“Free” Health Care or Pent-Up Utilization, or Both?
Nov. 05–SAN BENITO — Some officials have raised concerns over the San Benito school district health clinic’s new managed care plan, which has been touted as a model of the Affordable Care Act.
By Fernando Del Valle, Valley Morning Star, Harlingen, Texas
Nov. 05–SAN BENITO — Some officials have raised concerns over the San Benito school district health clinic’s new managed care plan, which has been touted as a model of the Affordable Care Act.
But Richard Garza, owner of ISD Managed Care Services, the company that operates the clinic, said some problems arose as a result of an unanticipated number of patients who enrolled in the plan.
“They’re repercussions of high participation in the managed care plan,” Garza said.
Now Garza has proposed that the clinic expand its operating hours to better serve employees who enrolled in the plan, which took effect Oct. 1.
Glenn Hillyer, the district’s insurance consultant, proposed increasing the clinic’s weekly operating hours from 40 to 52.
The proposal would cost the district $353,000 a year, Business Manager Emma McCall said. McCall said the clinic’s annual operation currently costs the district about $1 million.
The district’s managed care plan replaced Blue Cross Blue Shield, which served as the district’s third-party administrator for five years.
McCall and school board member Anna Cruz have raised concerns over the district’s operations since Oct. 1.
Cruz and McCall said they wanted to know why the clinic sent some patients to hospital emergency rooms; why the clinic had not implemented an Express Script, or eScript drug prescription system; why some patients reported long waiting times; why some employees had not received their insurance cards; why the plan’s network of doctors lacked some pediatric specialists; and why the plan has no provision for some medical equipment.
“This is not a proven plan,” Cruz said. “We’re not in the business of taking risks with our employees. (Clinic operators are) just wasting taxpayer money.”
The managed care plan’s high participation rate has led to long patient waiting times, Hillyer said.
Hillyer said 1,165 employees enrolled in the managed care plan while officials had projected 700 would participate.
“The clinic and its hours are not designed to handle this kind of flow,” Hillyer said.
Hillyer said the clinic sent three patients to emergency rooms to treat conditions requiring hospital care.”We don’t send people to the emergency room unnecessarily,” Hillyer said. “If they’ve got to go to the emergency room, they’ve got to go to the emergency room.”
Hillyer said the clinic was working on the implementation of an eScript system. Meanwhile, doctors are calling patients’ prescriptions into their pharmacies, Hillyer said.
While some employees had not received their insurance cards, Hillyer said, all have access to temporary cards.
Hillyer said the clinic has a provision for medical equipment. The clinic continues to work with medical equipment used under the district’s Blue Cross Blue Shield coverage, Hillyer said.
Hillyer said the managed care plan will add doctors such as pediatric psychiatrists, pediatric neurologists and pediatric cardiologists to its network of specialists as they become needed.
The managed care plans saves employees money, Hillyer said.
Hillyer said the plan charges employees no co-pay, offers no-cost lab work and imaging while deductibles dropped from $1,000 to $250 for in-patient hospitalization.
OTHER CONCERNS
Cruz and McCall said they wanted to know why Garza was out of town during the period in which the clinic transitioned to the new managed care plan.
But Garza said his staff was prepared to run the clinic.
“My company operates without me being present,” Garza said.
Cruz and McCall said they have questioned two expenses, including $4,000 billed for a dietician that was not on staff and $4,000 charged for overtime pay.
But Hillyer said operators have not paid out a $4,000 amount as they search to hire a dietician.
Interim Superintendent Alfonso Obregon has approved the overtime expenses to ensure that patients who arrive at the clinic shortly before its daily closing hour receive treatment, Hillyer said.
“We want to make sure employees who came in 30 minutes before closing time are taken care of instead of being turned away,” Hillyer said.
Cruz also said Garza and Hillyer were illegally signing preferred provider organization contracts that Obregon must sign.
But Garza and Hillyer strongly denied the accusation, saying they have signed no PPO contracts.
LOOKING FORWARD
Cruz said officials are working to correct any problems.
“It is my hope that in a short time this program will run as intended and our employees and dependents receive the best insurance program that they so rightly deserve,” Cruz said. “I ask that those being impacted by these concerns be patient while we work diligently to resolve them. Although, I was not in favor of this new insurance program that the district has implemented, I am working with all involved to address the issues that have arisen recently. The best interest of our students, employees, and school district will remain my focus and priority.”
School districts across the Rio Grande Valley are monitoring the program, McCall said.
“Everybody’s waiting to see if it’s working,” she said.
