This is an awesome idea! Contact your representatives in Austin now!

Health Homes / Health Teams Update

State Representative Sylvester Turner (D-Houston) has filed a companion “Health Homes / Health Teams” rider as an amendment to the House version of Senate Bill 1 (the state budget). As with the Senate rider (Article II rider 68) Turner’s amendment permits the use of Medicaid funds in for providing “patient-centered care” to homeless persons with chronic medical and mental health conditions.

The rider authorizes the State Medicaid Director (under the Texas Health and Human Services Commission) to seek an amendment to the state Medicaid plan from the Centers for Medicare and Medicaid Services (CMS).  If approved, the amendment will allow providers of patient-centered care (“Health Teams”) to deliver integrated health services (medical, behavioral and supportive) as a part of the Texas Medicaid program. The Health Homes option is a special provision (Section §1945 of the Social Security Act) which allows states to develop customized programs of integrated health service to deal with needs of targeted populations.  This option does not require the state to expand Medicaid.

This approach to care is an evidenced-based, best practice which is rapidly being adopted throughout the country.  Since the “Health Homes Option” first became available on January 1, 2011, eleven other states have requested approval of similar plan amendments.  Under this Medicaid strategy, patient-centered health care for the homeless:

Reduces the burden of uncompensated care on hospitals and local hospital districts. . .

Improves the performance of permanent supportive housing in stabilizing residents with serious and persistent mental illness, especially those diverted from incarceration. . .

Restores capacity to emergency medical and psychiatric health systems. . .

Improves the coordination of health services to extremely vulnerable populations. . .

 Provides efficiencies in care delivery and data production. . .

Is the best known means of providing consistent, whole-person care, and

Reduces the cost to the State for these services.

The Federal Medical Assistance Percentages (FMAP) for this optional program is only 10 cents on the dollar.  For every dollar billed to Medicaid for these services, the state will save three dollars against services now provided under the standard state FMAP.

Injured, broke, and trying to work. . .

Friday a man knocked on my front door.

His jeans were torn, his clothing filthy, his facial expressions bespoke his fear and embarrassment.

"I live down the street in the blue apartments," he began. He told me his name and then began telling me his story.

He needed to earn a few dollars to purchase his anti-seizure medication. Just out of the hospital after a series of episodes, he needed a job.

When I reached for my wallet, he stepped back.

"No, don't do that," he scolded me. "I don't want a handout, I want a job. May I clean your windows or rake your lawn?" he suggested.

As we negotiated the job options, he showed me the gunshot wound that marked the back of his head. He pushed back his drooping right eyelid to reveal the absence of a normal eye. He told me an incident of random gunfire had devastated him and his life.

"The bullet came out my eye," he informed me. "The brain injury changed me."

He then began to cry.

He told me his meager disability benefits don't near cover his cost of living. He wept when he told me that he used our food pantry at CitySquare so he could eat. 

He told me about his church.

He told me about his career before being shot.

He hugged me.

He went to work on the leaves in my yard, and I paid him well so that he could get his meds.

My neighbor should be doing better.   Make no mistake about it:  he's trying very hard.  He's doing all he can do.

I'll try to help him, to stay in touch.

But the scale of problems like his are overwhelming. With so many in dire need, we need economies of scale provided by collective, national solutions.

In Monday's newspaper I read about more cuts in our privatized mental health services for the poor and disabled in Texas.  As the report noted, Texas has made it to the bottom of the national ranking for these services. 

Think about it.

Dr. Ron Anderson on state Medicaid cuts

Few, if any, know as much about public health care and its cost than Dr. Ron Anderson, the President and CEO at Parkland Health and Hospital System.  Recently, I received the following legislative update from Dr. Anderson.  When Dr. Ron writes, we all should be listening.  Hear him out. 

Last week, the Texas House Appropriations Committee passed House Bill 1, which would drastically slash funding to hospitals and doctors. Similar discussions are happening in Washington about funding cuts as well as changes in health policy to try to deal with deficits and the cost of health care. Yet some of the proposals might not truly save any money, but rather simply shift the chairs around the Titanic.


Medicaid is not the reason for the current structural deficit in Texas. A cut to Medicaid may actually cost three times as much as it saves because Medicaid is a state-federal match program. When we cut a state dollar, we lose additional federal dollars.

The growth in Medicaid relates mostly to increased enrollment during economic downturn. This is exactly how Medicaid was envisioned to work, as a "counter cyclical" safety net. Many of the state dollars that are matched are local tax dollars that hospitals like Parkland send to the state in order to achieve the federal match. Out of $8.6 billion of state match in this last biennium, only $1.7 billion was actually general revenue. In fact, Medicaid local and state dollars were matched with more than $16 billion of federal money which is divided from taxes we Texans pay to Washington. We're simply returning money to Texas to support our neediest residents.

At the same time, Medicaid is already a program that does not pay the full cost of care. Only 38 percent of Texas doctors accept new Medicaid. Many may stop caring for Medicaid patients altogether if there were additional cuts.

In turn, patients go to emergency rooms that are already crowded. These patients may wait to seek care and therefore have a more advanced illness, requiring admission that could have been avoided through early intervention, prevention and primary care. The total cost of health care will go up and many people who are not Medicaid patients will be impacted.

How does this impact Dallas County? While the state might save money, it costs money for the local government, the local health care providers and the local taxpayers. Think of the total burden of illness that must in turn be supported solely by this community. It's simply a cost shift. Consider also that local tax values have declined yearly by 3 to 4 percent for the last four years leaving little ability to absorb these costs.

Texas has been remarkably short sighted in not taking advantage of federal matches. Some of the discussions are about expanding managed care, supposedly saving the state $50 million. On the other hand, it would also minimize the ability to match federal Upper Payment Limit dollars, costing Texas $800 million to $1 billion. If we take away a significant funding opportunity, we need something to replace it.

If we create a ripple effect downstream to local government, then the budget cut doesn't accomplish what was intended. Before we balance the budget on the backs of vulnerable people - the poor, the pregnant, the children and nursing home residents - we ought to take a comprehensive look at solutions, both in terms of state revenue and expenses. Whether it's use of the Rainy Day Fund or program cuts, I don't think there are any simple answers. I'm pleased that members of the North Texas delegation are looking for answers. However, there comes a time when we have to realize that a sacrifice is going to have to be made.

Because of the wonderful Dallas County citizens and their support of the bond campaign, we have money to build a new hospital. That won't be affected. In fact, it better prepares us for the future to stay competitive in the marketplace after health reform.

Yet as we plan the Parkland 2012 budget, we are taking a serious look at savings that make minimal impact on patient care. But we've done that now for the last four years, and as painful as it is, eventually we may have to curtail services.

We must consider the ripple effects of potential "savings" and the burden it creates on others. Parkland has an open door for the vulnerable and needy. We care for those with Medicaid even if the reimbursement is low. However, that means Parkland could also be impaled by volume if the private sector disengages from Medicaid due to cuts. That's a concern that keeps me awake at night. But above all else, we will continue to advocate by putting the patients first.

How will poor fare in Austin in 2011?

Fifteen months ago, Texas governor, Rick Perry appointed Tom Suehs Executive Commissioner, Texas Health and Human Services Commission.  This may have been the governor's best appointment during his historic term.  Suehs manages to get along with both sides of the predominately Republican Texas legislature.  He speaks bluntly, pulls few punches and understands what's at stake for the poorest residents of Texas as the state faces an historic $24 billion budget gap over the next two years.  Suehs understands that facing such a budget challenge legislators will find programs for the weak, the poor and the marginalized easy targets for cuts.  But Suehs' understanding of the problems of both the state and the poor make him a key player in the work that will begin later this month in Austin. 

Here's the report that appeared in The Dallas Morning News on Saturday, January 1, 2011:

Texas' social services chief expects agonizing budget process
By ROBERT T. GARRETT / The Dallas Morning News
rtgarrett@dallasnews.com

AUSTIN – As lawmakers gear up to hunt for every penny they can use against an unprecedented budget gap, Texas' safety net for the poor and vulnerable figures to get a lot of scrutiny.

The Legislature's Republican leadership will confront weighty questions, such as how many children the state can afford to provide medical care for and what level of care and supervision can be provided for the elderly and disabled.

At lawmakers' elbows will be the chief of state social services, Tom Suehs. He predicts an agonizing process.

"There are not too many nice and easy decisions," he said recently. "That's why they're going to migrate to cutting some of the optional" services in Medicaid, a health program covering 3.3 million poor children, pregnant women and frail adults.

But Suehs (pronounced "seas") is quick to add that optional services – which can be taken away from adults on the program, though not from youngsters – are not frills. Cuts will be costly and painful.

"I want to do a better job of describing the balloon effects," he said. "If you squeeze the community mental health, you're going to end up possibly with more people in prison, and that'll cost money over there."

Advocates for the needy hold out hope that the former lobbyist will prove to be the man of the hour. At the very least, they predict Suehs – fully vested in the state pension system and with nothing to lose – won't gloss over the consequences of reduced funding.

"Tom's been a straight shooter," said disability rights advocate Bob Kafka of Austin, who has known Suehs for decades.

Read the entire report here.

Denying health care to the poor in Texas

Now we're told that leadership in the Texas legislature, in the next session beginning in January, may consider ending Medicaid coverage for poor children, women, the disabled and seniors.

Read the story here.

Just when you thought Texas couldn't get much colder or non-responsive to poor people, our leaders come through to strike an even harsher blow to the weak, the sick and the impoverished.

Don't it make ya proud?

Thoughtful comment on Medicaid and its improvement

Dr. James Baker is the CEO of Metrocare Services here in Dallas, Texas.

Metrocare Services, formerly known as the Dallas County Mental Health Mental Retardation (MHMR) Center, has served Dallas County for over 40 years by providing first rate clinical and social services to persons with mental illness, developmental disability, or severe emotional problems.


Jim is an expert on mental health care delivery among the poor and, thus, an expert on Medicaid.

Click here to refresh your memory on my previous post that addressed what I considered an outrageous comment about Medicaid made by Senator Lamar Alexander (TN-R).   Be sure and read the comments on that post. 

Here's what Dr. Baker left in the comment box on that earlier post: 

I want to go back to the original question by c hand: Why do "so few physicians...accept patients covered by the ... very good plan?" and why do patients with these plans have to wait for care?


Medicaid IS a very good plans from the perspective of its benefits, that is, what it will pay for. It is very generous in that respect.


The reason docs dont "accept patients" (actually it is the insurance that many dont accept...) is that Medicaid's reimbursement does not even cover most docs' costs for the services.


And if Congress doesnt repeal a Medicare reimbursement cut of 21% that is set for Jan 1st, the same access problems will worsen for the elderly that already happen for the poor.


The fix is counter-intuitive: increase both the number of people covered and the doc rates for both programs, so that access is easier and happens sooner in the course of a disease, so that the cost of each episode goes way down -- and therefore so does the total cost to taxpayers...


Unfortunately since it is counter-intuitive, many policymakers have a hard time grasping this reality...


Wednesday, November 25, 2009 3:30:00 PM CST

Jim, thanks for the clear and rational explanation. 

Ever consider a run for Congress?

"Medical ghetto"?

Even though I expect this post will set off a firestorm of comments, many or most of which will be very negative, I cannot find the words to properly express just how offensive I find the words of Senator Lamar Alexander (R-TN) during a speech he delivered in the current Senate health care debate.

Give him your attention.



In the first place, Medicaid represents the only health care option available to a portion, and only a portion, of the very poor in America. The major negative associated with Medicaid relates directly to the fact that so few physicians will accept patients covered by the otherwise very good plan.

As a result, my poorest neighbors must wait for care, and not only in long lines or in crowded clinic and ER waiting rooms, but for weeks at a time for scheduled treatment. This would be remedied if we had the benefit of a comprehensive, national health care plan.

But second, and even more offensive, if the good Senator feels that Medicaid is a "health care ghetto." doesn't he have a moral responsibility to improve it? Doesn't he have a fiscal responsibility to the nation to reform it, extend it and promote it? Hasn't he signed on as a national leader with the responsibilities that accompany such a decision? 

Never mind the obvious race baiting here. Let's talk quality, equity and health care justice, not to mention improving the nation's wellness and health outcomes across a broad array of health measures.

Senator, please!

Neo-natal mortality

At one point during Meet the Press on Sunday, August 16, 2009, the hour-long discussion on health care reform in the United States turned to the "quality of our health care system." Every time that subject come up, the opposing sides begin talking about two very different issues.

On the one hand, someone will quote the comparative negative public health outcomes for the U. S. versus those of a number of other nations that spend far less per capita on health care. The fact is, in terms of overall public health, we are behind.

On the other, someone will point out that the U. S. enjoys the best system in the world in terms of treatment, innovation and research for those who can afford to access these benefits.

And from here the debates rage on.

But, back to Sunday's program.

At one point, Medicaid, the public health insurance program for the very poor, was blamed for our nation's terrible neo-natal mortality statistics when compared to other developed nations.

It was then that I almost turned the television off. I had done a good job, up until then, of trying to give both sides a fair hearing.

But, the Medicaid comment changed the entire subject and focus of the conversation for me. And, because no one on either side talks about poverty on any of the Sunday morning news programs (or much anywhere else today for that matter), no one raised any objection.

I wanted to reach out and pull the Congressman who made the comment through the television screen and into my den. I wished that I could give him a driving tour of the "Medicaid" neighborhoods here in inner city Dallas, Texas. I wanted to tell him that these neo-natal statistics would be far worse without Medicaid and that their origin won't be discovered in the existence of this public benefit for the poor.

No, our discouraging neo-natal outcomes aren't the result of Medicaid.

They are a cruel outcome of poverty itself.

Mark it down, anyone who says otherwise does not understand poverty today.

.

Oh, now I see! (or, you just can't make this stuff up!)

Texas routinely leads the nation in its record of draconian policy measures and miserly funding for health and human services. One of the reasons Texas enjoys such a surplus of funding these days is because we spend so little on our people, especially those who are very poor.

You know, things like most uninsured children, terrible enrollment rates for Medicaid and the Children's Health Insurance Program (CHIP), food stamps. . .the list goes on and on.

I've always thought that our problem resided in the state's current elected majority opinion when it came to public benefits. You know, like Governor Rick Perry's latest decision to turn down $555 million of federal funding that would benefit the unemployed in our state!

But, now I have reason to believe that I was wrong!

Our problem is much more basic than differences in philosophy.

The whole problem is grounded in simple ignorance!

Just go here to see what I mean!

You can't make this stuff up!

Unbelievable!

.

Failing Texas communities

I've always felt that making a profit on health care services, especially for the poor and most vulnerable, just didn't pass the ethical "sniff test." I know I'm likely in the minority on this one, or maybe not.

Tell me how you feel about it.

________________________________

Several years ago, I got into a conversation with a very bright young business man. Somehow the subject of universal health care came up.

I'll never forget his words, "Some people actually believe that health care is a basic human right. Can you believe that? That everyone is entitled to health care?"

I also remember that our talk came to fairly speedy end after I voiced my opinion about the matter.

What do you think?

__________________________________

Along these lines, hats off to The Dallas Morning News for its four-week series, "State of Neglect." You can get to the ongoing report here. The timing is perfect just as the Texas Legislature prepares to open its 2009 session.

So far the report reveals how the State of Texas has aggressively "outsourced" health benefits coverage for the poor, the disabled and the elderly to the private, for-profit insurance industry--in this case, Evercare of Texas, a division of UnitedHealth Group. To say that the company has under performed would be a great understatement. If you live in Texas, you'll want to read the report.

The result of this outsourcing has been neglected patient care, an incredible lack of responsiveness, inferior services for those who need them most and amazing profit for corporations and lobbyists who work on their behalf.

Here's how the Dallas Morning News sums things up:

"This month the Texas Legislature will open its 81st session with a $10 billion budget surplus. Many leaders have called this the happy result of a state government that keeps taxes low and regulation light, and that makes Texas, for the vast majority of its residents, a great place to live.

"Unless you are hospitalized. Or buy insurance. Or breathe the air. Or engage in any other daily activity that requires state oversight. . . .

"Texas is near the bottom among the 50 states in per-capita spending on health and human services, but it is a leader in outsourcing these functions to private contractors."

Frankly, the entire situation in Texas in the health and human services sector is an on-going disaster. Reform is needed, comprehensive, radical reform.

It is time we all called for better outcomes for everyone.

.

Real World

At times our conversations and debates concerning public policy leave us "stuck" in abstractions and theoretical concerns. After all, most of us here have the luxury of conversation about what are, for millions of other people, matters of life and death, literally.

Just this week I received a comprehensive report from the Children's Defense Fund of Texas (CDF) on how Medicaid and the Children's Health Insurance Program (CHIP) work or, in far too many cases, don't work in Texas ("In Harm's Way: True Stories of Uninsured Texas Children").

The format of CDF's report is brilliant.

Woven among the typical statistical analysis provided by such reports are the stories of real life people--men, women, children and families. These stories make the report "live."

Issues addressed include matters of recertification, income limits, delays in the process, impact of the value of owned vehicles, etc. Basically, the report educates us about what consumers of these insurance products already know all too well: they are not set up to serve the most in the best manner. Attepmts to contain costs by erecting barriers to useage can prove to be deadly.

The report is dedicated to the memory of Devante Johnson.

Here's his story as told by the CDF report:

Thirteen-year-old Devante Johnson had advanced kidney cancer and could not afford to be without health care coverage. But last year, that is exactly what happened, when Devante spent four desperate months uninsured while his mother tried to renew his Medicaid coverage.

For years, Devante and his two younger brothers were covered by Medicaid. Texas families who qualify for Medicaid or CHIP are required to renew their coverage every six months, and Devante's mother, Tamika, had tired to get a head start by sending in her paperwork two months before Medicaid was set to expire.

The application sat for six weeks until it was processed and transferred to CHIP, because an employee believed their family no longer qualified for Medicaid. At that point the paperwork got lost in the system. Tamika grew more and more desperate as she watched her son get worse. "I did everything I possibly could," Tamika said. "I would literally get off the phone in tears, crying because they [CHIP employees] frustrated me so much."

For four months, Devante went without health insurance as employees unsuccessfully attempted to reinstate his coverage. As a result, he could no longer receive regular treatment and had to rely on clinical trials for care. Meanwhile, his tumors grew. Time was running out.

It wasn't until a state representative intervened that Devante's coverage was immediately reinstated. Two days later, Devante was able to start a promising new treatment. But, it was too late.

Devante Johnson died on March 1, 2007.
____________________

The "bottom line" of the CDF report on Texas is very simple and straightforward. Every child in the state who is uninsured should be enrolled in either Medicaid or CHIP today. Making this policy decision is smart for children and for every Texas taxpayer.

Beyond being smart, such a strategy is the right, just and compassionate thing to do.

[Read and/or download the full report at: http://www.childrensdefense.org/site/
DocServer/InHarmsWay.pdf?docID=3961.]

Mental Health Services in the Lone Star State

More "good news" on the status of public health in Texas:

· Mental illness is a leading cause of disability in the U.S.

· One in five Texans (20%)faces some form of mental illness.

· Texas ranks 49th in per capita spending on treatment of mental illness.

· Inadequate community-based mental health programs increase the likelihood that persons with mental illness will wind up in the criminal justice system.

· Approximately 900,000 adults in Texas met the DSHS mental health priority population definition in 2005, yet less than half in greatest need received mental health services.

· Forty-six percent of ER visits have behavioral health issues as a basic or contributing factor.

· Untreated mental illness results in increasing pressure on state and local resources.

· Community-based services reduce the rate of costly care in emergency rooms, hospitals, jails and prisons, and reduce the need for transportation to state hospitals for stabilization.

· Every $1 spent on mental health services saves $5 in overall health care costs.

· In Fiscal Year 2005, Texas average monthly emergency room costs were 27% lower for Medicaid clients receiving needed community mental health treatment than for those who received no such treatment.

· In Fiscal Year 2005, Texas average monthly emergency room costs were almost 35% lower for Medicaid clients receiving needed substance abuse treatment than for those who did not.

· Untreated mental illness costs Texas $16.6 billion per year.

· Treatment for mental illness is highly successful. (Depression: 80%, Panic Disorder: 75%, Schizophrenia: 60%, Heart Disease: 45-50%).

[Mental Health Association of Greater Dallas]

If you live in Texas, you might want to pass this information along to your State Senator and your House Member.

Brace yourselves, poor folks. . .one more time

Just about every time the State of Texas decides it's time to "reform" anything related to health and human services, poor folks should prepare to take it on the chin.

That's why the headline in the "Texas & Southwest" section of Saturday's edition of The Dallas Morning News caught my eye: "State plans Medicaid experiment" (Saturday, January 27, 2007, page 3A).

On Friday, Governor Rick Perry, "key GOP lawmakers," and Albert Hawkins, Texas' health and welfare czar, met with U. S. Health and Human Services Secretary Mike Leavitt. No doubt Medicaid financing poses a formidable challenge to the state, given that 25% of the state budget is earmarked for funding the health care delivery system designed to serve the poorest of our residents.

According to the report, the Governor wants to:

• Offer subsidies to small businesses to fund the purchase of health insurance for their employees.
• Give "customized" benefit plans to certain groups of Medicaid patients.
• Transfer part of the funding to "savings accounts" for the patients.

I will reserve judgment until all of the details are revealed and worked through during this session of the Texas Legislature, but I have noted a trend following the announcement of these kinds of plans.

First, the cost involved is often covered by reducing overall benefits to the poor, and sometimes those who need help the most are cut off.

The last time Medicaid was "reformed" in Texas, benefits were cut, people found it harder to be certified and private industry got involved in trying to administer programs. The result to date has been a disaster, and I happened to be in on one of the original planning groups for Accenture, the private company contracted to "improve service and access" to the poor. Hasn't happened.

Second, whenever government begins suggesting private insurance as a remedy for bulging health care costs, I counsel my low-income friends to head for cover!

President Bush's current plan for a health care overhaul includes inducements in the form of tax breaks to motivate more Americans to buy private insurance. According to Dr. Ron Anderson, President and CEO for the Parkland Health and Hospital System, Dallas' public health care institution, the costs associated with these tax breaks would be covered by cuts in funding to hospitals like Parkland that treat the poor and uninsured. Dr. Anderson estimates that under such a plan the loss in Medicaid revenue to Parkland could be up to $83 million annually.

One note of concern for me, as I read the report, is the fact that our Governor asked Secretary Leavitt for "as much leeway as states can be given to tinker with Medicaid." I'd love to know the definition of "tinker" here. One thing I do know, shifting around already limited Medicaid funds never seems to benefit the poor.

I'll stay tuned, but I'm not optimistic.