NY Managed Long Term Care Gaffes Raise BH Community Concerns

NYAPRS Note: Today's meeting of New York's Behavioral Health Work Group will provide details of state plans to turn the care of hundreds of thousands of New Yorkers with serious psychiatric and substance use conditions over to managed care systems next year (April in NYC and October elsewhere).Today's NY Times article below underscores the critical importance of transparency and meaningful state oversight over the kinds and quality of the care vulnerable New Yorkers will receive. While NYAPRS has actively informed and supports the state's Medicaid Redesign reform plans, there are a number of transparent process and outcome measures the state must implement and publicly share to demonstrate that people get the right kind of care in the right setting at the right time. Relative to successful transitioning of people into the new designs, the state must:

* provide culturally and linguistically clear advance information in a number of formats (printed, web) to beneficiaries about upcoming changes to their healthcare and about their rights and choices along the process

* provide adequate access to culturally appropriate enrollment brokers (including peer brokers)

* provide prominently displayed access to a consumer help or complaint line

* accelerate plans to ramp up the number of ombuds workers who can help field and process complaints Relative to how beneficiaries fare in these new care systems, the state must

* regularly publish enrollment data that demonstrates where people are ending up in the new integrated care designs, e.g. which plans

* regularly publish data demonstrating plan and network adequacy and diversity

* closely follow and share information about the impact of new service designs on beneficiaries; for example, tracking people's residential status to see if they fell through the cracks during the transitions or as a result of potential new service gaps or failures; one way to do this is to track people's residential status to see how many people ended up in state or local psychiatric wards, adult or nursing homes, jails or prisons and homeless shelters....and/or to track how responsive care was for people transitioning from those settings back into the community.

* regularly publish outcome measures that look at the impact of care on people's residential and employment/economic statuses, their connection to social and peer support systems, their success at getting to and keeping up with appointments

* Regularly publish information about the types and amounts of services that new health plan designs authorize. Critical measures like these will be publicly discussed at this morning's 10:30 meeting of the state's Behavioral Health Work Group; you can watch the state's presentations and work group discussions at Windows Media http://pointers.audiovideoweb.com/asxfiles-live/1c2winlive6653.asx Real Media http://interface.audiovideoweb.com/lnk/avweb2reallive2161/live.rm/play -------------

Advocates Say Managed-Care Plans Shun the Most Disabled Medicaid Users By Nina Bernstein New York Times May 1, 2013

Managed-care companies in New York have come under fire for signing up vigorous older adults referred to them by social day care centers<http://www.nytimes.com/2013/04/23/nyregion/day-centers-lure-fit-elders-and-bill-medicaid.html>, customers whose health needs are relatively small. But on Tuesday, legal advocates for the disabled told the state's Medicaid director that the most seriously impaired people were getting the opposite treatment. Among the examples reported to the director, Jason A. Helgerson<http://nyti.ms/ZyuU3z>, in a meeting were cases in which the advocates said representatives of the managed-care plans deterred people who were bedbound or affected by dementia from enrolling in a plan, often by refusing to do an assessment at all, or by falsely saying that the plan's budget or policies did not allow as much care as the person needed. The meeting was closed to the news media, but Mr. Helgerson vowed to hold plans accountable, participants said, and some said they were encouraged that he worked with them to come up with a list of quick fixes, including a dedicated complaint line. But the issues raised at the meeting illustrated again the difficulties as Gov. Andrew M. Cuomo, through the state Department of Health, moves tens of thousands of Medicaid recipients who need long-term care, like personal aides or nursing homes, into managed-care plans. Medicaid pays the privately run managed-care plans roughly $3,800 a month for each person they enroll in New York City, regardless of how many services they need. The idea, borrowing from the use of health maintenance organizations to deliver health insurance, is to save money and harness competition among private plans to provide better, more efficient community care than under costly and fraud-ridden fee-for-service models. But representatives from a dozen advocacy organizations for disabled people warned Mr. Helgerson that they were seeing a systemic problem: some of the neediest people were not being allowed to enroll, or were being denied the hours of service they need without a meaningful chance to appeal. "The plan's incentive to enroll low-need people creates a conflict of interest and opens to Medicaid fraud - see adult day care," advocates wrote in an 18-page document for the meeting. They were referring to the state's new scrutiny of the relationship between the plans and proliferating day care centers that send the plans new customers from a largely healthy elderly clientele. The same financial incentives cause plans to deny enrollment to those with high needs, advocates contended. In an e-mail statement after the meeting, Mr. Helgerson said the move to mandatory managed long-term care had been successful in meeting its goals for patient care and lowering costs across the Medicaid system. "As I have made clear, we will continue to move quickly and aggressively to stamp out and prevent fraud, and address implementation issues," he wrote. Valerie Bogart, a lawyer with the New York Legal Assistance Group<http://nylag.org/> who was at the meeting, said advocates were encouraged. "Jason promised more transparency on quality measures, and more meaningful oversight," she said. Last week Mr. Helgerson suspended all new enrollment in VNS Choice<http://nyti.ms/ZxlkPi>, the largest managed-care plan, and other plans run by Visiting Nurse Service of New York pending an investigation into its use of social adult day care centers like R&G<http://nyti.ms/XSdYns> in Bensonhurst, where a stream of agile older people had been recently seen picking up free takeout food there and walking or bicycling away with it. Managed-care plans pay adult day care centers out of their Medicaid allotment to provide supervised activities and meals to plan members. But the centers also refer new customers to the plans. Medicaid fraud investigators are also looking into allegations that R&G and other centers used illegal inducements to lure new clients, like cash gifts and grocery vouchers, and that a VNS executive rebuffed complaints about such practices. At R&G on Monday afternoon, a man who had previously identified himself as a receptionist said he was in fact the owner, Wei Xin Liang. He denied that the center had used such inducements, and contended that people seen leaving the center with stacks of just-delivered takeout food were taking leftovers home or just stepping out for a smoking break. Mr. Liang, 28, said that members eager to attend his center every day chose to enroll in VNS Choice, because unlike other plans, it regularly allowed its members to attend social day care six or seven days a week, at $85 for each four-hour session, with door-to-door transportation. "We didn't force them," he said. At the other end of the spectrum, advocates reported to Mr. Helgerson that a VNS Choice nurse had acknowledged that one of her clients needed two 12-hour shifts of home care each day, but claimed that VNS would only provide half that much, and the impaired woman would have to privately pay for the rest. She has no funds and no family, her advocates said, and it took lawyers four months to obtain the care she was entitled to. "VNSNY CHOICE recognizes its obligations under New York and Federal law and does not discriminate on the basis of health, frailty or any other circumstance," a spokesman for VNS, Richard Rothstein, said in an e-mail statement. The daughter of a bedbound 87-year-old woman complained to advocates that after being promised two shifts of 12-hour care by another plan, Fidelis, a Fidelis nurse told her that the rules had changed, that Fidelis would not provide that much care, and that her mother should look for another plan. "Nobody can leave her for 10 minutes," said Bella Zaltsman, director of Social Services at the United Jewish Council of the East Side, who interceded for the woman with Fidelis. "She doesn't walk. She sleeps at night, but has to be changed five or six times." Darla Skiermont, a spokeswoman for Fidelis, said that although she could not comment on an individual member, "We would not inappropriately reduce the level of care or service provided to a member, and an individual's care is never influenced by financial considerations."