Justice Department may probe profit over quality care

KanCare draws ‘deep concern’ from National Council on Disability

By FINN M. BULLERS
Freelance writer/editor

TOPEKA, Kan. — Big news on the Kansas managed care front could reshape the health care landscape and growing national debate on the merits of privatized, for-profit care.

In a Dec. 13 letter from the National Council on Disability, several significant and non-binding recommendations to improve the state’s for-profit Medicaid plan — also known as KanCare — were made to the President and Congress.

“It’s clear to NCD that many unresolved issues remain for people with disabilities” in Kansas, the report said. “The federal Centers for Medicare & Medicaid Services should conduct an oversight review of the current administration of KanCare.”

Several other recommendations came after the disability council met Dec. 4-5 in Topeka to conduct a KanCare hearing for supporters and critics.

Kansas is ground zero for the contentious managed care debate now emerging. From here, the council will hit the road to cities including Chicago, New Orleans and Tallahassee to continue its national assessment of managed care.

While most state’s have tiptoed into managed care, Kansas has cannonballed into the deep end of for-profit care. And in the world of health care, all eyes are on Kansas.

Headline news out of December’s hearing::

—  NCD is “deeply concerned” about how managed care organizations use diagnostic and evaluation tools “that are resulting in significant reductions of service for individuals with disabilities.”

NCD members noted my case. I was  qualified under the former Kansas Medicaid program for 24/7 care, but under KanCare’s new managed care plan I now only qualify for 40 hours a week of care — a 76 percent reduction.

This contradicts the medical expertise of my primary care physician, my pulmonologist and my muscular dystrophy doctor, who — with a combined medical experience of more than half a century — all say 24/7 care is critical for me to live and raise my two children.

I have a degenerative muscle-wasting disease known as Charcot-Marie-Tooth, a rare form of muscular dystrophy. It only gets worse. It doesn’t get better. I have been an insulin-dependent diabetic for 37 years and use a breathing machine to draw air and a power wheelchair to move. I have no fine motor skills, write with a pen in my mouth and grasp with the palms of my hands pressed together. I cannot toilet myself and need help to urinate.

The diagnostic tools used to qualify me for care are the same pre- and post-KanCare, so how can the number of care hours assigned me by the state be so drastically different, questioned NCD members.

“Such a variance in service recommendations seems suggestive of aberrant implementation or external considerations such as managed care organization profit considerations over quality considerations,” the report said.

The report concluded that CMS and the Department of Justice Office of Civil Rights may need to examine the former state Medicaid office that — as KDADS Sec. Shawn Sullivan testified — was “previously negligent in consistently implementing evaluative and diagnostic tools” — which should have been noted or detected in previous CMS related quality audits, the report said.

NCD members want to determine whether Kansas adequately administered its past Medicaid program or if managed care organizations are using “external or variant mechanisms to place cost savings or profit over quality care for people with disabilities.”

Based on December testimony and a year of managed-care research, the 15-member disability council sent its four-page letter of recommendations to the administrator of the U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services.

Sec. Sullivan responded to the disability council report by saying readers did not get an accurate picture of managed care expansion in Kansas. The hearing was set up to “paint a distorted picture of the detailed planning and consulting” that went into KanCare, Sullivan said. He said the council’s recommendations that follow here are equally distorted.

Sullivan also argued, essentially, that my former Medicare case managers padded my need for hours for financial gain. Again this contradicts my medical experts — all saying 24/7 care is critical for my survival.

Finally, Sullivan argues that less than 8 percent of KanCare recipients who receive aid to live at home or in community group homes have had their plans of care reduced. Using Sullivan’s figure of 20,000 consumers like me receiving long-term support services, that equates to 1,600 Kansas. When it comes to caring for the state’s most vulnerable, is that not a big enough number of people with disabilities to care about?

Sullivan concludes by saying my proposed reduction in care hours is not an “accurate representation” of consumers receiving long-term support services.

In other recommendations, the NCD:

— Wants a one-year delay to fold people with intellectual and developmental disabilities into KanCare. A delay would allow CMS to conduct an “extended” review of the concerns raised by Kansas stakeholders and the disability council. Pushing such clients into long-term managed care by Jan. 1 is “troublesome” and “may result in negative consequences,” NCD members say.

— Believes Kansas must live up to its promise to meet the needs of 11,252 underserved and unserved Kansans with disabilities. Some people with disabilities have waited as long as 12 years for service. Under its current waiver approved by the feds, Kansas promised to meet those needs. Gov. Sam Brownback has failed to deliver on that promise.

— Says it is concerned that health care providers are not being paid in a timely fashion, forcing some small providers to fire caregivers  and/or go out of business. Even large providers are complaining.

One example: Dynel Wood, M.A., co-owner and director of operations for Options Services Inc., an Olathe-based service provider for about 50 people with disabilities. Options hires 55 employees. “These people will lose their jobs if we cannot survive KanCare,” Wood said in written testimony before the state’s KanCare oversight committee earlier this year.

As a small business owner, Wood is facing a cash-flow nightmare where in the last reporting period 30 percent of her payments were made successfully. Some providers reported a 0 percent success rate. Wood can’t continue to do business that way. She has bills to pay — or fire caregivers. Or simply close up shop for good.

Before KanCare, Wood says her state reimbursements were issued within two weeks. Today — with a tangle of new billing codes and ever-changing process changes — it can take up to 12 weeks. “The (managed care organizations) often can’t explain why claims are not paid or why information that was submitted is missing,” Wood told the oversight committee. “KanCare is not ready.”

— Says Kansas needs a “more robust and independent ombudsman’s program.” As it stands, Kansas offers an information-traffic-cop approach to define the role of the 1-person Ombudsman office.

In Kansas, one ombudsman represents the entire 380,000 people enrolled in KanCare compared to Wisconsin where one ombudsman represents every 3,500 people with disabilities to help them navigate the often tangled and confusing bureaucracy to receive state aid.

Ombudsman is defined as “advocate” in disability regulatory agencies across the country. But not in Kansas. The NCD wants that to change.

Brownback has said KanCare, by coordinating care, will save $1 billion over five years and improve health outcomes without cutting services, eligibility or provider payments.

The National Council on Disability was created under federal law as the “premier entity to advise the federal government on disability issues, so we cannot stress enough how important” the NCD recommendations are, said Rocky Nichols, executive director of the Disability Rights Center of Kansas.

Said one Topeka Capital-Journal reader: “KanCare is a privatized mess that does not serve the needs of disabled Kansans.”

The message is clear: KanCare is not ready for prime time.

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You can reach Finn Bullers, policy adviser for the Greater Kansas City Spinal Cord Injury Association, at: finn.bullers@aol.com or 913-706-2894. Read his “Squeaky Wheel” column at http://www.usersfirst.com.

FAST FACTS

— Kansas stands to lose $950 million by rejecting Medicaid expansion, according to a new report from the Commonwealth Fund, a private foundation whose stated purpose is to “promote a high performing health care system.”

— Kansas and the 19 other states rejecting Medicaid expansion are leaving billions of dollars in federal aid on the table, even as their taxpayers pay to cover expansion costs in states increasing Medicaid.

— The report was based on federal taxes paid by residents in each state. It concluded Kansas would see a net loss of $950 million in 2022, assuming it was the only state in the nation that had not expanded its program eligibility.

— The report also projected that if Kansas chose to expand Medicaid, it’s share of the cost in 2022 would total $108 million compared to the $1.2 billion the state is projected to devote to business incentives and subsidies.

— “No state would experience a positive flow of funds by choosing to reject the Medicaid expansion. Because the federal share of the Medicaid expansion is so much greater than the state share, taxpayers in non-participating states will nonetheless bear a significant share of the overall cost of the expansion through federal tax benefits — and not enjoy any of the benefits,”

SOURCE: Kansas Health Institute

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