Comments From The Colorado Cross-Disability Coalition On Targeted Rate Increased For 2014/2015 Budget Of The Department Of Health Care Policy And Financing
Comments From The Colorado Cross-Disability Coalition On Targeted Rate Increased For 2014/2015 Budget Of The Department Of Health Care Policy And Financing
Please accept these recommendations on behalf of the Colorado Cross-Disability Coalition (CCDC). CCDC is the largest statewide disability rights organization in Colorado that is run by and for people with all types of disabilities. The majority of our members with disabilities are Medicaid clients.
CCDC supports the concept of directed increases to address quality and access problems. These comments contain our responses and some additional thoughts. CCDC comments are based on what we hear from clients and from our experience monitoring and advocating for clients across the state. We are well positioned to understand what access issues exist and where lack of appropriate rates causes quality problems. CCDC is not able to comment on whether the increase can be implemented by July 01. When making these important changes, CCDC asks that we not make changes in policy or programs without trustworthy Colorado based data. HCPF data should be first information provided before any rate increase (or decrease).
Access/Quality Problems Not Addressed by HCPF Proposal: Most of the low rate quality problems are in the HCBS waiver programs.
a) Almost all of the rates for SLS are inappropriate and we support the increase. The way rates are calculated for SLS is a serious problem, as it contemplates all services in the community be provided in a group setting. This is contrary to the goals of Olmstead and even goes directly against other protocols in your waiver. This certainly is not person centered. We understand that this increase is a separate budget item along with wait list reduction.
b) The rate for personal care and homemaker in the EBD and other waivers is a problem. It is so low that a provider has three choices:
1. Commit fraud –bill for more hours than are used or bill for serviced not rendered.
2. Provide substandard services by hiring people who will work for minimum wage or slightly higher. One cannot find workers who are mentally balanced, able to comprehend care plans and instructions and with lives stable enough to get to work regularly at this rate. This relegates the most vulnerable to care providers that are unable to succeed at fast food or Wal-Mart. When we find people who are doing this out of the goodness of their heart (usually family and friends) they become so impoverished and are not able to maintain the quality of care needed.
3. Lose money:
The living wage is over $17 an hour and the personal care rate paid to agencies is only about $14. There is not only overhead but the costs to employer, such as SUTA, FICA, Social Security, etc. The rate needs to be at least $20 with enhancements for odd hours, weekends, holidays, and for working with clients with behavioral challenges or in rural areas. This can be accomplished by reducing the use of skilled personal care. CCDC hopes that CFC will accomplish this objective, but when looking at rates it is imperative to address this issue. The skilled rate for home health care is more than $10 an hour higher. While the skilled care requires a certified nurse aide license, the work is not necessarily more difficult. In fact, the work that takes the greatest amount of skill is the cueing, stand by assistance and assisting people with cognitive and psychiatric disabilities. It is also more difficult to help someone clean up after a bladder or bowel accident, than to change out a leg bag. There are numerous examples of a skilled task that pays higher than an unskilled task that is more challenging and should be paid at a higher rate. Some tasks that require nursing are paid at an outrageously high rate. The nurse practice act and expectations from CDPHE would have to be changed to enable agencies to be comfortable not using nurses.
CCDC is concerned that with the implementation of personal care for children, as required by EPDST, that there will be serious problems with provider capacity and quality as mentioned above. If higher expectations exist there may be provider unwillingness to do the work.
HCPF studies over the years have shown that there are problems with these services. One small study by the AG approximately 10 years ago indicated that there may be as high as a 50% fraud rate. The numbers bear this out because one cannot make money with the rates as they are.
c) Transportation is the final area where there are imbalances. Taxi cabs have rates set by the PUC apparently and we set rates for wheelchair vans that are less than what taxi cabs are paid. Therefore a taxi that simply drives up to a house, and a non-disabled person hops in and is taken somewhere is paid more than a wheelchair van. Drivers often have to go into the house, get the person, use the lift, use wheelchair restraints, and then help the client into their appointment. This adds anywhere from 8-20 minutes on each end. Vans are much more expensive to operate than a regular car. We must find a way to raise the rate for wheelchair vans, especially in areas where there are no accessible taxis. It is easy to measure the difference in work and cost between a taxi and a wheelchair van. People with disabilities deserve rates that are based on fact.
The other transportation rate problem is the mileage reimbursement. The reimbursement rate is low, but not so low that is a barrier. The department position that the rate of 37 cents per mile is adequate to cover gas, wear and tear AND to pay for a driver for a client that cannot drive is the problem. There should be a separate rate to cover people that require a driver due to their disability, who do not have available and legally responsible family members. In most parts of the state a service provider can be used in these situations. However that can be very costly, especially for longer trips. Creating a way to pay a driver $15 an hour (or so) would be appropriate and necessary to assure transportation to all clients, including wheelchair users. This would be a more cost effective option than having a service take a single client long distances. If the driver worked 10 hours that would only be $150 plus mileage—far less than any service will charge.
There are similar issues around non-medical transportation and policies that cause a lot of waste.
CCDC believes that HCPF should do analysis of rates for supplies and look at more efficient ways of providing them, including a voucher option for willing clients. Some supplies are vastly overpriced to Medicaid, others are not covering cost. Forcing clients to have to get delivery monthly, rather than quarterly or even annually for long term stable clients increases the cost of the service.
Comments on HCPF Proposals:
Children Hospice Payment Increase: It was unclear what service was being increased, however if there is an access issue that is a problem CCDC wholeheartedly supports any remedy that is necessary. CCDC would defer to Family Voices on particular policy issues regarding rates that apply to children.
It is important to understand that having numerous providers does not mean the rate is
OK. If providers cannot hold onto clients and clients move frequently between different providers that is a problem also. There should be close attention paid to the results of this increase especially with client satisfaction, usage patterns and avoidable incidents. There should be any limit on services for children in hospice, but perhaps the rate increase can be targeted to those who have highest needs or after a base level of services are provided?
Pediatric Developmental Assessments: CCDC defers to Family Voices on the necessity of this increase. If this is done however, it is important that these assessments address the need for complex rehab and assistive technology and involve a neuropsychiatric component. Usually these assessments can be done annually, however we would oppose a strict limit because children change frequently and complex children may need more frequent evaluations.
After Hours Physician Office Visits: CCDC does not support this increase at this time without seeing supporting data. Changes in policies that are not based on data are the cause of most program failures. HCPF data should be the first information provided before any changes are made. CCDC is not aware that lack of evening and weekend hours is the reason people go to the emergency room when a primary care doctor could have solved the problem. The problem is usually either a long wait (we have heard up to 6 weeks for PCP appointments), or clinics that have policies requiring the patient to call that morning at a specific time for a same day appointment. Clients relying on Medicaid transportation and/or paratransit cannot do same day appointments because they need to call several days ahead of time. Many emergency room visits happen because of the inability to obtain same day transportation. While it is theoretically possible, it is quite challenging and not practical. The transportation broker has to call the doctor to verify the need, wait for a call back before approving and arranging the ride.
CCDC encourages HCPF to work with urgent care centers to become Medicaid providers. These facilities are reasonably priced, good for dealing with medical care that is urgent but not emergent. They have weekend and evening hours. If there is data to support that people are going to the ER on weekends or evenings, then further study should be done to assure that the real reason for their using the ER is the PCP lack of evening hours. For example, if someone goes to the ER at 6 pm because they work until 5, then this is not an emergency. Client surveying should be part of data collection. If clients are employed, HCPF should assess how many work full time Monday-Friday jobs without flexibility. If many clients say that they have jobs that have no flexibility then it would make sense to offer this service. However, many of the jobs that do not offer flexibility, such as entry level service positions, are not 9-5 jobs either so people could go to a daytime appointment.
CCDC appreciates HCPF consideration of client convenience and better customer service and access. If resources were not scarce we would love this recommendation. Our reluctance is based on lack of knowledge of data and competing priorities.
Brain Injury CCDC supports this increase. This is a population in great need. There is plenty of data and hard evidence about lack of providers for this waiver program. Clients are shipped out of state or incarcerated due to lack of providers. Because of the challenges associated with serving this population and the extreme vulnerability of the clientele, tight monitoring of providers is important. HCPF should do everything possible to avoid a single provider. That would give that one provider far too much power and would leave a client that complained or was otherwise unable to work within the providers framework vulnerable. No provider can effectively serve all clients. The need is for a provider that can provide 24/7 residential and day services for clients that require 24 hour line of sight. Some of these clients require assistance with activities of daily living; others simply require a very high level of supervision. Many will require very tight structure with highly trained staff.
SEP Rate Increase: CCDC supports this rate increase based on data regarding increased case loads and responsibilities. HCPF should be clear as to the intent of this increase. Is it to lower the caseload or to bring on case managers with higher levels of skill? Will they be allowed to simply raise salaries without requiring increased training or lower caseloads? If this is simply an increase to make up for the increased responsibilities they have endured over the years then be clear, so there will not be expectations that cannot be met. CCDC would support a requirement to reduce caseloads for SEPs that have caseloads over 100 and to not allow those SEP agencies to increase salaries or pay administrators. CCDC would also support requiring increased education and training for SEPs that have not done disability cultural competency and person centered training. This should also come with an ability to tier expectations. Some clients need very little and others need much more. CCDC suggests piloting a tiered case management system with payment reform built into the pilot would be a good use of funds.
Ambulatory Surgery: CCDC has a grave concern about this incentive. We fear that this will be one more reason for surgeons to reject clients that are more complicated. Providers will be penalized if they have a patient that should have a surgical procedure in a hospital? How will that be monitored or assessed? Before this is implemented CCDC would like t know if there is data showing that surgeons are choosing hospitals inappropriately when there are ambulatory surgery facilities available? CCDC is also interested in understanding if there is there evidence that these facilities are not available? The rate increase pilot did not bear out a change in behavior. We do not understand why HCPF believes an incentive to use a different facility would bear a different result.
Targeted Specialty Rates: This comment comes with the caveat that CCDC does not have direct knowledge about many of these specialties. However, CCDC has seen no evidence of access problems in the areas mentioned. Many of the specialties mentioned are for vision and hearing services. Medicaid does not pay for glasses, hearing aides or other correction for vision or hearing for adults. Unless these rate increases for these specific specialties are for pediatrics, there should not be a huge demand for those specific specialists.
CCDC is aware of general lack of specialists in rural and frontier areas, but are not sure if this specific to Medicaid or not. Many specialists are readily available in the metro area and some are very difficult to find. There are some specific problems that are causing great harm and driving a lot of expensive, emergency room care and creating secondary disabilities.
a) Pain management specialists. There are NO pain management doctors for Medicaid clients. Many primary care doctors are uncomfortable doing long term narcotic prescribing. Some simply need more support on how to do pain management and others are afraid of the DEA and other enforcement agencies. We are aware of people forced to frequent the emergency room for pain related problems, such as blood pressure going out of control, suicidality solely because the pain is so unbearable, and due to being in uncontrolled pain. If there is any specialist that we need to entice to serve Medicaid clients it is pain management. Clients with disabilities whose conditions cause pain, particularly neurological pain, cannot just be ignored. They need strong medication and need to be monitored so they have a quality of life. CCDC has seen both extremes. We see Medicaid clients being denied reasonable amounts of medication (and for someone with a lifetime disability reasonable may be much higher than what a non-disabled person requires). We also see people drugged to the point of being unable to function, losing cognitive abilities, etc. People with no substance abuse history sometimes turn to alcohol and now frequently to marijuana because they cannot get relief from doctors. Living with untreated pain is unhealthy and causes numerous secondary problems and injuries.
b) Psychologists able to conduct neuropsychiatric evaluations. These evaluations provide critical information for a client who has a host of cognitive and psychiatric problems. It can help sort out what is a true “behavioral” issue that can be treated with a behavioral therapy in a mental health setting, versus a neurological deficit that must be accommodated versus a cognitive deficit that might be able to be addressed but not through a mental health treatment. These evaluations can also determine when medication is causing a cognitive problem. Working without data or evidence keeps these complex clients and their families living in crisis, going from emergency room to emergency room, and using many other high level services. Often one good neuropsychological evaluation can provide a road map for a person centered care team to use to provide cost effective and useful treatment and services.
c) Psychiatrists. While the BHO contract covers psychiatrists for people in the BHO, there is a serious gap in FFS. Clients with developmental disabilities and brain injuries that require psychiatric medication to address their behavioral problems that are not a result of mental illness are entitled to see a psychiatrist and they simply do not exist. The BHOs do not see these clients, even when there is a valid mental health diagnosis. This is a serious problem, and is likely putting HCPF out of compliance with federal regulations, at least for children.
CCDC was surprised to see increases for imaging, as we were under the impression that HCPF wanted to reduce, not increase the use of imaging. We are not aware of any access problem.
CCDC appreciates the opportunity to comment on these proposed changes. CCDC applauds HCPF for thinking outside the box and believes that targeted rate increases are a reasonable method of payment reform with the correct data. If there are questions, please feel free to contact me at any time.
Colorado Cross-Disability Coalition (CCDC)
655 Broadway, Suite 775 Denver, CO 80203 / 303.839.1775 office / 303.952.0528 VP / 303.839.1782 fax