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Uncompensated care, uninsured patients driving public health clinic into the red in Montana’s largest city
The campus of RiverStone Health in downtown Billings (Photo by Darrell Ehrlick of the Daily Montanan).
Citing the Medicaid “redetermination” process and challenges with reimbursement, RiverStone Health, the community health arm of Montana’s largest county, has announced that it is cutting 29 staff positions within the next month.
In a press release on Friday, RiverStone Health said it has been taking steps to reduce its budget, but losses of more than $3 million in Medicaid have led to the reductions that will be finalized mid-June, before the end of the organization’s fiscal year.
In total, the health care organization with a prominent footprint in downtown Billings said that it has cut nearly 9% of its workforce across the organization, including employees who were let go after some programs closed. Those include a rural schools travel nurse program and one inpatient hospice care.
“Several senior leadership positions and managerial roles were also consolidated or eliminated because of these challenges,” the press release said. “Rising costs, lower-than-expected patient volumes for primary care services and stagnant reimbursement rates have been exacerbated by the Medicaid redetermination process that began in April 2023.”
That redetermination process has been two-fold in Montana. While the Montana Legislature increased reimbursement rates for providers during the 2023 session, lawmakers have been hearing from organizations across the state that reimbursements lag months behind. Also, Montana’s “redetermination” rate — which tracks how many people in the state continue on the Medicaid rolls — has dropped at a higher-than-anticipated rate, with many losing healthcare coverage for lack of paperwork. Montana has also been among the states with the highest percentage of children dropped from the program.
“Despite efforts to keep all eligible Montanans enrolled in Medicaid, RiverStone Health has seen a drastic decline in the number of enrolled Medicaid patients, even though most patients still qualify for Medicaid,” the release said.
RiverStone Health is a federally-qualified health center, which means that it provides medical, dental and behavioral healthcare, regardless of a patient’s ability to pay.
“However, as more Montanans lose healthcare coverage because of inefficiencies in the Medicaid unwinding process, the burden of this uncompensated care impacts the livelihood of both our patients and our staff,” the statement from RiverStone said.
The Montana Department of Public Health and Human Services did not respond for requests for comment on Friday afternoon.
RiverStone said affected employees will receive a support package that includes a 30-day notice, access to assistance and support service and will be able to apply for any internal vacancies.
“Everyone impacted by these reductions plays a vital role in protecting life, health and safety,” said Jon Forte, RiverStone Health president and chief executive. “The elimination of these positions does not diminish the incredible difference they’ve made in serving our community.”
The losses, particularly in Montana, have been higher than normal. While 10 million people nationwide have lost Medicaid coverage since “unwinding,” a process in which states verified which patients qualified for Medicaid after a freeze on disenrollments during the pandemic, Montana has had the highest percentage of children disenrolled from April through December 2023, according to the Centers for Medicare and Medicaid. And the organization Cover Montana, which was launched to help stem the number of people losing insurance, said that 64% of those who have been “disenrolled” are doing so because of “procedural reasons,” often just a lack of paperwork.
Forte said that the number of patients RiverStone serves has seen close to 70% being disenrolled because of paperwork issues.
“We’ve been trying to help as many patients as we could, with some of our patient-care coordinators double and triple booked,” Forte said. “They have waited for hours on the phone and stood for hours in line at state assistance locations.”
Forte said RiverStone Health has around 14,000 patients, comprising a mix of Medicare, Medicaid, self-pay and private-pay insurance. About 1,600 patients have lost coverage, and that’s resulted in more than $3 million in uncompensated care. That amounts to more than 6% of RiverStone’s budget.
Regardless, clinics and other hospitals like RiverStone don’t have the ability to deny care, and so the organization experiences an uncompensated loss. While Forte said RiverStone’s client mix is more dependent upon Medicaid, he believes other hospitals and healthcare systems may be facing similar losses because of uncompensated medical care.
“We would never ever turn away an individual because of an inability to pay,” Forte said. “We’re just caught up in a negative trend. But, now we’re being forced to reduce our quality and dedicated staff at a time when we need a strong healthcare workforce and healthcare access.”
Despite the cuts, Medicaid in Montana has conversely seen an equally strong positive support from residents.
In a poll released last week, as many as 80% of Montanans favor Medicaid, and increases in reimbursements to agencies ranging from hospitals to nursing homes.
An annual report, released this week by the Montana Healthcare Foundation, shows that while most insurance costs have risen, Medicaid expenses for the state of Montana, as a percentage of the state budget, have remained flat. Moreover, more expensive in-patient and emergency department services have been replaced by less expensive preventative services.
Finally, Montana was singled out as possibly the only state in the country which was able to successfully bargain for work-requirements for those enrolled in Medicaid. The program required some work or retraining to remain enrolled. According to the same Montana Healthcare Foundation report, nearly 97% of the residents enrolled in Medicaid in Montana are either disabled, work at least part-time or spending full-time taking care of other family members.
In addition to residents losing coverage, providers have also reported widespread delays in reimbursement for providers across the state. Forte said larger clinics, like RiverStone, experienced some of the delays early on during the “redetermination” process, but the state has largely resolved that. He said at one point, RiverStone was waiting more than 12 months for reimbursement on some patients. However, he said some smaller providers are still reporting as long as an eight-month wait.
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PNS - Friday, May 10, 2024 - Biden says the U.S. won't arm Israel for a Rafah attack, drawing harsh criticism from Republicans. A judge denies former President Trump's request to modify a gag order. And new data outlines priorities for rural voters in ten battleground states.
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By Mark Moran - Producer-Editor, Contact - News
Big Sky Connection - Montana children's health advocates are grappling with a dramatic dropoff in the number of kids receiving Medicaid and Children's Health Insurance Program (CHIP) benefits. Critics argue the state rushed kids off the rolls instead of ensuring their well-being, those readjusting the post-pandemic rules say they are simply being efficient. Comments from Jackie Semmens, budget analyst, Montana Budget and Policy Center; and Joan Alker, executive director, Georgetown University Center for Children and Families and research professor, McCourt School of Public Policy.
Click on the image above for the audio. In Montana, 6.9% of children do not have health insurance, ranking the state 44th out of 51, according to Georgetown University's study. (Adobe Stock)
Mark Moran
May 9, 2024 - More than 4 million children nationwide were removed from Medicaid and CHIP health coverage by the end of 2023 as the government reset the programs after the pandemic. As a percentage, Montana children took the nation's biggest hit.
A new report showed 30,000 fewer kids receiving Medicaid or CHIP benefits in Montana than at the start of the pandemic, or a 15% drop, the largest falloff in the nation.
Jackie Semmens, budget analyst for the Montana Budget and Policy Center, thinks the state re-evaluated its Medicaid rolls much more quickly than it needed to, doing avoidable damage.
"We can see that the state's decision to rush through the process -- to not pause it when we knew large amounts of children were being disenrolled, to not use the flexibility from the federal government -- we can see that had real impacts," Semmens asserted. "Montana has ended up being an outlier in children disenrollment."
Semmens pointed out taking children off the Medicaid and CHIP rolls means they are denied services when they need them most, ranging from routine wellness visits to specialty services.
Joan Alker, executive director of the Georgetown University Center for Children and Families and co-author of the report, acknowledged there was some bureaucratic confusion when the government ended its pandemic protections keeping people insured but noted there were states managing to keep much higher numbers of children covered.
Alker blames states with dramatic dropoffs, such as Montana, on rushed bureaucracy.
"States that saw a really large number of children disenrolling, I place that squarely on the governor," Alker emphasized. "Because the folks doing the work needed the resources, they needed the staffing, they needed the procedures and the effort to make this a smoother process than it has been."
The report found the states of California, Florida, Georgia and Texas have seen the largest numbers of children dropped from receiving Medicaid and CHIP services.
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