Thursday, April 15, 2010

LME's to Get Meaner / Leaner Under Proposed Cost Cutting NC State Legislative Proposal: IT'S ALL ABOUT CAPITATION and that=Accelerated Human Suffering

Years ago, when I had my son, I had Kaiser Permanente Insurance HMO, Health Maintenance Organization (read: capitated: see below). On the baby's due date, I was informed by the Primary Care Physician that I needed to go immediately to Northside Hospital, the baby factory in Atlanta (yes, I chose it because it was a baby factory) where I would be induced with pitocin as the amniotic fluid was too low and the fetus could roll over on his cord and die.

The medical staff induced me but they didn't give me an epidural to diminish the agonizing pain until they noticed that I was screaming so loud that I was disturbing the other women trying to deliver babies ("Could you be a little quieter?": I kid you not).

I got my epidural but not until it became so blatantly obvious that I had dropped into hell and they couldn't avoid spending the money to give me one. For Kaiser was a capitated plan.

I don't see much of a difference between that situation and the one that is being proposed by the NC State Legislature which is ALSO a capitated plan though associated w/ mental health services.

Here's the scoop on what has just been proposed by the NC State Legislature:

Item 41 Counties Pay Portion of LME

This reduction option proposes that counties pay a portion of the non-federal share

Systems Management Costin varying amounts depending upon the size of the LME. This reduction serves to(Effective Jan. 1 2011)incentivize counties and LMEs to achieve economies of scale and to become prepared to participate in 1915 Medicaid waivers. Counties for LMEs that do not meet the minimum size requirements per G. S. 122C-115 would pay the highest
percentage, sharing in the non-federal cost of LME Systems Management equally
with the state.

County participation would break down as follows:

Under minimum size per G. S. 122C-115 - 50%

Over minimum size, but LME Systems Management cost >$18 per capita - 40%

LME Systems Management cost between $14-$18 per capita - 30%

LME Systems Management cost < $14 per capita - 15% Participating in 1915 Waiver - N/A *****And so, you might ask, what is the 1915 Waiver?******************* see:

N.C. 1915 b/c WAIVER: WHAT IS IT?

Waiver - Request to CMS that provisions of the Social Security Act
(SSA) be “waived”

State wideness

Fee-for-Service payment requirements

“Any willing and qualified provider”

1915(b) waivers are commonly known as a “freedom of choice” or
managed care waiver

1915(c) waivers are Home and Community Based Services waivers
in lieu of institutional care, such as our CAP-MR/DD waivers

b/c Waiver combines services for all Medicaid funded MH/DD/SA
consumers into a single capitated funding model

Waiver Allows: The operations of a capitated manage care system
as vehicle for service provision to Medicaid recipients

.......Waiver eliminates “any willing and qualified
provider” provision - LME MUST ADDRESS
provider network
Improved Access to Services
Improved Quality of Care
Increased Cost Benefit
Predictable Medicaid Costs
Combine the management of
State/Medicaid Service Funds at the
Community Level

****And so, we've already had a pilot project as indicated in the presentation, specifically****:

......PBH or Piedmont Behavioral Health Pilot Project: Medicaid funded services for
MH/DD/SA on a capitated basis in the five county (Cabarrus, Davidson, Rowan,
Stanley & Union) area.

When would this waiver program be expanded?

......January, 2011: Planned Expansion Waiver Start-Up Date

********What's the basic problem w/ providing capitated health care services? *****

"Under the capitated system the doctors were paid a flat fee per plan member per month (known in HMO lingo as PMPM). Under this payment system doctors were paid a set fee (usually around seven dollars) each month whether or not the patient is a healthy one who rarely visits the doctor's office or a sick person who needs frequent medical care. The capitation system for a while seemed to keep everybody happy, except the patient. Well, almost. Insurance companies loved capitation BECAUSE IT MAKES HEALTHCARE COSTS MORE PREDICTABLE.

Employers welcomed the capitation idea because it gave them a less expensive medical plan for their employees.

Some doctors even initially welcomed it since it gave doctors who had difficulty building or maintaining a practice access to a huge volume of patients and a guaranteed monthly income.

In theory this new system of healthcare delivery might even allow previously uninsured families to finally be able to afford healthcare insurance. In practice the percentage of people without medical insurance is higher than it has ever been. The gatekeeper in the capitated system and insurance companies were making handsome profits. HMO executives got yearly injections of healthy bonuses and the bureaucrats raked in profits."

*****......And so, the question that is begging to be asked is this: IF the LME's, which are going to come online in terms of managing NC Medicaid more and more closely----- are more closely tethered to the counties----as is being proposed by the NC State Legislature Appropriations Committee----- will they simply function more efficiently and, as conjectured, also provide more seamless services?

For, after all, the LME's do not stand to benefit like the administrators of an HMO in terms of executives getting year end bonuses for such a swell job (read: they spent less money on the people who needed the medical care). But don't the LME's still stand to benefit by driving down the cost of mental health care in terms of the pressure that will come on them as per the county commissioners elected by the people------ vis a vis the penalty of the proposed 'cost per capita' which is being proposed by the NC State Legislature Appropriations Committee?

Very obviously the LME's will cut to the bone services whose efficiency is to be measured in the 'cost/ capita' of Medicaid mental health services. The counties that have the most diminished costs/ capita will require their citizens to pony up funds at a lesser rate. The pressure won't build immediately, but as the political cycles wax on, the 'no tax naysayers' will drive their points home as the county commissioners pick up heat as re: LME's that provide more services causing those counties to come forward and be punished for their 'lack of efficiency.'

Don't we basically have the same beast as Kaiser Permanente that standed to benefit when they allowed me to scream in pain for hours prior to an epidural as associated w/ the delivery of my son------since Kaiser would, after all, have to pay for that 'benefit' of the epidural?

I don't see any difference.

I can still see the face of the physician as she walked out of my hospital door, wagging her head, as associated w/ the blood in my urine due to the undue pressure of the pitocin which caused me to descend into hell-----and drop I did straight into a bottomless pit of suffering-----all because Kaiser Permanente had a capitated plan and waited to see if I REALLY needed an epidural.


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