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Archive for Wednesday, April 10, 2013

Editorial: Ongoing concern

Concerns about including all services for people with developmental disabilities in the new KanCare program remain to be addressed.

April 10, 2013

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Leaders of organizations that advocate for people who have developmental disabilities may have won the battle in the Kansas Senate this session, but it’s certain that the war is not over.

Senate Majority Leader Terry Bruce, R-Hutchinson, stressed as much when he said he has no plans for the Senate to take up the Senate substitute for House Bill 2155 that would limit services a Community Developmental Disability Organization (CDDO) could provide. The issues the bill was attempting to address still need to be faced, he warned.

Yes indeed. And the assistance provided to thousands of Kansans remains to be determined.

The heart of the matter lies in the implementation of KanCare, the overhaul of the Medicaid system that is taking effect in Kansas, turning the state’s 350,000 Medicaid clients over to managed care plans (MCOs) run by three for-profit insurance companies.

Advocates for the intellectually and developmentally disabled (I/DD) community have said those persons should not be brought under KanCare for anything except medical situations — most certainly not for the management of their long-term, lifetime support services.

These advocates are concerned that in KanCare, the MCOs would conduct assessments of individuals, complete the plan of care for them and then have a financial incentive to influence the outcome of that care. Currently, in a CDDO such as Cottonwood, for example, one person conducts the assessment, another develops the care plan, and then the state approves it. It’s working well, does not involve a conflict, and “if it ain’t broke, don’t fix it,” they say.

As of right now, the intellectually and developmentally disabled are scheduled to be included in KanCare effective Jan. 1, 2014. Their advocates want them permanently excluded. Many cite the situation in Texas, where a three-year pilot program was proposed before such a major redesign of services to the I/DD community was implemented. Colorado is planning a similar three-year pilot.

InterHab, an organization advocating for I/DD persons, submitted a major study criticizing the KanCare plan and its related timeline in Kansas. It recommended instead a longer and more comprehensive pilot program with evaluation steps for the three MCOs selected for KanCare.

The Legislature may want to give that serious thought. Because, as Senator Bruce said, the issues are not going away.

Comments

Richard Heckler 1 year, 5 months ago

I am for IMPROVED Medicare Single Payer Insurance for ALL absolutely!!! http://www.pnhp.org/facts/single-payer-resources Physicians for a National Health Program

Make IMPROVED Medicare Single Payer Insurance for ALL available to all taxpayers as one of our choices.

Leave existing insurance on the table for those who enjoy spending large sums of money for medical insurance. What could possibly be more American?

I want my tax dollars spent on a useful endeavor not on:

--- insurance over charges.

--- or obscene CEO salaries.

--- or golden parachutes.

--- or shareholders.

--- or special interest campaign funding!!!

--- or corporate jet planes.

--- or ALEC Brownback's corporate insurance plan.

It is time for my tax dollars to support Medicare Single Payer Insurance a fiscally prudent insurance program. Using the Medicare template = not reinventing the wheel = expanding on a proven concept.

Repubs have never offered a comparable concept.

Listening to ALEC Brownback and other misinformed politicians on this issue is a dangerous route to accept. Listening to CEO's and lobbyists from the insurance industry is equally as dangerous as this is the source for misinformation coming from politicians.

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jafs 1 year, 5 months ago

It should be noted that there was a different bill in the beginning - after a concerted effort by DD advocates, the legislature eliminated that one, but gutted another and simply moved the contents over to it.

That way, the name of the bill was different, but the content identical.

Fortunately, DD advocates were aware of this, and so able to continue communicating to legislators about it. But it was clearly an attempt to sneakily get the bill passed without people being aware of it.

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tomatogrower 1 year, 5 months ago

"It’s working well, does not involve a conflict, and “if it ain’t broke, don’t fix it,” they say."

When has that stopped Brownback and his wrecking crew. The problem, according to them, with the old way, is none of their buddies were making a profit from it.

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Angela de Rocha 1 year, 5 months ago

This editorial is based on a number of factual errors. Advocates for the I/DD community in Kansas have done the community a great disservice by providing misleading information to the Lawrence Journal-World, which apparently doesn't include fact checking in its editorial process. A great deal of misinformation has been spread about how full inclusion in KanCare will affect consumers, causing them unfounded worry and anxiety. Here is the truth of the matter:

1) I/DD consumers can keep their current case managers under KanCare. The ability of a consumer to keep his or her I/DD targeted case manger through a CDDO, a community service provider or independent case management organization is protected by the Kansas Developmental Disability Reform Act.

2) KanCare I/DD consumers’ ability to keep their current providers is protected by KanCare health plan contracts.

3) The KanCare health plans (managed care organizations, or MCOs) will NOT have the authority to arbitrarily reduce consumers’ HCBS long-term services and supports because

4) CDDOs will continue to complete the BASIS assessments, which determine the level of services for which consumers are eligible.

Five other HCBS waiver programs providing long term services and supports systems, serving about 12,000 consumers, were successfully included in KanCare in January 2013.

KanCare will bring the HCBS programs include care coordination across the three systems that provide care to I/DD consumers: their physical healthcare, their behavioral healthcare, and their long-term services and supports. The KanCare contracts include an expectation that better coordinated care will demonstrate better overall outcomes than the old system did. These expectations of better outcomes are tied to how the health plans (MCOs) will be compensated. The KanCare contracts allow the State of Kansas to withhold payments to a health plan that does not achieve improvement in care coordination and health outcomes.

5) Looking at the big picture, and looking ahead, the inclusion of the I/DD HCBS program into KanCare ultimately will provide financial stability to the system. And it will allow the state to continue to provide these services and supports over the long run. Repeatedly during the past few years, the waiver program has experienced provider reimbursement challenges, benefit-rules changes and an expanding waiting list. These ongoing challenges could be magnified if the I/DD HCBS waiver is isolated -- set apart on its own -- as the only system not included in KanCare, under which reimbursement rates to providers, service levels and case manager consistency is guaranteed by KanCare contracts or state law.
Angela de Rocha, Kansas Department for Aging and Disability Services

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jafs 1 year, 5 months ago

Some of that may be true, but it's also misleading.

There is legislation being attempted that would make the MCO's CDDO's as well, and possibly case management and/or services. The obvious conflict of interest there is, well, obvious.

I would love to see that contract - when I've asked if there's anything in writing about that, I've been told there isn't. And, even if there is, the contract is only as good as the state's willingness to enforce it.

If an MCO is also the CDDO, then they'll have the ability to reduce services, by simply finding people not eligible for them.

Given that it's currently early April 2013 (three months into that implementation), I'd say it's much too early to claim that long term services have been successfully included and implemented in KanCare.

Co-ordination of care is a good thing, and even those DD advocates who oppose KanCare agree with that - I'm sure there are other ways of ensuring that. And, again, the plan is only as good as state enforcement.

How will it provide "financial stability"? All of the problems you mention are caused by the state, which still has the oversight and power with KanCare.

And, finally, given that the insurance companies are for profit entities, where will their profit come from, without reducing services or payments to providers?

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ForThePeople 1 year, 5 months ago

It's a pretty well known fact that at this point persons served will be loosing their current case management and the Kancare provider, will take over that position. Many case managers have already taken jobs with these Kancare providers because they know this is coming. It not only is a conflict of interest, but is a serious dis-service to the DD folks, as they will be assigned people who don't have a clue about their individual needs. So while Angela 'says' they can keep their case manager 'by law', she knows that when the time comes, the only case managers they will have to choose from will be those with the Kancare providers.
This also applies to the elderly effected by this change. These Kancare case managers work for the "for profit" company, NOT the person served, so their interests lay in what's best for the company, not what's best for the individual. Angela, IMO is blowing smoke up our collective arses, to cover her own.

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tomatogrower 1 year, 5 months ago

Will the managed care organizations make a profit? How much does their CEO make? Are they publicly traded, with a lot of investors who want to make a lot of money?

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lucky_guy 1 year, 5 months ago

Good job Angela, way to defend your boss. We all know how this works, meaning that patients can keep their care provider if the providers of services take at least a 10% cut and the middle men (MCO's in your terminolgy) will get to keep the difference. That is the only way this works,period. There is no coordination of services here unles you mean CLO gets too much and so we need to take some from them and give it to your contractors. The math here is simple and to the point. You can't interject another layer of management into this without it subtracting from care. All the rest is smoke.

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tomatogrower 1 year, 5 months ago

And Angela, what problem is this solving that could not have been solved in house without making money for a for profit company? Has there been a big problem? Or is it just another way for someone to make money from the taxpayers off the backs of the disadvantaged? Prove to me that someone isn't going to profit from this other than the disabled? I'll bet you can't do it.

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Wildcat94 1 year, 5 months ago

Whenever the Brownback Administration is smacked in the face with facts, the response is to dismiss it as misinformation. The Administration has actively worked over Legislators to support gutting the Developmental Disabilities Reform Act and all of the protections that families and advocates worked so hard to establish in law. Their goal is to dismantle the DD service system right along with all of the other social services in Kansas that have been hacked away since Governor Brownback took office and trade them in for the traps and failures of commercial managed care. The 3 KanCare corporations are in the business of making money for their shareholders and execs by cutting costs and services to people in need. The CEO of United Healthcare is the 8th highest paid CEO in the United States, making $48.83 million in 2012. Wellpoint is the new owner of Amerigroup, the second KanCare company, and their CEO earned $9.49 million while the CEO of Centene, the third KanCare company, made $10.5 million in 2012. KanCare is taking away locally driven services and turning them over to out of state multinational corporations and will be taking away local jobs. As for the so called "successful" transition of the other Waivers, just ask a provider or a person served on one of the other Waivers and you will get an earful about providers not getting paid for services from the KanCare companies or getting paid the wrong (lower) rates than the state requirement, services being cut, workers not getting paid so they cannot continue to provide care, and corporate case managers cutting workers against the client's wishes.

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Angela de Rocha 1 year, 5 months ago

“There is legislation being attempted that would make the MCO's CDDO's as well, and possibly case management and/or services. The obvious conflict of interest there is, well, obvious.” This is another misrepresentation of facts by the provider system. The bill that was advanced out of committee a few weeks ago would not make the MCOs CDDOs. The bill would have responded to two Legislative Post Audit studies from years past by requiring that CDDOs cannot also provide services. The information Interhab has put out saying that eligibility determination and the needs assessment (which determines level of funding) would be done by the MCOs is patently false.

“I would love to see that contract - when I've asked if there's anything in writing about that, I've been told there isn't. And, even if there is, the contract is only as good as the state's willingness to enforce it.” The contract is at http://www.kancare.ks.gov These assurances are in contract or state law.

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jafs 1 year, 5 months ago

Well, I'll let you and them argue it out.

But, I tend to believe them rather than you, given your job title.

And, it would be nice if you could give a little more info about how to find that contract - you just gave me the general website for KanCare.

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meggers 1 year, 5 months ago

Most CDDO's in Kansas are connected with agencies that also provide services. Who would complete the eligibility determination and needs assessment if the CDDO is no longer permitted to serve in that capacity?

Similarly, the majority of case managers in Kansas are employed by agencies that also provide services. If these agencies can no longer provide case management services, who will provide that service? The bill before the legislator expressly states that individuals can get case management through their MCO.

In other words, if the bill before the legislature passes, most CDDO's and case managers will no longer be allowed to function as such. Who will step in and fulfill those responsibilities?

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tomatogrower 1 year, 5 months ago

You still haven't answered my question. Are these for profit companies beholding to investors. We all know who comes first when that is the case. Are they for profit companies?

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Angela de Rocha 1 year, 5 months ago

“If an MCO is also the CDDO, then they'll have the ability to reduce services, by simply finding people not eligible for them.” An MCO would not be allowed to be a CDDO and perform eligibility determination and the needs assessment. This is misinformation sent out by a few in the provider community. Eligibility would still be determined by the CDDO. The level of funding available would still be determined by the CDDO.

“Given that it's currently early April 2013 (three months into that implementation), I'd say it's much too early to claim that long term services have been successfully included and implemented in KanCare.” Problems that have arisen have been quickly dealt with. This statement was more to counter misinformation from the provider community that managed care is only for medical services. There are other HCBS programs very similar to the I/DD waiver that were included and have started. Managed Care is just a financing mechanism. Managed care is the financing mechanism allowing the state to pay for the outcomes desired. The old Medicaid and HCBS systems are quickly going by the wayside around the country.

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jafs 1 year, 5 months ago

Source for your claim that MCO's wouldn't be allowed to be CDDO's?

Well, from those I know involved with that early implementation, from their perspective, problems haven't been adequately solved. Those included the problems mentioned by Wildcat above.

The fact that other states are privatizing these systems doesn't make it a good idea.

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meggers 1 year, 5 months ago

Problems have been quickly responded to. That isn't the same as problems being quickly resolved. One fairly large agency had to take out a line of credit just to make payroll, due to delayed payments from the MCO's. Insurance companies are notorious for paying claims as late as possible- the longer they hold onto their money, the bigger the profit for them.

What is to prevent providers from going under either because they are unable to absorb the administrative burden of three insurance companies and three sets of requirements for filing claims, or being unable to continue operating due to delayed claims? As providers are forced to close their doors, who is going to provide services to the people who are being served now?

And that doesn't even begin to address the cuts in services people on other waivers are experiencing. For people with I/DD, a reduction in supports could pose serious health and safety risks. Do you expect providers to be able to absorb the cost of providing more serves than are funded, or are providers supposed to just cut services off at the amount determined by the MCO, whether the person needs them or not?

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avarom 1 year, 5 months ago

www.kslegislature.org/li_2012/b2011_12/measures/hb2155

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Angela de Rocha 1 year, 5 months ago

“Co-ordination of care is a good thing, and even those DD advocates who oppose KanCare agree with that - I'm sure there are other ways of ensuring that. And, again, the plan is only as good as state enforcement.” The state gets what it pays for. In a fee-for-service system- the state pays for volume. In the KanCare system- the state pays for good outcomes. In this case- it pays for coordination of care, employment supports and better supports for I/DD behavioral healthcare.

“How will it provide "financial stability"? All of the problems you mention are caused by the state, which still has the oversight and power with KanCare.” If I/DD is included in KanCare- there is stability to providers with the reimbursement rates and stability of benefits and services due to KanCare contracts. If I/DD is carved-out, it becomes a line-item in the budget that could become an easier place for legislators to squeeze as has happened in the past.

“And, finally, given that the insurance companies are for profit entities, where will their profit come from, without reducing services or payments to providers?” Better coordination of care and better health care outcomes.

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jafs 1 year, 5 months ago

Only if the state vigorously oversees and enforces their contracts.

Ditto.

Since much of services for DD folks isn't "health care" per se, that doesn't apply as well here, which is one of the arguments against including them in this system, which is designed primarily for medical care.

Do you have any examples from DD services of care which isn't coordinated well enough, what the improvement in co-ordination would look like, and the savings from that?

By the way, money from the state can't simultaneously be saved and also go towards corporate profits, while at the same time providing a bunch of new services as claimed on the KanCare site.

It's smoke and mirrors, reminding me of Governor Brownback's campaign promise to cut taxes, balance the budget, and not cut education or social service funding.

6

scribe 1 year, 5 months ago

"Better coordination of care and better health outcomes"....the medical/health care services for individuals with I/DD are ALREADY included under KanCare. What the MCOs are trying to gain through the passage of these bills, such as SSub for HB 2155, is control over eligibility determination and utilization...for NON-MEDICAL day and residential services (long term care), by knocking out the CDDOs and case managers. If they win, the MCOs will then control eligibility, utilization, services, rates, payment....talk about a conflict of interest. And I find it funny that you quote that this won't happen because it isn't allowed per "the contract" and then don't produce a valid link to "the contract". It's all about the benjamins, Angela....and I thought you guys in KDADS were taking a neutral stance...what happened with that?

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jafs 1 year, 5 months ago

I found an "executive summary" of KanCare, but no actual contracts, signed by the state as well as the participating MCO's.

Another point about these systems - it's already problematic for some to find providers that take Medicare or Medicaid. If, as I suspect, these companies will simply reduce payments to providers, that problem will likely worsen.

The fundamental question is if we should believe a for profit insurance company when they claim to offer more and better services for less money than a non profit entity, like the state offers. I say the obvious answer to that question would be no.

That's not to say that a "fee for service" model is the best one, by any means. But, we can easily change that model, if we want, without introducing a for profit entity into the mix. That way, we could achieve whatever possible improvements there are, without the profit, thus saving the state money.

4

jafs 1 year, 5 months ago

And, I'll mention again that this bill was originally introduced, then abandoned after a concerted lobbying attempt by DD advocates, at which point the legislature gutted another bill, and put the contents of the first into it.

Clearly an attempt to sneak the bill into getting passed without people knowing.

But, we should trust these folks to be doing the right thing? If the bill is a good one, then they should be able to explain why to advocates rather than trying to sneak it past them.

By the way, conflicts of interest are often mentioned as a reason for this sort of legislation. While those are possible, the state oversees the system, and thus should find and/or prevent them. Assuming legislation is passed to disallow case management and services provided by the same organization, that would reduce the state's need to do that, of course. But, at the same time, the state has now taken on the need to oversee and enforce the massive contracts with the MCO's. If they do that job well, it's at least as hard as the previous one.

My prediction: If bills like this are passed, the state won't adequately oversee and enforce the contracts, services will be reduced and of reduced quality, providers will get less compensation, and the state won't save a dime. However, the insurance companies will make a tidy profit.

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jafs 1 year, 5 months ago

Meggers makes some excellent points as well - thanks!

Since there are 3 insurance companies, providers will now very possibly have to file different paperwork with each of them, adding to their already overburdened jobs (case management is about 60-80% paperwork now).

I'm an intelligent well educated and fairly assertive person, and I hate talking with my insurance company - it takes forever, is way too complicated, and it's hard to get clear and direct answers. I can't imagine having to advocate for a caseload of 30 people with 3 different companies.

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ForThePeople 1 year, 5 months ago

jafs said " I can't imagine having to advocate for a caseload of 30 people with 3 different companies." Yes, especially when the case management is taken away from the agencies that provide the service, since they are the people who have somewhat of an understanding of how to navigate this nonsense with these MCO's. And as someone mentioned it's very frustrating that they are now trying to say that CDDO's cannot be service providers. Utter BS, as our local CDDO was one of the first providers in the area and does a fantastic job of doing both!

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Angela de Rocha 1 year, 5 months ago

“Most CDDO's in Kansas are connected with agencies that also provide services. Who would complete the eligibility determination and needs assessment if the CDDO is no longer permitted to serve in that capacity?” If that bill were passed, the service provision part of the CDDO would have to form a separate entity with a separate board. In that case, the CDDO would still complete the eligibility determination and needs assessment. If the CDDO refused to do this, another CDDO would have to be contracted to perform the eligibility determination and needs assessment. I could not be done by a CDDO as the DD Reform Act still points to the CDDO as responsible for these functions.

“Similarly, the majority of case managers in Kansas are employed by agencies that also provide services. If these agencies can no longer provide case management services, who will provide that service? The bill before the legislator expressly states that individuals can get case management through their MCO. In other words, if the bill before the legislature passes, most CDDO's and case managers will no longer be allowed to function as such. Who will step in and fulfill those responsibilities?” It is pretty widely known that should the bill ever have been debated on the floor, or should it be in the future, an amendment would have been offered to eliminate the case management provisions to where a CDDO, Independent TCM or Service Provider and not an MCO would still be able to perform case management services.

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Angela de Rocha 1 year, 5 months ago

“You still haven't answered my question. Are these for profit companies beholding to investors. We all know who comes first when that is the case. Are they for profit companies?” I would assume that with this line of thought, you would like to ask all hospitals, nursing homes, mental health providers, substance abuse providers and disability providers that are for-profit to leave the state of Kansas? The MCOs are beholden to the state’s contracts.

“Source for your claim that MCO's wouldn't be allowed to be CDDO's?” Senate Bill 194, also known as Senate Substitute for House Bill 2155. Section A says the CDDO will directly or by sub-contract serve as the single point of application or referral for services as assist to have access. Section B says a CDDO will provide directly or by sub-contract eligibility determination and case management, if requested.

“Problems have been quickly responded to. That isn't the same as problems being quickly resolved. One fairly large agency had to take out a line of credit just to make payroll, due to delayed payments from the MCO's. Insurance companies are notorious for paying claims as late as possible- the longer they hold onto their money, the bigger the profit for them.” There have been payment issues. Go to the issues log on the KanCare website and you will see the state has been transparent about the issues and the resolutions. When the state and the MCOs have had issues brought to their attention, both have worked diligently to address them. With any transition this sized, there is expected to be problems. The issue you refer to with the line of credit has been resolved. There are stringent payment guidelines per contract.

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jafs 1 year, 5 months ago

Neither of those sections says that an MCO can't perform those functions, as you've quoted them.

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Butch851 1 year, 5 months ago

I have heard from people who work for the state that items on the issues log are being marked as "resolved" when in fact they have not been resolved, but have just been referred to the insurance company for follow up. That's not exactly what I would call being transparent. Why is the state not enforcing the "stringent" payment guidelines? Why are pharmacists, doctor's offices, hospitals, etc... saying they have called the insurance companies multiple times for the same issue and are frustrated with being told it is being resolved and then nothing happens?

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Angela de Rocha 1 year, 5 months ago

“What is to prevent providers from going under either because they are unable to absorb the administrative burden of three insurance companies and three sets of requirements for filing claims, or being unable to continue operating due to delayed claims? As providers are forced to close their doors, who is going to provide services to the people who are being served now?” As issues arise, the state and the MCOs are committed to addressing them quickly. It is difficult to look into the future and speculate. The Administration chose a system focused on outcome improvement through better care coordination instead of the alternative of cutting reimbursement rates, restricting eligibility and cutting services, which has happened in previous years.

“And that doesn't even begin to address the cuts in services people on other waivers are experiencing. For people with I/DD, a reduction in supports could pose serious health and safety risks. Do you expect providers to be able to absorb the cost of providing more serves than are funded, or are providers supposed to just cut services off at the amount determined by the MCO, whether the person needs them or not?”

Send us real information and we will look into it. All cuts or reductions to HCBS plans of care must be reviewed and approved by KDADS. The old HCBS system was more restrictive than the KanCare Care Coordination model where there is more flexibility to what can be provided. Again- there are no forced reductions that happened to HCBS in the first 90 days. Following that period- everything has to be approved by KDADS.

“Only if the state vigorously oversees and enforces their contracts.” We agree. This is why we have a managed care savvy team of staff devoted to enforcing the KanCare contracts and set outcome expectations.

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Angela de Rocha 1 year, 5 months ago

“Do you have any examples from DD services of care which isn't coordinated well enough, what the improvement in co-ordination would look like, and the savings from that?” Yes- lots of examples of family members and guardians who believe that the medical, behavioral and long-term services aren’t coordinated. The DD providers will agree that there are silos between systems. The Mental Health providers will agree that there are silos between systems. KanCare is a financing mechanism to pay for better coordination between these systems.

“What the MCOs are trying to gain through the passage of these bills, such as SSub for HB 2155, is control over eligibility determination and utilization...for NON-MEDICAL day and residential services (long term care), by knocking out the CDDOs and case managers. If they win, the MCOs will then control eligibility, utilization, services, rates, payment....talk about a conflict of interest.”

Read the bill. CDDOs would still perform eligibility determination and needs assessment.

“I found an “executive summary” of KanCare, but no actual contracts, signed by the state as well as the participating MCO’s.” Executive Summary is on KanCare website. Contracts are found on DoA website: http://da.ks.gov/purch/EVT0001028-AwardContracts.htm

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jafs 1 year, 5 months ago

Well, I was hoping for more specific answers. Family members and guardians sometimes believe things, but that doesn't make them true.

And, "a financing mechanism..." doesn't really answer the question either.

But, I have to give you credit for continuing to respond - I figured one round would be the end of your presence here.

So, you gave me a link that didn't have the contract, and said it was on there. Hmmm. I'll try the next one.

I looked at the first 14 page contract, and found no statement that people can continue to use their existing case managers if they want to - do you have a specific part of the contract that says that, in case I missed it?

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Angela de Rocha 1 year, 5 months ago

"Yes, especially when the case management is taken away from the agencies that provide the service, since they are the people who have somewhat of an understanding of how to navigate this nonsense with these MCOs."

Case management won’t be taken away from the agencies currently providing the service. CDDOs will still be service providers unless Senate Substitute for House Bill 2155 is passed. At this time, Senate leaders have expressed that it won’t be debated on the floor.

"Neither of those sections says that an MCO can't perform those functions, as you've quoted them."

It says that they are the functions of CDDOs. So, yes. If statute says these are the functions of CDDOs, then MCOs cannot perform these functions.

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jafs 1 year, 5 months ago

Nothing prevents an MCO from being a CDDO, as far as I'm aware.

The state gets to decide who the CDDO's are, right?

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Angela de Rocha 1 year, 5 months ago

Well, I was hoping for more specific answers. Family members and guardians sometimes believe things, but that doesn't make them true."

A person on the DD waiver is receiving day and residential supports through a provider. The person has diabetes and some very challenging physical conditions. The staff let a wound on his/her leg fester longer than they should due to their lack of clinical training and resources. Instead of sending the person to his/her physician, the wound gets worse over the weekend and by Monday has turned into a crisis and he/she has to have part of the leg amputated. As a result, the person has been in and out of the hospital and nursing homes at a much higher cost than if physical conditions had been properly taken care of. How does KanCare change this? As the MCOs are fully at risk for all of the person’s outcomes including medical costs, acute care costs, behavioral health care and long-term services and supports, they are fully incentivized to keep the person as healthy and as independent as possible. They will be more likely to ensure that the long-term supports staff are fully in-tune to the symptoms they need to be looking for on the conditions the person is at risk for. They will be more likely to serve as a resource to the staff in these situations. Why can’t this be accomplished with just medical services for the DD population carved-in to KanCare? With long-term services carved-in, the financial incentive is to keep the person in this environment using the long-term supports they are paying for instead of the acute care resources that are much more costly. In this case, the failure of the MCO will lead the MCO to pay for much more expensive acute care and nursing home care due to the inability to properly care for the person’s physical conditions which led to a bad outcome. More than 50 percemt of the State’s I/DD providers are small and lack the clinical and behavioral health care resources that a few large and long-standing CDDOs have. These resources -- through better care coordination of the whole person, and not just long-term services and supports -- will bring about better outcomes.

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jafs 1 year, 5 months ago

Ok - that's a good answer.

If staff at providers isn't doing a good job, that's a problem. But, it can easily be solved without turning over the whole system to MCO's.

Your example would never happen in a good provider. They would check with somebody, and make sure the person went to the doctor. It's well known, by the way, that folks with diabetes can have problems with wounds.

Any staff that lets a person with diabetes suffer a "festering wound" long enough that a limb has to be amputated should probably be out of a job, in my view.

With even just medical care in KanCare, they have that financial incentive, since they're paying for the medical care - there's no need to include other services. You can bet that they'll be doing their best to make sure staff doesn't make that sort of mistake.

By the way, my wife, who's worked in the field for over 25 years, says that complaints about co-ordination of care aren't common. Your example isn't really an example of a co-ordination issue, it's an example of lax staff.

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Angela de Rocha 1 year, 5 months ago

"I looked at the first 14 page contract, and found no statement that people can continue to use their existing case managers if they want to - do you have a specific part of the contract that says that, in case I missed it?"

I will send you the specific language that calls out the ability of a person on the waiver to retain his/her case manager. It may be in a contract amendment not on the website. Secretary Sullivan shared this amendment language to the advocacy group Interhab more than a year ago. I can be contacted at angela.derocha@kdads.ks.gov

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jafs 1 year, 5 months ago

Well, maybe the third time will be a charm.

It's interesting that it's taken so many turns to get what is supposed to be clear information in the contract - this is the sort of thing that happens with insurance companies all the time.

Also, I have to comment on the "amendment" mentioned above. We shouldn't have to trust that amendments will be offered and accepted when discussing legislation. The bill should include all of the provisions in the first place. That's the only way that people can make an informed decision about whether or not they support the legislation.

Trust us, there'll be an amendment isn't really convincing, given the actions of this legislature so far.

Hammer out the details, then present the legislation, and let us evaluate it in it's actual form. Otherwise it's much too easy to slip things in at the last minute or take them out, changing the legislation in significant ways. By the time we become aware of that, it's too late.

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Angela de Rocha 1 year, 5 months ago

“Nothing prevents an MCO from being a CDDO, as far as I'm aware. The state gets to decide who the CDDO's are, right?” The DDRA and the bill you have called into question calls for CDDOs to perform these functions. County government decides who the CDDOs are.

“Your example would never happen in a good provider. They would check with somebody, and make sure the person went to the doctor. It's well known, by the way, that folks with diabetes can have problems with wounds.” Yes, it would and IT HAS HAPPENED while consumers were being cared for by a good provider. Not to mention that more than 50 percent of providers are small and often don’t have the resources and/or training to handle complex situations.

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jafs 1 year, 5 months ago

Right, so they can easily decide to make MCO's CDDO's - nothing prohibits that, as you've claimed.

By definition, a good provider wouldn't let that happen, so it's not possible to have it happen while being cared for by a good provider. The example isn't that complex.

If there are issues like that, then I'm sure that all of us want them to be eliminated, or at least minimized to whatever extent possible - even the folks that are opposed to the MCO's would say that.

There are many ways to do that, other than turning over the entire Medicaid system to a for profit insurance company.

Still waiting for the part of the contract that ensures people can maintain existing case management.

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jafs 1 year, 5 months ago

According to people working in the field, when other waivers were included in KanCare, people weren't able to keep their existing case management. In fact, they were informed that the MCO's would be taking over case management services, and they had to get that through them.

That strongly suggests that the contracts with MCO's have no provision that ensures the ability to keep existing case management. Or, that the state isn't enforcing that provision.

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Angela de Rocha 1 year, 5 months ago

“According to people working in the field, when other waivers were included in KanCare, people weren't able to keep their existing case management. In fact, they were informed that the MCOs would be taking over case management services, and they had to get that through them. That strongly suggests that the contracts with MCOs have no provision that ensures the ability to keep existing case management. Or, that the state isn't enforcing that provision.” By state law, people on the I/DD waiver will keep their targeted case managers. Case management for the other HCBS waivers did become the responsibility of the MCOs. This isn’t a secret. But due to state statute specifically addressing I/DD case management, and because relationships with I/DD consumers are more long-standing as compared to consumers on the other waivers, that is not how it will work for the I/DD wavier. I/DD waiver consumers will retain their targeted case manager. The language included in the contract for the I/DD waiver is in the response to question #489 in the Excel file “Amendment Eight-Responses to Questions 01-13-12-1” -- this document is too lengthy to post here, so send me your email address and I will send it to you. Angela.deRocha@kdads.ks.gov

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jafs 1 year, 5 months ago

I'll send it to you at your e-mail address - that's not something I want to post here. But, I don't have Excel, so unless it's formatted in another format, I won't be able to read it.

Also, on the Amerigroup website (one of the MCO's), there's a very clear statement that they intend to take over the functions of assessment and case management for DD folks, and that they feel that's essential in order to create the efficiencies desired.

The state doesn't have to go along with that, of course. But, I'll bet they do, after a relatively short time period, if DD folks are included in KanCare - after all, they're after the efficiencies.

Thanks for the continuing information - I hope you can see the irony in this information being so hard to come by. The response to question....almost sounds like a Monty Python or SNL skit.

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jafs 1 year, 5 months ago

Thanks.

That's a statement of intent, not a contract.

Signed contracts are the only legally binding form, as I understand it. That's why I'd like to see the part of that ensuring existing case management will be maintained if desired by consumers.

Did you see what I posted about the clear desire and intent of Amerigroup to take over assessment (CDDO) functions and case management?

My best guess at this point is that if there's anything in the signed contract, it will only protect existing case management, etc. for a short period of time, after which the MCO's will take them over, as they propose.

They'll sell it to the state as the only way to achieve the efficiencies the state wants to achieve.

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meggers 1 year, 5 months ago

That is the portion of the DD Reform Act they are trying to change. They HAD to include those provisions in order to comply with current statute. If the bill before the legislature passes, all of that is out the window.

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jafs 1 year, 5 months ago

And, last year's contract didn't include DD services in KanCare.

If/when they do that, those contracts may or may not have any provisions like that, even if last year's contract has it.

In fact, that's sort of the provision that "carves out" DD services from KanCare, isn't it?

So, it's a little disingenuous to say that when it's "carved in", they'll still be protected, by pointing to a provision that carved them out of last year's contract with the MCO's.

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jafs 1 year, 5 months ago

My above posts are a little unclear - forgive me.

First, I still haven't seen that "amendment" is part of the signed contracts. It might be part of a bill instead, which is different.

Let's assume that it is in fact a provision in the current contracts. It will only be in force as long as they are, which is a few years. So, in a couple of years, when the new contracts are negotiated, everything is up for grabs.

I predict that the MCO's, as Amerigroup clearly states, will push to take over assessment and case management at that point, claiming it will offer even greater efficiencies (read more profits for them). So, advocates will have to fight this fight all over again, and the state very well may decide to go along with the MCO's. Especially if they succeed in changing the DD reform act, as meggers mentions.

It hardly gives one a sense of medium-long term security or stability as far as DD services go in KS, whether one is a case manager, service provider, CDDO, or consumer/family member.

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avarom 1 year, 5 months ago

Robbing Peter to Pay Paul and all the Apostles are broke...with empty pockets.... http://www.kansas.com/2010/01/17/1140244/tax-may-not-help-kansas-budget.html

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jafs 1 year, 5 months ago

One final comment (I think we've beaten this to death by now).

The language in the above quoted amendment (if that's what it is) has lots of soft language, like "intend", "want", we "will require", etc.

Generally, contract language is much more specific and concrete.

That makes me think it's not actually in the contracts, but part of something else, like legislation.

Contracts are specific agreements between parties, legally binding on both, and set out each party's duties and responsibilities. So, a contract might say "Amerigroup must honor consumers' choice of case management and service providers". That's the kind of thing I was looking for, and have yet to find.

And, again, even if it's in there, it would only apply to the term of the contract, which is 3 years.

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UneasyRider 1 year, 5 months ago

Seems Angela lacks the skills or knowledge to provide requested information. Wonder why she is in the position she occupies?

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jafs 1 year, 5 months ago

I have to give her credit for responding multiple times and trying to present the state's perspective.

It's not an easy job, being the frontline for the state at this point, and she's not a policy maker or legislator, so isn't responsible for their actions. But she gets the heat, since she's out front.

But, at the end of this interaction, it's clear to me that:

The only protection for DD services is due to the DD reform act. If that's changed, as they're trying to do, that protection will be weakened or gone. There's nothing in the contracts about it. The MCO's clearly want to take over the assessment and case management functions. Once that happens, they'll be able to reduce services/quality, and make a nice profit.

It's kind of striking that the MCO's actually say, in their proposal to the state, that that's their intention, so the state is very clearly aware of it. "We propose that the relationship of the MCOs with the CDDOs and CSPs evolve after the first year into one in which the MCO has full responsibility for assessments and targeted case management." That's specifically about I/DD folks.

So much for ensuring that DD folks can retain their case management, and that the MCOs are "prohibited" from being CDDOs. And, their proposal suggests it happen after the first year, which proves there's nothing in the contracts about it, otherwise they wouldn't be able to do it until the end of the contract period, which is three years.

So Ms. deRocha is incorrect in a number of her statements on here.

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Butch851 1 year, 5 months ago

The bottom line is that almost all of us can relate to the hassle, stress, and frustration of dealing with a health insurance company. Particularly when the insurance company decides to override our doctor's decision for a plan of treatment either with a flat out denial or a requirement to do a less effective treatment with greater side effects that our own doctor has determined is not in our best interest.

Now imagine that your health insurance company has total control over every activity in your day to day life. From the time you get up in the morning, to taking a shower, brushing your teeth, getting dressed, preparing your meals, going to work or trying to get a job, shopping for groceries or household supplies, socializing with your friends, going on a date, or visiting your relatives over the holidays, to the time you go to bed at night, your INSURANCE company will decide how much help you will get or won't get to make it through the day, day after day, for the rest of your life. I wouldn't want to live like that and I don't wish that on any one of my fellow citizens with intellectual disabilities. These are people who live and work right here in our community, our neighbors, our friends, and members of our family and they need all of US to speak up for them now. Tell Governor Brownback to keep insurance companies out of the personal lives of people with intellectual disabilities permanently!

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