Monday, November 15, 2010

Because I Said So

Remember asking your parents permission for what seemed perfectly sensible to you and getting the answer, “No?” And then asking, “Why not?” And then the inevitable response, “Because I said so.”

I still get that feeling when seeking answers from the various Colorado Departments and Divisions.

Unlike my parents, I don’t share unconditional love with State public servants, however I harbor no ill feelings and we do share mutual respect. When asking questions, from one Department, I often hear, “We will have to check with another Department.” Translation: “I’ll ask you father.” Sometimes when a question is posed, I often hear, “The federal regulations won’t allow it.” Translation: “Because I said so.”

Let me give you an example. In Colorado in 2006, the developmental disabilities service system shifted from a quasi-managed care system to a fee-for-service system. Before this shift, Community Centered Boards (CCBs) like Imagine! had a certain amount of leeway in how they used the funds provided to them, allowing them to be creative and innovative with how services were delivered.

Since the shift, resources are no longer viewed as tools designed to provide services to help people with developmental disabilities engage in their communities, they are instead viewed as insurance “benefits” payments based on a standard fee schedule throughout the State. As a result, we tend to direct our services to meet regulations rather than to meet the needs of the individuals we serve. Unfortunately, that often means we provide a lower quality service for the same costs (or often much higher costs) than we did before.

When we have pressed the State Department heads to consider other rate setting methodologies (such as geographic modifiers based of the cost of doing business), or suggest a shift away from the costly fee-for service, we are told the same thing – that the shift was made to meet requirements set by the federal Centers for Medicare and Medicaid (CMS). Translation: “Because I said so.”

An article from the Poughkeepsie Journal increases my curiosity. Here’s a brief synopsis (although you should really read the article, it is fascinating): The New York State Office People With Developmental Disabilities (OPWDD) is defending its $4,556 per-person daily rate at nine state institutions as "reasonable” in response to revelations in June in the Journal. (I know! …Upon my first reading, I thought the daily rate was a typo.) The rate, paid half each by the state and federal governments (similar to Colorado and some other states), is four times higher than any other nationwide and about four times the actual cost of care. For comparison, the average institutional rate in Colorado is around $606 per day, and the average community rate in Colorado is around $172 per day.

Now, I’m not pointing this out to say that providers in Colorado should be getting $4,500 per day for anyone, regardless of their needs – that would be hard to justify, and quite frankly, absurd.

Rather, what I’d like to point out is that there was a paragraph in the story that really hit home to me. Remember, a community based service is typically preferred, and funded by a different set of rules, funding mechanisms, and odd restrictions that, according to one of the three regulatory agents, insist the dollars must track all the way to the individual benefiting from the funded service. Have a look:

The state's argument in support of the rate . . . notes pointedly that the rate-setting formula was approved at every step by the federal Centers for Medicare & Medicaid Services. Fifteen pages of rate calculations, institutional payments and "cost-finding worksheets" were also provided to make the state's case, which contends that the money has helped pioneer a successful system of community care of the disabled and pays for other services beyond institutional care.

Did you get that? They are saying that when justifying funds for institutional care CMS in fact is willing to allow NY, and other states, to utilize the funds for services other than those intended for the specific individual. Now this piece of information is not news to me. The daily rate however, is an eye opener – and should be for anyone. Oddly enough it seems OK for the New York tax payers, OPWDD, and CMS. Apparently someone in Poughkeepsie is worked up in a lather.

With my parents, I said, “But you let Bobby do it, why can’t I?”

“Bobby is older,” might be the come back. Well, institutional care is older, less preferred, and funded on a level that is inconceivable.

And people wonder why families, providers, and advocates are frustrated with the Medicaid systems.

Believe it or not, I’m not trying to point fingers at anyone. I just want to ask the question, why are things the way they are? Why do we have the system we have? Who is going to answer the questions? Who will be held accountable? Who will be willing to step up and say, “Yes, we can change and make this system better?” The fact of the matter is that information in this day and age is readily available, and should be to those who are seeking it. Got a question? Google it.

“Because I said so,” will not work anymore.

Then again, what do I know?

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