Thursday, May 21, 2009

WCHO Board Meeting, May 19, 2009

"I go to meetings so you don't have to."

The Washtenaw Community Health Organization receives state, federal and local funds to serve people with developmental disabilities, mental illness, and substance abuse problems in our county. I have started to go to WCHO Board meetings to glean information that might be relevant to people with developmental disabilities and to get a better understanding of what exactly the WCHO does and why.

Much of the time I feel like I am in a Peanuts comic strip listening to the adults talking, who never say anything except,
"blah, blah, blah..."
It comes out a little differently here though - more like,
"blah, blah, ORR, blah ARR. blah, blah, Engagement Center, blah, OOC, blah, blah, blah, Integrated Health Care Management, blah, blah, SAMSA, blah, blah, blah, PIHP, etc."
I have confidence that some of this will be decipherable with time.

Here is what I learned:

Patrick Barrie, the WCHO acting Executive Director, gave the Director's Report:

  • The Governor's Executive Order from a couple of weeks ago laid out cuts of $10 million in"non-Medicaid" funds for mental health. CMH Boards will have cuts in funding from 1-5%, with Washtenaw County lucking out at the 1% level, at least so far. This amounts to a $74,000 cut in state funds.
  • The governor's order was quickly approved by the legislature, so there is no going back to restore the $10 million, but there may be appeals concerning the distribution of the cuts for the state's community mental health agencies.
  • The WCHO is going to get two grants for disease management programs. A phrase repeated several time was "Integrated Health Care" which has something to do with merging behavioral health care with medical health care. Using the phrase is apparently one way to make sure that mental health care is not forgotten in the push for health care reform. Everyone is a bit nervous about how mental health care will fit into the health care system of the future.
  • Policies on 1115 waivers (these are Medicaid waivers that allow a flexible use of Medicaid funding) are redone with every administration. Policy changes are expected at the federal level, but so far no one has been appointed to head the Federal Centers for Medicare and Medicaid Services.

At the April WCHO meeting, there was some discussion about the Engagement Center. I assumed that this was something like a clubhouse for people with mental illness, but that would be wrong. As was made clear at the May meeting, it is a place for people who are intoxicated by alcohol or drugs to go. Its purpose is to divert people to a more appropriate setting than a hospital emergency room to sober up. It could be used by people with developmental disabilities if they found themselves in this condition. Not likely for my kids.

The WCHO's Application for Renewal and Recommitment, the ARR, will be submitted to the state in June to renew the contract to provide mental health services. A summary was provided for the Board's approval.

As usual, the Devil is in the details.
I doubt that the Board has a much better idea than I do of what the WCHO is promising to do. Under the category of Assuring Active Engagement (there's that word again), the ARR promises full implementation of the "DD Outcomes tool", whatever that is. The agency will also "refine reports to analyze data pertaining to Community Life Domain.." and adopt system-wide the Evidence-Based Practices for Supported Employment (as opposed to practices not based on evidence?). Under Improving the Quality of Supports and Services, something or someone will "move to relational based contract where outcomes and performance targets are established with providers".

My head hurts.

A WCHO sub-committee, the Organization Operation Committee or O.O.C., submitted a preliminary communication regarding management and oversight of certain providers who staff supported living arrangements for particular consumers. Reading between the lines, there have been some problems with this and the committee is reviewing policies for monitoring these providers. An initial assessment indicates that these policies are inadequate. The size of the provider network has contributed to the inability to adequately monitor the provider's performance.

Intriguing. I will find out more. The next meeting of the O.O.C. is on June 3rd, 2009, 8 - 10 am at the Library Learning Resource Center, 4135 Washtenaw Ave., Ann Arbor, near the intersection of Washtenaw Ave. and Hogback Rd.

Martha Bloom, a parent of a DD adult, was sworn in as a new WCHO Board member. She is the VP of the Ann Arbor Area Community Foundation and involved with other families in Intentional Communities of Washtenaw .

More information on the Internet:
  • The Calendar where you can find when and where the WCHO and its subcommittees meet.
  • A list of WCHO Board Members and contact information.

Thursday, May 14, 2009

Trauma-free Dental Care

I don't know who is traumatized most by my son Danny's dental appointments. Danny? Me? The dental hygienists (it takes at least two)? The brave group home staff person who is in charge of keeping Danny's head still while juggling the sunctioning device? The dentist? We are all victims.

Danny has severe cerebral palsy, profound mental retardation, severe visual impairment, and an extreme aversion to touch, especially around his face, mouth, arms and hands. He is 32 and has been this way since he was a baby, although his tolerance of touch has improved some over the years.

The worst dentist we ever encountered had no idea what he was in for. He ignored everything I told him about Danny's aversion
to being touched and the problems that every dentist and dental hygienist had with him over a period of at least 15 years. The dentist plunged in without warning, jamming his fingers in Danny's mouth to do an examination. Danny flailed his arms, screamed,
gritted his teeth and shook his head back and forth until the dentist finally extracted his fingers from Danny's mouth and proclaimed that Danny had a "behavior problem".

No, the dentist had a "behavior problem".

A determined dental hygienist with the full support of a dentist and the rest of the team, can get Danny's teeth pretty clean. Fortunately, he has never had a cavity or needed other work on his teeth, so cleaning has been the greatest challenge so far. But I have often wondered why we can't just knock him out for 20 minutes every 6 months to do a really good cleaning and examination? He has had several surgeries with no problems with anesthesia, his breathing is good, and he is generally in good health.

I know there is a risk to placing a person under anesthesia and perhaps dentists worry about safety, the expense and who will pay the bill, and lawsuits when something goes wrong. But consider the risks of periodontal disease and its connection with serious health problems, such as heart disease, strokes, kidney disease, and diabetes. There are also horrendous stories about people with developmental disabilities whose behavior spun out of control until it was determined that the underlying cause was tooth decay or gum disease.

An article in the May 2009 issue of Exceptional Parent Magazine, caught my attention. "Anesthesia in Dentistry for People with Developmental or Acquired Disabilities" is by Anthony Charles Caputo, a Dental Anesthesiologist (DA). DAs specialize in providing a full spectrum of anesthesia services for special needs patients and dentists. They are trained to manage pain and
anxiety. A postdoctoral Dental Anesthesia residency is a 2-year program that must include experience providing anesthesia for patients with developmental or acquired disabilities. Most DAs provide office-based anesthesia (OBA) services in the offices of other dentists. By having the most modern anesthesia monitors, medications, and equipment normally found in operating rooms, DAs can provide safe and effective anesthesia and other pain and anxiety management in a regular dentist's office.

Dr. Caputo makes the point that just because "dentistry was able to be done" with a patient using milder forms of sedation, does not mean that it was done well. Dental anesthesia allows the dentist to focus on the needed treatment and not worry about the management of the patient. A paper published this year in the Special Care in Dentistry Journal concludes that when considering the risk of anesthesia with the benefit of delivering quality dental care, the risks were minimal and benefits significant to both the patient and the dentist.

The EP article concludes that,
With the full spectrum of sedation and anesthesia services available to dentists in the office-based setting, it is possible to treat the vast majority of patients successfully with sedation or OBA whether it is accomplished by the dentist or a separate anesthesia provider. Sedation and anesthesia techniques are available to dentists so that when other approaches to care are not successful, these treatment modalities are possible allowing the patient to receive treatment safely, comfortably, and successfully.

For more information go to the American Society of Dentist Anesthesiologists and the Special Care Dentistry Association.

Danny's dentist is going to hear about this.

Wednesday, May 13, 2009

Will Michigan Medicaid changes hurt both patients and providers?

Medicaid funding is a confusing and complex subject, which I will not pretend to understand completely. It is a shared state and federal program where the federal government matches state money according to a formula that varies from state-to-state and year-to-year, depending on the state's economic condition and need. Michigan is very needy, indeed.

According to an article in the Detroit Free Press, May 9, 2009, the increasing number of people in Michigan eligible for Medicaid has increased the state's share of federal stimulus funding. The state, however, will not spend that money on increasing funding to Medicaid providers, but will instead slash reimbursement rates by 4% to providers of Medicaid services. The result will likely be a decrease in the number of doctors who will accept Medicaid patients.

The article cites interesting statistics that raise questions about whether Michigan is doing more harm than good in trying to control costs by cutting fees to providers:
  • According to the Michigan Medical Society, the state reimburses doctors 61 cents for every dollar of service they provide. Decreasing that amount by 4%, as the Governor has ordered, will probably result in fewer doctors taking on Medicaid patients. [Several years ago the state eliminated preventive dental care for adults as a cost-saving measure. By the time the benefit was reinstated and reimbursement rates were reduced, the number of dentists that would serve Medicaid patients had significantly decreased.]
  • Medicaid participation by doctors decreased from 88% in 1999 to 64% in 2005, the last year surveyed. The number of residents covered by Medicaid has risen every year since 2000 with a 10% increase over the last year.
  • One out of every 6 Michigan residents qualifies for Medicaid. Children qualify more easily for Medicaid than adults: if their family income is 150% of the federal poverty level, they are generally eligible.
  • According to the article, the drop in reimbursement rates will cost Medicaid providers "...$5.3 million in state payments and about triple that in federal matching funds between now and Sept. 30. The state also will pay about $7.7 million less to Medicaid health plans."

To qualify for the federal recovery funds, the state cannot change eligibility for Medicaid, but the Governor's executive order will cut $3.3 million from Medicaid that will end payments for dentists, podiatrists, chiropractors, and optometrists for the next five months.

Generally, people with developmental disabilities need more specialized care. Reducing the number of doctors who are willing to accept their medical insurance (Medicaid) will surely result in some people not receiving the care they need or reducing the quality and adequacy of care that is provided. The Governor has always promised to protect the most vulnerable of Michigan's citizens, even during the state's most dire economic times. While the state can technically say that it is still providing services to these citizens it is setting the stage for further decline in the state's system of care for people with developmental disabilities.

Year after year, the Michigan Legislature and the Governor resolve their bickering over budget deficits with quick fixes. This year and next year the state will use its federal recovery funds to delay dealing with the state's structural deficits, especially with Medicaid and mental health funding. The difficulty the state is having economically cannot be underestimated, but at least the state might spare us the sanctimonious platitudes about never doing anything to hurt vulnerable people.