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���������� Note: It is hard to pick out what is most troubling about the excellent investigative piece below. We know that inhabitants of adult homes and nursing homes have been the victims of deplorable care and service management in fee-for-service, but managed care has the ability to only reprogram that victimization—away from redundant and unnecessary, sometimes harmful, services to shadow enrollment and entitlements only for the healthiest individuals. The most upsetting aspect of this from a state policy perspective is that conflict free case management and a robust assessment process should be a right for every individual, but specifically for persons with complex needs. Several state transitions incorporate this requirement, but the shift to managed long term care will not. Furthermore, the fragmentation of service management into specialty plans, instead of their incorporation into plans being overseen by departments dictating other public program transitions, leads to widely disparate experiences and poor oversight and accountability. As these managed care plans continue to bargain over the lives of individuals for an enhanced capitation, the care, the rights, and the dignity of our community members is marginalized.

Medicaid Shift Fuels Rush for Profitable Clients

���������� Times; Nina Bernstein, 5/8/2014

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When����flooded two adult homes in Queens, hundreds of disabled, elderly or mentally ill residents were caught in the surge. After weeks in public shelters, they were bused, over their objections, to a dilapidated four-story building called��, in a crime-ridden section of Brooklyn.

Many had not showered in days. Crammed three cots to a room, they lacked basics like clean underwear. But in the parallel universe of ����������’s redesigned����program, they represented a gold mine.

Business managers from��, a managed care company specializing in long-term services, huddled in a ground floor hotel room, poring over health data and spreadsheets that identified residents by name and room number. At the managers’ direction, crews of enrollment nurses tracked down residents to pressure as many as possible to sign up with the company’s long-term care plan, according to current and former CenterLight employees who were there.

To CenterLight, which had struck an unusual deal with the state to run the hotel as a temporary adult home, the evacuees were a captive audience, and each signature was worth $45,600 a year in fixed monthly Medicaid fees. To an agency supplying aides there, the signatures also meant more money.

But for taxpayers, the sign-up frenzy at King’s Hotel points to hidden costs and potential abuses in an ambitious Medicaid overhaul in ���������� that has shifted $6 billion in public spending on long-term services for disabled and aged people to managed care companies like CenterLight. The state’s goal was savings, but the changes set off a scramble among managed care companies and service providers to enroll clients requiring minimal care, including residents of adult homes who could be brokered in bulk, an investigation by The ���������� Times found. Many frail people with greater needs were dropped, and providers jockeying for business bought, sold or steered cases according to the new system’s calculus: the more enrollees, and the less spent on services, the more money the companies can keep.

Adult home residents, like those caught in the hotel, had long been victimized under the old fee-for-service Medicaid system, in which providers were paid for services rendered. Now, under managed care, they find themselves prey to new versions of old tactics, including intimidation to accept services they do not need.

“They came like vultures — ‘Sign here, sign here!’ — with their doughnuts and cookies,” recalled Robert Rosenberg, 61, who has a spinal disorder and Crohn’s disease, and, at 4 feet 4 inches tall, had����to escape the flood at Belle Harbor Manor in Queens. “They coerced people. They told residents they would lose their Medicaid if they didn’t sign.”

Ronald White, 70, a former Marine now back at New Gloria’s Manor, recalls refusing a $10 payment for his signature at the hotel (“a hellhole”), only to be awakened at night by a woman who said she was his aide. “I don’t need an aide!” he said he had protested. “It sounded like a get-rich-quick scheme.”

They were among many displaced residents whose accounts of the enrollment campaign were corroborated by CenterLight employees who were part of it. State officials had received similar complaints about the company’s summer-long marketing push at Belle Harbor Manor before the storm, email exchanges show. Since then, other emails have reported enrollment violations involving other companies, including attempted bribes.

But state officials see no systemic problems with the shift to managed long-term care, which they call a popular success. They cite an 87 percent satisfaction rate in a mail survey of members. “Any suspected violations of the law or contracts with the state are investigated,” Bill Schwarz, a State Health Department spokesman, said.

No complaints, he said, were reported from the hotel by state officials, who permitted the enrollment push and paid CenterLight about $350,000 for running the hotel for three weeks and supplying services. The state and the companies said they were proud of their work there and denied any improprieties.

“The driving factor,” Mr. Schwarz said, “was to protect and serve the hundreds of vulnerable individuals impacted by this unprecedented natural disaster.”

His statement was echoed by Constance Tejeda, a spokeswoman for CenterLight, who called its staff’s work heroic. Colin Mahoney, a public affairs consultant for Edison Home Health Care, which supplied the aides, cited “unprecedented circumstances.”

But the heavy-handed tactics revealed at the hotel are part of a larger pattern that emerges from interviews with industry insiders and patient advocates alike, and from court records, legislative hearings and emails obtained by The Times that discuss mass transfers of patients for money.

Michael Irvin, who was at the hotel as a marketing manager for CenterLight, said he complained to his supervisors and soon left for a better job. But he wound up working for a different managed care company where he fielded one offer to sell him cases by the thousand, and others that promised enrollees in exchange for money. He reported those illicit proposals to state officials, to little effect.

“It is a gold rush,” Mr. Irvin said. “You’ve got the Wild West, where everybody can do everything to get a case, to the extent of bribing people to switch over cases.”

The turbulence has intensified as the industry prepares for the next phase. Later this year, under a federal waiver obtained by Gov.�� of ����������, 25 Medicaid long-term care companies will also gain access to billions of dollars in federal����payments. Companies can automatically enroll qualified members into combined plans that are supposed to yield greater government savings and more coordinated care. Whether those benefits are realized remains to be seen, but the change will mean even more revenue for the companies.

At the hotel, many residents had refused CenterLight’s repeated sales pitches before the storm because they did not even need its services; some were clients of a rival company, ElderServe, which had already been sanctioned by the state for aggressive marketing; others did not have Medicaid, or were wandering the halls, disoriented.

But the nurses who cornered them had enrollment goals to meet — and authority to evaluate eligibility.

The threshold for enrollment in such plans is no longer a score on a numerical assessment of impairment, as before, but an ill-defined “need for 120 days of long-term care services” — services ranging from a few minutes’ help from an aide and a few hours at a social center, to round-the-clock home care or nursing home placement.

The biggest loophole, experts agree, is that ����������’s new system has no independent assessment of whether enrollees actually need services. Mr. Irvin, now a veteran of several companies’ marketing efforts, was blunt: “Allowing the companies to perform their own assessments is like leaving a hungry dog to guard the meat shed.”

Patient Selection

No group suffered more from the old system than the mentally ill residents of profit-making adult homes. Under fee-for-service Medicaid, many ��to unnecessary treatment, even surgery.

Though disability money has long gone to the homes to supply meals and personal care, operators kept cutting services. They����of home health care, who typically billed Medicaid at inflated rates, and paid inflated rent for access to the residents. Some of the same providers also����outside adult homes by assigning low-paid aides to cases around the clock, at high profit, regardless of need.

Governor Cuomo’s redesign was supposed to change all that. The first step, in April 2011, was to reformulate and shrink reimbursement for home care. Later, Medicaid beneficiaries already receiving more than 120 days a year of such services would be required to join a managed care plan that paid companies a fixed premium.

The state projected savings at more than $200 million annually, and says it succeeded. But a state plan obtained under the Freedom of Information Law noted a downside: “It may provide agencies an incentive to ‘cherry pick’ patients by serving only those with lower acuity and less intense needs.”

That is just what happened.

Farrah Rubani, then senior vice president of Extended, a home health agency becoming a managed long-term care company, said she was told to get rid of clients receiving round-the-clock home care. “I said, ‘What do you want me to do, load them up and drop them off at the Verrazano?’��” Ms. Rubani said, adding: “They were bed-bound, they were desperate. We just chopped them up and threw them away.

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