Patients, hospitals having problems with revised GAMC program

Three months after the state implemented a scaled-back health care coverage program for its poorest residents, many patients are waiting months for basic medical services and hospitals have lost millions of dollars in uncompensated care.

"They're trying to take our medical care away from us," said Bryan Sullivan, a Richfield resident who was unable to see a mental health provider for nearly three months as a result of the changes. "For some of us, we're going to die. They're fricking trying to kill us. And people take it personally when people are trying to kill them."

Sullivan, 48, has severe post-traumatic stress disorder, a condition brought on, he believes, by the trauma of living on the streets. Sullivan lost his house three years ago when his employer, a siding company, closed because of the economic downtown. His savings dried up, and he ended up sleeping in his car in a Wal-Mart parking lot during the winter and living in a tent during the warmer months.

Sullivan said his life started to improve last year after he moved into transitional housing and began receiving mental health services. He started seeing a therapist once a week to cope with violent nightmares and other symptoms of PTSD. But when his health care coverage changed, his therapy and psychiatry appointments ended.

What followed, he said, was a long summer of "extreme feelings of isolation and depression." He had to wait until mid-August to see a new psychiatrist, and had his first therapy appointment last week.

The restructuring of the General Assistance Medical Care (GAMC) program has forced thousands of low-income residents like Sullivan to leave their medical providers and receive care through one of four Twin Cities-area hospitals. Many enrollees report waiting months for an initial appointment, and even longer for appointments with specialists.

Another 18,000 GAMC clients across the state are either receiving charity care or no care at all.

The cuts in funding to GAMC were the result of months of political wrangling between Gov. Tim Pawlenty and legislators during the last legislative session. The compromise cut the program's funding by about 75 percent, and restructured the way the state pays for medical services.

The new structure, which went into effect June 1, provides lump sum payments to hospitals that provide medical care to GAMC enrollees, instead of providing payments for each doctor's visit or medical service. Only four Minnesota hospitals -- all in the Twin Cities metro area -- agreed to accept the lump sum payments and become a "Coordinated Care Delivery System," or CCDS.

Pawlenty has said the restructured program will rein in costs while preserving health care services for low-income Minnesotans. But hospital administrators and advocates for the state's poorest residents say this can't be the long-term solution.

"We really think we're on the verge of moving from chaos to catastrophe if there isn't a solution found for this population," said Mike Harristhal, a vice president for Hennepin County Medical Center, one of the four participating hospitals.

The impact on Twin Cities' based hospitals

Administrators at the University of Minnesota Medical Center said they're working as quickly as possible to provide care to about 2,600 program enrollees. The hospital has hired an RN care coordinator to triage the needs of its new patients, and plans to hire additional providers. But hospital officials acknowledged that most enrollees have to wait several months for an initial appointment.

"They're trying to take our medical care away from us. For some of us, we're going to die."

"We've totally disrupted their care," said Marge Page, the operations lead for the medical center's GAMC program. "All of a sudden one day, they could not use their previous providers and have to establish care at a new organization. So we closed lots of doors across the state, and essentially opened up four doors to people."

The four hospitals -- the University of Minnesota Medical Center-Fairview, Hennepin County Medical Center, North Memorial Medical Center, and Regions Hospital -- agreed to provide the care if they could cap the number of enrollees. HCMC is the only hospital that hasn't reached its cap.

The medical center has 4,821 enrollees -- slightly more than half of its cap of 8,249. Overall, nearly 15,000 people are enrolled in a Coordinated Care Delivery System.

Harristhal said he expects HCMC will reach its cap by the end of October. He said the hospital's average uncompensated care costs rose by $3.2 million in both June and July, compared to last year's average.

Regions Hospital officials also report financial losses due to the GAMC cuts. Regions spokesman Vince Rivard said his hospital will receive an average of $3,700 in reimbursement per patient per year, about $9,000 less than the actual cost of providing care. The hospital reports a 57 percent increase in uncompensated care in the past two months, compared to the same period last year.

Despite these losses, hospital administrators said the current program is better than nothing.

Donna Zimmerman, senior vice president of government and community relations for HealthPartners, which includes Regions Hospital, said because the St. Paul medical center is a safety net hospital, they would likely be seeing patients regardless of whether they were enrolled in a CCDS.

Zimmerman said Regions would lose about $26 million a year if lawmakers scrapped the GAMC program entirely. She expects that financial losses under the revised program will about half of that amount.

"Again, we don't know," she said. "Our experience may be worse because we also take on a certain amount of risk in participating in the program. But we still feel like from a financial perspective, if we didn't participate, we'd continue to see high numbers of patients with uncompensated care."

Zimmerman said the financial constraints have led to one positive development -- the hospital has experimented with ways to better coordinate care, and has opened a walk-in clinic specifically to provide behavioral health services to CCDS enrollees.

Other hospitals have adopted similar approaches. HCMC has opened a new clinic designed for patients who have been high users of health care services, in an effort to better coordinate their care.

At the University of Minnesota Medical Center, behavioral health specialists attend initial primary care appointment for CCDS enrollees, regardless of whether the patient has a history of mental illness.

A search for solutions

But hospital administrators, along with a chorus of DFL legislators and advocates for the poor, say that the state could reduce costs and provide better care by enrolling in the early expansion of the federal Medicaid program, an option offered under the new federal health care overhaul.

Pawlenty has declined to apply for early enrollment. In a statement released in June, the governor's office said the state cannot afford to match the funds provided by the federal government for Medicaid expansion. The statement also cited concerns about "uncertainty surrounding the federal government's ability to fulfill the massive spending obligations in the program going forward."

Regardless of Pawlenty's decision to reject early enrollment in the expanded Medicaid program, the federal program will expand in 2014 to cover adults in all states under the age of 65, who make less than 133 percent of the poverty level -- now $14,404 for individuals. That means most of the current GAMC enrollees will likely be eligible for Medicaid.

Pawlenty spokesman Bruce Gordon, reached via email, declined to comment on the specific concerns of patients and hospital administrators, and referred a reporter to the June statement.

Gordon added, "Also, please note that the GAMC compromise was a bipartisan agreement between the governor and DFL leaders in the Legislature, including Senator Berglin and Representatives Murphy and Huntley. Remember, without this agreement, GAMC was set to expire in June."

State Rep. Erin Murphy, DFL-St. Paul, who negotiated the GAMC compromise with Pawlenty, said the scaled-back version is better than nothing, but she echoed others' concerns about the new structure.

"The triage to GAMC, I think, has created a fair amount of chaos for those getting their care, because they're been displaced from their current provider and they can't see a provider in their community," Murphy said, speaking Tuesday evening by phone in between a panel discussion in Rochester about the impact of the changes.

When asked if she regretted the decision to compromise on GAMC's structure and funding levels, Murphy said, "You know, I have thought that question over so many times."

Murphy said she wishes she was able to convince Pawlenty to sign legislation passed by the House, which she said would have provided a more equitable health care coverage system across the state. She said the current system will likely raise property taxes and the health insurance premiums of non-GAMC enrollees.

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