Children’s hospitals say getting approval from Medicaid agencies and managed-care plans to treat out-of-state children and negotiating payment often takes more time than delivering the care. They have to arrange individualized case agreements for each patient.
Dr. John Cunningham, physician in chief at Comer Children’s Hospital in Chicago, said hospital staff members recently removed a brain tumor in a child from northwestern Indiana. But Medicaid refused a payment deal that would have enabled Comer to continue treating the patient, forcing the family to go to Indianapolis for follow-up care.
“The transfer was not because of the care. It was because of an artificial boundary called a state line,” said Cunningham, whose hospital is treating 275 kids from northwestern Indiana and has hired a lobbyist to push the Indiana bill. “That’s a fundamental problem.”
But Medicaid officials say that sending kids to out-of-state facilities can be too costly and that interstate travel may not be best for the family. “When a children’s hospital prides itself on being the top pediatric center for different conditions, it knows people will come and it doesn’t have to negotiate,” said Matt Salo, executive director of the National Association of Medicaid Directors. “It’s ‘take it or leave it.’ That’s not fair.”
Some states and children’s hospitals have been able to work out broader deals. The Illinois Medicaid program, for instance, has arranged to pay St. Louis Children’s Hospital in-state rates for serving children in the East St. Louis, Illinois, area.
In contrast, Children’s Hospital of Philadelphia leaders say their facility often treats children who live just across the Delaware River in New Jersey for much lower rates than New Jersey’s Medicaid program pays the more distant in-state children’s hospital — or without getting paid at all. It offers some services, such as fetal surgery to correct spina bifida, that aren’t available in New Jersey.
“None of the Medicaid [managed-care] plans in New Jersey has ever complained that our rates are too high,” said Ahaviah Glaser, senior director of health policy at Children’s of Philadelphia, which serves 25,000 New Jersey kids a year. “But behind closed doors, they say it’s too expensive to have a [renowned, out-of-state] children’s hospital in their plan’s network, because it attracts sick kids. That’s illegal and immoral.”
New Jersey lawmakers are considering a bill requiring the state’s five Medicaid managed care plans to offer adequate pediatric care networks within set distance limits.
Wardell Sanders, president of the New Jersey Association of Health Plans, warned that unless it adds rate limits, the bill would hike state Medicaid spending by forcing plans to cover even routine pediatric care at top children’s hospitals in Philadelphia and New York.
Other children’s hospitals around the country also complain about Medicaid barriers to treating out-of-state kids. Leaders at the Denver area’s Children’s Hospital Colorado, which serves thousands of patients from six surrounding states, say their doctors must obtain separate liability insurance policies in each state. And each has a different policy on covering families’ travel and lodging.
“Once we’ve started to see a patient, we don’t have a lot of negotiating leverage,” said Annie Lee, Colorado Children’s executive director of Medicaid strategies and community health. “We have rates from states that are all over the board, and we’re unable to consistently cover the costs of care.”
All this can produce hassles and anxiety for parents of very sick children, who already face tremendous stress and costs.
Vinessa Kirkwood, who lives in an Indiana suburb near Chicago, said she’s had to cancel appointments at Riley Children’s in Indianapolis for her 20-month-old son, Donte, because she can’t afford lodging. Also, she shares a car with her partner, who needs it for work, and she juggles Donte’s care with the needs of her four other children.
She wants Donte, who was born with cerebral palsy and severe digestive problems, to receive his regular care at Lurie Children’s, where he had surgery soon after he was born. So she’s closely watching what happens with Sen. Bohacek’s bill.
“I’ve got those Lurie doctors on speed dial,” she said. “I’m hoping to get back to them soon.©2021 Kaiser Health News. Distributed by Tribune Content Agency, LLC.