Nonprofits benefit from soaring Medicaid costs in New York

It is always instructive to look at how other states provide services to people with developmental disabilities. At the very least, we may learn what not to do.The New York Times has been investigating the crisis-in-care for people with developmental disabilities in New York and has come across some eye-opening discoveries on how Medicaid money is spent.

This article, Aiding Disabled, Nonprofits Rake in State Money by Russ Buettner, is one of the latest in a series. Community Habilitation is a state home care program that provides Medicaid Home and Community Based Services to people with DD. (Michigan's DD waiver services fall under the Habilitation Supports Waiver. Waiver services can vary from state to state.) According to the article, spending for this program has increased more than 40% over the past three years with much of the benefit going to the nonprofits who provide the services.

In New York, providers determine the services through an individualized plan and are reimbursed on a fee-for-service basis, with the fee negotiated with the state. Over all, providers are reimbursed about $40 per hour to pay for a program with little overhead. Workers, who provide the services in the homes of consumers, are paid only an average of $10 - $15 per hour. Medicare provides similar services to senior citizens, but the median reimbursement rate is $21 per hour.

The nonprofits are the proverbial foxes-guarding-the-hen-house and are apparently using the extra Medicaid dollars to pad executive salaries and build up reserves in their organizations. The state is considering doing away with the fee-for-service reimbursements and revising its incentive system to focus more on quality than quantity of services.

Here is a description of other financial shenanigans by nonprofits in New York.

Media coverage lacking on Michigan's dual eligibles proposal

Here is an article from Domemagazine.com by John Lindstrom on the state's project to integrate "dual eligibles". These are people who are eligible for both Medicare and Medicaid which makes them elderly and poor, developmentally disabled and poor, mentally ill and poor, or some combination of all of the above. The plan would place their care under a single entity that would manage and finance their medical care, mental health care, and long term care. 

Lindstrom points out this issue has tremendous import on the lives of the over 200,000 people affected, but it is receiving almost no coverage in the media. The state was surprised by the reaction it has received from critics. Despite the government's assurance that services will not be taken away and that the state's intent is to improve patient care while decreasing costs, the critics don't believe it.

In addition to the lack of coverage of this issue, despite the large number of people who would be affected by it, the subject is difficult to talk about. It is complex and encumbered by impenetrable jargon. 

At least one reporter is attempting to make sense of this:

"What is indisputable though is the genuine worry by recipients and their families that their care will be dramatically and drastically affected by whatever changes are made. The changes the state makes wouldn’t amount to a set of inconveniences. Those changes could trigger a massive change of life for some of these recipients."

Testimony on Dual Eligibles

December 6, 2011 
Jill R. Barker
Ann Arbor, MI    
  

To the Michigan House Appropriations Subcommittee on Community Health

I am the parent of two adult sons with severe developmental disabilities, including severe cerebral palsy and profound intellectual disabilities. I am also president of Friends of the Developmentally Disabled, a Washtenaw County group that provides support and information to families and friends of people with developmental disabilities. Friends of DD is part of ddAdvocates of Michigan, an Internet-based communication network with families and community groups all over the state.

I have strong reservations about Michigan’s proposal to integrate dual eligibles. The lack of consideration for populations whose services are currently managed by the Community Mental Health system could lead to disastrous outcomes. Other state’s have taken a less radical approach to integrating dual eligibles with plans that cause much less disruption to current service arrangements than Michigan’s proposal.

Habilitative mental health services for people with developmental disabilities are non-traditional Medicaid services designed as an alternative to hospitalization or institutionalization. These services can include housing in either licensed or unlicensed settings with varying degrees of support and many specialized services that maintain health, ensure survival, and lead to fulfilling lives in community settings. For people like my sons this care is both necessary and costly.

In the State Proposal that was submitted to the Centers for Medicare and Medicaid last February, the phrase “developmental disabilities” does not appear in the 10-page document. The assumption is that people with DD will be subsumed under Long Term Care that includes senior citizens over the age of 65, a much larger group whose needs are chronically and often tragically underfunded. Combining these populations together and expecting to reduce costs without eliminating services for people with DD and others served by the CMH system is simply not believable.

Where are the savings going to come from, if not from the elimination of services? The Community Mental Health System, though always in need of improvement, already has a managed care system in place for Medicaid-funded specialty services and has done well keeping Medicaid costs under control. Why remove CMH agencies as the managing entity for these special populations and replace them with Medicaid managed-care health plans that have little experience with these populations, especially people with developmental disabilities under 65 years old? 

Up to one-third of the people served by the CMH system are dual eligibles and account for up to half the costs of the CMH system. What will be the effects on the CMH system for people who opt out of the state plan and others left in the system? Will it be able to sustain itself under these circumstances and will the expertise and specialization of its employees be unnecessarily lost under this plan?

I worry especially about the loss of local control of decision-making under the state’s proposal. The lack of transparency and accountability of managing entities that have no obligation to include consumers on their governing boards will surely have an effect on the vital role that families now play in assuring the provision of mental health services for their loved-ones. Through their persistence and advocacy, parents and other family members fill in gaps in the service system that allow their DD family members to maintain their health and engage in a meaningful life. Families monitor the care of their loved-ones and establish networks that pass on an enormous wealth of information to people facing problems similar to their own. Relationships with CMH and other community agencies that are fostered by families, can be a check on the service system, making sure that local decisions reflect local priorities and needs, while preventing waste in the system. Most of this is done at no cost to the state. When agencies that local families have to deal with are more remote and less accountable, families become discouraged and their desire and ability to support and improve the system of care is diminished.

In my experience, the most creative solutions to increasing the quality of care without increasing costs to taxpayers comes from local family groups that have marshaled support from local community organizations including churches. For example, in Washtenaw County, the parent-directed Just Us Club serves more than 50 families with a licensed after school childcare program and an activity and respite program for adults with moderate to severe developmental disabilities. Space for the programs is donated by the Washtenaw Intermediate School District and Huron Hills Church in Ann Arbor. Fees to families are kept to a minimum by the parent Board of Directors. Intentional Communities of Washtenaw has been setting up residences for higher functioning adults using “community builders” to assure that DD adults stay engaged in the community with their friends and families. His Eye is on the Sparrow runs a supported living house in Dexter, Michigan, relying on volunteers and families as well as funding through the Community Mental Health agency. Harbor House in Ottawa County for severely disabled adults and many group homes in western Michigan are highly praised by parents and their communities. Encouraging these organizations and following their examples, leads to a higher quality of life for the people they serve.

Congress forgets how to pass a law

Revisiting Federal regulations on the use of Medicaid Waivers

Last April, the federal Centers for Medicare and Medicaid Services (CMS) proposed regulations that would restrict the use of Home and Community Based Service Waivers (this includes the Habilitation Supports Waiver for people with developmental disabilities in Michigan) to "prevent the provision of unnecessary or inappropriate care". The proposed regulations would effectively eliminate funding for Home and Community Based Services for many forms of congregate care for people with disabilities or for specialized services provided in group settings for people with specific disabilities. (See my blogposts from May and June 2011 for comments on specific issues raised by the proposed rules.)

There was a huge response to the proposed rules, both pro and con. Final rules have not yet been released by CMS.

According to an article in Disability Scoop, almost a hundred advocacy groups are demanding that CMS release the restrictive rules. CMS says there is no final date for publication of the rules, but they are a priority.

The proposed rules would limit the use of Medicaid Home and Community Based Services waivers to only those settings and services found acceptable by disability advocates who promote an ideology of full inclusion for everyone, regardless of the needs of the disabled person or the wishes of the individual and his or her family. The advocacy groups are aggressively pursuing a course that places them at odds with a significant segment of the population they presume to represent. This is a good time to remind CMS of how these restrictive regulations would affect your family member. 

Contacts at Centers for Medicare and Medicaid Services:

There is a new acting director of CMS, Marilyn Tavenner. Her e-mail address is Marilyn.Tavenner@cms.hhs.gov .

Cindy Mann, Director, Center for Medicaid, CHIP, and Survey & Certification, can be contacted at Cynthia.Mann@cms.hhs.gov

Henry Claypool is Director of the Health and Human Services Office on Disability. His e-mail is ODInfo@hhs.gov .

Refer to HCBS rules CMS-2296-P in the subject line of the e-mail.

Here is the letter sent by the National Disability Leadership Alliance.

More information on Michigan Dual Eligibles workgroups

The "Integrating care for dual eligibles in Michigan" Website has more information on the four workgroups that are making recommendations to the state. Rosters for each group are available along with meeting times and dates, agendas, summaries of meetings, and additional documents and information.

I have been participating in the Workgroup on "Education, Outreach, and Enrollee Protections". It is hard to tell if  the workgroups will have much of an impact on the state. The Michigan Department of Community Health has set limits on the topics that are covered by the workgroups, placing the most controversial aspects of the state's plan for dual eligibles out of bounds for discussion: whether Medicaid managed-care plans are the best entities to manage and finance services for dual eligibles, whether allowing consumers to opt-in rather than opt-out of the plan is a better idea, and whether the plan as it has so far been described by the state is worth the partial destruction of the Community Mental Health system. 

Other metaphorical elephants in the room: the issue of local control and access that is one feature of the Community Mental Health system that would likely be lost; citizen representation of people directly served by and affected by the system of care that exists in the CMH system but is lacking in the dual eligibles plan; a lack of transparency and access to Medicaid managed-care plans that appear to be the most likely entities to manage services for dual eligibles; managing costs of health plans that pay exorbitant executive salaries; the effects of privatizing mental health services for dual eligibles - an idea that was soundly defeated in the state more than a decade ago; rivalries between groups affected by the plan; different federal mandates for different groups of beneficiaries; and expecting to save money by combining several under-funded groups and transferring funds from a CMH system that has been successful at holding down Medicaid costs to another system that has little experience serving the populations served by CMH.

At the end of each Workgroup meeting there is a time for public comment. The Workgroups meet again on December 13 and 15 in Lansing. After that, the state will put together its plan and release it for public comment. This will be the first time that we see in detail what the state intends to submit to the Centers for Medicare and Medicaid for integrating care of dual eligibles and your comments on the plan will be important.

For background on the dual eligibles plan, see the DD News blog here.

Legislative hearings on Dual Eligibles

To review this confusing topic, see other posts on Michigan's plan to manage and finance medical and specialty services (mental health services for people with mental illness and developmental disabilities) for people who are eligible for both Medicaid and Medicare. 

Subcommittee Hearings:

Appropriations Subcommittees are looking at the possible affects of the Michigan "Integrating Care for Dual Eligibles" plan on appropriations and the state budget.

 
The following are recommendations from Tom Bird of ddAdvocates of Michigan of things to consider if you want to testify:

If you can attend and testify, the emphasis should be on financial impact: 

• How this will effect those who choose to "opt out" if there is no workable CMH delivery system left (should the "money follow the person"?)
• What will happen if the new plan isn't financially feasable? Will services to the most vulnerable be cut, or will "the most needy" be protected?
• If the anticipated (pipe-dream) savings do not occur, will the plan continue, anyway? Who will pay the bill?
• What if the Fed Government doesn't have the money to pay for the 400,000-800,000 new Medicaid enrollees? Do we dis-enroll them, or will services to all be dilluted?
• What if it actually winds up costing more, not less (as is the experience in Mass and Texas)?
• What negative impact on services would the proposed "savings sharing" plan have as a dis-incentive to provide the best array of services? (restrict services to pocket the profits)

You may also choose to discuss ways for the system to save money, such as eliminating the PIHP layer of administrative overhead; normalizing provider contracts and reimbursement rates across CMHs and for comparable service delivery. Recognizing the cost effectiveness of multi-bed settings for those who choose them.

Times and locations of hearings:

House Appropriations Subcommittee on Community Health

Tuesday, December 6, 2011 at 10:30 AM
State Capitol, 3rd floor, Room 352
Agenda: Public testimony on Integrated Care Planning for Dual Eligibles

If you wish to testify, fill out a card before the hearing. Bring enough copies of written testimony for all subcommittee members.
Clerk Phone Number: 517-373-8080
Chair: Representative Matt Lori
Other members: MacGregor (Maj. VC), Agema, Genetski, Tlaib (Min. VC), Bauer

Senate Appropriations Committee Subcommittee on Community Health Department
Chair: John Moolenaar

Thursday, December 8, 2011 at 12:30 PM
Location: Boji Tower, 124 W. Allegan Street, Lansing, MI
Clerk Phone Number: (517) 373-2768
Agenda: Presentation on the impact of the proposed Dual Eligible Waiver on the Department of Community Health Budget

The clerk for the Subcommittee said that a number of groups are lined up to testify and time is limited.

Support for Kids with Autism: Panel discussion in Ann Arbor

This is an announcement from the Washtenaw County Special Education E-Information Listserv:

Panel Discussion: Support For Kids With Autism

Monday, November 21, 2011

7:00 pm - 8:30 pm

In the multi-purpose room in the downtown library

Ann Arbor District Library

343 S. Fifth Ave.

Ann Arbor, MI 

A panel of teacher consultants at Washtenaw Intermediate School District (WISD), including Walter Kwik, Pamela McClure, Marla Sebu and Katrina Stewart, will talk about Autism Spectrum Disorder, what it is and how to help people/children with it in Washtenaw County feel more comfortable and successful in their daily lives. They will also discuss the START project, which gives professionals and parents the knowledge and skills to support individuals with Autism Spectrum Disorder in reaching their greatest potential. 

The STatewide Autism Resources and Training (START) project is committed to creating a sustainable structure of support for students with Autism Spectrum Disorders within each region of Michigan by provide training and technical assistance to educators and families that support students on the autism spectrum. 

The START project has been in place for 10 years through the funding and support of the Michigan Department of Education, Office of Special Education and Early Intervention Services. The rapid increase in the number of students with ASD entering public schools in Michigan has created a critical need for more in-depth training for educators in the use of evidence based practices. Additionally, the START Project has served a key role in meeting this need through innovative activities such as Regional Collaborative Networks, training and coaching models, and resource material development. 

For more information on this event, call the Library at 327-4555 or visit the Website

Ira Lax

Outreach and Neighborhood Services

Washtenaw Library for the Blind & Physically Disabled

Ann Arbor District Library

734-327-8365

Friends of DD newsletters, 2009-2011

I have posted Friends of DD newsletters from the last two years on Google Docs. You can find them here. 

Here are specific news letters that may be of interest because of the topics featured:

• Supported living in Milan, MI
• St. Louis Center in Chelsea, MI
• Our Lady of Providence, Wayne County, MI
• Group home in Ypsilanti, MI
• Harbor House in Ottawa County, MI
• Just Us Club, Ann Arbor, MI
• His Eye is on the Sparrow
• Community Mental Health Services for DD
• Home Help Services
• Romulus Athletic Club and Matthaei Botanical Gardens

Friends of the Developmentally Disabled, Washtenaw County, MI

Friends of the Developmentally Disabled, (aka Friends of DD) began as a group of families of people with developmental disabilities more than 10 years. Initially, our purpose was to support people with DD in local group homes and in the day program at Washtenaw Community Mental Health. We never organized formally, although we once may have elected a treasurer. This turned out to be unnecessary, because we never had any money. 
 
We have managed for a long time without a formal organization, although, at least until recently, we have met regularly, and we have cranked out a newsletter to go along with the (almost monthly) meeting notices. We tend to have family members whose loved-ones are on the more severe end of the range of people with developmental disabilities, but everyone is welcome to attend our meetings and sign up for the newsletter.
 
When we started, we came up with a set of principles. We rarely refer to this document, but we adhere pretty closely to it. Here it is:

• People with developmental disabilities have diverse needs based on the nature and severity of their disabilities, their experiences, and family circumstances.
• For people with developmental disabilities who cannot speak for themselves, the best advocate is a parent, other family member, or close friend who is aware of the individual’s needs and cares about the welfare of that individual.
• To meet the long-term needs of people with developmental disabilities, a full range of services, programs, and living arrangements, designed to meet their unique needs, must be available and the availability communicated to people with DD and their families.

Our purposes are:

• To ensure the availability and delivery of appropriate services to people with developmental disabilities while protecting the rights and preserving the dignity of those individuals.
• To provide information so that people with developmental disabilities and their families or friends can advocate for themselves to obtain the services they need.
• To communicate with public officials charged with the responsibility for providing services and protecting the rights of the developmentally disabled and to ensure the accountability of public agencies to people with developmental disabilities and the public.

And furthermore, Friends of DD does not dictate to you what is best for your family member or browbeat you into conforming to a particular ideology or belief.  

This year, we have not met as often as we have in past years, but I have been sending out more information by e-mail with frequent updates on issues affecting families and people with disabilities. Friends of DD has joined ddAdvocates of Michigan, an Internet-based network of community organizations and family members. The purpose of ddAdvocates is to provide information to families and friends and apprise them of opportunities to comment on local, state, and national policies affecting people with developmental disabilities.

Jill Barker
Friends of DD
Ann Arbor, MI

iPad, iPhone, and iPod apps for special ed students

I recently talked to a parent whose son was able to order food from a restaurant menu for the first time by himself using an iPad to communicate. Apparently, these new-fangled computer machines do all kinds of amazing things that make communicating and understanding easier for children with learning difficulties.

Through the Website Bridges4Kids, I found a list by Eric Sailer of dozens of apps for iPads, iPhones, and iPods. They teach communication skills, sign language, math and spelling, help with speech problems, provide interactive games and books, help with organization, and many other things. These are available through the iTunes store and have reviews that will help parents determine which apps will be the most suitable to their child's needs.

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.

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@aacil.org .

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

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".

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.

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.

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.

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.

More on Michigan's plan for "dual eligibles"

Common Buckeye

If Michigan’s proposal to the federal government for “dual eligibles” were to be implemented, approximately one-third of mental health consumers would have both medical and specialized mental health services managed and financed by a medical health insurance plan. About half the funding for Community Mental Health services would leave the CMH system to pay for the new system of care. Such a plan would affect everyone receiving services under CMH, including people who are covered only by Medicaid.

Most people with DD and other disabilities and their families would have welcomed a discussion on how to improve CMH services. It is a flawed and chronically underfunded system, but at the very least, the principles upon which it is based and the combination of federal, state, and local policies that protect the rights of the people it serves, give most of those individuals a fighting chance for the services they need, not only for survival, but for a life that is fulfilling and meaningful. The state’s plan to reform the system is a radical approach with too many unanswered questions about how it could be implemented.

The Michigan Department of Community Health (MDCH) has now held 6 public forums to receive comments about Michigan’s proposal to integrate dual eligibles. After attending two of these forums, I found no indication that the MDCH was willing or able to answer the many questions that were asked when the plan first came up for public comment. Those questions (see here and here) remain unanswered.

A compilation of information and analysis of the dual eligible plan was distributed at a 9/14/11 meeting of the Community Mental Health Partnership of Southeast Michigan (CMHPSM), an affiliation of the mental health boards for the Counties of Lenawee, Livingston, Monroe, and Washtenaw. This document explains the plan better than anything else I have read. 

Here are some notable quotes from the dual eligible plan analysis mentioned above: 

• “What are we to make of all the signs that portend expansion in the use of Health Plans for duals, moving benefits out of current managing structures [CMH and regional affiliations of CMH agencies]? One appraisal might be that the plan, while arguably audacious, is also ill conceived (perhaps to the point of recklessness), and designed – not to better coordinate care – but to achieve savings, to the detriment of dual eligible beneficiaries…”
• What is puzzling about the MDCH proposal is that it – in effect – transfers crucial Medicaid state plan and … waiver services and supports to be managed by entities that have little or limited experience with the dual eligible population.” 
• “The MDCH proposal also exhibits scant understanding of non-medical (e.g., housing, transportation, linkage with various social service programs, etc.) supports – accessed through other community agencies – that are critical to community inclusion and participation for seriously mentally ill and/or developmentally disabled dual eligibles.”

The 10-page initial proposal that landed Michigan a $1 million contract to develop a plan for dual eligibles can be found here.

The Kaiser Family Foundation summarizes all fifteen state plans that were awarded contracts by CMS in this document: “Proposed Models to Integrate Medicare and Medicaid Benefits for Dual Eligibles…” This policy brief can be downloaded here. Other states that had their plans accepted by CMS proposed more flexible arrangements with some offering different plans for different subpopulations of dual eligibles, a much better approach in my opinion.

These documents are not easy to understand unless you happen to be an expert on health care reform, insurance reform, mental health administration, etc., but they may help you to ask the right questions when you respond to the plans that the state has for you DD family member.

FYI: State of the WISD - Special Ed Washtenaw County

Washtenaw Intermediate School District (WISD)

Parent Advisory Committee (PAC)
invites you to our next meeting:

Tuesday, September 20, 2011                           

6:30 p.m.

Featuring:

The “State of the WISD” presented by WISD Superintendent Scott Menzel
Meeting Location: Seminar 1

Washtenaw Intermediate School District (WISD)

Teaching and Learning Center

1819 S. Wagner Rd.
Ann Arbor, MI  48106
734-994-8100

For directions please see the WISD website:  http://www.wash.k12.mi.us/about/wisddirections.cfm

Key Legislative Contact Information for Michigan Dual Eligibles Project

If you have unanswered questions and concerns about the Michigan's project to integrate dual eligibles, you can do more than just send your comments to the project Website. Contact the key legislative committees of the Michigan legislature and your own state senator and representative as well as the Governor.

Michigan State Senator correspondence can be sent to:

State Capitol, P.O. Box 30036, Lansing MI. 48909-7536
 
Michigan State Legislators correspondence can be sent to:
 
State Capitol, P.O. Box 30014, Lansing MI. 48909-7514
 
Michigan House Committees:

Health Policy Chair: Rep. Gail Haines, Room N-167 Capitol Bldg.  gailhaines@house.mi.gov 

Community Health Chair Rep. Matt Lori, Room N-993, Anderson Bldg. mattlori@house.mi.gov   

Human Resources Appropriations Chair Rep. Dave Agema, Room N-1093, Anderson Bldg. daveagema@house.mi.gov 

Appropriations Vice Chair Joe Haveman, Room N-1194, Anderson Bldg. josephhaveman@house.mi.gov

Michigan Senate Committees:

Appropriations Committee – Sen. Roger Kahn, Room S-324, Capitol Bldg. senrkahn@senate.michigan.gov 

Health Policy Chair Sen. Jim Marleau, Room 1010, Farnum Bldg. jimmarleau@senate.michigan.gov 

Families, Seniors and Human Services Chair Sen. Judy Emmons, Room 1005, Farnum Bldg. senjemmons@senate.michigan.gov 

Dept of Community Health – Chair Sen. John Moolenaar, Room 715 Farnum Bldg. senjmoolenaar@senate.michigan.gov  

Dept of community Health - Vice Chair Sen. Bruce Caswell, Room 720, Farnum Bldg. senatebcaswell@senate.michigan.gov 

Dept. of Human Services – Sen. Mark, Room S-324, Capitol Bldg. senmjansen@senate.michigan.gov

Michigan Senate Leadership:

Appropriations Senate Majority Leader – Sen. Randy Richardville, Room 106, Capitol Bldg. senrichardville@senate.michigan.gov 

Senate Majority Floor Leader – Sen. Arlan Meekhof, Room S-8, Capitol Bldg. senameekhof@senate.michigan.gov 

Michigan House Leadership:

Speaker of the House - Rep. James Bolger, Room H-164, Capitol Bldg.  jasebolger@house.mi.gov
 
Majority Floor Leader – Rep. Jim Stamas, Room 153, Capitol Bldg. jimstamas@house.mi.gov 

Governor Rick Snyder - P.O.Box 30013, Lansing, MI. 48909, (517) 373-3400 Rick.Snyder@michigan.gov
 
Attorney General Bill Schuette, G. Mennen Williams State Office Bldg., P.O. Box 30212,  Lansing MI. 48909 (517) 373-1110  MIAG@michigan.gov
 
Michigan Dept of Human Services – Dir. Maura Corrigan, 235 S. Grand Avenue, P.O. Box 30037,   Lansing MI. 48909 (517) 373-2035
 
Michigan Dept of Community Health – Dir. Ogla Dazzo, Captiol View Bldg., 201 Townsend Street, Lansing MI. 48913 (517) 373-3740 moyer1@michigan.gov

Questions on Michigan "Dual Eligibles" Project from Stakeholders

This is from the Michigan Association of Community Mental Health Boards Executive Board and includes the complete list of questions from stakeholders mentioned in the last blogpost:

Integrated Care for Dual Eligible Beneficiaries in Michigan
 
The following is a list of Stakeholder questions and concerns as discussed at the MACMHB Executive Board Meeting August 5, 2011. Several forums were held in July offering the opportunity “to learn about and offer input into the state’s plans for integrated care for dual eligibles in Michigan”, however we were engaged late in the process and those who facilitated the regional meetings did not offer answers to our questions.
 
The questions pertain to three areas.
 
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 process and its content regardless of the individual beneficiary’s opinions?
• Will the existing Supports Coordination system be continued and for how long?
• What services will be available for those who “opt out”?
• Has there been a real effort to ask Stakeholders for their opinions and what they want?
• At what point will the CMHSP system no longer be used to deliver MI and DD services?
• Will any real consideration be given to allowing regional health homes managed by CMHSP county partners?

Participating Payers:

• 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 system already serving these beneficiaries?
• Since these Participating Payers have apparently been promised a share in any “cost saving” realized by the plan, what prevents them from gutting services and treatments in order to protect and insure they attain their share of the profits?
• Assumed “Cost Savings” based on an improved treatment model for co-morbid conditions could take years before the individuals actually attain improved health and the system realizes the savings. What is the assumed source of additional funding in the interim? Will the Payers be required to use their reserves to cover this shortfall?
• Has anyone questioned the logic and/or reasonableness of creating such huge monopolies charged with overseeing both commercial healthcare and tax payer funded Medicare/Medicaid dollars?
• Who is responsibility for identifying fraud and abuse and what is the anticipated accountability process?

 DE Plan Governance Steering Committee:

• 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?
• Decisions on or approval of treatment routines and service opportunities could not only alter the quality of life of these beneficiaries but also decide who lives or who does not. Who ultimately makes the final decisions for the most severe segment of this population?
• 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