Category Archives: Sandy Terrell

NCFast: Should We Go Back to Atari???

Computer systems have come a long way. I remember my Tandy3000 when I was growing up (which had Lotus Notes on it). I also remember the best video game was Pong. Yes, slowly, we advanced to Pac Man, Q-bert and Frogger. But when I bought (actually when my parents bought) my Atari, it worked as expected. When I wanted to play the Decathlon, if I wiggled my joy stick fast enough, I could be an Olympian. When I pushed the jump button for Donkey Kong, Mario jumped.

So, now in this day and age of computer advancement, someone please tell me why computer systems put into place in NC for DHHS simply do not work, have glitches, and fail. Seriously! Why, with a price tag of $21 million and counting (although one journalist cites the price tag at $48 million), why does NCFast not work??? NCFast is simply not fast. NCSlow would be more apropos.

NCFast has a Medicaid eligibility backlog of approximately 86,000 applications.

While the food stamp backlog has mostly been cleared, an even larger backlog is looming. Acting Medicaid Director Sandy Terrell warned lawmakers that nearly 86,000 Medicaid applications are delayed beyond federal processing timelines.

Why is a backlog of Medicaid eligibility important?

Imagine you are on Medicaid and pregnant. You apply for Medicaid for your unborn child. And the Department of Health and Human Services (DHHS) tells you that there is a backlog. Your child is born (healthy), but you cannot take your baby to the pediatrician for the first check-up because the baby has not received a Medicaid card.

Or imagine you are an adult on Medicaid suffering from cancer. April 1, 2014, the Department of Health and Human Services (DHHS) re-processes your Medicaid eligibility. You have been on Medicaid for years and depend on Medicaid to get your monthly prescriptions for pain, etc. But now it is May 6, 2014, and your Medicaid eligibility has not been processed. You go to the pharmacy that you go to every month and the pharmacist says, “Sorry. We cannot give out medication hoping to get paid in the future. Your Medicaid application has not been processed.”

Are we as North Carolinians just doomed to hire contractors who cannot meet the standards required? Or are we poorly choosing contractors? Are these contractors overstating their abilities? Or are we not conducting due diligence to determine whether these contractors are overstating their abilities?

What if Superman told us, “Trust me! I can fly! I am super strong! I will foil all of your villains!” Only to find out that Superman is Verne Troyer in costume?

Why should we care?

Three reasons:

1. People are not getting food stamps in a timely way.
2. People are not getting Medicaid eligibility applications timely processed.
3. We, as taxpayers, paid for this computer system and expect it to run reasonably well.

My Atari, at least, met expectations!

Knock, Knock. Who’s There? Burwell. Burwell Who?

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

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.”

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.

Why?

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.

But Cummings?

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!

CMS Declares the Payment Structure for the MCOs Violates A-87…”So What Happens Now?”

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?

See my blogs: “NC MCOs: The Judge, Jury and Executioner.” Or “How Managed Care Organizations Will be the Downfall of Mental Health in NC.” 

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?

Wrong!

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….

…..drum roll….

PROFIT!!!!! and other increments above cost.

BOOO…freakin’ YA!

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???

Not I.

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:

MCOs as of October 2013

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…”

Sec. Aldona Wos Appoints Sandy Terrell as Acting Medicaid Director

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

Steckel

  • 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

Terrell

  • 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.