Friday, August 19, 2011

More on "Integrating Dual Eligibles" in Michigan

In July 2011, the Michigan Department of Community Health notified stakeholders about forums on the "Integration of Dual Eligibles". Dual eligibles are people who qualify for both Medicaid and Medicare. Most people with developmental disabilities become eligible for Medicaid when they turn 18 and their families' incomes are no longer considered in determining eligibility. Usually, people with DD qualify for Medicare in addition to Medicaid, when a parent who has been paying into Social Security retires, dies, or becomes disabled. 
Michigan is one of fifteen states that has a contract with the Centers for Medicare and Medicaid Services (CMS) to develop a model to "integrate dual eligibles". So far, it appears that the state's plan could radically change the way services are provided to this population. Because dual eligibles are a significant minority served by the mental health system, everyone who receives specialty services through community mental health may feel the impact of these changes.

Presumably, this is all about saving money. According to the Michigan Association of Community Mental Health Boards (MACMHB), "As a group, these individuals [dual eligibles served by the mental health system] have the most complex care needs of persons served by our system.  As a result, the Medicaid expenditures for the specialty services for these persons was $1.1M, almost 50 % of the total Medicaid expenditures for specialty mental health and developmental disabilities services statewide."

These figures would not be a surprise to anyone who knows this population well, just as most people would not be shocked to discover that it costs more to treat an aggressive cancer than it does to treat a sore throat or a broken arm. But we aren't necessarily dealing with people who have an intimate knowledge of what it is like to have a severe developmental disability, mental illness, or other condition covered by Medicare and Medicaid. As far as the state and the federal government are concerned, dual eligibles cost too much money and the costs must be reduced. The belief is that, “Providers will experience administrative efficiencies by working with a single administrative system and payer source [probably Blue Cross/Blue Shield or a similar entity] and instead of dealing with multiple entities for authorization and payment of services." The belief of many families and other advocates is that cost reductions are more likely to come from reducing services than from administrative efficiencies.

The State is required to include stakeholders in the development of this plan that will go into effect next year, but stakeholders were kept in the dark about it until recently. Even after four stakeholder forums with two more scheduled in August (see below), people who attended the forums and read the material distributed about the State plan are still scratching their heads wondering what this is all about. 

What is truly shocking about all this, is that the MDCH is either unwilling or unable to answer some very basic questions, such as those posed by stakeholders at the Michigan Association of Community Mental Health Boards Executive Board Meeting on August 5, 2011. Here are a few of those questions:  

Unanswered questions regarding changes to consumer services and treatments:
  • Who makes the final decision as to which treatments and services are
    “inappropriate” and/or “too costly”?
  • Will Habilitative Services be continued to the extent necessary to maintain functioning level and skills and for how long?
  • Will Payers have the final approval over the PCP [Person-Centered Planning] process and its content regardless of the individual beneficiary’s opinions?
Unanswered questions about participating payers [most likely Blue Cross/Blue Shield or similar entity]:
  • Will anyone address the exorbitant reserves and extravagant Executive salaries and benefits of the large carriers?
  • Will anyone address the extreme administrative cost rates that result from these large executive employment packages and insure that Medicaid dollars will not be used to feed increases to these already high costs?
  • Would it not be worthwhile to compare the participating carrier administrative costs ratios with those of the present CMHSP [Community Mental Health] system already serving these beneficiaries?
Unanswered questions about the Governance Steering Committee for the dual eligibles plan:
  • Why is there no Stakeholder participation in this committee?
  • If the committee is charged with governance and oversight, it would follow that part of their responsibility is to insure the stated goals of improving healthcare and cutting costs are included in its charge. What happens when those two objectives are in conflict? Which of the goals will take priority?
  • Will the most severe therefore be determined too costly to support in any meaningful manner? This is one of the most important questions as these individuals are the most severely impaired, most challenging to treat, and are considered the least able to contribute to their healthcare costs and/or healthcare needs.
Due to feedback from families and other advocates, the state has added two additional meetings for stakeholders regarding the "dual eligible" proposal for integrated care: 

Greater Lansing
Date: Wed., August 24
Time: 1–4 PM
Venue: Eagle Eye Golf Club (at Hawk Hollow), 15500 Chandler Road (directions)
(517) 641-4570


Date: Mon., August 29
Time: 1–4 PM
Venue: Greater Grace Temple Banquet Hall, 23500 W. Seven Mile Rd., Detroit
(313) 543-6000

If you were unable to attend the previous forums, go to the project Website or call Dawn Wade (517) 484-4954 to register. It is critical that as many people as possible attend. Ask questions concerning aspects of the plan you do not understand or cannot reconcile with your needs. To the extent that you have unmet needs, that should also be expressed as the purpose is to obtain stakeholder input concerning needs. If your needs are currently being served and you fear they will not continue, or will be diminished, that is also a valid statement to express. 

If the state is unwilling or unable to answer basic questions about the dual eligible integration project, the results could be disastrous for this vulnerable and relatively powerless population. 

Written comments can be e-mailed any time to See the project Website here and follow the links for more information.

1 comment:

Emily Palsrok said...

Jill - great article...i just came across your blog while researching some dual eligible items and wanted to say thank you for how well it's written and organized. nicely done.