Monday, April 11, 2011

Who is Really Ripping off NYS Medicaid

S’io credesse che mia risposta fosse
A persona che mai tornasse al mondo,
Questa fiamma staria senza piu scosse.
Ma perciocche giammai di questo fondo
Non torno vivo alcun, s’i’odo il vero,
Senza tema d’infamia ti rispondo.*


I do not know if I am the only one in State of New York who thinks this way. But I want to believe that among the 18 million people or so there is at least another. There just as to be at least one other person who finds Governor’s Cuomo Medicaid Redesign team an insult to what is decent and righteous in New York. 
Twenty seven people redesigning Medicaid -- not one person from the New York State Medicaid Audit and Investigative body; not one individual who has any first-hand experience dealing with the grimy business of Medicaid Fraud and Abuse. And believe me, it is a dirty business: a 54 billion dollar a year filthy business with an estimated 5.4 billion in outright fraud and another 11 billion to 20 billion in abusive practice.
If you don’t find that grimy; … well, what can I say? … Let’s just leave it at that. Still, though, make no mistake about it; the Medicaid Industry in New York State is fraught with thieves.  The worst types of thieves! – Thieves that steal with impunity and with an ingrained belief that they have the absolute right to embezzle from the public treasury.   They are worse than the street muggers; worse than the bank robbers; worse than the unprincipled financiers. These are thieves who use the infirm, the invalid, and the unfortunate to stuff their pockets. To  them, sick people, young and old, male and females, alive and dead are nothing more than a commodity, a means of milking a system that was established to assist those who have no place else to turn.
But don’t blame this scum! If you really want someone to blame, don’t walk too far from you own toilets. Look in your vanity mirrors and you’ll find the real culprits. You are to blame; you and me, and all the others who, instead of demanding a just government, simply stand by and allow unscrupulous politicians to favor those who contribute to their campaigns.
How dare I make such bold statements? Never mind that I’m allowed to do so by the Constitution. (You know that part about freedom of speech and stuff like that.) I am someone who spent thirty years working as a New York State Medicaid Auditor. I am someone who started as a trainee and climbed to mid-level management. I am someone whose lips would not have quivered, had this State’s Medicaid system not become a manger where pigs feed.
 It just too much for anyone in the know to sit idly by without commenting. Just too much!
Now let’s be clear about something, not all Medicaid providers are thieves of course, but just enough of them to give validity to the statement. They are heartless, not all of course, but just enough of them to make you worry about your afflicted neighbor, siblings, mother and grandmother, father and grandfather, sons and daughters, whom might have no other alternative but to visit Medicaid mills, clinics, or other types of Medicaid facilities.
Beware! Don’t trust them for one heartbeat! They may portray themselves as saviors, but they are in reality more ravenous than blood hungry vampires.   Not all of course, but just enough of them!
If I seem angry, I am. And if you are not angry after reading what follows, then truly the words inscribed above the portal of hell should be carved on the gates of New York State: Abandoned of hope yeah who enter here. ( Dante’s Devine Comedy)
If you still are not angry after reading this, then what in hell is wrong with you? But if you are, even in the least possible way, get up off your asses and do something: call you State Representatives and tell them you’re against the Medicaid Redesign Proposals.  What you want instead is more provider accountability.
In this first presentation let’s start with latest Medicaid farce.
 The Medicaid Redesign Team

Who are they?
Recognizing who they are can give an idea of whose interest they uphold. 27 people, not one representing the welfare of Medicaid Recipients or the welfare general public.   Not one!
Representing Healthcare Workers             2
·         Former Chair of SEIU Healthcare and currently the Senior Advisor to the International President of SEIU.
·         President of 1199 SEIU United Healthcare Workers East
Representing Medical/Healthcare Provider Association              7
·         Healthcare Association of New York State.
·         President of the New York State Nurses Association
·         President of the Community Health Foundation of Western and Central New York.
·         Executive Director of the New York State Association of Counties.
·         Former Chairman for the Commission on Health Care Facilities in the 21st Century and a board member for the Partnership for New York City.
·         CEO of the Community Health Care Association of New York State.
·         President of the Greater New York Hospital Association.
Representing Direct Providers       5
·         President and CEO of North Shore LIJ Health system.
·         President and COO of Emblem Health.
·         CEO of the Metropolitan Jewish Health System as well as the Chairman of the Continuing Care Leadership Coalition.
·         President and CEO of the Visiting Nurse Service of New York.
·         CEO of the United Cerebral Palsy of New York City as well as the President of the Interagency Council.
Representing healthcare Institute and Councils 2
·         Co-Chair of the JFK Jr. Institute for Work Education at City University of New York.
·         Chair of the New York State Public Health and Health Planning Council.
Former Advocates for providers 1
·         Coordinator at Medicaid Matters New York (a prior advocate for the Mental Health Provider Community).
Elected officials 5
·         Senator
·         Senator.
·         Assemblyman.
·         Assemblyman.
·         Deputy Mayor of New York City for Health and Human Services
Quasi Elected Officials 5
·         Commissioner of Health.
·         Commissioner for the Office of Mental Health.
·         Commissioner of the Office for People with Developmental Disabilities.
·         Commissioner of the Office of Alcoholism and Substance Abuse Services.
·         Deputy Secretary for Health and the Director of Healthcare Redesign.


What have they recommended?
This prestigious group of people received over 4 thousand suggestions on how to “reduce the cost” of Medicaid in New York State. They selected 79.
I am not going to comment too deeply on the directions for submitting suggestions.  It suffices to say that one had to make ones case in 2 minutes. Depending upon one’s ability to rapid-speak the limit was set to a maximum of 500 words. 
Appreciate that for a second! Roll it over in your minds! Let it linger there and then try presenting a potential solution for the restructuring of a 54 billion dollar per year industry in two minutes. 
God, that is exceptional!
And even more fantastic is that of 4000 recommendation 79 were so superior to the others that they merited recommendation.  
Let’s examine some: 30 (38%) neither decrease nor increase (if you can believe that) the cost of Medicaid; 6 (8%) will cost money to implement, and the remaining 42 (53%) are supposed to reduce costs. (The total percentage equal 99 because of rounding)
As a matter of substantive analysis the reduction of costs is a hopeful dream, at best. Recommendation number 131, for example, with an estimated savings (208.50 million) is nothing more than a way for providers to increase their own profits at the expense of impaired infants and the Medicaid system.
As the “Short Title” indicates, this recommendation is a backhanded way for providers to reduce the amount they pay in malpractice insurance. From a simple accounting perspective the less expenses paid, the greater the bottom line.  And here comes the tragedy the proposal focuses on - the “neurologically impaired infant….”
It makes no reference to children born with deficiencies. The proposal’s implied aim is at those infant that have been afflicted.  It refers to defects imposed through failed or improper procedures! It stands to protect provider’s incompetence or outright malpractice.
This recommendation then is a direct assault on everyone because providers would be able to get away with maiming infants without repercussions.
But recommendation 131 is only part of the whole farce. The overall essence of the recommendations is to enroll the majority of Medicaid recipients with chronic conditions in Managed Care. To those who do not understand the finer points of Managed Care, this may seem a viable way to reduce cost. The fact is, however, that Managed Care makes a few ultra rich while the many receive low standard treatment. 
Under the Medicaid system there are only two ways for a provider to receive payment: fee for service and managed care. The question that needs to be examined then is how providers earn under these two systems. In the fee-for service the issue of making money is quite simple: a provider makes money by receiving payment for services rendered … more services, more money; no services, no money. Under the Managed Care system, money is made in just the opposite manner: fewer services, more profits.
To understand Managed Care one needs to be familiar with the capitation system which is a scheme that pays a set amount per person whether that patient is treated or not. To repeat this in another way: the provider gets paid regardless of whether they provide services or not. More services does not equate to more money, in fact more services actual amount to less profit. So a Managed Care provider’s goal is to enroll as many patients as possible and provide as few services as possible. Enroll many provide few services, that’s the profit motive of Managed Care.
It gets even more odious. Managed Care does not only affect the patient. For the independent practitioner (your local doctor or local clinic) the situation is no better. To receive Medicaid funds the local practitioner must become a member of a health maintenance organization (HMO) and in New York State there are only 39 such organizations. Your local doctor has to either enroll with one of them or forgo Medicaid reimbursement.
Thus the reason why patients should resist Managed Care is obvious; they stand to get little or substandard service. The reason the local doctor and clinics should resist managed care is that they will likely get the patients who are in need of the greatest amount of services at no greater reimbursement.
In conclusion under Managed Care not only do the patients suffer, but so do the small providers.

Proposal 18’s short title is Eliminate Spousal Refusal.
In essence this is mostly applicable when an individual needs to be placed in a long term facility (nursing home).
Nursing homes have ranked among the top Medicaid abusers for decades. One of their tactics for stripping individuals of their savings is as follows: when the individual has money the nursing home charges them the “private pay rate”, which is substantially higher then what Medicaid pays. Usually the individual nest egg is exhausted anywhere between 6 months to a year. When all of the individual’s money is gone, the nursing home helps the individual enroll in Medicaid. This practice has been going on for as long as there have been nursing homes.
As a result many astute spouse and family members have refused financial support for their loved one in nursing home. While nursing homes, the politicians they bought and the media accuses these folk of being selfish, they are truly not. It has nothing to do with love; it has to do with survival. By accepting financial responsibility, the nest egg accumulated through a working life is basically hoarded by the nursing home in less than a year. And then after the total exhaustion of the individuals savings instead of having one person on Medicaid the spouse and the other member of the family will have to be enrolled.    
According to the Redesign Team, each recommendation falls into one of 7 “Themes.” By “Themes” these greatly-civil-minded individuals mean the expected results.
38        proposal are expected to “Recalibrate Medicaid Benefits and Reimbursement Rates”
The majority of these involve moving patients into Managed Care Programs. We’ve already discussed raising profits by diminishing services.
15        proposals are expected to “Eliminate Governmental Barriers to Quality Improvement and Cost”
The elimination of Governmental Barriers to Quality Improvement and Cost is just another way of saying eliminate governmental supervision of programs. In another word, get rid of the watch-dogs. I’ll leave it to your imagination what happens to service when no one is looking. If you lost your home, if you’re unemployed, if you can’t buy gas to run your car, if your retirement plans have gone up in smoke you are the direct result of deregulations.
9          proposals are expected to “Ensure Consumer Protection and Promote Personal Responsibility.”
Another way of saying it’s your fault for getting sick.
Eliminating Governmental Barriers eliminates Consumer protection. When governmental barriers are eliminated the individual consumer simply does not have the strength to stand up to the providers.
The individual consumer lacks the money, the know-how and clout to oppose the providers.
Three quick examples: the 60 month look back period for transfer of assets to non-institutional long-term care applicants with spousal impoverishment protections. And “Add Consumer direct Personal Assistance program (CDPAP) services to managed long term care plan packages.
 A third proposal would give statewide responsibility for making Medicaid Recoveries from the estate of deceased recipients, in personal injury action and in legally responsible relative’s refusal cases.
The great thing about this proposal is that it expands state authority (and eliminates a Social Services Regulation already established) but the direction favors providers.
7          proposals expected to “Ensure That Every Medicaid Member is Enrolled in Care Management”
“Déjà vu all over again.” Managed Care once more.
7          proposals are expected to “Empower Patients and Rebalance Service Delivery”
            Just look at the recommendation!
2          proposal are expected to “Eliminate Fraud and Abuse”
Of the 79 proposals only two are dedicated to the elimination of fraud and abuse.
One just has to admire this.
CMS the former HHS which is the federal agency that runs and administers Medicare and Medicaid have stated that a conservative estimate of Fraud and Abuse in the Medicaid program is 10%. Other have agreed,  and have stated that along with the 10% fraud rate there is likely to be 20 to 30% abuse in Medicaid thus the real percentage of fraud and abuse in Medicaid varies somewhere between 10% to 40%. (Look this up folks don’t take my word for it.)
When actual calculations are applied one finds that in dollar value Fraud and Abuse in New York State is somewhere between 5.4 billion to a possible 22 billion dollars. Even using the low figure of 5.4 billion one must admit that it is a lot of money being stolen.
Considering that hardly any part of this money ever gets into public hands or is used to assist the infirm, one can’t help but conclude a few people are getting awfully wealthy stealing public funds.
Doesn’t it make sense then if one were getting rich with public funds wouldn’t one want fewer regulators over your shoulders? Does a street-thief want a cop on every corner?
That’s the reason why of 79 proposal 15 want to eliminate governmental intervention and only 2 want to eliminate fraud and abuse. It clears the way for pigs to run to the manger.
1                    proposal is expected to “Better align Medicaid with Medicare and ACA”

My objective is not to provide a full analysis. That would take too long. I just wanted to present a few points and show how the proposals are actually slanted to favor the providers (the large ones) over the people (you and me).
Recommendation
Along with criticism there has to be a sound alternative. Thus, how would someone in the know solve the NYS Medicaid problem?
The first recommendation is, of course, to get rid of the pigs in the system:  exclude them, sanction them all that is required is a 45 day notification. And that does not mean to shut down services, it means to replace the bad managers with those who are civic minded
The second is reevaluating the guiding principles of the New York Department of Health, with the OASAS, with OMH with OMRDD. Their policy, written and unwritten, are the greatest causes of problems in the NYS Medicaid system. You know the one that favor providers over patients.
Another proposal is to extract the Medicaid program from the hooks of the Department of Health. You simply can’t have the wolf guarding the chicken coop. While federal law requires that Medicaid be administered by overall agency. It does not have to be one that makes Medical policies. Medicaid should be independent body. It accounts for 54 billion dollars a year, why does it have to be affiliated with those who make provider policies.  
I have only skimmed the surface as a way of introduction other topics will be covered in future discussion. One such analysis will be how some organizations have captive audiences and use them as a means to exploit the system, through DOH, OASAS, OMH, OMRDD services that many times simply duplicate each other.  
Another of my favorite topics is the way providers are granted Operating Certificates (licenses to operate.) As a way of introduction: Several years ago there were so many Operating Certificates issued for a particular types of health clinics that no one in the Department of Health knew how many of these Medicaid mills actual existed. (Remember the part-time clinic project.)
But don’t worry folks no names will ever be mention; well except for that politician who had the nerve to claim in public session that Medicaid Providers are doing God’s Work. That gentleman’s name must be made known. ‘cause we all need to ask which deity he is talking about -- Mr. J. does this deity’s name begin with an S?

No names, but I assure you that what I will tell is factual and traceable either to some periodical or some internal audit investigative document, which can be gotten through the Freedom of Information Law (FOIL) before they are “sanitized”.

Why sing?
Because I’m just f---ng fed up, with the b-ll--it, a few getting fat while over 3 million kids in NYS go hungry every single day. … This is not America! This is more Baghdad than New York, but at least the Iraqis have an excuse, - they have been devastated by war. What’s our excuse? ...  the few gorging off the misery of the many.

* From Dante’s Hell
If I believed that my answer would be to someone who would return to the world, this flame would never quiver, but because, if I hear the truth, from this hole no one has ever returned alive then without fear of infamy I shall answer.





1 comment:

Unknown said...

Fraud is definitely a huge part of the problem, but when you have health care providers and unions making the decisions when it comes to reform, it is no surprise why fraud and abuse is not getting adressed.