Homer Simpson on Health Insurance
Andrew Malekoff© June 2010
We are all familiar with stories about the ineptitude of government officials and regulators in protecting the public. At the SEC, they fell asleep at the wheel as Bernie Madoff made off with billions. In its eagerness to put more low-income families into its own homes, HUD failed to rein in Freddie Mac and Fanny Mae from saddling borrowers with mortgages they could not afford. So, it comes as no surprise to me that I cannot get a straight answer about who regulates the commercial insurance industry in New York State.
New York State is on the verge of implementing a plan for restructuring the financing of community-based mental health clinics. The plan discriminates against the underinsured middle class and working poor and is scheduled to commence on October 1. It represents a dramatic shift away from universal mental health care and towards care for families with Medicaid insurance only.
Those who have Medicaid are able to easily access community-based mental health services. Otherwise, you will soon be out of luck. When a family cannot get essential community-based mental health services that is what is known, in insurance industry parlance, as an inadequate network of care. Network adequacy has to be monitored and enforced.
In an attempt to get some straight answers, I contacted nuclear power plant safety inspector Homer Simpson, who was recently quoted as saying, “America's health care system is second only to Japan, Canada, Sweden, Great Britain; well, all of Europe. But you can thank your lucky stars we don't live in Paraguay!”
Andrew Malekoff: It is great to see you Mr. Simpson. You are looking dapper as ever.
Homer Simpson: D’OH!
AM: I know, I know, enough small talk. So, let’s get down to business. As someone with quality assurance experience, do you have any insights into who is overseeing the commercial insurance industry in New York State?
HS: D’OH!
AM: Are you expressing astonishment at my question, or are your referring to the D.O.H. - the New York State Department of Health?
HS: D’OH!
AM: A state official told me that this was the State Insurance Department’s (SID) jurisdiction.
HS: D’OH!
AM: Okay, okay, take it easy. I contacted a senior examiner at SID and she told me that they (SID) had regulatory authority over all licensed insurance companies and that they did enforce the insurance laws and all policy provisions but, she was quick to add, “We do not get involved in the network adequacy issue.” She said that that was the Department of Health’s job. I take it that you concur?
HS: D’OH!
AM: As I am sure you know, the commercial insurance industry uses managed-care companies to hold down costs. They decide, usually from hundreds of miles away, who gets what kind of mental health care, for how long and at what rate of reimbursement. In other words, they don’t really manage care, they manage cost and sometimes they even mangle care - at a nice profit.
HS: D’OH!
AM: According to Patrick Gauthier from Advocates for Human Potential Healthcare Solutions, “Despite the deepest and most enduring recession in 70 years…the five largest health-insurance companies in the nation disclosed combined profits of $12.2 billion last year — a 56 percent increase over the previous recessionary year. They managed this feat even though they experienced a combined loss of nearly two-million members to unemployment.”
HS: D’OH!
AM: My sentiments exactly! I am not sure that families know what to do if they cannot find a provider in the advertised network of care available to them via their health plan. May I ask you one final question, Mr. Simpson?
HS: D’OH!
AM: It will be quick. I promise. I raised the issue of network adequacy with the network manager for a well-known insurance company. She said to me, “We have a large volume of therapists within a five-mile radius of your agency that see young children which supports that our network needs are being met. What brings clients to your agency rather than an individual clinician's office?” How do you think I should answer her?
HS: First of all, Marge and I want to thank the Guidance Center for helping our family. Here is what I recommend you say in response to the network manager’s question: “The kind of comprehensive service that a community-based provider offers cannot be duplicated by any private practitioner in your network. For example, at North Shore Child and Family Guidance Center, the wrap-around services, for which they are not reimbursed by you or any commercial insurer, are by no means unnecessary frills or perks. They are essential services for working with a growing population of families in emergent crisis and in need of a community-based agency approach that is designed for this population, versus an individual private practitioner with limited availability, time and resources.” That should set her straight. Now I have to leave before happy-hour is over at Moe’s.
AM: D’OH!
To learn more about your rights as a health care consumer go to the following website: http://www.ins.state.ny.us/hrights.htm.
Published in the Anton chain of 18 newspapers, Long Island, New York in June 2010
Showing posts with label managed care. Show all posts
Showing posts with label managed care. Show all posts
Saturday, May 29, 2010
Friday, January 8, 2010
Medicaiding-the-System Redux
Medicaiding-the-System Redux
by Andrew Malekoff©
January, 2010
Executive Director, North Shore Child and Family Guidance Center
Roslyn Heights, New York 11577
BONUS-DOLLAR BLITZ CIRCA 1991
In 1991, New York State implemented a plan to use Medicaid dollars to fund outpatient community-based mental health services. That two-decade-old approach, also known as Medicaiding-the-system, is on its way out.
Medicaiding-the-system was a combination of (1) a base Medicaid rate applied for each outpatient mental health visit for Medicaid recipients only and (2) supplemental or bonus dollars paid on top of each base payment to subsidize non-Medicaid recipients. This approach to support community-based agencies was developed to replace local assistance or deficit-financing.
Local assistance was a simple and sensible public-private financing partnership. The partners were the State and County governments (through government contracts), mental health consumers (through fee-for-service payments) and the local community (through fund-raising).
Local assistance funding insured that all stakeholders chipped in a fair share to support an essential community-based service. However, New York State decided that if Medicaid could cover these costs, that they could systematically reduce and ultimately eliminate the amount that they chipped in through local assistance contracts.
If New York State will not support essential community-based mental health services for the most vulnerable members of our communities, who will?
BONUS-DOLLAR BLITZKREIG CIRCA 2010
In recent years, New York State recognized that the Medicaid bankrolled bonus-dollar approach of financing community-based clinics had the inadvertent affect of propping up commercial insurers that were paying substandard rates and limiting access to essential services. Having uncovered that festering wound, they got to work on creating a new financing plan that they refer to as clinic reform.
The clinic reform plan will raise the Medicaid-base rate and phase out bonus-dollars over a four-year-period. The Medicaid base-rate will apply only to those individuals that have what is known as straight Medicaid insurance; that is, Medicaid that is not managed by a commercial insurance company. There will be no reliable funding stream to replace the lost bonus dollars except for a finite pool of funds, presumably to cover services for indigent consumers.
In discussions with State officials about the devastating consequences of the clinic reform plan for the middle class and working poor, I was told that clinics must re-negotiate rates with commercial insurers. That is nothing new. It is common practice. The State officials advised me that if the commercial insurers do not raise their rates to sufficient levels that will help to cover the cost of services provided, then we should terminate our contracts with them.
Community-based providers routinely re-negotiate rates with the managed-care companies that represent the commercial insurers. However, they rarely agree to rates that will cover the cost of service. As one such managed-care company representative recently told us, “C’mon, we are hurting too.” For more information on public and private insurance markets in New York I refer you to the following website: http://www.uhfnyc.org/publications/880618.
If we drop the commercial insurers, as I was advised to do, it means that middle class and working-poor families are out of luck. They will not be able to afford to pay out of pocket to access community-based outpatient mental health services that are structured to meet their families’ needs. For example, at North Shore Child and Family Guidance Center, almost 30% of all evaluations in 2009 were emergencies that were seen within 24 to 48 hours. Who will take care of these emergencies? Private practitioners?
Clinic reform is nothing more than a downgraded version of Medicaiding-the-system. With clinic reform, the term community-based mental health center becomes a thing of the past as only a small segment of the local community will be able to access needed services.
APRIL FOOL’S DAY 2010
New York State is throwing in the towel at a time when there is unprecedented need for community-based mental health services. As the complex funding history described above is demystified, more and more families are advocating for a freeze on clinic reform. I urge you to call your local New York State legislators and tell them to extend the projected clinic reform start date of April 1, 2010 and to restore local assistance financing.
Don’t accept, “But there is no money!” for an answer. Please listen; the fact is that the cost to place a child or teenager in a psychiatric or juvenile detention center or a young adult in jail is far greater than what it costs to support quality community-based mental health care that will keep them at home.
We all know that familiar refrain, pay now or pay later.
This is an advance proof of Mr. Malekoff’s monthly column PARENTING PLUS, that is scheduled for publication in January, 2010 in the Long Island, New York Anton chain of newspapers.
by Andrew Malekoff©
January, 2010
Executive Director, North Shore Child and Family Guidance Center
Roslyn Heights, New York 11577
BONUS-DOLLAR BLITZ CIRCA 1991
In 1991, New York State implemented a plan to use Medicaid dollars to fund outpatient community-based mental health services. That two-decade-old approach, also known as Medicaiding-the-system, is on its way out.
Medicaiding-the-system was a combination of (1) a base Medicaid rate applied for each outpatient mental health visit for Medicaid recipients only and (2) supplemental or bonus dollars paid on top of each base payment to subsidize non-Medicaid recipients. This approach to support community-based agencies was developed to replace local assistance or deficit-financing.
Local assistance was a simple and sensible public-private financing partnership. The partners were the State and County governments (through government contracts), mental health consumers (through fee-for-service payments) and the local community (through fund-raising).
Local assistance funding insured that all stakeholders chipped in a fair share to support an essential community-based service. However, New York State decided that if Medicaid could cover these costs, that they could systematically reduce and ultimately eliminate the amount that they chipped in through local assistance contracts.
If New York State will not support essential community-based mental health services for the most vulnerable members of our communities, who will?
BONUS-DOLLAR BLITZKREIG CIRCA 2010
In recent years, New York State recognized that the Medicaid bankrolled bonus-dollar approach of financing community-based clinics had the inadvertent affect of propping up commercial insurers that were paying substandard rates and limiting access to essential services. Having uncovered that festering wound, they got to work on creating a new financing plan that they refer to as clinic reform.
The clinic reform plan will raise the Medicaid-base rate and phase out bonus-dollars over a four-year-period. The Medicaid base-rate will apply only to those individuals that have what is known as straight Medicaid insurance; that is, Medicaid that is not managed by a commercial insurance company. There will be no reliable funding stream to replace the lost bonus dollars except for a finite pool of funds, presumably to cover services for indigent consumers.
In discussions with State officials about the devastating consequences of the clinic reform plan for the middle class and working poor, I was told that clinics must re-negotiate rates with commercial insurers. That is nothing new. It is common practice. The State officials advised me that if the commercial insurers do not raise their rates to sufficient levels that will help to cover the cost of services provided, then we should terminate our contracts with them.
Community-based providers routinely re-negotiate rates with the managed-care companies that represent the commercial insurers. However, they rarely agree to rates that will cover the cost of service. As one such managed-care company representative recently told us, “C’mon, we are hurting too.” For more information on public and private insurance markets in New York I refer you to the following website: http://www.uhfnyc.org/publications/880618.
If we drop the commercial insurers, as I was advised to do, it means that middle class and working-poor families are out of luck. They will not be able to afford to pay out of pocket to access community-based outpatient mental health services that are structured to meet their families’ needs. For example, at North Shore Child and Family Guidance Center, almost 30% of all evaluations in 2009 were emergencies that were seen within 24 to 48 hours. Who will take care of these emergencies? Private practitioners?
Clinic reform is nothing more than a downgraded version of Medicaiding-the-system. With clinic reform, the term community-based mental health center becomes a thing of the past as only a small segment of the local community will be able to access needed services.
APRIL FOOL’S DAY 2010
New York State is throwing in the towel at a time when there is unprecedented need for community-based mental health services. As the complex funding history described above is demystified, more and more families are advocating for a freeze on clinic reform. I urge you to call your local New York State legislators and tell them to extend the projected clinic reform start date of April 1, 2010 and to restore local assistance financing.
Don’t accept, “But there is no money!” for an answer. Please listen; the fact is that the cost to place a child or teenager in a psychiatric or juvenile detention center or a young adult in jail is far greater than what it costs to support quality community-based mental health care that will keep them at home.
We all know that familiar refrain, pay now or pay later.
This is an advance proof of Mr. Malekoff’s monthly column PARENTING PLUS, that is scheduled for publication in January, 2010 in the Long Island, New York Anton chain of newspapers.
Wednesday, July 29, 2009
IT'S NOT REFORM WHEN IT HURTS THE MIDDLE CLASS AND WORKING POOR
It's not reform when it hurts the poor
By ANDREW MALEKOFF
First published in print: Monday, July 27, 2009, Albany Times Union
More low- and middle-income families than ever are in need of low-cost, high-quality community-based mental health care. Yet, the state Office of Mental Health, along with the state Health Department, is aggressively pursuing a "reform" plan that will assure continued access to care only to children and families with Medicaid fee-for-service insurance coverage. This will leave a significant number of children and adults in the lurch.
This clinic reform plan sets up a mental health service delivery system that will no longer assure access to care for children, regardless of their parents' ability to pay.
This represents a dramatic departure from New York's statutory responsibility to make sure our most vulnerable citizens -- our children -- get care, regardless of their family's economic status.
Clinic reform signals movement away from a universal model of care to one that will discriminate against underinsured middle-class and working-poor families. Because of the lack of parity between higher rates paid by government and those paid by commercial insurers, many children with what seems like adequate health insurance coverage will no longer receive behavioral health care services from community clinics.
Community clinics are the last bastion in addressing the needs of children and adolescents with serious emotional disturbances. Private psychotherapists, with rare exception, will not provide the labor-intensive work necessary to properly serve children and families struggling with serious emotional disturbances.
One step forward would be for the Health Department to pressure commercial Medicaid managed-care carriers to increase their rates to match Medicaid rates. A second step would be to do the same with commercial insurers.
As community-based clinics void contracts with underpaying commercial insurers, as they are sure to do, families will be denied service if they are unable to pay the full cost. Commercial carriers that cannot demonstrate an "adequacy of network" can and should have their licenses revoked.
Consumers must be educated about these issues so that they can join the fight now and later, when denied services because their carrier cannot offer them an adequate network of care.
Last but not least, the Office of Mental Health must restore and enhance local assistance funding, also known as deficit financing -- a partnership between local and state government, the local community and client-consumer -- for specialty children's outpatient mental health clinics that serve a significant proportion of non-Medicaid fee for service clients. If implemented in its current design, the clinic restructuring plan will guarantee only narrowly-defined treatment for those with Medicaid fee-for-service eligibility. Clinic reform is certain to increase the marginalized role of middle-class and working-poor families in society.
Action must to be taken now to modify the course of clinic reform, before it is too late.
Andrew Malekoff is executive director of the North Shore Child and Family Guidance Center in Roslyn Heights and a member of the state Office of Mental Health group developing the New York State Children's Plan.
By ANDREW MALEKOFF
First published in print: Monday, July 27, 2009, Albany Times Union
More low- and middle-income families than ever are in need of low-cost, high-quality community-based mental health care. Yet, the state Office of Mental Health, along with the state Health Department, is aggressively pursuing a "reform" plan that will assure continued access to care only to children and families with Medicaid fee-for-service insurance coverage. This will leave a significant number of children and adults in the lurch.
This clinic reform plan sets up a mental health service delivery system that will no longer assure access to care for children, regardless of their parents' ability to pay.
This represents a dramatic departure from New York's statutory responsibility to make sure our most vulnerable citizens -- our children -- get care, regardless of their family's economic status.
Clinic reform signals movement away from a universal model of care to one that will discriminate against underinsured middle-class and working-poor families. Because of the lack of parity between higher rates paid by government and those paid by commercial insurers, many children with what seems like adequate health insurance coverage will no longer receive behavioral health care services from community clinics.
Community clinics are the last bastion in addressing the needs of children and adolescents with serious emotional disturbances. Private psychotherapists, with rare exception, will not provide the labor-intensive work necessary to properly serve children and families struggling with serious emotional disturbances.
One step forward would be for the Health Department to pressure commercial Medicaid managed-care carriers to increase their rates to match Medicaid rates. A second step would be to do the same with commercial insurers.
As community-based clinics void contracts with underpaying commercial insurers, as they are sure to do, families will be denied service if they are unable to pay the full cost. Commercial carriers that cannot demonstrate an "adequacy of network" can and should have their licenses revoked.
Consumers must be educated about these issues so that they can join the fight now and later, when denied services because their carrier cannot offer them an adequate network of care.
Last but not least, the Office of Mental Health must restore and enhance local assistance funding, also known as deficit financing -- a partnership between local and state government, the local community and client-consumer -- for specialty children's outpatient mental health clinics that serve a significant proportion of non-Medicaid fee for service clients. If implemented in its current design, the clinic restructuring plan will guarantee only narrowly-defined treatment for those with Medicaid fee-for-service eligibility. Clinic reform is certain to increase the marginalized role of middle-class and working-poor families in society.
Action must to be taken now to modify the course of clinic reform, before it is too late.
Andrew Malekoff is executive director of the North Shore Child and Family Guidance Center in Roslyn Heights and a member of the state Office of Mental Health group developing the New York State Children's Plan.
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