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N.J. Medicaid Patients Struggle To Find Doctors

Courier-Post — Sunday, November 17, 2013

Written by
Kim Mulford
Courier-Post

Midway through her third pregnancy, Grace Ewing spotted a disturbing notice on the counter at her obstetrician's office.

Her Advocare doctor could no longer accept the UnitedHealthcare Community Plan as of Oct. 1, since the Medicaid managed care organization terminated its contract with the provider network.

Like 25,000 other Advocare patients in New Jersey, the practice told her she would have to find a new provider — and quickly.

But it was no easy task. For the next several weeks, the 28-year-old called obstetricians listed on the managed care company's website. She wanted to find a female doctor within a reasonable distance from her Bellmawr home, who could deliver her baby at Virtua.

One office worker after another told her the same thing: "We used to accept it, but we don't anymore."

"The website is completely inaccurate," complained Ewing, who runs a small business with her husband. The latter also works as a part-time school bus driver.

"When I say that this has been horrible for me, I had a mental breakdown ... I was treated for mental exhaustion and anxiety and dehydration at Virtua Hospital ... This has really, really affected my life."

Nearly 1.3 million New Jerseyans — about 15 percent of the state's population — are enrolled in Medicaid, most through plans administered by four managed care organizations.

The number of people covered by NJ FamilyCare is expected to swell next year, as an additional 300,000 uninsured residents will be eligible for free coverage, thanks to the Affordable Care Act.

But just as new patients enter the publicly funded program, health advocates believe it is harder for them to find doctors who will treat them.

What's more, some Medicare patients in New Jersey could experience the same problem starting Jan. 1, warned Melinda Martinson, general counsel for the Medical Society of New Jersey.

"This whole idea that if you like your physician, you can keep your physician? That whole promise is becoming increasingly difficult for patients who are in managed care," Martinson said.

New Jersey problem

About 54 percent of New Jersey primary care doctors reported they would not accept new Medicaid patients in 2011 and 2012 — the worst showing in the nation, according to a study published in the July issue of Health Affairs. That's compared with a national average of 33 percent.

Money is part of the problem. New Jersey's Medicaid reimbursement rates for primary care doctors are among the lowest nationally — just half the rate Medicare pays, according to the Kaiser Family Foundation. The rates are set administratively and can only be increased through state appropriation or a federal mandate.

Even though the Affordable Care Act has raised Medicaid reimbursement rates to match Medicare rates for two years, that doesn't apply to specialists such as obstetricians.

Nicole Brossoie, spokeswoman for the New Jersey Department of Human Services, said her agency disagrees with Health Affairs' findings, and pointed to a more recent study which found physician participation in Medicaid appears low because the state has more doctors, and proportionally fewer Medicaid patients, compared to other states.

And reimbursement rates are higher than they appear, she said, because "physicians rarely bill a single code. They almost always bill add-ons, which results in higher reimbursement."

Still, New Jersey's practice costs are among the highest in the country, said Martinson. The Medical Society has long been concerned about Medicaid patients' access to doctors.

"That access will only worsen under the expansion," Martinson warned. "I think it's fair to say that the state and the insurance companies can't expect that New Jersey physicians will fully embrace the Medicaid program unless it's appropriately funded."

Compounding the problem in New Jersey, at least one managed care organization appears to be pruning its provider network — one way such companies use to manage costs. UnitedHealthcare Community Plan terminated its contract Oct. 1 with Advocare, a provider network with about 400 doctors in New Jersey.

UnitedHealthcare also appears to be reducing its Medicare provider network, the Medical Society of New Jersey reports. Physicians have been receiving termination notices from United Healthcare's Medicare Advantage plan for 2014.

"We've been talking to UnitedHealthcare about this for some time, and they haven't given a lot of specific answers," said Martinson. "But I think they believe that a large network is not necessarily the best network."

Mary R. McElrath-Jones, a spokeswoman for UnitedHealthcare, said the managed care company isn't the only one taking such measures.

"Our provider network adjustments are part of a larger trend that includes changes in plan offerings," McElrath-Jones said. "Many insurers are looking to provide narrower network products to support the quality and affordability of coverage.

"While these changes can be difficult for patients and their doctors, they are necessary to meet rising quality standards, slow the increase in health costs and sustain our plans in an era of Medicare Advantage funding cuts," McElrath-Jones added. "We are ready to help our members understand their options, and we are working to ensure this does not interrupt care they may currently be receiving."

Despite longstanding concerns about access to care, it's hard to say yet what will happen next year as more patients gain insurance coverage, said Maura Collinsgru, a consumer health advocate for New Jersey Citizen Action.

"I don't know that there is actual data right now that can substantiate how we will fare in terms of the adequacy of the provider network. It is something to watch."

Contract terminations have sent patients like Ewing on frustrating hunts for new doctors.

A review of South Jersey obstetricians listed on the UnitedHealthcare Community Plan website found many private practices no longer accept the plan.

But their doctors also serve at a clinic that does. That clinic — the Virtua Center for Women — isn't listed.

When patients call their managed care plan, they are directed to providers listed on the same website. In some cases, UnitedHealthcare has directed patients to overwhelmed practices no longer accepting new patients. In others, contact information for the doctor's practice is wrong.

The result has been a confusing mishmash of misinformation for patients.

In one example, a reporter called the number UnitedHealthcare listed for a Virtua obstetrician. It led to Virtua's corporate offices. But that didn't matter, since the correct phone number was for a practice that no longer accepted the plan.

The reporter was advised to seek care from a primary care physician or a hospital emergency room.

Alliance Ob/Gyn Consultants, which has offices in Delran, Hainesport and Camden, still accepts UnitedHealthcare Community Plan and it is listed correctly on the managed care's website.

Practice manager Kim Hartman said her office has been fielding a lot of calls from frustrated Medicaid patients.

"I know they're having a difficult time. We had some that found us by Googling us."

McElrath-Jones said the company evaluates and changes its provider network on an ongoing basis, and added "supporting our customers is our highest priority whenever changes occur."

"We are working hard to ensure the information we provide about a physician's network status is accurate, and are working closely with members and providers to resolve their questions. Individual care providers may be affiliated with multiple practices for specific services or specialties — as a result, they can be in network for one practice but out of network for another."

Plan members with questions about providers are encouraged to call the customer service number on the back of their ID card, she said.

'A lot of stress'

It took a month before Mary Oliveri of Erial found a new pediatrician for three of her grandchildren, after she could no longer take them to the Advocare practice her family had used for 40 years.

One practice told her it had taken in 800 new patients and couldn't handle more. She found a practice in Williamstown from a list provided by UnitedHealthcare. She's now searching for new therapists and psychologists.

"You call and you try to find good doctors," said Oliveri, a 65-year-old who retired from a visiting nurses company. "I tell you, it's hard.

"These insurance companies have to take more consideration for families. Uprooting these kids from a doctor that they feel safe with, and now to have to go to a doctor they're not sure of — it's a lot of stress on the whole family."

Managed care companies administering Medicaid in New Jersey must follow the terms of their state contracts. That means they must ensure there are enough providers available within a specific geographic area.

Medicaid patients who haven't been able to find a new doctor through their managed care plan can call the state's Division of Medical Assistance and Health Services, said Brossoie.

"The Division continues to communicate with United daily to monitor the transition of members to new providers, continues to analyze provider participation and advocate on behalf of members who experience difficulty with the Advocare termination," Brossoie wrote in an e-mail.

"The Division is particularly committed to ensuring that individuals with special health care needs are transitioned appropriately to new physicians who can provide for their medical care."

An Advocare spokeswoman said the provider network is working on a contract with a new Medicaid managed care company and was not ready to make an announcement.

After a reporter raised questions about Ewing's case, Brossoie offered to have the state division follow up with the pregnant woman directly.

A nurse working for the state division contacted UnitedHealthcare and asked for a review of her case. Last week, a United Healthcare representative told Ewing she could keep her doctor under the "continuity of care" provision given to patients "undergoing medically necessary treatment."

Pregnant plan members can keep their obstetrician until their follow-up visit six weeks after delivery, McElrath-Jones said. To submit a request, patients should call the customer care number on their card.

Frustrated with the Advocare practice, Ewing declined the offer. Now 27 weeks' pregnant, she has taken her medical records to the Virtua Center for Women in Voorhees.

"The whole point of this health care law is we're supposed to have the power to choose who we have to see," Ewing pointed out.

"They give you a list of 76 providers from their website and nobody takes the insurance. They're telling you the information is accurate and it's not."

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