Ignoring the advice of community physicians and their own medical staff, officials overseeing Minnesota's Medicaid program have limited payments for birth control under certain conditions — one of several decisions that critics describe as missteps that are restricting patient access to critical forms of care.
The agency has also been faulted for delaying access to a drug regarded as the gold-standard treatment for opioid addiction and limiting access to cutting-edge drugs for hepatitis C, a disease that is spreading rapidly.
"It is about shortsighted, near-term cost concerns … at the expense of improved outcomes and longer-term savings," said Dr. Jeffrey Schiff, who for 13 years was medical director of the state Medicaid program, which covers 1.1 million Minnesotans. His position was eliminated in June.
After the Star Tribune wrote about the hepatitis and opioid medication restrictions, and with the intervention of at least one state senator, the Minnesota Department of Human Services, which administers the program, reversed course and lifted most of the barriers.
On Monday morning, Schiff sent a letter to Gov. Tim Walz, Acting Human Services Commissioner Pam Wheelock and the legislative leaders of the health committees, charging that the Medicaid leadership has been "hostile and dismissive about the need for medical input" in several areas.
In an interview with the Star Tribune, Schiff said he was rebuffed in his efforts to change the opioid and hepatitis C treatment policies, that he was excluded from Medicaid decisionmaking meetings and that he was even instructed not to speak on behalf of the program in public. "I had challenges with the current remaining leadership around developing evidence-based policy to care for people in the program," he said. "There is a culture in health care administration that is pretty insular."
In addition, Schiff told the Star Tribune he had been trying for five years to change Medicaid policy so that it will directly pay for reversible forms of contraception for women who have just given birth.
Without addressing Schiff's concerns directly, DHS Assistant Commissioner for Health Care Marie Zimmerman said the agency wants to hear suggestions from the public and that it has several advisory committees to solicit input.
"I certainly don't want to give the impression that DHS isn't open to changes," Zimmerman added.
Sen. John Marty, DFL-Roseville, said he was concerned that DHS is not adjusting policies, especially when doctors have presented evidence that changes would increase access and improve outcomes.
"In these three cases, my whole issue is that somebody else is making decisions that overrule a doctor's best judgment," Marty said. "That is what I would argue is practicing medicine without a license."
In a statement issued after Schiff's letter became public, the agency said, "In addition to capacity within DHS, Minnesota's Medicaid program is advised by multiple independent boards which include physicians and other clinicians.'' The agency also said that a recent redesign of the medical director's office "will allow us to bring on specialized expertise to better address significant areas of opportunity related to health equity, health access and better integration of care across the state.''
Minnesota's Medicaid program covers labor and delivery costs for eligible women, but it does not make an additional payment to health care providers in cases when their patients want an intrauterine device (IUD) or a birth control implant to prevent unintended pregnancies in the near term. Rapid repeat pregnancies can increase the risk of premature birth or low birth-weight babies. By contrast, state policy in some cases will pay hospital costs when a woman chooses sterilization after delivery.
Some community physicians approached DHS to say that lack of payment for the devices was costing the state in the long run and depriving their patients of choices.
"I didn't think it was going to be a very hard sell," said Dr. Christy Boraas, an obstetrician/gynecologist who practices and teaches at the University of Minnesota. "It saves money, saves public dollars and it improves access for patients, period."
DHS contends that because hospitals agree to accept a flat fee for all costs associated with labor and delivery for Medicaid enrollees, they should be providing any contraceptives that are inserted during the hospital stay as part of that global payment.
But nearly 40 states have moved away from that position and have instead found ways to reimburse hospitals for the costs of the devices, known as long-acting reversible contraceptives or LARC.
"We've seen nearly all of the state Medicaid agencies paying for this," said Dr. Michelle Moniz, an obstetrician/gynecologist at the University of Michigan in Ann Arbor. "Minnesota is at the back end of the trend."
"There are at least five papers in the medical literature that demonstrate savings for Medicaid agencies that provide reimbursement for this care," she added.
Indeed, DHS recognized in a 2017 budget proposal that providers were not being "adequately reimbursed." It proposed a grant program that would offset some costs and make the devices more widely available to women who wanted them during their hospital stay.
"The effort will reduce the risk of premature birth and improve outcomes for postpartum mothers and their babies," according to state budget documents.
That budget request did not pass and by 2018, DHS health care administrators advocated dropping the proposal altogether, according to an internal DHS memo obtained by the Star Tribune.
"I wasn't involved in any policy discussions around LARC," Zimmerman said, although she had been Medicaid director for four years before leaving the agency for a few months this past winter. She resumed that role when she returned this year.
Currently, DHS will pay for IUDs and implants in outpatient settings, such as a clinic. The agency also stressed that the HMOs that manage Medicaid for about 850,000 enrollees set their own payment policies. Three of the largest HMOs said they do not make separate payments for LARC as part of Medicaid hospital deliveries.
Advocates say that DHS should lead by example and that some states are requiring Medicaid HMOs to pay for the procedure.
"We know that if people are not able to access contraception in the hospital they oftentimes are not able to follow up as planned," said Dr. Janna Gewirtz O'Brien, a physician at the University of Minnesota. "We want women to have options."