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Nursing home budgets pinched by low, late Medicaid payments

DES MOINES — Many nursing homes in Iowa — particularly in rural areas — are struggling to make ends meet.

A big part of the problem, nursing home officials say, is payments from a government health care program are insufficient and sometimes not timely.

And the state’s privately managed Medicaid system adds another layer of stress to nursing home budgets, officials say, because of the management companies’ appeals process and administrative burden.

More than 400 nursing homes in Iowa accept patients who pay through Medicaid or Medicare, government-run health care programs for the elderly, disabled and poor, according to a federal database.

Many of those facilities, industry officials say, are feeling a budget pinch, in large part because Medicaid reimbursement rates are too low and payments often are delayed as claims are contested.

Medicaid is jointly funded by the federal government and states, which set their level of payments to providers within federal guidelines.

States, including Iowa, must be thoughtful when setting rates as the program continues to chew up a large share of the state budget. At $1.3 billion, Medicaid spending makes up 18 percent of Iowa’s general fund spending, second only to education, according to a nonpartisan legislative agency.

For states, that high price tag must be balanced with creating a payment system that is sufficient for health care providers to deliver adequate care. A growing number of nursing homes say payments are too low.

Iowa’s budget is experiencing its own struggles, with shortfalls that have led to spending cuts in each of the past two years.

Although the state has not cut Medicaid spending, reimbursement levels are “inadequate,” said Brent Willett, president of the Iowa Health Care Association, which advocates on behalf of more than 700 long-term care facilities.

Willett said long-term Medicaid residents in nursing homes are underfunded by an average of $30 per day, or $10,950 per year. He said because many nursing homes operate on profit margins of less than 1 percent and many at a loss, those costs are passed on to residents with private insurance in the form of higher rates.

Willett said often residents with private insurance are forced to spend down their savings, more quickly putting them in a position to need Medicaid, creating what he called “an unsustainable cycle.”

Rural facilities feel that pressure even more, Willett said, because they have more Medicaid patients than urban facilities. While more than a half of residents in Iowa long-term care facilities are covered by Medicaid, dozens of facilities have at least roughly two-thirds of their patients covered by Medicaid, Willett said.

And smaller, rural facilities do not have the resources to shoulder increasing costs, he said.

“This places rural facilities in an extremely precarious position: as state and federal Medicaid reimbursement continues to fall further and further behind the cost of care, and with fewer private pay residents to pass the costs along to, finding ways to absorb the losses becomes increasingly challenging,” Willett said.

Nursing homes closed last year in Charles City, Le Mars and Storm Lake. The Charles City facility cited finances as the reason for closure; the Le Mars facility had received poor service ratings from federal regulators.

Iowa’s privately managed Medicaid system is compounding the problem, Willett said.

While the private companies that manage the state’s $4.7 billion Medicaid program do not set payment rates, they oversee claims and payments. Sometimes payments are denied and wind up in an appeals process; Willett said this can put stress on small nursing homes that do not have the resources to cover the loss while a denial is appealed. He said some facilities are forced to take out loans to cover payroll costs while waiting for Medicaid payments from the managed care organizations, or MCOs.

“We continue to work with the managed care organizations to advocate for the development of more consistent managed care claims payment systems,” Willett said. “These denials — most of which subsequently enter an appeals process — are growing across the state and have resulted in providers accumulating large accounts receivable balances as they await approval for services rendered and costs incurred.”

A spokesman for United Healthcare, one of the two companies managing Iowa’s Medicaid program, said the company works closely with doctors and health care providers, and pointed to a recent state report that said 100 percent of medical and pharmacy claims were administered within 30 days and that providers are reimbursed at the full Medicaid rate.

“Having operated in Iowa for more than 30 years, UnitedHealthcare maintains strong relationships with providers across the state and we are committed to working with those partners to address any questions,” said Jesse Harris, a spokesman for United Healthcare.

A spokesman said the state health department is working with the MCOs to ensure appropriately prompt Medicaid payments to providers.

“While we’re hearing from providers that claims are being paid more timely, and the situation is improving, there may be some older outstanding claims that the MCOs are working to resolve. The department will continue to monitor this and is committed to providing strong oversight of our managed care partners,” state health department spokesman Matt Highland said.


Cedar Falls police are investigating a fatal crash near the intersection of Viking Road and Winterberry Drive on Friday in Cedar Falls.

Somber anniversary recalled this MLK Day

WATERLOO – It was early 1968. A charismatic minister Anna Mae Weems had hosted on a visit to Waterloo nine years earlier and his organization needed help. She answered the call.

Weems, who had been active with the United Packinghouse Workers of America at The Rath Packing Co., and other labor leaders were called to Memphis, Tenn.

Unionized municipal sanitation workers, predominantly African-Americans, were on strike for better pay and working conditions. The Southern Christian Leadership Conference was called in to help. Other labor organizations also were called in.

That’s what brought Anna Mae Weems to Memphis for what would be her last meeting with the Rev. Martin Luther King Jr., SCLC leader.

“We marched down Beale Street and around City Hall,” Weems recalled. Through it all, King maintained a humble persona. “He was a common person. It wasn’t like I was sitting with a celebrity. He was like someone you knew all your life. He was for the good of the community all the time.”

Weeks later, on April 4, 1968, King was killed by an assassin’s bullet on a Memphis hotel balcony. Weems, home in Waterloo, reacted as many, with shock and horror.

The 50th anniversary of King’s assassination makes this Martin Luther King Day particularly poignant for many, including Weems. She escorted King around Waterloo in November 1959 as the young minister was starting to make a name for himself with civil rights activities in Montgomery, Ala. He met community leaders, spoke at West High School and at Iowa State Teachers College, now the University of Northern Iowa.

Fifty years removed from the tragedy of his passing, Weems said King’s death reminds us leadership is not for the squeamish but is still needed today on issues of justice and equality.

“He would want us to build on leadership,” Weems, 91, said. “ If you get good leadership in a community and you get that motivation and you get that influence, then you would have a community that’s unified. ... You see, leadership is not for cowards. You have to know how to bring out the best in people.”

She supported King on some marches activities in the South.

“Some people would throw things, and he would say ‘Louder, children. Louder. They’re not hearing us.’ He would say things that are uplifting, not downtrodding.”

Weems said she and others were called to a meeting at the Lorraine Motel in Memphis, now the home of the National Civil Rights Museum. It was where King frequently held meetings and was ultimately assassinated. A fellow Rath-UPWA member from Waterloo, Russell Lasley, became national treasurer of the UWPA, which supported the SCLC.

“We were called down there to help the garbage workers,” Weems said. “I was volunteering all around,” working under King’s friend and SCLC associate, the Rev. Ralph David Abernathy.

King sought conciliation, not confrontation, through organizational efforts, Weems said.

“Dr. King always had that saying that you should inspire, not intimidate. People would say things are real bad. Dr. King would say, ‘There’s no such thing as an unmotivated person.’ A leader should go in, work with a person and stir up the energy God gave him. … Bosses drive men. Leaders motivate.”

Weems first met King in Washington, D.C., in the late 1950s. He gave the invocation at a breakfast hosted by then-Vice President Richard Nixon. She invited King to Waterloo.

While some locally initially were standoffish to the young minister, Weems said others, such as the Rt. Rev. Monsignor E.J. O’Hagan, pastor of Sacred Heart Catholic Church, welcomed him with open arms. Burton Field of Palace Clothiers fitted the young minister with a heavier suit of clothes for the chilly November Iowa climate. He stayed at the Russell-Lamson Hotel.

After his talk at West High, Weems recalled, King stood behind the auditorium curtain, buoyantly asking, “Did I do all right?”

“He was intoxicated with love for his fellow man,” Weems said.

She learned of King’s assassination when called by a Courier reporter. “It was such a shock,” she said. She hushed her children and called the UPWA union hall to verify it. The secretary was in tears.

She later told The Courier, “Dr. King taught us that violence is not the answer; it only creates fear. The wound of racial injustice can only be healed by the peaceful balm of religion and morality. We must — and we shall — try to fill the void and move forward with brotherly love.”

Errors plague Iowa family planning database

IOWA CITY — Wade Aldous, disease control director for the State Hygienic Laboratory at the University of Iowa, isn’t sure how the lab known for confirming cases of West Nile virus, influenza and food poisoning got on a state list of family planning program providers.

“I think that they use the term ‘provider’ very loosely,” he said. “We do not see patients.”

The state’s list of 1,431 providers as of Dec. 21 also includes dermatologists, surgeons and a pulmonologist — none of whom typically offer family planning services or prescribe birth control — and more than 100 providers without Iowa addresses or phone numbers.

The Iowa Department of Human Service offers the searchable database as a way for Iowans needing family planning services to find a provider under a new state program. But errors, duplicate names and listings for providers who don’t see patients may deter Iowans who need services such as birth control, pregnancy tests and treatment for sexually transmitted diseases, advocates said.

“That is not a very user-friendly list,” said Jodi Tomlonovic, executive director of the Family Planning Council of Iowa. “It would be difficult for a patient or potential client to use.”

New program

The Legislature last year created the $3 million Family Planning Program to funnel money to women’s health care clinics that do not perform abortions.

Though even under the previous program no taxpayer money was used directly to perform abortions, Iowa rejected federal money that allowed participation by providers — most notably Planned Parenthood — that include abortion among their services.

The rate of abortions in Iowa and across the nation has dropped in recent years, with 4,380 abortions, or 7.5 per 1,000 women, performed in Iowa in 2014. More than 5,600, or 9.7 per 1,000 women, were performed in the state in 2011, according to a report from the New York-based Guttmacher Institute.

Iowa’s new Family Planning Program helps cover the cost of birth control, pelvic exams, pregnancy tests and some testing and treatment for sexually transmitted diseases for women and men ages 12 through 54 with household incomes up to 300 percent of poverty level.

On June 6, less than a month before the federal funding was set to expire, Human Services sent a letter to all Iowa Medicaid providers asking them to attest online that they do not provide abortions in order to be listed as a provider eligible for reimbursement under the new program.

Two weeks later, Human Services sent a second letter to clarify that providers that don’t provide family planning services did not need to submit the paperwork.

“We think there were many providers who saw a letter from the government saying ‘Do you do abortions?’ Tomlonovic said. Clinics that don’t provide abortions — but also don’t provide family planning services — may have completed the paperwork, she said.

That might explain how Mark Wertheimer, a now-retired cardiothoracic surgeon in Dubuque, ended up in the database of family planning providers.

“I don’t have the faintest idea,” Wertheimer said about why he’s on the list.

He said he did not prescribe birth control pills or offer family planning services in his practice at the Medical Associates Clinic in Dubuque.

Wertheimer doesn’t recall getting a letter about the Family Planning Program.

“I get put on all sorts of lists for things,” he said. “They get my name mixed up with someone else’s.”

Dermatologist James Karkos and the Mercy Dermatology Center in Mason City also are on the list.

“Thank you for bringing this matter to our attention,” Stephanie Duckert, marketing manager for the Mercy Medical Center-North Iowa, wrote in a Jan. 10 email to The Gazette. “Dr. Karkos and the Mercy Dermatology Center do not provide family planning services.”

Duckert said she’s looking into whether Human Services can remove the names from the database. “We are committed to ensuring our patients and families have accurate information about our providers and services.”

More than once

Nearly 20 percent of the providers in the database are listed more than once — in some cases as many as five, six or seven times.

This may be appropriate if a doctor or nurse practitioner practices in multiple clinics, sometimes in different towns, Tomlonovic noted. However, there are many occasions in the database where the same provider’s name is listed multiple times with the same city and phone number.

“When you have the same provider and same number and office location listed, that is a problem,” Tomlonovic said.

The Family Planning Program database has 135 listings for independent laboratories, the bulk of which are located in other states including California, New Mexico, Michigan, Illinois, Tennessee and Texas. None of the out-of-state labs have Iowa phone numbers, although some have toll-free numbers.

Julie Lovelady, the state’s Medicaid deputy director, declined to talk by phone about the Family Planning Program database. But Human Services spokesman Matt Highland did answer some questions by email.

“The list is generated automatically from each provider’s enrollment record with Iowa Medicaid,” he said. “By pulling data directly from this system, it offers the most real-time information, as it updates each night.”

The list includes all providers who have attested they don’t do abortions and are eligible for reimbursement for family planning services, he said. Labs didn’t have to complete an attestation, Highland said, but if they did, they were included in the database.

The department stands by the multiple listings of providers who completed attestations at different addresses.

“If the provider is affiliated with a specific location, and if that location completed the attestation, Iowa Medicaid’s provider enrollment system recognizes the provider each instance,” Highland said.

Tomlonovic from the Family Planning Council said she’s asked the department to remove inaccurate and duplicative information from the database. “We have said to DHS several times they need to clean up the list,” Tomlonovic said. “They know that.”

When asked why concerns with the database remain, Highland said Medicaid “strives to improve our provider lists continually.”

However, he added: “Iowa Medicaid does understand that due to complex nature of provider enrollment, some confusion may be caused.”

Courier will not publish Monday

The Courier will not publish a newspaper Monday, Jan. 1, due to the Martin Luther King Jr. holiday. Our customer service department will be closed Monday but will reopen at 8 a.m. Tuesday.