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Medicaid managed care stressing children's therapy

MONROE - When little Dorian Parham wants something, he pulls at his grandmother instead of telling her.

Just four months from his third birthday, the boy from Social Circle should be communicating in simple sentences. Instead, he speaks only in phrases that are hard to understand.

Without speech therapy, he is going to have a hard time when he starts school, said Ellen Roberts, a speech language pathologist who was working with Dorian one day last week inside Children & Adult Therapy Services in Monroe.

"He wouldn't have practiced language as long as the other kids,'' she said. "He's going to be at a disadvantage.''

Down the hall, 7-year-old Tomia Vinson of Monroe, who suffers from seizures that affect her speech and fine motor skills, is learning how to color within the lines of a pattern. The first-grader has been suspended from school three times this semester.

"If you can't hold your pencil properly, you get tired,'' Roberts said. Then, you start doing other things, which leads to an outburst. Eventually, you get labeled a behavior problem.''

Both children were being treated for free that day. The therapy office was awaiting authorization to take Dorian as a new patient, while Tomia has used up her authorized visits and been denied coverage for more therapy.

Problems common

Roberts said the delays and denials her young patients face are typical of what is happening to children's therapy services across metro Atlanta and middle Georgia since the state introduced managed care to Medicaid enrollees in those regions in June.

Now, her colleagues in the rest of Georgia are worried that the same fate awaits them when the Department of Community Health completes the rollout of the program this Friday.

"The process is time-intensive, labor-intensive, paper-intensive and significantly confusing,'' Marisa Harvey, a physical therapist from Albany, told the board that oversees the DCH last week. "Children are missing needed therapy sessions.''

Three HMO-like plans hired by the state for about $3 billion began covering 600,000 low-income adults and children on June 1. A like number will be added to the program Friday.

The concept behind the initiative is to bring the same savings managed care has achieved with private insurance to Medicaid and, thus, to Georgia taxpayers.

At the same time, the program's backers say assigning Medicaid patients to a primary care doctor will lead to more continuity in their health care, with a greater emphasis on illness prevention.

But the program got off to a rocky start. Doctors have complained - some loudly - about delayed payments that have hurt their ability to treat patients.

A lawsuit filed by about a dozen doctors and medical practices this month alleges that some have been forced to lay off staff members. The suit seeks class action status for the plaintiffs, so it could affect thousands of providers.

State health officials and representatives of the three "care management organizations'' hired to run the program have conceded that delays in processing and paying claims occurred frequently during the early weeks.

But they say they're making steady progress.

Through Aug. 11, according to figures supplied by the DCH, the CMOs had paid out about $55 million in claims. In 96 percent of the cases, the companies were disposing of claims by either paying or denying them within 15 business days.

"It's not going badly at all,'' said Kathy Driggers, the agency's Medicaid director.

Visit limit

But the therapists' beef with Medicaid managed care goes beyond administrative glitches.

They're upset with a directive that limits children to an initial round of eight visits.

If a child needs more therapy after that, the therapist has to request another authorization from a primary care doctor, which may or may not be approved by the CMO.

Harvey said the vast majority of children receiving therapy services need more than eight sessions.

"If we could fix these children in eight visits ... everybody would be at our doorstep,'' added Roberts. "With children, you're not going to see progress from therapy session to therapy session. We tend to see change in 21⁄2 to three months.''

With that in mind, Roberts asked Gov. Sonny Perdue in a letter dated Aug. 18 to consider "carving out'' children's therapy services from the new program.

Driggers said the state is paying special attention to how the CMOs handle children's therapy. She said that although the companies run Medicaid managed care programs that cover therapy services for other states, each state is different.

"There's been a big learning curve for the plans in figuring out how we cover therapy services,'' she said.

At the same time, the CMOs defend the eight-visit threshold as part of well-researched standards they have developed for children's therapy.

"When any kind of request for therapy comes in, we use national guidelines,'' said Kent Jenkins, spokesman for Amerigroup, one of the CMOs hired for the program. "If it's something that's medically necessary, we want to cover it. If something diverges from that, we have a pediatrician who examines the case.''

But Roberts said such rationing of care misses the big picture.

"We understand about containing costs,'' she said. "(But) if you help children with these skills, they're going to be healthier, stay in school longer and become productive members of the community.''