Push is again coming to shove in the struggle over whether the long-term care and support services received by Kansans with developmental disabilities will become part of KanCare or remain outside the control of the private companies hired by the state to manage the Medicaid program.
Advocates pushing for a permanent “carve out” of developmental disability services have circled May 8 on their calendars. That’s the day that the Kansas Legislature is scheduled to return to Topeka to wrap up its 2013 session.
“When you show up in numbers, it makes a difference in the legislative process,” said advocate Tom Laing, speaking last week to approximately 175 parents and advocates at a meeting sponsored by Johnson County Developmental Services.
“A lot of times when politicians do the wrong thing it’s because they haven’t heard from the folks who are the most impacted. If they don’t hear from you, we can’t succeed,” said Laing, executive director of Interhab, an association that represents most of the state's Community Developmental Disability Organizations.
Laing and other advocates said they are hoping that thousands of Kansans with developmental disabilities would turn out with their parents and guardians for a rally on the south steps of the Statehouse and to meet individually with legislators to make their case.
“I’m not a guy who believes in pitch forks and torches. We need to be persuasive, not abrasive,” Laing said.
'Carve in' date approaching
Medical services for the developmentally disabled already are part of KanCare, the reform initiative launched on Jan. 1 by Gov. Sam Brownback. It moved virtually all of the state’s 380,000 Medicaid beneficiaries into managed care plans run by three insurance companies: Amerigroup, United Healthcare and Sunflower State Health Plan, a subsidiary of Centene.
But yielding to pressure from advocates and service providers, the governor and legislators agreed last year to delay the inclusion of long-term, DD support services for a year — until Jan. 1, 2014. With the “carve in” date approaching, advocates are pressing their case again.
“We have to keep these services out of the hands of the profiteers,” said Bridget Murphy, director of the Downs Syndrome Guild of Greater Kansas City.
'Misinformation' fueling concerns
Murphy’s concern that the for-profit managed care companies will disrupt services now generally provided by a network of community-based, non-profit organizations is shared by many parents and advocates.
That frustrates Shawn Sullivan, the secretary of the Kansas Department of Aging and Disability Services, who has spent more than a year meeting with stakeholders to convince them they have nothing to fear from the new managed-care system.
After months of advisory committee haggling over what it should look like, state officials say they are ready to launch the pilot program that will pave the way for including long-term services for the developmentally disabled in the new KanCare program.
Now, all they need to start the pilot are participants.
A recruiting letter went out Friday, seeking organizations and individuals willing to volunteer, but representatives from the state’s developmental disability organizations said doubts remain strong among their members about the pilot in particular and KanCare in general. It seems that nobody, including administration officials, expects a throng of eager participants.
“The advisory committee talked about really wanting, hoping to have a broad representation of providers (in the pilot), including different types of providers,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “I don't know that it’s necessarily as important to have numbers as it is to have different types. I’m hoping to have five providers, at least.”
The administration of Gov. Sam Brownback originally sought to have long-term services for the developmentally disabled included in KanCare when the managed-care program was launched Jan. 1. But groups, including parents, that represent the developmentally disabled, persuaded legislators to postpone that for a year.
KanCare is the governor’s ongoing remake of the state Medicaid program. Since it was launched a few weeks ago, virtually all the state’s 380,000 Medicaid enrollees have been assigned to health plans run by three commercial insurance companies.
The same legislative proviso that delayed the administration’s push to roll long-term developmental disability services into KanCare also called for the pilot program. But disagreement between the administration and advocates for the disabled over what the pilot should try to gauge or accomplish went on for months after the 2012 Legislature adjourned and still hasn’t been fully resolved.
What kind of pilot?
Advocates for the developmentally disabled said they wanted a pilot that would test the administration’s still-unproven theory that the KanCare insurance companies could effectively manage long-term or “non-medical” developmental disability services, producing healthier customers while cutting government costs yet presumably earning profits.
That ambitious set of pledges is something that hasn’t been solidly demonstrated anywhere in the country and sounds “too good to be true,” as Maury Thompson, former director of Johnson County Developmental Supports.
OLATHE — Workforce shortages prompted by the overhaul of the Kansas Medicaid program are hampering operations at some social service agencies in Johnson County and elsewhere in the state, according to executives at the organizations.
Human Services Director Debbie Collins said since September, her Johnson County agency had lost three of its nine case managers that assist frail elderly Medicaid clients through the Area Agency on Aging.
Collins said the workers all left for similar positions at UnitedHealthcare, one of the three insurance companies hired by the state as part of the new Medicaid program, which the state has dubbed KanCare. Virtually all the state’s 380,000 Medicaid recipients are scheduled transfer into the KanCare managed care plans effective Jan. 1.
The other two KanCare contractors are Amerigroup and Sunflower State Health Plan, a subsidiary of Centene. All three companies have been busy hiring workers for the past few months.
Collins and other agency administrators interviewed for this article said the bright side of losing the workers was knowing that the KanCare companies had hired qualified staff.
They said they didn’t blame their workers for taking the jobs because the employees told them they would get substantially higher pay at the managed care companies.
But the agency leaders said they weren’t sure how KanCare could save the state money, if the contractors will have significantly higher personnel costs.
“We are all befuddled about that,” Collins said.
Savings will come through a focus on patient education, preventive care, and by “ensuring members have access to the right care, at the right place and at the right time,” said Monica Stoneking, a spokeswoman for Sunflower State Health Plan.
Sunflower, she said, was paying “competitive wages in accordance with industry standards.”
Amerigroup spokesperson Maureen McDonnell declined to comment.
Alice Ferreira, a spokesperson for United Healthcare said the company was giving its new hires flexibility so that their former employers wouldn’t be left in the lurch.
“UnitedHealthcare has been working collaboratively with the agencies to provide case managers the work flexibility to ensure they are able to continue to work with the members as appropriate,” she said in an email. “We are committed to ensure members receive the care they need, and anticipate that this partnership will result in a smooth transition.”
She the company also was dedicated to “creating new jobs in Kansas.”
Officials at each of the KanCare contractors have said they would hire as many as 300 people as they prepare for the new program. Each company also has a Kansas headquarters office.
Officials in the administration of Gov. Sam Brownback estimate KanCare will save the state and federal governments $1 billion over the next five years.
Among the various social service and state agencies that have lost workers to the KanCare companies are the state’s Area Agencies on Aging, which, in any event, are seeing their roles change under KanCare.
Though the agencies are handing off case management for the frail elderly to the KanCare companies, they are expected to take on expanded roles in serving individuals with physical disabilities and traumatic brain injuries by assessing their needs for assistance and helping them choose the right KanCare plan, in the event the persons are not content with their state-assigned plans.
Collins said the changes have left her uncertain about what her staffing needs will be after the first of the year.
“We may very well have to expand,” she said. “We really don’t know what the workload will be.”
Other organizations experiencing KanCare-related personnel pinches include the Johnson County Mental Health Center and the Southeast Kansas Area Agency on Aging in Chanute.
Johnson County Mental Health has had 15 staff members take positions with the KanCare companies, according to agency officials, including a senior administrator and a number of clinicians and case managers.
In response, the center has pressed supervisors and everyone else with proper certification and training into service to coordinate care for clients, said Executive Director Maureen Womack.
The main problem, she said, was that clients had lost their connections to workers with whom they felt comfortable dealing.
“What is falling through the cracks,” she said, “is the therapeutic relationship.”
Top officials in the administration of Gov. Sam Brownback said today that they now have a list they accept as accurate of the 2,197 physically disabled persons who are awaiting home- and community-based Medicaid services.
Armed with the updated information, they said, they are ready to begin providing services to 100 people currently on the list by the end of the year.
"We now have a better handle on the waiting list and wlll be able to make better decisions about how to manage the waiting list and best utilize the funding provided by the Legislature for this program," said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services.
Sullivan, joined at a Statehouse press conference by Lt. Gov. Jeff Colyer, said his agency won't propose additional funding to further decrease the waiting list but would instead wait to see what legislators would appropriate in 2013 to help deal with the problem.
Kansas has drawn attention from federal authorities due to its slow moving and relatively large waiting lists for home- and community-based services, which advocates for the disabled have said puts the state in violation of the federal Americans with Disabilities Act as defined by the U.S. Supreme Court's so-called Olmstead decision.
It wasn't immediately clear if today's announcement would influence the course of the U.S. Justice Department's review of Olmstead complaints filed by disabled Kansans and their advocates.
Feds continue monitoring
“We are continuing to monitor the state’s activities on all issues that may relate to any potential Olmstead violations,” said U.S. Attorney for Kansas Barry Grissom in an email statement to KHI News Service after the press conference
Brownback officials for months have said they doubted the reliability of the lists, particularly the one dealing with the physically disabled. So, today's announcement made clear the administration now has a list it considers fully valid.
As of July, the state's Centers for Independent Living, had reported there were 3,462 people on the list.
Sullivan and Colyer said the state hired Answernet, a firm based in Hays, to start making phone calls in July to check the list. After the company was only able to reach 377 of the people, state officials asked the Centers for Independent Living to double check the list.
That process resulted in 1,226 people being removed from the official backlog after it was found for whatever reason that they no longer needed the services or were not eligible. But it also resulted in another 250 people being added to the list.
Audrey Schremmer-Philip, executive director of 3Rivers, Inc., a center for independent living based in Wamego, said the 250 new names were of people for whom the state's centers for independent living previously had submitted paperwork to the state but for unknown reasons had never made the state's list of people needing services.
Rocky Nichols, executive director of the Disability Rights Center of Kansas, a Topeka-based nonprofit group, was critical of the administration's handling of the waiting list and its review of the backlog.
“We are extremely concerned that the state is creating a self-fulfilling prophecy that is having the net effect of unnecessarily kicking people off the waiting list for services," he said. "The perspective is all wrong here. Not only do you have to wait years to clear the waiting list in Kansas, now the state is saying if they can’t get ahold of you — due to you not having the money to add minutes to your pre-paid cell phone, or you had to move to make ends meet — that they are going to add insult to injury and kick you off services. It makes no sense.”
State officials are changing the way they determine which in-home Medicaid services are provided to the frail elderly and people who are physically disabled.
The new system will rely on a single agency or organization with a presence in each of the state’s 105 counties to assess what services a person will receive. Currently, there are more than 30 organizations involved with the process. Some assess only the elderly. Others focus solely on the physically disabled.
State officials said their aim is to create a “one-stop shop,” so that services will be determined in the same place regardless of a person’s condition.
“The system we have now is a real mishmash,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “We’ll be going to one that takes more of a no-wrong-door, single-entry approach and implements a conflict-free provision of services.”
About 12,000 Kansans currently rely on the services provided by the system, at an annual cost to taxpayers of about $200 million.
A solicitation to potential contractors interested in managing the new system was put out in February. Bids were due April 3.
Sullivan said he hoped to have the contract awarded sometime next month so that a single, statewide Aging and Disability Resource Center (ADRC) will be up and running by Jan. 1, which also is the scheduled start of KanCare, Gov. Sam Brownback’s plan for letting managed care companies administer the state’s $2.9 billion Medicaid program. KanCare remains contingent upon federal approvals.
The resource center, according to Sullivan, would be in charge of measuring the needs of an elderly, physically disabled or brain-injured person. It also would do preliminary screening for Medicaid eligibility and help the person choose the managed care company best suited to meet the person’s needs.
Today, the assessments are handled by 11 area agencies on aging, 10 centers for independent living and about a dozen home health agencies that specialize in caring for the brain-injured.
“When you have this many systems in place, it can be confusing as to who to turn to for assistance,” Sullivan said. “With the ADRC, we’ll be going to one database, one information source and one hotline for people to call.”
The change, he said, was driven by a federal initiative aimed at increasing efforts to help Medicaid beneficiaries live in community settings rather than nursing homes and a concern among state officials that not enough was being done to prevent the centers for independent living from inflating their assessments in ways that generated more work — and therefore more revenue —- for their case management and home-health programs.
The Kansas Department on Aging has put together a list of 800 nursing home residents who officials believe might be able to move to less expensive, less institutional settings.
The agency has asked the state’s Area Agencies on Aging and Centers for Independent Living to have their case managers meet with each of the 800 residents to see if they are able and willing to move.
The effort is part of Aging Secretary Shawn Sullivan's ongoing effort to reduce the number of people in nursing homes. Kansas, with its disproportionately elderly population, has a higher percentage of people in full-care nursing homes than all but a handful of other states.
KDoA officials have pledged to pay the case manager’s employer $2,000 for each Medicaid-funded nursing home resident who is able to move out of the nursing home and stay out for at least 90 days.
KDoA Secretary Shawn Sullivan said the payments were designed to offset some of the uncompensated case management costs that hamstrung earlier efforts to reduce the state’s nursing home population.
But the notion of rewarding someone for helping people move out of nursing homes has upset the state’s nursing home lobby.
“It’s a bounty. There’s no other word for it,” said Cindy Luxem, executive director of the Kansas Health Care Association, which represents most of the state’s for-profit nursing homes. “If a nursing home paid a case manager a bonus for every resident they got to move there from another nursing home – that’s a felony,” Luxem said. “It’s illegal, but here we have the state paying bonuses to case managers who are essentially doing the same thing. They’re being rewarded for getting people to move out.”
She also said it seemed unfair that nursing homes aren’t paid $2,000 when their social workers help residents return home or move to community-based settings.
“For us, this is just beyond belief,” Luxem said of the agency’s new policy.
But Sullivan said the nursing home industry was mischaracterizing the payments, which have not started because the policy is so new.
“It’s not a bounty,” Sullivan said. “It’s an attempt to cover some of the administrative costs that haven’t been covered in the past.”
In recent years, KDoA stopped reimbursing Agencies on Aging for their case managers’ mileage and travel time.
The Kansas Department of Social and Rehabilitation Services has never covered the so-called “windshield time” incurred by case managers with the Centers for Independent Living.
Nor does either of the state agencies cover the costs of required training for the case managers.
The Area Agencies on Aging and Centers for Independent Living are the local agencies charged with assessing current or potential nursing home residents to determine what level of assistance each may need.
More independence, less cost
Sullivan said no one who’s living in a nursing home would be forced to move as a result of the new policy.
The initiative, he said, is designed to give the 800 residents and their family members information on services that could be made available to them in their communities. The result could be more independence for the beneficiaries and their families, and savings for the Medicaid program.
Sullivan said the $2,000 payments would be state-funded and come from the department’s administrative budget. Each payment will be made in three installments.
A company that is among the five bidding on the state’s Medicaid managed care contract has agreed to pay $137.5 million to settle claims it defrauded Medicaid programs in nine states.
The U.S. Department of Justice announced the settlement with WellCare Health Plans Inc. last week.
It was the second settlement the company agreed to after federal prosecutors in 2006 launched criminal and civil investigations stemming from complaints filed by whistleblowers.
In 2009, the company entered a deferred prosecution agreement and paid $40 million in restitution and forfeited another $40 million. WellCare’s former chief executive, Todd Farha, is scheduled to go to trial in January.
The settlement announced last week will be divided among the federal government and the Medicaid programs in Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Missouri, New York and Ohio.
Sean Hellein, a former financial analyst with WellCare, will collect more than $20 million, federal officials said. He filed the initial whistleblower claim that prompted the investigation.
WellCare officials said the settlement wiped the slate clean for the company.
“The company acted swiftly upon learning of the wrongdoing in 2007, took action to separate the individuals involved, and cooperated fully with state and federal authorities in their investigations. These matters are now resolved and a new leadership team has been put into place,” WellCare spokeswoman Denise Malecki told KHI News Service.
She said the company would bring high standards to its Kansas operations if it wins a contract to help implement KanCare, Gov. Sam Brownback’s Medicaid makeover plan.
“Today, WellCare's commitment to transparency and ethical behavior will be unparalleled in providing quality, cost-effective health care to the members of the KanCare program,” she wrote in an email.
As part of the settlement with the Justice Department, WellCare agreed to enter a corporate integrity agreement that allows the U.S. Department of Health and Human Services' Office of the Inspector General to oversee its “rehabilitation” for three years.
Sherriene Jones-Sontag, a Brownback spokesperson, said the qualifications of WellCare and other KanCare bidders would be thoroughly reviewed by the administration.
“The state conducts thorough evaluations to ensure the selection of qualified bidders who meet the requirements of the KanCare program, including financial sustainability,” she wrote in an email. “The contracts for the KanCare program will include mechanisms such as performance bonds and parent corporation guarantees as well as significant reporting requirements and ongoing reviews of the financial conditions of KanCare contractors.”
WellCare isn’t the only KanCare bidder that has been ensnared in a federal whistleblower lawsuit.
Amerigroup paid $144 million in damages and $190 milllion in fines after losing a whistleblower case in Illinois in 2008.
Wall Street analysts remained bullish on WellCare after last week’s announcement.
“It's conceivable that the company could double its revenues in the next couple of years," Tom Carroll, an analyst at Stifel Nicolaus, told Florida Health News, a partner of KHI News Service.
According to financial analysts, the company had $6.1 billion in revenue last year and has more than $300 million in cash on hand.
But the claims raised against WellCare in the lawsuit were alarming to some in Kansas who already have concerns about the governor’s Medicaid plans.
“I am deeply troubled and shocked by the contents of this settlement agreement, and I believe it underscores the need to slow down the process of implementing KanCare,” Shannon Cotsoradis, chief executive of the advocacy group Kansas Action for Children, wrote in an email to KHI News Service. “Thoroughly vetting potential contractors is a critical component of the implementation process and it must happen to protect the children and families in our state. I don't think this is the kind of Medicaid ‘reform’ we are looking for.”
Among the things cited in the case, WellCare:
• Created a wholly owned reinsurance subsidiary that inflated the company’s premiums in a way that made profits look like expenses;
• Hid information that would have caused the company to send money back to the Illinois Medicaid and Florida Healthy Kids programs;
• Falsified encounter and performance data;
• Rewarded physicians and clinics for referring healthy, low-cost patients to WellCare and sending sick, high-cost patients to competing health plans;
• Engaged in marketing and enrollment practices that discriminated against patients with chronic illnesses;
• Collected premiums on patients who were dead; and
• Operated a “sham” special investigations unit that allowed the company to “seek excessive reimbursement from the providers.”
The fraudulent activity was alleged to have occurred between 2002 and 2007.
Advocates for better long-term care for elders gave sometimes emotional testimony today as they asked a Senate committee to consider raising minimum staffing levels at nursing homes.
"We realize what we're asking for is a significant change," said Mitzi McFatrich, executive director of Kansas Advocates for Better Care. "But we believe it is reasonable to set a minimum standard for direct nursing care at the beginning of a major overhaul to the Medicaid system."
The administration of Gov. Sam Brownback is working to expand managed care to all currently on Medicaid, including those in nursing homes. The governor's KanCare plan is scheduled to start Jan. 1, 2013, contingent upon federal approval.
In Kansas, nursing homes are required to give direct staff care for at least 1.85 hours per resident per day, and to average at least 2.0 hours per day throughout the week. The minimum staffing level is one qualified employee per 30 residents, which translates to 2.06 hours per resident per day.
Qualifying staff are registered professional nurses, licensed practical nurses, nurse aides, nurse aide trainees, medication aides and paid nutrition assistants.
Several people who testified cited a 2002 study by the Centers for Medicare & Medicaid Services that recommended at least 4.85 hours of combined staff time per resident per day. Maren Turner, director of AARP Kansas, said legislators should consider raising the state minimum to at least that level.
"Residents in facilities that fell below the minimum staffing thresholds (recommended by CMS) were at a significantly greater risk of hospitalization for potentially avoidable causes, lack of functional improvement, incidence of pressure sores and skin trauma ... and weight loss," Turner said.
Committee members also heard several personal stories, including one from Barbara Braa, whose mother lives in a nursing home.
"If you cared for a child in your home and only gave them two hours of care a day, somebody would be at your door taking them away. And that's all we provide," for the elderly, Braa said, fighting back tears.
A report is expected in the next few weeks from the Legislative Division of Post Audit on how increased staffing levels at nursing homes would affect state spending.
Turner and others asked committee members to consider scheduling an interim hearing on the issue after the report is available.
There are 342 nursing homes in Kansas. McFatrich said that all facilities averaged 3.59 hours per resident per day in 2010. But the averages for individual nursing homes ranged from 1.4 hours to 5.7 hours. She said 151 nursing homes fell below the state average.
Senate Bill 184 would incrementally raise the minimum staffing levels to 4.44 hours per day. The bill was introduced last year but no action has been taken on it.
→ More from today's committee meeting at khi.org.
The system that helps more than 6,000 physically disabled Kansans across the state live in their own homes instead of long-term care facilities is undergoing sweeping changes that have been launched by the administration of Gov. Sam Brownback.
Administration officials say the shake-ups ultimately will result in a more efficient and accountable system with potential for helping more people.
But those who deliver the services at the local level through the state’s 12 regional independent living centers say they don’t see how those outcomes will be possible given the problems associated with implementing the changes.
They also complain that they are being asked to simultaneously deal with multiple initiatives, any one of which could be difficult to execute while coping with budget cuts unlike any they have experienced since the system began developing in 1978.
“They (Brownback officials) think they have all these great ideas, and they may be great ideas,” said Shannon Jones, executive director of the Statewide Independent Living Council of Kansas. “But they're flying at 40,000 feet, and when it comes to implementing (the changes) in the field they don't get it. They think because it’s a great idea it’s just going to magically work.”
Administration officials have acknowledged some of the centers' concerns and say they are working as quickly as possible to resolve them.
"I recognize that many aspects of providing supports and services for persons with disabilities is undergoing change," Secretary on Aging Shawn Sullivan told members of a House committee last week. "Change is often challenging."
So many changes, so fast
Directors at various centers for independent living told KHI News Service that they are operating with deficits or tapping financial reserves even as they reduce staff or trim services and plan for additional cutbacks.
“We’ve never been in the situation we’re in now in the 18 years I’ve been in business,” said Shari Coatney, executive director of SKIL, the state’s largest independent living center based in Parsons. “This is the most dramatic that I’ve ever seen. So many changes coming so fast with so little cooperation with the people actually delivering the services, based on the idealisms of the new folks in town.”
“Our financial projections are dire,” said Audrey Schremmer-Philip, executive director of 3Rivers, an independent living center in Wamego that serves people in 10 counties and American Indians on the Prairie Band Potawatomi Reservation. “We are currently running a deficit, utilizing agency savings to operate, while the management team and board try to determine the best plan of action. With extreme changes to how we will do business in the future, we are unclear if we should keep fully staffed … or reduce staff by a third and start a waiting list for services.”
With so many changes thrown at them at once, some of the center directors are convinced they are being punished by state officials for encouraging complaints to federal officials about the lack of services available for the disabled in potential violation of the Americans with Disabilities Act.
Last week, the state’s top welfare officials appeared before the House Health and Human Services Committee to answer charges that they had “retaliated” against the centers.
That allegation was made by Jones in a Jan. 26 email to center directors, a copy of which ended up in the hands of Rep. Brenda Landwehr, the Wichita Republican who heads the committee. Jones later told KHI News Service that the email was not intended for a wider audience and that “retaliation” was perhaps not the best word to have used.
“I was totally blindsided by that,” she said of Landwehr’s disclosure of the email.
“Those are serious charges. I thought they (administration officials) deserved an opportunity to respond to them,” Landwehr said of the hearing about the email, which featured testimony from Sullivan and Michael Donnelly, director of rehabilitation services at the Kansas Department of Social and Rehabilitation Services.
Also at the hearing was acting SRS Secretary Phyllis Gilmore, though she did not speak.
Not a conspiracy
The two men each offered detailed responses that refuted the claim of retaliation, and Donnelly talked about the charge at length in an hour-long follow-up interview with KHI News Service.
→ Continue reading at khi.org/CILs.