Yesterday’s post about Healthy Pennsylvania brought up an interesting set of questions. Would a straight up expansion of Medicaid instead of implementing Healthy Pennsylvania take less time to build the back-end infrastructure? The logic is that the current Medicaid system is already working, so adding another 500,000 people would be “merely” an increase in scale.
It is a bit more complicated than that.
The biggest complication is provider network contracting. Mayhew Insurance is a Medicaid managed care organization for the state(s) that we operate in. Our provider contracts have an opt-out clause for individual networks when there is a material change to business model, population, reimbursement or other critical circumstances. I am not a lawyer, but I have seen what our legal department considers a “material change” and a population increase of half a million people easily qualifies as a material change. The provider network would need a ninety day opt-out period where providers could opt-out without penalty.
After the provider opt-out period ends, new providers are needed to both replace the lost providers and to give a decent possibility of good access to care. This is another three to nine month process. It is not a critical show-stopping step, it is an ongoing process. More importantly, contracts will be revised with exisiting providers to insure that there is adequate capacity and adequate reimbursement to cover the newly insured people. This means provider offices will need to hire more CRNPs, more physician assistants, more nurses (not many more docs would be hired is my guess).
In conjunction with network expansion, is a significant behind the scenes ramp-up. Customer service reps need to be hried and trained. Some companies have a three day training period, others have a three month training period (and you can quickly tell which company trains to what standard). Medical management needs to be expanded and probably retrained as the expansion population is different in key aspects than the Legacy Medicaid population (expansion is more male, different age distribution, fewer comorbidities, fewer long term care problems).
New benefit grids need to be designed, tested, modeled and disseminated. My state covers a few populations that make more than 100% Federal Poverty Limit. These sub-populations already have co-pays and minimal deductibles for services, so if my state was expanding, I would assume that at least the expansion individuals who make more than 100% FPL would also have some cost-sharing. We could template off of exisiting plan designs which is faster than building from scratch, but it is still a significant process.
A straight up Medicaid expansion to do it right needs at least six months of prep work. I would prefer at least nine months to minimize stress, but six months is needed to get things done well the first time. Three months could get an expansion to Initial Operating Capacity with a signficant four to six month Phase 2 clean up. Simple expansion would probably save only a month or two over building out a brand new line of business.