Category Archives: Crisis Solutions Coalition
How much power does an Executive Order signed by your State’s Governor actually wield? Governors, all of whom are elected, serve as the CEOs of the 50 states, five commonwealths, and territories of the U.S.
As CEO of their particular State, Governors are responsible for ensuring that each State is adequately prepared for emergencies and disasters of all types and sizes. Most emergencies and disasters are handled at the local level, and few require a presidential disaster declaration or attract worldwide media attention. Yet here we are. A global pandemic affecting every single person on the planet.
This is not a tornado. It’s not Sept. 11 or giant killer hornets, which are also apparently a new thing. This virus has uprooted the world in a way that no one has ever witnessed.
Not everyone is following Governors’ Executive Orders. For example, multiple adult day care centers contacted me recently from New York. Governor Cuomo has issued multiple Executive Orders regarding telehealth, basically relaxing the rules and forcing higher reimbursement rates and allowing for more telehealth, when in the past, it would not have been allowed. However, private insurance companies are refusing to obey the governor’s executive orders. The private companies argue that the providers signed a binding contract that does not include telehealth. The private payors argue that contract law trumps a governor’s executive order, even though the governor has ordered it because of the pandemic. Governor Cuomo has suspended New York State Public Health Law §2999-cc, as well as numerous others.
These adult day centers have followed the governor’s executive orders and are providing telehealth to maintain elderly socialization. The mental health aspect is their main concern right now.
There is no consistency in how the private companies are complying or not complying. Some private payors have issued amendments to the providers’ contracts, allowing telehealth, but at a serious financial decrease. Where the visit would have been reimbursed at $100-200, the new contract amendments allow for reimbursement rates of $25.
Others stick to the contracts and refuse to reimburse telehealth for these adult day care centers at all.
According to one of the companies that spoke with me, the adult day care centers in New York are losing approximately $56,000 per month. Now, I know that most health care providers are losing money in this pandemic. My friend who is an ER nurse says she has never seen the ER so empty. We cannot have our hospitals close. But in the case of the adult day care centers, we can point to a legal reason that providers should be reimbursed during this pandemic. The private payors are blatantly not following the Governor’s Executive Order.
Here, in North Carolina, the reimbursement rates for health care providers are increasing, sometimes doubling, as in the case of home health due to the shortage of health care providers willing to go onto someone’s home. From about $15 to $33 per hour. Thank you to all you home health workers! It is a scary time, and you are essential.
The providers want to sue to get the reimbursements that they are owed.
This is just one example of how discombobulated COVID-19 has made everyone.
Then add in the next variable of New Yorkers re-entering society and the “stay at home” Orders being lifted. I do not think that the problem with private payors not following a Governor’s Executive Order will just vanish when the state reopens. These providers have lost their higher reimbursable rates and cannot get that money unless they sue.
If I were a betting woman, I would bet that there are hundreds of intricate ways that insurance companies have not followed their particular states’ executive orders. Think about this: even if the companies were truly trying to abide by all executive orders, those companies in multiple states may get opposing orders from different states. So then a nationwide private payor is expected to follow 50 different executive orders. I can see why it would be difficult to comply with everything.
We have to ask ourselves – does an Executive Order, in a time of crisis, trump normal laws, including basic contract law? If the answer is yes, then how do we make private payer insurance companies comply?
Knicole Emanuel is a permanent panelist on Monitor Monday. Listen to her live reporting every Monday at 10-10:30 a.m. EST.
I attended a Women in Leadership conference the other day. The keynote speaker asked for us to come up with a one sentence mantra or mission statement that we would use to describe our purpose in life. I had never thought about what my life purpose is…my career?..being a mom?….being a wife?
As a woman, I was torn. Was I a bad mom if I thought my “purpose of being” was my career? Do all women feel this? Was I a bad wife if I thought my “purpose of being” was my career? Does my career define me? I decided that what defines me are the indirect consequences of my career? (i.e., those who benefit from my advocacy, but could never hire me).
So my mission statement came out on paper as: I am here in order to advocate for the voiceless.
I have a rare opportunity with my career choice to indirectly help Medicaid recipients (the voiceless) by serving the providers who serve recipients. Obviously, Medicaid recipients cannot afford me or any other attorney. But, by serving those that serve recipients, indirectly I am serving recipients. For a more detailed explanation why I love my job, see my blog on Why I Have the Most Rewarding Career.
Sometimes, however, my job feels like I am David fighting Goliath. No…the flea on David’s shoe while he is fighting Goliath.
In my own head, I have always felt that changing government policy (fighting DHHS) is a true David and Goliath story.
Which, finally, brings me to my point. For those of you who have been reading my blogs, how many times have I blogged about MCOs not providing medically necessary mental heath care services??? Or Medicaid recipients being incarcerated or hospitalized because the MCOs were denying mental heath care services? But never have I written that DHHS is not providing the medically necessary mental heath care services, quite frankly, because DHHS has stood back and allowed the MCOs to run rampant.
Since the inception of the MCOs statewide, in my opinion and from what I see every day, the MCOs have increasingly taken more and more steps to deny more services, terminate more provider contracts, and recoup more money from providers. And DHHS has taken less and less steps to supervise, oversee or manage the MCOs. By the MCOs increasingly having a “I can do what I want attitude,” and DHHS increasingly having a “I can’t tell an MCO what to do” attitude, when it comes to the MCOs, the MCOs’ power has grown while DHHS’ ability to manage the MCOs has shrunk. Thus, in the behavioral health care world, the MCOs have morphed into the Goliaths. DHHS is an onlooker, and I am still the flea on David’s shoe.
Thereby creating a counterintuitive situation in which Sec. Wos is David and the MCOs are the Goliath. (Normally DHHS would be Goliath).
I have written approximately 230 blogs. (really???). I would wager a guess that over half of my blog topics have been MCOs denying medically necessary mental health services or MCOs reaping monetary rewards for terminating provider Medicaid contracts or denying services to Medicaid recipients.
The flea on the shoe of David fighting Goliath.
But….perhaps….last week….the flea was noticed.
Last week the Department of Health and Human Services (DHHS) (actually, Secretary Aldona Wos) announced a new mental health, substance abuse effort.
What is that new effort?
Sec. Wos announced, what she called the “Crisis Solutions Initiative.” “DHHS estimated that there were 150,000 visits to emergency rooms in the state last year for addition-related issues or psychiatric conditions.” See The Progressive Pulse blog. Remember my blog, “Prisons and Emergency Rooms: Our New Mental Health Care Providers?”
Sec. Wos, in a written statement, states “With today’s announcement, we begin a focused, long-term effort to ensure that individuals and families who are experiencing a mental health or substance abuse crisis know where to turn for the help they need. In turn, we can begin to reduce the tremendous burden that these issues place on hospital emergency departments and law enforcement.”
OMG…did she read my blog???? (And even more crazy….and agree???????)
Whether it was my blog, true statistics brought to her attention, or an epiphany, it does not matter. Bravo, Sec. Wos, but, please follow through.
The fact of the matter is if Sec. Wos wants to “reduce the burden on hospital ERs and law enforcement” AND truly provide Medicaid recipients with mental health/substance abuse issues, Sec. Wos will have to take on the MCOs head-on. Grab the bull by the horns. Pony-up. Put your big, boy pants on. Just do it! (Nike). Buck up…against the MCOs. The Goliaths will have to be defeated.
Here a little secret: The MCOs have monetary incentive to deny medically necessary mental health services….WHAT???? Shut the front door!!!
Let me explain:
The managed care organizations (MCOs) in NC are managing behavioral health care services for Medicaid recipients. However, the MCOs are pre-paid. What does that matter? It’s all about the money.
For example, a Medicaid recipient suffers schizophrenia with auditory and visual hallucinations. (We will call him Bill). Bill’s psychiatrist, after an assessment, requests assertive community treatment team services (ACTT), which is an extremely high-level mental health service (and very expensive). The MCO denies ACTT services based on “failing to exhaust lesser intensive services” (which is NOT a criterion for entrance criteria, but DHHS is not supervising or managing the MCOs, so who cares whether the MCOs follow DHHS policy). Bill becomes incarcerated. Yes, it is more expensive for tax payers to pay for Bill’s incarceration versus the community based services requested, but it is cheaper for the MCO. The MCO does not pay the prison for Bill’s room and food; tax payers do. The MCO is successful in keeping its money. Similarly, Bill becomes hospitalized. The hospital admits Bill into Butner or Holly Hill. Sure it is more expensive for tax payers to pay for Bill’s stay at Butner or Holly Hill, but it is cheaper for the MCO. The MCO does not pay Butner or Holly Hill; the tax payers do. The MCO is successful in keeping its money.
But, according to the Press Release from DHHS, Sec. Wos wants to stop the MCOs from pushing the mentally ill to prisons and emergency rooms. But in order to stop the MCOs, she will have to stop the Goliaths (MCOs).
Interestingly, everyone always thinks of David as the underdog to Goliath and, therefore, is surprised/excited when David beats Goliath. In reality, according to “David and Goliath: Underdogs, Misfits, and the Art of Battling Giants,” a book by Malcolm Gladwell, David was not the underdog. According to Gladwell, Goliath suffered from acromegaly or, more commonly known as, gigantism, which can cause people to grow to abnormal heights. People who suffer from acromegaly, usually, also suffer other symptoms, such as poor eyesight and mobility. Yes, Goliath looked scary and big, but, in reality, he may have been slow and somewhat blind. Remember his words to David? “Come to me so that I may feed your body to the birds of the air…” “Come to me.” As in, I cannot see you yet. Come closer.
Furthermore, David was a trained “slinger.” As in, the person in battle back then who did not wear armor and who became skilled at slinging rocks at high speeds to kill opponents. Imagine a major league baseball player with a fast ball of 100mph throwing the ball directly at your head. David was a shepherd, and he became a master with the sling to kill the wild life attacking his sheep. Back in biblical times, being large, massive and heavily armored against a master slinger would be like bringing a butter knife to a gun fight. Goliath had no chance. David was smart. Sec. Wos will need to be smart too, maybe even a master slinger.
A portion of the DHHS press release reads, “As a part of this initiative, a Crisis Solutions Coalition will be created to address the inefficiencies that currently exist surrounding crisis services in the state. Secretary Wos has charged Dave Richard, director of the DHHS Division of Mental Health, Developmental Disability and Substance Abuse Services, with leading this coalition. Patient advocates, along with leaders from healthcare, government, and law enforcement communities will be invited to join the coalition to help:
- Recommend and establish community partnerships to strengthen the continuum of care for mental health and substance abuse services.
- Promote education and awareness of alternative community resources to the use of emergency departments.
- Make recommendations related to data sharing to help identify who, when and where people in crisis are served, and what the results of those services are.
- Create a repository of evidence-based practices and provide technical assistance to Local Management Entities/Managed Care Organizations (LME/MCOs), law enforcement and providers on how to respond to crisis scenarios.
- Recommend legislative, policy and funding changes to help break down barriers associated with accessing care.
- Assist with the creation of LME-MCO Local Business Plans to provide a road map for mental health investments in the community.”
Hospitals are ecstatic and they should be! “I want to thank Governor McCrory, Secretary Wos and the Department of Health and Human Services for their commitment to this issue,” said Dr. Bill Roper, CEO of UNC Health Care. “We look forward to partnering with you and the community to solve the mental health problems facing our state.”
The prisons should be ecstatic too.
Herein lies the problem…the MCOs are, most likely, NOT ecstatic. Sec. Wos, by announcing this crisis solution, has placed her hand in the MCOs’ cookie jars.
Goliath will challenge David. “Come to me.”
Can you imagine the backlash by the MCOs if Sec. Wos actually followed through with this crisis solutions? In order to follow through with the crisis solutions, Sec. Wos will have to force the MCOs to authorize medically necessary mental health care services. With more services authorized, there will be a greater need for providers who accept Medicaid; thus reducing the number of terminations of provider’s Medicaid contracts.
Because if Sec. Wos wants, as she stated in the Press Release, to stop the revolving doors at the hospitals for the mentally ill, Sec. Wos has to take on the MCOs. DHHS will have to do its job and supervise/manage the MCOs.
But can David be smart enough? Or will the Goliaths prevail?
“Come to me.”