Friday, January 17, 2014

Governor Andrew Cuomo's infamous legacy with the New York State Early Intervention Program

The New York State Association of County Health Officials (NYSACHO) finds itself in an awkward position these days.  As a primer, you should be aware that County Health Officials are charged with administrating the Early Intervention Program in their respective jurisdictions.  They hire Early Intervention Officials and are responsible for directing the implementation of the programs.

In bygone days, the mechanisms in place for funding the Early Intervention Program were 'pay then chase' methods.  In simple terms, the County would pay the provider to see the child  for services and then the County would be responsible for chasing after the insurance companies and NY State to recover their costs.

County officials have been complaining for years that unfunded mandates, like the Early Intervention Program, are stressing their budgets severely. Residents of counties who pay property taxes don't want the County officials to raise property taxes any higher than they already are. Last year Governor Cuomo signed the historic property tax cap into law that requires local governments and school districts to raise taxes no more than 2 percent or the rate of inflation, whichever is less. Each community has the choice to  raise or lower property taxes according to the needs of the community. If the taxpayers want to pay more taxes they can, and they can override the cap with a 60 percent vote for schools and by a 60 percent vote of the governing body for local governments.

Most communities these days are not exactly rushing to raise their property taxes.

When property taxes are capped, it stresses County budgets - that is the point actually - these caps cause communities to start having conversations about the costs of the programs.  This is the problem in NYS: people want programs like Early Intervention, but don't necessarily want to pay the costs.

So as Counties are stressed they began clamoring for what they call 'mandate relief.'  In simple terms, they want someone else to pay for the mandated programs like Early Intervention.  The State responded by taking over the billing and payment system for Early Intervention and inserting a State Fiscal Agent that would act as an intermediary between the State's payment and the providers who are submitting claims.  Instead of 'pay then chase' the State started a 'chase then pay' system.  In other words, they would try to get the money from the insurance companies FIRST and then pay the providers after those attempts.

Insurance companies were very happy under the old system because County governments were hardly proficient with collecting claims.  Because the County was unable to collect money, the State would have to pitch in to cover the balance.  In order to make their State Fiscal Agent system work NYS got the Department of Financial Services involved and they heavy handed the commercial insurance programs to try to get them to share some of the burden for the costs of the program.

Now in theory that all sounds great.  Cost sharing with insurance makes sense, but obviously insurance companies are not in the business to pay claims; they are in the business to make money.  So, they do everything they can to avoid paying.  This is the standard dance between a health care provider and an insurance company.

The problem with the State Fiscal Agent system though is that the provider has no control over what the intermediary State Fiscal Agent is doing.  So, payments have been slow, incomplete, and completely confused.  That is a topic for another whole post, but suffice it to say that despite all of their good intentions the State Fiscal Agent was not adequately prepared to take over the Early Intervention billing system.  The system has imploded.

It has been my long held belief that if the State had simply given billing responsibility directly to Providers that the ability to implement cost sharing through commercial insurance would have been more efficiently achieved.  Instead, the State has imposed their Fiscal Agent, a company known as Public Consulting Group.  This company has done a poor job in its contracted functions.

Providers have had payments delayed for months, have had to hire administrative staff just to deal with the new State Fiscal Agent and the convoluted system that they put in place, and because the system has been so challenging agencies have closed, providers have left the early intervention system.  Now there are waiting lists all over the state because there are not enough professionals who are willing to work in this system.

Families and providers complained loudly about this throughout last Fall and they were actually heard by State legislators.  Companion bills were introduced in the Senate and Assembly that would return to a 'pay then chase' system so that there would be enough providers willing to work in this system and so families and children could receive their Early Intervention services.

To return to the original point of this post, this leaves the County Health Officials in a rather precarious position.  They can see with their own eyes that the Early Intervention systems they are in charge of are imploding.  At the same time, they receive marching orders from County Officials that they have to control costs and under no circumstance can they return to the old 'pay then chase' systems.


The New York State Association of County Health Officials released a memo in opposition of  the Senate and Assembly bills.

Summary of the attached Memo in Opposition to S. 6002/A. 8315: 
  
The New York State Association of County Health Officials (NYSACHO) opposes the above-referenced legislation which would weaken the ongoing transition of the Early Intervention (EI) payment model, a transition that is less than a year into implementation. NYSACHO strongly believes that the State must move forward with this transition under the existing statute to fully realize fiscal and administrative reforms that can ensure the continued viability and quality of the EI system for children between the ages of 0-3 years. 
  
Although a segment of EI service providers reported experiencing serious payment delays during the early months of the transition to a state fiscal agent, NYSDOH now reports significant and continued improvements in payment processing. NYSACHO believes the state must continue to pressure commercial insurance plans to pay for covered EI services. NYSACHO also believes that providers of EI services should legally be the providers of record for insurance claiming purposes and must continue learning effective claiming procedures as is done in all other sectors of the health care system. 
  
County governments cannot afford to return, in any way, to the system that was in place prior to April 1, 2013. 
  
Rather than implementing the changes proposed in this legislation, NYSACHO recommends that the Executive and Legislative Branches ensure that the NYSDOH is provided adequate resources to complete the transition and sustain its fiscal and administrative infrastructure as the lead agency providing families in our state with the EI services that they need. In particular, NYSACHO believes that NYSDOH must focus resources on continued improvements to, or replacements for, the NYEIS claiming, reporting and monitoring tool – improvements that are essential to all parties involved in EI. 
  
If this legislation moves forward, then the state, not localities, must bear 100% of the administrative and fiscal burden of a return to a "pay then chase" model. 

This is a disturbing development because Governor Cuomo listens closely to the Counties and has obviously been quite sympathetic to calls for mandate relief.  It seems that we have a situation where there is notable bipartisan support in the Senate and Assembly to fix this problem but the Counties and the Governor may be the highest hurdles to overcome.

Early Intervention Providers around NY State are expressing that they were just tossed under the bus by the Counties that they work for.  I can't find any reason for them to feel otherwise.

What happens next?  It is difficult to know.  The Department of Health is going full steam ahead with all of the development of systems for the State Fiscal Agent to interact with Providers.  They are reporting data that minimizes the appearance of any problems, and as Early Intervention Providers are a disparate and disconnected group of individuals as well as small and large agency groups there is no real coordinated method for them to counteract the Department of Health's information spin machine.

Mention of the Early Intervention Program was notably absent from the Governor's State of the State address.  As I have alluded to in previous posts, this is an election year and it is not likely that Governor Cuomo wants to have a lot of chatter about how utterly incompetent his team was with the administration of such a program.  The problems that have been seen in the Early Intervention Program don't fit the narrative of how great an Executive he is - and so it is all being ignored and swept under the rug and the best possible face is being placed on the data that spins its way into the newspapers.  The Albany Times Union today mentioned that providers were 'grumbling' and that there were just some 'initial snags.'  To state that there were only 'initial snags' is akin to saying that the Affordable Care Act rollout had a few 'glitches.'  Seems like a familiar cover story.

The issue has gotten an extraordinary amount of press despite the disconnected constituency of Early Intervention Providers and the families that they provide services to.  The two aforementioned bills are zipping through the legislative process but if County Health Officials get their way this will all get squashed.  It will be squashed because no one wants to pay for the therapy that a small child might need.  The insurance company doesn't want to pay for it.  The County doesn't want to pay for it.  The State doesn't want to pay for it.  And so the best outcome from their perspective is to create a morass of bureaucracy so thick that it will shield them from incurring the costs of this program.  According to Assemblyman Tom Abinanti, D-Mount Pleasant,

“The state is burying providers in an avalanche of red tape and paper work – forcing many small businesses to close and chasing speech, occupational and physical therapists to abandon Early Intervention services,” said Abinanti. “The state is hurting defenseless babies and toddlers and blaming everyone but themselves.”
This is your County Health Official throwing Early Intervention Providers and children receiving services under the bus.

This is Governor Andrew Cuomo's infamous legacy with the New York State Early Intervention Program. 

5 comments:

Bob Trapani said...

You hit it all on the head. A very good description of how and why we are in the place we are today.

Christopher Alterio said...

Thanks everyone for the positive feedback. King Lear had his moment of realization - maybe Governor Cuomo will:

Take physic, pomp; Expose thyself to feel what wretches feel, That thou mayst shake the superflux to them, And show the heavens more just.

Anonymous said...

excellent overview of the current EI legislation and issues. thank you for writing it.

Anonymous said...

great article and thorough review of EI. thanks for writing it.

Anonymous said...

Thank you for such a clear, coherent and accurate description of our current crisis. We are watching the dismantling of the NYS Early Intervention program, precisely as intended by the Governor. As an Assemblyman in our district said, "My children benefited from Early Intervention, but we can't afford it anymore." I guess he'll feel that way until his first grandchild needs help. Thank you for writing this.