The Medicaid Oversight and Advisory Committee meeting was held on Monday, August 18, 2008, at 1:00 PM, in Room 131 of the Capitol Annex. Senator Dick Roeding, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator Dick Roeding, Co-Chair; Representative Jimmie Lee, Co-Chair; Senators Walter Blevins Jr., Tom Buford, Julie Denton, and Dan Seum; Representatives Jim Glenn and Joni L. Jenkins.
Guests: Eric Clark of the Kentucky Association for Health Care Facilities; Curtis Wiggins for WestPort Medical Transportation; Karen Klempus for Able Care Transportation; W.D. Thompson for Christian Crusade Transportation; D.E. Chase for Greater Harvest Medical Transportation; Natalie Parrish for Valley Medical Transportation; and, Allison Lee for Apple Patch Community.
LRC Staff: Miriam Fordham, Mike Bossick, Jonathan Scott, and Cindy Smith.
The minutes of the October 22, 2007 meeting were approved without objection.
The first item on the agenda was an update on Passport Health Plan by Larry N. Cook, M.D., Chief Executive Officer and Chairman of the board for University Health Care, Inc., and Executive Vice President for Health Affairs, University of Louisville; Joyce S. Hagen, Regional President, AmeriHealth Mercy; and, Shannon R. Turner, Executive Vice President, University Health Care, Inc. Dr. Cook began by discussing Passport’s ten years of success. He said that over the past ten years, Passport’s profitability has been less than 1 percent, and Medicare Advantage profits are also modest, since there is no benefit from profitability. He said that Passport’s investment in membership is what has pushed them to the top. Passport Health Plan ranks number 11 of all Medicaid health plans in the country. Passport achieves quality measures highest in the United States. He stated that University Health Care, Inc. does business as Passport Health Plan. Passport has been the only successful health plan under the Sole Source Partnership model in Kentucky.
Passport covers 145,000 Medicaid and KCHIP beneficiaries in 16 Kentucky counties. Medical cost trends have averaged 5 percent each year. This compares to regional health care cost trends of 10.1 percent in 2007. Key success factors are that Passport is sole sourced and provider sponsored; is a Partnership model; has extensive physician/clinician involvement in developing, implementing and managing the plan; has collaboration with community agencies and health departments; has extensive provider network and enhanced reimbursement; has high member satisfaction and involvement; and, offers care management programs.
Dr. Cook stated that the Partnership Council is a group of committees made up of providers, advocates, and beneficiaries. These committees include Child and Adolescent Health, Women’s Health, Pharmacy and Therapeutics, and others. AmeriHealth Mercy Health Plan provides day to day administration for Passport Health Plan. The Commonwealth of Kentucky has a contract with UHC (Passport Health Plan) to provide services for Medicaid members in 16 counties. The Partnership Council is also a segment of this contract since that structure is a key component of the 1115 waiver. Under this waiver, which must be renewed every three years, Passport must demonstrate budget neutrality. The current waiver must be renewed by October, 2008.
Next, Dr. Cook discussed trends in medical costs and pharmacy cost containment. Passport’s 2007 medical cost trend is 4.9 percent, compared to the regional trend of 10.1 percent, and the national trend of 8.0 percent. In regard to pharmacy cost containment, the trend has gone from 22 percent in 2000 to 3.5 percent in March, 2008. Generic usage has gone from 54 percent in 2000 to 75.16 percent in March, 2008. Passport provider payments have consistently equaled or exceeded those of Kentucky Medicaid, with 92 cents of every dollar going to providers.
Dr. Cook noted that Passport Health Plan was awarded Excellent Accreditation, the highest level possible. Health plans undergoing NCQA accreditation are required to meet set standards covering both services and clinical care. He said that both adult and child satisfaction survey results have risen, while emergency room usage has gone down, and ongoing prenatal care has risen as well. He also stated that the Early Periodic Screening, Diagnosis and Treatment compliance rate has risen to an almost perfect level at 93 percent.
Representative Lee asked if the outcomes are an incentive for providers for enhanced reimbursement. Ms. Hagen said they were.
Representative Lee asked if there is a direct correlation in the enhanced program versus the cost of care for a particular individual. Dr. Cook said there is, but some is intuitive.
Representative Lee asked how to tell that enhanced management is working. Ms. Hagen said that trending shows that emergency room usage is going down and when trends continue to go down, it shows that the program is working. Ms. Turner added that enhanced payment is multi-faceted and demonstrates compliance with many other health measures.
Representative Glenn asked if Passport offers outreach programs. Ms. Hagan said they do. When they receive a membership roster from the Department for Community Based Services, members are sent information as to what services are available to them.
The next item on the agenda was an update on Medicaid Transportation Issues by Elizabeth Johnson, Commissioner; Carol Muldoon, Deputy Commissioner; and, Reina Diaz-Dempsey, Deputy Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services (CHFS); and, Vickie Bourne, Office of Transportation Delivery, Transportation Cabinet. Commissioner Johnson began by discussing Medicaid non-emergency medical transportation (NEMT). She said the Request for Proposals for new NEMT regional brokers were issued in October, 2007 for the 2008-2009 contract year. Proposals were submitted for Regions 1 through 14. Proposals were evaluated and scored and contracts were awarded in February, 2008, effective July 1, 2008. Regions 1, 3, 4, 5, and 6 experienced changes in brokers. In regard to payment for NEMT services, brokers are paid a monthly cap-rate per each Medicaid-eligible in their region, regardless of service utilization. From the monthly cap-rate, brokers reimburse providers for provision of all trips. There is also quality control in the request for proposal. The Office of Transportation Delivery maintains quality control over brokers. Brokers maintain quality control over providers.
Senator Denton asked about the problem with the transfer of information by the brokers and said she was concerned that the information was not transferred in a timely manner and asked why it was not. Commissioner Johnson said there were problems with the transfer of information and Ms. Bourne said the information was not obtained in a timely manner. Commissioner Johnson went on to say that the old broker filed a protest which made it more difficult to obtain information.
Senator Denton asked if things would operate better if Medicaid transportation were under the Cabinet for Health and Family Services instead of the Transportation Cabinet. Commissioner Johnson said transportation issues are very difficult, regardless of which Cabinet takes care of them. She said there is a good working relationship between both cabinets and bringing Medicaid transportation back to CHFS won’t fix the problem.
Next, there was testimony from various transportation providers. First, D.E. Chase of Christian Crusade Transportation and Greater Harvest Transportation testified. He said his main complaint was that since the transfer of brokers, Greater Harvest has lost 65 percent of its business. Christian Crusade Transportation has jumped through hoops and gotten promises of employment to no avail. Since the broker change, Christian Crusade Transportation has gone out of business because they have no contract.
Next, Allison Lee of Apple Patch Community testified. She is a case manager of Supports for Community Living (SCL) clients. She said her clients have struggled with the change of brokers. She said a big complaint is that many clients do not have freedom of choice of providers like they are supposed to have. When requests are made for a certain company, they are told that that company is “full up” for the day. She also noted that confirmation numbers would make things easier because currently there is nothing to confirm the calls. Also, the “Where’s My Ride?” line was helpful, and she hopes it will be back up and running. She also addressed the rate issues. She said the there needs to be an increase in rates that are paid because it is not feasible for companies to provide transportation at the current rates with the price of gas and overhead. Her final issue was the oversight and enforcement of the contract. She said that many caseworkers know the contract better than the brokers.
Next, Natalie Parrish of Valley Medical Transportation said that the rates make it almost impossible to operate. She noted that the rates for the 02 and the 07 clients are the same and are only $15 for travel anywhere in the county. She said with the current rates it is hard to afford to even operate the vehicles.
Next, Curtis Wiggins of WestPort Medical Transportation noted that there is too much chaos with the brokers. He said that he spent money to get his company up and running, and then was told that the broker was no longer in business. Mr. Wiggins was left paying for insurance, vehicles, and office space. He said the rates are too low, while the overhead remains high. It is impossible to stay in business at the current rates.
Next, Carol Klempus with Able Care Transportation said that since 2001, the rates have continued to go down, while the cost of everything else is going up. She met with the Office of Transportation Delivery in May and told them that the current rates were not acceptable. She did not sign the contract for fear that her company could not make it on the current rates.
Senator Denton asked if the providers have been paid for their time since the new broker was hired. The providers said they were just paid the day before.
Senator Buford noted that the providers had many important issues, but stated that the members of the committee could not resolve them. He told the providers to meet with the staff of CHFS and the Transportation Cabinet and many of their issues could be easily resolved .
Representative Lee discussed the broker bill that he sponsored. He said there is a clause in the law that says that any willing provider can provide services if their equipment meets the standards necessary. The brokers have to give contracts if the requirements are met. He also noted that the broker is required to tell the transportation providers when an escort is necessary, and it is the broker’s responsibility to provide one.
Senator Denton asked if provider co-pays would require legislative action. Commissioner Johnson said co-payments could be established by regulation.
Ms. Bourne also noted that the ride status line is coming and that there is currently a study being done about the rates. The official study will be released in January, but there is also a monthly Freedom of Choice report that is generated.
Representative Lee asked if it would be possible to implement confirmation numbers when calls are received. Ms. Bourne said that can be done.
The next item on the agenda was a discussion of the reorganization of the Department for Medicaid Services by Elizabeth Johnson, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services. Commissioner Johnson said that the Department for Medicaid Services (DMS) covers nearly half of all births in the Commonwealth per year. DMS provides health coverage to one out of every three children and one out of every seven seniors over age 65. DMS provides coverage to approximately 730,000 enrollees, representing about 20 percent of the Commonwealth’s total populations. There are approximately 26,000 enrolled providers. The budget for fiscal year 2008-2009 is $5.1 billion and the budget for fiscal year 2009-2010 is $5.4 billion. The total number of Medicaid eligibles is continuing to rise. Next, Commissioner Johnson reviewed the Department for Medicaid Services reorganization chart. She noted that there is a new Department of Community Alternatives, which is transitioning out of long-term-care. A goal of the Department will be to help Medicaid recipients to live in the community. She also noted that the Office of State Plans and Regulations is back in the Commissioner’s office and will play a vital role. The $100 million in federal referrals from January is down to only $6 million currently.
The last item on the agenda was an update on the Michelle P. settlement by Elizabeth Johnson, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services. Commissioner Johnson said the Michelle P. waiver was the result of a lawsuit filed in 2002. Individuals with mental retardation or developmental disabilities (MR/DD) may be eligible for enhanced community services, beginning August, 2008. The amended settlement agreement was approved by federal court on July 16, 2008, and the Michelle P. Waiver was approved by CMS on July 1, 2008. The waiver provides non-residential supports and services to individuals with MR/DD. The services blend Home and Community Based (HCB) and Supports for Community Living (SCL) services. Current HCB and SCL providers may provide Michelle P. Waiver services. Assessment and reassessment is provided through the Community Mental Health Centers. She also noted that provider training was completed on July 30, 2008, and a letter to urgent status individuals on the SCL waiting list was sent on July 15, 2008. Emergency and ordinary regulations were filed with the Legislative Research Commission on July 17, 2008. Waiver services include case management; personal care; adult day training; respite; behavioral supports; occupational and speech therapy; environmental and minor home adaptations; homemaker; adult day health care; supported employment; attendant care; community living supports; and, physical therapy. Services through the Consumer Directed Options include support broker, home and community supports, goods and services, community day supports, and financial management.
The meeting was adjourned at 2:55 p.m.