Updated: 8:38 p.m. Saturday, March 13, 2010 | Posted: 8:04 p.m. Saturday, March 13, 2010

CareSource, state's largest HMO, also has most complaints


CareSource, state's largest HMO, also has most complaints photo
Patient Josh Williams waits on the porch to see pediatrician Dr. Edward Cutler in the "The Bottoms" section of Columbus. Cutler sees the poorest of the poor children and soon may have to close his office because the Dayton based HMO CareSource doesn't pay him enough to care for his patients.
CareSource, state's largest HMO, also has most complaints photo
Pediatrician Dr. Edward Cutler examines a patient at his office in the "The Bottoms" section of Columbus. Cutler sees the poorest of the poor children and soon may have to close his office because the Dayton based HMO CareSource doesn't pay him enough to care for his patients.

By Jim DeBrosse

Staff Writer

Tonya Slusher of Dayton said a side benefit about landing a job with health care benefits a month ago was that she was able to quit CareSource, the largest Medicaid HMO in Ohio.

She said her doctor “had to go through all kinds of authorizations just to get simple things like birth control” prescribed for her. “You have to be persistent if you want to get through to them,” she said.

Doctors say CareSource and other Medicaid HMOs, the private insurance firms that manage care for Medicaid patients in Ohio, disrupt patient care and pay too little to cover their costs. Since 2007, the state has mandated that Medicaid patients enroll in an HMO as long as more than one serves their region.

The Dayton area is largely served by Dayton-based CareSource, which enrolls more than half of the 1.5 million family members covered by Medicaid managed care in Ohio, and Molina, the second largest Medicaid HMO at 15 percent.

CareSource not only dwarfs its competitors in size, it also logs more complaints, with the vast majority coming from health care providers. Of 717 provider complaints last year, 371 were lodged against CareSource and 46 against Molina, according to the Ohio Department of Job and Family Services. In nine of the months between January 2009 and January 2010, CareSource was at or above the state average for provider complaints.

Pam Morris, chief executive of CareSource, said the vast majority of its 23,000 providers have no complaints and that the number is remarkably low “when you consider that we paid out approximately 12 million claims in 2009,” up from 10 million in 2008.

But Dr. Lynn Grace of Springfield said many doctors know it’s useless to complain because “CareSource systematically declines to pay for services we deem necessary.”

Treatment denials are a common physician complaint. Grace said that before the state took over the Medicaid prescription drug program in February, CareSource refused to pay for more expensive medications for treating high blood pressure until patients first tried ACE inhibitors — a class of drugs that she says has proven ineffective in African-Americans.

CareSource officials say they never had such a requirement.

Dr. Edward Cutler, a pediatrician in Columbus who specializes in treating patients with mental health issues, said he can spend as much as 90 minutes on the phone trying to get a pre-authorization for a patient’s treatment from CareSource. “You can go through four or five different people. And if you get cut off, you have to start all over again. That’s an hour and a half wasted that I could be spending with patients.”

Cutler says he doesn’t want to abandon his patients because many would have no choice but to go to hospital emergency rooms for care. But he said he’s had to borrow thousands of dollars from friends to keep his doors open, in part because of low reimbursement. CareSource covers about 40 percent of his patients, he said.

Two weeks ago, Cutler said, his utility company “came over to turn off my electricity. I had to give them a bad check for $450, and then scrape and beg to get the money together to cover it.”

Cutler says CareSource uses a variety of technical reasons for delaying and denying claims.

“I’ve gone as long as seven weeks without a check from CareSource,” he said.

New system

In a statement, CareSource said its automated claims system “can feel more arduous ... for smaller, less technology-savvy physicians’ practices” such as Cutler’s.

The statement also said CareSource pays 97 percent of its claims within 30 days — well above the state requirement of 90 percent — and that the majority are paid in 17 days.

Morris pointed out that all HMOs must pre-authorize treatments that are not standard practice in order to remain financially viable and provide quality care to patients. However, she said CareSource is working on a system that would eliminate pre-authorization for doctors who “have pristine track records — where there are never any questions” about their treatment approach.

“That will allow us more time to spend with other (physicians) where there are questions,” she said.

Medicaid rolls swell

With the number of jobless people in Ohio at their highest levels in decades, Medicaid rolls have grown at a time when the state also is cash-strapped. The average monthly number of Medicaid clients grew from 1.31 million in 2007 to 1.57 million in January of this year, a 20 percent increase. In just 2010 alone, the rolls have climbed 11 percent over last year, according to state data.

But as their ranks swell, Medicaid patients say their choice of doctors is limited, especially for specialists.

Doctors say that’s because they can’t cover the costs of their staffing and other overhead on what Medicaid HMOs pay for their services.

Most doctors want to serve the poor in their communities, said Mark Jarvis, senior director of practice economics for the Ohio State Medical Association. “But when you take the low reimbursement and you add the administrative burden, the state, in effect, makes it impractical to take on more than a small percentage of Medicaid patients” in their practices, he said.

Specialists hard to find

Local hospitals and Medicaid patients say it’s especially hard to find specialists who will accept Medicaid reimbursement. CareSource, for instance, pays the same amount of money for an office visit whether the physician is in primary care, a specialty like orthopedics or cardiology or even a sub-specialty, such as brain surgery.

For hospitals, that means Medicaid patients showing up in emergency rooms with more serious problems may have to be hospitalized while they wait to be seen by an available specialist, such as an orthopedic surgeon for a broken bone.

“If they’re on Medicaid, it’s difficult to get enough slots for these patients to be seen on a timely basis,” said Bryan Bucklew, president of the Greater Dayton Area Hospital Association. Bucklew said hospitals are working with their community partners, including CareSource, to come up with a solution.

Although Brenda Holland-Brock of Harrison Twp. said she likes CareSource coverage overall, she has had trouble finding dentists and chiropractors who will accept the insurance.

Jeffrey Green of Dayton said it depends on what side of town you’re looking in. “You can’t go south of town,” he said. “But around here (downtown) is fine.”

Dr. Larry Litscher, a Dayton urologist with offices downtown and in Centerville, said sees Medicaid patients from as far away as Springfield because other urologists refuse to accept CareSource.

Finding specialists in all parts of the region and the state who will take Medicaid patients has been a challenge for all HMOs, Morris said. “We may need to do some creative things to get them involved.”

In the Zanesville area, she said, CareSource worked with a physician-hospital collaborative that now does its own pre-authorizations for hospital care. The collaborative includes 100 specialists, many of whom may not have participated in Medicaid on an individual basis.

“We have pockets here and there where specialists decide not to participate — maybe not in any managed care organization — regardless of what we try to pay them,” Morris said. “They have the right to tell us no.”

Contact this reporter at (937) 225-2437 or jdebrosse@DaytonDailyNews.com.


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