Comment period extended on Michigan Self-Determination Policy

MESSAGE FROM LYNDA ZELLER
Deputy Director, Michigan Department of Community Health
 
"We are extending the public comment period on the proposed revisions to the Self-Determination Policy until 5 pm on May 11 [2012].  Since we are experiencing difficulties with the state E-mail account for Ellen Sugrue Hyman, please send your comments to Cynthia Gilpin at gilpinc@michigan.gov.  If you sent comments to Ms. Hyman after April 17, they may have become lost so you are advised to re-send to Ms. Gilpin. We apologize for any inconvenience this causes."

Special Dreams Farm in St. Clair Township, Michigan

The Detroit Free Press featured an article today - Special Dreams Farm offers life skills to special-needs adults by Alexandra Bahou - about a Michigan farm designed for developmentally disabled adults who want to be active, outdoors, and learn life skills on a farm.

Special Dreams Farm was founded by parents of developmentally disabled adults in 2004. The farmers first worked on private farms until the non-profit organization bought a 31-acre farm in St. Claire Township north of Detroit in 2008. The Farm relies heavily on private donations, fundraisers, and grants for its $140,000 per year operating costs. The farmers are not paid, but they learn skills that help them be more independent. The video and photographs that accompany the article show the delight with which these adults approach their activities on the farm and the close bonds they have with each other and the job coaches and volunteers who work with them.

To learn more about the Special Dreams Farm, go to the Website. 

Here is a page on the Website that has many photographs of the farm and two videos about the farm and how it it came to be.

MDCH Proposal to change Self-Determination Policy and Practice Guidelines

Update: The comment period has been extended until 5 p.m., May 11, 2012. The e-mail address for sending in comments has not been working properly. Send comments, including those that were sent to Ellen Hyman after April 17, to Cynthia Gilpin at gilpinc@michigan.gov .

Comments due Friday, April 20, 2012

Self-Determination is a method of delivering services to people with developmental disabilities that allows individuals to have more control over the services they receive, the people who provide the services, and the expenditure of public funds to pay for the services. This is an option that must be made available by CMH agencies for anyone who desires it, including people with the most severe disabilities who have guardians who speak on their behalf. People who want and need a more traditional program of services may choose not to use Self-Determination.

The Michigan Department of Community Health (MDCH) proposal to revise guidelines for Self-Determination includes encouragement of Community Mental Health (CMH) agencies to police guardians and circumvent their authority to make decisions. Guardians are appointed by the probate court for adults who are unable to make decisions for themselves in all or some areas of their lives. The vast majority of guardians are parents or other family members of adults with developmental disabilities who have intimate knowledge of the needs and preferences of their family members.

Among other things, the proposed guidelines say that CMH must "…support  individuals who have guardians who are using arrangements that support self-determination to identify an independent advocate."(emphasis added). Presumably, you could find yourself at a Person Centered Planning meeting with an advocate you do not know and did not choose to be there, representing the interests of your family member.  The proposal goes on to say that when guardians "restrict the individual's rights", CMH can terminate the self-determination arrangements, even though the individual and the guardian have chosen this method of service delivery.

If adopted, this wording would become part of the contract language for CMH agencies with the state.

This is from Tom Bird of ddAdvocates of Western Michigan: 

"…DCH [Department of Community Health] has repeatedly tried to intervene in the Court's authority over guardianship. The Legislature has, in the past, issued 'boilerplate' restrictions on DCH using it's funding to usurp guardianship. Could this just be one more misguided attempt to assert the DCH 'superior wisdom' on services over the wishes of the family and guardians of those who may not be able to communicate their wishes effectively for themselves? The Bureaucratic arrogance of the 'professionals' who think they know better than everyone else must be tempered by the rights of the consumer and his/her guardian. This is the core principle of PCPlanning and 'choice' of the consumer in service delivery. It should apply equally in the area of self determination.

"Guardianship, when necessary, is firmly established in the state Mental Health Code as a matter under the authority and oversight of the Judicial Branch. If there are cases of guardianship abuse or neglect, then the proper manner of handling that is to bring it to the Courts to decide the matter, not for the DCH to overrule the guardian unilaterally. Watch out!!!"

Resources for understanding and commenting on the MDCH proposals: 

• Self-Determination Guidelines with changes in "Bold": Pages 10 - 13 are specifically about guardians. 
• Summary of proposed changes 
• "Proposed Policy diminishes role of guardians…" from 2010 in The DD News Blog. This was a similar attempt to change the Self-Determination Guidelines in 2010. Here the emphasis was on encouraging CMH agencies to challenge guardianships in court when CMH determined that guardians were not living up to their responsibilities.
•  Links to all sections of Michigan's guardianship law for adults with developmental disabilities

Comments are due tomorrow (!), 4/20/12. If you have comments prepared, send them to Ellen Sugrue Hyman . E-mail the Director of the Department of Community Health Olga Dazzo asking that the comment period be extended so that more families have a chance to weigh-in on these proposals. If the MDCH does not extend the comment period beyond tomorrow, send your comments anyway, but to more people. Here are others who need to hear from you: Lynda Zeller, Deputy Director of Mental Health and Substance Abuse Administration; state Representatives and Senators from Washtenaw County; Governor Rick Snyder at Rick.Snyder@michigan.gov

I will try to post my comments on the guidelines tomorrow.

Grandma Janet: April 18, 1913 - January 6, 2012

My mother Janet Eleanor Howard died January 6, 2012. Tomorrow is her 99th birthday. 

She was born in Chicago, Illinois, to Jennie and J. Fred Peterson. She and my father Fred S. Howard lived in Garrett Park, Maryland, a suburb of Washington, D. C., for 59 years until 2007, when they moved to Ann Arbor to be close to me and my family. My father Fred is now 101 years old and lives in an assisted living facility in Ann Arbor.

My mother worked as an elementary school librarian from 1957 to 1977 for the Montgomery County Public Schools. From the time Danny was born in 1976, she was a constant source of moral support. When my husband was out of town for meetings, my parents came to the rescue and helped me take care of Danny, and later Ian and Jennie. 

Anyone who has had a severely disabled child (or two) knows this is not the usual fun-filled romp that other grandparents experience with their more typical grandchildren. My parents made the difference between the maintenance of order and sanity in our household and a downward spiral into chaos and despair. Maybe I'm being melodramatic about this, but I think anyone who has lived in that world of worry, sleep deprivation, and never knowing whether tomorrow would bring another trip to the emergency room, can appreciate the relief of knowing you do not have to face it alone.

My mother was a world-class worrier, a trait that she passed on to me. I like to believe that we worriers are the early warning system for the human race, anticipating all that could go wrong and averting most disasters merely by having thought of them in advance. The disasters that did befall us were not nearly as bad as the ones we anticipated. Knowing that "it could have been worse" is a constant source of comfort to people like us.

In celebration of my mother's birthday, here is one of her favorite poems:

Loveliest of trees, the cherry now
by A.E. Housman from A Shropshire Lad, 1896

LOVELIEST of trees, the cherry now
Is hung with bloom along the bough,
And stands about the woodland ride
Wearing white for Eastertide.

Now, of my threescore years and ten,      
Twenty will not come again,
And take from seventy springs a score,
It only leaves me fifty more.

And since to look at things in bloom
Fifty springs are little room,       
About the woodlands I will go
To see the cherry hung with snow.

More Comments on Michigan's Dual Eligibles Plan

Below are links to comments on the Michigan proposal for "Integrated Care for people who are Medicare-Medicaid Eligible." The people commenting all have family members who have been served by the Community Mental Health (CMH) system as well as professional or volunteer experiences that give them insights into the workings of the system that serves people with developmental disabilities and mental illness.

Rita Bird, a parent and Ottawa County CMH  Board member, gave testimony to the Michigan Senate Appropriations Subcommittee on the Department of Community Health in March 2012 on the  Dual Eligibles plan.

She raises questions about the cost of implementing the dual eligibles plan: "Good judgment demands that cost estimates be as accurate as possible in order to determine whether the Plan is financially sound and sustainable. "..

She is also concerned about "general confusion about the meaning of the plan and the state's intent in implementing it":

"What happens when the two systems [physical health care and mental health services] are in competition for the same dollars?"

"Who makes the final decisions on which services are covered, which services have priority, who delivers the services, who receives the services, and who has 'veto power over services that may be deemed just too expensive to provide to a particular population or to someone who is deemed too disabled, to sick, or too old for the expense?"

Rita's recommendations to the legislature are:

• Do not allow mental health funding allocations to be co-mingled with physical health care losing vital dedicated funding allocations for those with mental, cognitive, and physical disabilities. 
• Insist on the assurance that all current mental health services including enhanced Waiver services be continued and monitor waiver negotiations between DCH and CMS. 
• Delay approval of the Proposed DE Plan until it can be presented in its final form following CMS negotiations.
• Insist on a complete “Carve Out” of the existing mental health system structure until it can be accurately scrutinized for any cost savings and unnecessary bureaucratic weight. This has not been done.
• Have the mental health system continue to serve the DD population.
• Do not allow their services to be included in Long Term Care.

Marianne Huff, Executive Director of Allegan County Community Mental Health Services (ACCMHS) also comments on "the lack of sufficient detail to know whether or not there is a reason to be concerned."

She believes that " persons with disabilities have not been afforded an equal opportunity to learn about the Plan nor have persons with disabilities been given equal opportunity to participate in public discussions regarding the Plan."

She says, "...it is our contention that the stakeholder involvement process was limited and not truly accessible to those who comprise the greatest number of the almost 198,644 Dual Eligibles in the state of Michigan:  Qualified Persons with Disabilities."
 

Of further concern is "the lack of detail in the Plan as it applies to the current CMHSP system as a provider network and county-based system of specialty supports to persons with disabilities...It is difficult to speculate about the rationale for not including a more detailed explanation about the role of CMHSPs, but there is a sense that the Plan is designed to eventually eliminate the county-based community mental health system. "

Ed Diegel is from DD Advocates of Wayne County. In his comments, he emphasizes the importance of assuring that funding intended for people with DD is not used for non-DD programs, that inappropriate uses of these funds should be prohibited, and that the rights of the DD must be protected.

He also makes the point that in Wayne County, "when two of three Major Care Provider Networks (MCPN’s) unilaterally cut funding to programs for the Developmentally Disabled (with no corresponding reductions in State funding), the cuts resulted in service reductions and health and safety issues across the county. The conclusion is that there is no ‘administrative excess’ in the DD system for funding services for other populations."

On physical health care, Ed says that many people with DD who have complex medical needs may  exhibit symptoms different than the normal population or they may be presented in a different way.  He also notes that many people with DD  have doctors in more than one medical center.

He is also knowledgeable about  business operations of public agencies, service providers, and contractors. He emphasizes the need for planning for additional personnel that may be needed and re-defining industry practices to guard against the following:

• Excessive overhead assessments from contracting agencies at every level. i.e. Wayne County assessments for contracts that include kick backs and favoritism and excessive buy out provisions included in the over all overhead assessment
• Excessive reserves – recently the Michigan Attorney General sued the Federal Government to allow Blue Cross and 10 or 11 other Michigan Insurers to accumulate excessive reserves for its Michigan business (more than the 25% the Federal Govt allows).
• For-profit and non-profit company returns must be uniformly reported to assure against excessive profit taking. For instance, Health Net, a California Medicaid insurer shares are up over 64% since Oct 3, 2011 on news it will get a portion of the California dual eligible business!!

My comments on the plan are here .
 
Comments on the state plan to the Michigan Department of Community Health (MDCH) were due on April 4th, 2012, but comments can be submitted anytime to this email address: Integratedcare@michigan.gov 

This is the dual eligibles website for more background information on the plan.

If you have comments, be sure to let your legislators know. After the state submits its draft of the plan to CMS (Centers for Medicare and Medicaid Services), there will probably be negotiations with CMS that may result in changes. Fortunately, language was recently placed in an appropriations bill that requires the MDCH to submit the final draft of the dual eligibles plan to the legislature before the final version is submitted to the CMS.

Is the Michigan CMH system too inefficient and costly?

In my experience, Michigan's Community Mental Health system is chronically underfunded and overburdened. It can be both frustrating and tremendously helpful, depending on who you are dealing with and the system's capacity to solve your particular problem. Despite its flaws, the CMH system has many things going for it.

This is from the "MACMHB [Michigan Association of Community Mental Health Boards] Guide to Integrated Care for Dual Eligibles":

There has been some talk of excessive administration in the existing public behavioral health and developmental disabilities structure. However, the actual expenditure data suggests a very different reality. Consider the following:

1. The MDCH Finger Tip report indicates that the managed care administrative expense for the PIHP [Pre-paid Inpatient Health Plan] system in FY 10 was 6.5% of reported expenditures. An Analysis of the Medicaid Unit Net Cost report data required by MDCH indicates that payments for services constitute 91.4% of Medicaid expenditures by PIHPs. The remaining expenditure of 8.6% consists of administration and payment to risk reserves. As there is no profit factor, this suggests an MLR [Medical Loss Ratio] for the PIHPs of 91.4%. In the letter from the Michigan Department of Licensing and Regulatory Affairs to the federal Center for Consumer Information and Insurance Oversight supporting the state's request for an extension for meeting the PPACA [Patient Protection and Affordable Care Act] requirements for MLR insurance companies cited in this letter (other than BCBS [Blue Cross Blue Shield]) reported MLR ranging from 55.5% to 86.1%
2. The average administrative expenditure for CMHSP [Community Mental Health Services Program] service delivery operations for all services (both Medicaid and non-Medicaid), as reported in the Administrative Cost report for FY 10 was only 9.9%. Consider that the excessive administrative cost in healthcare is pervasive and considered one of the most significant challenges to reducing expenditures. The CMHSP programs bear considerable regulatory burden and serve a chronic population which would suggest a higher administrative cost, which is not evident.
3. 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.

While the public mental health system may have various issues, an examination of the data demonstrates an efficient health care delivery system. The public behavioral health system--as the only system currently managing dual eligibles--has effectively transitioned Michigan from state-based institutional care to a network of community-based alternatives during the past 30 years. the PIHPs/CMHSPs have successfully expanded access to services by 16% since 2002 have demonstrated consistently good cost controls illustrated by low administrative expenses and rates increases significantly lower than our counterparts in traditional healthcare. The existing system, under public control and responsive to local needs, has a proven history as both the financial manager and the service delivery structure for the public healthcare safety net. It seems prudent to work within the existing system to create necessary improvements rather than to abandon this public management structure.

Michigan's Plan for Dual Eligibles: Comment on Self-Determination, Opting-out, and Physical Health Care

Self-determination and available service settings for people with DD

Currently, Self-determination is an option under state guidelines. It is an approach to serving people with DD (and others in the CMH system) that allows for individualized budgets and gives the person the ability to hire and fire service providers. While self-determination has been an innovative and useful approach for many people with DD, it is not the only or best approach for providing appropriate services for all people with DD, especially those with more extensive needs who may be safer, happier, and better served in congregate licensed settings.

In addition, under services provided by the plan, there is no mention in the proposal of Adult Foster Care homes in community settings that provide services for people who need a high level of care.

Will these settings continue to be available? Will day programs continue to be available for people with DD? Will self-determination continue to be optional, available to those who want to pursue this approach to providing services?

Penalties for opting out

There needs to be a fuller explanation of the services that will not be available to people who decide to opt out of the Dual Eligibles plan.

What are “enhanced dental and vision” services that will not be offered to people opting out? The ramifications of a decision to opt out needs to be fully understood by Medicaid and Medicare beneficiaries. Penalizing people who make that choice needs to be justified.

Physical Health Care

The ICOs will manage the provision of physical health needs of dual eligibles in the mental health system. The plan (page 17) says that ICOs may provide other physical health services at the option of the ICO, such as expanded dental services, vision services, and hearing aids, and are strongly encouraged to do so.

Does this mean that people with developmental disabilities will only receive these services depending on where they live and whether the ICO wants to offer these services rather than based on need?