Medicaid Wars (warning: boring)

(more fighting!)

NY Governor Candidates Seek Medicaid Spending Trim

By Michael Gormley, Associated Press October 25, 2010

ALBANY, N.Y. – New York's major candidates for governor shared their ideas Monday for letting some air out of the Medicaid balloon in New York, which spends more on the federal health care program for low-income people than Texas, Florida and Michigan combined.

Republican Carl Paladino released a plan Monday that he said would reduce New York's "gold-plated" system to be more in line with other states. He promises a $20 billion cut in the $52 billion program.

Democrat Andrew Cuomo said in Buffalo that he will work with the health care interests to reduce the "unsustainable" level of spending and would target inefficiencies and fraud. If the health care providers don't cooperate — they've opposed past efforts — Cuomo threatened to simply cut spending.

New York's Medicaid program has grown from government health care for those on welfare to encompass millions more poor and working poor. Nearly one in four New Yorkers receive Medicaid services.

Over the years, lawmakers lobbied by powerful special interests, including hospitals and health care worker unions, have added optional coverage benefits to a program that has long been called the "Cadillac" of state systems.

In 2008, the most recent year of available comparisons, more populous California spent $10 billion less than New York on Medicaid. New York spent more than Texas, Florida and Michigan in total, according to the Kaiser Family Foundation.

Lt. Gov. Richard Ravitch, a widely respected expert on fiscal crises, issued a study last month that found the unwieldy system serves "contradictory goals and provides perverse incentives" and is "ill-equipped to control costs."

E.J. McMahon of the fiscally conservative Empire Center for New York State Policy said the state is already scheduled for a big cut when federal stimulus money runs out next year. That will create an immediate 20 percent reduction in funds, he said, while Medicaid inflation and the rising number of recipients are increasing costs 8 percent a year.

"Paladino deserves credit for recognizing that you can't reduce Medicaid costs unless you are willing to reduce the number of people eligible for Medicaid and reduce the array of services to which Medicaid-eligibles are entitled," McMahon said Monday.

Paladino's goal of cutting $20 billion immediately is implausible, he said, but his plan could save a lot of money over the course of years.

Paladino called Medicaid "probably the single biggest cause of New York's stagnant economy." The $52 billion cost is part of a $135 billion state budget that increased taxes and spending over the past two years.

He said his cuts would save state and local property taxpayers $10 billion in the first year. Paladino said the cut in the county contribution to Medicaid will allow for reductions in county taxes of more than 30 percent.

McMahon called Cuomo's plan "very vague and general."

"Cuomo's solution — 'make Medicaid more efficient' through various administrative reforms — is simply inadequate," McMahon stated in a review of the two proposals.

"We have the highest rate in the nation, and it is just not sustainable," Cuomo said Monday at the Roswell Park Cancer Institute.

He wouldn't detail any cuts but said he would "redesign the entire program," which he considers "fundamentally flawed." He said he would also take over administration from the counties.

And he said he would bring in the health care special interests that have pushed the Legislature to drive up the cost.

"I want to bring in the providers," Cuomo said. "I want to bring in people who are actually doing business with the state and say, 'Guys, we can't afford it anymore. We have to reduce the amount we spend on Medicaid; let's redesign the program together.'

"Otherwise," he added, "I'm just going to have to cut off the top, and that's not the best way to do it."

Associated Press writer Carolyn Thompson in Buffalo contributed to this report.

http://news.yahoo.com/s/ap/20101025/ap_on_el_gu/us_ny_governor_s_race_medicaid/print

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Medicaid Crackdown Paying Off

By Carl Campanile New York Post October 25, 2010

The number of suspected Medicaid-fraud cases handled by state investigators -- ranging from dirty dentists and druggists to millionaires illegally on the dole -- more than doubled last year, according to an explosive new report.

The state Office of Medicaid Inspector General referred 208 cases to Attorney General Andrew Cuomo's office for potential criminal prosecution of health-care providers -- a 136 percent increase from 2008.

Meanwhile, the number of suspected cases of Medicaid-patient fraud referred to local prosecutors also skyrocketed.

For example, the number of suspected forgeries tied to the diversion of prescription drugs jumped from 304 to 683.

Overall, the number of substantiated fraud cases involving Medicaid patients increased 50 percent, the report said. A total of 552 cases were referred to New York City investigators for potential prosecution, the report said.

Medicaid Inspector General James Sheehan attributed the surge in cases to an overhaul of his office the last few years that included an increase in the number of undercover investigative staffers and auditors and the use of a new, more sophisticated, data-mining system that flags suspected problems.

"It's better detection, and more people on the street means more cases. We have the resources and trained people. We're finding the cases," Sheehan said.

"We are also getting a lot more reports [of fraud, waste and abuse] from the public and more disclosure from providers. People know we're looking," he said.

But one state lawmaker said investigators were just scratching the surface of Medicaid fraud.

State Sen. Marty Golden (R-Brooklyn) said OMIG's done a much better job of auditing health-care providers to recoup money from billing mistakes than nabbing fraudsters.

"The inspector general has to put more investigators in the street. We're spending $1 billion a week on Medicaid. Let's get real," said Golden.

Sheehan said the state recouped more than $500 million last year from Medicaid fraud, waste and abuses -- thanks largely to prosecution by Cuomo's office. He said OMIG helped save $1.6 billion overall through audits and cost-prevention measures.

New York spends about $52 billion on Medicaid.

http://www.nypost.com/f/print/news/local/medicaid_crackdown_paying_off_QYiNo9jzsSvZsBcclKYKRN

Cutting Medicaid To Curb Debt Won't Be Easy

by Elizabeth Moore Newsday December 11, 2010

WHATEVER Governor-elect Andrew Cuomo decides to do to close New York's multibillion-dollar Medicaid gap, he'd better be ready to deal with New Yorkers like Geraldine Flynn.

"I fight for everything I need," said Flynn, 55, who has cerebral palsy and uses a wheelchair. Medicaid pays for 24-hour-a-day home health aides for Flynn and for the complicated medical care she needs. It pays monthly rent so she can remain in the family home in Point Lookout while her ailing 88-year-old mother resides in a nearby assisted living center. And it just bought Flynn a new power chair.

"Doesn't mean you get away with anything," said Flynn, who will be moved to Section 8 housing after her mother dies. "Some people think I've got it easy - I don't."

Trouble is, New York State hasn't got it easy these days either.

With federal stimulus aid set to expire next year, intense scrutiny is being trained on the largest single expense driving the budget off a $9.3-billion cliff: Medicaid, on which New York spends twice as much per capita as the rest of the country. Spending on care like Flynn's is soaring even though fewer people are receiving it, noted the Citizens Budget Commission: The cost of caring for a nursing-home patient has gone up 19 percent in the past five years, while personal care services cost 40 percent more and the per-patient cost for certified home health agencies is up 76 percent.

Call For A Redesign

Cuomo, who has vowed not to increase taxes, wants to trim the cost of Medicaid by reorganizing it to eliminate waste and focus spending in ways that really improve health.

"We haven't redesigned the Medicaid program in decades in this state, and now it's time," he told Newsday at an October campaign stop in upstate Delhi.

That's a tall order. New York has the nation's most expansive safety net, one that covers far more services than federal rules require and now stretches to cover 4.7 million people - nearly one in four state residents.

Half of all the babies born in the state are covered by Medicaid. So are three quarters of all nursing home stays. The program not only serves welfare recipients, the disabled and childless indigent adults, but also insures low-income working families, with sliding-scale coverage for children from families earning up to $88,000. And it reimburses hospitals that care for the uninsured. The recession of 2008 and 2009 drove 600,000 people onto the rolls, and federal health care reform is expected to add many more.

"I don't blame people for taking advantage of a program that is available to them," said Lt. Gov. Richard Ravitch, who this fall issued proposals for reform. "I fault all the expansions of Medicaid and child health care that occurred without the government being willing to tax to pay for it . . . The course we're on is not sustainable."

A System With 'Contradictory Goals'

New York's system, created in the 1960s for welfare clients, is saddled with "an unwieldy and overly decentralized structure that serves contradictory goals and provides perverse incentives," Ravitch wrote.

It is the counties that determine who is eligible for Medicaid, but a jumble of different state agencies oversees the various things it pays for - and the legislature controls reimbursement rates, the subject of perennial haggling that helps keep a small army of Albany lobbyists employed.

Lawmakers have made plain they don't intend to give up their rate-setting power. Hospitals, which have seen provider reimbursement rates cut nine times since 2007, warn some of them could go under if those rates drop again. Medical malpractice reform, another long-sought source of savings, has gone nowhere. For now, saving money by reducing eligibility or services is blocked by a moratorium in the federal health care reforms.

Still, "The severity of the state's shortfall is so large that I think more basic questions than we've ever asked have to come to the forefront now," said Sen. Kemp Hannon (R-Garden City).

Cuomo says he'd like to see New York imitate Wisconsin, which last year let health officials and stakeholders decide how to trim 10 percent of the Medicaid budget without reducing care. Those changes, like ending unnecessary Caesarean sections, were accepted by the public with little controversy.

Already the politically powerful health care union 1199 SEIU United Health Care Workers East has begun talks with Cuomo on a proposal it promises will bring "significant savings" by changing the payment model for home health care to predetermined bundles of care based on need, rather than reimbursing providers by the hour.

"The hospital and nursing-home industries are in dire financial condition," warned 1199's political director, Kevin Finnegan. "Any changes . . . have to be dealt with very gingerly."

But Vincent J. Russo, the attorney who helps Flynn with her Medicaid, called the talks in Albany "very concerning. We're seeing difficulty with clients accessing the Medicaid home-care program, and limitations on what they are going to be able to receive."

"I get worried," agreed Peter Belmonte, an airfreight dispatcher whose 85-year-old father was felled by two strokes and has lived for the past seven years in a nursing home on Medicaid. Belmonte's father, a former iron worker who is fed through a tube, is visited daily by his 83-year-old wife, a retired seamstress who remains at the couple's Valley Stream home, living on their pensions and Social Security. Their home was placed in trust to Belmonte and his sister so they can keep it after she dies, rather than having to sell it to pay off Medicaid.

Belmonte doesn't want to see any of these kinds of benefits touched as Cuomo seeks to address the Medicaid budget crisis - a mess Belmonte blames on "poor management."

"We've got a new governor, and I hope he does something about it. If not, he'll have to go too, in four years."

http://www.newsday.com/long-island/cutting-medicaid-to-curb-debt-won-t-be-easy-1.2535981?print=true

newspaper wrote: "I fault all the expansions of Medicaid and child health care that occurred without the government being willing to tax to pay for it . . . The course we're on is not sustainable."

BG wrote: funny how that works.

But such a course is often charted by people of both parties who want to be re-elected or elected.

"If you elect me class president, I will eliminate homework, make ice cream free, and have more snow days"

....campaign donations are now being accepted.

P.S. Like Bloomberg, I'm an independent. :scratch:

Maybe I'll try to become a benevolent dictator as a result

Do Not Tinker With Medicaid! Most Americans Say

Written by Christian Nordqvist Medical News Today May 25, 2011

The majority of Americans do not want to see any reductions in Medicaid spending and are against the proposed plan to convert the health program to block grant financing in an attempt to reduce the federal deficit, according to a May Kaiser Health Tracking Poll, involving a nationally representative random sample of 1,203 adults.

60% of all the people surveyed want Medicaid to remain as it is - with guaranteed coverage from the federal government and minimum standards set for eligibility and benefits. 35% would like to see states receiving a fixed amount of money from the federal government, with each state deciding what services should be covered and who is covered.

Just 13% favor reducing Medicaid spending to bring the deficit down. While 30% say they would accept minor reduction, 53% are against any reductions whatsoever.

These poll results may encourage some Washington politicians and discourage others. Washington is in the middle of a fierce debate about Medicare and Medicaid - in fact, any entitlement program is currently under the microscope as a possible avenue for saving money.

Approximately half of all US citizens either have a household member or friend who has received Medicaid assistance. Half of those surveyed see Medicaid as important to their family. 20% of adults have had personal coverage experience with Medicaid and they say they are happy with it.

Kaiser President and CEO Drew Altman, said: "If you watch the debate about the deficit and entitlements, you would think that almost everyone has a problem with the Medicaid program and wants to change it, or cut it - or both. The big surprise in this month's tracking poll is that one group who does not want to cut Medicaid is the American people. With about 69 million people expected to be covered by Medicaid this year, it is no longer the -welfare-linked program it once was. Medicaid may not be the lower-hanging fruit that many who want to reduce federal entitlement spending have assumed it is."

Medicaid Experience

51% of all Americans say they have some personal connection to Medicaid

20% have received direct Medicaid help

31% say they have a friend or family member who has received Medicaid assistance

49% describe Medicaid as "very" or "somewhat" important to them and their family

71% of those who favor Medicaid say their main reason is, knowing there is a safety net to protect those on low income. Others feel encouraged knowing that Medicaid is there in case they or a family member need the assistance.

Mollyann Brodie, a senior vice president and director of the Public Opinion and Survey Research group at the Kaiser Family Foundation, said: "Medicaid is a complex program that varies considerably from state to state, but the public's initial reaction upon hearing about proposed spending reductions and structural changes is negative. Such concerns reflect the fact that the program is important not only to those who have been directly enrolled in it but those with friends and family who have received Medicaid benefits as well."

Medicaid and Private Insurance Personal Experience Ratings

86% of recipients of Medicaid benefits describe their experience as "positive"

45% of recipients of Medicaid benefits describe their experience as "very positive"

89% of private health insurance users describe their experience as "positive"

44% of private health insurance users describe their experience as "very positive"

Under the Patient Protection and Affordable Care Act, Medicaid is set to expand. 81% of respondents said that if they were uninsured, needed medical therapy and had no insurance, and also qualified for Medicaid, they would enroll.

However, some 32% of those who have ever used Medicaid said that at some point, finding a doctor or health care provider willing to accept Medicaid patients was difficult, versus 12% among those with private insurance cover.

http://www.medicalnewstoday.com/articles/226483.php

NY State Gov to towns and cities: Sorry, we won't pick up your share of medicaid.

http://www.lohud.com/article/20111007/NEWS05/110070351/Cuomo-shuns-counties-Medicaid-plea?odyssey=mod

In a desperate attempt to control costs, the state implements Health Homes.

Medicaid 'Health Homes' Not Built

Schenectady, Saratoga Counties Await State Action As Networks Begin To End Fee-For-Service Care

By Cathleen Crowley Albany Times Union October 26, 2011

On Jan. 1, the state's Medicaid system will start moving into a new model of care. But as one Department of Health official said, describing it is like trying to explain a world inside Dungeons and Dragons: It doesn't really exist.

Schenectady and Saratoga counties are among the first counties that, starting Jan. 1, are supposed to enroll Medicaid patients into "health homes," or networks that will manage the care of a Medicaid patient. The state has yet to designate the counties' health homes, or set details of how they will run.

Many providers are overwhelmed by how fast the state is changing policies, and fear that patients will slip through the cracks. Organizations are scrambling to partner and form health homes. Even though the start date is Jan. 1, state officials said it will be an evolving process that will take years and enrollment will happen gradually as health homes get up and running.

Health homes are not brick-and-mortar structures, but networks of local providers that will share the responsibility of caring for each Medicaid patient they enroll, including physical, mental health and addiction needs. Most networks will be led by a hospital, a community health organization or an insurance company.

For example, the Visiting Nurses Association of Schenectady and Saratoga Counties is the lead agency in a proposed network that includes Ellis Medicine, Hometown Health Centers, CDPHP and MVP Healthcare.

State leaders believe that coordinated care will be cheaper and better compared to the scattered fee-for service care Medicaid patients currently receive.

"There are probably a bunch of people here mourning the loss of fee-for-service," said Michael Hogan, commissioner of the state Office of Mental Health, referring to the previously dominant model. "But get over that. We are not going back there."

Over the next several years, state leaders hope to move all five million Medicaid recipients into managed care. The early focus will be on high-cost, high-need patients, including 150,000 Medicaid patients who account for $7 billion in Medicaid spending.

Medicaid patients will be assigned to health homes, but they have the right to opt out or choose another network, said Greg Allen, director of the state Department of Health's financial planning office.

Health homes will receive incentive bonuses for keeping their members healthy. The state expects to save $33 million in Medicaid expenditures in the first year by reducing hospitalizations and ER visits.

More than 300 providers and mental health advocates spent Wednesday morning learning about health homes at the annual conference of the Mental Health Association in New York State held at the Albany Marriott.

Speakers at the event encouraged the audience to embrace the changes.

"This is our chance to get it right for patients who have multiple chronic illness or mental health illness," Allen said.

Health Homes

Many organizations have filed letters of intent with the state indicating they plan to form a home health network. The state plans to approve a few networks in each community. Here is a look at some of the lead organizations that have filed letters in the Capital Region, along with a sampling of their partners. The full list is available on the Department of Health website.

Making the List

· Visiting Nurses Association of Schenectady and Saratoga County with Ellis Medicine, Hometown Health Centers, CDPHP and MVP Healthcare.

· Glens Falls Hospital with Adirondack Medical Services, Hudson Headwaters Health Network and Saratoga Hospital.

· Samaritan Hospital Behavioral Health Services with the Rensselaer County Department of Mental Health, Northeast Health Primary Care Network and Seton Primary Care.

· Whitney M. Young Jr. Health Center with Albany Medical Center, St. Peter's Health Partners, CDPHP and Fidelis.

· AIDS Council of Northeastern NY with Albany Medical College's AIDS Treatment Center, Hudson Headwaters, Clearview Center and Four Winds Hospital.

· Belvedere Health Services with Ellis Hospital, Samaritan Behavioral Health, and Rehabilitation Support Services, Inc.

· ClearView Center with Albany County Mental Health, Albany Medical Center, and Saratoga Hospital. Rehabilitation Support Services, Inc., with Ellis Medicine, Catholic Charities AIDS Services, and Albany Medical Center.

The full list of "health homes" is available on the Department of Health website.

source: http://www.timesunion.com/local/article/Medicaid-health-homes-not-built-2238351.php#ixzz1c6uYvsk9

The answer makes being a member of SCOTUS seem less appealing.

Meanwhile, the policy wonks wonder what should be tried next if the Supreme court strikes down Obamacare implementation and we are left with our current mess: http://www.kff.org/pullingittogether/dual-eligibles-health-reform.cfm

Expansion of Medicaid seems to be something that will be left to the states. Will poor states do the federal minimum?

How The Medicaid Expansion Could Actually Save States Money

By Suzy Khimm , Washington Post Blog July 5, 2012

Republican governors opposing the Medicaid expansion have focused on the costs their states would have to take on. But there are also ways that the expansion would save state governments money, helping to offset at least some of the new upfront Medicaid costs. And in some cases, they’re likely to save states more money on Medicaid than they currently are spending.

First, many state and local governments help hospitals offset the cost of care they provide to uninsured patients who can’t pay for medical care — paying about $10.5 billion, or 18.5 percent, of the cost of uncompensated care, according to a 2008 study cited by the Urban Institute. Having more patients on Medicaid would help bring down those costs for everyone, which is why hospitals are lobbying hard for states to participate in the expansion.

Second, the Medicaid expansion would also reduce state spending on mental health services for lower-income and uninsured patients, which has also grown over time. State and local governments covered 42 percent of the cost of state mental health expenditures in 2009, totaling $16.3 billion. That covered mental health services provided by state mental hospitals, emergency ER visits and, increasingly, community health clinics.

Enrolling more state residents into Medicaid would help offset some of the spending on mental health that state and local governments are shouldering already. States will have to begin contributing to Medicaid coverage as well, starting in 2017, but they will still be matched by federal dollars at a 9:1 ratio, getting more bang for the buck on the money they do spend.

Advocates for mental health are appealing for states to join the Medicaid expansion on similar grounds. “The expansion of Medicaid also requires those who are newly eligible to receive mental health and substance use services at parity with other benefits. State participation in the Medicaid expansion is therefore critically important,” Mental Health America said in a statement after the ruling.

Overall, the savings will likely bring down the upfront costs to states of the Medicaid expansion. The Center on Budget and Policy Priorities calculates that state Medicaid spending will ultimately rise by 2.8 percent by 2022 if they join the expansion. However, that figure “actually overstates the net impact on state budgets because it does not reflect the savings that state and local governments will realize in health-care costs for the uninsured,” says CBPP spokesperson Shannon Spillane. “In fact, states could end up with a net gain.”

Without factoring in these hospital and mental health savings, only Maine, Massachusetts, and Hawaii are likely to see net savings* from participating in the Medicaid expansion, according to a report that the Urban Institute produced for the Kaiser Family Foundation. The GOP states that have opposed the expansion will pay more upfront, largely because they already have more restrictions on who can participate. But with the savings from uncompensated care and mental health, the number of states seeing net savings could rise.

http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/how-the-medicaid-expansion-also-saves-states-money/

New York’s Medicaid Reforms

New York Times Editorial September 17, 2012

New York State has substantially changed its Medicaid program in the past year and a half in ways likely to improve the health of its poorest residents and rein in the program’s enormous costs.

Now the state is asking the federal government to let it use $10 billion in projected federal savings from its reforms to modernize hospitals and clinics serving the poor and to expand primary and preventive care. If spent wisely, that investment could turn New York into a model on how to cut Medicaid without harming the beneficiaries.

New York’s Medicaid program, the nation’s costliest, spends more than $54 billion a year to cover some five million people, about a quarter of the state’s population. Roughly half the cost is paid by the federal government and the other half by state and local governments.

New York faces the same problem as many other states: its share of the costs of this state-federal insurance program for the poor has been rising steadily, limiting its ability to pay for other urgent needs, like education.

Last year, Gov. Andrew Cuomo, working in collaboration with health care providers and labor leaders, pushed through a budget that seems to be easing the stress. It places a cap on what the state can spend on most Medicaid programs, cuts payments to health care providers and managed care plans and sets up a mechanism to make further cuts to provider payments to stay below the cap, which, so far, has not been breached.

The cap started at $15.3 billion last year and is allowed to rise by only 4 percent a year, bringing it to $15.9 billion for the current 2012-13 budget year. The state’s total budget for Medicaid, including noncapped programs, is $20.8 billion for the current year.

The reforms do not impose higher cost-sharing on beneficiaries or make significant cuts in benefits except in a few programs, like home care visits for housekeeping services or unlimited rehabilitative services.

Most important for the long term, the budget accelerates movement from uncoordinated fee-for-service care to managed care, from high-priced specialists to primary care doctors, and from high-cost institutions to care in the community through grants, technical support and financing for health information technology. Most providers have agreed to accept lower payments in return for having a say in the reforms, rather than having them dictated by Albany. The state estimates its reforms should save the federal government $17 billion over the next five years.

The Centers for Medicare and Medicaid Services should allow New York to plow $10 billion from money the federal government will save if New York’s projections of future Medicaid savings are as plausible as they look at first glance. The agency should also look hard at New York’s plans to track and measure how well its reforms work and to obtain independent evaluations from outside experts. New York could serve as a model to other states if it can show which reforms work, which don’t, and what their combined effects are on statewide spending.

http://www.nytimes.com/2012/09/18/opinion/new-yorks-medicaid-reforms.html?_r=1