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Area agencies and non-profits challenge state’s Medicaid reform that will soon affect them

Posted: December 9, 2013

Area agencies and non-profits challenge state’s Medicaid reform that will soon affect them

By CHRIS DORNIN

 December 9, 2013

NASHUA – Clients, parents and employees of Gateways Community Services packed a showdown meeting at Harbor Homes last week on the state’s plans to impose cost efficiencies on a state Medicaid system considered to be hemorrhaging money.

Medicaid officials told the Governor’s Commission on Managed Care that more than 100,000 Medicaid subscribers on Dec. 1 smoothly switched into care management for their visits to hospitals, clinics, doctors and other medical providers.

New Hampshire is the 48th state in the nation to offer managed care under Medicaid and state budget writers are relying on the reform to save $16 million in state spending over the next 22 months

From now on, three private insurance companies getting paid by the state an annual fee per subscriber will in turn pay doctors, nurses clinics and other Medicaid providers.

The ambitious new program reportedly went live with a minimum of glitches.

Ellen Curelop works for the Life Coping program in Nashua that helped 900 Medicaid subscribers transfer into managed care this fall.

“It was quick, it was easy, it was clean,” she told the commissioners. “You ought to take what we did to Washington and tell the President how to do it right.”

Lisabritt Solsky, the state’s deputy Medicaid director, said her people are tracking potential problems with prior authorizations, transportation services and drug prescriptions. So it’s too soon to say the program launch is a smashing success.

The state’s plan is to convert the care from a fee-for-service insurance plan to one like those offered by a health maintenance organization.

But some area agencies and non-profits do not like the fact the reform effect will soon affect them.

These agencies oppose forcing their own non- medical, long-term care services into managed care about a year from now.

Nobody is sure how that transition will happen or what the final product will look like. It worries many families with disabled loved ones.

Gateways is not waiting to find out.

It is one of the 10 area agency plaintiffs in the proposed class action suit, Wallace v. New Hampshire, to keep managed care from applying to them.

Two of its clients are listed among the 15 individual co-plaintiffs with development disabilities or head injuries: 50-year-old Richard Quinlan of Amherst and 28-year-old Erin Flynn of Milford.

The suit filed in Northern Hillsborough Superior Court claims that people with developmental disabilities would lose their hard-won right under state and federal law to freely choose their care providers. The suit also argues that Medicaid managed care would violate the federal court order in Garrity v. New Hampshire, the civil rights case that ultimately closed the Laconia State School.

Until it shut down for good in 1991, Laconia was the state’s institution for people with intellectual disabilities, cerebral palsy, autism or Down syndrome. In its heyday in the 1950s, the school housed and allegedly warehoused 1200 residents, many of whom wore straitjackets all day. They are served now by community programs like Gateways. They live with their families or in homes that look like everyone else’s. They spend the day like most people do – shopping, dining out, volunteering, working or going to movies.

Richard Pietravalle has a 25-year-old son with a developmental disability and chairs the Gateways board of directors. In his opinion, the state’s managed care law in 2011 specifically excluded area agencies from the strictures of managed care because they offer “voluntary” rather than “mandatory” services, in Medicaid terminology. “And the legislature never intended to include us,” he said.

Pietravalle said the New Hampshire developmental services system ranks number two in the country for the efficiency and quality of its services. “Why push to change it?” he asked. “Why disturb a system that’s working?”

Kaelan Richards, the spokesperson for the national advocacy group, United Cerebral Palsy, said its study entitled “The Case for Inclusion” compares states on the way they foster independence for people with cognitive or developmental impairments, track quality and safety, keep families together, promote productivity, and reach those in need.

New Hampshire has consistently been at or near the top of the rankings, Richards said. The report is online.

Joanna Grzywalz, the sister and caretaker for a woman with developmental disabilities, asked the commissioners how area agencies can possibly work with managed care companies. They will duplicate each other’s work.

Cathy Spinney cares for a grown daughter with complex medical problems and developmental disabilities. Spinney spends a lot of time at the State House as board member for the Community Crossroads area agency next to the catchment area for Gateways. She warned in an interview that area agencies giving long term support for essentially healthy people are incompatible with the medical philosophy and business model of managed care.

The Pelham woman predicted the state’s Bureau of Developmental Disabilities will close when the managed care companies take over, that some of the area agencies will go out of business too, and that parents will see a new definition of choice in their lives.

“It will be A, B or C,” Spinney said.

Gateway is nonprofit and mission driven, Spinney explained. It is governed by its parents and clients to help them live full lives of their own intention. According to Spinney, a profit-driven insurance company is the antithesis. It takes a cut off the top, doles out care by rigid formula, and makes money by saying no as often as possible.

Chris Foreman, a head injured client of Gateways, said he trusts and wants to keep the staff who help him organize his life while he looks for work as a handyman.

He spent a month in a coma from a vehicle accident several years ago.

“I can’t drive until I get my license back, and I can’t get it back until they get my seizures under control,” Foreman said. “Sometimes I can tell one is coming, but not always. Gateways is a good company and they have great people.”

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