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SD Medicaid Denies Payment for Mayo Treatment; Patient Moves to MN

Here's the tough call of the morning. Jonathan Ellis reports that South Dakota implemented a new rule on September 1 requiring Medicaid patients to get authorization from the state to seek medical treatment more than 50 miles from South Dakota (with the exception of folks headed to Bismarck for service, which makes perfect sense for folks all along lonely Highway 12). The rule is a reasonable cost check, used by many states as well as private insurers. The state hasn't been wielding it too avidly: Ellis says in the first two months of the rule, the Department of Social Services denied only 14 of 483 requests for out-state care.

Enter Nicole Cook, 31, mom of six, from Madison:

Cook originally went to Mayo in August after repeated doctor and hospital visits in Madison and Sioux Falls, she said. She was rapidly losing weight, was exhausted and in pain.

Testing at Mayo determined that she has a lung tumor, scarring in her lungs, bone lesions and other health problems. She was scheduled to return to Mayo in October with the hope that doctors there could find a cause for her maladies.

But this time, she was unable to go because the Department of Social Services would not authorize payment for the visit [Jonathan Ellis, "Medicaid Rule Drives Woman from S.D.," that Sioux Falls paper, 2014.12.01].

Cook says the state says South Dakota doctors can provide the care Cook needs. But South Dakota doctors evidently couldn't provide the diagnosis Cook needed. Nicole's husband Ryan says on his fundraising page that Nicole's local doctor actually dropped her, saying her case is too complex for him. One can thus understand her lack of confidence in her local docs and her preference to seek treatment from the Mayo docs. According to Ellis, Cook's Sioux Falls doctors are recommending Mayo for treatment.

But who gets to pick the piper: the patient or the payer? Cook or us, the taxpayers?

Cook is relieving us of that choice. She is moving to Minnesota and applying for Medical Assistance. As far as I can tell, Minnesota has no rules against moving primarily to qualify for public benefits. Minnesota's residency rules say that once she's physically present in the state and made clear her intention to stick around, she can qualify.

So how do we feel, South Dakota, about driving away someone who needs help?

p.s.: Cook's fundraising page shows about $4,800 raised toward a $150,000 goal. Please don't tell me that private fundraising is an effective way to pay for everyone's medical bills.


  1. leslie 2014.12.01

    yup, this is the real deal stuff. mayo can act on a cancer recurrence in a day, where out here in the west, the sole oncologist delays three weeks restarting chemo applications, while the tumors are growing. yikes.

  2. Tim 2014.12.01

    Those death panels republicans made such a big deal out of a few years ago?

  3. SDBlue 2014.12.01

    My 79 year old dad recently underwent a sleep study at Avera in Sioux Falls. My 77 year old mom was worried because he holds his breath in his sleep. Within 90 minutes, the nurse monitoring the study concluded that yes indeed, my dad was not breathing properly while he slept and she placed him on oxygen immediately. My dad said the oxygen helped him and he had the best sleep he has had in ages. So, did Avera send my dad home with the equipment he needed? No. It has now been over three weeks and he is still waiting for the doctor to review his sleep study and prescribe the CPAP machine he needs. Oh, and my dad was also told if he has not heard from the doctor, he should probably call and remind him that he is still waiting.

  4. Jenny 2014.12.01

    I don't subscribe to the Argus. Cory, did the GOP vote this bill in last session? I'd like to know more about this Medicaid rule, and which legislators voted to prevent access to healthcare.

  5. Jenny 2014.12.01

    The GOP party of SD would rather let a young mother die of cancer than get the treatment that is needed out of state. The State is not bankrupt, it HAS the money to pay for this woman's care. And the GOP claims to be the party of morality, of family values! Uhhh!!!

  6. Francis Schaffer 2014.12.01

    The 'Right to Life' or is it 'Right to Birth' people should set in to help!

  7. 12 2014.12.01

    South Dakotans reap what we sow. We vote against our own best interests election after election. When are the people in our state going to wake the eff up???

  8. Francis Schaffer 2014.12.01

    Step not set. To where did my preview button disappear.

  9. Nick Nemec 2014.12.01

    Jenny, I suspect this is the Daugaard administration implementing rules in an attempt to either hold costs down or favor large in-state companies. In SD new laws usually go into effect on July 1.

  10. mike from iowa 2014.12.01

    The wealthiest nation on earth,ever, and ordinary citizens have to depend on the charity of other ordinary citizens for help with catastrophic health care bills. You know what the problem is.

  11. Nick Nemec 2014.12.01

    If local doctors have said this is beyond our expertise and advise a referral to an out of state facility I don't see why the state would have such heartburn.

  12. Katie 2014.12.01

    I agree that this is unfair but MN's state aid has always done the same in reverse (at least for the providers office I work for). They provide no coverage for out of state services. I don't think this is unusual for state aid.

  13. Jenny 2014.12.01

    The State of SD could easily write it off on the books as a goodwill gesture. She's probably not related to any of the Good Ol' Boy Club members though, so she's on her own.

  14. Francis Schaffer 2014.12.01

    All she needs is a couple EB-5 'investors'

  15. Jenny 2014.12.01

    The far majority of Minnesotans have no need to go to SD for their healthcare needs, so this so-called rule hurts poor South Dakotans more.

  16. Bill Fleming 2014.12.01

    Francis, that's a brilliant comment! I'm guessing you may have meant it as satire, but thinking about it a little, One has to wonder, how many jobs are created and/or preserved when you set out to save a sick person's life? And how many more if the effort is successful? Could an organ donor or a monitary inversor or a combination of the two get permanent visas for themselves and their immediate families if they saved lives instead of businesses? And wouldn't, it in essence, be the same thing?

  17. Bill Fleming 2014.12.01

    Above, ...monitary inveSTOR... Sorry.

  18. jerry 2014.12.01

    Our new friend Steve Hickey wants to bring up payday loans prohibition in the legislature to stop the destruction of family life due to legal loan sharking. When confronted about a suicide due to mental health issues, he quickly decided that kind of treatment was not to be considered for Medicaid Expansion and would not support the passing of this life saver. There is nothing sexy in helping the poor stay healthy and providing them a chance to live, what the legislators want is something they can be lobbied on. You can bet that payday loan lobbyists are going to be thicker than a coyotes coat in January when they get together for drinks and chow. South Dakota's priorities are in the toilet along with the thinking. There is no money in poor people's health for them.

  19. Nick Nemec 2014.12.01

    Maybe this is the Republican plan to reduce Medicaid costs in SD, force all the poor sick people to move to some other state.

  20. Lynn 2014.12.01

    If Nicole had health insurance from DakotaCare, Sanford or Avera could her physicians have been more thorough and been able to come up with the same diagnosis that Mayo discovered? Did being on Medicaid really limit the quality of care she received?

    With the expansion of Medicaid in Minnesota for example health insurance plans are available there on a sliding scale where as in South Dakota where Medicaid has not been expanded those lower income customers only have the option to pay full retail for insurance if they can afford insurance at all.

    Nicole's video was and music was very touching! Her and her family's chances are much better in Minnesota.

  21. larry kurtz 2014.12.01

    Daugaard is a mean-spirited partisan hack: as this is being typed Wyoming's GOP governor is proposing a massive expansion of Medicaid.

  22. Joan Brown 2014.12.01

    In mid September I was diagnosed with stage three colon cancer at Sanford in SF. I went to the hospital by ambulance and laid in the ER for more than 2 1/2 hours before seeing a doctor. I can't complain about the other care that I received in the hospital, but the follow up appointments with an oncologist and for another cat scan left an awful lot to be desired. I wasn't considered at all about when appointments would be convenient for me and when you aren't feeling well, having to find rides on the spur of the moment makes it that much harder to get to appointments. Several years ago I had prety much made up my mind not to do treatment if I ever developed cancer, mainly because I didn't like the way side effects of the treatments sounded. Then after visiting with the oncologist and being told that the other life saving medications that I take would make the complications that much worse and that the chem would make it hard to control another pre-existing chronic health condition. So after discussing it with my daughters and adult grand kids I decided to live a quality life as long as I can rather than a longer life and feel rotten most of the time. So far I feel good most of the time and don't have any pain.

  23. JeniW 2014.12.01

    Joan, I am sorry that you are having to go through this. Please consider getting assistance from Sanford, or if preferred, Avera's Hospice program, if you have not done so already.

    I used to be a hospice volunteer, and I have had relatives who received hospice care. It is a great program and they will be with you and your family every inch of the way.

  24. Jaka 2014.12.01

    Private fundraising or benefit drives are the new norm in SD as our gov't doesn't believe in those Federal medicaid proposals under the Obamacare model. We are a little peculiar about what gov't handouts we want to take here, ya know! If'n it's good for business, banking or ag we'll dang sure grabit in a sec, but not for people we think shouldn't be askin' fer it!!

  25. Donald Pay 2014.12.01

    Isn't this a "death panel?" Where are the Tea Party goofballs?

    Isn't South Dakota really being "deadbeat dickheads?" Is there any reason why Minnesota couldn't sue South Dakota to collect the money to provide for the medical care for a resident who has to move to another state to obtain medical care?

    It seems to me this is the state equivalent of the "deadbeat dad" issue, where non-custodial fathers welch on their duties to support their children. South Dakota is refusing to pay for needed medical treatment of a person who is lawfully qualified under their medical aid program, and another state has to pick up the cost when the person has to move to get the treatment.

  26. larry kurtz 2014.12.01

    DD's death panel is just soylent green on subsidies.

  27. jerry 2014.12.01

    To me, the whole idea about the denial of the Medicaid Expansion has nothing whatsoever to do with the bottom line of South Dakota's fiscal business, it has to do with pain. Republicans love that stuff, they like it very much when they can inflict pain on the poor the elderly and the weak. Giving people health care would actually lower costs significantly for the state, but it would not satisfy their lust to see people in pain, their base expects it and they will not deny the votes that keep their greed in office. Here is from Arizona's living proof of how Medicaid Expansion worked long before Obama.

    Some give Daugaard cover for his choice being political in the regards of a dislike of Obama, this proves it has nothing to do with the current occupant of the White House.

  28. Dave D. 2014.12.02

    Isn't this Obamacare wonderful!! This is what we got voting that in and you all know it!!

  29. Tim 2014.12.02

    Trolls, got to love the ignorance, this is medicaid Dave D, has nothing to do with the ACA.

  30. caheidelberger Post author | 2014.12.02

    What Tim said, Dave D. I missed the part where this Medicaid decision had anything to do with the ACA.

  31. jerry 2014.12.02

    Dave D. proves my point exactly about wanting to see pain. The sad fact for them is that with people getting coverage under the ACA and its components, that pain the republican base loves to see inflicted on others, has dissipated substantially. To the base, no pain no gain. So they are off to pulling the wings off flies while they keep up the pressure on Daugaard to not give in to the needs of the people he is responsible for. Red state rules!

  32. Jenny 2014.12.02

    This doesn't have anything to do with the ACA, Obamacare, whatever you want to call it. This is simply indifference to SDs poor. I'm proud that my state govt in MN is decent enough to pay for a young mother's medical care. Is this that common sense Rounds talks about, hand off your sick to that blue state next door? To think of all the stress the SD govt has given this sick mother and her family.

  33. JeniW 2014.12.02

    I wonder if Daugaard and Rounds would be willing to look this individual in the eye and tell her that she is not "good enough" to deserve medical treatment?

  34. jerry 2014.12.02

    JeniW, of course they would have no problem with that. They do it each and every day, those eyes of theirs, are empty.

  35. Richard 2014.12.02

    I read the original Argus story and what struck was not SD Medicaid's refusal to fund a consult at Mayo, but rather the writer's lack of information of the NEED for a consult. The writer could have had the complainant sign a release of information for her MDs. Then the story would have had balance. As it stands no one at Medicaid can explain why the consult was turned down UNLESS she agrees to share her protected health information. I think the Argus writer did a disservice to the readers. Only one side of the issue (hers) was presented.

  36. jerry 2014.12.02

    Richard, so sorry you missed this "According to Ellis, Cook's Sioux Falls doctors are recommending Mayo for treatment"

    In a consult with insurance companies or in the medical field itself, when there is a consensus that the patient cannot be treated adequately through their hands or the capabilities of their heath delivery system, you are referred to a place that can deliver the healthcare. The author did in fact inform his readers of this. You just missed it.

  37. Richard 2014.12.04

    No. Mr. Ellis kindly responded to my emailed requestfor more information on his sources. He did not interview the patient's providers. I do not want to belabor this. I believe in Medicare E(veryone). I believe the Declaration should read "Healthy Life, Liberty and Happiness". This particular patient's health care may be a good example of poor Medicaid management judgment and limitation of benefit, OR it may not be. I think it is important to better understand the various diagnoses and prior threatments prior to assuming she was mistreated by her carrier.

  38. caheidelberger Post author | 2014.12.04

    Yeah, but Ellis probably can't interview those doctors. A patient can waive her HIPAA rights and talk all she wants about her medical conditions and treatments, but the doctors and hospitals cannot.

  39. Catherine Ratliff 2014.12.04

    A disabled client of mine moved from Sioux Falls to Luverne, MN and now receives excellent medical care including care at Mayo Clinic. Since then I've advised other SD clients to take a drive to Luverne, look it over, consider the move.

  40. Richard 2014.12.04

    When you sign a release of protected healthcare information it specifies what kind of information will be released and to whom. You are not waiving HIPAA rights, you are using the law to open your healthcare records to other interested parties. Doctors and and hospitals cannot give any information to anyone without the permission of the patient or the patient's designee. Doctors and hospitals MUST comply with the request and send the information. The same goes for interviews on the telephone or in person. The provider must cooperate and discuss the healthcare information.

    My point (and I do have one) is that judging the fairness of a healthcare insurance provider like SD Medicaid is difficult unless all the information is available. The patient could have released all her healthcare information and allowed her providers (and Medicaid) to be interviewed, but for whatever reason, that did not happen. So not all information is available for the reader.

  41. Jenny 2014.12.04

    Sioux Falls doctors refer patients to the Mayo Clinic all the time when they can't find a diagnosis that detects the symptoms from all the tests and labs that have been done. This is routine. The state of SD just did not want to pay for the Mayo Clinic bills, which was wrong in my opinion. The young mother has cancer for gosh sakes! She wasn't just making it all up! She had severe symptoms of weight loss and pain. I don't understand this information that is needed that you're talking about, Richard.

  42. caheidelberger Post author | 2014.12.04

    And that's a reasonable point, Richard: HIPAA and professional ethics mean we can't get all sides of this story, as is often the case in stories about teachers and school discipline.

    So which is the responsible journalistic choice: to tell the necessarily incomplete story (which I'll admit, I do all the time, on a variety of topics), or tell no story at all?

  43. Jenny 2014.12.04

    I just read her fundraiser page and hadn't realized she had gone to the Mayo Clinic without a referral from their SF doctor, but then Ellis says in his article that SF doctors are recommending treatment at Mayo. I understand what Richard is saying now. The info seems to contradict each other. Why did they go to Mayo without a proper referral in the first place? Why did SF doctor not write up the referral in the first place? The husband said they then went into the ER at Mayo, b/c Mayo wouldn't see them without the referral. ER visits are the costliest of visits.

    This is just a very sad, complex medical case, and I think Ellis should do a followup to this story so we can get the correct information. Sorry Richard, I know what you mean now.

  44. jerry 2014.12.04

    When you get a refereal to go to another facility, it is because you cannot do the treatment yourself. So if the doctor said that, as indicated by the report that he basically dropped her, she has the right under President George Bush's ruling, to seek help at the emergency room.

    What they discovered there should be cause for celebration that they could now find the road map to treat her conditions. What the family could do is get her a Wellmark policy, as an example, and get her the treatment she needs wherever that may be. This is the open enrollment season so they would take her immediately and she could make the plans to take care of her needs starting the 1st of January 2015. They already have 4 grand in the fundraiser so they could purchase insurance for her for a few months until they can get situated. We must do better for all of our people.

  45. Jenny 2014.12.04

    So according to the rules of the ACA, this young lady can not be refused health insurance b/c she has cancer and other serious diagnoses. Am I correct, Jerry? Whereas before, no insurance company would have touched her.

  46. Vickie 2014.12.04

    Medicaid does like to raise a fuss about any number of things at any given time. Often times the alternatives that they propose are more costly and/or cause delays in treatment. They deny coverage even with proper referrals. Question them about it and they will then deny that they ever denied anything. (I'm totally serious) However,they always leave a paper trail. Use that paper trail against them and they will fold. I've done it.

    What's really stupid is that if SD would pull their heads out and expand Medicaid,they would save money AND lives. All DD and the legislature are doing is sitting on their hands in hopes that somehow some way,the ACA will go away. Meanwhile they make lousy excuses for their behavior and people suffer and die.

  47. Richard 2014.12.05

    My Last Post (whew!). Jenny if this patient has cancer there is no mention in the article. Mr. Ellis reports he has seen a letter or note which says she has a lung tumor. Tumors come in three varieties: benign (non-cancerous), pre-cancerous (yeek), and malignant (cancerous-double yeek). Since the reader does not know which kind of tumor is present, the reader cannot deduce she has cancer...

    The story began as a report on SD Medicaid refusing consults to tertiary medical centers like Mayo. Unfortunately, the example of a person who suffered as a result of that policy, is NOT a strong case. There are reasons to go to a tertiary medical center, but the reporter makes a weak case that this patient needs that consult.

    I am reminded of the old joke: Anecdotes are not data, otherwise Fox News would always be right!

    Thanks to everyone for attending and for their patience.

  48. Jenny 2014.12.05

    She has a history of a brain meningioma, which always has a chance of reoccurring, and other serious diagnoses like Rheumatoid Arthritis. Obviously, what was going on with this woman was serious enough that her husband took her to Mayo Clinic, where they found tumors growing on her lungs. Go to her fundraiser page and it mention all of these diagnoses.
    I'm not going to argue the symptoms and diagnoses with you, Richard. That is not up to us. I know I would never like to go through what this woman and her family has to do endure and then having to move to another state to get the proper treatment.
    To me, this just speaks volumes about how the richest country in the world treats its poor.

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