Different perspectives on concerns with CPSE services in NYC

The following material was copied from the NYSOTA Facebook page.  A fan of the page (George Nickel) posted a general "calling out" to NYSOTA which prompted my response.  This might be lengthy, but I believe that it is instructive.

Post from George Nickel on Facebook:

Okay, I am calling you out. We have received written support from The New York State Speech Hearing and Language Association and the Regional Physical Therapy Association but none from the OT regarding the issue of the Related Services Tier System of The NYC Department of Education. Is it not an important issue that children with special needs and their families need you to join with the other organizations to advocate for not just them but for your profession?

Christopher Alterio responds:

George, this sounds like a local RFP that you lost and not a professional problem. if you have some more detailed information to share I would be interested in seeing it. I looked at various Facebook pages that are linked off of your page and I also reviewed the information on the United EI Providers site about CPSE services. From what I can tell there was an RFP process. Some people won and some people lost. It seems that the transition is bumpy and some kids are allegedly not getting services. There is no way to confirm these allegations and the DOE has not issued a response that I can find.

Why should a state association meddle in a local RFP process? When I bid on contracts sometimes I get them and sometimes I don't. Transitions between agency providers is sometimes rocky, both when starting a contract and sometimes when ending the contract. I never considered calling on the state association to intervene on behalf of a local RFP process just because I lost. That is just business - and it is up to people to be competitive or to re-tool themselves if they want to continue.

There is no doubt that the system is over-stressed and that is precisely why you are seeing competitive bidding for service provision. That is also why you see parents just bailing on the system and getting services privately.

So I am just your counterpart on the other side of the state, and I don't ever hear providers around here ask NYSOTA to save them when contracts are competitively awarded and service providers are changed. Help me understand more if there is some larger issue at play. Why should a state association be involved in this if it is a local RFP and some people lost??

George Nickel responds:

Chris you have assumed a great deal but missed the important facts.First, there are children not receiving services and the primary agencies are not sending children through the tier system in a timely manner. Secondly, many of your organizations members fees are being brought down by agencies bidding for lower fees.Further, most agencies are not taking the same percent it cuts but passing it directly to therapists.Thirdly,when a system promotes "too big too fail"/monopolies and small private practices to close that is not business as usual. Lastly, I asked you to join in advocacy for the children and their families, however by your response you seemed to have targeted the wrong issue. What is that about? And you checked my links,what is that about? Why didn't you call some of your members and find out from them directly what is going on?

Christopher Alterio responds:

 George, just to be clear (and to also ease NYSOTA's liability concerns!) I am not a NYSOTA member and I don't represent NYSOTA's position. I am just an OT who will probably become a member in the near future based on some good progress that I understand NYSOTA is making on some previously identified concerns - all beside the point.

Anyway, you are asking for support and I am always interested in professional issues so I am asking for details. I looked at your links, on some blogs, and at the United EI Provider site because these are just about the only place I could find any information on this topic. Not surprisingly, there is no information to be found on the NYC DOE website or on some of the websites of large agencies that were listed in some of the blog posts I found. I actually was going to call the NYC DOE for information but their website is a maze and there is no place to call!

If children are not receiving services then of course that is a problem but like I said previously - transitioning and service coordination when contracts change can be a nightmare, and I can only imagine how complex the problem is in a system as large as NYC. So is this a structural problem where NYC DOE is purposely denying services? There are remedies for that, obviously via due process proceedings. If there is evidence that there is purposeful structural manipulation to deny care then of course that would seem to be a large issue for a professional member association to weigh in on. I am just asking for the evidence.

Instead of evidence that this is a purposeful structural manipulation most of what I can find online are concerns like yours - that small providers have lost contracts and are out of work because of a competitive RFP process. If rates are cut because someone in the marketplace is able to provide the care at that rate then I suggest that is just the free market at work. Now if over time that care provided at a lower rate does not meet standards or needs then the free market will correct itself.

I just don't understand the outrage. These are municipal funds being used to pay for these services and the municipality has a fiscal responsibility to be judicious caretakers of funds. As was noted by a blog commenter on this topic - the municipality is responsible for providing FAPE and appropriate care is not the same as 'Cadillac' care. The legal system has been trying to find a line on what is 'appropriate' for a long time and the push and pull between cost and value is an old old debate. This is nothing new.

So this does not get a knee jerk response of support from me. As many people in our community know I am generally the last person to stand up and believe that the municipalities are blameless. However, if you are looking for support, how about some more information and evidence??

Just to reiterate, I don't represent NYSOTA and this is my own opinion. It sounds like people are asking for a membership organization to solve concerns that some people have about a local NYC RFP where there were winners and losers. That almost sounds like a call for a quasi-Union - and I will be following this rather closely because I am not of the opinion that a state association should be trying to function as a Union and to restrict competition in a free market where many therapists (self employed OR in large agencies) are all supposed to be on a level playing field. If the NYC DOE is doing something structurally incorrect then that is fine. But if NYSOTA is supposed to support one group of therapists over another just because someone lost in a fair bidding process then I don't agree at all.

George Nickel responds:

Sorry, but I thought you were a NYSOTA Board Member weighing in, thanks for your input. Perhaps you need to do more research on the issue. You are welcome to join conversations at SI Parents Therapists Unite on FaceBook and perhaps one of your colleagues would respond to your questions. As far as free market, again there are dangers when individual private practices are threatened to join large agencies or face losing work or their practices. This is even more important in today's economy and our country relies on small businesses. I am in favor of those agencies having their roots in our community and not being from out of state or country. I am against greed and as one of my mentors has thought me, "take enough for yourself and leave the rest for others". Not such a bad practice, now is it? In a health related field we should be networking more and competing less that is what would work best for the individuals we provide our services to in our community. Further, We educate and advocate for our professionals and those we provide our services for in our communities.

Christopher Alterio responds:

Research = reading everything to be found on the Internet including Facebook pages, websites, blog posts; scanning news services for articles on this topic, engaging in online discussion forums, and asking for those concerned to provide more details. Is there anything I am missing?

What are the 'dangers' you are talking about? Unless NYC has some different ruleset that I can't locate, municipalities the size of NYC are required to keep a list of approved service providers and the municipalities are responsible for determining the appropriate rate for those services.

Where is the 'greed' if an agency can provide a service at a lower cost or if labor supply and the economy dictates that the reimbursement point is lower than you might like? Are these large agencies greedy just because they won a competitive bidding process? I don't understand.

Lack of competition breeds inefficiency. Inefficiency contributes to waste. According to the US House of Representative Committee on Oversight and Governmental Reform in a report earlier this year, "these school based (Medicaid) services, which cost taxpayers $800 million annually and account for 44% of national Medicaid spending of this type, have created a Medicaid monster in New York schools. A number of audits in recent years indicate that 86% of Medicaid claims paid to New York City schools from 1993 to 2001 either lacked any explanation as to why the services had been ordered or violated some other regulation or requirement."

All of us as school based providers are acutely aware of the State Plan Amendment and the tremendous pressures everyone is under because of the lack of fiscal responsibility and in fact the outright fraud in these programs. I don't know about anyone else but I would like to see school based services available far into the future - but if we close our eyes and fail to acknowledge the HUGE problems in front of us we will serve our short term interests about our own salaries but fail to appreciate the long game and whether or not we are contributing to a real solution.

I am a small private practitioner. I have won and lost contracts. I also saw the Medicaid train wreck and before it hit I re-tooled my practice and oriented it toward direct access and private insurance. I still participate with municipal contracting and still recognize that we all need to be more fiscally sensitive and contribute to a long term solution. I don't see how attempts to quasi-unionize the workforce and eliminate competitive bidding brings us any closer to solving the large problems.

Then again maybe I just don't know much and need to keep researching. But I don't think so.

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