The 4th meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, November 13, 2002, at 1:00 PM, in Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 1:15 PM, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Charlie Borders, David K. Karem, Ed Miller, Richard Roeding, and Dan Seum; Representatives Paul Bather, Brian Crall, Bob DeWeese, Bob Heleringer, Joni Jenkins, Mary Lou Marzian, Stephen Nunn, Jon David Reinhardt, Kathy Stein, and Susan Westrom.
Guests: Judy Levey, Homeless & Housing Coalition of Kentucky; Gerry Roll, Hazard Perry County Community Ministries, Inc., Hazard; Aaron Cox, Kentucky River Foothills Development Council, Richmond; Jim Daily, National Association of Mental Illness, Louisville; Linda Kuder, Kentucky Association for Gerontology, Georgetown; Nancy Andrews, Ombudsman Program of the Bluegrass, Georgetown; Amey C. Hugg, UNISYS, Frankfort; Sergeant Nikki Henderson, Jefferson County Police Department, Louisville; Kelly Knoop, Consumer; Tina Silva and Barbara Henchey, Mattingly Center, Louisville; James Millard, Equity Tech, Lexington; Todd Lyles and Jeff Andail, Almost Family, Louisville; James D. Marsh, Agent, Medi-Cab of Kentucky, Indiana; Donna Burks and Maurice Burks, Genesis, Louisville; Denise Simpson, Regional Interagency Council; Roger Romine, All County Transport, Mt. Washington; Sue Jeffers, Bluegrass Community Action Agency, Frankfort; Pam Shepherd, Federated Transportation, Lexington; Lois O’Keefe, Central Kentucky Community Action, Lebanon; Shirley Cummins, Rural Transit Enterprises, Mt. Vernon; C. Dale Shelton; Margaret and Michael Fleitz, Consumers; Bill Montgomery, Office of Aging Services, Cabinet for Health Services; Ramona Johnson and Cherish Wolfe, Bridgehaven; Janet Samuels, Medicaid Recipient, Fairdale; Diane Lee, Opal Poll, Genny and Dan Cowen, and David Black, Options for Individuals; Linda Wooten, Advocate; Mary Hass, Kentucky Disabilities Coalition and Brain Injury Association of Kentucky, Louisville; Oliver Barber, Public Transit outside Region 6, Louisville; Beecher Hudson, ARC Red Cross, Louisville; Lola Johnson and Dave Martin, Louisville Taxi Drivers Association/Yellow Cab, Louisville; Linda Capell, Medicaid Recipient, Louisville; Joe and Margaret Stuart; Debbie Mills, Louisville; Deborah Faser, Patricia Cumming, Carol Carrithers and Diane Harbin, Seven Counties Services, Louisville; Karen Johnson, Corydon; Sharon and Nelson Moody, Louisville; Cissy Childress, Louisville; Allison Lee, Valley Medical Transportation, Louisville; Dora Jones and Leanna French, Yellow Cab, Louisville; Damian and Jan Barthle, Louisville; Karen Thomas Lentz, Johnson & Johnson, Louisville; Bob Busch, Community Action Council, Lexington; Wanita Elison, Lexington; Sam Thomas, Yellow Checker Cab Company of Kentucky, Inc., Louisville.
LRC Staff: Robert Jenkins, CSA, Barbara Baker, Eric Clark, DeeAnn Mansfield, Murray Wood, Gina Rigsby, and Cindy Smith.
The first agenda item was the report of each subcommittee. Representative Burch, Co-Chair, Families and Children Subcommittee, reported that the subcommittee met and heard testimony from the Cabinet for Families and Children about the increase in the number of foster child adoptions. Representatives from the Cabinet for Families and Children, the Department for Public Health, Prevent Child Abuse Kentucky representatives, and the Medical Examiner’s office discussed “Shaken Baby Syndrome.”
The next agenda item was testimony on affordable housing and support services by Judy Levey, Executive Director, Homeless and Housing Coalition of Kentucky and Gerry Roll, Executive Director, Hazard Perry County Community Ministries, Inc. Ms. Levey said that the coalition represents 100-member organizations across the state, including homeless shelters, housing development organizations, and multi-service agencies. Every night, an estimated 600,000 people are homeless in America. Of these, about one-third are single adults with serious mental illnesses. In Kentucky, it is estimated that about 50,000 people are homeless annually. A study released by the National Low Income Housing Coalition indicated that a person in Kentucky must earn $9.46 per household, almost twice the minimum wage, to afford a modest two-bedroom apartment. Across Kentucky, minimum wage earners must work 74 hours per week to afford a two-bedroom unit.
Ms. Levey stated that people with disabilities who receive Supplemental Security Income, also known as SSI, subsist on $540 per month. According to HUD’s affordability standard no more than 30 percent of the household income should go to rent, individuals on SSI statewide cannot afford a one-bedroom apartment at HUD’s Fair Market Rent. She said that, since the committee will hear testimony on the ramifications of the federal Olmstead decision, she wanted to call attention to the lack of affordable housing with appropriate supports, which she said is the largest housing issue in rural and urban areas across the state. The most difficult challenge for non-profit organizations working in the communities is to improve decent, stable, and affordable housing. Appropriate supports refers to the need for case management, access to emergency services and medication, and, for a small percentage of people, on-site support. Additionally, integrated mental health and substance abuse treatment opportunities are essential because the lack of these services has been found to be an important factor in chronic homelessness.
Ms. Levey reported that the largest struggle that shelters in Southeastern Kentucky have faced is the release of people with mental and physical limitations into the care of the emergency shelter system. If someone is not elderly or disabled with good references, there is at least a six-month wait. The Affordable Housing Trust Fund is an outstanding and innovative example of support for housing, that operates with unclaimed lottery winnings. Organizations need funds to provide support services for housing.
Ms. Roll testified that housing in rural eastern Kentucky has passed the crisis stage. As director of a non-profit community development corporation, she is concerned with the approach chosen to address the issue. During the past several years, she said that a good job has been done with economic development, but not with affordable housing. Affordable housing is crucial in keeping young people in the mountains, to stabilize families, educate children, and support schools and municipalities. The good news is that a housing crisis can create more economic development. She said that the 20 to 25 units of affordable housing that her local housing group produces each year will substantially increase the tax base over time. More than $1 million each year will be spent paying carpenters, plumbers, and painters. Local banks, businesses, non-profits, and the private sector must work together to make it work. Local non-profits must be willing to welcome participants into economic development planning for the communities. She stated that, where jobs exist, housing solutions must be met. When considering new jobs, there must be plans for housing. Housing is the foundation, and economic development is not going to matter if there is no place to live.
A motion to approve the minutes of the October 16, 2002 meeting was made by Representative Marzian, seconded by Representative Stein, and approved by voice vote.
The next agenda item was testimony on elder abuse by Tim Jackson, Deputy Secretary, Cabinet for Families and Children; Sergeant Nikki Henderson, Jefferson County Police Department; Dr. Pam Teaster, Sanders-Brown Center on Aging, University of Kentucky; and Wilson Wong, Ph.D., Elder Abuse Commission.
Dr. Teaster testified that Adult Protect Services (APS) agencies are the focal point for receipt of reports of abuse and for intervening when appropriate with an array of medical, social, housing, and legal services. The purpose of APS intervention is to reduce risks and to assure the safety of vulnerable adults. APS programs predominately provide protective services to older adults.
Dr. Teaster said that the national Association of Adult Protective Services Administration conducted a survey in 2000 which demonstrates that, of the 396,398 reports of elder abuse investigated nationally, only 166,019 allegations could be substantiated. In Kentucky, there were 28,507 reports investigated, and only 17,210 allegations were substantiated. The types of abuse reported were self-neglect, physical abuse, caregiver neglect, financial exploitation, emotional or verbal abuse, and sexual abuse. In Kentucky, physical abuse was the largest category of abuse. The victims of abuse were predominantly female, with 65 percent being Caucasian and 18 percent African-American. The perpetrators were predominantly male and usually a spouse or family member. She said that 61 percent of abuse was in domestic settings, and eight percent was institutional.
Deputy Secretary Jackson said that the cabinet is working on a draft bill that would make the following changes to KRS Chapter 209: 1) repeal and reenact 209.005, pursuant to Executive Order 2002-786, that replaced the Elder Abuse Committee with the Commission on Elder Abuse; 2) clarify agency roles in a seamless system of protective services for vulnerable adults and provide new emphasis on the important role of law enforcement; 3) define the focus of the Cabinet for Families and Children on the victim, law enforcement and prosecutorial system on the crime and perpetrator, the Office of Inspector General on the facility involved, and the Long Term Care Ombudsman on the protective process; 4) mandate cooperation among public and private agencies in the protection of vulnerable adults, while making appropriate provisions of confidentiality; 5) conform to the decision of the United States Supreme Court in L.C. & E.W. v. Olmstead; 6) clarify and strengthen definitions and remove the stigmatizing definition of a vulnerable adult; 7) strengthen agency access to records, including financial records, that are necessary to conduct thorough investigations; 8) provide protection from criminal and civil prosecution for those acting in good faith to assist a vulnerable adult; and 9) remove criminal penalties from KRS Chapter 209 and place them in the Kentucky Penal Code.
Sergeant Henderson testified that the Jefferson County Police Department works directly with APS. Senior victims fall through the cracks because the laws do not adequately protect them, changes in KRS Chapter 209A would take care of seniors that are not covered by APS. She said that the goal is to have speedy trials because people who abuse seniors are starting to be prosecuted for their crime. The primary recommendations for KRS Chapter 209A are: 1) expand the definition of adult protected to include all adults sixty-five years of age or older without any reference to dysfunction as required by the current definition; 2) provide comprehensive definitions of various terms and several new terms not previously defined; 3) increase the penalty by one classification when the victim has a listed physical or mental dysfunction or when the abuse is by a caretaker or person of trust and confidence to the victim; 4) allow a prosecutor to move for an expedited trial in any elder abuse prosecution that might be jeopardized by the failing health and/or imminent death of the elder victim or witness; 5) exempt persons who make good faith reporting of abuse from criminal liability; and 6) prohibit perpetrators from asserting ignorance of the victim’s age as a defense in a prosecution.
Dr. Wong testified that one issue under the current KRS Chapter 209 is the problem of ambiguous definitions for an elder victim of maltreatment and the lack of clear standards and uniform procedures for responding to complaints or reports of maltreatment. A second issue is the lack of a system of timely and reliable measurement for evaluation of the operations in Adult Protective Services that would allow for an objective assessment of outcomes and planning for improvements. He said when considering how to revise elder abuse laws, we must keep in mind that we will fail to meet the goal and responsibility to protect seniors if we do not take steps that squarely face the fact that the population of the elderly in Kentucky is continuing to increase. At regional forums conducted by the Kentucky Association for Gerontology, senior citizens identified elder abuse as one of their priority issues. Kentucky has the opportunity to put in place programs designed to address the problem of an increasing population of seniors and to evaluate what works and how well it works. Elders deserve a program that delivers services to victims when needed and is measurable and accountable to the public.
The next agenda item was an update on Medicaid transportation in Jefferson County by Secretary Kevin Flanery, Finance and Administration Cabinet; Mike Robinson, Commissioner of the Department for Medicaid Services, Cabinet for Health Services; Vickie Bourne, Executive Director, Office of Transportation Delivery, Transportation Cabinet; Reverend Bill Curry, Director, Coordinated Transit Group; Julian Carroll, Attorney for Coordinated Transit Group; Ramona Johnson, CEO, Bridgehaven Opportunity House; Diane Harbin, Division Director, Behavioral Health, Seven Counties Services, Inc.; Jim Dailey, Director of Advocacy, National Association of Mental Illness, Kentucky; Todd Lyles, Almost Family; David Marsh, Medi-Cab of Kentucky; Cherish Wolf, Mike Fleitz, Janet Samuels, and Linda Capell, consumers; Donovan Fornwalt, Director, Governmental Affairs for the Council on Mental Retardation; Jodi Stamper, Louisville Taxi Drivers Association/Yellow Cab; Lola Johnson, Louisville Taxi Drivers Association; Ken Kurtz, President, Louisville Drivers Association; Sue Jeffers, Bluegrass Community Action Agency; Pam Shepherd, Federated Transportation; Mike Jackson, broker; and David Huff, cab driver.
Secretary Flanery testified that the Transportation Cabinet and the Department for Medicaid Services have been examining the Region 6 brokerage and recommended to the Finance and Administration Cabinet the termination of the contract with Coordinated Transit Group. The Finance and Administration Cabinet filed a motion with the bankruptcy court seeking permission to either terminate the contract or to appoint an interim trustee to operate the brokerage. Senator Denton asked what steps would be taken upon contract termination to assure that services would be delivered in a more effective and efficient fashion. Secretary Flanery said that, if an interim trustee is appointed, recipients would still contact the broker for services. In planing for possible termination of the contract, the Transportation Cabinet and the Department for Medicaid Services are working on an emergency plan to allow for minimal disruption to recipients. A recipient would contact the transportation provider directly, and service would be provided. If the recipient is Medicaid eligible, then the Department of Medicaid Services will reimburse the transportation provider.
Secretary Flanery responded to Representative Burch by saying a new system would not use a voucher system. Representative Burch asked who would replace the providers that have already quit providing services. Secretary Flanery said that any willing provider that wants to be a participant in the brokerage system is eligible under the interim system upon obtaining the proper license. Potentially during the interim there will be an expanded base of transportation providers to make sure the program operates. Representative Burch explained that recipients, as well as the providers, have to understand that there are limited funds available, and everyone has to do their part to make the system work.
Representative DeWeese asked about the cost to the state due to the problems in Region 6. Secretary Flanery said that the capitated rate of $5.43 per member per month for 90,000 recipients in Region 6 is approximately $500,000. A broker is reimbursed by the Department for Medicaid Services after services are provided, and to date the Coordinated Transit Group has been reimbursed for three months of services.
Senator Denton asked about subcontractors who have already provided services but have not been reimbursed by the Coordinated Transit Group. Secretary Flanery said that the subcontractors have a contractual relationship with the broker and, therefore, need to seek reimbursement from the broker. Senator Denton asked about the timeframe of reimbursement to providers if the contract is terminated. Commissioner Robinson said that claims would be processed the same as any other provider. Senator Denton asked if there were a way to reimburse providers retroactively based upon what they are owed on a one-time basis. Secretary Flanery said that there is a prime contractor/subcontractor relationship and the only recourse is for the subcontractors to seek reimbursement from the prime contractor. The cabinet does not have the ability to reimburse providers for past services for which the broker is responsible.
Senator Denton asked if a provision could be put in the contract that if a provider chooses not to participate during a specific timeframe, it would be banned from participation in the program for a period of time. Secretary Flanery said that no entity can be forced to participate in the brokerage. Senator Denton asked about a list of providers being distributed to recipients. Secretary Flanery said that if there is an interim system, the cabinet would communicate to the consumers through a variety of methods such as television, newspapers, legislators, and user agencies.
Senator Roeding questioned whether the contractor had been paid and had not paid the subcontractors. Secretary Flanery said that the contractual relationship the cabinet has is with the broker who reimburses the subcontractors. The cabinet is still reviewing data from CTG to validate if the subcontractors have or have not been reimbursed for submitted claims. There is a prompt pay provision that a subcontractor must be reimbursed within three days after the state has paid the broker.
Senator Denton asked Secretary Flanery to provide the committee with a list of breaches in the contract by CTG. Secretary Flanery said that the cabinet is concerned about the capacity to perform in the region, that complaint resolution has been inadequate, that data submitted to the Transportation Cabinet from CTG has been incomplete, inconsistent, or erroneous, that payments of subcontractors have been late or partial, and that CTG has utilized unauthorized subcontractors. The major issues have been no-shows, late pick-ups, late arrivals, and recipients who were picked up but who never arrived at the appropriate destination. Senator Denton asked Secretary Flanery to provide the staff with a copy of the letter and papers filed with the bankruptcy court.
Secretary Flanery answered Representative Marzian by saying providers of services may be required to reduce staff because of not being paid.
Representative Lee asked about the year the survey was taken to indicate the appropriate capitated rate for Region 6, and Secretary Flanery said that the actuarial study was performed in 1999. The contract that was executed contained the capitated rate, and CTG indicated that it would provide services for this price with the understanding that at the end of the first quarter, utilization and appropriateness of the numbers would be reviewed. Representative Lee asked about the timeframe to obtain the revised proposed cost per eligible in Region 6, and Secretary Flanery said that it would depend on the utilization data submitted by CTG and would be available as soon as possible. Representative Lee stated the survey data should be provided to any broker that chooses to bid for Region 6. Secretary Flanery said that the data collected over the last four months from CTG would determine the capitated rate and would be available to any interested broker. Representative Lee asked if the data reflects the percentage of the eligibles utilizing the transportation system in Region 6, and Secretary Flanery stated that the data is being analyzed to determine this rate. Secretary Flanery stated that the cabinet is trying to verify the data. Representative Lee asked if other regions submitted encounter data and Secretary Flanery said encounter data is collected from all of the regions.
Representative Lee asked if the data from other regions had to be cleaned up or is usable. Ms. Bourne said, initially, it had to be cleaned up but now the cabinet receives good data. Senator Denton asked if the other regions had had the same start-up problems as Region 6. Secretary Flanery said that every region has had start-up problems. Representative Lee said that every run is documented and the cabinet should be able to determine the number of trips. Ms. Bourne said that the broker takes this information and puts it into Access software format. Representative Lee said that providers should have to submit their data within a certain timeframe. Secretary Flanery said one must look at the manifest along with the billing cycle to determine utilization. The prompt payment measure is for validated claims, and it is the broker’s job to look at a claim, validate it, and make payment. If the claim has been coded wrong or is inaccurate, it is up to the broker to find out why and correct it to make sure the correct amount is paid. Representative Lee said that the broker system was part of Empower Kentucky and was not implemented by the General Assembly. Senator Denton asked if the encounter data included no-shows. Ms. Bourne said that some were documented but could not be verified.
Mr. Carroll testified that the state has been inefficient in implementing the contract with CTG. The broker is limited to contacting a subcontractor, who then provides transportation to the recipients. The old system had a greater potential for fraud. A major problem CTG has encountered has been the inability to obtain a monthly eligibles list from the Transportation Cabinet, as required by the contract. He said that CTG started with a capitated rate of $5.43 per eligible recipient based upon data for 1999, and CTG now is entitled to an inflationary increase. The broker cannot make a provider submit claims on the number of eligibles for reimbursement and, therefore, cannot provide this information to the cabinet. He said that the contract has a provision that the brokerage owes no money to subcontractors unless there are available funds from the state to reimburse providers; therefore, some subcontractors have not been paid because the state has not provided the funds to the broker. It costs $700,000 per month to transport eligible recipients, but the broker only receives $500,000 per month from the state.
Senator Denton asked Reverend Curry if he had received a salary to date. He said he had not received a salary and does not expect to receive one through the end of the year. She asked how he expected to provide services for $5.43 when he knew, upon signing the contract, that he could not provide them at that rate. Reverend Curry said a letter was sent to the cabinet in 2001 stating that the $5.43 capitated rate was too low, and he signed the contract with the stipulation that the cabinet would review the data in 90 days and increase the capitated rate. In July, the subcontractors were paid 100 percent of the invoices submitted to CTG. In August, CTG received $488,711 from the state but paid the subcontractors over $600,000 for clean claims billed. He said that CTG never missed a payment date. He stated that there is overutilization in Region 6 and that it will continue. Senator Denton asked if there were a provision in the contract as to the amount of time a client was to spend in a vehicle. He stated 45 minutes or less. Senator Denton asked if the contract stated that CTG would escort minors. Both Reverend Curry and Mr. Carroll said “no.” She asked what evidence he had that a subcontractor would not submit claims for reimbursement for six months. He said that Almost Family has a unique billing system whereby they bill themselves first then bill CTG. On December 1, 2002, CTG will have a billing system, Genesis, in place that will assure 100 percent accountability and clean data for every trip. Reverend Curry told Senator Denton that Yellow Cab is still picking up recipients for free.
Representative Lee said that any broker who bids on a region must have accurate utilization data, because if the data is inaccurate, the broker could not survive. Mr. Carroll said that overutilization, created by the state, is destroying the brokerage. Reverend Curry invited the cabinet and department to visit his office to confirm the high rate of utilization. He said that because the cabinet would not provide the list of eligibles, CTG transports 2,000 recipients each week who should not be transported. If CTG had accurate data, it could do a better job of providing quality services for eligible recipients. Mr. Carroll said that the state cannot give an increase to Region 6 because the waiver program would be lost entirely. The state has not given CTG legal notice required by law that allows a brokerage 30-days to fix the contractual default.
Senator Denton said that while money is an issue CTG is overlooking the misery inflicted upon human lives because of CTG’s inability to carry out the contract. She emphasized to Reverend Curry that CTG made the decision, knowing before the contract was signed that services could not be provided for this amount.
Senator Denton asked who owned Healthcare Transport. Reverend Curry said he did not know. She said she wanted to make sure that when people call CTG, someone answers the phone. Senator Denton said that CTG is not holding subcontractors accountable when complaints are received. Reverend Curry said that, to date, CTG had answered 100 percent of the complaints received and would take care of all complaints recipients have. Reverend Curry said that to provide better services funds needed to be available.
Representative Bather questioned why CTG would want to continue to be a broker if it is losing money. Reverend Curry said that CTG does not and will never make any money because it is a service company. The voucher system did not work, and the state needs to be held accountable. Representative Bather said that everything possible needs to be done to correct the problems to get a quality system in place.
Representative DeWeese said that capitation has failed to control costs. He asked if he understood correctly that Reverend Curry’s two companies had not been reimbursed. Reverend Curry stated that Mainstream is owed approximately $500,000 because he has not submitted a lot of billings for payment. If all billings had been submitted, Mainstream’s portion of funds from the state would have exceeded the other subcontractors. Mainstream has hired people to get the billing into the system. All subcontractors have been reimbursed for billings received. If a subcontractor submits claims from one month with another month, only the claims in the current month will be reimbursed because there are no funds available from the previous month to pay outstanding claims. Representative DeWeese asked if Reverend Curry had used funds from the state to buy new vehicles and not provide services. Reverend Curry said that he has a $1 million personal loan and had not used state funds to purchase new vehicles.
Representative Marzian expressed concern about dialysis patients not being picked up on schedule. Reverend Curry said CTG is reviewing the dialysis problem. Mr. Carroll requested anyone at the meeting who had a complaint to leave it with him and assured that CTG would respond.
Ms. Ramona Johnson said that almost all Bridgehaven members who depend on Medicaid transportation have experienced disruption in service since the transition to the broker system on July 1, 2002. Since July, there have been 750 separate incidents of members who were scheduled to attend but did not due to transportation failure. She said that at least four percent of the members consistently arrived 45 minutes to an hour later than the scheduled time, resulting in their inability to participate in assigned rehabilitation activities. Six individuals had been terminated from Bridgehaven due to the inability of the member and staff to resolve transportation problems. Members complained about the inability to cope with stress and anxiety over the uncertainty of transportation arrangements and also reported being treated disrespectfully by both the telephone staff at the brokerage and the vehicle drivers.
Ms. Johnson stated that these statistics and anecdotes have been reported to CTG and representatives from the Transportation Cabinet and Department for Medicaid Services in two community forums and in letters with little or no improvement. Efforts to resolve transportation inefficiencies for Bridgehaven members by requesting that CTG assign Bridgehaven clients to ARC Wheels were unsuccessful. CTG failed to respond to telephone calls requesting a meeting to discuss this proposal and to respond to a registered-mail letter describing the proposal and requesting a meeting. She said that concerns about safety for vulnerable consumers requiring medical transportation include drivers who appear to be untrained, no safety locks in some vehicles, and no door-to-door service for frail, elderly, and disabled consumers.
Ms. Johnson testified that ongoing transportation requests for the same schedule of attendance each week by recipients is subject to change by the broker without notice and/or not automatically renewed at the beginning of the next month. This requires that service providers resubmit paperwork each month, but CTG staff reported that the information had been lost or was never received. She said that the newly implemented broker system is creating inefficiency, is unreliable, and in some cases is unsafe for consumers, with the result that consumers cannot access mental health services needed to maintain them in the community. When consumers cannot access the appropriate community-based services, the results are increased symptoms, deteriorating quality of life, and higher utilization of more costly treatment options such as crisis stabilization and inpatient treatment.
Ms. Diane Harbin testified that concerns about hardships, sometimes life-threatening in nature, for Medicaid recipients who use the medical transportation system in Region 6 to access both physical and mental health services stem from poor implementation of changes in the Medicaid transportation program. She said that both the Department for Medicaid Services and the Transportation Cabinet assured everyone that the broker, CTG, Inc., was ready to take on the transportation needs of 94,000 Medicaid recipients, but the experiences of recipients, family members, providers, and advocates indicate that CTG was not prepared to adequately handle the task. Significant and disturbing problems continue to exist three months after implementation.
Ms. Harbin stated that two public forums were conducted, and the following complaints and problems about CTG were reported: 1) lack of communication with Medicaid recipients and healthcare providers; 2) poor and no response to complaints; 3) unwillingness to share the results of the readiness survey with the public; 4) lack of oversight and accountability; 5) recipients stranded at clinics, doctors’ offices, or treatment programs for two or three hours past the time they should have been taken home; and 6) inability of drivers to pick up recipients on time at their houses. She said that special needs on transportation orders are frequently ignored or overlooked by the broker or transporter. Vehicles are not always marked, drivers do not have proper identification, there are no safety locks on some vehicles sent to pick up persons in a wheelchair, and there is no air conditioning in vehicles sent to pick up those who are medically fragile.
Ms. Harbin said that at least three transportation firms that CTG subcontracts with report they are ceasing to operate or are on the brink of financial failure because of nonpayment for services. Both physical and mental health providers are reporting significant revenue losses since July 1 because patients are unable to get to services; and therefore health care providers are unable to bill for services and receive payment. She said that while the Department for Medicaid Services has shown interest in trying to resolve all the issues, the Transportation Cabinet and the broker have been much less responsive. She emphasized that the difficulties do not seem to be with the brokerage concept, but rather the Transportation Cabinet’s lack of oversight of the broker and its indifference to complaints, and the broker’s inability to safely and efficiently provide the transportation services of Medicaid recipients.
Ms. Harbin stated that a Transportation Cabinet staff member went on record at a meeting and discouraged people from calling the toll-free number set up for concerns and complaints in the brokerage system, claiming that people were trying to run up the number of complaints to make the cabinet look bad. She assured the committee that recipients and/or family members had legitimate complaints and concerns that needed attention and were not trying to run up the numbers. She urged the committee to not accept excuses from the broker for recipients not being safely and efficiently transported to health care settings.
Mr. Jim Dailey said that it is not a matter of money, contracts, or the voucher system, but that it is a matter of figuring out how to serve the people. Everybody needs to stop blaming someone else and try to fix the systematic problem. He stated that $5.43 is not adequate reimbursement, and more funds need to be found.
Representative Lee questioned Ms. Johnson about the classification of the majority of Bridgehaven’s clients. Ms. Johnson said that most are 02 but ten to twelve percent are 07 or 08. He asked who provided the escort service for the 07 clients, and she said that there is no escort service for them. Representative Lee said that only the agency providing the service or the custodial guardian can be an escort. The objective for the system is to provide reliable, safe, and efficient transportation for eligible recipients. He stated that the problem must be addressed by the provider as well as the brokerage.
Senator Denton asked who classified recipients and who determined how many recipients would ride in a vehicle. Ms. Johnson said that service providers did not classify recipients and that the transportation providers determined the number of riders per vehicle. Senator Denton said that the contract between the state and CTG requires the broker to ensure that an escort accompanies all certificate type 07 recipients. Representative Lee said that the broker does not have to provide an escort but make certain each recipient has one.
Representative Bather said that more attention needs to be given to creating a system that will work, and all parties must work together to find a solution.
Representative Marzian asked who is responsible for getting an escort for 07 recipients and eligible children under 12. Ms. Harbin said that it is primarily the family’s responsibility to arrange for an escort.
Mr. Todd Lyles said that he submitted billing for July in the first part of August and received partial payment. CTG owes Almost Family over $400,000, and a motion has been filed in bankruptcy court to stop transporting CTG clients. Senator Denton asked about cancelled checks to prove that CTG had paid all the providers the full amounts owed. Mr. Lyles said that he thought Reverend Curry meant that he could provide cancelled checks for all the funds that the state had given to CTG to pay the other providers. In an attempt to be fair to the smaller providers, CTG had continued to pay providers selectively. Mr. Lyles said that CTG has paid out all the funds the state had sent but had not paid all the providers for submitted claims. He said that providers had asked the Transportation Cabinet and the brokerage for an interpretation of the regulation regarding escorts and had been told that drivers can be escorts for 07 recipients. Representative Lee said that it was the intent of the legislation that drivers not be escorts.
Mr. David Marsh spoke about the problem of transporting clients who require escorts and the need to stop the vehicle if a fight occurs. Escorts are needed to make certain that these situations do not occur. Ms. Allison Lee asked Representative Lee to question CTG about the escort problem.
Ms. Cherish Wolfe stated that she knew medical transportation services were not a mandated benefit for Medicaid recipients, and she was very grateful to have them. However, because of rising costs and widespread fraud, this new transportation system for Medicaid recipients was created. She said she was worried about having to ride in a different cab each day with unfamiliar drivers and/or other riders. There were many times that she was scheduled for appointments, but either the driver was late or did not arrive at all. Pickup times should not be arbitrarily set, but rather should be set to get clients to appointments on time. She stated that the service CTG and its member companies provide is inadequate.
Mr. Mike Fleitz said that, prior to July 1, 2002, there were no problems obtaining transportation for his brother-in-law, but problems began when transportation was scheduled through CTG,. CTG said a client could not dictate which company would actually provide transportation. Mr. Fleitz found it odd that while Mainstream, one of Reverend Curry’s companies, continued to grow to accommodate growth in transportation, four other companies had to either cut back drastically or shut down completely. Drivers should have basic medical training relating to those they transport and a two-way radio system to enable them to contact the dispatcher in the event of an emergency.
Mr. Donovan Fornwalt stated that there should be statutory protections in place. He recommended that: 1) the role of the broker should be redefined to eliminate a conflict of interest; 2) the broker should not have direct financial interest; 3) the Transportation Cabinet and the Department for Medicaid Services should solicit the support and consultation of the disabled community to help eliminate fraud and improve efficiencies while monitoring for quality; and 4) the financing of the brokerage system should be analyzed through the Legislative Research Commission.
Ms. Lola Johnson testified that consistency provides stability and peace of mind to recipients and parents. The irreplaceable experience that comes with transporting children with special needs on a regular basis is an asset that cannot be overlooked and a skill that cannot be devalued. While the quality of the system depends on the quality of its drivers, other factors also play a crucial role. A system that pays its drivers living wages is as important as a system that aims to provide both freedom of choice and consistency for its recipients. A system that attempts to cut unnecessary costs by limiting waste and fraud is as important as a system that is properly funded and staffed. A system in which the public feels ownership and there is oversight and accountability is a system that provides efficient and effective service to the public without discrimination. She stated that a public service that puts the needs of the public first will express a renewed commitment to the fundamental values of service, professionalism, and accountability.
Ms. Jodi Stamper said that, as a former Medicaid recipient and now a cab driver, she was aware of the concerns and anxieties faced by current Medicaid recipients and that their means of transportation should not become another factor for concern or anxiety. Since she was able to become a consistent presence in her clients’ lives, she was able to form relationships with them and their caregivers and formed a bond of trust. Her concern is recipients no longer have the opportunity to be provided with feelings of safety, security, and freedom of choice that they once had.
Mr. Ken Kurtz testified that Yellow Cab drivers have only picked up former clients and taken them home at no charge because CTG had not arranged for their transportation.
Senator Denton said that the contract states, “There is no recent historical data on which to base a new rate. The bidder who is awarded the contract may request to have the rates reviewed after the first quarter of operation.”
Representative Lee said that the brokerage system works unless the utilization data is invalid, and that providers should not depend solely upon Medicaid for their source of income. Region 6 is going through some of the same problems that the other regions have experienced. Mr. Kurtz said that the broker should not have a conflict of interest. Representative Lee stated that the statutes address that problem.
Ms. Sue Jeffers said that she is the broker for Region 8 and had experienced start-up problems. She feels that the brokerage system as a whole is not broken and can provide good services. Sometimes there are problems with some of the subcontractors. She stated that she pays her providers every week.
Ms. Pam Shepherd said that she is the broker for Region 10 and explained that she, too, had a rough start. She said that the brokerage is a coordinated system, and she decides who provides services. She pays her providers once each month.
Mr. Mike Jackson said that he is the broker for Regions 5, 13, and 15 and that the brokerage system is working. Interested parties must be patient when a new broker is trying to get started. He always pays providers first. He asked that one region not be allowed to bring down all the other regions.
Representative Lee commended the brokers that lasted through the battles and made the brokerage system work. He said that Louisville is a large area for a brokerage.
Ms. Janet Samuels reported that she and her husband use two different cab companies for services. They experienced problems and could not get through to CTG to file a complaint.
Representative Lee asked Ms. Samuels if she had received an orange sticker that provided contact numbers. He said that there is no excuse for someone not to be able to get through to a transportation coordinator, who is an advocate for the recipient.
Mr. David Huff said that there had been miscalculations on the capitated rate. He said that he has been able to work with Reverend Curry but will support whoever is the broker for Region 6. The brokerage system can work but the General Assembly must provide more funds to brokers.
Senator Denton explained that the committee meeting was not intended to try to fix the brokerage system but rather was intended to provide a hearing for complaints about problems in Region 6. She expressed concern about the lack of responsiveness from CTG.
Ms. Linda Capell said that she does not care who picks her up as long as she gets to her appointments on time. She stated that she was going to file a complaint with CTG. One problem she has encountered is that even though she has called several times, her address is still wrong in the system so drivers continue to go to the wrong address to pick her up. She said that, if she did not give her doctor a twenty-four hour notice of cancellation, she is charged for an office visit. Senator Denton said that doctors cannot charge her for office visits and told her to contact the Department for Medicaid Services to rectify the problem. Ms. Capell said another concern is there are not enough drivers.
The administrative regulation, 907 KAR 1:019 & E, was available for consideration, but the committee took no action.
A motion to adjourn at 6:18 p.m. was made by Representative Marzian, seconded by Senator Denton, and approved by voice vote.