By JIM HADDADIN ; fosters.com | May 6, 2012
SOMERSWORTH, N.H. — To Somersworth parent Karen Salter, it's impossible to measure the benefit her son, Jeremiah, receives from the state's Medicaid system by the numbers alone.
He currently qualifies for 30 hours per week of one-on-one assistance from a personal aide, which is reimbursed by the state Medicaid system and administered by a regional nonprofit called Community Partners.
Jeremiah Salter spends six hours per day with an assistant, working part-time jobs and taking part in therapeutic recreation activities at The Works Health Club in Somersworth.
Later this year, Jeremiah Salter is slated to be among the 130,000 New Hampshire residents who will be affected by a sweeping change in the state's Medicaid system.
Salter and all other Medicaid recipients will be enrolled in a new managed care system administered by private companies, pending the approval of a $2.3 billion contract by the Executive Council.
Under the new system, the state will pay managed care organizations (MCOs) a monthly sum to provide all necessary services for each Medicaid client, and MCOs will determine how to use the money.
The move toward care management was ordered by the Legislature, which is counting on saving $16 million in the first year by transitioning to managed care.
Ideally, the cost-savings will come from redirecting patients away from unnecessary procedures and emphasizing preventive care.
While most states have implemented some form of care management for Medicaid recipients, New Hampshire's decision to place people with long-term disabilities, such as Salter, into the care management system will be the first move of its kind.
If the contract is executed, it would be a full year before people with developmental disabilities would see their Medicaid services transitioned to a care management model.
But with little information provided in the multibillion dollar contract about how the care management system will treat people who receive long-term support, advocates for the developmentally disabled have been asking the state to put the care management transition on hold.
Karen Salter worries people with developmental disabilities and their families will inevitably suffer from either a reduction in services or a loss of the community-based supports that have helped them thrive.
Currently, the state relies on 10 area agencies, including Community Partners, to administer Medicaid services to people with long-term disabilities. Salter pointed out that the area agencies have been in existence for more than three decades, and have long-standing relationships with their clients.
While there's no indication the area agencies would be cut from the service network, Salter worries their expertise will be lost through cutbacks in eligibility for clients.
Karen Salter and her husband, Chris, raised Jeremiah in Somersworth, where the family has been since 1986. They also have a 22-year-old daughter, Ali, who lives with the family.
Jeremiah, who is now 25, spends a portion of his week delivering interoffice mail at the Community Partners facility in Dover, and on other days, he travels to the University of New Hampshire to hang posters and stock shelves at a convenience store on campus.
Salter fears the care management companies will look to save money in the provision of care to people like her son.
"You know, (the area agencies are) very creative in how they provide services that don't cost money," Salter said. "They pretty much do what it takes, not financially, but resource-wise, to be able to meet that need for a family. The (managed care organization) is not going to do that."
Advocates speaking out against Medicaid contract
Some 30 years ago, New Hampshire began transitioning people with long-term intellectual and developmental disabilities out of institutions, and instead, allowing them to receive services at home through community-based service models.
"We've known many of our people since they were born," Community Partners Executive Director Brian Collins said in an interview with Foster's last week, "and we've known their parents since they were born, and we were the support system to support those folks along the way through any transitions they've had from early diagnosis."
Collins feels the Legislature has not fully vetted the care management proposal, and wants the Executive Council to push for more information about the ramifications for people with developmental disabilities.
"I don't think that anything is a done deal until a contract has been signed," he said, "and as of today, a contract hasn't been signed."
New Hampshire lawmakers set a target start date of July 1, giving Department of Health and Human Services Commissioner Nick Toumpas less than a year to solicit feedback, design the plan and put the contract out to bid.
The effort wrapped up at the end of March, producing what is ostensibly the largest contract in the state's history.
The fate of the more than 1,000-page document now sits in the hands of the five members of the state's Executive Council, who are scheduled to discuss the contract on Wednesday, May 9.
The care management system will be launched in three phases over the course of three years. During the first phase, all 130,000 Medicaid patients in the state will be required to enroll in one of the new care management plans offered by the MCOs, which will take over responsibility for all medical services.
The care management system would expand one year later, and the MCOs would take over financial and administrative responsibility for people who require long-term care services, such as those with developmental disabilities.
Year three would bring the inclusion of people made newly-eligible for Medicaid benefits by the Affordable Care Act, the health care reform championed by President Barack Obama and signed into law two years ago, should it remain in effect.
The care management system would launch at some point in December if the Medicaid contract is approved by the Executive Council in the near future.
The state will need to submit the entire proposal to the federal Center for Medicare & Medicaid Services, which must grant New Hampshire a waiver to move clients into a care management program.
In an April 16 letter to Gov. John Lynch, Carol Stamatakis, executive director of the N.H. Council on Developmental Disabilities, urged the governor and Executive Council to remove long-term care from the Medicaid contract.
She wrote that the companies vying for control of the state's Medicaid system have little or no experience meeting the "unique support needs of individuals with disabilities." The bidding process was conducted under a "shroud of secrecy," she continued, with "absolutely not transparency" or "'real' stakeholder input."
Lynch responded in an April 20 letter that DHHS has been fully committed to transparency during this process to the extent possible, and the commissioner has committed to obtaining "broad public input" about the design of the system, including from those with developmental disabilities and their families.
Lynch wrote that he appreciates the desire to see the contracts "fully and deliberately vetted," and indicated the Executive Council has delayed taking action on the contract in order to allow the commissioner to formulate a public input process.
"(Commissioner Toumpas) will be sharing his plan with the Governor and Council in the coming weeks," Lynch wrote.
'Enormous potential' in care management
Health and Human Services Commissioner Nick Toumpas acknowledges that managed care will be a profound change for the state, but Toumpas believes it's not a change that Medicaid recipients should fear.
The three companies taking over administration of the Medicaid system will be bound by strict guidelines and federal law, Toumpas said. The MCOs cannot reduce the number of services offered in the state, and must provide services at a level of quality defined and measured by the state.
"Managed care has enormous potential in terms of improving the overall health of the population by focusing in on some of things we believe really need to be focused on — primary care, that being one of the central tenets of it," Toumpas said during an interview with Foster's last week.
He acknowledged there is no detailed plan in place for how phase two will be structured, but said DHHS staffers are "committed to engage" the families who will be affected.
Toumpas stressed it's not the intent of DHHS to take a system "that works reasonably well today and destroy it."
"That's why we want them involved at the table — to be able work with us on this," he said. "That is my plea, if you will, to work with us on this."
Of the three health plan providers selected by the state to take over the Medicaid system, Granite State Health Plan has the backing of the largest company.
The plan is owned by St. Louis-based Centene Corp., a "leading, multiline health care enterprise that provides access to quality care for the rising number of under-insured and uninsured individuals," in the country, according to spokesperson Deanne Lane.
Centene subsidiaries serve 2.1 million members with operations in 16 states.
"A fortune 500 company, we already do business in Massachusetts and are excited to bring our vast experience and suite of products to help provide the best health care possible for the people of New Hampshire," Lane wrote in an email last week.
Asked how the company is preparing for care management, Lane wrote that it's "the state that will drive Phase II and the MCO's will be integral to the process by bringing their experiences and expertise to the discussion."
Granite Care-Meridian Health Plan of New Hampshire is owned by Meridian Health plan, which has operations in three states. Meridian is a privately held, for-profit company, which started 15 years ago in a rural Michigan county.
It has grown from some 11,000 members in 1999 to more than 300,000 in Michigan, Illinois and Iowa.
Chief development officer Raymond Pitera said he cannot discuss the company's preparations for managed care in New Hampshire, citing the ongoing contract negotiations.
Boston Medical Center Health Plan, the third provider, is a nonprofit HMO founded by the hospital and incorporated in 1997.
Scott Polansky, chief of business development, said the company is the largest safety net hospital in New England, and has statewide operations in Massachusetts.
It covers three populations in the state, the largest of which is Medicaid recipients, totaling some 190,000 members. In total, the company manages care for some 235,000 members.
Polansky said with three product lines in one geography, the company is hoping to expand geographically and diversify its product mix.
"We would like to take our expertise and skill and bring that to other regions to help serve underserved populations," he said. "That's really in a sense been our mission."
The company already administers acute care services to about 5,000 Medicaid clients who are developmentally delayed, Polansky said.
"The difference is we are, today, fiscally responsible for only the medical services," he said, "whereas, in New Hampshire, what we'll be asked to do in step two is to take it to another level, and to be responsible for all of the other services," such as approving personal care attendants and residential and adult day care.
According to Polansky, the company does not anticipate it will need to lower reimbursement rates to service providers — a fear that has been voiced by some agencies in the state.
However, BMC will apply "creative methodologies" to its reimbursement payments, he said.
Polansky stressed the company is focused on value, which is a function of both cost and outcomes.
"This isn't just a hit-and-run opportunity for us," he said. "We're not venture-capitalist backed in any way. We don't have shareholders to answer to. This is our mission."
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