No Medicaid?? Really??
They are in the healthcare business. Kaiser should Never refuse any patient
Remember, in January Joe Souki wanted to prevent doctors from getting their licenses if they did not take Medicaid patients. Souki and Roz Baker were the architects of the takeover by Kaiser of the Maui healthcare system, so now all those poor people in Maui county can thank Souki and Baker for cutting them off from Medicaid. Good move, save the State lots of money!
Thank you President Obama! You tried to help the needy coming up with the ACA/Obamacare but you’ve failed paying the Doctor’s bill!
It is not just Quest.. . I have regular medicare and and it was almost impossible to find a doctor as a new patient. Socialized medicine! Vote Republican because not everybody can be on welfare.
Remember folks, social programs were created as a crutch when you are down and out and was NOT set up to be a way of life. It was NOT set up to be from cradle to grave kind of program, if you can not get yourself out of the situation you got yourself in, then you don’t deserve to breath the same air as those who are being forced to put money into these programs.
What ever happened to the Doctor’s Creed?
But really, can’t you just hit up the Emergency Room? I mean, if Emergency Rooms won’t deny illegal migrants from service why should they deny US citizens the same service when your down on your luck?
Meanwhile the homeless just play “collapsed” and the expensive ambulance takes them to the even more expensive emergency room where doctors cannot refuse to treat them – all at our expense.
Doesn’t matter to HMSA because they take care of NO ONE. They are simply a bank for the govt.
just another form of taxation to pay for government services.
What the article fails to note is that under Federal law and our State Medicaid contracts, each of these managed care plans are required to maintain adequate doctor Networks so that all plan members are able to access medically necessary service in a timely manner. Plans must attest to having adequate networks as a condition of receiving federal funds or they have to request a formal waiver and meet special reporting requirements. None of this is happening in Hawaii.
Although it is well known that throughout the system that the provider Networks of MedQuest plans are not adequate, there is no monitoring or enforcement by state officials as required by federal law. Instead, medquest officials are intentionally turning a blind eye to the problem, as is apparent from this article.
This is extremely unfortunate because Medicaid managed-care plans in Hawaii have billions in combined annual revenue and are in a position to improve the adequacy of their networks, yet there is no appreciable action being taken to do so. Instead, UnitedHealth and Ohana/Wellcare extract hundreds of millions in profits from the state each year. Part of their business model is to pocket more of the monthly capitated payments from the state by maintaining inadequate physician networks.
If patients can’t find a doctor, they don’t receive service, no claims are made, no payments are made and the plan retains all the revenue. To make matters worse, there is no data entered into the system about the member not being seen. They will appear to be healthy and satisfied! As an added bonus for the plan, these higher risk plan members, who could be costly to properly cate for, are more likely to switch to another plan out of frustration and necessity. Again, the data-driven system is blind to this, especially when responsible State officials turn a blind eye.
This distorts the HealthCare Marketplace by penalizing plans that provide more adequate provider networks and access to care for their members. It is likely these properly run plans, and their doctors, are shouldering the burden of caring for these sicker patients.
The doctor shortage is a problem that must be faced. In our privatized heath care system, where nearly all the resources ($$$) are being turned over to insurance companies, only they are in a position to fixing the problem. Most importantly, they have the legal obligation to do so. Apparently, this won’t happen without enforcement.
Please Governor Ige and legislative leaders (Roz Baker), tell MedQuest to start providing proper oversight of health plan provider networks.
See: http://familiesusa.org/product/medicaid-managed-care-rule-network-adequacy-standards
Or just Google “medicaid network adequacy”
Makes sense for HMSA. For Kaiser, they provide access to all enrolled Quest members. No hunting for a doctor. Hence the need to manage how many Quest folks that they can serve.
Let’s pass the plan to see what’s in it. Hope & Change.
You keep talking about the provider of the service. What I get from this article is that the payment for services under the Obamacare welfare taxpayer provided plans are not adequate for the hospital or provider to continue to provide the service. Like a business who sells things for less than they cost, they will go out of business. I have been going to my clinic for over 30 years and they have stopped taking new patients too. Makes you wonder if the government taking over the healthcare industry for our own good has done the opposite. Don’t confuse premiums with the actual cost of service provided, it is not a 0 sum game, no insurance is. I get the impression that you blame the insurance companies for all the problems citing their high paid executives. In that case you must be in favor of single payer insurance run by the government. See what happens then. Don’t forget if you like your doctor you can keep your doctor.
Excellent points, AllDunn. Let’s look at premiums (revenue), the actual cost of service provided (claims paid), and the margin (total premiums minus total cost, or retained revenue) for the two for-profit MedQuest contractors:
Revenue 2013
UNITEDHEALTHCARE $591,967,500
WELLCARE – OHANA $523,477,202
—- Total —– $1,115,444,702
Claims Paid 2013
UNITEDHEALTHCARE $496,547,763
WELLCARE – OHANA $441,290,635
—- Total —– $937,838,398
Retained Revenue (%)
UNITEDHEALTHCARE $95,419,737 (16.12%)
WELLCARE – OHANA $82,186,567 (15.70%)
—- Total —– $177,606,304 (15.92%)
In 2013, these two Medicaid managed care plans had potential profits of nearly two hundred million dollars – a margin of 16%. The other plans had much more reasonable margins: Alohacare (3.61%), HMSA (4.94%) and Kaiser (4.66%).
[These figures come from the annual report of the Hawaii Health Insurance Commissioner to the legislature, 2013]
See: http://cca.hawaii.gov/ins/files/2014/11/Final.pdf – pages 30 and 45
I am not necessarily in favor of single payer, but I am certainly against corruption and mismanagement within our current patchwork system of privatized health plans. Aren’t you?
Totally agree. This is just another example of Roz’s horrible work and Ige’s being asleep at the switch. More than that, Hawaii’s monopoly party has lost its once invincible mantle and now is slowly unraveling before our eyes. Which party will take advantage and provide some real intelligence and diligence?
They probably would cut their Quest rolls in half if they stop accepting new Micronesian patients.
Stay healthy my friend….
Excellent reporting by Ms. Consillio, would love to see more on the QUEST program. As the article points out, QUEST is a $2 billion a year program, making it second only to the state Department of Education for funds spent. Seems like there would be a lot there for a reporter to dig into. I hope her editors give her that freedom.
“Medicaid is one of Hawaii’s largest government programs, with an annual budget of $2 billion and 345,000 members”. It’s the number 345,000 that should be bothering us. That is a third of our population! Our democrats way of improving the economy by taxing the workers and spreading it to the non workers, is not working. Let’s try something else. Vote in November.
IRT – (MedQuest spokesperson) Reelitz said the Department of Human Resources doesn’t track Medicaid doctors. “We do not currently have information on how many providers accept Medicaid or are open to new Medicaid (patients). We contract with each health plan to ensure enrollees have access to an adequate provider network,” Reelitz said. “It will take us at least a week or two to compile and analyze the information.”
—–
For years and years, there have been constant reports of MedQuest members/beneficiaries being unable to access care due to plans not maintaining adequate provider network. Everyone knows this – doctors, case managers, discharge coordinators, family caregivers, advocates, legislators and most of all Medicaid patients who are sick. Yet MedQuest officials still don’t have any listing or other informatiom about participating providers?!
Clearly, this is not because the informatiom is unavailable – it will only take 1-2 weeks to gather. It is apparently because responsible officials did not want to know the truth and instead wanted to perpetuate the official position that the Hawaii DHS-MedQuest is a well-run agency. Was this laziness, incompetence, wilful fraud?
Yes, Kristen, please do some digging. This scandal has life and death implications for our poorest, most vulnerable and voiceless citizens, and it had undoubtedly contributed to disability, unemployment, homelessness and a myriad of social costs.
The most fundamental measure of a health plans operations is the adequacy of its participating provider Network. This is because if members are unable to access care when they need it, then the health plans entire complex operation, including its highly paid Executives and complicated computer systems, is a worthless waste of money. It’s not about year end compliance reports, it’s about sick members being the care that was promised and paid for.
Imagine if an airline sold tickets and collected payments but then failed to provide the airplanes and Pilots needed. Imagine that such an airline was able to keep those payments for itself while blaming the situation on a pilot shortage. Imagine that for over a decade, the airline failed to take action to recruit or train more pilots because this allowed it to make more money (profits are maximus by selling tickets without having to pay for pilots, planes or fuel). Finally, imagine that the government officials responsible for regulating the airline industry ignored this widespread problem for years, did nothing and instead submitted reports saying that the airlines had sufficient equipment and staff. This is essentially what has been happening with our Health care system and particularly with our private Medicaid managed-care plans.
There may not be a pulitzer in this story, but it deserves to be fully investigated and thoughtfully reported. Keep going Kristen.
“’s about sick members being the access health care that was promised and paid for.”
“It’s about sick members being able to access the health care that was promised and paid for.”
Sorry for the typos. [BTW, an edit option like the Washington Post has would be helpful for those of us presbyopics who can barely read the small font in the comment box.]
To help with enlarging the screen: hold the CTRL button while tapping + to enlarge. Reduce by holding the CTRL button while tapping – to reduce the size.
Thanks. I’ll try it.
Kristen is too close to HMSA to do the real digging.
It seems it’s impractical to expect these insurers and medical companies to take on this heavy load. But us working taxpayers…
Kaiser is backing out because it is hard to be both the insurer and the care provider. Ohana-Wellcare and UnitedHealth are making approx $200 million per year from Hawaii MedQuest members. They are like an airline (or maybe a travel agent) that sells tickets without adequate carrying capacity, and then keeps the payments while state regulators stand by doing nothing about it. Kaiser couldn’t or wouldn’t commit this fraud, perhaps because Kaiser is owned and operated by the doctors themselves (pilots).
UnitedHealth and Wellcare-Ohana will pick up the slack (not really, they will enroll more members and provide them with the same inadequate doctor networks, and pocket the profit. They will use internal data to formally attest to MedQuest and NCQA they are in compliance. These for-profit corporations have charged with fraud in a few other states, but not here. This is their business model. That’s why they are in Hawaii.
See: http://www.tampabay.com/news/courts/criminal/former-wellcare-executives-convicted-on-some-medicaid-fraud-charges/2125820
Medicare patients are next on the chopping block. Kaiser only want people with Gold or Platinum plans.
And no sick or unhealthy people!
These are no Kaiser’s policies or my suggestion that the whole health system is falling apart.
“no” is “not” and “or” is “only”. Proof read, proof read, proof read since S-A doesn’t have an Edit function.
Standard Medicare does not have any network adequacy requirements, and physicians can participate or not. Most had no problem with Medicare’s system until it began mandates and penalties regarding onerous electronic data entry and reporting. Now this has become more of a problem.
Private Medicare Managed Care plans (Medicare Advantage) DO HAVE Federal network adequacy requirements. Plans such as AARP Medicare Complete or HMSA Akanai advantage are required, by law, to have sufficient numbers of participating doctors. For commercial plans, like UHA, HMSA, HMAA, etc… there is a state law requiring adequate provider networks. Unfortunately, like with our MedQuest plans, there is no scrutiny or enforcement going on.
I guess I have to keep working to have premium medical coverage. I’m one of lucky minority with great boss and decent job but I wanted to retire in a couple of years and counted on Medicare and a gap coverage. Guess not.
Get rid of Obamacare and watch the problem go pffftt!
You mean replace Obamacare with pffftt…
Side benefit to Kaiser is all of those potentially doctor damning, patient satisfaction scores they will avoid with the loss of notoriously demanding Quest patients. Don’t be fooled, Kaiser knows exactly what they’re doing.
Not exactly consistent with their “THRIVE” motto now is it?
Kaiser has moved from “THRIVE,” to “THRIFT.”