The Mental Health Association in Michigan

is the only statewide, non-governmental agency concerned with the broad spectrum of mental illness across all age groups.

August 17, 2012

Coalition Testimony, Possible New State Program for Those Enrolled in Medicaid & Medicare

Testimony of Mark Reinstein, Advocates Concerned with Dual Integration

Senate Appropriations Subcommittee on Community Health – March 2012

Thank you, Senator Moolenaar and Members of the Subcommittee.

I’m Mark Reinstein, President & CEO of the Mental Health Association in Michigan. I’m here today on behalf of the coalition known as Advocates Concerned with Dual Integration, the membership of which is attached to my testimony.

We commend the Subcommittee for having this hearing. DCH in its draft plan says that no legislation is needed for the new program. We’re not sure the situation is that cut-and-dried, and this is going to be a process with ongoing variations; for example, the final plan that goes to the federal government will presumably have revisions. Your future involvement may be necessary to address something the administration needs done, or advocates like our coalition may be coming to you with requests for certain things which would benefit service consumers. I will try to give you a heads-up today on some of those possible issues.

First, we recognize and welcome the potential good that can be done by integrating health care for persons dually enrolled in Medicaid and Medicare. And we commend DCH’s plan for not proposing a major disruption to the current public service mechanisms for persons with mental illness, developmental disability and substance addiction. The state’s plan would use those CMH programs known as Prepaid Inpatient Health Plans (PIHPs) for this population, while employing a new type of entity – an Integrated Care Organization (ICO) – for other health care needs.

Having said that, however, the plan is short on addressing how any of the deficiencies of our CMH system – e.g., the disparity that can exist from one county to another – would be addressed in the new program, or how those CMH programs that aren’t PIHPs will or won’t fit into the picture. If you’re 200 miles from where the nearest PIHP is headquartered, how will your service access be structured and organized in a way that is uniform and accountable across the state?

One of the most glaring omissions in DCH’s draft plan is adequate rights protection for service recipients. The Department has ignored the recommendation of one of its work groups that a single statewide independent entity be created to handle all consumer rights, grievance, appeal and dispute resolution matters, including facilitated mediation. This recommendation was made for two reasons: (1) the multitude of existing rights mechanisms and places to go when you combine all aspects of someone’s health care is an almost-impossible maze for anyone to traverse – we need simplified “one-stop shopping” here; and (2) most of the procedures that do exist right now are under the control of the providers and managers of service. That’s not really rights protection, and we may be coming back to you for assistance on this.

Another glaring omission, despite the plan’s otherwise commendable attention to person-centered planning, is the issue of independent facilitation of such planning for consumers who desire it. Person-centered planning has been part of Michigan’s Mental Health Code since 1995. In the 16 years since, we have learned that it is sometimes difficult for the managers and providers of service to balance their own interests and requirements with a consumer’s desires and stated needs. For this program, designed to serve an extremely vulnerable population group, recipients must have the opportunity to select any independent individual or entity they desire to assist them in exercising their person-centered planning privileges.

We believe there are several other areas where the state’s plan needs work before submission to the federal government. They are as follows:

*The DCH plan says that consumers may get a choice of who their ICO manager is. There should be no “may” here; there should definitively be a choice. And since the plan would give no choice on the “behavioral” health side – it would automatically be a PIHP – the plan should clearly state that consumers with both behavioral and non-behavioral health needs can if desired select the ICO to be their lead management and care coordination entity. (The lack of choice regarding one’s behavioral health manager is another reason supporting an independent statewide system of rights protection for the new program.)

*The draft plan proposes something regarding prescription management that failed badly when tried in Michigan in the late 1990s. The plan says that the ICOs will have all management responsibility (and presumably hold all the money and risk) for consumer prescriptions, even those involving behavioral health. When our state went heavily to Medicaid managed care in the late ‘90s, the Medicaid HMOs were initially given the money and responsibility for all prescriptions, including those coming from CMH. That proved totally unworkable and lasted less than two years. Both the ICOs and PIHPs must be given management and fiscal responsibilities when it comes to consumer prescriptions.

*The administration has missed some opportunities for extensive stakeholder involvement so far in the process – e.g., stakeholders weren’t directly involved in drafting the plan, and there’s never been comprehensive dialogue on what funding reimbursement model to be used. No more opportunities should be missed. We commend the plan for proposing an ongoing stakeholder advisory group, but this group should be started sooner rather than later, and there should be specification that “stakeholders” include consumers, families and advocates. Additionally, the plan should state that consumers, families and advocates will be involved in the development and review of RFPs for this program. The state has commendably said that RFP applicants will have to show consumer involvement in their governing boards. Shouldn’t the state’s RFP development and review process have the same fidelity to consumer involvement?

*With further regard to RFPs and subsequent program contracting, the final plan that goes to the federal government should state that all applicant and contractor documents and meetings related to the new program will be open to public inspection and attendance. And, given the nature of this program, the plan should specify that RFP applicants demonstrate experience with aging populations and those experiencing cognitive disorders.

*There is grave concern among advocates about what happens to persons needing public service who aren’t in the new program – e.g., the huge number of people who are Medicaid-only. How do we assure no harm for them? The administration’s plan is light on this subject, and needs to assure that those not in the program won’t lose access to their current scope of services and providers. One way of helping in this regard would be to assure that any savings generated under the new program would go back into publicly funded health care in Michigan. Unfortunately, the draft plan does not do this.

*With further regard to “doing no harm,” something has to be done to alleviate the problems of Medicaid spend-down, where individuals facing it go in and out Medicaid eligibility every month, with major continuity of care problems resulting. Some would say this doesn’t need to be tackled in conjunction with the dual-eligibility project, but we would point out that several thousand state residents who have Medicare but are in Medicaid only through spend-down are being completely eliminated from consideration for the new integrated care project under the state’s draft plan.

*The draft plan is largely silent on what the administration’s preferences are in areas where Medicaid and Medicare don’t presently have the same processes and procedures. The plan should include as a principle that, within the parameters of what the federal government ultimately allows, Michigan’s preference in resolving these differences is what portends to be most advantageous for individual well-being in areas such as service access, treatment-and-support outcomes and quality-of-life. (We commend the plan for mentioning the latter as an area meriting evaluation.)

*Consumer enrollment is not yet adequately addressed in the draft plan. The state is going to automatically enroll all eligible people, and then those people will have to decide if they wish to disenroll.  Given that the state would not be using the more consumer-friendly tactic of determining whether people wish to enroll in the first place, it becomes imperative that the opportunity to opt out of the program be available at any point in time – something the administration’s draft doesn’t specify. Additionally, it is unclear to us how the plan’s periods for consumer assessment and consumer enrollment mesh; we would remind the administration that until someone is assessed, knows what they’ll be offered and can compare that (in writing) to what they presently receive, an informed decision about whether to accept the automatic enrollment or exercise the opt-out privilege can’t be made. And, while we appreciate the plan’s provision that everyone wanting consultative assistance on enrollment would get it, we believe that every non-respondent to the state’s initial project notification letter should receive proactive consultative outreach, and assistance should not be provided by what the plan calls an “enrollment broker,” but rather what we call a “choice broker” – one that has absolutely no financial stake in whether an individual accepts their automatic project enrollment or decides to opt out of it.

*Finally, the draft plan’s material on project evaluation is not yet satisfactory. We commend the proposal to have a quality improvement advisory committee, but right now there are too many generalities and not enough specifics. How often will there be public reporting? Are we going to measure loss of contact with enrollees, which would be very important in the estimation of our coalition but is not mentioned in the draft plan? How can we have meaningful qualitative input from service recipients so that evaluation is more than just a set of numbers, and “consumer satisfaction” is more than a few limited categories on a survey form? And since this project would be rolled out in phases, how and when do we evaluate for each phase; how do we assure that things learned form evaluation of a given phase can be incorporated in the next phase; and if evaluation of a given phase would suggest that the program has to temporarily cease, will Michigan have the political will to do that?

Thank you for your thoughtful consideration of our views.