Ahcccs Failing Gila County Patients

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If Jennifer Cotney's 5-month-old son gets sick, she knows where to take him.

Phoenix.

That's where 19-year-old Cotney, her husband, Adam Eason, and their son are moving in August for the sole purpose of getting a new health care plan.

The family lives in Pine and is currently on Arizona Health Care Cost Containment System, which is Arizona's Medicaid program.

There are 13,294 AHCCCS patients in Gila County and many in the Payson area say the system is problematic.

There is a doctor shortage and some contracts have been dropped without being replaced, the program's officials said.

Cotney's main beef with the program is that ironically, AHCCCS doesn't give her enough access. She said getting a doctor appointment in Payson is incredibly frustrating. She has been on the system for nine years.

"I'm sick right now, but I'm not even bothering to call for an appointment because I probably won't get in for a month and a half, if I get in at all," Cotney said. "That's what always happens."

Cotney said her husband injured his back three months ago and was in a lot of pain.

"He could barely move. But no doctor would schedule him in less than two months," she said, "He had to quit his job because he couldn't work with his back messed up and he didn't know what to do to make it better. That's why he wanted to see a doctor."

Cotney eventually took him to the emergency room -- twice. She said she would do the same with her son if he got sick and she couldn't get an appointment.

"That's the only choice you've got," she said. "I think insurance plans around here should be better so more people can use them. Just because you have insurance doesn't mean it does you any good."

And it might get worse. On Oct. 1, 2003, Mercy Care -- one of Gila County's two AHCCCS insurance plans-- will terminate all its contracts in the county. Their 5,563 patients in Gila County will have the option of switching to Community Connection or the new provider, Health Choice Arizona.

AHCCCS directors say the transition will likely be smooth.

But in the meantime, there are a lot of sick people, many problems with the system, and not enough doctors.

Nuts and Bolts

AHCCCS is an umbrella system that contracts with seven separate insurance plans statewide. There are about five agencies that determine eligibility, but Department of Economic Security workers do the bulk of approvals.

Patients choose from the health care plans offered in their county and are usually not billed. Doctors bill the plans and the plans get money from AHCCCS depending on how many patients they served that month.

AHCCCS receives federal, state and county funds, plus some money from Arizona's tobacco tax.

Some health care professionals say that other federally funded programs like Medicare are easier to work with than AHCCCS.

Dealing with the program can be stressful for health care providers, said Tammy Gressley, Payson Health Care Management office manager.

"AHCCCS patients have to have a referral from their family practice physician if they want to see a specialist, and that means more paperwork," Gressley said. "It's time consuming and makes more work for the staff."

Getting paid, however, is typically not a problem.

"It's less money, but we still get it," she said. "It's a discounted fee so you take in less than if the patients were self-paid."

Despite being paid on time in most cases, two of Payson Health Care Management's three physicians recently stopped taking AHCCCS patients. They have 250 right now and say they will keep them.

Gressley said she is concerned for the AHCCCS patients who will not be able to get appointments in the Payson area.

"You bet it's a problem," she said. "I don't know why so many practices have been dropping their plans this past year. It makes it real hard for patients to see a physician. It there's no one out there, what do sick people do?"

Where have all the doctors gone?

There is only one doctor in the Payson area who is taking new AHCCCS patients, said Frank Lopez, AHCCCS spokesman, although he couldn't determine who that doctor is.

Many health care professionals said accessibility has been a major problem in Payson for almost five years. Lopez said that lower level AHCCCS workers knew about accessibility problems since early May, 2003, but that directors didn't know until May 12.

"There was a lapse in communication and the situation just snowballed," Lopez said. "I'm not too keen on how the situation went down. But now the directors know that there is reason to be concerned. We're trying to find out why doctors aren't wanting to see plan members."

According to AHCCCS data, 70 to 80 percent of doctors are registered to take AHCCCS patients, but they do not have to, Lopez said.

"A private practice can choose to see whoever they want. Our job now is to make sure that patients find a doctor somewhere, if not in Payson," he said.

Sometimes a practice might want to take more AHCCCS patients, but can't, said Lori O'Haver, health information specialist at Payson Regional Medical Center.

"If you take too many patients from a certain insurance plan, it throws off the balance in a practice, and you might not get a good representation of age groups or sexes," O'Haver said.

Most AHCCCS patients are women or children.

Payson's Red Mountain Family Practice used to take AHCCCS patients, but recently announced the termination of its contract with Community Connection. Red Mountain Family Medicine officials wrote in a letter to the Payson Roundup that the decision to terminate was difficult.

"The responsibilities associated with the Community Connection contract are beyond our capabilities at this time," they wrote. "We understand that our decision is difficult for those patients affected and we are deeply concerned for their health care."

Red Mountain doctors said they respect the AHCCCS program and said it is one of the finest in the nation. "(AHCCCS has) assured us that they are actively seeking primary care providers for those patients we were regrettably forced to discharge from our practice."

Lopez said that since the situation was dealt with in a lower office, the directors did not know about the termination until weeks later. AHCCCS's contract with Community Connection states that they should have notified AHCCCS "within one working day of any unexpected changes that would impair its provider network."

"The AHCCCS system is enormous," Lopez said. "But now that we know about the problem in Payson, we are fixing it so that people can get to a health care provider. Any medically necessary transportation will be provided."

Most practices that canceled AHCCCS services lately had Mercy Care plans. Lopez said they may be canceling contracts now to make sure they get their money by the time Mercy Care leaves town in October.

In a May 12, 2003 letter to Community Connection and Mercy Care CEOs, AHCCCS workers said they were concerned about hearing of accessibility problems too late, and from outside sources instead of plan directors.

"Please prepare a formal, focused corrective action plan on how the Payson Provider Network is going to be managed," they wrote, "with specific emphasis on: member complaints, appointment availability/wait times, provider satisfaction report, reasons why physicians are closing their panels when they have not met capacity, how are new members being assigned in this (area) and any other strategic points."

The CEOs of both companies were surprised by the letters they received. The only difference is that the CEO of Mercy Care says there is no accessibility problem and the CEO of Community Connection says Gila County has suffered a severe doctor shortage for years.

Time is of the essence

Finding a doctor who accepts AHCCCS patients in Payson is often a matter of persistence and luck.

Payson resident Stephanie Lopez got in just in time. Her doctor stopped taking new AHCCCS patients a few months after Lopez's first appointment.

"I'm lucky to have found a good doctor before that happened," she said. "It took three months and I know people who can't get in anywhere now."

Even when the situation was less dire, it took two weeks for Cotney to find a doctor who would accept her son and the earliest appointment she could schedule was a month away.

"What if my son gets sick again?" Cotney asked. "I don't know where to take him, and that's really scary."

Having to wait months to see a physician is a widespread problem in the health care industry and is not particular to AHCCCS patients, Lopez said.

"The load of patients is growing. Especially in Arizona where the population keeps expanding before doctors can set up practices," he said.

Seventy-three year-old P.J. Boyer of Jakes Corners was not so lucky. She started conducting her search six months ago when she was already sick.

"I was so sick for almost a month and kept getting worse," she said. "I was really worried and needed to see a doctor, but it was hard to find a doctor who would take AHCCCS patients. I called all these different doctors but no one would see me, so I finally called Lisa York's office because people said she was taking AHCCCS patients. Her office wouldn't take me though."

Boyer said she called AHCCCS and was told that York's office had to take her.

"Finally I got an appointment there," she said. Boyer added that after the appointment was made, the treatment she received there was excellent.

"But the whole thing was so hard and I wondered if I'd ever get to see a doctor, and it made me so mad," Boyer said.

York's office has recently stopped taking new AHCCCS patients.

A silver lining?

AHCCCS reform in Gila County could make life easier for Robert and Laura Young. The couple lives in Payson but has been going to Pine and Strawberry for appointments that were made months in advance.

Laura, 50, is diabetic and has to see the doctor often.

"My wife's case is serious and she has a lot of problems," Robert said. "If she got bad sometime and I couldn't get an appointment with a doctor, I would just take her to the hospital and they would have to deal with that."

Mercy Care representative Javier Aros said AHCCCS pays the entire bill almost every time their patients use the ER.

This frustrates Gressley, who said emergency rooms are burdened by patients who don't need to be there.

"Mercy Care should tell their patients not to use the emergency room unless they really have an emergency," she said. "And they should educate their patients on calling when they want to cancel appointments, instead of just not showing up. If they would call ahead of time, we could get someone else in."

Mercy Care's director of provider services Denny Bierl said this is a problem for all AHCCCS plans, not just Mercy Care's.

"When you don't have to pay any real co-pay at the emergency room, it's very difficult to educate people to not do that," he said.

Bierl and Mercy Care CEO Stanley Aronovitch said there are too few doctors in Payson, but that there is not an accessibility problem.

Both said there are currently a nurse practitioner, internist, pediatrician and family physician taking new AHCCCS patients in Payson.

"There is certainly physician capacity in Payson" Aronovitch said. "If a member can't get an appointment, they need to call us and we'll help them get in somewhere."

Bierl said that when Mercy Care checked appointment books at their contract offices in June, 2002 everything looked fine. They are going to check again this June.

"We need to contact the physicians up there to make sure that they are still taking (Mercy Care) patients," he said.

Mercy Care contracts with 10 physicians in Payson and has about 2,500 patients there. The most recent panel to close was on May 12, but Bierl said this is business as usual.

"I would expect that, for example, Dr. York will call us back when she's ready to take more patients and then she'll take more," he said.

Aronovitch said that some practices might purposely be quiet about accepting AHCCCS patients.

"I don't know if they want to advertise that they are taking AHCCCS patients because then they might wind up getting more of them," he said. "They might not want their practice classified as only taking AHCCCS patients."

Doctors should want to take AHCCCS patients, said Nancy Novick, Community Connection CEO.

"There are people on AHCCCS who are very well educated but have just fallen on hard times," she said.

"If we had any information about our providers treating our patients differently than patients from any other plan, we would definitely end our contract with that provider. We do monitor for that because it happened once years ago."

AHCCCS plans pay better than Medicare and a lot of other plans, Novick said.

"But we've still had an accessibility problem here for about five years," she added. "The whole community has been under served for a long time now.

That's why Novick was surprised by the letter AHCCCS sent her.

"What is going on in the Payson area has been discussed for some time," she said. "It was no secret. They've stated for a long time how challenging it is to provide for Gila County."

There may be a ray of hope, however. Novick said two new doctors are coming to Payson in the summer of 2003. They could take between 2,500 patients between the two of them.

"Having these two new doctors up here will be a godsend," she said. "We're real excited about this."

Until then, Novick suggests that mildly ill patients call AHCCCS's 24-hour nurse advice line if they cannot get an appointment.

If the situation is severe but not emergency room worthy, AHCCCS patients should notify their provider and will be sent to the nearest doctor, Lopez said.

"That's our duty to our patients," he said. "If they can't get to a doctor then we're not doing our job."

AHCCCS 24-Hour Advice Line: (800) 654-8713

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