Wednesday, November 14, 2012

Medicare/Medicaid Eligibles: The Kaiser Report on State Plans and Michigan's Plan so far

Way back in 2011, Michigan was one of fifteen states to receive a contract with the federal Centers for Medicare and Medicaid Services (CMS) to develop a model to integrate the care of people eligible for both Medicare and Medicaid. (CMS is the federal agency that regulates and oversees Medicare and Medicaid.) Michigan was among the first 15 states to receive funds to develop a plan. By July of 2011, 26 states were participating in planning. A Report from the Kaiser Commission on Medicaid and the Uninsured from October 2012, summarizes and provides data on the plans from 26 states. 

Michigan's Dual Eligibles plan would affect about 200,000 people who are elderly, mentally ill, or physically or developmentally disabled and poor.  The purpose of the plan is to reduce costs and improve care. But the premise on which federal and state governments justify the idea that the share of spending can be reduced for the Medicare/Medicaid eligible population is  questionable. As stated in the introduction to the Kaiser Commission Report, "Dual eligible beneficiaries are among the poorest and sickest people covered by either Medicare or Medicaid and consequently account for a disproportionate share of spending in both programs." How is the share of spending disproportionate after one accounts for the characteristics of this population?

I think it is safe to assume that medical and hospital costs are generally too high and that we pay too much for prescription drugs and  medical devices and equipment. But almost half of the Medicare/Medicaid population are people under 65, many of whom receive Medicaid-funded mental health services through Michigan's Community Mental Health system.  Cost increases in areas covered by CMH have been relatively stable: 

"Per capita health care costs in the US increased by more than 5% per year between 2002 and 2009, with a total increase of 57% during that period. The public mental health system has seen an increase of approximately 2.2% per enrollee per year in that same period."
(from the MACMHB Guide to Integrated Care for Dual Eligibles)
Finding ways to control the high cost of medical care is laudable, but the fear by individuals and their families who receive services through the CMH system is that reducing the costs of mental health services can only be achieved by reducing the number and quality of services available and by cannibalizing existing programs for people with developmental disabilities and mental illness to fund  services to other under-funded populations.

Other objections to the plan include:

The use of state-wide standardized assessments to determine needs and identify services is contrary to the idea of Person-Centered Planning. Assessments should be used by the PCP team to determine needs and services, but assessments alone should not be the determining factor. The state plan for dual eligibles reduces the PCP meeting to a little get-together to ratify the decisions that have already been made through the assessment process.

The proposed revisions to the Dual Eligible Plan's  "Care Bridge" give more control over assessment and determination of services to an Integrated Care Organization, ICO, a Medicaid health plan, thereby giving decision-making power to the medical system of care rather than the mental health system. While locally controlled Community Mental Health agencies may continue to play a role in assessing and determining needs of people with developmental disabilities, they do so under contract to the ICOs, organizations  that have little experience with the populations served by the CMH system. Case management services may or may not be provided by CMH agencies, further diminishing the role of publicly controlled local CMH agencies in implementing and overseeing the provision of services. 

Key Questions 

Overall, according to the Kaiser Commission Report, there are crucial questions that remain to be answered regarding how the 26 state's will implement their plans.
(Page 16) As CMS continues to review the 26 states’ proposals and finalizes MOUs [Memoranda of Understanding] to implement demonstrations in selected states over the coming months, attention should be given to several key questions, such as:

  • How will beneficiaries be notified about the demonstrations and enroll and disenroll?
  • How will Medicare and Medicaid contributions be calculated, risk-adjusted, and adjusted over time?
  • What will the source(s) of savings be, and how will savings be shared among CMS, the state, plans and/or providers?
  • How will the demonstrations affect access to home and community-based services?
  • How will medical necessity determinations be made, and how will beneficiaries appeal decisions with which they disagree?
  • Will beneficiaries be able to retain their current providers and services and access an adequate provider network?
  • How will plans and providers meet the needs of and provide reasonable accommodations to beneficiaries with a range of physical, mental health, and cognitive disabilities?
  • How will quality be measured, and how will the demonstrations be monitored and evaluated?
  • To what extent will the specific standards that health plans must meet to participate in the demonstrations vary from existing Medicare Advantage and Medicaid managed care requirements?
  • How will stakeholders continue to be engaged throughout the design and implementation process?
These are not trivial questions that must be answered. But of course, once a plan is approved it's not set in stone, is it? Well, apparently it is. This is from pages 18 and 19 of the Kaiser Commmission Report:

CMS’s financial alignment models for dual eligible beneficiaries are based on the Center for Medicare and Medicaid Innovation’s (CMMI) new § 1115A demonstration authority created in the ACA [the Affordable Care Act]. The following questions and answers explain the scope of the Secretary’s authority and the process for testing new payment and service delivery models under § 1115A. 

What is the scope of the Secretary’s [of Health and Human Services] § 1115A waiver authority?

The law [the Affordable Care Act] prohibits administrative or judicial review of the Secretary’s selection of models, organizations, sites, or participants; the elements, parameters, scope, and duration of models; determinations regarding budget neutrality, termination or modification of a design and implementation; and determinations about the expansion and scope of models.

Wow! A law that is outside the reach of administrative or judicial review? That's a chilling notion. This means the plan will have to be absolutely perfect before it is finally submitted to CMS by the state. What could possibly go wrong?

Wednesday, November 7, 2012

St. Louis Center "Fitness for Life" Program

St. Louis Center is a residential community for children and adults with developmental and intellectual disabilities located in Chelsea, Michigan, about 15 miles west of Ann Arbor.

St. Louis Center began offering a "Fitness for Life" program  this fall for qualified residents of Chelsea, Dexter, Grass Lake, Manchester, and Stockbridge, Michigan. The program is available to people with special needs. It's purpose is to increase the physical fitness level of participants, thereby increasing their capacity to perform normal daily activities more safely and independently.

According to an article in the Journal Register:

Caitlin Deis, a 2001 graduate of Chelsea High School with a bachelor's in psychology from Alma College, was hired to become the part-time fitness specialist in September 2011 and was offered the position full time in June 2012.

She had this to say about the program:

“What’s unique about our approach, is that if someone is afraid of using a free-weight to build arm strength, we might use a household object like a water bottle instead. Several of our participants don’t like standard exercises, but most like to dance, and we’ve even introduced them to yoga as a fun way to stretch and increase their flexibility and core strength. We’ve already experienced tremendous success with several of our residents, who have lost as much as 15-20 pounds. One young man here has even dropped 60 pounds through regular exercise and a change in his diet.”

For more information on the program schedule and fees, see the SLC Web site or contact Caitlin Deis, Fitness Specialist, by phone at 734-475-8430 or by email at  .

Monday, November 5, 2012

Election Eve - Make it stop!

Michigan HCBS Waiver Conference: November 28 & 29, 2012

Home and Community Based Services (HCBS) Medicaid waivers fund services to targeted groups of people with disabilities who "but for the provision of such services" would require the level of care provided in a hospital, a nursing facility, or an intermediate care facility for the mentally retarded (ICF/MR). These services are considered to be "medical assistance" and must be provided to eligible individuals in accordance with a written plan of care. Waivers available to adults with developmental disabilities are called Habilitation Support Waivers (HSW) in Michigan. They are also called 1915(c) waivers because they are described in Sec. 1915(c) of the Social Security Act.

The Michigan Department of Community Health & The Michigan Association of CMH Boards are sponsoring the "ANNUAL HOME AND COMMUNITY BASED WAIVER CONFERENCE", November 28 & 29, 2012 at the Kellogg Hotel & Conference Center, East Lansing, Michigan 48823

3 Featured Waivers:

  • Children’s Waiver Program (CWP)
  • Habilitation Supports Waiver (HSW)
  • Serious Emotional Disturbance Waiver (SEDW)
Conference Objective:  This conference will provide technical assistance and training on the implementation and maintenance of the 1915(c) waivers, clinical issues, and administrative functions relevant to these waivers.

Who Should Attend:  Case managers, supports coordinators, wraparound facilitators, clinicians, administrative staff, providers, people receiving services and family members.

Special Rate:  A special $20 conference rate will be offered for people receiving waiver services and their family members. A limited number of scholarships are available to people who receive services and their families. Scholarships may cover registration fees, overnight rooms, travel expenses, meals and child care.  Deadline to request scholarship: November 14, 2012. To request a scholarship form, contact Chris Ward at or 517-374-6848.

If you have any questions, call (517) 374-6848

Conference Registration Form

Conference Agenda

Friday, November 2, 2012

Study shows autistic students have similar outcomes whether or not in inclusive settings

An article from Disability Scoop, "Study: Inclusion May Not Be Best After All" by Michelle Diament, 11/1/11, summarizes an article from the journal Pediatrics . The study involved almost 500 autistic students and compared those who had spent 75 to 100% of the time in regular classrooms with those who were in more segregated settings. Those in inclusive settings were no more likely to complete high school, go to college or see improvements in cognitive functioning.

“We find no systematic indication that the level of inclusivity improves key future outcomes,” researchers from the University of Alabama at Birmingham and Johns Hopkins University wrote.

The Disability Scoop article goes on to misleadingly state that the Individuals with Disabilities Education Act requires that special education students be served in the "least restrictive environment"(LRE) meaning in regular classrooms. This is what most advocates for inclusion will tell you, but it's not true and it never has been true. The LRE is part of the placement decision and is based on the needs of the individual student.

Beyond the outcomes that were investigated in this study, there are all kinds of reasons to place children in inclusive settings or to opt for more segregated settings. The problem is that Inclusion fanatics have for years asserted that placing all children in regular classrooms with their non-disabled peers is better in all respects for everyone involved. But then Inclusion fanatics have always existed in a fantasy land undisturbed by reason or evidence.

Be sure to read the excellent comments on the Disability Scoop article.