Doctors say HMO plan impedes quality prenatal care

Friday, Oct. 4, 2002 | 11:07 a.m.

Gov. Kenny Guinn said he wants to make it easier for low-income pregnant women to receive prenatal care through Medicaid, but local obstetricians say they fear the governor won't go far enough.

Guinn, who called a meeting on Sept. 18 in Las Vegas with executives of the Clark County OB/GYN Society and other physicians, said Wednesday that he plans to meet again with the doctors within the next two weeks.

"This is a priority of mine, just like mental health," Guinn said. "We will take a look at everything we can do. We're collecting a lot of data. But we have to be a little careful that we don't get crosswise with federal requirements."

The obstetricians are complaining that a Medicaid health maintenance organization program launched in 1997 that the state runs only in Clark County has resulted in thousands of pregnant women annually getting inadequate prenatal care.

The doctors want the state to discontinue the HMOs and allow pregnant women on Medicaid to see them directly on a fee-for-service basis as they did prior to 1997 and as they continue to do in Nevada's other 16 counties.

Medicaid is a program that relies on matching state and federal funds.

Guinn and Charles Duarte, Nevada's administrator of health care financing, conceded that part of the problem is that the state makes it too difficult for pregnant low-income women to even qualify for Medicaid, leading to delays in prenatal care for those women.

Under the current process, applicants must show proof that their income and assets -- including homes, cars and bank accounts -- meet the financial guidelines to receive Medicaid. The problem is that it is often difficult and time-consuming for applicants to gather all their asset information. And it can take the state several weeks to verify that a pregnant woman is financially eligible for Medicaid.

"We have requirements that are not as liberal as in other states and an application process that is daunting for women," Duarte said. "Our requirements make it hard for pregnant women to get prompt care."

The Nevada Legislature approved a plan endorsed by Guinn in 2001 to spend $1.6 million in state funds this year to ease the Medicaid application process for pregnant women.

The plan would have required applicants to provide proof of income only -- eliminating the need to dig up records of assets -- and would have put together a team of state welfare employees to fast-track applications from pregnant women for Medicaid eligibility.

But Guinn and Duarte said the state's ongoing budget crisis forced them to table that program. That means the state cannot take advantage of matching federal funds that also would have gone into streamlining the Medicaid application process.

"We don't have enough general fund money to leverage this," Guinn said. "And if you don't have enough general fund money, you can't get the matching 50 percent in federal money."

The obstetricians say easing the Medicaid application process for pregnant women isn't enough, however. They say that dealing with for-profit HMOs allows those plans to reap some of the Medicaid dollars that should be used instead to help defray physicians' expenses. The doctors also say they must jump through hoops to get authorization from HMOs to perform standard services for their pregnant patients, including deliveries, causing needless delays and potential danger for women who need immediate care.

And the doctors say they have had to hire additional clerical staff to handle the HMO paperwork.

"The ultimate goal would be to carve out OB/GYNs from managed care Medicaid," Dr. John Nowins, Clark County OB/GYN Society president, said. "But I don't know that we will achieve that goal."

Guinn said that when the Medicaid HMO contracts are renewed early next year he'll push for streamlined authorization procedures that will make it easier for obstetricians to deliver services in a timely fashion. But Nowins said he is pessimistic that such change will occur.

"It'll get lost," Nowins said of Guinn's streamline proposal. "We've been complaining about the Medicaid program for two years and I feel like nothing is getting done."

Duarte said the state went to the Medicaid HMO system for pregnant low-income women based on the belief that managed care companies could save the state money and better guarantee that those patients would receive medical care. The two Medicaid HMOs in Clark County are run by Sierra Health Services and Nevada Care Inc.

Sierra Assistant Vice President Jenny DesVaux Oakes defended the current system. She said, for instance, that her company requires authorization for medical procedures because that information is audited on behalf of the state for proof that the care is being provided.

"We have met or exceeded every one of the state's standards," DesVaux Oakes said. "We have met all obligations to provide access to care and control costs."

Duarte also said the Medicaid HMO system has saved the state money. He said managed care saves the state an estimated $312 per Medicaid recipient annually. With 70,000 Nevadans enrolled in Medicaid HMOs, that translates to a savings of $21.8 million a year.

"It assures a single point of accountability for care," Duarte said. "Under our contracts I can force the HMOs to make sure that Medicaid patients see physicians."

But the obstetricians vociferously disagree, citing national studies that they showed to Guinn. The doctors said that HMO Medicaid patients are far more likely to have difficult births than Medicaid patients without HMOs because the former have fewer doctors and hospitals to choose from and often have to wait for authorization to get necessary treatment. Medicaid patients without HMOs have more doctors and hospitals to choose from and don't need prior authorization for services, the doctors say.

"Medicaid HMOs may save money on the front end but they cost more money on the back end in terms of longer hospitalization because those women are 25 percent more likely to have low birth-weight babies," Dr. Robert Comeau, another obstetrician terminated by Sierra, said. "An extreme premature baby can cost $1 million in medical bills and $5 million over a lifetime because of disabilities."

Duarte, who sat in on the meeting with Guinn, told the doctors that there were 3,300 births in Clark County last year that were fully covered by Medicaid. But the doctors told him that national studies show that 55 to 75 percent of pregnant women covered under Medicaid HMOs don't receive proper prenatal care until their seventh month of pregnancy.

If those numbers applied to the 3,300 births, that means there were as many as 2,475 mothers who did not have proper prenatal care.

"These women are sick and tired of getting all the authorizations, so they don't get care at all," Karen Odell-Barber, the OB/GYN society's political action committee co-chairwoman, said. "The result is low birth-weight babies, and babies with blindness, learning disabilities or cerebral palsy."

Even Duarte conceded that the doctors may have a valid argument on the lack of prenatal care.

"Some of the women get lost in the process and don't become eligible for Medicaid until they're ready to deliver," Duarte said. "Some of it is also cultural and they don't apply for coverage until late in their pregnancy."

The state gives the HMOs roughly $5,200 to cover each pregnancy, including hospital costs and all other aspects of care for the mother. Of that amount, $1,930 is allocated for physician services for each pregnancy.

Some local obstetricians have claimed that the HMOs keep as much as $500 of the $1,930. On a fee-for-service basis, the doctors would get the full $1,930.

Duarte said, however, that the doctors receive about 90 percent of the Medicaid allocation for physician services, with the HMOs keeping the remaining 10 percent to manage those services and assume the risk associated with that care. DesVaux Oakes said that the HMOs often lose money on the deal if a client has a difficult birth that requires additional funding.

But Nowins said that even 10 percent is too much for the HMOs.

"That's 10 percent for managing a program that is nothing but a hassle for physicians," Nowins said. "Try giving someone 10 percent to manage what you do."

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