Idaho Medicaid Managed Care Proposal

DisAbility Rights Idaho’s Comments on Idaho Proposal to Contract with a Managed Care Organization (MCO) for Medicaid Services for People Who are Eligible for Both Medicaid and Medicare.

Introduction:

The Idaho Department of Health and Welfare (IDHW) has requested public comment on their proposal to contract with a Managed Care Organization (MCO) to provide Medicaid services to people who are eligible for both Medicaid and Medicare (Dual Eligible). This contract is intended to cover not only the types of medical services typically handled by health insurance companies, but also mental health services including psychiatric rehabilitation services, home and community based, long term care services and developmental disability related community supports. There are important differences between traditional medical treatment services and these community based support services which require careful and cautious planning and implementation. Although there are examples of MCO contracts covering some of these services in other states, we have not found any examples of states with a significant history of using a single MCO contract to provide all of these services statewide. This proposal appears to be without precedent.

The degree of uncertainty and the potential for large scale unpredictable changes in Idaho Medicaid in the next three years is enormous.

1. Idaho is currently preparing a Request for Proposals (RFP) for an MCO contract for Medicaid mental health services.
2. That contract is expected to be expanded to include substance abuse services after about a year of implementation.
3. Sometime this summer, the U.S. Supreme Court is expected to rule on the constitutionality of the Affordable Care Act.
4. In 2014, if the Act is upheld or partially upheld, a large number of people with severe and persistent mental illness (SPMI) will become eligible for Medicaid. Most of them will also be eligible for Medicare.
5. Implementation of the Children’s Developmental Disability Redesign and changes in the Adult Developmental Disability including changing authority to §1915(i) are in process.

If the Mental Health MCO is different from the Dual Eligible MCO, there will be overlap or conflict between the populations served. Since the Mental Health MCO will already be in place by the time the Dual Eligible MCO is initiated we should expect to see large shifts of participants and costs into and between these two contracts as each of the events described above occurs. These shifts will cause confusion, and disruptions which are generally not beneficial to the participants or anyone else involved in the process. Even if the same MCO wins both contracts, the differences in terms and “per member per month” (PMPM) rates between the two contracts will cause problems. It may be unreasonable to expect any system to absorb all of these separate but interconnected changes in such a short period of time. Coordination of all of these change processes may simply overwhelm a newly created system which has no history or precedent.

Incentives to Provide Effective Preventive and Supportive Mental Health Services

It is imperative that the financial incentives built into the system reward high quality care and effective preventative practices. It has been demonstrated that it is possible to save money by employing effective preventive and support services for several chronic conditions such as asthma and diabetes. There is evidence that bundling traditional physical health with mental health treatment can reduce the cost of traditional medical care and reduce psychiatric hospitalization. However, these demonstrations placed the burden for the cost of psychiatric hospitalization on the MCO.

1.    If the cost of hospitalization is borne by the state, the MCO has an incentive to place people in state hospitals and to delay their return to the community as long as possible. Unless the full cost of hospitalization in state hospitals is somehow charged to the MCO, there is no incentive to prevent hospitalization or to have robust mental health supports to prevent recidivism.

2.    The system should also provide incentives for preventing people with SMI from entering the criminal justice system or jails, or committing suicide. All of these events can actually lead to cost shifting or cost savings for the MCO unless the payment system provides disincentives for these events.

DD Services and Supports

The PMPM method does not by itself provide incentives for effective DD supports services or treatment. The goal of these supports is to increase the capacity of the person for self determination, independence and community integration. The success of such services is not measured by their physical health status or need for more expensive medical treatment. Short of institutional placement, there is no consequence to the MCO for providing inadequate or ineffective services and supports. Placement in a state facility like SWITC would even be a net savings to the MCO and for certain individuals ICF/ID placement could be a savings over a robust and effective community supports plan. To be effective, there must be a strong incentive to provide effective developmental services and supports. This can only be accomplished with a robust and accurate quality assurance system and well designed incentives to meet the expectations of that system. We are not aware of any examples of such a system. Traditional health insurance plans do not have expertise or experience with these services.

1.    The MCO should be required to contract with a highly qualified, independent entity to evaluate the quality and effectiveness of DD supports and services.

2.    IDHW should consider carving out DD supports and services from the plan or preserving them as a fee for service system. With a robust system of quality assurance and care management practices.

Enrollment:

1.    Require that consumers have at least 90 days to make a choice among plan providers.

2.    Require plans to contract with community-based organizations such as Independent Living Centers, and others.

3.    Include programs for people with mental illness, to educate potential enrollees about their options and to assist them in selecting delivery systems that best serve their individual needs.

4.      Allow enrollees to change plans at any time, without imposing a lock-in period.

Provider Networks:

Many dual eligibles have longstanding, beneficial relationships with providers that might not be in the existing network of a health plan or delivery system that participates in the program. To maintain continuity of care and respect these relationships, participating plans should:

1.    Maintain an open network provider system in order to contract with providers that are not currently in the network.

2.    Offer single case agreements that allow participants to continue seeing their current provider without arbitrary limits on the duration of the relationship.

3.      Require that all providers are trained on independent living and mental health recovery approaches.

Long Term Services and Supports (LTSS):

The goal of LTSS for dual eligibles should be to promote their independence, choice,

dignity, autonomy and privacy. LTSS must emphasize community and home-based services over institutional care in compliance with the Olmstead v. L.C. and E. W.  decision.

1.    LTSS services and should be based on conflict of interest free comprehensive evaluations which include an evaluation of functional status, social and vocational needs, socioeconomic factors, personal preferences, and the ability to obtain accessible services.

2.    Require plans to maintain current levels of LTSS until a comprehensive assessment is conducted.

3.    Contract with LTSS providers who have the capacity and expertise to meet member needs.

4.    Have the beneficiary play the central role in the LTSS assessment and in the development of an LTSS plan.

5.    Support family care giving through designation of family members as paid aides when consumers request this, as well as through respite services.

6.    Provide personal care assistant services, including an option for self-directed services.

7.    Ensure that people with developmental disabilities (DD) have the opportunity to participate in the My Voice, My Choice HCBS Waiver option.

8.    Ensure that people with both a developmental disability and a mental illness have coordinated LTSS from providers with expertise in supporting both conditions.

Care Coordination:

Most health insurance companies have no experience with community based services for people with SMI or DD.  Typical health plan care coordination generally consists of having a nurse call the member occasionally on the phone. Case Management and Service Coordination services for people with SMI or DD must be much more “hands on”. It must include regular face to face meetings and intervention or advocacy on behalf of the member with other providers and community contacts such as landlords or the courts. Traditional health plan care coordination must not replace these vital support services. Plans must be required to contract with qualified and experienced DD service coordinators and SMI case managers, and whenever possible to continue with the member’s current services.

The care coordination team must include a LTSS provider or coordinator (could be the case manager or the TSC) who is responsible for maintaining the LTSS. Few PCPs are able or willing to perform this function.

LTSS care coordinators will often be needed for people receiving home care LTSS as well.

Crisis Services:

People who require LTSS for physical disability, DD, or SMI are at risk for crises in their lives and in their care needs. Plans will need to be able to quickly approve and provide additional services to deal with a crisis caused by a change in the person’s physical or mental health status, the imminent loss of living arrangements, unpaid supports, or other catastrophic events.  The ability of the system to respond to unexpected crises in the community without resorting to institutional placement should be a key requirement of the plan.  The plan should also be well coordinated with non-Medicaid crisis services and be able to access them when needed.

Compliance with Olmstead v. L.C. and E.W. and Best Practices for community based services.

The MCO must be in full compliance with the community integration mandate of the Americans with Disabilities Act (ADA) and the Supreme Court decision in Olmstead v. L.C. and E.W. Although the ADA has lesser implications for private health insurers, the Medicaid program must comply with Title II of the Act and the community integration mandate. This will require the contractor to make community services available in cases where institutional placement would be less expensive. It also requires services to help prevent hospitalization for people with mental illness.

1.    There must be incentives and requirements in the plan to provide for recovery oriented, person centered plans of service.

2.    The plan must allow for self directed services in all areas of long term services and supports including mental health.

3.    DD services should emphasize self determination, community integration, employment opportunities and training for eligible individuals.

The proposal for a single MCO contract for all Medicaid services for all people with dual eligibility is unprecedented and moves Idaho into uncharted territory in LTSS models. IDHW should be extremely cautious and move slowly and deliberately toward this project. Planning to implement it in the current time frame with such an array of both known and unknown variables (e.g. the Mental Health MCO contract, the implementation of the ACA, the pending decision in the Supreme Court on the constitutionality of the ACA, the efforts to redesign DD services, several pending federal lawsuits) may be too ambitious and ill advised.

If Idaho does proceed at the proposed pace, there are serious issues to be addressed in the areas of DD services, mental health services and other LTSS.

Submitted by

James R. Baugh

Executive Director, DisAbility Rights Idaho.

Psychosocial Rehabilitation (PSR) is NOT the same as Developmental Therapy.

One of the misguided changes made to Idaho Medicaid benefits in order to cut the budget, is the refusal to allow a person who has both a psychiatric illness and a developmental disability (DD) from receiving both developmental skill building services and psychosocial rehabilitation.  People who have both diagnoses are expected to give up treatment for one or the other. This makes no more sense than asking a person with both diabetes and heart disease to pick which one they want to receive treatment for.

There are about 600 Idahoans on Medicaid who have a developmental disability (such as autism, or intellectual disability) and also have a severe and persistent mental illness, or emotional disturbance.   Dealing with both of these conditions at the same time can be very challenging.  Idaho Medicaid covers both developmental services (like developmental therapy and residential habilitation) and mental health services (like psychosocial rehabilitation, and partial care). However, under a new rule recently enshrined in Idaho Code by H 260, Idaho Medicaid will cover only one of these services even if the person qualifies for both.  The rationale for this approach is that since all of these services include teaching skills, any one of the services can accomplish the same goals.  Unfortunately, the fact that the services all include some type of skill building is the only thing that they have in common. The Department of Health and Welfare’s (H&W) web site offers this one sentence justification: “A participant may obtain all of his specific skill training service needs through one program even when he has dual diagnoses”. But just saying something does not make it so.

The Department’s own rules do not allow Developmental Disability Agencies (DDA) to provide PSR, unless they are also a licensed Mental Health PSR provider. Their rules also require specific credentials and certification of the people who provide PSR which is not required of people who provide DDA services. [i] Agencies which provide developmental therapy and Intensive Behavioral Intervention must be licensed and meet and meet a host of requirements, not required of PSR agencies.[ii] People who provide developmental therapy must be supervised by people with specific credentials and experience in developmental disabilities. [iii] PSR providers are not. Although these services both include skill building, they require radically different capabilities, training, credentials and supervision.  How is it that DDAs are qualified to provide PSR services to people with a dual diagnosis but not to other people with severe and persistent mental illness? Why should we believe that PSR workers are qualified to provide Intensive Behavioral Intervention to people with dual diagnosis but not to other people with developmental disabilities?

Most people with both diagnoses will choose to keep their DD services and abandon their PSR.  This will happen because many of these people need the DD services for day to day maintenance. For many adults their living situation is tied to their DD services, as in Certified Family Homes or in Supported Living apartments.  For these people, giving up DD services means being forced out of their homes.  The overall effect of this policy will be a wholesale loss of PSR services for people with both a developmental disability and a severe and persistent mental illness.  This will result, over time, in increased mental illness symptoms, emergency room admissions, involuntary hospitalizations, arrests and other costly consequences as well as unnecessary increased suffering.  Some of these people are already experiencing these problems.

PSR providers are trained in psychiatric rehabilitation and must be credentialed by the USPRA. The service includes helping clients to recognize emerging symptoms, or changes in symptoms, helping people work through difficulties caused by delusional thinking, general self care for mental illness, monitoring symptoms and medications, insuring that clients participate in ongoing mental health care, maintaining housing and when appropriate employment, and problem solving for other life stressors.  DDA staff simply is not generally qualified to do these things and are not expected to do them based on DDA rules.

PSR providers however are not trained in designing individual developmental plans, intensive behavioral intervention, behavior shaping, reinforcement schedules or many other components of developmental programs. Medicaid requires specific training and certification for DD service providers which are not required for PSR workers.

The idea that DDAs will provide the same mental health symptom management, mental health monitoring, and psychiatric rehabilitation that people with severe and persistent mental illness receive through a qualified and credentialed PSR provider; or that a PSR provider will provide the same intensive behavioral and developmental training that DDAs provide, is a convenient fiction to justify elimination of a service for purely budgetary reasons.  When we make policy decisions based on convenient fictions there are always undesirable consequences.

This policy has been in effect since January 2011. It will take more time for the damage done by this policy to become evident or widespread.  However, there are people who are already experiencing adverse effects such as suicide attempts, hospitalizations and arrests.

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[i] IDAPA 16.03.10.130 (PSR agency requirements)

[ii] IDAPA 16.04.11 (Developmental Disability Agency requirements)

[iii] IDAPA 16.04.11.420 (DDA staff qualifications)

“Blended Rates” for Medicaid Developmental Therapy is Very Bad News for People with Disabilities in Idaho.

The Idaho Department of Health and Welfare (IDHW) has implemented the new “blended” reimbursement rates for adult developmental programs. “Blended” rates were suggested by DD service providers and endorsed by the Department as a way to cut costs for Fiscal Year 2012. The suggestion was embraced by the Legislature in H 260 (see the previous post for information on H260).

Developmental therapy is teaching new skills and behavior patterns to people with developmental disabilities, such as, intellectual disabilities, autism or cerebral palsy.  This might be basic self care skills like dressing, grooming, bathing or going to the bathroom, or independence skills like shopping for food, cooking, managing money, using public transportation and house cleaning.    Until recently, Developmental Disability Agencies (DDAs) have been paid four different rates for providing the therapy based on whether it was provided on a one to one basis, or in groups and whether it was provided in the community or in a facility.  A distinction is no longer made between individuals or groups – there is one rate for serving people in the community ($13.36/hour/person) and one for providing developmental therapy in a center ($12.08/hour/person).   

 Some skills can be taught to some people very well in groups. Some skills cannot realistically be taught in groups at all. Teaching a person to use the bathroom, bathe or shower, dress, or take care of personal hygiene in a group is patently impossible or inappropriate. Most self-care and independent living skills are best taught one to one.

Whether skills can be taught in a group often depends greatly on the level of learning difficulty experienced by the learner. People who can learn on an abstract level and can generalize a skill to be used in different circumstances may be able to benefit from group instruction. But many people with intellectual disabilities, brain injuries, or severe autism simply cannot do this. People in these circumstances cannot learn “how to use the bus” but with good individual instruction can learn how to take a particular bus route every day to a particular destination. They may not be able to learn “how to use a stove” but can learn how to make a particular set of meals on a particular stove, with markers on their stove and pictures geared to their own adapted stove in their apartment. I could go on to list hundreds of examples, but these illustrate the principle well enough.  Indeed, the development of adapted tools and environments and individualized learning strategies in the 1970’s made it possible for hundreds of thousands of people with disabilities to move out of state institutions and to live in the communities with some supports and assistance. 

Idaho’s implementation of “blended rates” threatens to virtually eliminate individual therapy by making group therapy much more profitable and making individual therapy a money losing proposition. The rate that Idaho Medicaid has set for home and community based  therapy ($13.36/hour) will not cover the cost of a minimally qualified staff person and their payroll taxes, and certainly will not  pay for supervision by a professional, training, travel to client’s homes, insurance, etc. In most cases the total cost of providing the service will exceed the new rate. Groups of three, however, will have about the same cost but will be reimbursed at $40.00/hour. This is potentially quite profitable. Medicaid’s hope that agencies will continue to provide individual services at a loss and be satisfied with making it up on a smaller number of group therapy hours has not been fulfilled. Most agencies are virtually eliminating individual therapy and converting almost everyone’s programs to group therapy.  Skills that must be taught one to one are not being addressed. Individual learning capabilities are being ignored. Agency employees are being laid off.  The system grinds on using state and federal funding, but it will no longer serve its intended purpose which is teaching people with significant disabilities the skills they need to live their lives in the community. 

Imagine that you go to a language instructor and ask to learn Spanish.  They tell you they can provide really effective instruction but it will cost you $5,000.00.  You tell them that you can’t afford that. Well for $4,500.00 they say they can give you an English Spanish Dictionary and a recording of the pronunciation of the 500 most commonly used words. You’re pretty sure that you’re not going to be able to figure out how to speak Spanish from that, but then, hey, you saved $500! 

Medicaid will report to the legislature that the change is working because they are spending a small fraction less in state funds. Provider agencies will breathe a sigh of relief because they avoided some cuts that may have put them out of business and now have a way to stay in business and perhaps increase their profits. But in reality, we all lose with this short sighted change because it has virtually eliminated the most effective tool we had for building community survival skills for people with developmental disabilities, individualized instruction.  The government will now pay a little less for a service, but will receive far less value for their expenditure. When it becomes apparent that group instruction is not meeting people’s needs, developmental therapy will lose its credibility. Over time we will pay more for the many different problems that will arise from the lack of effective skill building and behavior training. But, as usual, the biggest price will be paid by people who need one to one instruction to get by in the community.  For some of them they could lose everything, their opportunity, their independence, their home, their freedom.

Community Based Disability Services Will Be Seriously Hurt by H 260.

My last blog was posted in the middle of the Idaho legislative session and chronicled the terrible effects  H221 would have on Medicaid services for people with disabilities.  I am pleased to report that H221 was held in committee and did not pass.  Unfortunately, it was replaced H260 which dropped some of the worst parts of the first bill, but still has enough harmful features to qualify as a disaster. H260 passed easily, was signed by the Governor and is now law.

Fortunately, H260 does not include the elimination of developmental therapy for some adults.  It does not include the section forcing people with developmental disabilities over the age of 45 to switch to the nursing home based waiver. But, it still has a lot of sections that will degrade services for people with disabilities and threaten the welfare of many.

Some of the changes made by H260:

1.       Change adult developmental disability (DD) services budgets to tiered budget levels “similar to children’s services”.  This could result in large reductions in the amount of services for many adults. The Department expects this change to reduce adult DD services by $2,000,000 per year in state funds or $6,667,000 in total funds. The tiers will likely be based mostly on scores obtained on the Scales of Independent Behavior –Revised (SIB-R). Although the SIB-R claims to yield a score for level of support needed, the assessment instrument only asks about the person’s level of skills, not their individual needs. There is probably a statistical correlation between these two levels, individual circumstances can result in huge differences in the cost of needed services between two people with the same score.  Grouping people into tiers will result in some people getting less than they need and some getting more than they need.  Even if this works out on average, individual people could be harmed by the system.  In any case, the only way that budget tiers can save $6.6 million, is by cutting a lot of peoples’ basic supports.

2.       Prohibits a person from receiving both psycho social rehabilitation (PSR) and developmental Services, even if they have both a developmental disability and a mental health diagnosis and qualify for both services. Although both services involve “skill training” they are not the same. The people providing the services have radically different training and qualifications, the types of issues addressed are different and the linkage to the rest of the service system is different. Some of the 600 people who have both conditions will face serious consequences by having to choose only one service.

3.       Requires Health and Welfare (H&W) to develop a “blended rate” for developmental disability services. Medicaid currently pays a higher rate for individual compared to group DD therapy. This will result in the same rate for both types of supports. .  This means that it will twice as profitable to do therapy for two people at the same time and three times as profitable for three people. In fact it will probably be cost prohibitive to provide individual therapy. This will be a powerful incentive to DDAs to make all of their services group services. Unfortunately group services may not be appropriate in many cases and integration will be more difficult.

4.       Repealed all automatic Medicaid rate adjustments in Idaho Code. This includes the rate formula for personal assistance services (PAS). The rates were previously based on a formula tied to the average wages paid to nursing assistants in nursing homes. This formula has saved PAS from the stagnant rates that have plagued other services like DD therapy. Under H260, all rate increases have to go through a specific legislative authorization and appropriation process.

5.       Limited physical, occupational and speech to the Medicare caps, except for children who can prove that they have a medical necessity for more.

6.       Adult dental services will be limited to adult coverage shall be limited to medically necessary oral surgery and palliative services.

7.    Mandates the Department to impose co-pays on some services, not yet identified.

8.       Mandates the use of managed care “approaches that provide case management for high-risk, high-cost disabled adults and children that reduce costs and improve health outcomes, including mandatory enrollment in special needs plans. Managed care contracts to pay for behavioral health benefits as described in executive order number 2011-01 and in any implementing legislation. At a minimum, the system should include independent, standardized, statewide assessment and evidence-based benefits provided by businesses that meet national accreditation standards. The elimination of duplicative practices that result in unnecessary utilization and costs. Contracts based on gain sharing, risk-sharing or a capitated basis” (sic).

9.       Eliminates all payments for “collateral contact”.

10.   Eliminates service coordination for people getting PAS waiver services.

11.   Cuts the amount of time reimbursed for assessments and evaluations from 12 hours to 4 hours.

12.   Changes Certification criteria for Certified Family Homes and add licensing fees

All of these changes deserve an entire blog post to themselves and I will be addressing some of them in future posts.  People concerned for the welfare of people with disabilities in Idaho should get detailed information on programs that are likely to affect them and be watching for publication of new rules for public comments.  Watch this site for future posts.

H221 violates federal law and deprives vulnerable adults of essential safety net services.

The most egregious problems with H221 are the elimination of developmental services for people who are not eligible for waiver services and for all people over the age of 45 (p. 10 lines 43-46).

1.       People with developmental disabilities who do not meet institutional level of care will lose all developmental supports and services. 

a.       Who are these Idahoans? -They are 524 people who have a severe, lifelong disability occurring at birth or in childhood.  The disability must cause significant limitations in at least three major areas of life activity, and it must, by definition, require lifelong services and supports which are planned and supervised (see definition from Idaho Code, attached).  People with developmental disabilities (DD) who do not meet the Idaho standard for institutional care can have a measured level of independence skills as low as a child who has just turned eight (8) years old, a second grader. They may also have other conditions such as epilepsy, cerebral palsy or autism. They can function slightly above the 8 year level if they have severe and frequent maladaptive behavior like violence or tantrums.

b.      What services are left for them? -They may receive medical services like physical therapy if they have physical illnesses, but they will not have any other service designed to help them live safely or independently at home.

If a parent were to abandon an eight year old without any supervision or supports, they would be liable for child neglect. Yet the state is abandoning these vulnerable adults by removing their only safety net service. Some of these adults have some support from families but for many, their parents are dead or elderly, and they may not have any siblings available for support. H221 would eliminate their services regardless of the lack of family or community supports.

2.       People Over 45 who do meet the level of care provided in an institution for people with Intellectual impairments (ICF/ID) will be transferred to a waiver for people with physical disabilities, if they need nursing home care.  Otherwise they lose all in home supports.

a.       Who are these Idahoans? – These are people who have an evaluated independence level of less than eight (8) years, or slightly more than eight years with severe behavior problems.

b.      What services are left for them? –

                                                              i.      Some will be transferred to the Aged and Disabled (A&D) waiver if they can prove that they need nursing home care.  They must be evaluated by a nurse using an assessment instrument, for medically related personal care needs such as assistance with bathing or eating and chore services if they cannot do things like cook or clean house, do to physical limitations. But under the A&D waiver limits, no one can receive more than 8 hours per day of personal assistance under the A&D waiver. Even people who qualify for the A&D waiver may need 24 hour supervision, since all of them function at less than an 8 year level of independence. This will not be available in their current placements forcing them into institutional care.

                                                            ii.      Since the A&D waiver has completely different eligibility criteria from the DD waiver, some people on the DD waiver will not meet the nursing home level of care requirements. People who do not have physical limitations, but do have severe intellectual impairments and behavioral problems, may not qualify for the A&D waiver at all.  After H221, their only option will be institutional placement. 

These sections violate Federal Medicaid laws and the Americans with Disabilities Act.

1.       Federal Medicaid laws require people who need “active treatment” to receive it in either the ICF/ID level of care or in the Skilled Nursing level of care. The federal definition of who needs “active treatment” is attached. It would include every person currently on the DD waiver and many of the people who currently do not receive DD waiver services. The federal laws and regulations do not make any arbitrary age cutoff much less one as early as 45. The Centers for Medicaid and Medicare Services (CMS) have also required states to show that their HCBS Waivers provide an equivalent for active treatment.  By prohibiting active treatment for people over 45, H221 places Idaho in immediate violation of federal Medicaid standards. 

2.       The Americans with Disabilities Act as applied by the Supreme Court in Olmstead v. L.C. and E.W. requires state Medicaid programs to insure that people with disabilities are not forced to accept institutional care when community based services could meet their needs. H221 prohibits people with developmental disabilities from receiving active treatment in Idaho’s community based waivers, leaving the ICF/ID facilities as the only place where active treatment can be provided.  This is a violation of the ADA integration mandate on its face and puts Idaho in direct conflict with the ADA, and the Olmstead decision. (See attachment on the ADA).

Statutory reductions in psycho-social rehabilitation (PSR) impose needlessly rigid and inadequate limits which will force many people with severe and persistent mental illness into higher cost services or into the criminal justice system.

1.       Allocating the caps by the week, instead of the month or the year robs people of flexibility needed to respond to crises. At the same time it induces people to use the maximum number of hours each week to keep their allocation.  Authorizing PSR hours by the month would allow a person to reduce hours when they are doing well and have hours available when they need them for a crisis. Establishing a weekly limit in statute prevents people from budgeting their services in the most efficient way and insures that they will not have enough hours to deal with a crisis when one occurs. This is another example of why most of these changes should be made in rules and not imposed as inflexible statutory requirements.

2.       Four hours is not enough time to deal with a person who is decompensating or dealing with a personal crisis. When a person begins to be overwhelmed by symptoms of increasing severity they need intensive supports to avoid hospitalization. With a limit of four hours per week PSR workers are forced to simply send the person to the emergency room or call law enforcement when the hours run out.  This is already happening under the current five hour cap.

Imposing Medicaid caps on physical therapy, occupational therapy and speech therapy will be inadequate for people with lifelong disabilities. Medicare caps are devised for the purpose of addressing an injury or trauma caused need for these therapies. People with cerebral palsy, for example, need a lifetime of therapeutic interventions to maintain their level of functioning, and they may need many sessions to adapt to new augmentative communications devices. By putting these limits in statute, H221 ignores the unique needs of people with disabilities. These issues should be addressed in negotiated rules, not statutes.

H221 prohibits people with dual diagnoses of mental illness and developmental disability from receiving appropriate services.  About 600 people in Idaho have the great misfortune of having both a serious mental illness and a developmental disability. About 300 of these people are children. Very few professionals are trained or qualified to treat both conditions. Making a person choose between treatment for one or the other is like asking a person with both diabetes and heart disease to choose which condition can be treated. H221 does this on page 15 lines 41-45 and again on page 16 lines 25-27.  This was suggested as a short term limitation to get through temporary budget crisis. As a permanent change it will have serious consequences. Developmental specialists are not trained to recognize psychiatric symptoms and PSR workers are not trained in behavioral management techniques for people with autism, for example. These services are not duplications but separate and necessary interventions designed to keep people safe in the community. In some cases the Medicaid rules for one service would exclude dealing with the problems addressed by the other. This provision also violates the Americans with Disabilities Act by denying access to one service based on a person’s need for another service caused by their specific disability.

Liberty and Disability

Liberty and Disability

The preamble to the Constitution of the United States says “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”(spelling and capitalizations are in the original, emphasis is added). 

The framers and drafters of our Constitution clearly intended that the national government should be committed to protecting the liberty of its citizens and actively securing the blessings which liberty has to bestow.  It has taken over 230 years to understand what that commitment means. At the time, the blessings of liberty were not secured for slaves, or for women. But America eventually found ways to secure the blessings of liberty for both groups. No thought was given to how the nation would secure the blessings of liberty for people with disabilities until recently.

In the 1960s tens of thousands of people with mental illness or intellectual disabilities were incarcerated in shocking human warehouses without having committed a crime and often without the benefit of a trial or a hearing.  People with physical disabilities were also given no choice but life in restrictive nursing homes where their lives were short and devoid of the freedoms that the rest of us take for granted.  There were no armies of volunteers or charitable organizations to assist these Americans.  The blessings of liberty were no more than a forgotten dream. It seems that securing the blessings of liberty for people with disabilities requires more than just leaving them alone or releasing them from institutions to die on the streets.   If a person is not capable of moving their arms or legs, of getting out of bed, of eating, or using the bathroom, they cannot experience liberty until they have assistance. To really experience the basic freedoms of choice, of action, of association and of movement, some people with disabilities need the regular assistance of another human being.  In order to be free of the incarceration of institutions, some people with mental or cognitive disabilities need specialized training and supports in their homes and communities. In the last forty years we have learned how to secure the blessings of liberty for people with disabilities through government sponsored community based services, primarily through the Medicaid program. With these services people with disabilities have moved into homes and apartments of their choice, when they could afford it. They have directed the people who provide the supports they need and they have experienced real liberty for the first time. If the mission of government is to spread freedom and to promote liberty, there is no finer example of that mission than community based services for people with disabilities.  People deprived of freedom of movement and choice through no fault or action of their own, were finally liberated by redirecting government resources away from efforts to segregate and confine them, and into programs that liberate and free them.  We should not be surprised that this is less expensive than the institutional model.  In this case, freedom isn’t free, but it is a lot less expensive than the alternative. 

If we truly value freedom, if we truly want to “secure the blessings of liberty” for our citizens, we must preserve the programs that make that liberty possible.

Medicaid- When Are Cuts NOT Savings?

Of course the Idaho Legislature faces some tough decisions.  The projected revenue (whether accurate or not) is far short of the cost of running the state government for 2012. Medicaid is a very large part of the cost and so it is a natural target for cuts.  But, like any enterprise, you can’t always balance the budget by cutting the largest cost centers. A retailer can’t recover by closing its most profitable stores. A family can’t make ends meet by eliminating food from the budget, or selling the car that takes them to work.  Medicaid is the largest single source of federal revenue to the state of Idaho. It is our best opportunity for bringing back into the Idaho economy the hard earned tax dollars Idahoans have sent to Washington D.C. For every three dollars of State funds spent on Medicaid we bring back to Idaho seven dollars of federal funds. If we cut 3 dollars, we leave the 7 dollars in Washington.

Where do Medicaid dollars go? Medicaid is extremely labor intensive. Almost all of the money funds jobs for hard working Idahoans. When they get paid they buy food, shelter, clothing, and other Idaho products, and they pay taxes. Then the businesses they support pay wages for other people’s jobs and they also pay taxes. So what is the effect of cutting $50,000,000 in state funds from Medicaid?  We suck $166,000,000 out of Idaho’s economy. We kill about $208,000,000 in total economic activity. We eliminate about 4,000 Idaho jobs. Based on economic studies in other states we lose about $30 to $50 million in tax revenues wiping out the “savings”.  We cause untold suffering and some deaths.  We force people into poverty and unemployment. We shift Medicaid recipients into state funded programs like county indigent services and the catastrophic health care fund. We shift people with severe mental illness into Hospitals, courts systems, jails creating a huge burden on local taxpayers.  Even if only 10 percent of the cost is shifted, the added state tax burden is estimated to be about $16.7 million in the first year and more after that. There is every reason to believe that the shift would be far higher than that.  This does not even count the cost shifts that will take place within Medicaid from lower cost optional services to higher cost mandatory services. This does not count the costs of increased psychiatric hospitalization, emergency room visits.

 Does anyone still think we can solve our budget problem by cutting Medicaid?

Like any business or family in economic trouble, we need to cut out waste, but preserve and increase our ability to bring in income.  You cannot balance the budget by destroying jobs, eliminating essential public health services and shifting costs to local government while leaving $116,000,000 of our federal tax dollars in Washington D.C. 

 A little effort on the revenue side, whether it is tobacco, alcohol, or sales taxes will prevent a lot of suffering, save lives, and might actually balance the budget.  Cutting $50,000,000 out of Medicaid will do just the opposite.

Families and Volunteers Cannot Replace Developmental Disability Agency Services or Psycho-social Rehabilitation

Few, if any, volunteers have the training or skills to provide Developmental Therapy.  According to the Idaho Administrative Rules (IDAPA 16.04.11.10.14) “Developmental therapy is the use of therapeutic intervention and positive behavioral techniques that result in measurable skill acquisition or prevent regression …”  

Most volunteers from the community have no training or education in “therapeutic intervention” or “positive behavioral techniques” and volunteers will not have professional supervision. Currently, developmental therapy (DT) requires supervision by a “developmental specialist” with specific qualifications and experience, on a weekly basis. Without this supervision and training the therapy is unlikely to have the desired outcomes. DT should never consist of merely taking a person to the store.  It should include teaching the person how to behave in the store or managing tantrums or inappropriate behavior in the store. It may also include providing first aid for seizures in the event that one occurs. Injecting an untrained, unsupervised volunteer into some situations could be risky for the volunteer, the person with a disability or others.

PSR also requires trained and qualified professionals.  PSR professionals go into the homes of people with severe and persistent mental illness (SPMI).  They assess the person’s status and symptoms and evaluate their surroundings for health and safety concerns.  They monitor and assist when necessary with getting people to their medical and mental health treatment appointments. They provide 24 hour on-call response to emergency situations and, when needed, they help people in crises to get to hospitals, emergency rooms or crisis centers. They also guide people through other personal crises which the person may find overwhelming such as evictions or family deaths. People with severe and persistent mental illness may or may not have complete medical control of their symptoms such as hallucinations or delusions, panic attacks or suicidal depression.  The severity of these symptoms may wax or wane depending on their circumstances and the need for changes to medications. The proper supports for people with SPMI can be the difference between life and death as well as the difference between home and hospital.  There are few volunteers who are capable of performing this work. 

There is no current infrastructure to provide training, supervision, insurance and liability protection for volunteers to perform these tasks.  The PSR worker is exposed to risks for themselves and for the people they serve.  They need to be a part of a network that includes ready access to supervisors, clinicians and consultants.  They need to be familiar and connected with other agencies and know how to efficiently access community resources for their clients.  Someone needs to follow up and provide coverage when they are sick or unavailable. They need to be replaced when they stop volunteering. They need insurance protection from liability and injury.  These things are not readily available from local churches or families.

A large contingent of qualified and willing volunteers will not spontaneously arise from the elimination of DD and PSR services.  If we are confident that volunteer assistance could replace these services we should be willing to guarantee that a person’s services will continue until adequately trained volunteers are obtained to replace them, and that the services will be restored if the volunteers are no longer available.

There may be a few examples of people whose disabilities fall on the milder end of the spectrum who would get by for a while with volunteer services, if they could be found.  However if services are eliminated or severely reduced we must also consider the people who have the most severe symptoms, or the highest levels of need for these supports.  If volunteers cannot meet these needs, we must accept serious consequences and greater cost burdens shifted to other areas.  Our expectations for families and volunteers to step up to meet these needs should be realistic. Historically, these services have never been provided by volunteers or family members to any significant degree.  If we look to a period of time before Medicaid funding for these services, Idaho operated Adult and Child Development Centers (ACDC) with general funds and state employees. This program was privatized through Medicaid saving the state large sums of money.  Before ACDCs people with intellectual disabilities were believed to be incapable of learning and were generally institutionalized in state funded facilities (In the 60’s ISSH had 1,100 residents) or kept in large shelter homes in poor conditions without training.

Medicaid’s scenario for eliminating these services applies to adults.  Adults receiving these services may or may not have living family members. Just as baby boomers make up the largest group in the general population, they also make up the largest group of people with disabilities. Their parents are now either deceased or of advanced age.  Few can offer any more support for their adult children than they already do. If these people have siblings, they may not live in the same area and they have primary responsibility for their own children and spouses. Families that can and will provide some support to people with disabilities are often already doing so, and are stretched to the limit.  In these cases, they cannot make up for services lost by elimination of the programs.

Conclusion: Untrained and unsupervised volunteers will not have the skills, the support or the resources to replace Medicaid services. If volunteers can be found, they will need training, supervision, liability and insurance coverage. We should continue providing services for people with disabilities until the volunteer services are available and after they stop.