Category Archives: Medicaid Recipients Under 21

Knicole Emanuel to Appear on UNC-TV Tonight! Tune In at 7:30pm!

Heather Burgiss, a UNC-TV journalist, created a 3-part television series called, “Mental Health Services in NC.” Part 1 will air tonight on UNC-TC at 7:30, and I will be discussing the important topic of the current status of our mental health system in NC. ¬†So tune in to watch!!!!

The three-part series is intended to educate North Carolinians on the current state of mental health in NC, as well as discuss the upcoming Medicaid reform consisting of the Accountable Care Organizations (ACOs) for physical health services.

P.S. It is intimidating how UNC-TV interviews you, so forgive any bad grammar, etc. ūüôā ¬†During the interview, they cut off all the lights and shine a bright light on you. ¬†It creates a strange environment in which you can hear the person asking you questions, but you cannot see him or her. ¬†Plus, the light is super hot.

But, we will see, Heather was very nice in dealing with my novice handling of the interview.

And, BTW, when you see the scene during which I am walking down the hall of my law firm, I had a strange sensation to start doing the MC Hammer.  But I did not succumb.

Carolina Access, Medicaid and Health Choice: What Are These Programs and Who Qualifies?

Medicaid, Carolina Access, and Health Choice.  Three completely different, and, somewhat, independent programs.  What are the differences?  Who is eligible for what? 

I am reminded of the Monty Hall problem that I learned in a college Statistics class (which, BTW, was my most-hated class in college).  The Monty Hall problem is a brainteaser, a hypothetical, statistical mindbender and it goes like this:

Suppose you’re on a game show, and you’re given the choice of three doors: Behind one door is a car; behind the others, goats. You pick a door, say No.¬†1, and the host, who knows what’s behind the doors, opens another door, say No.¬†3, which has a goat. He then says to you, “Do you want to pick door No.¬†2?” Is it to your advantage to switch your choice?

I am not alluding that Medicaid, Carolina Access, and Health Choice are the equivalent of picking¬†a prize from behind three doors.¬† Obviously, not.¬† But when you don’t know the difference between the programs or which program could benefit you, it can seem as if you are just picking a prize behind three doors.¬† Or throwing darts at a dartboard of choices.¬† Without information, knowing which program can benefit you can be a mystery.¬†

In this blog, I would like to take the mystique out of Medicaid, Carolina Access and Health Choice.  So that you know which program, if any, could be applicable to you, a relative, friend, or, even, a client.

First, door number 1: Medicaid is health insurance for low-income families and individuals who are eligible.  Depending on the category for which you are applying, the income cap differs.  For a complete rundown of Medicaid eligibility, click here.

Medicaid is a highly regulated program, both federally and on the state level.  But no federal statutes speak to how Medicaid recipients can choose their health care physicians or a long-term treatment plan.

Hence, door number 2:

Carolina Access (CA).¬† CA¬†is¬†an option for comprehensive managed care that directs Medicaid recipients to primary-care doctors or clinics that can best serve all their needs. CA helps find Medicaid recipients “health care homes.”¬† With CA, recipients also have 24-hour access to medical advice and emergency treatment.¬†

If you are eligible for Medicaid, you may be eligible for CA, but not always.

CA began as a pilot program within 5 counties in 1991 and went statewide in 1998.

Medicaid recipients are enrolled in CCNC/CA by the Department of Social Services located in the county in which they reside. Enrollment can be done at anytime during the recipient’s eligibility period; however, it is required at application or review for continuation of eligibility. The program aid category of eligibility determines if a recipient is mandatory, optional, or ineligible for enrollment in CCNC.  See NC DMA website.

Below is a chart of eligibility for CA:

MANDATORY OPTIONAL INELIGIBLE
AAF (Work First Family Assistance) HSF (Medicaid Non-Title  IVE Foster Care Children) MQB (Medicare Qualified Beneficiaries)
MAB (Aid to the Blind) IAS (Medicaid Title IVE Adoption Subsidy Foster Care Children) MRF (Medicaid for Refugees)
MAD (Aid to the Disabled) MPW (Medicaid for Pregnant Women) RRF (Refugee Assistance
MAF (Medicaid for Families and Children) MAA (Medicaid for the Aged ‚Äď over 65 years of age) SAA (Special Assistance to the Aged)
MIC (Medicaid for Infants and Children)    
MSB (Special Assistance to the Blind)    
SAD (Special Assistance to the Disabled)

According to the December 2013 CCNC/CA Enrollment Report, there were 1.58+ Medicaid enrollees throughout North Carolina.  1.47+ of those Medicaid enrollees were eligible for CA.  1.35+ actually enrolled in CA at a 92% realization rate.

And now we come to Door #3:

Because Medicaid only covers those with low-incomes and many people who are not eligible for Medicaid still cannot afford insurance, NC has created door number three: Health Choice.  Health Choice only covers children.  Eligibility for Health Choice is defined by NC statute.  According to NC Gen. Stat. 108A-70.21, children are eligible for Health Choice if they are:

  • Between the ages of 6 through 18;
  • Ineligible for Medicaid, Medicare, or other federal government-sponsored health insurance;
  • Uninsured;
  • Live¬†in a family whose family income is above one hundred thirty-three percent (133%) through two hundred percent (200%) of the federal poverty level;
  • A¬†resident of this State and eligible under federal law; and
  • Someone who has paid the¬†Program enrollment fee required under this Part.

So….there it is….the three programs, Medicaid, Health Choice and Carolina Access, somewhat de-mystified.¬†

I understand that I cannot cover all aspects of all three programs in this blog, but, hopefully, this helps a bit.  So it does not feel like you are picking randomly a prize from 3 doors.

How EPSDT Allows Medicaid Recipients Under the Age of 21 To Receive More Services Than Covered By NC State Plan

EPSDT. What in the heck is EPSDT?

EPSDT¬†is an acronym for the “Early and Periodic Screening, Diagnosis, and Treatment (EPSDT).” It only applies to Medicaid beneficiaries under the age of 21. As in, if you are 21, EPSDT¬†does not apply to you. The point of EPSDT is to allow beneficiaries under the age of 21 to receive medically necessary services not normally allowed by the NC Medicaid State¬†Plan. (These beneficiaries under the age of 21 I will call “children” for the sake of this blog, despite 18+ being a legal adult).

The definition of each part of the acronym is below:

Early:……. Assessing and identifying problems early
Periodic:…… Checking children’s health at periodic, age-appropriate intervals
Screening:…. Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
Diagnostic:…. Performing diagnostic tests to follow-up when a risk is identified, and
Treatment:…. Control, correct or reduce health problems found.

Federal Medicaid law at 42 U.S.C.¬ß 1396d(r) [1905(r) of the Social Security Act] requires state Medicaid programs to provide EPSDT¬†for beneficiaries under 21 years of age. Within the scope of EPSDT benefits under the federal Medicaid law, states are required to cover any service that is medically necessary ‚Äúto correct or ameliorate a defect, physical or mental illness, or a condition identified by screening,‚ÄĚ whether or not the service is covered under the North Carolina State Medicaid Plan.

The services covered under EPSDT are limited to those within the scope of the category of services listed in the federal law at 42 U.S.C. § 1396d (a) [1905(a) of the Social Security Act].

For example, EPSDT will not cover, nor is it required to cover, purely cosmetic or experimental treatments.

Again, EPSDT¬†allows for exceptions to Medicaid policies for beneficiaries under the age of 21. For example, if the DMA clinical policy for dental procedures does not cover a certain procedure, if the dentist determines that the procedure is medically necessary for a beneficiary under the age of 21, then the dentist can request prior approval under EPSDT simply by filling out a “non-covered services form” along with the other supporting documentation to establish medical necessity. More likely than not, the “non-covered procedure” would be approved.

Medical necessity is an interesting term. Medical necessity is not defined by statute. The American Medical Association (AMA) defines medical necessity as:

“Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, treating or rehabilitating an illness, injury, disease or its associated symptoms, impairments or functional limitations in a manner that is: (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, extent, site and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider.”

But, legally, the courts have construed medical necessity broadly when it comes to EPSDT. As in, generally speaking, if a doctor will testify that a procedure or service is medically necessary, then, generally speaking, a judge will accept the medical necessity of the procedure or service.

It seems as though I am degrading the intelligence of the judges that take the face value testimony of the doctors. But I am not.

Judges, like I, are not doctors. We do not have the benefit of a medical education. I say benefit because any education is a benefit, in my opinion.

It would be difficult for anyone who is not a doctor to disagree with the testimony of a physician testifying to medical necessity. I mean, unless the person stayed in a Holiday Inn Express the night before. (I know…bad joke).

Some courts, however, have ruled that the decision as to whether a procedure is medically necessary must be a joint effort by the state and the treating physician. Obviously, for courts that follow the “joint decision for medical necessity” holdings, less procedures would be allowed under EPSDT¬†because, more likely than not, the state will disagree with a treating physician (I say this only from my own experience representing the state when the state disagreed with EPSDT treatments despite the treating physician testifying that the procedure was medically necessary).

For example, the 11th Circuit has held that both the state and the treating physician have a role in determining whether a procedure or treatment is medically necessary to correct or ameliorate a medical condition. The 11th circuit disagreed with the Northern District of Georgia’s determination that the state MUST provide the amount of services which the treating physician dreamed necessary. Moore v. Medows, No. 08-13926, 2009 WL 1099133 (11th Cir. Apr. 24, 2009).

Regardless, in practice, EPSDT¬†is interpreted broadly. A long, long time ago, I worked at the Attorneys’ Generals office. A mother requested hyperbaric oxygen therapy (HBOT) for her autistic children (and I had to oppose her request because that was my job).

For those of you who do not know what HBOT¬†is (I sure didn’t know what HBOT is prior to this particular case)…

“Hyperbaric Oxygen Therapy (HBOT) is the use of high pressure oxygen as a drug to treat basic pathophysiologic¬†processes and their diseases. HBOT¬†has acute and chronic drug effects. Acutely, HBOT¬†has been proven to be the most powerful inhibitor of reperfusion¬†injury, which is the injury that occurs to tissue deprived of blood supply when blood flow is resumed. This is thought to be one of the primary mechanisms of hyperbaric oxygen therapy effects in acute global ischemia, anoxia, and coma. Chronically, HBOT acts as a signal inducer of DNA to effect trophic (growth) tissue changes.” See http://www.hbot.com/hbot.

I went and saw a hyperbaric oxygen treatment chamber in preparation of my case. It’s pretty intimidating. It is a large chamber made of thick metal. It looks like you could get inside, have it submerged under the ocean, and explore. It appears similar to a submarine. And, interestingly, it is most often used for divers who get the bends.

It is highly controversial as to whether HBOT¬†cures, remedies or ameliorates autistic symptoms. I had two experts testifying that HBOT¬†was experimental, and, therefore, not covered by Medicaid, even with EPSDT. (Remember, back then I was at the AG’s office).

Yet, despite the fact that HBOT¬†was still controversial as to whether it ameliorates the symptoms of autism, the Administrative Law Judge (ALJ) used the EPSDT¬†doctrine to rule that the mother’s children could receive HBOT and Medicaid must pay for the services.

That is the power of EPSDT. HBOT was clearly not covered by Medicaid for the purpose of ameliorating symptoms of autism. But, for the children named in the Petition who were under 21, Medicaid paid nonetheless.

HBOT allows beneficiaries under the age of 21 to receive medically necessary services that would not normally be allowed under the North Carolina Medicaid State Plan.

Importantly, EPSDT provides for private rights of action under 1983. At least all the federal circuit court of appeals have held such.

Oh, and, BTW, NCTracks will soon also be in charge of EPSDT determinations.

DHHS Blunder Could Cost Millions! “Oops I Did It Again!”

We can add one more “oops” to the Department of Health and Human Services (DHHS) repertoire of “oopses.” I am reminded of Captain Edward Smith when he banged the Titanic into an iceberg.¬† Talk about an “oops” moment.¬† Not to mention the lives lost, hitting that iceberg cost $7.5 million in ship building costs back in 1909.

DHHS hit another iceberg yesterday.¬† How much will this “oops” costs?

DHHS¬†made its “oops” by sending 48,752 new Medicaid cards to¬†the WRONG people.¬† Oops! Medicaid cards have HIPAA protected information on them, such as names, Medicaid numbers and dates of birth.¬†

Let me tell you a little about HIPAA. HIPAA stands for the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  It was signed into law by Bill Clinton,  Title II of HIPAA requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.  Why is this important?  This act also provides significant penalties if privileged information is disseminated.

Hence the DHHS Medicaid card debacle. Iceberg, ahoy! “Oops I did it again!”

The questions are (1) how much will NC be penalized for the dissemination of so much private information; and (2) will NC actually have to pay the penalty?

Recently, HIPAA was revamped.  Beginning September 2013, HIPAA became even more stringent with harsher penalties and began to apply to more people (including law firms).  For example, prior to September 2013, my firm Williams Mullen treated my documents received from clients the same as all other privileged information in our firm.  Obviously, almost everything at a law firm is confidential.  Now I have to lock my door (we had to install a lock) anytime I leave my office, even for lunch.  Bright yellow flags have been added to all my files that contain privileged health information (PHI), which is every file.  My partners cannot access my documents on our computer network system unless granted access.  I feel like Edward Snowdon.

I also remember a story about a nurse who worked at a hospital.  Her husband was admitted into the ER while she was on her shift and she looked up his condition on the computer.  She was fired for violating HIPAA.

How bad can it be?

The feds imposed a penalty of $4.3 million against Cignet Health of Prince George’s County, MD, for HIPAA violations in 2011. Oops!

And, in light of the “new HIPAA,” last week, DHHS disseminates privileged information to 48,752 people.

What are the penalties for violating HIPAA?

There are four violation categories (1) did not know; (2) reasonable cause; (3) willful neglect-corrected; and (4) willful neglect-not corrected.  Here are the penalties:

HIPAA

Assuming¬†DHHS’ HIPAA¬†violation is the least severe, “did not know,” DHHS could be liable for $100-$50,000 per violation.¬† Here, there are, at least, 48,752 violations.¬† So we are talking a penalty anywhere from $4,875,200 to a number bigger than my calculator allows.

Thankfully for DHHS and, ultimately, our tax dollars, there are caps to HIPAA penalties.  There is a $1.5 million cap per calendar year.

However, DHHS could be liable for multiple violations of multiple provisions and a violation of each provision can be counted separately.  So, theoretically, DHHS could be liable for multiple violations of up to $1.5 million cap for each violation, which would result in a total penalty well above $1.5 million.

Oops!

The other question is whether the federal government will hold a state liable for such HIPAA¬†violations.¬† I don’t know the answer to this, but it would seem fundamentally unfair if HIPAA applies to people and companies, but not the state.

Then, again, how many of you want our tax dollars going toward paying these HIPAA penalties?

You can also see this story on WRAL. (Yes, I was interviewed ūüôā )

Will Aldona Wos also have a $7.5 million “oops” like Captain Smith?¬† Because, regardless who committed the “oops,” Wos is captain of the ship.¬† It is believed that Capt. Smith went down with the Titanic.

Medicaid Alert: Arkansas Medicaid Going Private? Others To Follow? Should NC?

On September 27, 2013, the Centers for Medicare and Medicaid (CMS) approved Arkansas’ request to begin a Private Option demonstration.¬† Arkansas is the first state to receive approval for a “private option” as an alternative to Medicaid expansion.

Remember my “A Modest Proposal?”¬† Providing Medicaid recipients with private insurance….

Basically, Arkansas will accept federal money for Medicaid expansion, but instead of expanding¬†Medicaid, Arkansas will purchase private insurance for these “newly eligible” Medicaid recipients, adults who make $15,280 or less.¬†¬†Those individuals who earn up to 138 percent of the poverty line ‚ÄĒ or $15,415 per year ‚ÄĒ would purchase subsidized private insurance through the state’s insurance exchange.¬† From my understanding, the federal funds will cover the newly eligible recipients’ premiums and any co-pays above the co-pays set by statute.

Coverage is to begin January 2014, although enrollment opened today.

Arkansas estimates that 225,000 individuals will be eligible for the demonstration project.¬† Iowa has submitted a similar request for a “private option” program.¬† CMS has not yet ruled on Iowa’s request.¬† Likewise, Pennsylvania Governor Corbett submitted a request to CMS based of the Arkansas model.

It seems that some Republican governors are thinking outside the box to provide health care coverage for additional Medicaid recipients without merely providing the newly eligible simply a Medicaid card.¬† Because, remember, receiving health care is completely different from receiving health insurance.¬† Having insurance does not always allow Medicaid recipients to receive health care.¬† Obviously, many provider refuse to accept Medicaid.¬† But these newly eligible Medicaid recipients will have health care…with private insurance…just like I have…or you have….

And I ask you…What is more important….handing a person a Medicaid card?…Or providing that person with quality health care?

Editorial: The real trouble at DHHS: Failing the needy – Winston-Salem Journal: Editorials

Editorial: The real trouble at DHHS: Failing the needy – Winston-Salem Journal: Editorials.

Because of PCG Audit, New Mexico Freezes Mental Health Services!

Last week, I was busy working in my office when a woman named Shawn called me. The area code showing on my caller ID was definitely NOT from North Carolina. Turns out Shawn lives in New Mexico.

Pop Quiz: (For those of you who have been with me for a while): What is similar between New Mexico and North Carolina Medicaid? Answer: Public Consulting Group (PCG).

Remember my blog, “New Mexico and NC: Fraternal Twins?”

Seems that the bloopers surrounding PCG do not only lie within the state border of NC.

Oh, no! PCG is much more far-reaching than just NC.

Hence, Shawn calling me up to fly to New Mexico to speak to the New Mexico State legislature about PCG in NC. And, perhaps, how Medicaid providers can defend themselves (maybe without me since I do not have my NM law license, although I am sure I could pro hac in).

So what was I supposed to say to a bunch of state legislatures? Why would they even care what I have to say?

I ask Shawn this.

In July, New Mexico’s Human Services Department suspended Medicaid funding to 15 providers while conducting an investigation into allegations of fraud. An out-of-state consulting group released an audit in June accusing the mental health providers of overbilling the federal and state government by tens of millions of dollars.

New Mexico has frozen mental health services for Medicaid recipients?

Can you imagine? What has happened to the New Mexico Medicaid recipients who need mental health services?

 And this mental health services freeze is based on an audit conducted by Public Consulting Group? Are you kidding?  The same company that stated that my client owed $706,000+ Medicaid reimbursement overpayment, yet, after legal arguments, DHHS held that my client only owed $336????

THAT COMPANY????

So, here I am,¬†flying to New Mexico… I am on a plane (obviously, coach) squished into a window seat, unable to straighten my legs, typing this, thinking that allowing me only¬†one cup of water¬†over a 3 hour trip constitutes cruel and unusual punishment, all to explain to NM legislators the ineptness of PCG.

Worth it?

Heck, yes, if my message does not all on deaf ears. I will keep you posted.

McCrory Signed SB 553: The Legal Burden is Now on Medicaid Recipients

August 23, 2013: Governor Pat McCrory signed Senate Bill 553.  Senate Bill 553 is now Session Law 2013-397.

No words can express my disappointment.

Starting Monday, Without a Veto, the Legal Burden of Proof Will ALWAYS Be on the Medicaid Recipients

I am not sure whether you have noticed, but Medicaid recipients have very little pull in North Carolina government.  Medicaid recipients have very little voice in our society.  Obviously, Medicaid recipients are indigent, so they do not have the money to hire lawyers and lobbyists. 

Politicians (while they are campaigning) always protest that they believe that Medicaid recipients are important…that Medicaid is important…but, most¬†importantly, that it is important¬†that¬†Medicaid recipients receive quality health care….right?

We’ve heard the rhetoric over and over.

But then what happens when the politician takes office?

I can tell you what does NOT happen. Medicaid recipients do not band together, hire a lobbyist and begin influencing government policies.

Per norm, the Medicaid recipients remain invisible.  And mute.

I have a client with a daughter.¬† This daughter, we will call her Jennifer,¬†is in her 30s, but with mentality of an 18-month old.¬† Jennifer is diagnosed with Tuberous Sclerosis Complex (‚ÄúTSC‚ÄĚ), a rare, multi-system genetic disease.¬† She is nonverbal and requires 24 hours/day supervision for health and safety and total care for activities of daily living and incidental activities of daily living, just as an 18-month old would require.

The Managed Care Organization (MCO), where Jennifer resides, is Smokey Mountain Center (SMC).¬† For¬†the last 4 years in North Carolina (five years ago Jennifer resided in California), Jennifer has received 16 hours/day Medicaid. Once SMC went live and Jennifer’s yearly authorization was up for renewal, SMC reduced Jennifer’s services to 12 hours/day, thereby leaving a 4-hour gap in which Jennifer would be¬† unsupervised. (Shocking that the MCO did not want to foot the bill for the extra 4 hours, right?)

I will spare you the details of the legal arguments on both sides, as, today, my husband made a comment that my blogs were “too long.”

So, we are in the administrative¬†hearing in front of an Administrative¬†Law Judge (ALJ) with the attorneys for SMC and the Department of Health and Human Services (DHHS) present.¬† The ALJ asks me, “Counselor, who has the burden of proof, the Petitioner [us] or the Respondents [them]?”

To which I had to think back to my days during which I worked as an Assistant Attorney General (AG) for NC¬† (yes, I used to work on the other side…where do you think I learned this stuff?? At law school?)

For those of you without law degrees, the burden of proof (onus probandi, in Latin) is the obligation (hence the Latin word “onus“) on the party in a trial, who must prove [something] in court in order for the burden to shift to the other party to dispute.

Sometimes people will explain the burden of proof as “the necessity of proof always lies with the person who lays charges.”¬† As in, if you claim that I stole your watch, you must prove I stole it.¬† I do not have to prove that I did NOT steal it.

This may seem like ridiculous semantics to you, but, legally, who bears the burden of proof is huge.

In Jennifer’s example, the ALJ was asking me whether we (Jennifer) had to prove that she medically needed 16 hours/day Medicaid services or whether the State had to prove why Jennifer did NOT need the 16-hours/day Medicaid services.

If we (Jennifer) put on compelling evidence that she needed 16-hours/day services, and Respondents SMC and DHHS put on equally, compelling evidence that she did NOT need 16-hours/day services, then the Judge would have to rule against the party bearing the legal burden of proof.

As of today, here is the law as to burden of proof for Medicaid recipients:

(d) Burden of Proof. ‚Äď The recipient has the burden of proof to show entitlement to a requested benefit or the propriety of requested agency action when the agency has denied the benefit or refused to take the particular action. The agency has the burden of proof when the appeal is from an agency determination to impose a penalty or to reduce, terminate, or suspend a previously granted benefit. The party with the burden of proof on any issue has the burden of going forward, and the administrative law judge shall not make any ruling on the preponderance of evidence until the close of all evidence.

(emphasis added). 

Senate Bill 553 will change all this.

Senate Bill 553 states that, “The enrollee has the burden of proof on all issues submitted to OAH for a contested case hearing under this section and has the burden of going forward. The administrative law judge shall not make any ruling on the preponderance of evidence until the close of all evidence in the case.”

The enrollee = the Medicaid recipient.

Therefore, even if the MCO terminates an enrollee’s services (and even if the termination is arbitrary and without merit), the Medicaid RECIPIENT bears the legal burden to prove this.

Really?¬† Let’s make it even harder for Medicaid recipients to appeal denials or reductions in services.¬† They can handle it!¬† They can hire a lawyer!¬† Right?

Who does this change benefit? Who benefits from the Medicaid recipients bearing the burden of proof in a legal action?

Answer? The MCOs.  And guess what?  The MCOs have lobbyists.  The MCOs have lawyers.

Senate Bill 553 was ratified July 26, 2013.  Which means that SB 553 will be law beginning Monday unless Governor McCrory vetoes the bill by Sunday.  On Sunday (August 25, 2013), McCrory can choose to sign SB 553, allow SB 553 to pass without his signature, or veto the bill.

If McCrory does NOT veto the bill, Medicaid recipients will bear the burden of proof in all contested cases. 

I ask you, why would we as a society place the legal burden of proof on the party LEAST likely to be able to afford a lawyer?

Send Gov. McCrory an email. Veto SB 553!!!

NC Medicaid: “A Modest Proposal for Medicaid Reform”

Medicaid recipients in North Carolina are not getting the same, quality health care that citizens with private insurance receive.

Health care providers refuse to accept Medicaid due to low, Medicaid¬†reimbursement rates.¬† There are not enough Medicaid providers for all the Medicaid recipients.¬† Medicaid recipients have difficulty finding health care providers, especially dentists and other specialists. Many Medicaid recipients are forced to go to the¬†emergency departments (EDs)¬†for medical issues that could have been conducted in a primary care doctor’s office, thereby creating excessively long, waiting periods at EDs.¬† Medicaid recipients, who understand they need mental health services, are left to the whim of an employee at a managed care organization (MCO) as to whether the recipient meets medical necessity for a behavioral health care service.

I’ve blogged before that the disparity between the health care a Medicaid recipient receives and the health care a citizen with private insurance receives reminds me of the “separate, but equal”¬†doctrine during the Civil Rights Movement.¬†

Medicaid recipients in North Carolina are not getting the same, quality health care that citizens with private insurance receive.

Separate is not equal!

As a nod to the great author, Jonathan Swift, I have “A Modest Proposal for Medicaid Reform.”¬† Jonathan Swift is probably more well-known for “Gulliver’s Travels,” but, by far, my favorite Swift work is “A Modest Proposal.”¬† With “A Modest Proposal,” Swift defined satirical writing, but about 300 hundred years ago.¬†

“It is a melancholy object to those who walk through this great town or travel in the country, when they see the streets, the roads, and cabin doors, crowded with beggars of the female sex, followed by three, four, or six children, all in rags and importuning every passenger for an alms. These mothers, instead of being able to work for their honest livelihood, are forced to employ all their time in strolling to beg sustenance for their helpless infants: who as they grow up either turn thieves for want of work, or leave their dear native country to fight for the Pretender in Spain, or sell themselves to the Barbadoes.”

Interestingly, Swift published “A Modest Proposal” anonymously in a newspaper.¬† At the time Swift wrote it, Ireland was in an impoverished state with an over-population problem.¬† Some lawmakers had suggested a number of population-control methods that, apparently, insulted Swift to his core.¬† One person suggested running the poor through a joint-stock company, presumably¬†for the¬†“rich, educated” people to control the “poor.”¬† Others suggested population-control, such as preventing childbirth for certain demographics.

Similarly, today I was listening to CNN when the newscaster explained that a mother of an autistic child received a hateful letter from a neighbor about her autistic child.   

Here are some statements found in the letter: (Please understand that these words are not mine.  In fact, when I heard this story, I was torn between crying for this mother and child or becoming infuriated at the ignorance and narcissistic hubris of the author).

The letter goes on to criticize Begley for allowing Max to play outside and says: “That noise he makes when he is outside is DREADFUL!!!!!!!!!! It scares the hell out of my normal children!!!!!!!”

The letter also tells Karla that she has a “retarded kid” and “should deal with it properly”.

“What right do you have to do this to hard working people!!!!!!!! I HATE people like you who believe, just because you have a special needs kid, you are entitled to special treatment!!! GOD!!!!!!”

The writer finishes by demanding the family “go live in a trailer in the woods or something with your wild animal kid!!!” and asks the family to do the right thing and move or “euthanize him. Either way, we are ALL better off!!!”

I hope that the above words impacted you as¬†they did me.¬† I simply cannot believe that a person…any person….would THINK those words, much less write those words.¬† Has our society¬†become so callous to people with special needs that the people with special needs have become (in the author’s view) burdensome or annoying?¬† To the author of that hateful letter, I say, “Shame on you!”¬†

I also say, “If there were laws against being heartless, you would be sentenced for life!”

In “A Modest Proposal,” Swift suggests (satirically) that the impoverished Irish might ease their¬†troubles by selling their children as food for rich gentlemen and ladies. “This satirical hyperbole mocks heartless attitudes towards the poor, as well as Irish policy in general.”¬† See Wikipedia . (It amazes me that the authors of¬†Wikipedia¬†draft better English essays than I did in college).

According to DMA, in 1999-2000 more than 1.22 million individuals were covered under North Carolina’s Medicaid program.  By 2009, that number had grown to more than 1.81 million individuals, an increase of approximately 50%.  That means that 1.81 million people in North Carolina depend on Medicaid.  These are our neighbors; these are our children; this may even be us.

I have my own “A Modest Proposal.”¬† My “A Modest Proposal” is:

A Modest Proposal for Medicaid Reform.”

Our Medicaid budget¬† is¬†approximately $14¬†billion.¬† According to Kaiser, our Medicaid expenditures were $10,546,984,914 in fiscal year (FY) 2011.¬† However, Kaiser also notes that “expenditures do not include administrative costs, accounting adjustments, or the U.S. Territories. Total Medicaid [federal and state…as in, nationwide] spending including these additional items was $427.4 billion in FFY 2011.”

We spent $10.5 billion (estimated) on Medicaid services for Medicaid recipients in FY 2011.  According to the January 2013 State Audit of DHHS, in fiscal year 2011, North Carolina Medicaid incurred administrative expenses of approximately $648.8 million.  Now, here in 2013, with the MCOs in place statewide, I wager that the administrative costs for Medicaid for fiscal year 2013 will, at least, double due to the salaries and benefits awarded to MCO employees. 

67.4% of our $10.5 expenditure went to acute care (hospitals).  No shock there. Medicaid recipients generally do not receive continuity of care through a primary physician.  Therefore, many Medicaid recipients end up in the ED for an ear ache (ever wonder why the waiting period at the ED is so long?). 

Plus, North Carolina is, sadly, floundering as to providing mental health services, so it is no wonder that¬†¬†“almost one-third of ED visits by those with underlying mental health disorders resulted in hospital admission, more than twice as many as those without underlying mental health disorders,” according to a new study released by North Carolina School of Medicine researchers.¬† For the study, click here.

28.8% of our Medicaid expenditure went to long-term care.  Again, not surprising with the rise of more aged, NC citizens.  Kaiser Family Foundation data for FY 2009 show that approximately 27% of those enrolled in the North Carolina Medicaid program were categorized as aged or disabled, and that the cost of services for those 2 categories of recipients made up approximately 63% of the program’s total costs that year.

3.9% of our Medicaid expenditures for 2011 went to DSH payments.  Disproportionate Share Hospital (DSH) adjustment payments provide additional money to hospitals that serve a significantly disproportionate number of Medicaid recipients.

3.9 + 28.8 + 67.4 = 100%

North Carolina’s total Medicaid spending including these additional items was approximately $11.149 million in FY 2011.¬†($10.5 billion + $648.8 million administrative costs).¬†According to Beth Wood’s January 2013 Performance Audit, private contractor payments represent about $120 million (46.7%) of DMA‚Äôs $257 million in administration expenditures for FY 2012.¬† Almost half of the administrative costs for Medicaid, in 2012, went to contracted companies, such as Piedmont, Carolinas Center for Medical Excellence (CCME), Public¬†Consulting Group (PCG), etc…

So…here is my “A Modest Proposal:”

If you take the total Medicaid budget (currently, over $14 billion) for the fiscal year ended June 30, 2012, and divide the budgeted amount by 1.8 million (the approximate number of North Carolinians on Medicaid), you get: $7,777.78.

$7,777.78/year for each Medicaid recipient.

My health care premiums for a “Cadillac health care” with my husband costs $9000/year.¬† And it is great health care.¬† All copays are $10 for generics, $15 for non-generic.¬† Doctor visits are $10, a specialist is $25.¬† The beauty of my health care, though, is the deductible is only $500.¬† I hit $500, and everything is covered.

Now, mind you, the $9000 ($750/month) includes my husband.  If I wanted individual insurance  it would only have cost $228/month or $2,736/year.  Why the addition of my husband increases the premium from $228 to $750, I have no idea, but it does. (He does not even have pre-existing conditions!!! In fact, he flatly refuses to visit a doctor unless pending death.  In my mind, he should have been cheaper than I).

As an individual, in order to pay for this “Cadillac” policy, you would have to pay $2,736/year.¬† Add in the $500 deductible and the total cost (barring unexpected and individual costs) would¬† be $3236.¬†

Our Medicaid budget allows each Medicaid recipient approximately $7,777.78/year. 

First, I propose North Carolina downsize 80-90% of the Division of Medical Assistance (DMA) and keep running a much smaller DMA for the sole¬†purpose of determining yearly Medicaid eligibility, thereby cutting almost all administrative costs.¬† I also propose hiring¬†ZERO contracted companies for Medicaid.¬† There is no reason for any contracted companies under my “A Modest Proposal for Medicaid Reform.”

17,000+ people are currently employed by Health and Human Services.¬† But employment of citizens is not a reason to maintain an agency.¬† Therefore, if we can manage Medicaid without 16,500 employees (which my “A Modest Proposal for Medicaid Reform” purports to do), then we are paying unnecessary administrative costs.

Secondly, taking the Medicaid funds, and, instead of paying administrative¬†costs to DHHS, DMA, PCG, CCME, all the MCOs, we purchase¬†excellent, quality private insurance for each Medicaid recipient.¬† We pre-pay the deductible for all Medicaid recipients.¬† We hand the Medicaid recipients a private insurance card that is “pre-paid” with no deductible.

A pre-paid, private insurance card!  With no deductible! (Because the deductible is paid).

No more doctors refusing Medicaid!¬† Think about it….all doctors would take the new “Medicaid,” because the recipients would have private insurors paying the full price for medical services.¬†

No more placing the burden of whether a recipient meets medical necessity for a medical service in the hands of DMA or a contracted company.¬† The private insuror would take on that burden and use the same standard of medical necessity as it does for all its consumers.¬† And why not? The insurance company is getting paid the same…

Medicaid recipients would get quality care just as if¬†they were not Medicaid-eligible.¬† And isn’t that our goal? For the Medicaid recipients to be cared for just as well as if they were not Medicaid-eligible?

No more difficulty finding health care providers that accept Medicaid. Medicaid recipients would have the “Cadillac” Blue Cross Blue Shield just like I do.

No more excessively long, waiting periods at the ED! Medicaid recipients would benefit from continuity of care just like I do.  No need to go to the ED for an ear ache.  The primary care physician can tend to the ear ache.

No one would worry about Medicaid fraud anymore because, as to health care, everyone would be the same.  (So, we could also eliminate the need for Program Integrity).

No more Medicaid provider contracts, as all health care providers would accept the new “Medicaid.”

No more Medicaid recoupments.

I profess, in the sincerity of my heart, that I have not the least personal interest in endeavoring to promote this [Medicaid reform], having no other motive than the public good of my [state], by advancing our trade, providing for [Medicaid recipients], and giving some pleasure to the rich.

Think what an impact North Carolina would have on the nation if we were to implement my “A Modest Proposal for Medicaid Reform!!”