What's the Whole Story Behind Louisiana's Medicaid Expansion for the Dead?

I've read the legislative auditor's report and various articles on Louisiana compensating private industry insurers for Medicaid services rendered to dead people; and the more I read, the more unanswered questions I have.

In this article, Kathy Kleibert blamed it on Social Security records.

Department of Health and Hospitals Secretary Kathy Kliebert said Monday that the problem occurred because DHH was relying on “a very sloppy database in Social Security” to determine who should be enrolled in the managed care plans. Most of the cases involved older adults with disabilities qualifying for Medicaid through the Social Security system, she said.

“In the future we are going to be using our vital records database,” she said, referring to the state’s registry of birth and death records.
http://theadvocate.com/home/7492510-125/auditor-state-pays-health-coverage

This Town Talk article implies the state relied on data from the DHH vital statistics office.  http://www.thetowntalk.com/viewart/20131104/NEWS01/131104017/Audit-Louisiana-DHH-paid-1-9M-Medicaid-dead-people

The legislative auditor definitely used DHH Vital Stats data to conduct the audit, but why would he use that method if the state uses/used Social Security info? http://app1.lla.la.gov/PublicReports.nsf/5BBFA4B0591132DB86257C14004DD0C4/$FILE/00035F69.pdf

Also, wouldn't Kleibert's response suggest that all of those people kept receiving federal and/or state SSI payments after they died?

I understand using a different methodology to audit payment errors.  That makes sense, but why wouldn't the state legislative auditor also use the same methodology as a means for comparison to lend more validity to his findings?

Or did the auditor intentionally employ a methodology that provides a safety escape hatch for DHH?

An Open Letter to LA State Treasurer John Kennedy

Dear Mr. Kennedy,

I would like to begin by lauding your tireless efforts in ensuring that Louisiana's tax dollars are spent wisely and, specifically, your vocal advocacy for sensibly balancing the needs of our citizens with those of individuals and companies who contract with the state.  Because of the credibility you've established in addressing such matters, I urge you to ensure that the money received from pharmaceutical settlements finds its way back into the healthcare services budget from which it originated and to which it belongs. 

$38.8 million from Allergan, Covidien, United Research Laboratories, Merck, and Pfizer 

+

$258 million (+ $70 million for attorneys' fees) from Johnson & Johnson

+

$8.5 million from Watson Pharmaceuticals  
+

$45 million from GlaxoSmithKline (+ $7 million for attorneys' fees) 

_________________________________________________________________

= $350.3 MILLION DOLLARS FOR MEDICAID 

Attorney General Caldwell and DHH Secretary Kliebert acknowledge that these monies are "the result of Caldwell's office aggressively pursuing the recovery of Louisiana taxpayer's vital Medicaid dollars."  One of the attorneys for the state also stated that the money "will go directly to Louisiana’s Medicaid program."  By my estimate, at least $258 million of this money (from the J&J settlement) should specifically go back into the state's mental health budget.  

Mr. Treasurer, please make sure that happens.  

A jury found Janssen’s marketing campaigns violated the state law 35,542 times at a cost of $7,250 per violation, resulting in $258 million in fines. It awarded the state another $70 million in counsel fees.  The Louisiana Supreme Court will decide whether the verdict will stand. - See more at: http://www.whistleblowerlawyernews.com/2013/03/07/anti-marketing-fraud-statute-used-to-prosecute-johnson-and-johnson-in-risperdal-case/#sthash.6ee2lzso.dpuf

A jury found Janssen’s marketing campaigns violated the state law 35,542 times at a cost of $7,250 per violation, resulting in $258 million in fines. It awarded the state another $70 million in counsel fees.  The Louisiana Supreme Court will decide whether the verdict will stand. - See more at: http://www.whistleblowerlawyernews.com/2013/03/07/anti-marketing-fraud-statute-used-to-prosecute-johnson-and-johnson-in-risperdal-case/#sthash.6ee2lzso.dpuf

 A jury found Janssen’s marketing campaigns violated the state law 35,542 times at a cost of $7,250 per violation, resulting in $258 million in fines. It awarded the state another $70 million in counsel fees.  The Louisiana Supreme Court will decide whether the verdict will stand. - See more at: http://www.whistleblowerlawyernews.com/2013/03/07/anti-marketing-fraud-statute-used-to-prosecute-johnson-and-johnson-in-risperdal-case/#sthash.6ee2lzso.dpuf

 A jury found Janssen’s marketing campaigns violated the state law 35,542 times at a cost of $7,250 per violation, resulting in $258 million in fines. It awarded the state another $70 million in counsel fees.  The Louisiana Supreme Court will decide whether the verdict will stand. - See more at: http://www.whistleblowerlawyernews.com/2013/03/07/anti-marketing-fraud-statute-used-to-prosecute-johnson-and-johnson-in-risperdal-case/#sthash.6ee2lzso.dpuf

 A jury found Janssen’s marketing campaigns violated the state law 35,542 times at a cost of $7,250 per violation, resulting in $258 million in fines. It awarded the state another $70 million in counsel fees.  The Louisiana Supreme Court will decide whether the verdict will stand. - See more at: http://www.whistleblowerlawyernews.com/2013/03/07/anti-marketing-fraud-statute-used-to-prosecute-johnson-and-johnson-in-risperdal-case/#sthash.6ee2lzso.dpuf

 A jury found Janssen’s marketing campaigns violated the state law 35,542 times at a cost of $7,250 per violation, resulting in $258 million in fines. It awarded the state another $70 million in counsel fees.  The Louisiana Supreme Court will decide whether the verdict will stand. - See more at: http://www.whistleblowerlawyernews.com/2013/03/07/anti-marketing-fraud-statute-used-to-prosecute-johnson-and-johnson-in-risperdal-case/#sthash.6ee2lzso.dpuf

A jury found Janssen’s marketing campaigns violated the state law 35,542 times at a cost of $7,250 per violation, resulting in $258 million in fines. It awarded the state another $70 million in counsel fees.  The Louisiana Supreme Court will decide whether the verdict will stand. - See more at: http://www.whistleblowerlawyernews.com/category/false-advertising/#sthash.VVI5MdXy.dpuf

A jury found Janssen’s marketing campaigns violated the state law 35,542 times at a cost of $7,250 per violation, resulting in $258 million in fines. It awarded the state another $70 million in counsel fees.  The Louisiana Supreme Court will decide whether the verdict will stand. - See more at: http://www.whistleblowerlawyernews.com/category/false-advertising/#sthash.VVI5MdXy.dpuf

Jindal: No need to expand Medicaid since Obamacare will be effective

There you have it, folks.  Gov. Jindal finally gives a legitimate reason for why he won't expand Medicaid eligibility.  You see, contrary to all of his previous arguments against healthcare reform, the Governor argues that Obamacare WILL be effective in reducing the number of uninsured Americans.  See Argument #4 in this article:

Without expanding Medicaid, and once eligible people are enrolled into healthcare exchanges set up by the federal government, there will be less than six percent of Louisianians without health insurance. That's why the state is focused on implementing public-private partnerships with charity hospitals across the state to expand access.

http://www.businessreport.com/article/20130422/BUSINESSREPORT02/130429997#ixzz2RpBwwhJF

For Mitt Romney's Health Plan, Look to Gov. Jindal

Want to know how Mitt Romney would fix America's healthcare problem?  Just look to how Gov. Bobby Jindal is reforming healthcare in Louisiana: by eliminating it.  If you think I am kidding, look at the Governor's travel schedule.  Louisianians already know that Jindal spends more time with Romney and raising money for him than he does at the state capitol.  Who else would Romney look to for advice other than the Republican-proclaimed healthcare guru?

Every time Jindal and his band of suck-up, "whatever you say, boss" state healthcare administrators have reassured us they are only cutting healthcare costs without sacrificing services, it has turned out to be a boldface lie.  Each time, they and Jindal have known exactly what the plan was all along, then proceeded to tell the public the exact opposite.  

It all started with mental health. Three years ago, the state's Medical Director clearly stated their intent to eliminate inpatient psych services for youths.   Remember New Orleans Adolescent Hospital? Remember how all those beds in New Orleans were moved to the northshore?  Isn't it convenient how NOAH was sold earlier this year just before the state decided publicly announced that Southeast Louisiana Hospital was closing and that those "psych beds" would be relocated back to the southshore?  I put "psych beds" in quotes because even though the state has already moved the patients out of Southeast Louisiana Hospital, it has yet to even identify where those "beds" will ultimately physically exist, which means they don't exist. And they likely never will.  Just like those more abundant outpatient services to replace the shuttered hospital units don't exist -- and in many cases never did. 

Using the loss of federal Medicaid funding as an excuse for decimating the LSU system is, in my estimation, Jindal and Greenstein being less than totally honest, to put it charitably.  The trip down that road has been underway since last summer when Jindal single-handedly and against the will of the legislature, and therefore that of the people, CHOSE to eliminate about $24 million in federal healthcare funds when he CHOSE to veto the renewal of the 4-cent cigarette tax.  The trip continued with the privatization of Medicaid with his brainchild the Bayou Health Program and with giving control of mental health services to the private insurer Magellan which slashed reimbursement rates to providers 30-40% before Jindal even learned of the federal Medicaid funding cuts, which of course led to even deeper cuts.

The latest outcry, which will of course be ignored by Jindal, is against his cuts to the LSU system that stand to cripple the training of future doctors.  Even his handpicked henchmen on LSU's Board of Supervisors weren't aware of the extent of Jindal's destructive plans:

"The shortage came as a surprise to members of the LSU Board of Supervisors, who recently approved a plan to cut $150 million out of operations of seven LSU hospitals in south Louisiana." -The Advocate 10/29/2012

Oh wait. Except they were lying about not knowing.  An article from six days earlier titled, "Medical Plan Caught Up in Cuts to LSU," noted:

"...the LSU budget cuts could jeopardize training programs’ accreditations and standards, threatening medical education in Louisiana and chasing away medical students needed to treat patients in a state that already has issues about access to health care and doctor shortages in rural areas.  LSU leaders and the governor’s health secretary, Bruce Greenstein, say they’re keeping all of that in mind and have graduate medical education at the forefront of their planning." -The Advocate, 10/23/2012

How are you surprised to learn of something you promised a week ago to keep in the forefront of your mind?  Seems to me that Jindal and his yes-men are lying about saving medical education too.  Why would they if they're getting rid of the places those doctors would practice?  

So if you're down with that, then by all means, cast your vote for Romney and roll out the welcome mat for incoming Secretary of the U.S. Department of Health and Human Services & new Cabinet member Gov. Bobby Jindal.

I Am So Not Gellin', Magellan!

Louisiana completely privatized mental health services on March 1, 2012.  The behavioral health insurance company Magellan is now the gatekeeper to pretty much ALL mental health services paid for by the state.  

True, there appear to be some advantages.  Services heretofore unavailable to LA Medicaid recipients, such as group therapy and reimbursement for meeting with your child's therapist without the child having to be present, are now available. 

Other than that, it's been HELL.  Where do I even begin?

1. Provider reimbursement rates have been SLASHED by about 30%.  Imagine finding out    

on March 5th that your salary would be cut by 30% -- beginning March 1st.  Yes, March 1st of the same year.  Uncle Bobby Jindal decided to privatize healthcare, or so he says, because the private sector provides the same or better services for lower costs without all the bureaucratic overhead and logjams.  What he didn't mention is that in his kingdom, he would let the private sector insurance company pay psychiatrists and therapists 30% less for services provided to its Medicaid customers than it pays the very same psychiatrists and therapists to see its non-Medicaid customers. 

2.  As of yesterday, zero of my clinic's claims appear to have been processed, so we have no feedback regarding whether Magellan is the type of insurer that will regularly deny 15%, 30% or whatever% of our claims (i.e., payment for services already provided).  You would think the lauded private sector would understand that to keep a business from going under you need to be able to project your revenue.

3. As reported yesterday by Gambit, Clinical Advisor still doesn't work.  

Clinical Advisor is an online records management system intended to streamline inter-clinic communications and the mechanism through which clinics submit Medicaid claims. It's not working. As a result, providers — many of which, like the Guidance Center, serve Medicaid clients — haven't been able to submit Medicaid claims. What's more, they say, the newly formed Louisiana Behavioral Health Partnership (LBHP) between the state and the private contractor is denying certain types of claims that used to be paid. [Gambit, 3/20/2012]

4. Forget about Magellan paying for your child to undergo a formal psychological evaluation.  They are denying ANY test that in ANY way could POSSIBLY be used to diagnose learning or educational problems even if the test has other uses, AND even if the psychologist states s/he wants to use that test for one of its other uses.  Magellan reasons that the federal government already provides that service.  In reality, the federal government mandates that school districts evaluate any child 0-21 years of age suspected of having a learning or emotional disability.   They just don't provide the schools with all the funding needed to accomplish that.  

5. Our insurance specialist has spent most of her time on hold when calling Magellan, one time for 30 minutes before the call was simply disconnected.  I emailed a question to the provider account plastered all over their website and on DHH's site -- 8 days ago.  Still no response, not even a form reply stating they have received my email.

6. We have heard that Magellan is requiring inpatient psychiatric providers to obtain daily authorization for hospitalized patients, a process that colleagues say is taking about 2 hours/day.  This despite what is written on page 15 of their 21-page FAQ document for providers [updated 2/24/2012]:

Q: For our inpatient unit, I was requesting authorizations practically every day, for different patients. I would get multiple authorizations of two days or three days or four days. If a patient comes in to this short-term unit, am I going to have to get an authorization every day?

A: You do not have to obtain an authorization every day, but the authorizations will be for short periods of time. We want to be sure first of all that the person still clinically needs the inpatient level of care and could not be safely returned to services in their community. Secondly, we want to have a discussion at every review about the discharge plan. Discharge planning, in our view, begins at the time of admission. We want to make sure that members have a well-established plan for aftercare services in place when they are discharged. So we are going to be reviewing every two to three days depending on the status of the person’s clinical condition and the plan for discharge.

And those are just the things I care to write about right now. 

Is LA Medicaid Putting Fat Cats' Profits over Patient Health?

No, I don't mean the so-called "fat cat" doctors that people who aren't doctors think get rich off Medicaid payments.  I mean pharmaceutical companies.

I learned today that Medicaid patients need prior authorization for generic ADHD medications.  Name-brand (i.e., more expensive than generic) ADHD medications are on the current Louisiana Medicaid Preferred Drug List, but generic versions of those same medications are not.  This means that LA Medicaid will pay, no questions asked, for Adderall XR, Focalin, Focalin XR, and Concerta; but physicians must submit Prior Authorization forms for the less expensive generic forms of these medications.

That means that providers who prescribe these drugs to Medicaid patients must fill out additional paperwork, and may even have to call the state medicaid office, to justify why the state should pay for the CHEAPER  generic version.    

As if that isn't problematic enough, there is a shortage of stimulant medications used to treat ADHD, and many pharmacies only have generic versions.  They couldn't get the name-brand versions of the drugs if they wanted to.

I find this policy interesting, considering Governor Jindal's push to save healthcare dollars by privatizing Medicaid and his constant hootin' and hollerin' about how much Louisiana pays to fund Medicaid. 

Now Learn the Reverse Jindal Two-Step

In my previous post, I taught y'all how to do the Jindal Two-Step. Now I'm going to show you the Reverse Jindal Two-Step. You may recall that in the simple Jindal Two-Step you do something THEN you claim you're not doing that exact same thing. The Reverse Jindal Two-Step is merely the same thing except backwards:

1) DON'T do something (or say you're not going to do that thing):

Governor Jindal said: Unlike Alabama, California, Florida, Georgia, Maine, Maryland, Massachusetts, Missouri, and New Mexico, which all assumed in their budgets that FMAP aid would be extended for their states - this budget does not anticipate federal relief for FMAP, out of an abundance of caution. [nwlanews.com, 2/15/2010]

2) Then do that thing you told the world you would not do:

By relying on a federal bailout to solve the 2010-11 budget deficit, Jindal is courting potential opposition from legislators who might be leery of using that money until Congress has acted. [T-P, 4/17/2010]

As you can see, you'll add flair and pizazz to the first part of this dance move if you also criticize others for doing something that you'll turn right around and do yourself. Try out these moves at your next Fais Do Do. It'll be a hit! Let me know how it works out.

LA Legislators Think About Doing Something

From the Baton Rouge Advocate:

Legislative leaders are expressing concern about the cuts to health-care programs in the governor’s $24.2 billion proposed state operating budget.

However, members of House and Senate budget committees said they do not have an alternative spending plan for the fiscal year that starts July 1.

Senate President Joel Chaisson II, D-Destrehan, said there still is time for legislators to develop their own agenda. [Advocate, 2-18-2010]

Umm, yeah, y'all might want to get crackin' on that.

Gov. Jindal DOES Care

I've always been pretty tough on Genius Boy Bobby, but maybe I was wrong about him. I cynically assumed the surprise announcement on Monday that he was giving state employees off on New Year's Eve had something to do with budget cuts (a la Nagin's 4-day work week proposal); however, I see now that his decision was completely driven out of concern for us.

He knew how difficult it would have been to work today anyway after being up all night worried sick about whether we're one of the hundreds who won't have a job by the end of next week.

The Tebo on CNN. Gotta Lurve the TEBO!!

Jill on S-CHIP Veto (and Getting Your Priorities Straight!)

President Chimpy actually vetoed health insurance for children. FOR CHILDREN Y'ALL! Thirty-five billion dollars is apparently too much to spend on making sure working- & middle-class kids stay healthy. A trillion or so in tax cuts for the wealthy is apparently not. Neither is a few hundred billion to CONTRACT out this war and Katrina clean-up to cronies in his inner circle.

If you didn't make noise over the tax cuts which decimated the Treasury, if you didn't pitch a fit when the 3 states hardest hit by Katrina & Rita received only 16% of the billions Congress allocated for recovery, then maybe it's time you call folks like Sen. Vitter, who says he will not vote to override this veto and remind them we put them there to actually be of HELP! (I think "Vitty Cent" done really lost his damn mind as of late.)

My first ever guest blogger, Jill, is not pleased; and she is back to have a word with some of you (you know who you are):

It's on, people! PLEASE MAKE YOURSELVES HEARD ON THIS ISSUE! There are tools all over the web for you to write letters and send emails to your congressmen and women; there will be rallies held all over the country tomorrow as well. Also, now is as good a time as any to check your voter registration -- if you're not registered, get registered; if you need to update, do it.

At the risk of calling folks out, I'll go ahead and make it plain -- I got about a hundred emails from people about that ignorant Don Imus some months ago. I got a ton about the "Read a *&^%^ Book" video. Some folks even sent messages expressing outrage at PepsiCo for taking "in God we trust" off of their marketing materials or some similar foolishness. If y'all have time and energy to engage that madness -- you've certainly got time and energy enough to stand up for the health and wellness of our poor and near poor children. Let your reps know in no uncertain terms that this is a priority issue, and their vote gets yours. Let's go!

All the best,

Jill

Jill on S-CHIP Reauthorization

This is a historic day for the N.O. - It's Just Me blog. For the first time, I present a guest blogger! I received an email from a dear college friend of yore, Jill of the Bay Area (i.e., San Francisco for the non-caffeinated folks & those educated in the Gret Stet of Loo-ziana) regarding President Bush's vow to veto a bill passed with bipartisan support in both houses of Congress to provide health insurance for uninsured children. I couldn't have written it more eloquently myself, and she has kindly allowed me to share her sentiments (her words in this reddish brown'range hue).

-------------------
Fratto said Bush might be amenable to increasing the funding level above his suggested $5 billion over five years if the expansion of eligibility was limited. Fratto said, "This should not be an issue where you decide what the funding is, and then (set) the policy," adding, "We should decide what the policy is and let the funding land where it lands." However, Fratto said that once a government program subsidizes children in families with annual incomes above 300% of the federal poverty level, "you are talking about people who are solidly within the middle class of America, and you are extending another unfunded entitlement to the middle class" (Alonso-Zaldivar, Los Angeles Times, 9/28).
--------------------------------

Okay, the reauthorization and expansion is good news. The vote tallies below put a veto override vote barely within reach in the Senate and slightly out of reach in the House, if my math is correct. Promising attainability; however, it is REALLY disheartening that there should be any scramble for veto override votes, or support of any kind for this measure!

What's really got my blood boiling is the highlighted text, though. The words "unfunded entitlement to the middle class" make me want to shake somebody! Even if the allegation that this compromise measure would provide some unintended support for "middle class" families by extending coverage to families earning 300% above the federal poverty level, SO WHAT?! First, consider that the 2007 federal poverty guideline for the "American Dream" family (2 parents, 2.5 kids) is right around $24,000. That's right a family of FIVE is not considered poor within the federal guidelines until there income rock bottoms to $24,130. (http://aspe.hhs.gov/poverty/07poverty.shtml.) Three-hundred percent of $24,000 is $72,000 for a FIVE-PERSON HOUSEHOLD! That family needs some help!

Next, consider that one of the leading causes of bankruptcies in the United States is non-covered medical expenses. Finally, consider that the bankrutpcy code amendments that took effect in 2005 make it more difficult to fully discharge debts in Chapter 7 bankruptcy. One of the considerations used to determine eligibility for Chapter 7 discharge is a "means" test, whereby if a family's income is above the median income level for their particular state (based on family size / # earners, I believe), then guess what? That family might not be able to fully discharge their debts in Chapter 7 bankruptcy! Sure, sure, other provisions apply, and I'm no bankruptcy lawyer, but dangit, common sense says that that puts full discharge out of reach for a greater number of "middle class" families -- particularly if earnings of 300% over the federal poverty level puts you "solidly within the middle class."

"Unfunded entitlement to the middle class," indeed! The only spot-on word in that phrase is "entitlement." We are entitled to have kids that are healthy without worrying about whether we're going to have to sell our blood, organs, houses, etc. in order to pay for care that ensures their health.

Grrrrr.... I'll stop seething and get back to work so that I won't be staring down that poverty level income figure in my personal economy, but it's gonna be a while before I stop cursing in my head about this one!

You probably got my message a couple of days ago (blank subject line -- sorry -- typing fast): CONTACT YOUR ELECTED REPRESENTATIVES AND MAKE YOUR VOICES HEARD ON THIS!

Be well (evidently you can't afford not to),

Jill

"Whenever I hear anything described as a heartless assault on our children I tend to think it's a good idea."

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-William Kristol, Compassionate Conservative, Describing his reaction to the President Bush's intent to veto the new Childrens Health Insurance Program, Fox News Sunday, 9/30/07

Let's Go Crazy, Let's Get NUTS!!

Aaaaaand apparently we all will, because the people the feds ARE PAYING to reimburse centers for mental health costs could really give 2 shits about us. Some local providers, the few we have, have been treating Medicaid patients for free for several months because they can't get certified for reimbursement by the jesters WE ARE PAYING to do so. This quote is from Tony Salters, spokesman for the Texas regional office of the Centers for Medicare and Medicaid Services, the agency that must inspect facilities before Medicaid can reimburse them:

“If we are in the particular area, we will try to get to them with the personnel we have.”

What? ummm, excuse me? IF you're in the area? IF, MUTHAFUCKA?! Seriously, NOBODY from the Texas office can get their ass in a car and fuckin spend the equivalent of a workday to drive over here to do a fucking shitty ass inspection???? He basically just told us " uhhh, yeah, 'k whatever -- when I get to it." But he didn't stop there.

Also from today's T-P (by Bill.Walsh@newhouse.com):
" Salters, the CMS spokesman in Dallas, said that even if Southern is approved, it won’t get reimbursed for the money it already has spent treating Medicare patients. He expressed little sympathy for the plight of the facility. Salters said the company’s owners accepted a risk when they began treating patients that the federal government might not pay for or that payment would be delayed.

“It was a total business decision,” Salters said. “If this is his only line of business, this was his decision when he stepped out there.”

Oh my God. Where do I even fucking start? I know. I'll start by callin' his ass. Please join me if you are moved so:

HHS Employee Details

Last		Salters
First name		Tony
Middle name		A
Agency		CMS
Organization		DHHS/CMS/OA/SC/REG06
Room		NA
Duty station		Dallas TX
Mail stop		NA
Phone		214-767-3225
Internet e-mail		tony.salters@cms.hhs.gov