(Cross-posted from the COFAR blog)
Hang Lee struggled to get his words out in testifying yesterday morning before a packed public hearing in Boston on a proposal by the Patrick administration to introduce managed care into the delivery of services for the disabled.
Hang said he is concerned that under the proposal, he and thousands of other disabled people who are eligible for both Medicaid and Medicare, will see reduced funding for medical equipment and services they currently need and might need in the future.
Hang suffers from cerebral palsy and scoliosis, debilitating and progressively worsening diseases of the spine and nervous system that he anticipates will leave him completely immobilized in a few years. “I am in constant pain and emotional agony,” said Hang, his face contorted with the effort to speak each sentence.
He said he anticipates he will evenually need a body brace, which costs thousands of dollars. “A cut in services means a reduction in funding for the brace,” he said.
Hang was one of dozens of people, who are dually eligible for Medicaid and Medicare-funded services, who testified at the hearing held by the Executive Office of Health and Human Services. Under the EOHHS proposal, private vendors, known as Integrated Care Organizations (or ICOs) would be hired to manage medical, prescription drug, and disability services to thousands of those people.
Medicaid helps fund a range of residential, employment, and other services for persons with disabilities, while Medicare funds medical care and prescription drugs for many of those same people. The EOHHS maintains that their proposed system would cut costs of care by eliminating overlap, redundancies, and a lack of coordination between Medicaid and Medicare. Medicare and Medicaid will spend a projected $3.85 billion in 2011 on health care for dual eligible adults ages 21-64 in Massachusetts, according to EOHHS.
COFAR and the SEIU Local 509 state employee union called for exempting the management of residential care, day and transportation, service coordination and other services from the proposal. SEIU representative Stu Dickson maintained that while the union “agrees with the need to address needless costs of medical procedures, tests abuse, billing and administrative redundancies, etc., this is profoundly different than the care of human beings.” Dickson contended that in implementing the proposal, Massachusetts would compete with other states in a “race to the bottom” in care for the disabled.
“This proposal appears to be another step in this administration’s quest to privatize key services to the state’s most vulnerable people and to remove government from its responsibilities in that area,” I testified on behalf of COFAR.
Even the human service providers are not sold on further privatization in this area. In a December 16 email to members, the Association of Developmental Disabilities Providers stated that “the Arc (of Massachusetts) and ADDP do not believe there is current research available that validates significant cost savings attained by turning over large parts of State Medicaid programs to managed care companies.”
As did Hang, many in packed hearing on Wednesday said their main concerns were the retention of consumer choice and access once a corporate entity was making decisions on who gets what services.
Other speakers maintained that they had spent years, in some cases, in finding doctors and therapists for their conditions and might lose those specialists under a managed care system. “My doctors all work together,” one woman testified. “My concern is I’m enrolled in a managed care plan and my doctors are not enrolled in it, what do I do?”
“We have to make sure the big corporations don’t just look at the bottom line,” said one man who relies on Medicaid-funded personal care attendants for his disability.
Others called for more planning for oversight of the ICOs, and more accountability. Dale Mitchell of Ethos, a nonprofit provider of services to the elderly and disabled, called for an “independent care management entity” that would oversee the managed care system and prevent it from “chipping away at consumer control and input.”
Victoria Pulos of the Mass. Law Reform Institute said the involvement of consumer-based organizations is needed to establish “accountability systems” to oversee the ICOs. And Laurie Martinelli of the National Alliance on Mental Illness maintained that the “role of families needs to be spelled out” in the EOHHS proposal, in addition to more planning for issues such as transportation of clients.
Let’s hope the folks at EOHHS are listening to all this.
If I undertand this correctly, this sounds a lot like an HMO (managed care) like the current health insurance industry. The same model that has driven the cost of health insurance premiums through the roof.
This is the adminstration’s answer to needless costs of medical procedures, tests abuse, billing and administrative redundancies. Another bureaucracy to fix the problems of an existing bureaucracy. Give me a break.
The same model that makes you go to one doctor to get permission to go to the specialist that you already knew you needed in the first place. (If I can’t hear I don’t need one doctor to tell me I need to see another doctor that is an ear specialist–but I guess I do). I never have been able to figure out how paying 2 doctors instead of 1 is cost effective–probably because it isn’t!) The same model that, when you are sick, makes you wait a couple of weeks for a doctors appointment because they are so busy with appointments to tell people they need to see another doctor. The same model that dictates endless tests, not because you have a symptom or a complaint or even a history, but because of some bureaucratic timetable. So much so that when you have a problem and need a test you have to wait weeks or months to get one because the system is bogged down with needless test. The same bureacracy that treats hospital stays and surgeries like an assembly line and dictates how long a hospital stay is, not a doctor–the person with the alphabet soup after his name–but some clerk. When they have to pass a law that they can’t kick you out of the hospital after having a baby for so many hours, its a clear indication that the system is out of control.
The system rolls over people who are able bodied and can speak for themselves. Can’t imagine what it will do to those who can’t.
It never ends!!!
I agree generally, but not entirely. When Massachusetts did a “carve-out” of the behavioral health side of Medicaid in the mid-90s, it seemed like a bad idea to NAMI and other mental health advocates, since in other states this had resulted in such “reforms” as restricting the list of psychotropic drugs psychiatrists could prescribe, or their ability to prescribe more than one medication of a class for patients with complex issues. Moreover, the winning bid was filed by Value Options, which had been seen as a service-gatekeeper in the private health insurance area.
However, the new company, Mass Behavioral Health Partnership, hired local professionals and even some people from mental health advocacy and the parent movement, and has proved to be a generally good actor, especially since the Rosie D. v. Romney class action suit settlement to reorganize child and adolescent services. (Is it sad that skilled clinicians get paid more to make decisions on authorizing services than they did for providing direct services to people? Yeah, it is.)
For example, after the legislature passed the ARICA parity bill requiring some private insurance companies to cover services for people with autism, Governor Patrick announced that Medicaid could not afford to do that, and would not comply for several years. But by late spring of last year (ARICA went into effect on plan-renewal dates on or after January 1, 2011) the MBHP had organized the other Medicaid managed care entities (which can sometimes be described accurately as adding another layer of cumbersome bureaucracy to mental health service access) to extend most of the “Rosie D.” services to people under 21 with any autism spectrum disorder, even without a “mental health” diagnosis otherwise — effectively putting in some of ARICA for medicaid-eligible youth.
It cannot be strongly argued that managed care in behavioral health in itself has brought large savings, and there are still wasteful uses of expensive services, public and private, in mental health — but in some cases the managed care has provided case management services for heavy service users that manage care better (and deliver better care) than overwhelmed DMH case workers would be able to.
The difference between MH and the DD services (with Dave starting this on the COFAR blog) is that the mental health system in Massachusetts is already so far gone that cheap substitutes look like novel resources. The DDS system actually has been fairly functional for many clients and their families, and thus the addition of managed-care companies has a larger chance of screwing up something that works than it does of disciplining providers to provide what they are contracted to do — but it’s not 90-10, and that’s how I read the measured opposition of ADDP, ARC, COFAR, and NAMI (which includes adult consumers who have been slammed by cuts for six years). Advocates and providers are worried, but not ringing all the fire bells. I’d put the odds at 70-30 that managed care in itself does more harm than good, maybe even 60-40.
The real problem looking forward is that the managed care companies are going to be given fewer marbles to play with, as the federal government keeps planning on cutting Medicaid and possibly Medicare as well. Those cuts are likely to eat up any efficiencies discovered by the managed care entities (over and above the additional cost of having the managed care companies exist) and then some. Given a level-funded playing field and some strong court direction by the Rosie D. settlement, MBHP has managed care in a generally positive way, and the other Medicaid MCEs in behavioral health have tended to fall in line, as far as I can see. Given big federal cuts in one or both programs, the managed care ventures in Medicare-Medicaid for people with DD or any long-term disability (including chronic mental health diagnoses) — are going to have a very hard time being good care coordinators under the pressure of becoming tight-fisted financial gatekeepers. In that looming but not inevitable scenario, it would be more efficient to build up care management and contract management staff at the state and federal agencies to manage care than to add another layer of for-profit contractors to discipline the existing private providers, who are in our state are still mostly private non-profits.
The state’s effort with regard to the issue of so called Dual Eligibles is an outgrowth of compliance with the Affordable Care Act of 2009 and it’s effort to both expand the number of people covered with regard to health insurance and cost containment. It does appear that both the Obama Administration and Congressional Republicans support managed care, thus it’s momentum seems assured. There are very serious policy considerations including eligibility, case management and consumer protection that must be addressed before the state finalizes it’s proposal. The understanding of this proposal is not widespread, thus the more public discussion on this matter, the better.