Category Archives: Joint Legislative Oversight Committee on Health and Human Services
Medicaid Reform: As Addictive as Fortnite
Do you have a kid addicted to Fortnite? The numbers are rising…
For those of you who have been living under a rock for the past year, this is how Fortnite is explained on the internet:
“In short, it’s a mass online brawl where 100 players leap out of a plane on to a small island and then fight each other until only one is left. Hidden around the island are weapons and items, including rifles, traps and grenade launchers, and players must arm themselves while exploring the landscape and buildings. It’s also possible to collect resources that allow you to build structures where you can hide or defend yourself. As the match progresses, the playable area of land is continually reduced, so participants are forced closer and closer together. The last survivor is the winner.”
More than 40 million people play Fortnite. According to the May 2018 Medicaid Enrollment Report, 73,633,050 Americans are enrolled in Medicaid or CHIP, so government-assisted health insurance definitely trumps Fortnite on participation.
Recently, the General Assembly passed and the Governor signed two Bills into law pertaining to Medicaid reform: (1) HB 403 (Session Law 2018-48); and (2) HB 156 (Session Law 2018-49). Notice that the Session Laws are one digit separate from each other. That is because Governor Cooper signed these two bills consecutively and on the same day. But did he read them? I do not know the answer, but I do know this: Medicaid reform in NC has become a Fortnite. The MCOs, provider-led entities, ACOs, auditors, DHHS…everyone is vying for a piece of the very large Medicaid budget, approximately $3.6 billion – or 16% of NC’s total budget. It is literally a firehose of money if you can manage to be a player in the Medicaid Fortnite – a fight to eliminate everyone but you. Unlike Fortnite, the pay-off for winning Medicaid Fortnite is financially lucrative. But it is a fight with few winners.
Session Law 2018-48 is entitled, “An Act to Modify the Medicaid Transformation Legislation.”
Session Law 2018-49 is entitled, “An Act to Require Medicaid Prepaid Health Plans to Obtain a License from the Department of Insurance and to Make Other Changes Pertaining to Medicaid Transformation and the Department of Insurance.”
Don’t you like how the House decided to use the term “transformation” instead of “reform?” The term “reform” had been over-utilized.
Recently, the North Carolina Medical Society announced that it is throwing its metaphoric hat in the ring to become “Carolina Complete Health,” a provider-led patient-care center.
The New Laws
Session Law 2018-48
Session Law 2018-48 defines provider-led entity (PLE) as an entity that meets the following criteria: (1) A majority of the entity’s ownership is held by an individual or entity that has its primary business purpose the operation of a capitated contract for Medicaid; (2) A majority of the entity’s governing body is composed of licensed physicians, physician assistants, nurse practitioners, or psychologist and have experience treating Medicaid beneficiaries; (3) Holds a PHP license issued by the Department of Insurance (see Session Law 2018-49).
Services covered by PHP’s will include physical health services, prescription drugs, long-term services and supports, and behavioral health care services for North Carolina Health Choice recipients. The PHP’s will not cover services currently covered by the managed care organizations (MCOs).
Session Law 2018-48 allows for 4 contracts with PHPs to provide services for Medicaid and NC Health Choice (statewide contracts). Plus, it allows up to 12 regional contracts.
What is the future of behavioral health and the MCO system?
For now, they will still exist. The double negative wording of the new Session Law makes it seem like the MCOs will have less authority, but the MCOs will continue to cover for services described in subdivisions a, d, e, f, g, j, k, and l of this subdivision.
Session Law 2018-48 also creates new entities called BH IDD Tailored Plans. Session Law 2018-48 carves out developmentally disabled services (or IDD). It mandates that DHHS create a detailed plan for implementation of a new IDD program under the 1115 Waiver. Services provided by the new Tailored Plans shall pay for and manage services currently offered under the 1915(b)(c) Waiver.
Here’s the catch for providers: “Entities operating BH IDD Tailored Plans shall maintain closed provider networks for behavioral health, intellectual and developmental disability, and traumatic brain injury services and shall ensure network adequacy.” (emphasis added). Fortnite continues with providers jockeying to be included in the networks.
For the next four years only an MCO may operate a BH IDD Tailored Plan. This tells me that the MCOs have sufficiently lawyered up with lobbyists. After the term of the initial contracts, the Tailored Plans will be the result of RFPs issued by DHHS and the submission of competitive bids from nonprofit PHPs.
DHHS was to report to the Joint Legislative Oversight Committee with a plan for the implementation of the Tailored Plans by June 22, 2018. – Sure would’ve loved to be a fly on that wall.
Starting August 31, 2018, DHHS is authorized to take any actions necessary to implement the BH IDD Tailored Plans in accordance with all the requirements in this Act.
Session Law 2018-49
A provider-led entity must meet all the following criteria: (1) A majority of the entity’s ownership is held by an individual or entity that has as its primary business purpose operating a capitated contract with with Medicaid providers; and (2) A majority of the governing body is composed of individuals who are licensed as physicians, physician assistants, nurse practitioners, or psychologists and all of whom have experienced treating Medicaid beneficiaries.
Session Law 2018-49 requires that all PHPs apply for a license with the Commissioner of Insurance. With the application, all entities would need to provide proof of financial stability and other corporate documents. This new law definitely increases the authority of the Commissioner of Insurance (Mike Causey).
The remaining portion of the law pertains to protection against insolvency, continuation of healthcare services in case of insolvency, suspension or revocation of licenses, administrative procedures, penalties and enforcement, confidentiality of information, and that sort.
Session Law 2018-49 also applies to the current opioid crisis. It allows a “lock-in programs” for those consumers who use multiple pharmacies and multiple doctors to “lock them in” to one pharmacy and one doctor.
Besides the “lock-in” program, Session Law 2018-49 is basically a law that brings the Department of Insurance into the Medicaid arena.
Let Fortnite begin!
CEO of Cardinal Gets a Raise – With Our Tax Dollars!
You could hear the outrage in the voices of some of the NC legislators (finally, for the love of God – our General Assembly has taken the blinders off their eyes regarding the MCOs) at the Joint Legislative Oversight Committee on Medicaid and NC Health Choice on Tuesday, December 6, 2016, when Cardinal Innovations‘, a NC managed care organization (MCO) that manages our Medicaid behavioral health care in its catchment area, CEO, Richard Topping, stated that his salary was raised this year from $400,000 to $635,000 – with our tax dollars. (Whoa – totally understand if you have to read that sentence multiple times; it was extraordinarily complex).
Senator Tommy Tucker (R-Waxhaw) was especially incensed. He said, “I received minutes from your board, Sept. 16 of 2016, they made that motion, that your 2017 comp package, they raised your salary from $400,000 to $635,000, they gave you a 0 to 30 percent bonus potential which could be roughly another $250,000 and also you have some sort of annuity or long-term package of $412,000,” said Sen. Tommy Tucker.
FINALLY!!! Not the first time that I have blogged about the mismanagement (my word) of our tax dollars. See blog. And blog.
Sen. Tucker was not alone.
Representative Dollar was also concerned. But even more surprising than our legislators stepping up to the plate and holding an MCO accountable (MCOs have expensive lobbyists – with our tax dollars), the State’s Department of Health and Human Services (DHHS) Secretary Rick Brajer was visibly infuriated. He spoke sharply and interrogated Topping as to his acute income increase, as well as the benefits attached.
As a health care blogger, I receive so many emails from blog readers, including parents of disabled children, who are not receiving the medically necessary Medicaid behavioral health care services for their developmentally disabled children. MCOs are denying medically necessary services. MCOs are terminating qualified health care providers. MCOs are putting access to care at issue. BTW – even if the MCOs only terminated 1 provider and stopped 1 Medicaid recipient from receiving behavioral health care services from their provider of choice, that MCO would be in violation of federal law access to care regulations. But, MCOs are terminating multiple – maybe hundreds – of health care providers. MCOs are nickeling and diming health care providers. Yet, CEO Topping will reap $635,000+ as a salary.
The MCOs, including Cardinal, do not have assets except for our tax dollars. They are not incorporated. They are not private entities. They are extensions of our “single state agency” DHHS. The MCOs step into the shoes of DHHS. The MCOs are state agencies. The MCOs are paid with our tax dollars. Our tax dollars should be used (and are budgeted) to provide Medicaid behavioral health care services for our most needy and to be paid to those health care providers, who still accept Medicaid and provide services to our most vulnerable population. News alert – These providers who render behavioral health care services to Medicaid recipients do not make $635,000/year, or anywhere even close. The reimbursement rates for Medicaid is paltry, at best. Toppings should be embarrassed for even accepting a $635,000 salary. The money, instead, should go to increasing the reimbursements rates – or maintaining a provider network without terminating providers ad nauseum. Or providing medically necessary services to Medicaid recipients.
Rest assured, Cardinal is not the only MCO lining the pockets of its executives. While both Trillium and Alliance, other MCOs, pay their CEOs under $200,000 (still nothing to sneeze at). Alliance, however, throws its tax dollars at private, legal counsel. No in-house counsel for Alliance! Oh, no! Alliance hires expensive, private counsel to defend its actions. Another way our tax dollars are at work. And – my question – why in the world does Alliance, or any other MCO, need to hire legal counsel? Our State has perfectly competent attorneys at our Attorney General’s office, who are on salary to defend the state, and its agencies, for any issue. The MCOs stand in the shoes of the State when it comes to Medicaid for behavioral health. The MCOs should utilize the attorneys the State already employs – not a high-dollar, private law firm. These are our tax dollars!
There have been few times that I have praised DHHS in my blogs. I will readily admit that I am harsh on DHHS’ actions/nonactions with our tax dollars. And I am now not recanting any of my prior opinions. But, last Tuesday, Sec. Brajer held Toppings feet to the fire. Thank you, Brajer, for realizing the horror of an MCO CEO earning $635,000/year while our most needy population goes under-served, and, sometimes not served at all, with medically necessary behavioral health care services.
What is deeply concerning is that if Sec. Brajer is this troubled by actions by the MCOs, or, at least, Cardinal, why can he not DO SOMETHING?? Where is the supervision of the MCOs by DHHS? I’ve read the contracts between the MCOs and DHHS. DHHS is the supervising entity over the MCOs. Our Waiver to the federal government promises that DHHS will supervise the MCOs.
If the Secretary of DHHS cannot control the MCOs, who can?
North Carolina Medicaid Reform Update – Round and Round She Goes
Given how long the Medicaid reform discussions have been going on at the legislature, you may be glazed over by now. Give me the memo when they pass something, right? Fair enough, let’s keep it brief. Where do things stand right now?
Last Wednesday, the Senate staked out its position in the ongoing debate between the House and the McCrory administration.
The Senate’s newest proposal is an unusual mix of different systems and new ideas. Not willing to commit to one model for the whole Medicaid program, the latest version of the bill includes something new called Provider Led Entities, or “PLEs.” PLEs are yet the latest in the alphabet soup of different alternatives to straight fee-for-service billing for Medicare/Medicaid. You’ve all heard of HMOs, PPOs, MCOs, and ACOs. PLEs appear to be similar to ACOs, but perhaps for political reasons the Senate bill sponsors saw the need to call the idea something different. See Knicole Emanuel’s blog.
In any event, as the name suggests, such organizations would be provider-led and would be operated through a capitated system for managing the costs of the Medicaid program. The Senate bill would result in up to twelve PLEs being awarded contracts on a regional basis.
PLEs are not the only addition to the Medicaid alphabet soup that the Senate is proposing in its version of HB 372. The Senate has also renewed its interest in taking Medicaid out of the hands of the N.C. Department of Health and Human Services entirely and creating a new state agency, the Department of Medicaid (“DOM”).
(One wonders whether the continual interest in creating a new Department of Medicaid independent of the N.C. Department of Health and Human Services had anything to do with embattled DHHS Secretary Wos stepping down recently.)
The Senate also proposes creating a Joint Legislative Oversight Committee on Medicaid (“LOC on Medicaid”).
But creating the DOM and using new PLEs to handle the provision of Medicaid services is not the whole story. Perhaps unwilling to jump entirely into a new delivery system managed by a wholly new state agency, the Senate bill would keep LME/MCOs for mental health services in place for at least another five years. Private contractor MCOs would also operate alongside the PLEs. The North Carolina Medicaid Choice coalition, a group which represents commercial MCOs in connection with the Medicaid reform process, is pleased.
One very interesting item that the Senate has included in its proposed legislation is the following requirement: “Small providers shall have an equal opportunity to participate in the provider networks established by commercial insurers and PLEs, and commercial insurers and PLEs shall apply economic and quality standards equally regardless of provider size or ownership.” You can thank Senator Joel Ford of Mecklenburg County for having sponsored this amendment to the Senate version of House Bill 372.
By pulling the Medicaid reform proposal out of the budget bill, the matter appears headed for further negotiation between the House and the Senate to see if the two can agree this year, unlike last year.
By legislative standards, that counts as forward progress… Here come the legislative discussion committees to hash it out more between the two chambers. We will keep a close eye on the proposals as they continue to evolve.
By Robert Shaw
Williams Mullen Hosts “The State of the State of Health Care” Panel Discussion
Williams Mullen is hosting a free panel discussion on “The State of the State of Health Care.” Please see below!
The panelists will be Rep. Nelson Dollar, Steven Keene, General Counsel to the NC Medical Society, Barbara Burke, from BCBS, and me. The panel discussion will begin at 4:00. Then from 5:00-6:30 we will have free drinks and appetizers.
Please feel free to come and bring others. But we do request that you register here by October 10th in order for us to have a correct head count.
DHHS reviews options for Medicaid expansion
From the News & Observer:
RALEIGH, N.C. — North Carolina’s health secretary said Wednesday her agency is collecting information for Gov. Pat McCrory to offer him possible ways to expand Medicaid coverage to more people under the federal health care overhaul.
The Republican-led General Assembly and McCrory declined to accept expansion last year because they said the state Medicaid office consistently faced shortfalls in the hundreds of millions of dollars. A state audit and other troubled operations led McCrory to call the $13 billion program “broken.”
But Health and Human Services Secretary Dr. Aldona Wos told a legislative committee the agency’s financial and structural improvements make offering credible options doable.
“We are at a point …. where we have an ability to evaluate options for the state and will be presenting those options to the governor,” Wos told the Joint Legislative Program Evaluation Oversight Committee. Last week, Wos trumpeted to another General Assembly panel how the Division of Medical Assistance held a $64 million cash balance at the end of the last fiscal year.
Wos stressed it would be up to others to decide on expansion, most of which would be paid by the federal government for the near future. Expansion is designed for hundreds of thousands of uninsured North Carolina residents who make too much for traditional Medicaid but not enough for subsidized insurance exchange plans. Medicaid currently enrolls more than 1.8 million state residents — mostly poor children, older adults and the disabled.
Wos gave no timetable for offering McCrory those options but said it would be more than just determining whether it would make financial sense. For example, she said, there needs to be enough health care providers to oversee any wave of new enrollees.
McCrory said in July he would be willing to revisit Medicaid expansion if cost overruns were repaired and provided the federal government in part gave the state flexibility to target any coverage increase based on North Carolina’s needs.
Earlier Wednesday, DHHS also announced plans for a retooled organizational structure for the division, the first of its kind in 36 years. It shifts from two division sections to what the agency calls five clearly defined functions. An outside consultant has been helping with organizational, finance and budget forecasting within Medicaid.
Again Wednesday, Wos rejected arguments from the legislature, particularly the Senate, to remove Medicaid from DHHS, saying it would undo recent progress.
Our Medicaid Budget Does More Than Allocate Money; It Places the Burden of Proof on Medicaid Providers!!!
Are you a health care provider in NC? Are you wonderful enough to help Medicaid patients but accept low Medicaid reimbursements? Are you dedicated to helping our most needy? Well, guess what???? YOU now have the burden of proof if you disagree with an adverse determination by the State.
That’s right. The newly-enacted state budget quietly changes the statutes and shifts the burden of proof from the Department to YOU. I am reminded of my Grandpa Carson. Whenever he couldn’t believe what he just heard, he would bellow, “Wooooo weee.” Growing up in the south, we have certain sayings, such as “Bless your heart,” “Y’all come back now, ya hear?” and “That food is so good I could slap my momma.” My Grandpa Carson, God rest his soul, was as southern as southern can get. If he were here and heard about the burden shift onto the providers, he would say, “Wooo weeeee.”
Last week while I was on my first week-long vacation in 2 years, the North Carolina state budget, known as Session Law 2014-100, was signed into law by Governor McCrory. (Which is why I missed a week of blogging…my vacation, not McCrory’s signature). Since I was at my family reunion started by my Grandpa, I am dedicating this blog to my grandpa, Nat Carson, who created a family tradition that has lasted for over 40 years. Our (huge) extended family vacation together once a year at Emerald Isle for a family reunion. FOUR generations attend!
Going back to the budget…
An “adverse determination” in this case includes decisions by North Carolina’s Department of Health and Human Services (DHHS) under the Medicaid program such as the Department’s termination of a contract with the provider, a Managed Care Organization’s (MCO) termination of a provider contract, or the Department or one its many vendors determines that the providers owes an overpayment back to the state.
Not only does the state budget shift the burden of proof onto providers when they contest an adverse determination by the State, which we will discuss more below, but it also takes a lot of DHHS decision-making power away. It is apparent that the General Assembly does NOT think DHHS can do its job of managing Medicaid and creating Medicaid reform competently. The General Assembly (GA) has decided that, for whatever reason, it will be more hands-on regarding Medicaid decisions in the future.
Here are a few examples of the GA’s hands-on attitude found in the Session Law 2014-100 (with some emphasis I have made by putting some words in bold-faced type)
- “Until the General Assembly enacts legislation authorizing a plan to reform Medicaid, the Department of Health and Human Services (i) shall continue to consult with stakeholder groups, study, and recommend options for Medicaid reform that will provide greater budget predictability for the Medicaid program and (ii) shall not commit the State to any particular course on Medicaid reform and shall not submit any reform-related State plan amendments, waivers, or grant applications nor enter into any contracts related to implementing Medicaid reform.”
- “The Department may submit drafts of the waiver to the Centers for Medicare and Medicaid Services (CMS) to solicit feedback but shall not submit the waiver for CMS approval until authorized by the General Assembly.”
- “The Department of Health and Human Services shall make payments to the contractor hired by the Joint Legislative Oversight Committee on Health and Human Services from funds appropriated elsewhere in this budget for this contract…”
- “The Department of Health and Human Services shall not make any other modifications to the portion of the Medicaid State Plan referenced in this section, except as provided herein.”
- “The Department may submit drafts of the waivers to the Centers for Medicare and Medicaid Services (CMS) to solicit feedback but shall not submit the waivers for CMS approval until authorized by the General Assembly.”
- “[T]he Division of Medical Assistance shall ensure that any Medicaid-related or NC Health Choice-related State contract entered into after the effective date of this section contains a clause that allows the Department or the Division to terminate the contract without cause upon 30 days’ notice.”
- “No fewer than 10 days prior to submitting an amendment to the State Plan to the federal government, the Department shall post the amendment on its Web site and notify the members of the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division that the amendment has been posted.”
Basically, the GA has estopped DHHS from reforming Medicaid without the consent of the General Assembly.
Then, stuck in the middle of the state budget is the amendment to N.C. Gen. Stat. 108C…. “Woooo weeee!”
MODIFY MEDICAID APPEALS SECTION 12H.27.
(a) G.S. 108C-12(d) reads as rewritten: “(d) Burden of Proof. – The
Department petitioner shall have the burden of proof in appeals of Medicaid providers or applicants concerning an adverse determination.”
Does anyone else understand what this teeny, tiny clause within Session Law 2014-100 means????
What is the importance of burden of proof? Enormous! And this clause changes the playing field for Medicaid providers. It may not have been a level field prior to Session Law 2014-100, but now it’s even more slanted.
The easiest way to explain “burden of proof” is that when a petitioning Medicaid provider challenges some adverse determination by DHHS, for example, the Department’s termination of a contract with the provider, the “burden of proof” decides which party must persuade the reviewing tribunal that the party’s assertions are correct. Up until this amendment of G.S.108C-12(d), the Department has had the burden to present evidence showing that its adverse determination was correct. The petitioner could then respond to that evidence, to try to show the contrary, but the burden of proving the correctness of the adverse determination still rested on the Department in cases filed by Medicaid providers under Chapter 108C.
In court, one of the first questions a judge will ask is, “Who carries the burden of proof?” Because the legal burden of proof is just that…a burden…that must be satisfactorily carried in order to win.
Health care providers who accept Medicaid have notoriously been given the short-end of the stick, i.e., low reimbursement rates, undergoing burdensome audits, but, at least, in NC, historically, the Department has had to prove the correctness of its allegations, whether it be an alleged overpayment, a termination of a Medicaid contract, or other allegations.
But now? DHHS’ allegations against a health care provider are true…unless the provider can prove DHHS wrong. The uphill fight of a provider seeking to correct a DHHS adverse determination, just became much steeper, and it was done with little or no fanfare.
So can you do? Only options as far as I see it:
- Call and email your state representatives.
- Hire a lobbyist.
- Bring a lawsuit to change it.
- Do nothing.
Per L. Warren’s comment, I am adding #5.
5. Stop taking Medicaid clients.
Our Medicaid Budget: Are We Just Putting Lipstick on an 800 lbs. Pig?
Too often, I have heard an analogy about the Medicaid budget and a pig wearing lipstick. Normally it goes like this: “Are we just putting lipstick on an 800 lb. pig?”…and the Medicaid budget is the 800 lbs. pig, not the lipstick.
For those of you who do not know, I own a pet pig. She is a micro pig. Not a pot belly pig; those get to be 150 lbs. Oh, no. A micro pig; those stay very small. Our Oink is only 21 pounds.
Here is a picture:
Notice she does not have lipstick on. So when someone says, “Are we just putting lipstick on an 800 lbs. pig?” I think, “Is that so bad?”
I understand that saying to put “lipstick on a pig” is a rhetorical expression. An expression used to demonstrate that making a superficial or cosmetic change is a futile attempt to disguise the true nature of a product. However, Oink and I take offense, because she is so much more beautiful than the Medicaid budget (and much smaller).
Although my Oinky-Oink is only 21 pounds. The expression that I have heard most often involves an 800 lbs. pig. If our Medicaid budget were Oink’s size, the General Assembly would probably be home.
Seriously, here is my question on my “Pigs and Medicaid” blog:
How can we expect the General Assembly to create a “knowable” and “concrete” Medicaid budget when the Department of Health and Human Services (DHHS) cannot provide the General Assembly with accurate data?
Literally, DHHS cannot tell the General Assembly how many people are enrolled in Medicaid. Legislatures are being told to guesstimate. Guesstimate???
Between 2009-2012, North Carolina exceeded its approved Medicaid budget by 5.4 billion. In the last decade, our Medicaid spending has increased by more than 90%.
Not to mention DHHS has difficulty filling and retaining employees. Attrition is prominent. As of June 1, 2014, a quarter of the division’s 332 jobs were vacant; the average unfilled job had been open for 347 days, or nearly a year. In November, DHHS’ chief financial officer sent out a cry for help. The Medicaid office “does not have adequate staff with the necessary experience and skills to properly manage the … program,” Rod Davis wrote to the state budget office.
To compensate for too few employees, DHHS gave a no-bid contract to Alvarez & Marsal to help create a Medicaid budget. We all know how that turned out.
With the help of Alvarez & Marsal, DHHS proposed to tax the then-10 managed-care organizations (MCOs) that manage Medicaid services for mental health, developmentally disabled, and substance abuse. But we needed approval by the feds.
It was DHHS’ hope that the extra funds would be the catalyst for a federal match twice that size. Once we got the federal match, DHHS would refund the taxed dollars to the MCOs and use the federal money to pay for programs. Maybe I’m wrong, but the idea sounds like a “bait and switch.” Analogously, I have a client pay me $50,000 on January 31, 2015, the end of our fiscal year, only to refund it February 1, 2015. I would get credit for collecting the $50,000 in fiscal year 2014, but it was not a real collection. It was fake.
And the feds knew it. The answer was, “No.”
Sen. Bob Rucho, R-Mecklenburg, said the information presented Wednesday should have been made available months ago, and he noted that it’s still not detailed enough for a forecast.
“When will we get the numbers that we need to have so that we can have a good budget number?” asked Rucho. And his question is not an anomaly. He is not alone.
“I’ve asked them every time I’ve had the opportunity, and I’m astounded that a $13 billion organization does not have budget numbers,” said Sen. Tommy Tucker (R-Waxhaw), one of the more outspoken members of the Joint Legislative Oversight Committee on Health and Human Services.
Medicaid Chief Financial Officer Rod Davis told Senator Ralph Hise that his department has an idea of how much they’ve paid to providers, but that they can’t forecast what’s to come.
“Would it be like saying we know what checks we wrote, we just don’t know what we’ve paid for,” Hise asked.
Going back to my question:
How can we expect the General Assembly to create a “knowable” and “concrete” Medicaid budget when the Department of Health and Human Services (DHHS) cannot provide the General Assembly with accurate data?
Are we putting too much pressure on the General Assembly and not on DHHS?
The General Assembly is responsible for creating a Medicaid budget. But how can we hold the General Assembly to create an accurate Medicaid budget if the “single state agency,” DHHS, charged with managing Medicaid cannot provide the General Assembly with accurate data???
Here is my political soapbox: We have a Republican General Assembly and we have a Republican governor. Shouldn’t the General Assembly and the governor be on the same side???? Perhaps it’s more than politics. Perhaps it’s more than a donkey and an elephant.
Otherwise with a Republican General Assembly and a Republican Governor, there should be no tension between the “balance of the powers.” Yet there is.
Let’s put lipstick on a pig:
By the way, whoever created the saying “Are we just putting lipstick on an 800 lbs. pig?” obviously did not own a pig. Because Oink did NOT enjoy getting lipstick on her snout. In fact, she squealed like a pig.
Medicaid Mishaps Cause Tempers to Flare
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.
Right Wing, Left Wing: Does It Equal a More Balanced Senate Bill 744?
Our Senate put forth Senate Bill 744 with radical and shocking changes to our Medicaid system. However, one section of our General Assembly cannot create law. Both sides,the Senate and the House, much agree on a Bill in order to create law.
Senate sent SB 744 to the House on May 31, 2014. Between May 31 through June 13, 2014, the House revised, omitted, and added language to SB 744, making SB 744 a much different document than what the Senate had fashioned. Today, SB 744 is back in the Senate for more revisions. The end result will be a law that appears nothing like the initial SB 744 brought to the Senate on May 15, 2014.
The “ping pong” revision system between the Senate and the House that our founding fathers installed in order to generate actual laws is a well-crafted, finely-tuned balancing machine. It is an effort to keep all ideological agendas in-check. When one side dips too low, the other side counters in an effort to maintain balance. It reminds me of a bird in flight.
Our nation’s symbol is the bald eagle. I am sure everyone knows that, right? But did you also know that the bald eagle is not named the bald eagle because its white head gives the appearance that it is bald? No, bald eagle, in Latin, is haliaeetus leucocephalus (from Greek hali-, which means sea; aiētos , which means eagle; leuco-, which means white, and cephalos, which means head). So, literally its name means “sea eagle with white head.”
Even more important about the bald eagle is its set of wings. A bald eagle has a right wing and a left wing, and without both, the bald eagle would not be able to fly.
We need both the right and the left wings in order to maintain balance in our government. Both sides are necessary, and, yet, it seems that nowadays the left and right sides are at war with each other. Politics has become so polarized that the right wing and the left wing forget the attributes of the other.
The result of the ping pong revision system, in theory, is that, by the time a bill is brought into final shape and enacted into law, all polarized ideations have been balanced out in order to move forward. It does not always work that way, and it becomes increasingly difficult to balance the sides when the sides become more and more divided.
The Senate created SB 744, the House has made its alterations…and, if SB 744 passes, it will pass after many more modifications, no doubt.
When our state Senate passed Senate Bill 744 and sent it to the House, I blogged about the shocking ramifications to Medicaid had that bill been passed.
I listed the most shocking changes included within SB 744:
1. DHHS must immediately cease all efforts to transition Medicaid to the affordable care organizations (ACOs) system that DHHS had touted would be in effect by July 2015;
2. DHHS, DMA will no longer manage Medicaid. Instead a new state entity will be formed to manage Medicaid. (A kind of…scratch it all and start over method);
3. All funds previously appropriated to DHHS, DMA will be transferred to Office of State Budget and Management (OSBM) and will be used for Medicaid reform and may not be used for any other purpose such as funding any shortfalls in the Medicaid program.
4. Categorical coverage for recipients of the optional state supplemental program State County Special Assistance is eliminated.
5. Coverage for the medically needy is eliminated, except those categories that the State is prohibited from eliminating by the maintenance of effort requirement of the Patient Protection and Affordable Care Act. Effective October 1, 2019, coverage for all medically needy categories is eliminated.
6. It is the intent of the General Assembly to reduce optional coverage for certain aged, blind, and disabled persons effective July 1, 2015, while meeting the State’s obligation under the Americans with Disabilities Act and the United States Supreme Court decision in Olmstead v. L.C. ex rel. Zimring, 527 U.S. 581 (1999).
7. Repeal the shared savings program and just reduce the reimbursement rates by 3%.
8. DHHS shall implement a Medicaid assessment program for local management entities/managed care organizations (LME/MCOs) at a rate of three and one-half percent (3.5%).
9. Additional notices as to State Plan Amendments (SPAs), DHHS must post the proposed SPAs on its website at least 10 days prior to submitting the SPAs to the Center for Medicare and Medicaid Services (CMS).
10. Reimbursement rate changes become effective when CMS approves the reimbursement rate changes.
11. The Department of Health and Human Services shall not enter into any contract involving the program integrity functions listed in subsection (a) of this section that would have a termination date after September 1, 2015.
12. The Medicaid PROVIDER will have the burden of proof in contested case actions against the Department.
13. The Department shall withhold payment to any Medicaid provider for whom the DMA, or its vendor, has identified an overpayment in a written notice to the provider. Withholding shall begin on the 75th day after the day the notice of overpayment is mailed and shall continue during the pendency of any appeal until the overpayment becomes a final overpayment (can we say injunction?).
Since my last blog about Senate Bill 744 (the Appropriations Bill), Senate Bill 744 has reached its 7th revision.
The House took it upon itself to delete many of the shocking changes in the Senate Bill. Just like the bald eagle using its right and left wings to balance out.
First, the General Assembly’s proposed cease and desist order that would have stopped Gov. McCrory and Sec. Wos from implementing Medicaid reform and the accountable care organizations (ACOs), is deleted from the current version of the bill. Gone too is the “new state agency” created to manage Medicaid. Medicaid services are no longer eliminated. The Office of State Budget and Management (OSBM) is no longer receiving all funds appropriated for the Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA).
On June 13, 2014, the House finished its revisions to SB 744 and sent the revised bill back to the Senate. On June 18, 2014, the conference committee for SB 744 was formed and includes:
- Sen. Harry Brown, Chair
- Sen. Andrew C. Brock
- Sen. Kathy Harrington
- Sen. Tom Apodaca
- Sen. Ralph Hise
- Sen. Neal Hunt
- Sen. Phil Berger
- Sen. Brent Jackson
- Sen. Wesley Meredith
- Sen. Louis Pate
- Sen. Bill Rabon
- Sen. Shirley B. Randleman
- Sen. Bob Rucho
- Sen. Dan Soucek
- Sen. Jerry W. Tillman
- Sen. Tommy Tucker
SB 744 is still not law. It takes both the House and Senate to pass the bill, and then the Governor has to sign the bill. So we have a ways to go. We need the agreement of the right wing and the left wing.
The two main political parties were not always so polarized.
A couple of our founding fathers, John Adams and Thomas Jefferson, were fierce political adversaries. Imagine the political distance between Barack Obama and Ted Cruz. Despite their political differences, both Adams and Jefferson believed in the importance of funding public education. Rather than defaming the other’s point of view, Adams and Jefferson collaborated and compromised. “The whole people must take upon themselves the education of the whole people and be willing to bear the expenses of it,” wrote Adams. “There should not be a district of one mile square, without a school in it, not founded by a charitable individual, but maintained at the public expense of the people themselves.” Adams and Jefferson were able to balance out the right wing and the left wing in order to fly a straight path.
Back when our founding fathers squabbled and debated key issues, both sides worked together, instead of running mudslinging commercials and scoffing at the other side’s position on the media. During one of the biggest debates in history, the creation of our government, the lawmakers convened together for about 4 months. The Constitutional Convention lasted from May 25 to September 17, 1787 (the first one). The delegates were within close proximity of one another, which led to more conversations and more compromises. Until the Constitution was drafted, the delegates continued to meet together. I imagine they ate lunch together and shared whiskey and cigars in the evenings.
Maybe our lawmakers should schedule a new constitutional convention, both on the state and federal level. At least, both sides need to realize that the right wing and the left wing are necessary. Otherwise we would just fly in circles.
North Carolina Has a New Medicaid Director!!! Careful, It’s a Hot Seat!
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!