Author: MM_ADMIN

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Clay’s Weekly Medicaid RoundUp: Week of February 6th, 2017

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2lygShv

Or you can click the Special Valentine’s Day treat for optimist readers –  http://bit.ly/2lyalTX

 

It’s been a while my dearest readers. As is our custom when returning from hiatus, let’s begin with the normal ending segment…

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award.  Maria Navarro and Judith Bench of Orlando are charged with using their special needs school to bill 21,000 bogus Medicaid therapy claims. They billed for 8 hours a day but only had staff to provide 2. Taxpayer tab – $4.5M. Pedro Garcia of Mission, TX was charged this week with submitting Medicaid claims for dead people – to the tune of $300k. John Holland of Miami was CEO of Portneuf Medical Center when he (allegedly) took bribes that facilitated $12M of Medicaid fraud. He plead not guilty this week. Michael Johnston of Broadheadsville, PA got sentenced for pilfering $100k from Medicaid using bogus mental health services claims. Mr. Johnston took the cash and used it cover trips to Jamaica. Stephen Monaco (awesome name), a podiatrist from Haverton, PA was sentenced this week for stealing $4.9M from Medicaid, Medicare and other payers. Dr. Monaco would barter opioids with patients in exchange for them letting him shoot painful (but unnecessary) injections into their feet. Eduard Zavalunov of NYC became the 9th fraudster to plead guilty in a multi-clinic racket that bribed Medicare and Medicaid bennies (with cash) to undergo unnecessary tests. Taxpayer tab – $70M. Shalonda Suggs of Oklahoma City pled guilty this week to a $200k mental health services not provided scheme. Julia Faigel of Boston, MA was ordered to pay $475k for Medicaid dental fraud. She had TWENTY ONE corporations she used to rob the taxpayers. Robert Windsor of Cumming, GA pled guilty this week of bilking GA Medicaid, KY Medicaid, Tricare and FEHBP (the healthcare federal employees get) for more than $20M. His gig? Medically unnecessary balance tests, electromyography (whatever the heck that is) and qualitative drug screens. IPC – a hospital staffing firm that provides doc labor, also goes by Team Health if you are googling for it- will cough up $60M for defrauding Medicaid and Medicare via upcoding. Dr. Oughatiyan was the whistleblower and he will get $11.4M. Bernard Greenspan of Newark, NJ got $200k in bribes for his role in a $200M fraud scheme. He’s pleading innocent (he’s also 80 years old), but 2 dozen other docs have pled out on this scheme which involved Biodiagnostic Lab Services bribing docs for referalls to Medicare and Medicaid. And now, drum roll (we have a lot of contestants this week!)… Mr. Windsor you win this week’s award for your tenacity and not settling for ripping off just one Medicaid program. Indeed – stealing from both GA and KY sets you apart. I hope you stashed some cigarette money someplace, so you can barter in the slammer.

 

Sadly, I was able to fill an entire Roundup with fraud follies (with a total of about $384M stolen by my rough count). I could do this each and every week (but that would be boring). And I left out several big ones this week, too. Nothing to see here, move along. Regardless of whether we repeal, replace or repair there will always be this wonderful gravy train for fraudsters. As I pay my taxes in the next month or so, I know that makes me feel good. How about you?

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (I swear we never have winter anymore here in AL. Must be global warming, or maybe the Russians?) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Papa a voye Pitit la pou konsève pou mond lan

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Clay’s Weekly Medicaid RoundUp: Week of January 9th, 2017

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2irmSci

Or you can click the one for optimist readers –  http://bit.ly/2irnjDt

 

WAIT A MINUTE- WHO’S SURPRISED AT THE CURRENT ACA REPEAL EFFORTS? It’s been hated by millions since day 1 (and loved by millions, especially on the left), the GOP has introduced 60+ repeal bills over the last 7 years – and now everyone is floored that one of the first things the Right does once it regains control is renew repeal efforts? The Senate took step 1 of a 10-step procedure to repeal ACA early Thursday morning. Here’s the best guide I have seen so far – http://read.bi/2ipCPji

 

THE LAND OF OPPORTUNITY STATE PUTS APPLICATION BACKLOG TO REST- AR brought in about 250 temp workers, but they got it done. Back in June there were 100,000 “pieces of paperwork” overdue, including 34,000 or so apps that were 45 days old. At year end (just a few weeks ago – weird), there were no overdue apps. Hey AR – can you send those temp workers over to KS?

 

SOONER STATE MCD NEEDS ANOTHER $200M TO KEEP THE LIGHTS ON- My crystal ball says they will get it. Just look at last year- when the overall OK budget was $1.3B short, OK Mcd got $1B (which was an increase over the previous year). You silly lawmakers need to just submit to the Mcd dominance of your budgets and move on.

 

MAGNOLIA STATE NEEDS ANOTHER $75M NEXT YEAR- Backers of the bump point to cuts in prior years, as well as a recent $58M cut in September that addressed lower-than-expected state revenues. It is interesting that the request for more money is happening when MS enrollment is decreasing.

 

KUDOS TO HPP ON THE KEYSTONE WIN- Health Plan Partners was awarded new membership  in PA this week. The award will expand the HPP PA footprint into 13 more counties, home to nearly 500,000 Mcd members. Congrats HPP!

 

THE COPPER STATE ANTI-EXPANSION LAWSUIT MOVES FORWARD- Its only been four years of spending money on the 300,000 new bennies, but the AZ Court of Appeals has scheduled the hearing challenging whether the way the Good Guvn’r Brewer unilaterally expanded was legal in the first place.

 

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award.  Family Care Nursing (such a wholesome name!) of Meriden, CT settled this week for $5.3M related to billing for 60 day assessments knowing it was not an RN doing the work. Aretha Derrico was arrested for billing Mcd for $57,000 of home health services not provided in Havana, FL. Randy Crowell of Henderson, NV plead guilty to a $100M Rx reverse-diversion scheme last week. Mr. Henderson had an impressive range – from Utah to NY. How did he do it? He was a licensed wholesale rx distributor, of course. Still wondering what “reverse-diversion” means (I made that up, I think)? Instead of the pills going from legit sources to the black market, Mr. Henderson acquired pills in the black market and sold them to pharmacies. Sort of like money laundering, but with oxycontin. Although the specific hit to Mcd is not enumerated, I am more than impressed with this one. There are wonderful details like the use of lighter fluid to remove labels from bottles. Mr. Henderson – you win this week’s award! I would be interested in acquiring the movie rights to your story, when you get out of the slammer.

 

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (or stay inside and order your pepper seeds. They will need 30 days to germinate, and then that’s March and you want them strong when you put them out in May, right?) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pitā sēva dha varlḍa dīkarānī

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Medicaid Industry Who’s Who Series: Shannon McMahon

Medicaid Who’s Who: Shannon M. McMahon– Deputy Secretary, Health Care Financing with Maryland Department of Health and Mental Hygiene

Shannon M. McMahon, MPA, was appointed the Deputy Secretary of Health Care Financing at the Maryland Department of Health and Mental Hygiene in February, 2015. In this role, she is responsible for the operation of the state’s Medicaid program, which serves over 1.2 million Marylanders.

Previously, Ms. McMahon was the Director of Coverage and Access at the Center for Health Care Strategies (CHCS) where she lead Medicaid eligibility, benefit design and purchasing implementation efforts and learning collaboratives for states and the federal government. Prior to CHCS, she worked in executive and management-level roles in Minnesota Medicaid, most recently as the Chief Administrative Officer, where she oversaw finance and operations for Minnesota’s three public health care programs.

Ms. McMahon also spent several years working on health policy issues as a non-partisan analyst at the Department of Legislative Services in Annapolis and also held the position of senior budget and policy adviser to the Secretary and Principal Deputy Secretary of Maryland’s Department of Health and Mental Hygiene.

Ms. McMahon has a bachelor’s degree in justice from American University, Washington, D.C. and a master’s degree in public administration from Northeastern University, Boston, Massachusetts where she was a recipient of a full tuition public policy fellowship. She is a member of the board of directors of the National Association of Medicaid Directors.

Shannon McMahon is the featured panelist in the upcoming State Spotlight Webinar on Feb. 6th at 2pm EST. Learn more and register for free here.

  1.  What is your current position and with what organization?

Deputy Secretary, Maryland Department of Health and Mental Hygiene/Medicaid Director   

  2.  How many years have you been in the Medicaid industry?

 I’ve been working in health care policy/operations and consulting for 19 years; my focus has always been on the public sector, and Medicaid in particular.

  3.  What is your focus/passion? (Industry related or not)

My passion is making the government side of health care (enrollment, access) more person-centric.  I love Lean and business process re-design.

  4.  What is the top item on your “bucket list?”

Snuba the great barrier reef

  5.  What do you enjoy doing most with your personal time?

International travel with my family; I think that foreign travel is the greatest gift you can give kids, as it imparts two key business and life skills: organization and resilience.

  6.  Who is your favorite historical figure and why?

Eleanor Roosevelt; I’ve always admired her commitment to public service and her ability to problem solve in the most politically charged environments.

  7.  What is your favorite junk food?

Snickers

8.  Of what accomplishment are you most proud?

The recent Section 1115 waiver that we secured for Maryland Medicaid is a very big step to begin addressing the social determinants of health at the local level while also expanding access to substance use disorder services in the State.  The partnership forged between the State and local governments, as well as the support from the provider and advocacy community made it possible.  The amazing team in Maryland Medicaid worked hand and glove with our federal CMS counterparts to get ‘er done.

  9.  For what one thing do you wish you could get a mulligan?

I have a knack for calling people by the wrong name, and have done so with some pretty senior people in both government and the provider community. 

  10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

In Maryland, we are coming off the recognition of the 50th anniversary of Medicaid in 2016.  Our  two big focuses for the next six months are

(1) Implementing the SUD expansion under the 1115 waiver which includes a physical health-behavioral health integration component;

(2)  Developing a new payment and delivery system for individuals dually eligible for Medicare and Medicaid.

(3) Potential changes to the ACA will be of particular interest to Maryland as well, and as a member of the NAMD board, I have had the opportunity to engage with the key executive and legislative branch leaders on potential changes.  

 

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Clay’s Weekly Medicaid RoundUp: Week of January 2nd, 2017

Soundtrack for today’s RoundUp pessimist readers- https://www.youtube.com/watch?v=9jK-NcRmVcw

Or you can click the one for optimist readers –  https://www.youtube.com/watch?v=cYrUW68kggg

BONUS Optimist Song: https://www.youtube.com/watch?v=btPJPFnesV4

 

SOMEBODY TELL THE GOOD GUVN’R HE’S WEARING LAST YEAR’S FASHIONS: Perhaps the protracted battle with the outgoing Guvn’r has left NC Good Guvn’r Roy Cooper a little confused. He is talking about expanding Mcd in the Tarheel State, seemingly unaware that expansion is yesterday’s news. He promised to submit a state plan amendment by this Friday to expand under ACA rules, which have to be approved by CMS. This is either a PR stunt only, or the new Guvn’r is more clueless than the average bear.

 

NOW THERE’S AN IDEA: AK ASKS TO KEEP ACA CASH FLOWING BUT WANTS MORE CONTROL ON LIMITING ELIGIBILITY THAN ALLOWED BY MASTERS IN THE DISRICT (CAN I USE 2 COLONS IN A HEADLINE?): The Good Guvn’r Hutchinson has been in talks with the new cabinet members about letting AR tighten eligibility requirements for its expansion bennies. He may end up getting what he’s been begging CMS for for years after all. Amazing the difference a new king (er, President) makes.

 

AND SO IT BEGINS- One half of the country seems to be moving into the next phase of grief. The denial phase was like watching a train wreck- fascinating (Stein’s stratagem and the attempts at electoral mutiny), terrifying (Fake News pots calling kettles black) and pitiable (b-b-but the Russians did it!) all at the same time. We are now witnessing the negotiation and acceptance phases best I can tell. I now see Op Eds discussing how block grants may not be that bad (as long as its tied to healthcare inflation) and detailed analysis of the expected GOP battle plans to repeal the sacred cow of ACA (as opposed to the previous stance of “but they can’t do that).

 

KS ELIGIBILITY APPS: STILL LATE- 2 years and counting for the backlog. State officials did get it down to 1,400 or so in September (from a high of 15,000), but its climbing again. The latest number is 2,247 apps at least 45 days old.

 

MCO TIDBITS: Item 1) WellCare completed its acquisition of Care1st of AZ this week, adding 115,000 lives to the ledger. Item 2) Iowa newspapers are now reporting they have obtained secret documents showing MCOs calling the Iowa program “drastically underfunded” and a “catastrophic experience.” Sensing that these documents reveal a disconnect between what is being said publicly and privately, Mr. Pin Ochio has stepped in with new evidence that Oceania hacked the Iowa Medicaid agency. He insists we ignore the contents of the documents and focus on the manner of their discovery.

 

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. There’s actually just one this week: Abe Freund, operator of Acacia Mental Health Clinic, LLC in Milwaulkee has been charged by the feds with stealing as much as $7M from Medicaid. Acacia was billing $474 for drug tests that should have been paid at $20. At the end of the feeding frenzy, 99% of all Wisconsin substance abuse counseling payments were going to Acacia. Acacia payments surged from $300k to $3M over a few years. Lesson learned (?)- when you see 99% of your SA payments going to one provider that’s grown tenfold in a few years, maybe you should have something in place to stop paying that provider number before it gets to that point?

  

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (enjoy the snow! One Yankees nuisance is a Southerners magical experience) and keep running the race (you know who you are).

****

FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: o Patéras ésteile ton Yió gia na sósei ton kósmo

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Saying Goodbye to 2016 (The Year in Review)

I needed to write this review of the last 12 months.

I was not going to, but then my dog died last night and now I need to. All the stored-up objections to writing this article melted in the face of that reminder of how precious, how miraculous our lives are. I have had humans die in my circle recently, and of course that’s much more serious and painful than losing a dog. But sometimes the smaller things become the bigger things when you hold back the bigger things for a while. Last straw, finger in the dam and all that.

For those of you who have followed my work these last few years, you have noticed I have an ongoing conversation with readers. It’s a strange conversation in which I am unable to separate work from life and life from work. This entangled-ness is perhaps because of the nature of Medicaid (it calls for all-in-ed-ness, and a bit of extremity in working), perhaps its because of working too hard (like so many of us are guilty of- and it is a real problem, not a badge of honor). Perhaps it (the entangled-ness, in case you lost the noun, which I almost did) is simply because I am no good at setting boundaries between readers and clients and friends.

My writing is also strange in that it’s a mix of macro-analysis about Medicaid, seasoned with sarcasm and redeemed (I think) with small glimpses into the human heart.

For those of you that read my writing, this entry is my Thank You Note for 2016 to you. Its me showing you what just falls out of my head when I let it. Thank you for reading, for commenting, for writing in, for calling and leaving voicemails just to say you appreciate what I am doing in the space. And thank you also to those who disagree in sometimes very frustrated manners.

What you all (who am I kidding? I mean, y’all!) may see as small gestures are incredibly powerful fuel and encouragement to me.

As is my way, after a top-heavy windup, here are my summarized reflections for 2016 across various topics:

Reflections on Work

  1.  The industry itself has seen so much excitement this year. First there was the ongoing saga of expansion. And the guilt-tripping of those who still had concerns. And the ignoring of the gigantic cost overruns by those who leapt into expansion a few years back. It got so boring to see the same news articles written over and over again, just with different characters playing heroes and villains in the story of the Medicaid Expansion Crusades. It became scary to see otherwise Very Smart People unable to grapple with ideas they disagree with (i.e., not expanding Medicaid) by labeling expansion the Highest Moral Issue of the land. We often forget that there are other things discussed in state houses besides Medicaid. Important things. Yes – Medicaid is uniquely important. But not All Important. And those of us living in the bubble of the healthcare world would do well to remember that. We must continue our fight to help the Least of These, but not at the expense of what is important to other people (like education, and roads, and state parks and a hundred other things that don’t get enhanced Federal matching funds).
  2. ACA’s nakedness is beginning to show. The true costs of ACA became painfully apparent in mid-2016. With a few years of data behind us, we were able to see that new bennies cost 50% more than promised during the sales phase. And that annual promises of “but it will go down next year, we’re sure of it!” were well-intentioned, but ultimately empty promises. All the wacky, tried-and-true health policy explainer theories stopped working. No matter how persuasive celebrity pop-economists are that the economy can be whatever we think it is, that common sense doesn’t matter, that new chapters in new best sellers peddling new sophistry will trump laws of economics (or that there are no laws, even there)- we hit the cold, hard wall of reality this year. Giving millions more people “coverage” will cost billions and soon trillions more. De-linking “access” to personal responsibility will risk the whole thing. And yes, of course, many good things happen when people have easier entry into the healthcare system via an insurance card – but if we want to the world to fund our Crusade, we must be crystal-clear about the true costs.
  3. The election. I stopped there with just the subject of a sentence I honestly don’t know what verb to end it with. The election is disruptive innovation for Medicaid (though I don’t see all those hipsters who worshiped Uber for disruptive innovation looking at the New President this way). The election will bring change (as it always does). The election was divisive (as it always is). The election followed the established laws of the United States of America- but it will still be resented by those who lost (as it always is). Various forms of mutiny will be attempted. Hold on tight. Don’t trust any politician on either team until they deliver something tangible you want. If you haven’t seen my article focused on this, you can read it here – “Make Medicaid Great Again.”
  4. Mostly Medicaid has had an incredible year. The Webinars were an insanely popular success. As are most things we do, we started the webinars because I had a random thought one morning at 4 am that webinars where people just talk about Medicaid would be interesting. So we started doing them. For the State Spotlight Series, we hit 8 states in 2016. The talent and passion by each of the Medicaid agency team members that joined the panel is incredible. The News Roundtable show was a blast – and I get to chat about Medicaid news with some of the smartest people in the space every month. The Weekly RoundUp continues to be my favorite part of all of this. I am still amazed that nearly 10,000 people read this thing (we think, based on various data points we have strung together). And it seems that about 96% of them love it. And the other 4% still read it, sometimes as a guilty pleasure I think. We also got to work with tons of new clients on the consulting side and training side in 2016. We assisted people with everything from basic and advanced Medicaid training in government agencies to implementing MCO programs in the private sector to winning technology RFPs and about two dozen other things that were rewarding and fun to do.

 Reflections on Life

1. There was a lot of really good and pleasant things in our life this year. The kids have met the new challenges placed on them in our homeschool model and flourished even more in 2016 than in 2015. My garden did well, considering (see item 2). Hot peppers of various Scoville heat units were had all around. A Zinnia forest sprung up and I rooted dozens of gardenias. We made our first batch of wine, and have started on a large batch of fig wine. We went on a safari with the kids (in Georgia, where you drive a car through a few acres of herbivores and they stick their heads in the car because you have food pellets). My wife and I celebrated our 10th anniversary. We met each other randomly in Disneyworld 11 years ago. Come up and say hi at a conference some time (so far I am chairing 3 of them in 2017) and I will tell you that story. It’s a good one.

There’s another story that I have become fonder of telling in 2016, too. It’s the Gospel and how it relates to Medicaid. I have realized there are many who have not heard the true Gospel, and there are many who are secret believers afraid to speak. I hope that I am bolder in 2017 about speaking, and that they are encouraged by that.

2. There was also sadness. And scary things, too. My wife almost died in my living room in July due to a pulmonary embolism. Our world was rocked by something neither of us had ever heard of (and I am a healthcare guy). She is recovering very well, but I still think of that moment often. It was terrifying and an incredibly clarifying experience. Everything stopped for about 3 weeks. I have wonderful clients who were 100% supportive when trips were cancelled and deliverables delayed. I think overall, the experience taught me that “healthcare” is a real thing when it hits you, and its not just an 1115 waiver application, or an MCO HEDIS report. Husbands love your wives. You are likely (like me) a fool who does not realize how precious they are until you are reminded by tragedy (or near tragedy). 2016 also saw a return of my father’s severe depression. Each year I learn more how deep the impact of a Father is on a Boy. Sometimes there’s nothing you can do but listen and sit with your loved ones. And to believe that they will get better.

2. And then there was the dog. I find that it is important to write while things are fresh on your mind. Keegan died about 12 hours ago. He was a beautiful dog, a Sheltie. A very good and well-trained dog. A vacuum cleaner under our table after the chaos of dinner with 4 children. A loud sentry when the UPS or postal person dropped packages at the door. An obstacle in the middle of the night on the tile floor of the bathroom, because the tile is cooler and he likes(d) that. A herding dog that actually got herded by our ducks. A friend. Especially to my young children who struggle this morning as they wake up and their friend who has been around most of their little lives is not where they expect him.

I am not yet to the part of the experience where I can offer insights other than this: Life is precious, and it is bound up in the relationships we have with people, animals, our work, and our God. Cherish it. Help others along the way.

 Looking Ahead to 2017

And now a few thoughts about next year.

  1.  Work – We will continue with the webinars, and I am excited about that. I hope to get back to work on the book about Medicaid Directors themselves (working title: “A Day in the Life: Running a Medicaid Program Really is Rocket Science”). I look forward to what new clients I will meet and help.
  2. Life – I am sure 2017 will be unique and bring its own mix of good and bad.
  3. 2017 itself is a prime number. I like prime numbers.
  4. I will turn 40. 40 is not a prime number.
  5. I have big plans for the garden. I will keep you posted.
  6. I plan to be more positive about Medicaid in general. Maybe reduce the sarcasm (I prefer “wit”) just a bit. A tad. A dollop. A smidgen. A hair.

Most of all I intend to focus on one simple thought: Live Today Now.

That’s it for this year. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (build a fire with all those boxes from the presents) and keep running the race (you know who you are).

****

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Medicaid Industry Who’s Who Series: Sheila Wilson

Medicaid Who’s Who: Sheila Wilson, BSN, RN, CCM – Director of Care Management, Medicaid with Priority Health

Sheila is a Registered Nurse with over 31 years’ experience in both clinical and managed care environments. She has extensive experience in case management, and is especially knowledgeable about the challenges facing the Medicaid population. Currently Sheila serves as the Director of Care Management for Medicaid at Priority Health, a Michigan based company serving HMO, PPO, Medicare and Medicaid members across the State of Michigan. Her responsibilities include the development, implementation and administration of programs to achieve medical cost goals for the Medicaid Business Unit. She directly oversees case and disease management, as well as medical utilization operations. Sheila and her team recently received two prestigious Pinnacle Awards from the Michigan Association of Health Plans for work done to incorporate children with special health care needs into managed care, and for spearheading a pilot project with the use of a medical mobile application for children with asthma.

Sheila obtained her Bachelor of Science degree in Nursing from Alverno College, and has held her Certification in Case Management (CCM) since 1994. She has completed the first year of a 2 year Executive MBA Program with Grand Valley State University. She currently lives in Grand Rapids, Michigan with her husband Bill and daughter Ashley.

At the Medicaid Innovations Conference, where Clay Farris of Mostly Medicaid is the Event Chairperson, Sheila Wilson is presenting the following case study:

Taking a Multidisciplinary Approach to Care Management and Delivery: Creating Provider, Health System, and Community Partnerships
Priority Health created the Medically Complex Children’s Program to improve the member experience. A team of Pediatricians, Care Managers, Community Health Workers, Nurses and Specialists within the Academic General Pediatric Residency Clinic (part of the Spectrum Health System), coordinate care for members and aid with basic needs like food, housing, clothing, medication management and transportation. One of our most vulnerable members, a child whose family was new to the United States, arrived to the hospital with acute liver failure and needed a transplant. His parents lacked the resources that the child needed for proper care, so he was enrolled in the Medically Complex Children’s Program. After he was enrolled, a complex care plan was created with input from all team members, including the member and family. The care team assigned to his case helped plan, anticipate his needs between appointments, provide ongoing reinforcement of the care plan and minimize unnecessary Emergency Department visits. The program focuses on one patient, one family, one care plan and one care team to create a better member experience and better health outcomes!

You can learn more about this topic and the rest of the agenda at http://www.medicaidinnovations.com/

  1. Which segment of the Industry are you currently involved?

I am currently working within the Medicaid Program at Priority Health.  Priority Health is one of 11 Managed Medicaid Health Plans here in the state of Michigan. 

   2. What is your current position and with what organization?

I am the Director of Care Management for the Medicaid Program here at Priority Health.

  3. How many years have you been in the Medicaid industry?

I have been working within the Medicaid Care Management Field since 2002. 

  4. What is your focus/passion? (Industry related or not)

I have a passion and commitment to the underserved in the counties in which I live and work.   Understanding the barriers and challenges to obtaining the needed health and social services by segments of our population who are often overlooked and disenfranchised is a core element of my being.  I believe that we each can impact the trajectory of another person’s life through the hard work and examples that we set for each other.

  5. What is the top item on your “bucket list?”

I actually have two items that occupy the top spot.  I would love to have the ability to go to Washington, meet with our Legislators and discuss some of the current issues facing our Country and our State today.  My minor in college was Political Science, so I have a strong interest in our political system.  On a more personal note, I would love to travel the country, visiting small towns and big cities along the way.  I particularly enjoy the coastal areas and would love to spend some time sailing with my family.

  6. What do you enjoy doing most with your personal time?

I love spending time with my 3 grandchildren.  Time stops whenever they are around.  I love curling up with a good book in front of the fireplace during the cold winter months and tending to my garden during the summer months.

  7. Who is your favorite historical figure and why?

I would love to meet both Hillary Clinton and Michelle Obama.  I think they are both brilliant women who believe in the strength and tenacity of all women.

  8. What is your favorite junk food?

I love vanilla frosted unfilled long johns.  My father use to get them for me when I was a little girl and I’ve loved them ever since.

  9. Of what accomplishment are you most proud?

I am almost finished with my Executive MBA Program. I was able to do this while caring for my 89yr old mother, my husband and 16 yr. old daughter as well as working full time as the Clinical Lead for our Medicaid Product.  So many times, I doubted my ability to do it all and yet have somehow managed to meet the needs of my family and myself, both professionally and personally. 

 10. For what one thing do you wish you could get a mulligan?

Very early in my career, I was given the opportunity to attend an OB GYN Nurse Practioner Training Program at virtually no cost to myself.   I turned down that offer.  I often wonder how different my life would have been had I decided to take advantage of that opportunity.  

 11. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

  1. With the change of leadership in Washington, I am concerned about the future of Medicaid in general and of Medicaid Expansion more specifically.
  2. Pharmacy cost trends are rising at an unsustainable rate.  There is very little that Care Management can do to impact this as it is largely a pricing/contracting issue.
  3. Payment for Health Care is moving away from a Fee-For-Service Reimbursement Model to a Value Based Reimbursement Model.  I worry that our Provider Partners are not moving as quickly to meet the rapid changes that are State is requiring of its Medicaid Health Plans.

 

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Clay’s Weekly Medicaid RoundUp: Week of November 28th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2gUFDkF

Or you can click the one for optimist readers –  http://bit.ly/2gUFq0R

 

MAKE MEDICAID GREAT AGAIN- I have had clients and readers ask my thoughts on what President-elect Donald Trump’s shocking (gasp!) victory means for Medicaid. I have intentionally waited a few weeks for the dust to begin to settle.  You can read my thoughts here- http://www.mostlymedicaid.com/?p=1874

Since most of the Medicaid news in the past few weeks has been speculation over what the Trumpening means for Medicaid, I have reserved this week’s RoundUp for news summaries of other items.

BUT FIRST, A CORRECTION – An earlier RoundUp incorrectly listed the Good Guvn’r Brandstad as the Governor of Illinois. I have written it correctly at least a dozen times (he gives me lots of material), but the one time I get it wrong, I hear from Richard, Rob, Marni, Claudia and others who wrote in to Correct the Record. I love it when people write in, and I love it even more when they provide corrections. It means they are paying attention. Thank you, and everyone – keep me honest!

 

SPEAKING OF IOWA- MCOs playing in the Iowa statewide rollout continue to post loss numbers (in the press). Losses in the latest stories range from 18-25% for UHC, AmeriHealth Caritas and Amerigroup in the Hawkeye State. The Good Guvn’r Brandstad tossed another $33M in the MCO pot in October to help cover unexpected costs (especially Rx). Its not all dollars and sense, though- 25,000 members now are getting care coordination services, 230,000 have been engaged with health risk assessments and other outreach efforts and more than 2,000 have been taken off the waiting list for a DD program. Aren’t these smashing successes? Where are the advocates showering confetti and throwing a parade for the MCOs? Seems a bit one-sided to me. Sometimes the naysayers remind me of cavemen- “MCO bad. Me get angry. Me repeat tired arguments against MCOs and me ignore abysmal outcomes in fee for service.”

 

ARKANSAS STRUGGLING TO KEEP UP- About 28,000 Medicaid applications are in purgatory in the Natural State. DHS officials are still saying they can get them all done by year end (that’s now less than 3 weeks when you adjust for the impact of the Christmas break).

 

MEDICA MCO WALKS AWAY FROM MINNESOTA- About 300,000 bennies in the Gopher State will need to cut up their old Medica card (“Medica” is the MCO name, which is confusing, and looks like I dropped an “id” or an “re”). Medica says it will end up losing around $150M on 2016 Minnesota Medicaid business. Of course the party line is: ”The evil MCO is making too much money and got greedy.” Assuming they are not lying, can you blame any business for wanting to not lose money?

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Deborah Brown of Warwick, RI will serve four years and pay $230k for billing for DME (incontinence supplies) not medically necessary. Gregory Dodds, a counselor in Camdem, AR was ordered to pay $250k for defrauding Medicaid. His counseling practice operated from inside the building for Camden’s “Connection International Ministries Church.” His excuse? Mr. Dodds needed to pay off student loans. Bernie – where are you? Riyad Altalla and his wife Muna Alnoubani pled guilty to using their home health company to steal more than $1M from Ohio Medicaid. The lovely couple from Ohio wins this week’s award.

 

That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (build a fire! And while you are at it, read London’s “To Build a Fire”) and keep running the race (you know who you are).

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FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: mamam moavlina dze gadarch’ena msop’lioshi

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Make Medicaid Great Again

I have had clients and readers ask my thoughts on what President-elect Donald Trump’s shocking (gasp!) victory means for Medicaid. I have intentionally waited a few weeks for the dust to begin to settle. At first the punditocracy was silent, then the fear-mongering began about 2 days after election day. And now there is a deluge of mostly panic pieces, with some general fluff crystal-balling out there.

Here’s a few thoughts:

1) The sky is not falling, but there is rain in the forecast. Although you wouldn’t know it as the 4th estate continues their delusional narrative with headlines like these: “Millions could lose coverage under Trump plan,” “Trump victory worries KY Medicaid advocates,” and “Gov. Edwards hopes Medicaid Expansion isn’t at risk under a Trump presidency”. Medicaid will change, as it always does (I have a chart showing major changes in Medicaid over 50 years and its full). And we likely will see a rebalancing towards cost control as opposed to the spending orgy of the past 20 years (but its free federal money! They print the stuff!). The go-to answer of spend more money, like Death-Star-construction-budget amounts of money, probably is weakening. And that’s a good thing. We need to think harder and come up with additional strategies besides additional spending.

Which brings me to my next assessment-

2) Reducing or beginning to limit Medicaid spending growth will force states to prioritize like never before. It will change the current highly conceptual “value-based care” paradigm to one in which there are real winners and losers based on risk ultimately tied to performance (not just symbolic tiny percentages based on who had the best data, marketing or lobbyist). This is what those of us who love Medicaid because it helps those in the most need truly want. Medicaid has had fundamental and terrible issues for decades. We need disruption in Medicaid. But we are all so accustomed to looking the other way on the waste and fraud- which is way bigger than anyone thinks, just read the fraud follies each week- and that’s just what I happen to find in the press – that we are almost entirely unequipped to look at Medicaid in an honest, constructive way. We don’t even have the words to criticize it in our language- Medicaid is the great untouchable policy idol in our lives. We are so practiced in defending it with sometimes ridiculous theories that we end up with nothing but weak defenses that just get us through the next budget cycle. And Medicaid always grows in those state level budget discussions, even when education and roads and parks and other things do not (we just robbed the AL coast of BP oil-spill money here to fund one more ride on the Medicaid carousel next year). We do this (fight for more Medicaid funding) because we care about the populations, but we have become intellectually lazy as we swim in oceans of money. We can do better.

It may well be that, after finally forced to do so, all of us actually with some ability to fix it (consultants, health plan management, providers, agency officials), may be motivated to do just that.

 

But lest you be encouraged, here’s number 3-

3): The foggy delusion that more money is the answer will likely continue, and most in our Medicaid world will not rise to the challenge. Instead we will dig in our heels and look for ways to resist the change. We will wait and only react to whatever is “done to Medicaid” by that mean-ole’ GOP. Perhaps the best opportunity to really improve outcomes for Medicaid members to come our way in 50 years will be met with fierce opposition disguised as virtuous panic. So what will be done with Medicaid, the reason you have read all these words to this point (and either loved me more for them or decided to finally set aside the RoundUp after all those years of reading in secret guilt) is the subject of number 4-

4): A very large Pause Button is being pressed. In February it will be a pause on all the late comers to expansion. Between now and late January, it will be the Fast Forward button on any of those waivers seeking to trim back expansion (hurry up and deny them, like CMS did with NH’s request a few weeks back). When the Pause is over (likely around Q3 2017), we will see Medicaid transformation as part of federal repeal and replace efforts. Expect block grants or something like them. Expect it to be a fight, and expect there to be some sort of compromise but not 50-50.

Regardless of what 2017 brings for our Medicaid world, I can safely predict this will be the most exciting time to be in Medicaid in the history of the program. For those afraid, find the fire in your gut to fight whatever you perceive as the danger. For those able to peek past the fear, pursue the opportunity to improve this critical program like never before.

Onward and Upward!