Tuesday, January 27, 2009

News Flash: Budget Cuts and Rosie D.

From the CBHI:

An Important Message from CBHI

MassHealth has recently filed a motion in United States District Court seeking a partial extension of the service implementation deadline in the class action lawsuit known as “Rosie D. v. Romney”.

The proposed modification would extend the implementation deadline for four services: In-Home Behavioral Services, In-Home Therapy Services, Therapeutic Mentoring and Crisis Stabilization --- moving the start date twelve months from June 30, 2009 to July 1, 2010. The original implementation deadline of June 30, 2009 would remain for Intensive Care Coordination (ICC), Mobile Crisis Intervention and Caregiver Peer-to-Peer Support. (Note that all of these services must be approved by the federal Center for Medicare and Medicaid Services (CMS) prior to implementation. CMS has approved ICC. Approval for all other services is pending.)

MassHealth has made a careful decision not to request an extension for the implementation deadline for ICC, Caregiver Peer-to-Peer Support and Mobile Crisis Intervention. ICC is the “heart” of the new system, addressing the most significant unmet need identified by the Court: the lack of comprehensive care coordination for MassHealth children and youth across the State with a serious emotional disturbance. Caregiver Peer-to-Peer Support, which is provided by “Family Partners,” is an integral part of ICC. Mobile Crisis Intervention will be provided by teams of mental health professionals trained to work with children and youth and their families and will be an essential resource for providing behavioral health services to children and youth living at home. MassHealth believes that these services, in combination with the current Family Stabilization Team (FST) service, will go along way in this proposed first wave of implementation towards meeting the needs identified by the Court.

Currently, MassHealth is on track to implement all services by the current June 30, 2009 deadline and, pending the Court’s action on this request, MassHealth will continue all implementation activities to meet this deadline.

MassHealth’s decision to file a motion to modify the implementation schedule comes in the wake of the state and nation’s severe fiscal crisis. Decreased state revenues forced Governor Patrick to implement a fiscal action plan in October, cutting $1.053 billion from the state budget including $353.7 million from the Executive Office of Health and Human Services ($292 million from MassHealth alone).

Unfortunately, the economy has not improved. Governor Patrick recently announced the need to reduce current state spending by another $1 billion and Administration and Legislative officials anticipate even more cuts to the state budget in State Fiscal Year 2010, which begins July 1, 2009.

MassHealth Has Few Options
During an economic downturn, demand for Medicaid goes up as more people fall into poverty, lose their employer-provided health insurance coverage and become uninsured. Given further budget cuts that will be announced soon, MassHealth has three ways to respond. MassHealth can: 1) reduce the number of people eligible to receive services, 2) reduce the services available to eligible people or 3) decrease the amount paid for these services.

MassHealth’s top priority has been to maintain eligibility standards to protect its core mission, as well as the structure of the Commonwealth’s 2006 health care reform law. In order to continue to provide services, MassHealth has, so far, primarily reduced or contained growth in payments to providers for services. In the current fiscal year, MassHealth is holding provider reimbursements for most services to prior fiscal year levels, forgoing planned rate enhancements for physicians, community health centers, adult dental providers and managed care capitation rates.

Hospital spending will be decreased in the areas of direct medical education, heightened pay for performance standards and other rate changes. Additionally, in the area of Behavioral Health, all planned rate increases to providers in FY09 have been eliminated and utilization management activities have been increased.

Opportunity for Improved Implementation
Given the harsh realities of the economic downturn, the state’s budget shortfall and the certainty of further cuts in public service, MassHealth believes that the proposed implementation schedule provides a more realistic plan for implementing high-quality services.

The successful implementation of Intensive Care Coordination (ICC) will be the foundation for the success of the new system as a whole. By establishing ICC first, including the Caregiver Peer-to-Peer Support service that plays an integral role, and allowing that foundation to settle for a year, we will likely be more successful when we add the “next floor” to that foundation with the implementation of the other services.

Additionally, the implementation of In-Home Therapy, which will replace FST, will likely be the second-most-used service behind ICC. The launch of this service is a tremendous opportunity to enhance the availability of high-quality, effective, community-based clinical services for children and youth with mental health needs, and their families. There are important emerging best practices and evidence-based practices in this field. A 12-month implementation delay would also allow us to incorporate the latest research and best practices into the design, implementation and training activities for In-Home Therapy.

Again, MassHealth remains on track to implement all services by the original implementation deadline established by the Court. We strongly believe, however, that the amended implementation schedule, if approved by the Court, will help to protect other state services while allowing for a better implementation of higher quality services for the many children, youth and families that will be served.

We will continue to keep you informed.
Well, this certainly is an unexpected twist.  The request is not unreasonable;  in essence the State is pleading for a little more time to get to the place that we all want to go without cutting it from the parts of Medicaid that are not covered under the lawsuit.  The budget is very tight; the fact that the Commonwealth is risking to cost of litigation to defer this expense makes me think that they are going to be very bad indeed.  So, what is an advocate to do?

1)  Fight it (and I don't doubt for a second that the the CPR is thinking about this as we speak):  This would be a natural response.  This runs the risk, however, of splitting the mental health community, and driving a wedge within many coalitions;  if the judge says "no", then the Commonwealth will have many other programs that will need to be cut more.  And the quality of the programs built in this style will likely be low.
2)  Don't fight it:  The judge may respect that the defendants are being reasonable, and really work with the plaintiffs  to ensure the ICC and Home-based services are in place.  It really isn't in anyones interest for this to fail.
3)  Fight it a little and compromise: Perhaps one could think:  "We do need to fight this- it is ones job as a plaintiff."   I hope that we don't do this.  Eventually, we have to accept that we can only do what we have the resources to do, and it is worth not getting our partners upset.  Another year may not be so long to wait, especially when, for some of these services,  we may not actually know how to do them properly.  Getting ICC and HBT on line is going really tax our workforce on July 1-  getting those services up and running will help a lot of kids.  Of course, getting the rest of the services up and running will help more.

As the old Chinese curse goes:  "May you live in interesting times!"  We will see how this dance plays out.

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