- Associated Press - Friday, June 30, 2017

RENO, Nev. (AP) - Lying under a bridge on a freezing night in February, Bill George had an idea of how close to death he might be even if he didn’t want to admit it to himself.

He had tried to keep his feet dry. Five years of living on the streets in Reno taught him the importance of dry feet. But the sleet and snow of this record-busting winter got the better of him.

Once his feet were wet, nothing could be done to keep them warm, and they began to freeze.

That’s how he got stuck under the bridge.

“At that time, I wasn’t able to get downtown,” George said in an interview with the Reno Gazette-Journal. “My feet were freezing up. I had no water. No nothing. I was starting to feel it and it was hitting you quick.”

By the time Lisa Lee, a case manager for Northern Nevada HOPES, found George, he was likely hours from death. Frostbite had eaten away at his feet so badly that they hung from exposed tendons. Infection was creeping up his ankles, giving off the stench of rotting flesh.

Through Lee’s patient ministering, George made it to the hospital, where he had both feet amputated and spent weeks recovering, followed by two months in a rehab hospital.

“Well, it’s a miracle I did make it,” he said.

George’s case made headlines earlier this year when Lee testified at the Nevada Legislature, showing gruesome photos of his feet in an effort to win funding for more community case managers to help people like George.

But George’s story has exposed a larger problem.

Although George, 52, is homeless, he has health insurance through the state Medicaid program for severely low-income individuals. His Medicaid insurance, paid for by state and federal tax dollars, is through Health Plan of Nevada.

But George never received his insurance card, despite listing the downtown homeless shelter as his address. Nor did he receive the welcome phone call for new enrollees, nor the packet of information explaining how his managed care organization works.

So, he never saw a doctor. Never saw a psychiatrist. Never had a prescription filled. Even as his feet rotted off of his body.

For 16 months, however, the state paid Health Plan of Nevada a monthly fee of up to $563 for George’s health insurance. That insurance would have paid for him to see a doctor, access psychiatric care if he needed it or even possibly get housing.

And, according to a Reno Gazette-Journal investigation, there were 30,817 Nevadans just like George - enrolled in a Medicaid managed care plan but not seeing a doctor - last year.

Although these Medicaid clients never saw a doctor, or any other health care provider, the state paid between $254 and $576 per person per month to their insurance company. That’s as much as $213 million in tax dollars paid directly to insurance companies for people who never received health care.

The actual dollar amount is likely lower depending on the demographics of the clients who aren’t seeing doctors. The monthly rate paid to insurance companies depends on factors such as a client’s age, gender and where they live.

But the state knows little about those Medicaid clients who don’t use health care services. In fact, most states and the federal government don’t even track how many of their Medicaid clients never use any health care.

“You have two issues: first is people should have established access to care. That is the most important thing,” said Julia Paradise, associate director for the Kaiser Program on Medicaid and the Uninsured. “And from a payment standpoint, you don’t want states to pay plans too much or too little to finance their health care activities.”

It’s a problem that Nevada director of Health and Human Services Richard Whitley wants to fix.

After George’s case hit the media earlier this year, Whitley wanted answers about how many Nevadans may be in the same situation as George: covered by state-paid health insurance, in dire need of health care and not getting it.

“It is our responsibility to ensure that they get adequate health care, and this man did not get adequate health care,” Whitley said. “The bigger issue is how many other people are there like him? Let’s look at the data and see.

“We clearly have to do better. To have coverage and not access it is a problem.”

The number of low-income Nevadans covered by Medicaid has more than doubled, from 300,000 to 600,000 since 2014, thanks to Gov. Brian Sandoval’s decision to opt in to the expanded coverage provided under the Affordable Care Act.

Nevada is expected to spend $1.4 billion on Medicaid in the next two years - a large portion of that will be refunded by the federal government.

As Nevada expands its reliance on Medicaid and cuts the mental health services it provides directly, managed care insurance companies such as Health Plan of Nevada and Amerigroup will be shouldering the responsibility for caring for the community’s most vulnerable populations.

It’s a system that failed George.

All his life, George has been a walker. That’s how he would stay in shape and out of the doctor’s office, he said.

Born in Springfield, Ohio, George lived much of his life in Florida. He endured Hurricane Katrina there. He ultimately left after an argument with a deputy, hitching a ride with a friend to Los Angeles 11 years ago.

George said his friend stranded him in Los Angeles, so he started walking, making it all the way to Truckee.

“Back then, I had legs and pretty much stayed in shape,” George said.

But police in Truckee began to hassle him, George said. They worried he was going to vandalize something, he said.

“So they spent $15 and put me on a Greyhound and sent me here (to Reno),” he said.

His first five years in town, George said he could easily find work and mostly stayed off the street.

“I pulled myself out of it, but the economy was better back then,” he said. “It was easy to get a job. At that time I had almost three jobs.”

When times were bad, George would seek shelter along the river or in the tent city that had sprung up near the Community Assistance Center. He applied for federally assisted housing, which never came through.

“It’s hard when you’re single,” he said, noting that most public assistance, such as housing and health care, is geared toward families.

That changed in 2014, when Sandoval opted in to the expanded Medicaid program, which extended health care coverage to many low-income single men, like George.

When George signed up for food stamps in 2015, he also began receiving Medicaid benefits and was provided coverage through Health Plan of Nevada. He said he listed his address as the homeless shelter but never received his insurance card.

Health Plan of Nevada, an affiliate of UnitedHealth, refused to discuss George’s case despite the fact he signed a patient confidentiality waiver.

But in an email exchange with the state obtained by the Reno Gazette-Journal, a Health Plan of Nevada executive confirmed George did not receive any health services until he lost his feet.

The reason? The company didn’t have a phone number for him.

“Unfortunately, because he did not have a telephone number, we are unable to contact him,” Kelly Simonson wrote to Nevada’s Medicaid Administrator Marta Jensen.

If the company knows an enrollee is homeless, it will send its outreach staff to find the person, Simonson wrote. But, despite the fact George listed the homeless shelter as his address, the company did not flag him as homeless and never went to find him. As a homeless man, George did not have a phone.

Simonson went on to explain in a separate email that “our staff reported this week that there are an increasing number of members without telephone numbers and are therefore unreachable.”

That explanation was unacceptable to Whitley.

“From the managed care perspective, they’re not paying for any service and so that’s profitable for them,” Whitley said.

“But you have very high-risk people who aren’t accessing any services until they probably have a very costly encounter and we could have intervened earlier,” Whitley said.

New federal rules for Medicaid require insurance companies to make their “best effort” to do a health risk assessment on all new enrollees within 90 days, said Julia Paradise, an associate director with the Kaiser Program on Medicaid and the Uninsured.

“It’s the plan’s ‘best effort’ as opposed to a requirement, but it at least gives you an idea what the federal expectations are of plans that contract with Medicaid,” she said.

Both Health Plan of Nevada and Amerigroup said they have a variety of outreach measures in place to find hard-to-reach clients, including mobile clinics, on-the-ground community health workers and partnerships with nonprofit organizations.

Amerigroup, for instance, has a rapid response team that springs to action if a previously unreachable client walks into an emergency room.

Whitley said the state should explore moving clients who don’t use health care under one company to another managed care company that has demonstrated a better ability to reach and care for difficult-to-find clients. The state now contracts with four companies. Whitley hopes that competition will force the companies to improve their outreach efforts.

He also said when clients re-enroll for food stamps, the state can check to see if they’ve accessed health care and help them navigate the process if they need to.

“We don’t want this to happen twice,” said Jensen. “It’s tragic. We need to monitor things more closely.”

In the end, it was Lee, not a health insurance outreach coordinator, who found George and saved his life.

Lee is a community-based case manager with Northern Nevada HOPES. Her position is funded by a state grant administered by Washoe County. Her job is to essentially walk the streets of Reno in search of people like George who are “service resistant” and find a way to provide them health care, food and housing.

But her job is in danger, as well. The grant that funded her position and two other case managers in northern Nevada has expired and officials are scrambling to find a way to find alternative funding.

“They have come across people with stage four cancer living on the street; people with brain tumors,” said Sheila Leslie, behavioral health program coordinator for Washoe County. “These are chronically homeless people who have lived for years on the street and have not been able to access medical care. Some of their conditions are just horrendous.”

Lee said she is successful because she takes time to build a relationship with her clients, gently nudging them over time to take advantage of services that will get them off the street and in better health. She said that can’t be done over the phone by insurance company case managers.

She added that insurance companies tend to focus on individuals who use a lot of health care services.

“The people who continue to be off the records are the ones who are not using services,” she said. “They are not going to appear on anybody’s list.”

George said when Lee first approached him, he sent her away. But she came back.

“If she hadn’t come by, I don’t know what would have happened,” George said. “I’d probably be dead.”

___

Information from: Reno Gazette-Journal, https://www.rgj.com

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