Public forums on the future of Michigan's behavioral health system (a.k.a. Community Mental Health)

This is a notice from the Michigan Department of Health and Human Services (MDHHS) inviting anyone interested in the future of the behavioral health system (Community Mental Health), including Medicaid services for people with intellectual and developmental disabilities, to attend a forum to voice your opinion.

Here is the notice followed by links to background information and my personal opinion about the cluelessness of state officials regarding the problems in our system of care and services.

MDHHS PUBLIC FORUMS:

THE FUTURE OF BEHAVIORAL HEALTH IN MICHIGAN

Please join the Michigan Department of Health and Human Services (MDHHS) for a conversation about the future of behavioral health in Michigan.

In December 2019, MDHHS outlined a vision for a stronger behavioral health system that integrates specialty behavioral health and physical health services. If you are served by Michigan’s Medicaid-funded behavioral health system or are the family member of a person served, we want to hear from YOU.

MDHHS is hosting five public forums throughout the state and online in early 2020. Department leadership will be in attendance to further discuss the vision, answer your questions, and listen to your feedback. Please join us!

Detroit: January 8, 2020, from 5:00—6:30 p.m.
Cadillac Place, 3044 W. Grand Blvd
Conference Room L-150

Grand Rapids: January 9, 2020, from 5:00—6:30 p.m.
Grand Valley State University L.V. Eberhard Center, 
301 W. Fulton, Room 201

Marquette: January 22, 2020, from 5:00—6:30 p.m.
Marquette Senior High School
1203 W. Fair Ave
Little Theater

Saginaw: January 30, 2020, from 5:00—6:30 p.m
Saginaw Valley State University, Gilbertson Hall, 
7400 Bay Road
Ott Auditorium

Virtual Forum: February 6, 2020, from 5:00—6:30 p.m.

The link for this event will be shared on www.Michigan.gov/FutureOfBehavioralHealth
in late January.

To learn more about the Department’s vision, please visit www.Michigan.gov/FutureOfBehavioralHealth. 

If you cannot attend an event, we would still love to hear from you. You can email your feedback to FutureOfBH@michigan.gov.

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Speech by Robert Gordon, Director of MDHHS, to the Community Mental Health Association of Michigan

The vision MDHHS is proposing

Section 298 Initiative The 298 Initiative has been abandoned, but it looks like current proposals by the state are trying to resurrect it. 

For many years, Medicaid Health Plans, both for profit and nonprofit, have been trying to get their  hands on Medicaid funds for behavioral health services (CMH) with promises that they can do it better and for less money than the public agencies that most people rely on. For some very good reasons, people don't believe them. Medicaid Health Plans do not have experience providing the social service supports people with IDD and other disabilities need to survive (housing, case management, caregiving, family supports, health maintenance, etc.). When medical health systems are faced with limitations on funding through a managed care system, they naturally turn to denying and limiting services to the people they are supposed to serve.

Let's not kid ourselves.The community mental health system leaves much to be desired with its inability to recognize or serve the full continuum of services that are needed by this diverse population. 

The State's proposals for reforming the behavioral health system (again) do not tell us what they are trying to reform other than a system of financial management for Medicaid funds. It seems to me this is starting at the wrong place again with the wrong people.

If you want a say in the future of Behavioral Health, tell the MDHHS what you know and what they need to know to do a better job. Lead with that, and don't let the state's proposals be the only thing you respond to.

The Disastrous Privatization of Medicaid in Iowa

See more on Iowa's managed care disaster here.

Iowa: Managed Care and Privatization of Disability Services Create a Crisis

https://www.desmoinesregister.com/videos/news/2018/01/17/disabled-iowans-struggle-managed-care/109548320/

What's the matter with Iowa? Managed care and privatization of Medicaid for the State's poor and disabled have created a crisis in the delivery of Medicaid services. The Des Moines Register features over 60 articles from 2015 to the present reporting on the rocky road to the takeover of Medicaid by private health insurance companies.

Michigan should take note. We have a modified managed care system that so far preserves services provided by public Community Mental Health agencies and (at least theoretically) ensures that all medically necessary services will be provided to people with developmental and other disabilities. The move to privatize all services under private Medicaid Health Plans (MHP) is underway, however, with the implementation of three pilot projects and one demonstration program in the state.

Here is a sampling of articles from the Des Moines Register:

The Register’s Editorial: Medicaid plan is gift for private firms, 3/22/15

The Des Moines Register foresaw problems with the idea of privatized managed care for Iowa’s poor and disabled citizens. The editorial board encouraged the public to be skeptical, especially when the state throw’s out numbers, out of context, to show how expensive Medicaid is. It turns out that in 2015, Iowa was doing pretty well in serving people with disabilities and other low income citizens and keeping costs down in comparison to other states:

“In fiscal year 2013, a Medicaid recipient in this state cost an average of $5,491 — less than the per-person cost in 29 other states and much less than people insured by private coverage. For an adult who is not a senior or disabled, Iowa spent an average of $2,000 on health care, less than that spent in 47 other states, according to research from the Kaiser Family Foundation. Health insurance for a state lawmaker costs Iowa taxpayers about $9,000 per year.”

...“Administrative costs are low because the program is largely managed by the government, which is not beholden to stockholders or obligated to pay huge CEO salaries. The cost of operating the program is currently 4 to 8 percent, according to the Iowa Department of Human Services, which oversees Medicaid. When privatized, the cost could grow to as much as 15 percent. Those are dollars not spent on actual health care.”

...“In its comments to state officials, the Iowa Hospital Association noted that managed care companies reduce costs by denying coverage for services, including emergency room visits. The association is 'deeply concerned' that the private model could reduce access to care and reimbursement rates for providers.”

Branstad touts Medicaid contracts, but few hospitals signed

by Tony Leys, tleys@dmreg.com, 11/19/15

Signs of trouble. The takeover of Medicaid by private health plans was scheduled to go into effect January 1st, 2016 [the starting date was later moved to April 1, 2016], but by November 2015, most hospitals and physicians had not signed contracts to participate in the new system.

“Gov. Terry Branstad, who is pushing to shift management of the state’s Medicaid program to private companies on Jan. 1, said Thursday that the firms have signed more than 12,000 contracts with pharmacies, doctors and other health care providers.

“But most Iowa hospitals and physicians have not signed contracts to participate in the new system, according to the Department of Human Services. The issue is important, because the managed-care companies are supposed to show they have broad networks of health care providers willing to care for the new plans' members."

…"None of the four managed-care companies reported signing more than 17 of the 118 Iowa hospitals now participating in Medicaid. One of the companies, WellCare of Iowa, said it hadn’t signed up any hospitals. Another, AmeriHealth, said it had signed up just two.”

…”Branstad contends the shift to managed-care companies will save millions of dollars for the state and federal governments while offering flexibility and coordinated care to Medicaid recipients.

“Critics fear the change to for-profit management will lead to service cuts. They say Iowa’s 560,000 Medicaid recipients are being put in the impossible position of choosing a managed-care plan next month without knowing whether their doctors, hospitals and other health care providers will be participating in any of the networks.”

Iowa Medicaid payment shortages are 'catastrophic,' private managers tell state

by Tony Leys, tleys@dmreg.com 12/21/16

By December 2016:

“The for-profit companies running Iowa’s Medicaid program have been complaining to state administrators that the controversial project is 'drastically underfunded' and that the situation has been a 'catastrophic experience,' newly released documents show.

"One managed care executive wrote that Iowa’s recent offer to give the companies an extra $127.7 million in state and federal money this budget year 'is not acceptable.' He added that without major changes, the privately run Medicaid program could be unsustainable.”

…”Gov. Terry Branstad last year ordered the shift to private Medicaid management, which took effect April 1. Branstad, a Republican, predicted the private companies could allow the state to save tens of millions of dollars by helping the program’s 600,000 poor or disabled participants stay healthy. Critics are skeptical of the savings estimates, and they say the main effect of the switch has been to tangle Medicaid recipients and care providers in red tape.”

….”During a Statehouse hearing last week, a Democratic legislator asked executives of the three companies if they planned to ask for big raises in their payments for next fiscal year. They declined to answer.

“We really just don’t discuss those things in public settings,” Cheryl Harding, who is Iowa president for AmeriHealth Caritas, told Sen. Joe Bolkcom of Iowa City.”

Nevertheless, the health care plans complained that the plans were vastly underfunded and unsustainable. 

State should hold managed care accountable 

by Michael Bugeja, Iowa View contributor, 7/29/17 

This is the editorial viewpoint from a conservative Republican: The writer refers to a teenage “victim” of Medicaid who has a severe mental illness. Medicaid is pressuring treatment facilities to shorten the length of treatment regardless of the recommendation of the professionals involved. 

“As the former director of the Greenlee School at Iowa State University, I know Gov. Terry Branstad. I usually sat next to him at the Iowa Newspaper Association convention head table. I have the utmost respect for Gov. Branstad. His service to the state of Iowa is exemplary. But he made one colossal misjudgment in privatizing services for the mentally ill and others dependent on Medicaid services and managed care. 

"As a fiscal conservative Republican, I understand why he did it and why he believed that privatization saves the state millions of dollars. It may appear so on the surface, but savings in one area often results in expenses in others, and Iowa communities are paying the price.” 

AmeriHealth's exit should curtail disabled residents' suit against Iowa, state lawyers say

by Tony Leys, tleys@dmreg.com 11/6/17

A class action lawsuit was filed in June 2017 by Disability Rights Iowa on behalf of 6 disabled Iowans, “who argue that the state’s shift to private management of Medicaid led to illegal cuts to their in-home care services. The plaintiffs say without those services, they could be forced to move into nursing homes, violating their constitutional rights.” The class action is on behalf of about 15,000 Iowans with disabilities.

Meanwhile, Amerihealth Caritas, one of the Managed Care Companies announced that it is dropping out of the state’s Medicaid program, “because of a contract dispute. The state lawyers noted in a court filing last week that AmeriHealth oversees Medicaid benefits for all six initial plaintiffs in the Disability Rights Iowa lawsuit. None have had their benefits overseen by the remaining two managed-care companies, UnitedHealthcare and Amerigroup.”


By its very design, managed-care Medicaid discriminates against severely disabled Iowans

by Bill Dodds, Iowa View contributor, 1/26/18

"By its very design, managed-care Medicaid discriminates against disabled Iowans who require costly, long-term treatments simply to live in their communities. It’s the only way today’s managed-care organizations (MCOs) can deliver on their promise to slow the growth of Medicaid spending and generate profit for shareholders.

"Iowa, like many states, has sought to gain control over the increasing costs of its Medicaid program by doing away with a state-run system in favor of managed care. This has resulted in state contracts with multiple managed-care organizations in an attempt to incent these companies to compete in Iowa for Medicaid members by offering services that best meet their needs while simultaneously reducing costs.

"This might sound good in concept but is difficult to achieve in reality, especially for recipients who have severe mental illness and disabilities. At Optimae, we have seen this play out daily in the lives of the more than 5,300 Iowans we serve."

…"It is virtually impossible for an MCO [Managed Care Organization] to determine which of the millions of units of services provided each year is truly 'medically necessary,' given that more than 600,000 Iowans receive services under Medicaid. To compensate, the companies focus on managing the most expensive services, especially those that are long-term. This includes longer term inpatient and outpatient services, including home health and home- and community-based services for individuals with disabilities, and nursing and residential care facilities."

…”Additionally, the MCOs in Iowa and most other states are publicly traded, for-profit companies. Their management is under pressure to constantly produce better financial results for shareholders, meaning taxpayer dollars that previously paid for Medicaid services are now set aside for profits. This puts the most expensive services at even greater risk for reductions by the MCOs regardless of the outcome."

Iowa House passes Medicaid cleanup bill in effort to address managed care woes 

by Brianne Pfannenstiel, bpfannenst@dmreg.com, 3/8/18

“The Iowa House of Representatives approved legislation Thursday that lawmakers said would begin to fix some of the problems that have plagued the state's Medicaid system. "

...“The Iowa House of Representatives approved legislation Thursday that lawmakers said would begin to fix some of the problems that have plagued the state's Medicaid system. “

Iowa privatization of Medicaid generates complaints

As Iowa experiments with the privatization of its Medicaid program, complaints have spiked. Is Michigan paying attention?

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As Medicaid Managed Care Proliferates, So Do Complaints


by Clay Masters, Iowa Public Radio | November 6, 2017

Iowa is one of 38 states that radically changed the way it runs Medicaid over the past few years. The state moved about 600,000 people on the government-run health program into care that is managed by for-profit insurance companies.

The idea is that the private companies would save the state money, but it has been a rocky transition in Iowa, especially for people like Neal Siegel.

Siegel is one of six Iowans with disabilities suing the state, alleging that Medicaid managed care, as it is known, deprives thousands of Iowans with disabilities the right to live safely in their homes.

Medicaid serves people with disabilities, low-income people and people in nursing homes. A combination of federal and state funds pays for it. It covers 74 million people across the country these days, about half of whom are in Medicaid managed care.

Siegel, a former financial consultant, was in a hit-and-run bicycle crash four years ago that left him with a severe brain injury. He uses a wheelchair and can barely speak.

“I would probably put Neal at about 98 percent cognitive (awareness) of what’s going on around him, but unfortunately (he’s) not able to articulate it,” said Siegel’s girlfriend, Beth Wargo. “So it’s being trapped inside your own body.”

After the accident, Siegel qualified for Medicaid. He lived in a rehabilitation center for a while, and the lawsuit, filed in U.S. District Court in June, says he was the victim of abuse and neglect while living there.

Eventually he moved home with Wargo, where he’s totally reliant on caregivers to assist him with all activities of daily life.

Then last year, Wargo said, they got a letter in the mail from AmeriHealth Caritas, the company that manages his care. Siegel’s budget for home help had been slashed by 50 percent, Wargo said. Siegel’s face lit up as Wargo talked about the lawsuit, and he managed to say, “Oh yeah,” when she mentioned how happy they were that they could be part of it.

Cyndy Miller is the legal director with Disability Rights Iowa, the advocacy group that spearheaded the lawsuit.

“The system is too stressed right now with the way it’s being managed, and it’s not healthy for individuals with chronic or serious disabilities,” said Miller.

According to the lawsuit, the company claimed that spending on Siegel’s case was cut because it had exceeded a limit set in state policy. A spokesman for AmeriHealth Caritas said the company could not comment on ongoing litigation. The state has asked for the lawsuit to be dropped.

In addition to the suit, complaints about Medicaid from hospitals, doctors and patients have spiked in Iowa.

Iowa’s Department of Human Services Director Jerry Foxhoven defended moving the entire Medicaid population to managed care. He said more taxpayer dollars will be saved under private management.

But he said his agency is willing to make changes, especially for people like Neal with serious disabilities.

“Everything’s always on the table. We’re always looking at everything to say, ‘How do we best serve the people we’re trying to serve and be the best stewards of taxpayer dollars?'” Foxhoven said.

For their part, the three companies with contracts in Iowa said in statements that the first 18 months of Medicaid managed care have been successful. But they also have said to state officials that reimbursement rates were based on deeply flawed cost estimatesprovided to them before the project began.

They are now negotiating to get millions of dollars more in state funding.

So where’s the savings? So far, no state has actually done a comprehensive review of whether private companies actually save Medicaid dollars, said Kelly Whitener, an associate professor with Georgetown University who studies managed care.

“You’d really need to be able to see, are you saving money overall or not, and if you are spending less money, are you suppressing services that are needed? Or are you really finding efficiencies and only delivering care that families really need?” said Whitener.

For the moment, those questions don’t have definitive answers.

Meanwhile, Iowa has to balance its books. Republican Gov. Kim Reynolds had to tap more than $260 million of the state’s reserve fund this year, and officials expect next year’s budget will be even tougher to negotiate. Medicaid funding is likely to continue to be a large part of the discussion.

This story is part of a reporting partnership with NPR, Iowa Public Radio and Kaiser Health News. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

Iowa to switch to Medicaid managed care; 25,000 people receiving Home and Community-Based Services affected

“Problems With Medicaid Privatization Plague Other States Ahead of Iowa's Switch” is a TV news report from Cedar Rapids, Iowa, looking into a similar plan in Kansas that has been in effect for three years. Kansas has had multiple problems with managed care affecting people with developmental and other disabilities. Here is a link to a video of the report and the written story from 2/29/16. 

According to KCRG.com, the problems that Kansas has encountered include “a lack of meaningful oversight, confusing reimbursement requirements from the three managed care organizations, or MCOs, who are contracted with the state, and cuts to care.” In Iowa and Kansas, two of the managed care organizations (MCOs) are the same - “Both companies are facing accusations in Kansas of systematically denying claims to turn a profit.”

For people who receive Home and  Community-Based Services (HCBS) (13,000 in Kansas and 25,000 in Iowa), the threat of service cuts is a significant problem.  According to Sharon Spratt, CEO of Cottonwood, Inc.,  a provider of long-term community-based care in Lawrence, Kansas, round-the-clock services are not cheap and it has been a constant battle to maintain them:
 
“We understood there could be some efficiencies on the medical side,” Spratt said. “But the right service at the right time doesn’t cure our folks. Our folks have lifelong disabilities.”
 
Spratt said Cottonwood often deals with the same problem of denied or unpaid claims, but most levels of care have remained the same. But following our Feb. 19 interview, Cottonwood received its first notice of an MCO denying all residential care for one of its clients. Cottonwood plans to appeal the decision.
 
Despite the warnings from Kansas, Iowa is poised to take the plunge into privatization and managed care. Whether Iowa has any better chance of success, remains to be seen. 

More dysfunction from Kansas:  A couple with a 21-year-old daughter with intellectual and developmental disabilities, autism, and a seizure disorder has been waiting since 2008 for state-funded services. 3,450 people are on the waiting list. On a lighter note (?), a woman whose daughter needed a new wheelchair and receives state services, says the state covered the wheelchair, but not the wheels.