Saturday, February 26, 2011

When the Medicaid Hit Squad comes calling

UnitedHealth is sending "hit squads" out to the homes of medically fragile children. Their job is to bully and intimidate parents into agreeing to a reduction in the home medical services that keep their children alive. We are the families of children and adults whose disabilities are so complex and severe that the only alternative to institutionalization is for Medicaid to pay for providing nursing and care services in our homes.

Hawaii entered into its 2009 Medicaid contracts with UnitedHealth and Wellcare granting individual per person per month budgets ranging from $2,000 to $30,000. The purpose of the contract, and the higher monthly rates, is to pay for the nurses, personal aides, CNAs and other help that is medically necessary to keep each individual at home. Institutionalization costs more, not to mention the benefits of keeping someone home with their family, so the money is there to spend, so to speak, at least two-thirds of it federal in origin, without taking money from other programs.

Last summer, Evercare (UnitedHealth) and Ohana (Wellcare) once more got Hawaii to agree to raise the capitation fees. Did more money mean more medical services? No, not when the insurance company's profit depends on spending as little of that monthly per person fee as possible.

I had been hearing of these "hit squads" for several months but didn't experience one for myself until February 18. It's taken me since then to sort through the experience enough to isolate why it was so deeply disturbing. Under the guise of a standard quarterly nursing evaluation of Hannah's medical needs, my ability to be a good mom to my daughter was attacked. I was a bad mom if I couldn't provide the same level of professional medical care to my daughter that she gets from her nurses. The point was to get me to agree to taking over some of Hannah's nursing shift hours, thereby lowering UnitedHealth's "medical loss ratio" for my daughter and thus increasing company profits.

Unless you "live the life" so to speak, it can be hard to understand the daily stress of living with the potential your child could die at any minute, while surrounded by medical technology and treatments that you may or may not completely understand. Studies released in November 2009 showed the parents of kids with disabilities are prone to "shell shock", "battle fatigue", or PTSD as it's now known.

My daughter has seizures ninety percent of the time she is sleeping, and almost continuously when she is awake. She is at constant risk of death from something called SUDEP - Sudden Death in Epilepsy. Nurses are with her so that if any of those seizures start to escalate, it can be stopped before we reach the point of calling an ambulance. Every time her seizures have reached the point she needed to be flown to Kapiolani, it was when there wasn't a nurse home with her.

I've sat next to my little girl in an ambulance when she stopped breathing. There is a panic that sets in now if I'm alone with her and she starts seizing, to ensure she keeps breathing. That panic doesn't allow me to do the five other things that need to be going on simultaneously when she starts seizing: get the pulse oximeter hooked up, get the oxygen out and set up, get the diastat out and ready, cool her down if her body temp has gone over 99, all while keeping her in a position to minimize gagging since she's stopped swallowing.

Yet the rude, belligerent attack I experienced on February 18 was designed to make me feel I was a bad mom if I couldn't handle all this with the same skill and detachment as a professional nurse.

I am not the only one who has come away with similar impressions after visits from one of these "hit squads". Another mom was attacked with the accusation that she wasn't spending enough time with her child or she would know how to take care of her. A third family, for whom English was a second language, was belittled and intimidated for not understanding the technical medical terms for all their daughter's care.  Even taping the so-called evaluations did not inhibit the viciousness of these attacks on parents.

There is no doubt these attacks are designed to provide a justification for cutting home services. In December, UnitedHealth cut home services for a young man by sixty percent, on the basis he could use his hands and arms to move himself. The UnitedHealth employee who did the "evaluation" and recommended the cuts in services had spent the previous six years signing off on medical care reports for her previous employer, acknowledging he had no use of arms or hands. His medical situation had not changed overnight, only her employer had.

This is the same UnitedHealth that experienced a ten percent increase in earnings in fourth quarter 2010, "as the health insurer continued to benefit from people's relatively lighter use of medical services."  That Wall Street Journal article goes on to say

UnitedHealth's medical claims in relation to its revenue, a key statistic called the medical-loss ratio, were lower than financial analysts' views, and, according to analysts Leerink Swann, were the lowest in five years. The lower medical-loss ratio helped to boost per-share earnings beyond analysts' expectations.

For a company deriving forty-six percent of its $87.14 billion annual income from federal Medicare and state Medicaid "capitation" contracts, a lower medical loss ratio means the company has more likely cut services than mysteriously benefitted from "people's relatively lighter use of medical services." A simple read of UnitedHealth's SEC filings, along with the unsealed federal whistleblower complaint which includes taped conversations where Wellcare executives openly discuss strategies for committing Medicaid fraud, makes it clear these lower medical loss ratios are no accident.

It's what I've called "the new Medicaid Math", where sixteen to forty percent of state payments to private health insurers are being skimmed off the top by means of these lower "medical loss ratios". The Affordable Care Act tried to make health insurance companies responsible to their policy holders for how much of each monthly premium is spent on actual care. For private enrollees (i.e., non Medicaid or Medicare policyholders), the Act was trying to set a maximum twenty percent profit, and the insurer would have to rebate any difference to the policyholder at the end of the year. A financial analyst with Oppenheimer found that if that limit had been in place for 2009, private health insurance companies would have had to rebate over $1.9 billion back to policy holders.

But these limits do not apply to state Medicaid contracts. Florida recently found that all eight contractors for one specific Medicaid program were out of compliance with a required 80% medical loss ratio, with actual MLRs as low as 60%.

And so we've come back full circle to the Medicaid Hit Squads, whose ultimate purpose is to lower the company's "medical loss ratio" for adults and children like my daughter. They are targeting families where loved ones require what's called "total care" because we are where they get the biggest financial bang for the buck cut. If they're getting paid, say, $15,000 per month from the state to provide home medical services for a particular person, slashing those services by sixty percent puts more money into company coffers than cutting services to folks they get paid only a few hundred dollars a month for from the state.

I do not understand why neither state governments with health care deficits nor the disability rights community nor even the media have looked at the billions of federal Medicaid and Medicare dollars wasted on private corporate profits. The resulting levels of human misery being created in our caregiving families to support these outrageous profits isn't even being recognized.

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About Me

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I'm the mom of a child with disabilities. Hannah's first neurologist said she might never develop beyond the level of a 2 month old infant, and there wasn't anything I could do about it. The brain damage was just too severe. Nine years later, she walks, uses a touchscreen computer and I've just been shown she can learn to construct sentences and do simple math with the right piece of technology. Along the way, I discovered I needed to teach myself what Hannah's rights to services really were. Learning about early intervention services led to reading about IDEA and then to EPSDT. I've been waiting for the Obama administration to realize the power and potential of EPSDT for the medical rights - including the right to stay at home with their families - of children with disabilities. The health reform people talk about long term care, and the disability people talk about education and employment, but nobody is talking about EPSDT. So I am.