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Clay’s Weekly Medicaid RoundUp: Week of February 18th, 2019

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2SgkS5m

For optimist readers- http://bit.ly/2XiLara

NEW ONLINE TRAINING COURSE IS OUT– Want to understand the opioid crisis? Our newest online course will help. Check it out here- http://bit.ly/2WEL3G4

YES, DOROTHY, WE ARE STILL IN KANSAS AND WE ARE STILL WAITING ON OUR MEDICAID APP TO BE PROCESSED AFTER STANDING IN LINE FOR 2 YEARS- A lot of the eligibility processing backlog has been handled, but there are still issues. New stories out this week give more depth to the issue, and it does look like Maximus (the eligibility processing vendor) doesn’t share all the time. But they are in over their heads. The SNAFU seems to have started when the vendor took on a new (to them) type of eligibility determination, related to long term care members. They had done the much more simple apps for kids and families for 20 years. There’s a really good article on this in this week’s News Curator, btw.

REASON #472 TO EXPAND MEDICAID: IT MAKES HOSPITALS EVEN RICHER- TransUnion Healthcare (a credit reporting agency trying to grow up into a broader info services role) released a report this week showing that Medicaid expansion can help add millions to hospital bottom lines (see this week’s soundtrack for a related song). The researchers reviewed thousands of cost reports to identify self-pay bad debts that could be covered by Medicaid if a state expanded.

QUESTION TO ALL THOSE #RESISTERS AGAINST WORK REQUIREMENTS- You keep talking about how hard it is for members to comply with reporting. Are you thus volunteering to make it easier in some way? Or are you really just continuing to beat your gums about how you think work requirements are just bad? Say what you mean, footsoldiers. Multiple regurgitated stories this week about how hard it is to call in, log on or in various other ways report that you tried to work if you were able to in Arkansas. I think Resisters know they lose the argument on whether its fair to ask those that can work to work, so they incessantly talk about challenges with reporting compliance. Yes, its hard. So roll up your sleeves and help out. Here’s an idea – ACA had gabillions in funding for “navigators” to help people sign up for coverage. Maybe repurpose those same staff to help people prove they are eligible to keep it?

TARHEEL GOOD GUVN’R TEASES EXPANSION- Cooper is now doing townhalls / expansion “roundtables” as of this week.

PINE TREE STATE EXPANSION TICKING AWAY NOW THAT LEPAGE IS OUT OF THE WAY- 6,000 bennies added to the Maine rolls since January.

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Anita Ramiriz-Ambriz of McAllen, TX was convicted of stealing $4M Medicaid bucks almost 2 years ago, but yet again was able to delay sentencing this week (pro-tip for convicted fraudsters in here somewhere). Her crime? Getting paid for DME not provided. Head on up to Plattsburgh, NY for our next caper, in which Arshad Nazir and Muhammad Jahangir were convicted of Medicaid taxi-cab fraud (isn’t it great that this is a thing? Its become its own category in recent years). Messieurs Nazir and Jahangir pilfered a combined total of $567k by operating a kickback scheme. Medicaid patients were paid (often times with a bag of tobacco) to say they needed to get somewhere related to their health condition. The taxi companies then would get $230 (or so) for a “non emergency medical transportation ride.” Taxpayers, we truly are gullible fools. Skip on down to Durham, NC to check out Tamara McCaffity’s scheme. She was sentenced this week for stealing $900k using her mental health provider companies (one of them DBA “Dreamworks II,” which frankly is a great name. We should maybe start a new award category for best named bogus mental health provider companies. There have been some doozies over the years). McCaffity bought stolen Medicaid member IDs so she could submit bogus claims to Medicaid. And you, dear taxpayer, paid them (if you live in NC, you only paid about 30%. If you are outside of NC, you paid about 70% through the FMAP. See that whole “but its free federal money” silly argument goes both ways). Mrs. Ramiriz-Ambriz- you win this week’s award on technique alone. I am truly impressed that you have avoided sentencing for 2 years despite being convicted of Medicaid fraud. (Why do we even try to fight this stuff?)

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

 

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 (plant asparagus – did you know it takes 2 years?) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Ntate o rometse Mora ho pholosa lefats’e.

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Medicaid Who’s Who Interview: Richard Edwards

Richard Edwards is Chief Program Officer at Community Based Care, LLC
Check out his LinkedIn profile HERE.
Which segment of the industry are you currently involved?

Community Based Care and its family of providers serve people who have long-term service and support needs, primarily with intellectual and/or developmental disabilities, most often through Home and Community Based Services.

 How many years have you been in the Medicaid industry?

I’ve been in behavioral health, broadly speaking, since 1995 — mostly as a member of provider organizations.

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

Within the industry, I’m especially interested in the balance between the civil rights origins of our field — deinstitutionalization; access; reasonable accommodations — and the need to integrate with healthcare systems and models of care. We have — especially since deinstitutionalization — built habilitation and community integration into the Medicaid system, and in some very significant ways, it has never been a perfect fit, because of the influence of the medical model over healthcare funding structures. The fee-for-service reimbursement system is a good example: a procedure or service or medication might address a symptom, but it does not make us healthy. Extending that concept, being healthy is a goal, but it is not the only or even the ultimate goal. Better health provides a foundation on which other quality of life pillars can be built. We seek to aid people in achieving their best possible health so that they can have an improved quality of life. Public funding sources like Medicaid, in this sense, help people with extraordinary challenges do very ordinary things that most people — including me — take for granted. That is what keeps me coming back to this work.

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

Outside of work, seeing the Northern Lights. Something I haven’t done.

What do you enjoy doing most with your personal time?

I am happily married with two amazing daughters — spending time with my family is very important to me. If we can be outside together — that’s a perfect afternoon.

Who is your favorite historical figure and why?

Difficult question, but I would say Martin Luther King Jr. — a prophet for our times, speaking to the most difficult issues of our culture. To borrow several phrases, his words leave you with no defense; his actions bent the arc of history. His life, speeches, and writings have had a permanent effect on how we talk and think about racism, prejudice, and discrimination.

What is your favorite junk food?

Peanut M&Ms. I can’t (won’t) walk past a bowl without grabbing a handful.

Of what accomplishment are you most proud?

There isn’t anything in my career, or my life, that I have accomplished on my own, so it feels a little awkward to say “proud”. I think my greatest accomplishments are still ahead of me. And, even then, I am sure I will benefit from a lot of help.

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

 Only one? The good news in life and work is there will always be more tests to bring your average up — if you take the time to assess and learn from your mistakes. If I had to pick one, not the biggest mistake I ever made, but just stupid on purpose…I once spouted off to a friend over email — commiserating with her about a workplace change that I knew there were multiple sides to, but, we were old friends, and I was just trying to be sympathetic. That email got forwarded (inadvertently) to my supervisor who was, in part, responsible for the change, and who took my jerky comments very personally. I caused a lot of pain with my thoughtlessness, to someone whom I very much respected. I learned several lessons on that one. Years later, I’m still sorry about it.

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

Addressing constitutionality questions about the ACA will drive activity at the state levels where expansion is still in discussion. In my home state of NC, for instance, there is a lot of interest across the political spectrum in expanding Medicaid, in some limited fashion, but questions about the status of the ACA could delay any serious conversation. Success/failure of new models — like the I/DD Health Home model in NY — to address integrating healthcare and long-term services and supports for people with I/DD. Some of these models are very promising but combining these two practices has always been harder than it looks. While these models are new and should be given time to mature, I think their viability will be evident sooner than later.

 

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.

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Clay’s Weekly Medicaid RoundUp: Week of February 11th, 2019

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2X0xroM

For optimist readers- http://bit.ly/2X0qqEz

NEW ONLINE TRAINING COURSE IS OUT– Want to understand the opioid crisis? Our newest online course will help. Check it out here- http://bit.ly/2WEL3G4

IDAHO DECIDES TO MEASURE IMPACT OF EXPANSION- Medicaid expansion is getting its very own budget item so it can be tracked precisely. I know about 30 states who wished they would have thought of this.

ALASKA BACKLOG OF APPLICATIONS GOING DOWN BUT STILL A PROBLEM- The Frontier State is struggling to scale its Medicaid program after expansion nearly doubled its rolls.

 MEDICAID ROLLS DECREASING IN SOME STATES; LEFTIES FORGET THE “BUT MEDICAID IS COUNTERCYCLICAL TO THE ECONOMY” LINE- To admit the economy is improving would admit The Duly Elected President of the United States of America (DEPOTUS) just might be helping rescue us from the disastrous economy he inherited. Such an admission is impossible for most in our Medicaid world. Other theories: re-enrollment apps are too many pages long (TN has 47 pages to fill out to get back on the rolls) or bennies re-applying have to wait on the phone lines too long (MO). Overall, Medicaid enrollment declined about 1.5% nationally last year. Which really isn’t that much when you realize it basically doubled in an 8-year period under ACA. So, class- Medicaid grew 100% in 8 years, then it took a 1.5% step back in the last year. (At this rate it would be 2120 before we got back to pre-ACA bennie levels). Let’s all FREAK OUT!!!! ORANGE MAN BAD! I’ll leave you with this quote from a TN Medicaid official – ““Tennessee is experiencing a state economy that continues to increase at what appears to be near-historic rates.”

 MICHIGAN WORK REQUIREMENTS BATTLE RAGES ON- The Good Guvn’r (the new one- Whitmer) is looking to undo the work requirements plans already approved by CMS. She has a new report with bigger numbers on how many will lose coverage if they don’t comply with the requirements. Pro tip for those wanting to undo work requirements already approved by elected (that word is put there to remind you that about 50% of voters disagree with you) officials: looks like you just need to know the right consulting firm to get the numbers you need to justify the reversal.

 

VOLUNTEER STATE STEPS FORWARD FOR BLOCK GRANTS- TN state reps filed 2 bills this week (1 in the house, 1 in the senate) to require the Medicaid agency to request a waiver from CMS to convert to a block grant program. 1st shots fired. For history buffs wanting to chase a rabbit trail right this moment instead of doing whatever you are supposed to be doing at work, read the wiki page about an American hero involved in the first shots fired during the American Revolution- Crispus Attucks. For all you whippersnappers drinking the green kool-aid, the American Revolution was how this unique, wonderful country got started and began the beautiful, unique, one-of-a-kind story that is America. Thank you, Crispus, for your role in making this place awesome.

 

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. Manuel Barit of WV plead guilty to stealing $200k. His crime? Submitting claims for treating bennies when he was actually out of the country. The scam went on for six years. Ryan Sheridan of Austintown Township (Ohio) was charged with stealing $31M with bogus substance abuse treatment claims (DBA “Braking Point Recovery Center”). He and his buds operated recovery centers all over town. Lillian Richardson and Bridgett Burrel of Minnesota got convicted this week of stealing $7.7M in Medicaid bucks using five (count em’, five!) home care agencies they set up under the names of different family members. They submitted lots of bogus claims for helping disabled Medicaid members with daily tasks. Fun Fact- Richardson was convicted on a different Medicaid fraud in 2012 but pinky-swore to not do it again. Guess pinky swears are not what they used to be in 4th grade.  Mr. Sheridan – you win. $31M is a decent chunk of change, even for Medicaid fraud.

Need even more Medicaid fraud stories? – You can get your fix in the FWA Curator archives.

Want to read the articles summarized here, highlighted for your reading pleasure? Check out the News Curator archives.

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 seeds – its that time again) and keep running the race (you know who you are).

FULL, FREE newsletter@ mostlymedicaid.com . News that didn’t make it and sources for those that did: twitter @mostlymedicaid .

Trystero: Rama dikirim Putra ka ngahemat dunya.

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Medicaid Who’s Who Interview: Deborah Watkins

Deborah Watkins is Founder and Chief Disruption Officer of Care Bridge International.
Check out her LinkedIn profile HERE.
Which segment of the industry are you currently involved?

Health Data Analytics, specifically involving bodily injury claims. About 20% of workers comp and auto injury claimants have serious enough injuries to qualify for Social Security Disability Benefits, followed by Medicare benefits. A percentage of those individuals eventually receive Medicaid benefits due to the severity of their injuries and income constraints. There is a real opportunity to ensure these individuals receive quality care to promote their independence, while preserving and maximizing these State & Federal funding resources to improve outcomes, but also to ensure the fiscally responsible use of these funds.

How many years have you been in the Medicaid industry?

On the insurance side, over 18 years, but have been in the healthcare space my entire career.

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

Dual Eligibles, individuals who receive both Medicare and Medicaid benefits, as these individuals are the most compromised and most vulnerable in our healthcare system. This small subgroup consumes the largest portion of our healthcare dollars having a big impact on our healthcare GDP. Being a small part of the solution in the healthcare delivery and payer systems, is my passion.

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

To snorkel or scuba dive with humpback whales. I have had an interest in whales since childhood and want to get as close as safely possible.

What do you enjoy doing most with your personal time?

I’m an outdoor girl and enjoy out-of-door activities, particularly trekking in scenic places around the world and downhill skiing.

Who is your favorite historical figure and why?

Abraham Lincoln. He was our President during a very polarizing time in our country’s history during the Civil War and is one of our most respected Presidents. In addition, he experienced tragedy in his own personal life including the loss of his mother at age 9 and the death of a son that led to his wife’s mental health issues, so he was a man familiar with tragedy, yet very resilient. I admire that, because I have a daughter who had an acute head injury at age 9 and suffers with chronic, intractable epilepsy. I understand at a personal level the pain of loss and the challenges caregivers face in navigating a fragmented delivery system and the need for a Medicaid safety net. The story of Honest Abe gives me hope that we can successfully solve our healthcare crisis and reunite.

What is your favorite junk food?

Salt Water Taffy, I love its sticky sweet taste that melts in your mouth; it reminds me of the Boardwalk in Ocean City, MD, not far from where I grew up.

Of what accomplishment are you most proud?

Being an advocate for my daughter, successfully navigating both the healthcare and education systems and adult community resources to help her live as healthy and full a life as possible, to achieve her highest potential despite her afflictions.

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

Well, there are many! But for public consumption, I would like to get back the hours of vacation that I worked instead of enjoying that vacation. Time off, disconnecting from the laptop and the stresses of work, is important to maintaining balance and well-being.  Vacation is important for restoration. I encourage my own employees to use their time off for that purpose, and stop checking email!

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

I think the most important issues involve, not just figuring out how or how much to fund Medicaid, but how best to manage these funds. Throwing money at a program is not the solution, understanding how best to deliver care to Medicaid beneficiaries in the most cost-effective way to obtain the best possible health outcomes is a complex task, but this is what needs to be done. The use of Data analytics offers a powerful means to learning and understanding and seeing the problems and solutions more clearly. Engaging and gathering Data from all stakeholders including payers, beneficiaries, community leaders, caregivers, providers, facilities, pharmacies, and more to create a better understanding of where the opportunities are to build a more efficient ecosystem is what I believe should be the focus in the next six months. It is the hard, but important work that needs to be done to strip out biases’ and false assumptions that are holding us back from better serving the Medicaid population.  

 

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.

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Medicaid Who’s Who Interview: Benjy Green

Benjy Green is Vice President, Business Development of Magellan Health.

Check out his LinkedIn profile HERE.

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

I have been at Magellan for about 18 months now, and loving it. I’m currently working on various Medicaid RFPs, ranging from LTSS to TANF populations in different states.

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

I have over ~20 years experience in Medicaid and Government programs, with areas of focus including provider, state, federal and managed care organizations.

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

My number one focus is my wonderful family, wife Amanda and three teenagers (Ben, Zach and Kate). Outside of that is my passion to help the underserved and vulnerable populations.

I stumbled into this career path by starting in the business office of a small provider. I quickly felt the desire to do more for this population and transitioned into state employment at a Texas Medicaid Agency. I can’t imagine doing anything else, this is what drives me.

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

I’m not sure I have one top item, but we love to travel. We are looking at options in Europe in the near future and plan to visit Scotland for my 50th in a few years to play St. Andrews, the home of golf.

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

Spending time with my family, friends, including my four legged friends. My family is heavily involved with the DFW Labrador Retriever Rescue Club, so in addition to our Jack Russel (Scooter) two labs (Bria and Kenner), we often have a foster dog running around as well.  I also enjoy as much golf as I can get in.

6. Who is your favorite historical figure and why?

I’m not sure I could pick just one. But if hard pressed, I’d go with any of our country’s founders. They were a complimentary mix of writers, philosophers, and politicians who not only led the revolution, but had the foresight to put the structure of this great country in place hundreds of years ago.

7. What is your favorite junk food?

I love chocolate and anything covered in chocolate.

8. Of what accomplishment are you most proud?

I am a first generation college graduate with a Master’s degree. Even though my parents didn’t have the means or opportunity to attend college, they understood the importance of higher education, and pushed my brother and me to graduate from college. As a parent myself, I share the same philosophy, and will do everything possible for my children to have the same opportunities that I did.

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

Running for my neighborhood HOA board! (This is my sense of humor coming through, if you don’t know me personally).

In all seriousness, I’m not a fan of mulligans on the course and therefore wouldn’t take one in life either. I feel the decisions, good or bad, have lead me to where I am today, both professionally and personally. I’m living my best life today, and am very thankful for the experiences that have gotten me to this place.

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

Approach to “managing” members – historically the focus has been on managing the physical health of Medicaid populations. As organizations dig deeper into the data, it’s becoming apparent to be successful we must focus on the behavioral diagnoses (where applicable), then the physical. Here at Magellan, with our more than 40 years of behavioral experience, we are evolving our approach which is making a difference, especially with the vulnerable populations we are entrusted to serve. We are also using technology to our advantage to not only reach the members but gathering data from all streams (physical, behavioral and pharmacy) to better understand how we can make a difference.

SDoH – as organizations improve the importance of the interdependencies in Medicaid populations, the relevance of the Social Determinates of Health is a driver to be successful to improve outcomes within the Medicaid populations.

Opioids – this has a tremendous financial impact on all of healthcare, not just Medicaid. Everyone (payers, pharma and providers) must meet on common ground to address the epidemic and find a solution.

 

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.

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Medicaid Who’s Who Interview: Bill Henderson

Bill Henderson is the Sr. VP Business Development at Liberty Dental Plan. 

Check out his LinkedIn profile HERE.

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

LIBERTY Dental Plan is a leader in the Medicaid /Medicare industry. A leading National Provider of Dental Managed Care Services since 2001. Providing quality, innovative and affordable dental benefits with the utmost attention to member satisfaction

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

I started back in 1993 partnering with MCO’s within TennCare for vision care. 

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

Increase access to dental services and oral health education to all members, focusing on co-location and prevention. Providing more education to underserved population so they can have a clearer picture of what great oral health is and how it can assist them in their whole-body health.

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

To establish & set up pop-up housing for the social determents and provide fresh vegetables for them, and a clinic to assist them within the housing unit.

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

I travel every week for work but I still like to travel to areas I do not get to see, love to experience local food and culture.

6. Who is your favorite historical figure and why?

Lincoln, to me he put everything ahead of himself & his career. He was concerned about the country and the rights of the people and wanted to make sure he resolved the issues we were having at the time.

7. What is your favorite junk food?

Street hot-dogs, love them in NY

8. Of what accomplishment are you most proud?

Being able to assist LIBERTY to grow across the country, we’ve built a great team, and winning culture that all the team care about the people we get to serve and the communities we operate in.

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

Not always being home to see the kids growing up

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

A. The cost of end of life

B. States need to flexibility working with MCO’s to manage the programs set forth and develop strong relationships with plans/provider and communities

C. Get a better handle on Social Determents and the cost of care for this populations

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.

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Medicaid Who’s Who Interview: Amanda Ratliff

Amanda Ratliff is the CEO of ACR Consulting Services & COO of Paragon Technology Partners.

Check out her LinkedIn profile HERE.

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

Network Development for Payers, Managed Care Consulting, Credentialing, FQHC/Radiology and Vision Billing, Directory maintenance and IT Solutions (BigData, encryption, PDM).

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

I have the worst baby face (I literally look 12), but over eighteen years.

I started at Aetna in the member services call center and worked my way up to CEO. I never turned work down – I always did the dirty stuff no one wanted to and kept learning. When it was hard and there was no structure or policy, I kept at it until we had clear sight. Medicaid is a tough industry and doesn’t have a lot of funding. It takes dedicated teams with a true passion and vision. I have been lucky enough to work with some of the greatest teams.

I always wanted to do the best I could with minimal spend. We helped to orchestrate a consolidation of 3 different systems while at an MCO. They were paying 3 different teams and 3 separate software programs. It didn’t make sense. All data should be in one source.

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

My main passion is Contracting and Provider Data Maintenance. I love to contract Providers/Groups/Hospitals and make sure the data collected in the process is correct, clean, valid and complete. Incorrect directories and fat finger typos drive me absolutely INSANE. Also, automation – if there is a way to do something faster – I am visioning how to make it happen.

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

Professionally – I would like to see Provider Data Management (PDM) solution solved so Payers could manage their data, and not be fined for incorrect information.

Personally –  I would love to be able to go to Italy with my husband – his grandfather came over off the boat from Naples and he wants to visit his history (and eat a bunch of pizza and pasta!)

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

Watching non stop episodes of Heart of Dixie on Netflix, women’s bible study, helping others, Horseback riding, and quality time with my 16 yr old son and 10 yr old daughter (if they like me that day).

6. Who is your favorite historical figure and why?

Martin Luther King Jr. – he rose above all odds, stuck to his faith and did what was RIGHT in every scenario. You don’t see people STAND UP like that with deep concern to risk everything. He didn’t give up and he had every right to. His battle is unlike anything I’ve ever experienced and I admire his unwavering passion. That man changed the complete path of our nation, amazing.

7. What is your favorite junk food?

Fritos and Nacho cheeeeeeese

8. Of what accomplishment are you most proud?

Stepping out in faith and opening a business with employees (I never thought of myself as a boss – it’s still weird for me to think about).

My employees are simply the best and often outwit me. Steve Jobs said – “you should hire people who are smarter than you”, and I am thankful that my team is well equipped and have such a deep knowledge of the space.

I just continue to let God lead – he pushed me off the cliff and I haven’t fallen yet! When in doubt, take the risk and TRUST HIM.

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

Not finding Christ sooner……… and picking on my older brother and him always winning!

He stuck me on top of a 6 foot bookshelf, turned the lights off and left Opera music playing so loudly he couldn’t hear my screaming and crying.

Then, one time I asked him what to do about my skinned knee – and he told me to put lemon juice on it…and I DID! I wish I was the oldest and not youngest.

(Yes, I am whining about it after 30 years).

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

A. BigData, lots of data and data analytics. Smaller MCO’s and new MA plans coming in don’t have access to well adopted systems/policies/etc. They lose a lot of revenue in start up or initial bids/risk to secure agreements.

B. Technology – who is coming out with what and why? Is there a list of all this awesomeness?

C. Patient Care and Access – we need more doctors and nurses to care for (and accept) patients. Lots of them are lost in the shuffle, especially the homeless.

Know someone in the space who’s doing great work and is an all around interesting person?
Send a note to clay@mostlymedicaid.com to nominate them for the next round of Medicaid Industry Who’s Who Interviews.
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Clay’s Weekly Medicaid RoundUp: Week of January 14th, 2019

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

For optimist readers- http://bit.ly/2W235C3

ABOUT THAT WHOLE MEDICAID TRANSFORMATION IN NY THING. YEAH, LET’S STOP DOING THAT- After years of major overhaul efforts to transform its Medicaid program, Cuomo just pressed pause on the key device real driving change. For 8 years, NY has capped Medicaid spending to be within a 10-year rolling average of medical inflation. In this next budget, the Good Guvn’r decided to give Big Med (primarly hospitals) a pass and allow Medicaid spending to exceed the cap (3.1% is the cap; Cuomo is authorizing 3.6%). Why, you ask? As a pre-emptive strike (in his view) to shore up against federal changes coming to Medicaid. What federal changes? Reductions in DSH that were started when ACA passed (in 2010), but Big Med has been able to get delayed year after year.  Lefties, rejoice (and don’t forget to vote for him when he runs for Pres in 2020). Righties, observe yet another tax and spend Dem refusing to reform their ways (cuz, you know, they’re the good guys and your’e evil if you doubt that). Total Medicaid budget now that NY Medicaid is on a cheat-day? $19.6B (which is roughly the GDP of Botswana, and more than the GDP of 118 countries. For freakin’ Medicaid in NY, people).

HOW WAS YOUR EXPERIENCE? MA TO POLL PATIENTS- Medicaid members in The Old Colony State will be asked to rate providers and plans for the first time. Results will be made public in 2020. From what I can tell this is basically a CAHPs-type survey. Results will also likely be used for value-based care payments.

SHAKEUP IN ARKANSAS NEMT- For readers keeping tabs on the Medicaid transportation scene: Southeastrans is picking up more regions as MTM will exit. Handover starts Feb 1.

JUST WHY ARE HOSPITALS IN VIRIGINIA SO EAGER TO BE TAXED? Why do hospitals exist? To help people AND to make money. When asked why they exist, what is the answer? “To help people.” They conveniently leave out that second part. When you put it back in, it makes a little more sense why VA hospitals are eagerly paying a “tax” to help fund the recent explosion (expansion) in Medicaid spending. State reps are getting their first taste of the “surprise” cost over-runs in the expansion they approved last year. This week new adjustments to expansion costs show at least $85M more than what they were told when they voted “yes”. Hospitals, those noble creatures they are, are running full press coverage highlighting how they are so, so happy to pay a tax to help fund expansion. Long time readers remember that Medicaid provider taxes are often a total sham described thusly: we pass the hat to hospitals, who all chip in money. We then beam up the hat to planet CMS, who puts in 6x more money (or 7x or whatever your fmap is), and then sends it back down. The state gets more cash, and so do the hospitals.

PALMETTO STATE JOINS RANKS OF WORK REQUIREMENTS REFORMERS- Looks like another 1115 app will be hitting the halls of 7500 Security Blvd in Balto soon (where planet CMS is). South Carolina is doing town halls on a work requirement proposal as of this week.

IMPLEMENTING BALLOTED (IS THAT A WORD?) EXPANSION PROVING TO BE HARDER THAN CHECKING A BOX ON VOTER CARD- Utah lawmakers are trying to figure out how to pay for the expansion approved by voters in November. There are 2 issues in play: 1) how to keep the limited expansion already in place going while applying for CMS to approve full / “standard” expansion we’ve all come to know and love; and 2) how to come up with numbers during the current budget cycle that at least try to pretend there’s a way the state can pay for it. A sales tax increase is projected to come up about $45M short in the next few years.

HOSPITALS AFRAID SETTING LIMITS ON MEDICAID SPENDING COULD HURT THEIR REVENUES- See earlier entry above about why hospitals exist. As CMS suggests states may find approvals for block grant waiver apps if they only ask, hospitals are going nuts in the press. Sky is falling, cutting spending will kill everyone- you know the dril by now. There are increasingly insightful quotes coming from Verma on this. Here’s a good lil’ nugget: “We also believe that only when states are held accountable to a defined budget can the federal government finally end our practice of micromanaging every administrative process.“ Hear, here!

IN A RELATED NOTE, GA WANTS MORE FREEDOM FROM FEDERALI MICROMANAGING FOR ITS CITIZENS’ HEALTHCARE NEEDS- The Good Guvn’r Kemp (who recently barely beat romance novelist Stacy Abrams) announced a $1M project to explore a waiver with CMS that would give the state more flexibility with its use of federal Medicaid dollars. No other details than that. You get to fill in the blanks (most fill them in with block grants based on early analysis). In a somewhat related news item, GA teachers will be getting a $3k raise this year.

PASSPORT STRUGGLING WITH NEW NORMAL IN KY- For those of you watching this MCO market, Passport has been unscuccessful in getting the state to budge on recent cap rate cuts that hit Passport particularly hard. Short version – state changed up regions and rates in a way that Passport got hammered. And Passport’s whole business is Medicaid. More to come.

CANARY IN COAL MINE IN AR? We all like to think we are special and unique. Medicaid programs are no different (see what I did there?). Arkansas cooked up yet another version of the “here’s how we’ll transition legacy behavioral health providers to a capitated rate” idea a few years back. (It’s an acronym that spells PASSE; did no one look that up in French?) Like most of these inititaives, year 1 starts out all nice and you get basically extra cash to play along and maybe do a little more case management than before. In year 2 you are expected to manage medical services, pay claims, etc (depending on the state). Well, ForeverCare sees the writing on the wall (or is chickening out if you listen to state officials) and is dropping out. They say they will come back in if the Phase II implementation date is moved to July 1. It has already slid from Jan 1 to March 1.

 

READY FOR MEDICAID INNOVATIONS 2019- I will be there again this year (my 9th time), chairing one of the very best Medicaid events you can go to. Also, its sunny Florida in February (I’m looking at you, Michigan). If you decide to go, let me know and we can meet up. Check it out here – https://www.medicaidinnovations.com/

 

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- not so fast fraud junkies. No where near enough space this week. You can get your fix in the FWA Curator archives though.

Want all the highlighted news items from this week? Check it out here-Medicaid News Curator Volume 5

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 (buy or chop some firewood) and keep running the race (you know who you are).

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Trystero: Baba alimtuma Mwana kuokoa ulimwengu.