Friday, March 15, 2013
"We are building the plane while we are flying it."
The New York State Early Intervention Coordinating Council was scheduled to meet a couple days ago but the meeting was cancelled and a subsequent video/teleconference was scheduled for today, 3/15. The original meeting was rescheduled to 4/18, but that may still change based on member availability.
It is difficult to not be cynical, but did they cancel the meeting to limit participation and comment prior to their 4/1 switchover when NY State takes responsibility from the Counties for administration of the program? I asked people in the Bureau of Early Intervention in Albany and they told me that they thought that having a video/teleconference would allow more people to participate than if they just had the meeting in Albany. What they failed to mention was that the new meeting would not be open for public comment or participation. In other words, today's meeting was a one way communication and propaganda opportunity for the Department of Health.
During the meeting today they spent 2/3 of the allotted time discussing the Governor's proposals for the 2013-2014 budget year. The NYS Assembly has already rejected most of the Governor's proposals and the NYS Senate has also similarly rejected reform proposals. Budget negotiations are still ongoing so where this will all end up is still anyone's guess. We will undoubtedly know more after the weekend and early next week. I was disappointed that they spent so much time discussing a budget process when immediate and pressing concerns about the State Fiscal Agent and new contracting with the State needed more conversation.
During the meeting today Director Brad Hutton indicated that there were conversations about delaying implementation of the new SFA but he warned of unintended consequences with delays because the Counties have already terminated provider agreements effective 3/31/13. What he failed to mention is that these actions are a response to LAST YEAR'S budget and that the DOH has pushed off implementation until the 11th hour, so functionally it is the Bureau of Early Intervention's fault that they are trying to cram all of these changes through at the last minute. In reality, providers have only had a few short weeks to learn that their contracts were cancelled, to try to review the new contract from the State, and to prepare for an entirely reconfigured billing and payment system. In Director Hutton's words, "We are building the plane while we are flying it." This is a stunning statement from a public official and in my opinion a direct reflection of a total lack of functional implementation of the 2013 budget requirements. In a previous blog post I called this a 'planned demolition' and after hearing Director Hutton's comments today I am more convinced that this was an accurate description.
In just two weeks all early intervention provider contracts will be terminated, and the DOH is frantically scrambling to get contracts approved so that children across the State will still be able to receive services on 4/1. According to Director Hutton it is likely that an interim State Fiscal Agent will be put in place but the DOH is also allegedly prepared to process claims themselves. Although he acknowledged providers concerns about payments and cash flow, Director Hutton does not demonstrate any clear understanding of the impact of 11th hour implementation. In reality, some providers are simply not going to contract with the State. Others will contract with the State but at the same time there is a parallel crunch to authorize providers as 'non-billing' Medicaid providers so they can get paid. Anyone who has attempted to navigate the OHIP maze of Medicaid approval knows how daunting that can be - so even if providers have contracts there is little chance that many will have their Medicaid approval in time. Again, this is the direct result of last minute cramming and is an irresponsible way to run this important program.
In a series of less than honest statements, Director Hutton answered questions about payment schedules by indicating that the State would process claims in a rapid fashion and that the first batch of payments would be processed on April 15. What he does not say is that this only applies to Medicaid and no-insurance cases, and if the provider is not yet Medicaid approved no one yet has an answer for how claims will be processed. Apparently this is being reviewed by the lawyers, because the Counties are afraid that lack of Medicaid approval will cause payment responsibility to waterfall down to their level - and they don't want that burden! If you think that the program administrators in Albany and in Counties have any interest in shepherding a functional program for children then you should have been in on this call and listened to them all maneuver so that they could shuffle the fiscal responsibility off to another party. In all these conversations there is no mention of the fact that providers are leaving the system, that waiting lists are likely, and that children who were getting services on 3/31 really might not be getting them on 4/1.
Based on the information provided, it seems that Medicaid claims (IF the provider is actually a Medicaid provider!) might actually get processed and paid in a timely fashion, if the system operates the way that they say it will. Again, the devil is in the details, and what they DON'T mention is that commercial insurance will bottleneck this system because claims adjudication for those insurers will slow down the reimbursement process to a snail's pace. This is perhaps the most ironic twist for providers: it is generally easy to find providers to work in the wealthy suburbs but those cases may actually be the ones that are slowest to reimburse because there is increased likelihood that those families will have commercial insurance. It is probably not a stretch to imagine that there will be some modest correlation between socioeconomic status and Medicaid eligibility. Providers will now likely have to consider that working in those wealthy suburbs will come at the price of generally slower reimbursement. I am very curious to see how this plays out - because if providers opt to accept cases in high Medicaid-concentrated areas, how squeaky will the wheels of those wealthy families be when there are now waiting lists to provide services in the burbs? Will providers make the link and suddenly be more willing to accept cases in the urban environments?
I expect that this level of analysis is lost on the Albany widget counters or maybe they know and just don't care. It is hard to know.
A lot of the success or failure of this early intervention system will now actually rest on the willingness of agencies to float salaries over time and to access credit to make their payrolls if their caseloads are 'burdened' by families in the wealthy suburbs who have commercial insurance adjudication that will gum up the payment cycle. The days of the small agency and solo private provider are most likely over, at least to the extent that this is what the system was previously built and dependent on.
The sum total here is that the State has boxed itself into reform, had no functional plan for implementing the reform, crammed it all down the throats of the provider community at the last minute, and has no real plan or idea if their implementation is even going to work in two weeks. The result will be that on April 1 there will be fewer providers, longer waiting lists, and a very unknown billing process and payment system. The system will lurch along, propped up by those agencies who will fund the madness until the dust settles. In the meantime, just in case anyone thinks that they have this all figured out, the next round of disaster is being negotiated behind closed doors for the 2014 budget.
Most notable for people who are paying attention, Director Hutton made repeated statements that 'people have misinterpreted our intent' or 'people are misinterpreting the impact of this or that.' Director Hutton should consider that if there is so much misinterpretation, whose responsibility is that? His management of these reforms has been a disappointment, and that is really a generous understatement.
That is my blunt analysis.