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.

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