Category Archives: Carol Steckel
With the recent passing of the torch from Aldona Wos to Rick Brajer (see blog), I’ve been thinking about…
What are the qualifications of a Secretary of DHHS?
What exactly are the qualities that would make a great Secretary of DHHS? Remember, in Mary Poppins, when the children draft their requirements for a nanny? Or, better yet, what are the “Seven Habits of a Highly Effective” Secretary for DHHS? Or…in this case, the “Nine Habits”…
Here are my “Nine Habits of a Highly Effective Secretary of DHHS;” our Secretary of DHHS should have the following:
- A health care background
- A successful track record of his/her ability to manage large companies or agencies
- An understanding of the Medicaid system, and, maybe, even have first-hand knowledge of how the system affects recipients and providers
- A relationship with someone on Medicaid or a parent of someone on Medicaid
- A working knowledge of clinical coverage policies, reimbursement rates, and regulations surrounding Medicaid
- Both the capacity to listen and speak and do both eloquently and genuinely
- True empathy about the physical and mental health of Medicaid recipients and about providers, plus have the patience to handle all types of demographic differences
- An understanding that he/she is handling tax payers’ money, that redundancy in staff is excess administrative costs, and ability to trim the fat
- An ability to communicate with both the Senate and the House and to be frank with both
Let us analyze the qualifications of Wos that we came to witness over the last few years, as well as, review the qualifications of soon-to-be Sec. Brajer with information to which we are privy.
Let’s see if both, either, or neither have these “Nine Habits of a Highly-Effective Secretary for DHHS.”
- Health care background:
Wos: Yes. And, yet, maybe not. She is an M.D. Although I do not know whether she ever practiced medicine in North Carolina. According to Wikipedia, (which is never wrong) Wos “prides herself on her work in the field of preventing HIV and AIDS.” However, I was unable to find a single clinic in which Wos provided services. While, generally, an “M.D.” automatically bestows a certain aura of understanding health care, I question whether this “M.D.” automatically has a working knowledge of billing for and receiving reimbursements under Medicaid in North Carolina.
Brajer: Hmmmm. This one is more tricky. The two companies that Brajer owned, Pro-nerve LLC and LipoScience Inc., are health care related, in that Pro-nerve was an intraoperative neuromonitoring (IONM) company and LipoScience sold a diagnostic tool to health care providers. Arguably, both companies are health care related, at least, in an ancillary way. However, Brajer is not a health care professional, and, to my knowledge, has never rendered health care services. Furthermore, neither of Brajer’s companies was successful; quite the opposite is true, in fact. From my understanding, one company declared bankruptcy and the other was not far behind. Which brings us to the next category…
2. A successful track record of his/her ability to manage large entities:
Wos: Prior to acting as the Secretary to DHHS, Wos served as the Ambassador to Estonia until 2006. What she did besides political functions between 2006 and 2012, I do not know. Acting as an Ambassador does not entail managing large entities. The most managerial skills that I can find in her background, prior to being appointed Secretary, are related to political fund-raising. Since I would not call her brief reign as Secretary of DHHS a success, I give Wos a “two thumbs down” on this criterion.
Brajer: He managed two companies. We can bicker as to whether these companies should be considered large…neither employed 17,000 employees. Regardless, the “successful” criterion appears to be lacking.
3. An understanding of the Medicaid system:
Wos: “You’re asking me without having all the data available to answer a question,” she told lawmakers on October 8, 2013. In her defense, she responded as such when asked whether the State was moving toward privatization for Medicaid. No one could know the answer, except, maybe, McCrory.
On the other hand, the implementation of NCTracks was nothing short of a catastrophe of epic proportion. See blog. See blog. Anyone with nominal knowledge of the Medicaid system would have, at least, paused to consider keeping HP Enterprises under contract during the switch to NCTracks or pushed back the go-live date.
Answer: Here’s to hoping that Brajer does. I’m cheering for you! Go! Fight! Win!
4. A relationship with someone on Medicaid or a parent of someone on Medicaid:
Wos: Unknown. If I were shaking a proverbial “8 Ball,” it would read, “Doubtful.”
Brajer: Unknown. Perhaps one of his former employees at Pro-nerve, LLC and LipoScience, Inc. is on Medicaid.
Answer: Gimme a ‘B’! B! Gimme a ‘R’! R! Gimme a ‘A’! A! Gimme a ‘J’! J! Gimme a ‘E’! E! Gimme a ‘R’! R! Whats that spell? Brajer!!
5. A working knowledge of clinical coverage policies, reimbursement rates, and regulations surrounding Medicaid.
Wos: Unknown. Whatever Wos’ knowledge of regulations and clinical coverage policies is or lacked, she, initially, made up for any knowledge lacked with the key hire and quick resignation of Carol Steckel. Unfortunately, Steckel’s experience was never replaced.
January 2013: “I am pleased to say that we are already taking steps to address some of these issues,” Wos said. “Now, the most important of this is that we have hired Ms. Carol Steckel, a nationally recognized — nationally recognized — expert in Medicaid to run our Medicaid program for the state. Carol is already moving ahead with systemic reviews of operations in this division. She is reviewing and establishing new policies and procedures.”
Answer: B! R! A! J! E! R! Let’s go, Brajer!
6. Both the capacities to listen and speak and do both eloquently.
Wos: Wos brandished an ability to speak publicly with ease. Listening, on the other hand….eh?
Answer: I think you can, I think you can, I think you can…
7. Genuine concern about the physical and mental health of Medicaid recipients AND about providers PLUS have the patience to handle all types of demographic differences
Wos: She seems to think so. Her country club does not discriminate.
Answer: Go! Go! Go! Go! Go, Brajer!!
8. An understanding that he/she is handling tax payers money and that redundancy in staff is excess administrative costs and trim the meat
Wos: “My obligation as secretary is to find the best possible team in order to get the job done.” Les Merritt served as CFO of DMA on a $300,000-plus contract. Joe Hauck was paid over $228,000 for 6 months of advise to Wos. Matt McKillip was paid $87,500 to serve as chief policy maker without any health care background. Ricky Diaz pulled in $85,000 as communications director. Id. Wos has handed out $1.7 million in pay hikes to 280 staffers, many with “no career or educational experience for the jobs they hold.” Id. The implementation of the MCOs also fell under Wos’ watchful eye. The MCO system has created thousands upon thousands of high-paying jobs with our Medicaid dollars. I believe that in the “trim the fat” category, Sec. Wos scores a goose egg.
Answer: Please, Brajer! For the love of Pete!
9. Ability to communicate with both the Senate and the House and to be frank with both.
In April 2013: “I think the word transparency can get pretty dangerous,” Wos said. “Because what does transparency mean? If transparency means that we’re in a planning process and you’re asking us, ‘Tell us all the things you’re planning,’ well, my goodness, allow us to work, and then we’ll give you everything that you want.”
Answer: Brajer, Brajer, He’s our man! If he can’t do it…[gulp].
It concerns me that so many of future Sec. Brajer’s core abilities/habits to run and manage DHHS and the Medicaid program in a highly effective manner are unknown. Nothing like placing all your money on red! But we have HIGH hopes for Brajer!!! Don’t let us down!!
The whole point of this blog is to pause and really contemplate what characteristics would comprise a great Secretary for DHHS. Obviously, the Governor has the full authority to appoint the Secretary, meaning that we taxpayers have little to no input as to whether we deem a person qualified, except in the indirect method of voting or not voting for the Governor.
Call this blog an exercise in examining what habits, if in existence, would make the most highly effective Secretary of DHHS and an opinion as to whether these habits exist in our former and future Secretaries.
We are cheering for Brajer! But…
One fact about the future is that it is unknown.
Here is an interesting article…
Article from Carolina Journal Online by Dan Way:
RALEIGH — With $2 billion in cost overruns the past four years, Medicaid continues to be North Carolina’s most volatile political conundrum, and now unanswered questions about its spending and growth threaten to delay passage of 2014-15 state budget adjustments before next Monday’s deadline.
Things got nasty in a Senate Appropriations Committee meeting last week, and one is left to wonder whether Gov. Pat McCrory and the state Department of Health and Human Services squandered political capital by snubbing budget writers struggling with alarming lapses in vital Medicaid data.
Medicaid “is the linchpin” to writing the 2014-15 budget, said an irritated Sen. Bob Rucho, R-Mecklenburg. “Would someone explain to me why we don’t have [Office of State Budget and Management] or staff people from DHHS here to help us get to an answer so that we can move this budget forward?”
If not a prairie fire, the meeting at least exposed the slow burn of senators handcuffed by a dearth of crucial budget numbers from DHHS. Capital press corps reporters instinctively asked one of their most oft-repeated questions: Is DHHS Secretary Aldona Wos to blame for yet another major Medicaid predicament?
Due to significant backlogs, DHHS cannot provide accurate Medicaid enrollment numbers, valid claims data, and categories into which new enrollees are entered. Without precise, up-to-date information for this fiscal year, drafting an accurate budget for 2014-15 is impossible.
That’s a tough corner to be backed into for McCrory and Wos, who have made Medicaid budget predictability a holy grail.
The exasperation of Sen. Tom Apodaca, R-Henderson, typified the level of lawmaker frustration.
“If push comes to shove,” he said, “we can always issue subpoenas and have the numbers come to us. So let’s not take that off the table.”
The irritability in Senate Appropriations was bipartisan.
“Will we ever know what we need to know?” Sen. Angela Bryant, D-Nash, asked incredulously. “Do we have to be completely at the mercy of executive branch agencies on an issue like this that is so critical to what we do?”
Senate leader Phil Berger, R-Rockingham, explained, in measured but heart-attack serious tones, why there is an elevated sense of urgency, and why he had wanted someone from the budget office at the Appropriations Committee meeting to explain Medicaid numbers that have swung from wildly varying to unaccounted for.
“Our feeling is we need to reach some understanding on the Medicaid number before we can realistically start talking about most of the other things,” including teacher pay raises and pay hikes for state workers, Berger said.
And then there was this jaw-dropping exchange between Sen. Joel Ford, D-Mecklenburg, and Susan Jacobs of the legislative Fiscal Research Division.
“Based upon the uncertainty and the lack of data, how can we say for certain that people are not being overpaid or underpaid?” Ford asked.
“We probably can’t say that,” responded Jacobs. She also dropped a bombshell that it could be “probably late next year” before all necessary numbers are completely and accurately obtained.
“To me that is a very disturbing scenario where we are taking taxpayer money with good intentions, but with no verification that we’re doing the right thing because of a broken system,” Ford said.
Whether he realized it, Ford’s characterization of Medicaid as a broken system oozed irony.
In one of their first official acts upon assuming office in January 2013, McCrory and Health and Human Services Secretary Aldona Wos lambasted the state’s Medicaid program as a chaotic, broken system. Eighteen months later and holding Swiss-cheese Medicaid reports, state senators are grumbling that the agency’s disarray persists.
Pressed by reporters, Berger stopped short of saying he has lost confidence in Wos’ leadership.
“I’ll leave it to others as to why they’re not able to provide that information,” he said, but he insisted this budgeting fiasco shows the need to remove Medicaid from Wos’ control and make it a standalone agency.
The Senate budget calls for $88 million more in Medicaid spending in 2014-15 than the House version. Berger said the Senate used higher, worst-case-scenario numbers.
Berger and his counterparts rightly expressed no appetite for once again using rosy projections only to find out halfway through the budget year that there is a whopping shortfall.
To make matters worse, Senate Majority Leader Harry Brown, R-Onslow, said Fiscal Research staff isn’t even confident the worst-case numbers are sufficiently high. “I think that’s important to make sure everyone understands it.”
Sen. Louis Pate, R-Wayne, co-chairman of the Senate Health and Human Services Appropriations Subcommittee, agreed with frustrated Fiscal Research staff that much of the problem with missing data stems from NC Tracks, the new but deeply flawed Medicaid billing system.
But he was quick to note that Republicans inherited the woefully underperforming computer system that was in development for years under Democratic administrations.
“I don’t know if they made up-to-date adjustments as they went along, and we don’t know if it was tested properly before it went live,” Pate said. Others, including State Auditor Beth Wood, warned last year that the nearly half-billion-dollar system was not ready to launch.
Wos lost control and never regained the upper hand in messaging after she defiantly promised she was going to drag the long-beleaguered NC Tracks over the July 1 finish line, and declared it sound when she did.
The bravado and exuberant can-do proclamations might have seemed politically appropriate for a new administration seeking to position itself as an intrepid change agent.
But Wos would have been wise to have tempered her rookie remarks with caveats about the huge challenges left behind by previous Democratic administrations, downplayed expectations, and more candidly acknowledged what IT skeptics already knew — the system was going to encounter plenty of rollout problems that would require a long time to correct.
Pate was among those declaring that the current Medicaid budgeting calamity further demonstrates the “critical necessity for reorganization” of the agency. But restructuring has been hampered by the unsteadiness of tectonic policy shifts.
Pate is among senators who continue to oppose the latest reform plan favored by McCrory and Wos, and now in bill form in the House. He said the proposal only tinkers around the edges of budget predictability and restraint.
This latest iteration is an accountable care model comprising networks of doctors and hospitals. It was rolled out after the administration’s stunning U-turn from months of championing full-risk managed care, and scoring a coup in recruiting Carol Steckel, a highly sought, nationally renowned expert on Medicaid managed care.
Steckel, former head of the National Association of State Medicaid Directors, left her $210,000-a-year job in North Carolina last September after only eight months working for Wos.
Whether there was a back-story to the swift departure of a highly heralded Medicaid reformer, much like what this year’s Medicaid numbers are, remains a guessing game.
As I am sure most of you have heard, April 10, 2014, Kathleen Sebelius, former Secretary to Health and Human Services (HHS), resigned. Some journalists wrote that her resignation came 6 months after “the disastrous rollout of Obamacare,” obviously alluding that she was fleeing from her position as Secretary. But is that why Sebelius left? And who is Sylvia Mathews Burwell?
It is no secret that when Healthcare.gov went live on October 1, 2013, Sebelius called the roll-out a “debacle.” But recent figures show enrollment in Obamacare exchanges has surpassed 7.5 million.
Sunday Sebelius stated that “Clearly, the estimate that it was ready to go Oct. 1 was just flat-out wrong.”
According to Politico Pro, “a White House official said Sebelius told Obama in March that she planned to resign. She felt that the Affordable Care Act trajectory was back on track, and believed “that once open enrollment ended it would be the right time to transition the Department to new leadership.””
It seems that Sebelius did not want to resign during the height of the debacle. She waited until things smoothed out a bit before walking away.
Obama has chosen Sylvia Mathews Burwell, his budget Director, to replace Sebelius.
Who is Burwell?
Burwell served as deputy White House chief of staff during the Clinton administration. She also served at the Office of Management and Budget (OMB) twice, once as director. She has also worked at the Bill and Melinda Gates Foundation. (Speaking of Bill and Melinda Gates Foundation and people with obscene amounts of money, why don’t people ever set up charities to pay for Medicaid recipients to receive private insurance with the co-pays all covered? If I ever get an obscene amount of money I would set up a Medicaid Foundation. The Emanuel Medicaid Foundation. Look for that in the VERY FAR future, folks.).
Going back to Burwell…she received her bachelor’s degree in government from Harvard University. She also received her bachelor’s degree in philosophy, politics and economics from Oxford University. Seriously? Is that a quadruple major from 2 colleges?
Her grandparents were Greek immigrants, and she grew up in West Virginia.
There isn’t much more information on Burwell. She is relatively young (48) and holds a relatively small resume considering the enormous undertaking she is about to assume.
Obama nominated Burwell one day after Sebelius resigned. There is no indication of whether Burwell was Obama’s first choice. It took him one day to replace Sebelius, which is pretty amazing. Remember, we still haven’t replaced former Medicaid Director, Carol Steckel. Sandy Terrell is still the “Acting Director.” Whew, it has got to be difficult to fill these intimidating positions.
I can only imagine how many people would NOT want to be Secretary of HHS. Talk about a big job! Talk about high stress!
Burwell has not been confirmed yet. Despite Burwell not being a common household name when Obama nominated her, it is without question that Burwell has now stepped into the limelight. If confirmed, Burwell will be one of the most powerful people in health care…and one of the most scrutinized.
Good luck, Burwell!! Make Burwell a household name…for good reasons. And when someone says, “Burwell who?”
Someone else will respond, “That is the Secretary for HHS.”
Dr. Robin Gary Cummings was named the new state Medicaid director today.
Dr. Cummings, a former cardiovascular surgeon, had been serving as the Acting State Health Director. He ceased pursuing surgery in 2004.
Interestingly, if you go the NC American Indian Health Board (found here), according to the website, Dr. Cummings is currently serving as the Medical Director for Community Care of the Sandhills. Obviously, Community Care of the Sandhills (CCS) is one of 14 non-profit organizations participating in the Community Care of NC (CCNC). CCS is covers Medicaid for Harnett, Hoke, Lee, Montgomery, Moore, Richmond, and Scotland counties.
However, when you go to CCS’ website, and click on “staff,” then, using the drop-down box, click on “leadership,” the Medical Director is Dr. William Stewart. So, obviously, Dr. Cummings has served in the past as the Medical Director for CCS.
After a bit more research, it appears that Dr. Cummings left CCS this past July 2013, when Sec. Wos appointed Dr. Cummings as the Acting State Health Director in lieu of Dr. Laura Gerald’s resignation. If you remember, Dr. Gerald’s resignation was unexpected and Sec. Wos gave no reason for Dr. Gerald’s resignation. Sec. Wos announced that Dr. Cummings would be taking Dr. Gerald’s place the very same day that Sec. Wos announced the resignation of Dr. Gerald.
So my question is this:
Why was Dr. Gerald replaced immediately by Dr. Cummings as the Acting State Health Director, while Carol Steckel resigned back in September 2013 and is being replaced by Dr. Cummings 4 1/2 months after Steckel’s resignation?
We haven’t had a State Medicaid Director (officially) for 4 1/2 months. Sandy Terrell stepped up as the temporary Medicaid Director. And we know Sec. Wos and team has been actively searching for new Medicaid Director.
In fact, the February 11, 2014, agenda (today) for the Joint Legislative Oversight Committee on Health and Human Services shows as its 11th topic, “Ideas to Address Staffing Concerns and Update on Medicaid Director Search.” Which tells me that there was little to no forewarning as to the appointment of Dr. Cummings.
It would be one thing if, after 4 1/2 months, Sec. Wos announced that the new State Medicaid Director was ____, someone from outside NC with excellent experience. She didn’t want to announce that _____ was coming to NC prematurely because it was confidential and ____ did not want the public to know prior to a final decision.
He has been working in NC Medicaid since 2004. He has served as the Acting State Health Director. Obviously, he was not hard to find. Obviously, Sec. Wos had contact with Dr. Cummings way back in September 2013. So why not appoint Dr. Cummings as the State Medicaid Director back in September 2013? Why wait 4 1/2 months? And announce his appointment the same day as the February 11, 2014, Joint Legislative Oversight Committee on Health and Human Services meeting? It just seems odd…
Maybe he refused the appointment back in September 2013. Maybe it took Sec. Wos 4 1/2 months to convince him to take the challenge. Because, come on, folks, Dr. Cummings has just elected to place himself in one of the hottest public seats in the state…and I mean scorching! Remember my blog: “Wanted: North Carolina Medical Director: Transparent and Open!”
Regardless the reason for the delay, it is encouraging that we have a new State Medicaid Director. I am sure Dr. Cummings is fully aware of the current disarray of the NC Medicaid system. So, even knowing the turmoil of our current Medicaid system and how daunting his task will be, Dr. Cummings still chose to accept the appointment to the State Medicaid Director position. And, for that, I say “Bravo!” And “Good luck!” And “We really hope you are successful!”
But, gracious, that seat will be hot!
Hey, everybody!! Anyone miss me? I feel like I haven’t blogged in forever. And, the thing is, I am so excited about this blog!! I actually found out about the CMS letter last week, but have had zero time to blog (had a very intense, two-day hearing). So I apologize if you have already seen the CMS letter…but, for others, read on…
I have to say…I love it when I am right!
In North Carolina, we set up managed care organizations (MCOs) to manage behavioral health care for Medicaid. For the past year, I have been blogging that the MCOs’ payment arrangement with the Department of Health and Human Services (DHHS) is fishy. These MCOs are pre-paid. Their profit hinges on spending less. In order to spend less, the MCOs deny medically necessary services (usually the most expensive) and terminate quality health care providers’ Medicaid contracts. I mean, come on, why authorize more services and contract with more providers if doing so would directly decrease your profit?
Apparently, I am not the only person concerned with how the MCOs are compensated.
On October 24, 2013, the Centers for Medicare and Medicaid Services (CMS), which is the federal agency charged with overseeing Medicare and Medicaid (as in, if CMS says jump and you accept federal money for Medicaid, you jump) sent correspondence to our Acting Medicaid Director Sandy Terrell. (Remember Carol Steckel abruptly left our Director position, leaving Terrell holding the conch…I bet that conch is getting mighty heavy!).
CMS’ correspondence states that, during its review of NC’s contracts between DHHS and the LME/MCOs, CMS determined an issue. Specifically, CMS determined that the arrangement between DHHS and the MCOs may be classified as “subgrants or intergovernmental agreements that are subject to the cost principles set forth in the Office of Management and Budget (OMB) Circular A-87 (A-87).”
So what? Who cares if the arrangement between the MCOs and DHHS is classified as a subgrant subject to A-87? Blah…blah….blah….right?
If the MCOs are subject to A-87, then the use of Medicaid funds is limited to “allowable costs.” Why is that important? Allowable costs do NOT include….
PROFIT!!!!! and other increments above cost.
For a rant and rave about the MCOs’ profit, high salaries and expensive health care benefits, see my blog: “NC Taxpayers Demand Accountability as to Behavioral Health Care Medicaid Funds (And That Medicaid Recipients Reap the Benefit of Such Funds).
If you take away the ability for the MCOs to profit off of our taxpayers’ Medicaid money, then you take away the monetary incentive for the MCOs to deny medically necessary services and to terminate provider contracts.
Know what else you take away? The desire to be an MCO.
So what happens now? Just because CMS wrote a letter to NC saying it does not agree with our payment arrangement with the MCOs, does that mean that we have to immediately stop and desist from paying the MCOs? No.
In fact, CMS also states that it “recognize[s] that changing a long-standing delivery system will take time and potentially state legislation. We know the process begins with a frank discussion of these issues…”
CMS did, however, provide a couple of choices for us (if, in fact, A-87 does apply):
1. Openly procuring behavioral health services and making the counties compete on the same basis as with any other commercial entity; or
2. Comply with A-87 by changing the payment methodology and reimburse only for the cost of services actually rendered plus administration costs.
I am actually doing the Snoopy dance as you read this.
Herein lies the problem…How many times in the last 10 years, has NC changed the mental health care system? How many mess-ups? How many Medicaid recipients have not received medically necessary mental health care service because of NC changing the mental health system over and over?
So what happens now?
On a sidenote, I love North Carolina’s response to CMS. Over a month after receipt of the CMS letter, on November 27, 2013, DHHS finally responds with a short, 2 paragraph letter signed by Sandy Terrell. “As you might expect, North Carolina was surprised to receive the letter outlining [CMS’] concerns regarding the cost principles set forth in the Office of Management and Budget (OMB) Circular A-87…”
NC was surprised???
I am reminded of Andrew Lloyd Webber’s “Evita,” when Eva Peron follows her lover to Buenos Aires only to discover he is married with children. She has all her belongings in a suitcase, turns from her ex-lover’s home and sings, “Another Suitcase in Another Hall.”
So what happens now
(Another suitcase in another hall)
So what happens now
(Take your picture off another wall)
Where am I going to
(You’ll get by you always have before)
Where am I going to
Just like Eva Peron, NC had full faith the MCOs, enacted them statewide, and, then, not even a year into the statewide MCO progam…BOOM! The MCOs are married with kids.
So what DOES happen now?
In the short-term, probably nothing. And, there is a chance that nothing happens in the long-term. In NC’s response, Ms. Terrell wrote that “[w]e believe we have information to share with CMS that should alleviate those concerns…”
Most likely, Ms. Terrell will explain to CMS how the wonderful MCOs are completely objective and how they save NC millions in Medicaid money…We will see whether CMS drinks DHHS’ Kool-Aid…
If, on the other hand, CMS demands change, in the long-term, there will be great change.
If we go with Door #1…”Openly procuring behavioral health services and making the counties compete on the same basis as with any other commercial entity,” what will that look like?
I believe CMS is envisioning not allowing the MCOs to monopolize their catchment areas.
Here are the MCOs “jurisdictions” today:
And more mergers are currently being contemplated. But, for now, if you live in Mecklenburg county and need behavioral health care services you must go through MeckLINK. Raleigh? Alliance is your MCO. You have no choice of MCOs and must use a provider within the MCO’s catchment area.
The way I understand CMS’ proposal, if you live in Mecklenburg county, you would not have to receive services from or (if you are a provider) have a contract with MeckLINK. You could, but there would other options as well. Door #1 is what I call, “Busting up the Baby Bells!”
What about Door #2? “Comply with A-87 by changing the payment methodology and reimburse only for the cost of services actually rendered plus administration costs.”
For this option, I believe, that the MCOs could remain where they are, but contract to be paid some, sort of, “cost-plus.” No more…if you do not spend it, it is your profit. Theoretically if the money were not spent, it would be returned to DHHS, or, somehow, kept for additional services. Bye, bye, monetary incentive to deny services and terminate providers!
Door #2 is what I call, “Busting up the Ponzi scheme!”
No matter which door NC chooses, it has to be better than our current situation with the MCOs.
Ok, I stopped doing the Snoopy dance.
Because, in reality, there will be change. We do not know what the changes will be. And, dag on it, change is scary, especially we are talking about changes to mental health services for Medicaid recipients.
As Eva Peron says, “Where [are we] going to?”
Then, if you have seen the motion picture “Evita,” Antonio Banderes sings, “Don’t ask anymore…”
With Carol Steckel’s abrupt resignation September 27, 2013, only 8 months after accepting the job as NC Medicaid Director, we North Carolinians were left without a Medicaid Director. I posted a week or so ago that I can only imagine how difficult it would be to fill the position, considering the absolute mess the Department of Health and Human Services (DHHS) has created recently…the calamity of NCTracks…the negative PR…the high salaries of administration…Who would want to inherit this mess???
While I cannot imagine the person who would actually apply to be our Medicaid Director in the midst of such storms, I do have some advice for whomever attempts to carry the burden of being NC’s Medicaid Director.
I don’t know why Ms. Steckel left. I’ve heard numerous hypotheses. I’ve heard that she didn’t get along with Sect. Wos. I’ve heard that she left because the NC Medicaid system cannot be fixed. I’ve heard the bad media press upset her. I’ve heard she couldn’t handle the scrutiny of the public.
Regardless, anyone who is thinking of applying to be our Medicaid Director needs to understand that this is a public servant job. This is not a private sector job. Why is that important? Because as an officer in the public arena, you are accountable to the taxpayers. You cannot hide behind rhetoric or stop speaking to media. As a public servant, you have duty to be transparent to taxpayers. You will be scrutinized by the public…and this is allowed.
Recently, Secretary Wos responded with this comment when asked about transparency… “I think the word transparency can get pretty dangerous. … If transparency means that we’re in a planning process and you’re asking us, ‘Tell us all the things you’re planning,’ well, my goodness, allow us to work, and then we’ll give you everything that you want.”
While I understand Sect. Wos’ assertion that if all we do is talk then nothing gets done, in the public sector, transparency is, not only desired by taxpayers, but public servants owe a duty to be transparent. Public servants are not spending their own money. It’s my money and your money. We deserve to know how our money is being spent and we deserve to have an opinion as to whether our money is being spent in an economically intelligent fashion.
For example, my blog about the managed care organizations paying the health insurance for its employees and the employees’ families was to point out that our tax dollars are paying for these employees’ families’ health insurance…tax dollars that are meant to provide health insurance to our most needy population.
Similarly, all the media hype about the high salaries of the two 24-year-old staffers, who were given salaries making $85,000 or more, the media are angered because, again, those salaries are paid by us.
Because the money that the Department of Health and Human Services (DHHS) spends is our money, not private funds, transparency is essential.
A few weeks ago, when I flew to New Mexico, I had to go through airport security. I had to take off my shoes (yuck! and walk on the airport floor), place my purse and laptop on the conveyor belt and step into the “All-Seeing Machine.” You know, the machine that you have to place your feet a little apart and raise your hands above your head, while the machine whirls around your body. I always feel slightly mortified every time I have to go through that machine. I even suck in my breathe a little so my belly doesn’t poke out. It is just a strange feeling to have a stranger look that closely at you and scrutinize your body. You never know what the person looking at your image is thinking. Being scrutinized is not fun.
Similarly, as NC Medicaid Director, and a public servant, you will be scrutinized. Every word. Every action…and non-action.
Remember Mary Poppins? Remember the sweet, little song the two children sang about the criteria for their new nanny?
If you want this choice position
Have a cheery disposition
Rosy cheeks, no warts!
Play games, all sort
You must be kind, you must be witty
Very sweet and fairly pretty
Take us on outings, give us treats
Sing songs, bring sweets
Never be cross or cruel
Never give us castor oil or gruel
Love us as a son and daughter
And never smell of barley water…
Well it applies to the Medicaid Director position too. Here is the “Perfect NC Medicaid Director Song:”If you want this choice position Have an open disposition Know Medicaid laws and rules Don’t treat media as fools You must be strong, you must be smart Very tenacious, open heart Take on naysayers, show guts Move our Agency out of ruts Be transparent, don’t circumvent Never say to media, “No comment.” Love our citizens; our state And always, always update…
I found the job posting for our Medicaid Director on the National Association of Medicaid Directors’ (NAMD) website.
Here it is:
DIRECTOR OF MEDICAL ASSISTANCE
The North Carolina Department of Health and Human Services (DHHS), in collaboration with our partners, protects the health and safety of all North Carolinians and provides essential human services.
Within DHHS, the Division of Medical Assistance (DMA) provides access to high quality, medically necessary health care for eligible North Carolina residents through cost-effective purchasing of health care services and products. The Department of Health and Human Services and DMA are devoted to quality customer service.
The Director of Medicaid directs the administration of the state’s Medicaid and NC Health Choice Programs. The Medicaid program serves more that 1.7 million North Carolinians and provides services to children, the elderly, the blind, the disabled and those eligible to receive federally funded assisted income maintenance payments. The North Carolina Health Choice (NCHC) Health Insurance Program for Children is a comprehensive health coverage program for low-income children. The goal of NCHC is to reduce the number of uninsured children in the State. The program focus is on families who make too much income to qualify for Medicaid but not enough to afford private or employer-sponsored health insurance.
DMA has approximately 400 employees and a budget impact of 14 billion dollars which includes 3.8 billion in state appropriations. DMA partners with over 78,000 physician providers throughout the state to provide essential services to recipients. The Director is responsible for multi-million dollar contracts and performs an array of fiscal agent and administrative services which include cost reimbursement and integrated payment management reporting to local management entities (area mental health programs). The position manages the state waiver program and demonstration projects. The Director is the primary interface with the Federal Centers for Medicare and Medicaid Services (CMS) and for the Committee Management Office. (CMO)
KNOWLEDGE, SKILLS AND ABILITIES:
Prior leadership and policy role in large complex organization administering the Medicaid Program or within a Medicaid Reimbursement or Health Insurance Agency
Demonstrated knowledge of the federal and state funding process for Medicaid and Medicare
Proven ability to build consensus among diverse stake holders which includes constituents, providers, advocacy groups, the media, the public and the legislature
Demonstrated ability to provide leadership during a time of change or reorganization
MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS:
A Masters Degree in Business, Public Health, Health Administration, Social or Clinical Science or a related field and six years of broad management experience in Health Administration or in Healthcare financial management of which at least three years must be at the Director or Assistant Director level of a statewide or federal division in Health Administration or Financial Management.
To be considered for this opportunity please submit a detailed resume to firstname.lastname@example.org
To learn more about the North Carolina Department of Health and Human Services, please visit our web site at: www.ncdhhs.gov
All applications will remain confidential.
Equal Opportunity Employer
Nowhere in the advertisement for the NC Medicaid Director does it say what the Medicaid Director ACTUALLY has to do in real life.
Undergo scrutiny. Talk to the public. Maintain transparency. Be a public figure in a time of crisis.
It’s our money. So talk to us.
Whew…more bad press for the McCrory administration, Secretary Aldona Wos, Carol Steckel and the Department of Health and Human Services (DHHS).
Ms. Rose Hoban, a journalist for North Carolina Health News, a website that I, personally, visit often, accuses the McCrory administration of suppressing information about Medicaid that, in her opinion, indicates that Medicaid was not as broken as the January 2013 Performance Audit conducted by Beth Wood, our State Auditor demonstrated. According to Ms. Hoban, the McCrory administration suppressed the Medicaid information in order to push forward the McCrory administration’s intent to privatize Medicaid.
That is quite an accusation with immeasurable consequences if correct? Right?
Did the McCrory administration suppress Medicaid information with the intent to push for privatization? I have no idea.
Ms. Hoban suggests that Ms. Steckel’s revisions to the former administration’s responses to the Beth Wood audit on DHHS indicates the McCrory administration’s intentional suppression for a political reason. I am not so sure that Steckel’s revisions to the former administration’s responses proves prima facie (on its face and without any other evidence) that the McCrory administration was “suppressing insight into Medicaid,” in order to privatize Medicaid… But, who knows????
According to Ms. Hoban’s article, another related article will be published in the future, so maybe she has more evidence to support the accusation. We shall see….
Here is Ms. Hoban’s article:
McCrory Administration Officials Suppressed Insight Into Medicaid
For months, members of the McCrory administration have maintained that the state’s Medicaid program is “broken.” But in the first of a two-part investigation, North Carolina Health News shows McCrory officials sat on information that would have depicted the state’s much-lauded Medicaid program in a better light.
By Rose Hoban
Soon after taking control in Raleigh in early 2013, people hired by Gov. Pat McCrory to run the Department of Health and Human Services made strategic edits to the departmental response to State Auditor Beth Wood’s audit of the North Carolina Medicaid program.
Documents obtained by North Carolina Health News through a public records request show that in January, incoming Sec. Aldona Wos and Medicaid head Carol Steckel eliminated detailed explanations of alleged high administrative costs, management problems and budget overruns in past years.
The resulting document accepts the criticism in Wood’s assessment wholesale and paints the health care program that covers 1.6 million North Carolinians as “broken.”
The criticisms contained in the audit have yielded talking points used by Wos, Steckel and McCrory for the past eight months as justification for turning down a federal expansion of the program under the Affordable Care Act and proposing to privatize the program.
State Auditor Beth Wood describes the results of her audit of the state Medicaid program, while Gov. Pat McCrory listens.
The original response to the audit created in December 2012 by outgoing officials from Gov. Bev Perdue’s administration was revised in successive editions of the document throughout January, with a decisive, near-final edit by Steckel.
In a document that displays “track changes” that include Steckel’s electronic signature, whole paragraphs were deleted, with evidence that, for example, North Carolina’s administrative costs are lower than most states rather than 30 percent higher, as maintained by McCrory administration officials.
Incoming administration officials also deleted whole sections explaining that budget overruns were in large part a function of under-budgeting by the General Assembly.
And in her first week in her new office, Steckel struck through paragraphs explaining that Community Care of North Carolina had been studied by two national groups that found cost savings. Instead, she inserted language casting doubt on the efficacy of CCNC and suggesting further study of the statewide program that’s been lauded nationally and that is being replicated in several states.
‘Administrative costs are 30 percent higher’
During a press conference to present the audit in January, Wood said her analysts had determined that North Carolina was spending significantly more on administrative costs than states with Medicaid programs of comparable size (see table, below).
“The administrative spending for the state’s medicaid program is 38 percent higher than the average of nine states with similarly sized Medicaid programs,” Wood maintained. “While those states on average have administrative costs of 4.5 percent, the state of North Carolina spent over 6 percent of its total budget on administrative cost. In real dollars that means that the state is spending $180 million more than the average of our peer states.”
For her analysis, Wood used information from the Centers for Medicare and Medicaid Services.
In a February appearance before the Joint Legislative Oversight Committee on Health and Human Services, Steckel cast some doubt on those numbers, telling the committee that in many states administrative costs are hidden inside the contracts with managed care companies that run Medicaid programs.
Administrative cost comparison calculated by state auditor staff (screenshot from final audit)
“Actually, the administrative cost functions are in the managed care entities. And if you look at what is termed the ‘medical-loss ratio,’ which is what the managed care companies are allowed to use for administration, if you look at that for Arizona, their administrative costs would actually be 13.74 percent,” Steckel told the committee, explaining that the managed care company, rather than the state, was spending the administrative dollars.
Steckel may have gotten the Arizona figure from an analysis prepared by outgoing DHHS officials in December 2012. In the original departmental response to the state auditor’s report, which called Wood’s comparison “incomplete and misleading,” DHHS officials used actuarial data from national firm Milliman and from an Academy of Health report to calculate actual administrative overhead in the states Wood used in her comparison, including overhead from state expenditures and from managed care companies.
That table shows Arizona’s administrative expenditures at 13.74 percent.
When figures from all the states are tallied up and compared, North Carolina is among the lowest for administrative expenditures (see table and document, below).
Wos wrote in the final departmental response that DHHS agreed with Wood’s findings and recommendations on controlling administrative expenses.
During the press conference to announce the audit, Wos said, “Cost overruns will not be tolerated and will not be acceptable. There’s a budget for a reason, and we must adhere to this budget.”
Administrative cost comparison compiled by DHHS using data from July 2012 study by Milliman & Academy of Health report. Source: Issue Sheet 3, “Admin Costs w Responses,” dated Dec 18, 2012 (screenshot from document shown below).
Since release of the audit, Wos and McCrory have used Medicaid’s supposedly high administrative costs as talking points for problems in Medicaid; most recently, McCrory cited that figure in a September interview with Tom Campbell on NC SPIN.
“We had a more than $500-million overrun based on Gov Perdue’s projections on Medicaid, and our costs are 30 percent higher than other states in Medicaid administration,” McCrory told Campbell, “just basic operational issues.”
“The state overspent its Medicaid budget by $1.4 billion under the previous administration, and this administration thought that was indefensible,” wrote DHHS spokesman Ricky Diaz in response to a request for comment on this story.
Another talking point used by Wos and McCrory is the Medicaid budget overruns that have plagued the program over the past three fiscal years. Both have been quoted numerous times stating that Medicaid has been over budget by a total of $1.4 billion during that time period.
In the audit, Wood tallies the state budget overrun for the three years at $375 million, which includes federal matching funds to reach the $1.4 billion total. And Wood states that administrative overruns were the result of an “apparent lack of oversight.”
Initially, DHHS officials strongly disagreed with this assessment, writing that any exceeded budget amounts were due to “other factors such as consumption and price, not lack of oversight.… Since Medicaid is an entitlement program, the Division has little control over consumption.”
But this defense was edited out by Steckel, as evidenced in the tracked-changes version of the audit response dated Jan. 22, 2013. Steckel noted that telling Wood Medicaid is an entitlement would be “speaking out of school to the auditor.”
Steckel also deleted most of the language that provided any defense or explanation of departmental actions. In her edits, Steckel added that the department would be implementing a system where “we track contract requirements and expenditures on a weekly basis,” something DHHS officials had been doing since the previous summer, as noted in earlier versions of the document prepared by outgoing Perdue officials.
Perdue’s team had also included explanations of how the Office of State Budget and Management had been consulted on – and approved of – any overruns, explaining: “The Department cannot unilaterally expend funds beyond budgeted amounts.”
Later in the document, former officials argued that the department had repeatedly provided legislators, OSBM and the legislative Fiscal Research Division “with information regarding the inability to achieve savings included in the budget for [fiscal year] 2012-2013 as early as April, 2011.”
That was around the time former DHHS Sec. Lanier Cansler began sending letters to legislative leaders and to OSBM warning that budget targets were too low, essentially forcing DHHS to overspend its budget. Cansler sent letters in May and June, and again on Oct 27, 2011, when he wrote that “aggressive budget cuts mandated by the General Assembly’s budget are unreasonable and unattainable.”
In a letter to Speaker of the House Thom Tillis and Senate President Pro Tempore Phil Berger dated June 2, 2011, then-governor Perdue wrote that she believed the amounts budgeted for Medicaid were too low.
Perdue pointed out that since 2008, the state had grown by 400,000 people and the state was still struggling to emerge from the economic downturn that meant many workers lost insurance, with some of those workers and many of their children swelling Medicaid’s rolls.
“[Y]our budget relies on over $750 million in reductions to Medicaid over the course of the biennium,” Perdue wrote. “When the loss of Medicaid matching funds are accounted for, your cut is actually $2 billion in real money taken out of the North Carolina economy….
“It is anticipated that over $200 million of these reductions will not be achievable due to technical mistakes and overestimating of savings.”
But any references to departmental attempts to warn others outside DHHS of issues were edited out by Steckel. She also removed references to the fact that federal rules prohibit states from changing their Medicaid programs unilaterally; any rule changes require federal approval, which can take months, and those delays mean a state ends up spending at a higher rate than desired in the meantime.
Later, in sections of the audit that fault the Division of Medical Assistance for poor forecasting of expenditures, Steckel edited out the following: “The Department disagrees that actions were not taken to reduce expenditures to stay within budget. Despite the actions taken by the Department, estimates were exceeded largely due to factors outside the Department’s control. Medicaid is an entitlement program and changes require approval outside of the Division and the Department.”
Again, these explanations of budgeting procedure and warnings by DHHS to other branches of government were edited out by Steckel, adding to an overall impression of a rogue department that was spending out of control.
“North Carolina Medicaid is not broken,” argued John Oberlander, professor of social medicine at the UNC School of Medicine. “This is a contrived crisis.”
“They had a solution and they were looking for a problem. And they were looking to portray Medicaid in as negative a light as possible in order to justify what they wanted to do, which is privatize.”
But DHHS spokesman Diaz said administration officials “stand by our final responses to the audit.”
“We continue to update and improve the Department’s forecasting practices as we reform our state’s broken Medicaid system,” he said.
Part 2 (tomorrow) – Casting doubt on a national model
Steckel track changes edit, Jan 22, 2013
With Carol Steckel’s surprise resignation only 8 months after accepting the job as North Carolina Medicaid Director, Sec. Aldona Wos (appointed by Gov. McCrory) underwent the important, yet, probably, difficult job of appointing a new Medicaid Director to stand-in starting October 11, when Ms. Steckel effectively resigns.
Well, folks, I tell you what…I bet that finding a person willing to stand in as Medicaid Director was a daunting task. With the amount of negative publicity recently published against the Department of Health and Human Services (DHHS), I can only imagine that the first few people Sec. Wos approached answered with a resounding….NO!…Or when Hades freezes over!! (BTW: I was not asked).
Enter stage left: Sandy Terrell, MS, RN, Assistant Director.
On September 9, 2013, Ms. Terrell presented a slide show at the North Carolina Institute of Medicines annual conference. According to one of Terrell’s slides, she wrote that there would be “changes within the Division of Medical Assistance.” Boy, was she right!! Did she know about Steckel????!!!!
We (the public) found out about Steckel’s resignation September 23, 2013. Terrell was appointed Friday, September 27, 2013. So it is unlikely that Terrell knew about Steckel’s future resignation.
Let’s compare: Steckel v. Terrell
- Coordinated the Louisiana’s response to the federal Patient Protection and Affordable Care Act of 2010 (PPACA) legislation.
- Led initiatives to improve the Louisiana’s public health care services while reducing costs, and to revamp its information technology capabilities, taking extensive advantage of the private and academic sectors.
- Led Alabama Medicaid from 1988-1992 and from 2003-2010.
- Served as president of the National Medicaid Directors’ Association and worked to create the independent organization serving the needs of Medicaid programs.
- Provided instrumental support to the Republican Governors Association in developing a report titled “A New Medicaid: A Flexible, Innovative and Accountable Future.”
- Quit NC Medicaid in 8 months
- Is a licensed RN
- Worked in Medicaid since 2010 (3-years experience)
- Has not quit NC Medicaid in 3 years
Hmmmm. Well, who know? Personally, I had high hopes for Steckel in NC Medicaid. I found her qualified, intelligent and, seemingly, compassionate about Medicaid. Yet, 8 months into her job, she leaves.
I do not find Terrell qualified; I have no idea whether she is intelligent (most likely she is, given her career success) or compassionate about Medicaid.
But, crystal ball holder, I am not. Maybe Terrell is what NC Medicaid needs. Maybe not.
It seems, as of now, that Terrell will only be the stand-in during the interim between Steckel departing and Wos finding a permanent Medicaid Director. Given the current DHHS situation and public negativity, I can only wonder who would be so bold as to accept the position as NC Medicaid Director. Undoubtedly, Wos is hearing a lot of “NO’s” and “When Hades freezes over!”
Without question, Director Steckel’s position will be a hard position to fill permanently.