by Sheila A. Schuster, Ph.D.

“Medicaid Managed Care is coming!”
The chant resonated through the halls of Frankfort at the conclusion of the 2011 Kentucky General Assembly Special Session. This was our salvation—the way out of a huge deficit in Medicaid and its escalating costs. The way to avoid dumping individuals off the Medicaid rolls as other states had done. The solution, which would keep intact Kentucky’s array of Medicaid services to 540,000 poor, disabled, elderly or frail Kentuckians. The Governor seemed relieved. The legislators seemed relieved. The advocates, however, were apprehensive. The Medicaid members had no clue about what was happening.

We worried that the safety net of services—particularly for those with behavioral health needs—would not survive. Those of us who work in behavioral health tried very hard to get a carve-out for our services. We looked at what was happening in other states that implemented Medicaid Managed Care. We did our homework. We shared information with anyone who would listen. And in the end, we prayed that it wouldn’t happen.

The Kentucky Cabinet for Health and Family Services issued its RFI. Although the provider and advocacy community were not to be bidders, we weighed in with questions full of concerns. To their credit, the Cabinet responded to them and tried to be reassuring. But all along, we worried, and we prayed.

The Managed Care Organizations (MCOs) made a beeline for Kentucky. Their CEOs and outreach staff came and wanted to meet and pick our brains. So we did—with every single one who asked.

We told them proudly that Kentucky was the very first state in the nation to take full advantage of the Community Mental Health Act brought forward by the Kennedy/Johnson administration. Kentucky was number one in creating a statewide network of regional mental health/mental retardation boards, established in statute, and designated to be the planning and delivery entity for the full range of behavioral health services for Kentuckians in every county.

We continued to express our concerns. We worried that managed care would result in members not having access to the medications that helped them achieve stability. That managed care would reduce access to needed services and supports. That costs would be the driver, and not recovery. That the chronically-underfunded and fragile safety net created by the community mental health centers would be destroyed.

And over and over, we received assurances and promises. All Medicaid members would be “grandfathered” on their current medications. There would not be a need to change medications if the member was stable. That access to services would not only be maintained, but enhanced. That previously unfunded services such as those provided by trained Peer Support Specialists would be strongly considered for funding “because it makes so much sense.”

The RFP was issued. Behavioral health was not carved out. Anxiety escalated. The timeline was tight and the MCOs complained. The members were still in the dark. We again submitted many questions, and the Cabinet patiently responded to them, trying to reassure us. Then the bids were submitted. The Cabinet deliberated. Everyone held their collective breath. The three successful bidders were announced. The contract negotiations went on. Then the timeline was set—three months to put it together and launch. Three months! No one had heard of it being done that quickly. What did that mean?

What it all Means
What it meant was a roll-out that was incomplete, poorly communicated and nearly disastrous. The MCOs did not have their staffs in place. They didn’t know Kentucky, particularly on the behavioral health side. There was precious little time to begin one of the most important tasks—educating members, their families, advocates and providers about what was happening. Explaining why they would have two cards now instead of one. Why and how they were being assigned to an unknown MCO. How they were to get information so they could make a choice.

The MCOs accepted our invitations and those of other advocacy and provider groups to come and speak, to answer questions, to sort it all out before it launched. Everyone tried. Questions were answered in a positive way and promises were strongly restated. Members would be grandfathered on their medications. Access to care would not be denied or reduced. Consumers, family members, advocates and providers “would all have a place at the table” to shape the program.

In Reality
It simply has not happened. Our number one concern—that there would be a reduction or ratcheting down of access to needed services and supports, particularly with regard to medications, has unfortunately been the experience of many members, especially those dealing with behavioral health issues. The impact on the community mental health centers has been disastrous. The ratio of time spent on paperwork vs. time spent delivering services has tipped dangerously in the wrong direction. The growth in CMHC staff is solely in the clerical department.

We keep trying. The Cabinet keeps trying. And now, some legislators are involved in trying. The MCOs keep talking and meeting. The CMHCs are hanging on by their fingernails, but they keep trying. The members are only slightly less confused by it all. And we advocates keep on gathering stories, putting a face on the problems, reminding everyone of the promises that were made.

We keep trying our very best to protect and support these most vulnerable Kentuckians—to give them the opportunity to make recovery a reality.

Sheila A. Schuster, Ph.D., a licensed psychologist, is the executive director of the Advocacy Action Network and an advocate for mental health and healthcare issues.