ABQ Journal "Some N.M. Tribes Fear Overhaul of Medicaid":

http://www.abqjournal.com/main/2012/09/05/news/nm-news/some-nm-tribes-fear-overhaul-of-medicaid.html

Some N.M. Tribes Fear Overhaul of Medicaid

By Winthrop Quigley / Journal Staff Writeron Wed, Sep 5, 2012



JEMEZ PUEBLO — Some of New Mexico’s Indian tribes have been among the most vehement critics of a state proposal to overhaul Medicaid, the $3.9 billion program that finances health care for low-income children and disabled and elderly people. They argue the state would interfere with federal compacts the tribes have signed, would cost tribal health systems money, and would degrade care.
A visit to Jemez Pueblo in the red-rock canyons 55 miles northwest of Albuquerque is a good way to understand some of the tribes’ concerns.
In many ways, Jemez is running the kind of integrated, patient-centered program health policy experts envision when they talk about medical homes and accountable care, ideas that are enshrined in the federal Affordable Care Act and which are the philosophical basis of the state’s Medicaid overhaul plan known as Centennial Care. It is unclear whether health outcomes, as opposed to health care, are better because that data are still being collected.
The pueblo’s medical operation is housed in a new, well-equipped center staffed by physicians, dentists, physician assistants, nurses and other professionals. It offers everything from radiology to dental care. The center had almost 12,000 patient visits last year. Its pharmacy filled 41,000 prescriptions in 2011. Its dental clinic averages 300 patient visits per month.
The pueblo’s health program emphasizes prevention, fitness and care for the whole person. It’s the kind of program managed care organizations strive to provide.
Its fitness center hosts an average of 51 visits per day. Jemez has a 17-member Senior Olympics team. A network of exercise trails snakes through the valley. The pueblo organizes fun runs, bicycle clubs, weight-loss competitions and other fitness activities. The comprehensive behavioral health program integrates the care it provides with pueblo cultural, religious and judicial traditions and organizations.
Like most tribes, Jemez once relied almost entirely on the Indian Health Service to provide care to members, under the federal government’s treaty obligations. No one liked the system, including the feds. Money was always short, services were hard to deliver to rural areas, it could take decades for IHS to build the facilities tribes needed, and tribes could not create the systems that would work for their own people.
Jemez began building its own health care system starting in 2000, by obtaining grants and contracting with agencies, including the IHS, to deliver care on its behalf. A change in federal law ended the contractual relationship with IHS. Instead, Jemez signed a compact with the federal government in 2011 which authorized the pueblo to take over health care responsibility for the tribe’s members. In 1995, 1 percent of members’ health care was delivered at the pueblo. Today, it’s 98 percent of care.
Care has improved at Jemez. Mammography rates for women medically indicated for the test were at 30 percent, for example. This year, they should reach 55 percent.
Health care is free for members. To cover its costs, the Jemez system does what every other health care operation does. It bills third parties, including the commercial insurance that members get from their employers. About 70 percent of third-party reimbursement comes from Medicaid.
There are about 3,000 enrolled members, and total money spent on health care, including public health programs, youth services and the medical center, is about $22 million. The medical center by itself costs about $3 million a year.
The state Human Services Department wants all of New Mexico’s 500,000 or so Medicaid recipients, including all of the 89,000 Native American recipients, to enroll with a few managed care organizations. Today, about 15 percent of Indians receive benefits through an MCO. The rest visit providers of their choice who are then paid a fee for the services they provide.
It’s rather as if Texas had told New Mexico how to set property tax rates, in the view of some tribes. Jemez has an intergovernmental agreement with the feds giving it, not the state, the final word on how its members receive care.
Managed care organizations are supposed to contact Medicaid enrollees, assess their needs, assign them to medical practices, then monitor their health status to ensure their needs are being met. The MCOs can’t do it, Jemez health officials say. Many pueblo residents don’t have phones, some speak only Towa (only Jemez people speak it), and many of their homes are difficult to find. MCOs’ provider networks are concentrated in urban areas, far from the pueblo, so members would have trouble accessing the care they need.
This is what Jemez officials fear:
Jemez members will go to the health center, as usual. Their care will be coordinated by pueblo health providers, as usual. The health system will be asked to negotiate a provider contract with the MCOs that will pay a fraction of what the system receives today. Jemez will have to make up the difference by finding new sources of revenue from no one knows where.