A lot happens in Medicaid in 30 days. We cover it all in 60 minutes with our distinguished panel this month being Craigan Gray, Joe Moser, Kris Vilamaa, and Alex Shekhdar.
2018 June Medicaid News Roundtable
Category: Amazing Free Content
Clay’s Weekly Medicaid RoundUp: Week of June 11th 2018
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2HND9BG (from the Arsenio Hall Show – How awesome is that?!?!)
For optimist readers- http://bit.ly/2HOUdqO
NY BLEW $1.3B ON IMPROPER MEDICAID PAYMENTS- BUT WHO’S COUNTING?- NY State Comptroller DiNapoli (am I the only one who has long-thought “comptroller” is a very strange word?) released data this week showing $1.3B in “unnecessary” Medicaid spending since 2012. The audit pins the errors on electronic systems. State HHS officials say they are working on the issue and are trying to get the cash back. From what I can tell this could be a mix of inappropriate capitation to MCOs and TPL issues. If anyone in NY knows, please write in.
MR BEVIN GOES TO WASHINGTON (OR RATHER WASHINGTON LEFTIES GO TO COURT AND TRY TO DRAG MR BEVIN WITH THEM)- The lawsuit against KY’s work requirements (remember they call it “community engagement”; their opponents call it “work requirements”) is set to have its day in court this Friday. Keep in mind the long list of exemptions means no elderly or disabled person will have to meet the requirements (nor children or pregnant moms)- basically this new Medicaid innovation feature (its done under an 1115 demo waiver) will only affect a subset of the KY Medicaid expansion population. Stay tuned.
NC SAYS NO TO STUDYING EXPANSION- A last minute amendment was added to a rural health bill on the floor this week, but it was promptly removed by the program evaluation committee. Committee leadership says it should be in charge of what gets evaluated, and that all efforts are focused on current efforts around bringing managed care to the state right now.
NASBO SAYS MEDICAID SPENDING TO SLOW DOWN IN NEXT FY, BUT THEN SPEED BACK UP- A NASBO report published this week shows most Medicaid program spending increasing by about 4.5% in FY 18’. When they take out their crystal balls for FY 2019, its around 1.5%. After this slow down, Medicaid hits the gas again and starts spending 5.5% more in future years. The report examines proposed Governor’s budgets each year. If the Medicaid spending adds proposed in those budgets goes through, and additional $5.3B in state funds will be added to the Medicaid industry next year. Well, a lot more than that when accounting for agencies overspending their budgets (which invariably will happen).
NH SA PROVIDERS NEED MORE MONEY- They currently get $162.60 per patient per day for inpatient substance abuse treatment ($4,878/month). Providers say this is well below cost, and are asking for $10M per year from Medicaid.
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. Duke Ellington Ellis of Durham, NC will have to repay $1M (yeah, right!) for his role in fraud scheme in which he forged signatures of licensed psychologists to submit fraudulent claims. His company – gotta love the names they give these things – “Nature’s Reflections” stole $8.7M over the course of the scheme. LaGracia Burnett of Philadelphia plead guilty this week to stealing $211k for false claims for behavioral health services for autistic children. Seems she had broken the laws of physics and was delivering services at 3 different clinics at the same time. Arkady Goldin of Brooklyn stole $1.5M using a kickback scheme involving his pharmacy. He paid a local medical center employee to send expensive cancer scripts his way. Goldin also billed for drugs never delivered. And this is cool- the state figured that out by checking his Medicaid reimbursements against his orders from wholesalers. Mr. Ellis – you win this week’s award on sheer volume alone. Congratulations!
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 nice fence) 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: ua tono mai te Metua i te Tamaiti ia faaora i te ao nei
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Medicaid Who’s Who Interview: Jon Hamdorf, Kansas Medicaid Director
1. Which segment of the industry are you currently involved?
A: Public Insurance – Medicaid
2. How many years have you been in the Medicaid industry?
A: 1 year
3. What is your focus/passion? (Industry related or not)
A: I have a passion for serving others. Throughout my life I have always gravitated toward service orientated positions. In my college years, I was a deputy sheriff. Post-college, I worked in healthcare IT for multiple companies in leadership roles that either supported a sales organization or customer organizations and now I am serving as Kansas Medicaid director and Director of the Division of Health Care Finance serving the individuals on our Medicaid program and in our State Employee Health Plan.
4. What is the top item on your “bucket list?”
A: To finish my PhD. I am currently a PhD candidate at University of Kansas Medical School in the Health Policy and Management Department.
5. What do you enjoy doing most with your personal time?
A: With serving as a Medicaid Director and trying to finish a dissertation, personal time is rare. When I do have it, I enjoy riding in my Jeep Wrangler with the top down, driving across the Kansas countryside with my wife Angela and my dog Samantha.
6. Who is your favorite historical figure and why?
A: Dwight D. Eisenhower. Eisenhower was a leader and a hero, but also a down-to-earth personable man who united the nation. I love that when he decided to run for president, he was courted by both the Republican and Democratic party. I often walk over to the Kansas capitol building and look up at the statue of Eisenhower and imagine what it would be like to have a conversation with him and learn from his experiences.
7. What is your favorite junk food?
A: Giordano’s Pizza. If anyone from Giordano’s corporate office sees my answer, please strongly consider opening a restaurant in Kansas City. It would make me very happy.
8. Of what accomplishment are you most proud?
A: I am most proud of the culture changes we have been able to make in Kansas Medicaid. My staff is amazing and they have done a fantastic job engaging with stakeholders, legislators and individuals in our program to develop solutions and better serve the individuals in the Kansas Medicaid program.
9. For what one thing do you wish you could get a mulligan?
A: My mother made my older brother, my younger sister and I play the piano when we were young. We all were able to stop when we went to junior high and started participating in athletics. If I had a mulligan, I wouldn’t have stopped playing the piano. I have a keyboard that I still play on when I have time, but I would love to be proficient at it.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months
A:
1) Integrating social determinants of health to provide whole person care
2) Establishing individualized plans of service to understand members life goals and develop tailored solutions
3) Figuring out early, targeted interventions to change the life trajectory of young people in Medicaid to give them the skills to live independent, fulfilling lives. This will provide financial solvency to the Medicaid program and help end the cycle of poverty.
Medicaid Industry Who’s Who Series: David Brueggeman
Medicaid Who’s Who: David Brueggeman – Medical Economist and Manager of Actuarial Science @ Caresource
1. Which segment of the industry are you currently involved?
A: I work at CareSource, an Ohio-based nonprofit health plan that serves nearly 2 million members spread across Ohio, Kentucky, Indiana, West Virginia and Georgia. Our membership is supported by a workforce of 4,000 employees.
2. How many years have you been in the Medicaid industry?
A: I have been in the Medicaid industry for seven years, concentrating on FP&A, Medical Economics, and Actuarial areas. Prior to joining the payer side, I spent three years on the provider side, which I think gives a healthy perspective of the challenges on both sides of the table – challenges magnified by the fact that Medicaid is often the lowest payer in the portfolio.
3. What is your focus/passion? (Industry related or not)
A: I try to understand the needs and motivations of others. In Medicaid, we are challenged with helping policymakers and sometimes our own staff in understanding the motivations of the populations we serve who may lead vastly different lives than our own. At CareSource, we have a Poverty simulation that our staff goes through to understand the mindset and day-to-day experience of our members, including those with chronic health conditions. I am a firm believer that you have to walk a mile in someone’s shoes if you want to truly understand them, and I apply that to both work and in my personal life.
4. What is the top item on your “bucket list?”
A: There are several people I would like to meet, including former President Barack Obama, Atul Gawande (surgeon and author of the Checklist Manifesto), and Richard Thaler (father of behavioral economics). I did most of the other items (skydiving, rock climbing, motorcycle riding, backpacking in Europe) before I had children in case something went terribly wrong.
5. What do you enjoy doing most with your personal time?
A: I enjoy spending time with my wife and two young children. A recent favorite moment involved laying in the grass explaining the vastness of space and all the interesting discoveries humanity is making about black holes and exoplanets to my intensely curious 6 year old. I am also a voracious reader of science, technology, business, and political magazines and blogs.
6. Who is your favorite historical figure and why?
A: Leonardo Da Vinci. His incredible breadth and depth of knowledge and ability to connect disparate concepts to create innovation are the same capabilities I strive for every day.
7. What is your favorite junk food?
A: Here in Dayton we have something called Killer Brownies from Dorothy Lane Market. They are incredible slices of heaven – brownies with chocolate and caramel and optional nuts – but not so good for the waistline.
8. Of what accomplishment are you most proud?
A: Early in my career at CareSource, I was assigned to an internal think tank that was tasked with figuring out how we could get past certain roadblocks in our member experience. Why was health so low on our member’s priority list? We really dug into the social determinates of health both from an academic and applied perspective. We also sat down with real members and asked them some important questions and gained key insights that led to the creation of our Life Services division, which is focused on assisting members with several aspects of the social determinants model. We are actively trying to help people move out of Medicaid and be the best version of who they can be.
9. For what one thing do you wish you could get a mulligan?
A: This is a difficult question. I would initially say that starting my career in banking was a mistake as I eventually realized that being a monetary lubricant was not a life goal for me; however, I learned a lot about technology and consumer-centric approaches that serve me well today. I believe the only true mistake is one you don’t learn from.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
A:
One, as participants in IN, OH, and KY Medicaid programs which all have either approved or pending waivers, we are seeing firsthand both the opportunities and challenges that come with work requirements and “skin in the game” benefit designs. The jury is still out on whether these concepts will have the desired outcomes, but many states are jumping in with both feet.
Two, I think that Medicaid plans need to start collaborating more in designing value based models to minimized the burden on providers who are trying to accommodate ten or more models with differing goals and intentions from different payers.
Three, I think we as an industry need to start thinking about what health means to our populations and how we can best engage. At the TEDMED conference, I was inundated with app developers promising to move the needle. I asked a simple question: “If better health is #15 on the priority list of an individual, #1 being food, #2 being shelter… and #10 being Facebook, how does this move me above Facebook?” These are the questions we need to ask ourselves if we are going to have a real impact on our members’ lives.
May 24th, 2018 Medicaid ACOs
In this webinar we discuss Medicaid ACOs with Rosemarie Day, President of Day Health Strategies and Sarah Matousek, Senior Consultant of Day Health Strategies.
Medicaid Industry Who’s Who Series: David Newell
Medicaid Who’s Who: David Newell, President and CEO @ PromiseShip
1. Which segment of the industry are you currently involved?
A: Children and family services
2. How many years have you been in the Medicaid industry?
A: Around 26 years
3. What is your focus/passion? (Industry related or not)
A: To transform child and family services in the United States.
4. What is the top item on your “bucket list?”
A: I would love to travel extensively across India and Nepal.
5. What do you enjoy doing most with your personal time?
A: Film photography usually of my kids and family.
6. Who is your favorite historical figure and why?
A: Abraham Lincoln. I have always been fascinated by his brilliance, leadership, humor and tenacity despite many life challenges and personal failures. I am in awe of him.
7. What is your favorite junk food?
A: Pizza
8. Of what accomplishment are you most proud?
A: The work at my current agency, PromiseShip, makes me very proud of how we have been able to improve child and family outcomes in Nebraska
9. For what one thing do you wish you could get a mulligan?
A: Well, I wish I could start over being a husband and dad with what I know now.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
A: I am very interested in the intersection of the Family First Prevention Services Act and Medicaid services for kids and families.
Clay’s Weekly Medicaid RoundUp: Week of May 25th 2018
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2KSCG2Y
For optimist readers- http://bit.ly/2KT2aNX (A Dick Cavett reference for my friend Jeff, the Tall Irishman)
ABOUT LAST WEEK- There was way too much parenthetical thought (I apologize). [I will try to do better this week]. I promise.
MINNESOTA ASKS FOR WAIVER TO ALLOW RESIDENTIAL SA TREATMENT- Now that views on residential treatment in places with more than 16 beds are changing (under the weight of the opioid epidemic), states are looking to relax rules meant to defund those horror-story mental health facilities from back in the day. If approved, MN will join 11 other states who have recently received the exemption to allow drug addiction treatment in facilities with more than 16 beds.
NC ADDS WORK REQUIREMENTS TO MUCH-WATCHED WAIVER REQUEST- Journalists now see this as a poison pill to the NC effort based on 1 comment Verma made a few weeks ago about concerns over non-expansion states and work requirements.
GEM STATE REACHES VOTER CRITICAL MASS- The evolving nature of U.S. Government- in which the Constitution is but a piece of junk mail sent to us from those crusty, silly, old (add in still-socially acceptable slur here) guys back in the day from some place in the Northeast I think- now includes voters taking over the power of appropriations from Congress. Seems voters in Idaho are joining the mob of MoveOn-ers who think they can ballot anything they want into existence. Idaho activists confirmed they reached the necessary 58,000 signatures to put Medicaid expansion on the ballot in November. If they had to pay for what they are voting for, they would swipe their card for $3,206 (each, annually) to cover the costs (state and federal) for the 62,000 members their vote will add to the Medicaid rolls. But we all know its silly to expect voters to consider costs of their decisions. That’s someone else’s problem, right?
LEPAGE MAY GET OVERRULED- A Maine judge is deciding whether to order the state DHS to file a waiver request for expansion as chosen by voters. Roundup readers will remember that the Good Guvn’r LePage said he ain’t doing nothin’ to move it forward unless the legislature funds it.
SD WORK REQUIREMENTS PLAN GIVES SECOND CHANCES- SD policy makers have added another step before getting booted off if you don’t meet work requirements. Under the new proposal, bennies would get on a corrective action plan after not working 80 hours in a given month. Then if the CAP doesn’t fix it, they would get booted. The new feature is designed to avoid getting shot down by CMS as “too harsh” in a non-expansion state.
EVERGREEN STATE ANNOUNCES MCO WINNERS- The latest round of MCO awards in Washington concluded this week. Congrats to Amerigroup, Molina, UHC, CHPW and Coordinated Care. Special congrats to Molina and Amerigroup who nabbed statewide contracts for integrated care in all 9 regions.
VA LETS EVERYBODY DOWN- Everybody hoping for expansion this week, anyway. Virginia Dems were expected to push through an expansion vote on Tuesday, but needed 1 Republican to defect to the SpendMore side. Without getting to much into the weeds of VA legislative procedure, basically this bill needs to get out of committee and it didn’t do that just yet. The majority leader in the VA senate announced this week that he expects it to pass, even if it does take a minute to work out the details. Be patient my dear Dems – you will be able to implode the VA state budget soon enough.
IOWA ON THE REBOUND WITH CENTENE – After a nasty breakup with Amerihealth, Iowa announced Centene is its new love interest this week. Announced this week, will start July 2019. Congratulations to all our Centene colleagues!
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. Khurram Gondal of Ticonderoga, NY (and 11 other co-conspirators) were arrested this week for defrauding Medicaid out of at least $8M using their bogus transportation business. This scheme includes trips that never happened and kickbacks to complicit bennies. Roshanak Khadem (and 4 others) of Los Angeles were arrested on Tuesday for their part in a $20M scheme. Khadem (aided by a former Anthem investigator, who knew the ropes) and team would bill MCOs for things not provided using the billing numbers from bennies who were happy to get “discounts” on cosmetic procedures. Seems an allergy-related lab test CPT code was a hole about the size of a Mac truck in the MCO edits system. Keisha Demas of Brooklyn was arraigned this week for stealing about $500k, of which $60k was from NY Medicaid via a false claims scam related to her role as a nurse at Interfaith Medical Center. Congrats, Roshanak- using a former MCO investigator as a fraud consultant gives you the style points needed to win this week!
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 (take some cutting, and propagate something already doing well on your property) 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: il-Missier bagħat lill-Iben biex isalva d-dinja.
2018 May Medicaid News Roundtable
A lot happens in Medicaid in 30 days. We covered it all in 60 minutes with Elena Nicolella, Cathy Huff, Joel Menges and Darin Gordon.
Clay’s Weekly Medicaid RoundUp: Week of May 14th 2018
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2ISXzOf
For optimist readers- http://bit.ly/2y9t7L7
HEADED TO BALMORE. DO DROP BY AND SAY HELLO- I will be at MMCC 2018 starting Monday. Chairing a panel Tues morning. Would love for any and all readers at the event to say hi.
Y’ALL SIMMER DOWN NOW- NM recently awarded new MCO contracts. So the protests were filed by the losers. And HHS rejected the protests via the administrative process yesterday, so now the losers can take it to court. Yay! Even longer time to make changes needed for the program… Member impacts include uncertainty over whether they will have to switch providers Jan 2019. You have to understand the losers’ position though. It’s a lot of cash. Example – Molina had $1.3B in premium revenue in NM Medicaid last year. Assuming a 2% profit yields $26M a year lost if the protests don’t work out. So as long as the litigation costs less than $75M or so (3 years of premium profit in the market), why not roll the dice and sue? And that doesn’t even take into account impacts on market capitalization on news of losing key contracts, etc. Want to track the impact of lawsuit on stock price? Follow ticker symbol MOH on the NYSE.
SOUTH CAROLINA EXPANSION LOBBY PRIMES THE PUMP- The Urban Institute (are they still around?) just released a study showing the amazingly 1-sided impacts of a potential Medicaid expansion in SC. 194k would get “coverage” (please define “coverage” class, and then compare and contrast it to “access,” then triangulate it with “intersectionality” – oh bother, I lost myself) if the state moved forward with expansion. Per the study, the state would “only need to chip in $111M per year.” Because you know its magic federal money, that comes from the sky every time you wish upon a star. It makes no difference who you are. Anything your heart desires will come to you (and other states will pay for it!).
ALASKA SLOWING HOSPITAL PAYMENTS- Since the legislature did its job and passed a budget (you know, how the US Constitution and all state ones work?), there is $20M less than requested (do not make the mistake of confusing requested with “needed”) going to Medicaid between now and June 30. That’s about 45 days, people. So when you realize how people are freaking out (that they have to follow what the legislature says when it comes to appropriations) its clear Medicaid is living check to check. Normally the state cuts the checks weekly, but starting this week they will float larger providers a bit longer. Some reps point out that all this is driven by higher than projected costs of Medicaid expansion (remember when the Good Guvnr Bill Walker did it all by his lonesome back in 2015?), but those reps are quickly silenced and reminded on the non-politic nature of such comments. Even more daring reps point out that services for the most vulnerable are being impacted because of expansion overloads. Those reps are so offensive that they are immediately sent to Siberia. You can see it from the Governor’s back yard, you know.
PATIENTS SUE ILLINOIS OVER MEDICAID DELAYS- Illinois just can’t get it together. Seems like the state thinks after it sent us the best-President-ever they don’t have to do anything else at all. Resting on their laurels. Latest chapter in the dumpster-fire story (tragi-comedy? Especially considering sub-plot arcs over the years like Blagojevich) of the Prairie State is a lawsuit from patients suing over long-delayed eligibility applications. Seems the state is out of compliance with federal rules on determining temporary eligibility for new applicants. They are supposed to process apps within 45 days. The biggest pain points are in nursing homes. Per the write-ups I’ve seen, there has not been a single applicant approved under temporary eligibility since the summer of 2016.
FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph – not so fast. I was too wordy up top this week. Plus gotta keep you coming back for more.
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 (time to get the yard in shape for your Memorial Day party) 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: lēākaṁ rakṣikkānāṇ pitāv putrane ayaccat
Clay’s Weekly Medicaid RoundUp: Week of May 7th 2018
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2IaCtew
For optimist readers- http://bit.ly/2jNiSm7
QUICK ANNOUNCEMENT – Our webinar provider had a “major outage” yesterday and we did not get to do the full MESC 2018 preview webinar. Look for details re a rescheduled show in the newsletter.
BEEHIVE STATE TILTS AT WINDMILLS – Please write in if you get the reference (no googling!- but you can go to your local library and check the 863s under Cer)… Officials in Utah continued the farce of a post-obama expansion this week by trotting out a series of public hearings to discuss adding 90,000 adults to the rolls. Do people really think CMS will approve this? Or maybe I missed something and Utah is willing to pay 50% of the costs (vs the sweet, sweet 90-100% deal offered in years past?). Think they will agree when CMS comes back with work requirements and other “evil” conditions of paying for it?
IT’S GETTIN’ HOT IN HERE; I’M GONNA CUT SOME BUH-JETS – Apologies to Nelly fans worldwide. Louisiana may be doing it for reals, though. Letters were sent to 37k bennies that they may get booted from Caid based on recent changes to Medicaid budgets. The proposed budget would remove 4 programs (not sure which ones, please write in if you know more). Bennies will also get contacted about getting services on other programs they may still be eligible for.
NO DICE, KANSAS! CMS rejected the KS waiver request to establish a 3-year limit on Medicaid benefits for non-disabled adults. This doesn’t bode well for AZ, UT, ME and WI who have asked for a similar budget relief measure. Since this rejection is in keeping with the dominant paradigm of The Healthcare Left, many are confused. At time of running this article, CNN was trying to figure out how to tie this to Stormy Daniels. Or the Russians. #Resist!
ILLINOIS GETS A LOT OF CASH TO HELP FIGHT THE OPIOID CRISIS- CMS approved a $2B transaction to IL this week, as part of an 1115 waiver application to address challenges in meeting the needs of behavioral health patients. Per analysis used to make the case for the funding, bennies with behavioral health needs drive more than half of all Medicaid spending. July 1 will see new efforts funded around short-term drug addiction treatment centers, moms and babies showing drug withdrawal symptoms, employment assistance and other programs. IL had asked for some of the cash to go to things related to social determinants of health (like rent payments), but CMS shot that down.
TRIBES CONCERNED OVER NEW MEDICAID RULES APPLYING TO THEM- Seems some policy statements / positions in April from CMS / Trump classify tribes as a race. The next step in the Administration’s argument is that exempting tribes from work requirements would show preference for one racial group over another and thus be discriminatory. Different tribes are assessing the impact on them, with Cherokee Nation putting about $46M impact due to a proposed work requirement in OK.
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. Beverly Coker of Windsor, CT was sentenced for her part in a $214k fraud that involved unlicensed providers. (She got probation while her co-conspirators got much harder sentences. May be because she is 70 years old). New Era Rehabilitation Center in Bridgeport, CT will pay back $1.37M for double-billing for methodone treatment. There are some services-not-delivered details in that one, too (check the twitter feed for more). Mrs. Coker – You win this week’s award because you are the oldest convict ever to appear in the Roundup! Congratulations!
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 (Meet a new neighbor this weekend) 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: Bapa menghantar Anak untuk menyelamatkan dunia