Monday, October 31, 2011

Dual Eligibles plan hits speed bump in Michigan House Subcommittee

This is a brief summary of a hearing held on 10/25/11 by the Michigan House Appropriations Subcommittee on Community Health. The hearing was only one hour long and will be continued on Tuesday, 11/1/11, in Room 352 of the Capitol building in Lansing. Subcommittee members are Representatives Matt Lori, (C), Peter MacGregor (Maj. VC), Dave Agema, Bob Genetski, Rashida Tlaib, and Joan Bauer. Contact information for all members of the Michigan House of Representatives can be found here.

The Michigan House Appropriations Subcommittee on Community Health met last week on October 25th, 2011, to hear testimony on the state's proposal to "integrate" the care of people eligible for both Medicaid and Medicare. Under the state proposal, Medicaid managed care plans would finance and manage the care for dual eligibles. 

It was obvious that committee members had heard from constituents about the plan, particularly from the significant population of dual eligibles who receive Medicaid-funded services through the Community Mental Health system. Subcommittee members asked many pointed questions about the role of the CMH system in the proposed plan with implicit and explicit support for the system that has been providing specialty services to people with developmental disabilities, mental illness, and other disabilities for decades.

Lynda Zeller, the Deputy Director of the Michigan Department of  Community Health (MDCH), and Steve Fitton, Medicaid Director, presented the state's plan and answered legislators' questions about it..

Steve Fitton stated that the Integration of Dual Eligibles initiative is a top priority for the state. The intent of the initiative is to improve health, improve care, and lower costs. Mr. Fitton seemed to be defending the plan against some of the criticisms that the MDCH has received. He said the state wants stability in the system and to continue "important services". They have no intention to "medicalize" what is not "medical". They hope that by pooling funding they will have collaborative purchasing. Capitation will lead to more flexible funding rather than having funding reserved in "acute" settings. They plan to continue all services.

They are reconsidering parts of the proposal that may not work, including the idea of a single assessment tool and one care coordinator. They may consider the idea or a care coordination team. He said the state has no intention to discontinue non-traditional services. They will continue to offer Habilitation Support Waiver services and behavioral services.

He explained the process for stakeholder involvement of the plan. This began with "key informant" interviews followed by forums with a total of 1,000 participants. There is a Website where anyone can comment at any time. A questionnaire was also available on-line for public comments. Workgroups on a variety of topics will meet in November and December. April 1, 2012 is the target date for submitting the final plan to the federal Centers for Medicare and Medicaid Services (CMS). After that they will put out an RFP that a variety of entities can bid on.

Q & A:

Representative Agema asked, what if you can't save money without cutting services? What is the back-up plan?

Zeller and Fitton said they did not know where they would go with that.

Representative MacGregor asked, will you share the plan with the legislature before you submit it to the feds?

Fitton and Zeller said yes, although we know there has been reluctance to do this. The initial proposal submitted to the CMS claimed that the plan could be implemented administratively and without legislative approval.

Representative MacGregor responded by saying that "yes" was the right answer. He said it is key to review this with the legislature. He also said, they should integrate the services that we do well, referring to CMH services.

Representative Bauer asked, what will be the role of CMH agencies? The proposal should have something in it that deals with the issue of CMH and how to use their talents and relationships. She also said that CMH has kept Medicaid cost increases to 2% per year. We need to keep non-traditional services such as club houses for people with mental illness.

Lynda Zeller said they are working with MACMHB (Michigan Association of Community Mental Health Boards) and will be meeting with them soon. She said that what CMH has not done is preventive care, screening, and focusing on care coordination. [I found this to be a surprising statement. Care coordination, in the sense of making sure consumers get appropriate medical care and treatment is one of the things that CMH does or is supposed to do for consumers.]

Michigan Assisted Living Association

Robert Stein gave testimony urging that the state maintain funding and not compromise quality of care. The state must provide options for consumers to choose from and preserve the quality of the provider network. He supported the possibility of implementing the plan with a phased-in approach.
MALA written testimony can be found here.

Michael Brashears, Executive Director, Ottawa CMH

Dr. Michael Brashears testified about his concern that no actual plan has yet been developed for dual eligibles. He said the MDCH has solicited input on only a handful of issues, but there is no process to present the actual model to stakeholders or to allow review of the plan once it is finished.

He also noted that the participation of so many stakeholders in state forums and other opportunities to comment would not have occurred without the dramatic outreach of CMH agencies that held their own forums and emphasized to consumers the importance of the state’s proposal and their participation in it.

Here are Dr. Brashears' written comments expanding on the idea that stakeholder participation has been limited and that "there is no stated 'plan' or 'methodology' related to Dual Eligible Integration for public review prior to the deadline of submitting a 'plan' to CMS of April 1st, 2012."

In response, Representative MacGregor stated that there should be at least a 30-day public review process of the finalized plan.

Chief Executive Officer for the Southwest Michigan PIHP (Pre-paid Inpatient Health Plan)

The state initiative has a very “narrow focus”.

In 1998, the state carved out behavioral health [mental health services] and combined the 1915 b & c waivers (Home and Community Based Waivers). Services are protected by the carve out.

By law and constitution, the state transferred services to local CMHs from the state. There has been continual transformation of this system and development of a professional workforce.

The hearing was adjourned at 11:30 a.m. and will continue on Tuesday, November 1, 2011 at 10:30 a.m.

Monday, October 24, 2011

Halloween Party

The Ann Arbor Center for Independent Living is sponsoring a free Halloween Party for youth 14 to 26, with apple bobbing, bingo, pumpkin painting, caramel apples and more.

Costumes encouraged.

Friday, October 28, 2011, 6 - 9 p.m.

RSVP required: Ann Dusbiber Gossage at .

Anna Dusbiber Gossage coordinates youth events. Contact her for information and questions on future events.

Thursday, October 20, 2011

Michigan Direct-care workers vs. Michigan CEOs and Board Presidents

A commenter on my last blog entry on Michigan's Direct-care Workforce suggested I check out the compensation for some of the Executive Directors, Board Presidents, and CEOs of provider agencies. The place to find these figures and other information about non-profits is on the Website Guidestar. Registration is free and it gives you access to the IRS Form 990 for the non-profits in their database. 

Here is a sampling of what I found:

JOAK American Homes, Inc., in Ann Arbor, Michigan 
  • Mission: "The corporation is set-up to provide residence, treatment and support to children and adults with mental retardation, mental illness, substance abusers and shelter for homeless citizens in various counties in the state of Michigan."
  • The compensation for Board President Josephine Akunne was $235,680 for 2009. It appears that she was paid an additional $44,000 as President of the Board of four other related non-profits.
Hope Network of Grand Rapids, Michigan
  • There are several Hope Network non-profits providing services to people with developmental disabilities and mental illness.
  • President of the Board of Directors Phillip Weaver received compensation from "related organizations" of $200,248.
  • Five more Board members made over $100,000 apiece.

Progressive Residential Services of New Mexico and Progressive Residential Services of Tennessee, both at the same address in Troy, Michigan, provide services to people with developmental disabilities, mental illness and other disabling conditions.
  • CEO Everett DeHut was paid $346,196 base compensation for 2009.

Community Living Services, Inc. in Wayne, Michigan provides "care, treatment, housing education, and protection of developmentally disabled children and adults."
  • Executive Director James Dehem  received $189,776 in base compensation for 2009.
As I have said for years, "non-profit" does not mean  "no money".

Wednesday, October 19, 2011

Michigan's Direct-care Workforce

Since 1997, my son Danny has lived in a licensed group home, where he is taken care of by a variety of caregivers. Because the residents at his group home have severe disabilities and high medical needs, the home is well-staffed. At times, however, the quality of care has suffered because of the inability of the provider managing the house to retain good workers. The job is difficult, demanding, requires a high degree of responsibility, and comes with obscenely low pay. I remember many years ago talking to a full-time house manager and discovering that her daughter qualified for food stamps. I naively thought it was not possible to work full-time and still not have enough money to feed your family.

I do not believe that money is the solution to every problem with providing care to vulnerable people. It is hard to put a price-tag on the qualities that make a person an ideal caregiver, starting with a good heart and a genuine desire to help people in need, but the importance of direct-care workers in the lives of people who depend on them cannot be overstated. The way direct-care workers are treated and compensated for their work is in many respects a reflection of how society values the people they care for. 

The Paraprofessional Health Institute or PHI is a national organization that works to improve the lives of direct-care workers who provide essential daily living services and supports to people with disabilities and chronic care needs, including people with developmental disabilities. PHI's fact sheet on Michigan's Direct-Care Workforce  demonstrates how far we have to go in valuing the work that direct-care workers do.

According to the fact sheet, Michigan's direct-care workforce, at 156,000 workers, is larger than any other occupational group. Paid caregiving is also among the five fastest-growing occupations in Michigan. Nevertheless, the median hourly wage for personal care aides and home health aides falls below 200% of the poverty level at $10.42/hour, compared to the median hourly wage for all occupations of $16.26/hour. Hourly wages for nursing aides are somewhat higher than for home health aides, but still substantially below the state's median hourly wage.

Over the last ten years, "real wages" for nursing aides, orderlies, and attendants increased by 3 %, but "real wages" for home health aides have stayed the same and wages for personal care aides have fallen. 32% of direct-care workers do not have health insurance compared to 13% of the general population. Part-time work is common.

Over half of personal care aides live in very low-income households as do 40% of nursing and home health aides. 41% rely on some form of public assistance such as food stamps, housing subsidies, or Medicaid.

According to PHI, "Michigan's booming demand for direct-care workers cannot be met without making these jobs more competitive so that they attract enough workers, especially at a time when the state has set goals to offer more long-term supports and services options to elders, their families, and persons living with disabilities." 

Here is a state-by-state look at the status of direct-care workers.

Monday, October 10, 2011

Comment period on Michigan "dual eligibles" extended

The deadline for the Request for Input on Michigan's plan to "integrate" people who are eligible for both Medicaid and Medicare has been extended by one week.  The new deadline for response is October 14, 2011. See the Blogpost for October 6, 2011 for detailed information.

In addition, an invitation regarding the formation of work groups for the Integrated Care project for people who are eligible for Medicare and Medicaid has been sent out.   Included are charters for the four workgroups and meeting dates.

Here is the link to the Integrated Care Work Group Participation Notice.

Thursday, October 6, 2011

Comment on the Michigan plan for "dual eligibles"

Responses to the Michigan Department of Community Health (MDCH) "Request for Input" on the state's plan for dual eligibles (people who are enrolled in both Medicaid and Medicare) are due by 5 p.m., October 7, 2011. 

Here is the link to the full RFI with background information.

Here is where you go to respond online.

This is a document distributed at the Washtenaw Community Health Organization Program Services Committee summarizing the issues and offering points to consider in responding to the RFI.

This is the state's official Website collecting comments on the dual eligibles plan. Comments can also be sent to your state representatives (here they are for Washtenaw County) and other state officials. See other blogposts here for more background and contact information and links to relevant documents.

Wednesday, October 5, 2011

Meeting on "dual eligibles" in Washtenaw County

NOTE: The term "dual eligibles" is an awful-sounding label that categorizes people according to their health insurance status. Included in this group are the poorest, sickest, oldest, most disabled, and most vulnerable people imaginable. They are under scrutiny because they cost more than other people to treat and care for. They are among the easiest people to target for "cost savings", because it is so difficult for them and their families to fight back when the supposed savings come at the expense of the services they need to survive. We may have to use the same vocabulary that government agencies use so that we can enter into a discussion about government schemes to balance budgets, but it is our job to put a human face on the "DE's" and not allow government agencies and our legislators to forget who these people are.

Michigan's project on "Integrated Care for Dual Eligibles" applies to people who are fully eligible for all parts of Medicare and all Medicaid benefits. This includes about 204,000 people in Michigan. 40% are either people under 65 who are developmentally disabled or people with Mental Illness who started receiving SSI (Supplemental Security Income for low income people - this also qualifies a person for Medicaid in Michigan)  and then later qualified for SSDI (Social Security Disability Insurance)

Medicare, a federal health insurance program, covers most physical care. Medicaid, a joint federal and state program, covers almost all long-term care and specialty mental health services, including people with developmental disabilities.

The State proposal will move all Dual Eligibles (DE’s) into Medicaid. Presumably, private managed-care health plans would finance and manage physical and mental health services for DE’s, even though these managed care plans have little experience with developmentally disabled people under 65 or people with mental illness.  There is little competition among private managed care health plans and even less transparency into their operation.

It appears that the proposal would allow the state to redistribute funding to cover more long-term care for seniors at the expense of people with developmental disabilities and mental illness. No one can deny that more support for seniors is needed, especially for those who want care in their own homes or want to move out of nursing homes, but robbing Peter to pay Paul is a poor substitute for an ethically sound policy for serving both seniors and people who are now served by the CMH system who have developmental disabilities and mental illness.

The state legislature, through the appropriations process, has already signed off on assuming there will be savings of $10 million if the plan is accepted by the federal Centers for Medicare and Medicaid Services (CMS). The state wants to begin selecting health plans to cover DE’s by January 2012 and put the plan into effect by April 2012.

It is not necessary for the state to push this proposal through to implementation on such a fast track. The federal CMS expects states to refine and reconsider their initial proposals until the final plans are submitted in April 2012. CMS will approve selected plans submitted to them probably 6 months after that. Other states have submitted proposals that are far more nuanced and do not disrupt existing care arrangements.

The state claimed in its initial proposal that it does not need approval from the legislature and that the executive branch can implement the plan administratively. There is some doubt, however, about the legality of the proposal. There are regulations for Medicare and Medicaid that the plan may violate. There is also Section 400.109f of the Michigan Social Welfare Act that says:

"…Medicaid-covered specialty services and supports shall be managed and delivered by specialty prepaid health plans [regional Community Mental Health entities] chosen by the department of community health with advice and recommendations from the specialty services panel created in section 109g. The specialty services and supports shall be carved out from the basic medicaid health care benefits package…” 
Changes to these requirements in state law could only be made by the legislature . 

At the end of the meeting we discussed the best course of action for people affected by this proposal to express their views. The state needs to hear from people with developmental and other disabilities, their families, and friends.  Comments can be sent directly to the official Website for the Integration of Dual Eligibles by email, to state officials who are involved in the development of the plan for DE’s, and to legislators to make them aware of the proposal and to ask for legislative hearings on the Integration of Care for Dual Eligibles plan.