LA must pay closer attention to delivering disabled help

It may not be coincidental, but surely Louisiana is looking much more carefully into how it delivers Medicaid services to the developmentally disabled as a result of budget crises and a lawsuit concerning delivery of such services.

The same day the state announced it was going to alter this delivery, particularly in the mental health area, a family sued the state arguing it was not complying with federal law regarding provision of services to a developmentally-disabled man. Courtesy of the federal Olmstead court decision in 1999 and the state’s Barthelemy court decision in Louisiana in 2001, state governments must, when possible, deliver such services in the least-institutionalized manner.

The family argues that cuts in service, prompted by large budget deficits with a state fiscal structure that forces the largest absolute reductions to be made in the area of health care, will force unnecessarily the man into an institution instead of receiving home care, by lopping off hours allocated per day from 24 to seven or fewer. The state notes that there is no absolute right to unlimited care provided by the state.

This conflict has resulted from the state’s imposition of a Resource Allocation Model that attempts to align genuine needs of those who qualify for Medicaid (because they are poor, or had to spend away almost all assets to become poor enough to qualify, or who went through lengthy temporal and expensive legal maneuvers to rid themselves of enough assets to qualify for the assistance), in order to make maximal efficient use of resources. As the state points out, when Medicaid pays for this it requires that the least costly method be used, and for some in Louisiana the cost of their home- or community-based care exceeds that of what would be paid for in an institution.

Both parties in these kinds of disputes are not without fault. There are some clients who had been receiving, chiefly through the New Opportunities Waiver program but also through others, more care than they really needed and/or more expensively than if institutionalized. Yet the state also has lumped all recipients into categories unreflective of reality; for example, people requiring use of mechanical ventilation to breathe not in this program are capped at 42 hours a week (for another particular waiver program) outside an institution when they probably could receive at least 40 more hours a week more and still have costs below that of being in a nursing home since their conditions are so incredibly expensive to treat in an institutionalized setting.

If nothing else, this suit may force the state to revisit these assumptions and improve upon the aligning of actual need to cost, Additionally, it will force it to begin to apply the model to institutional settings for which to date, despite promises last year, it has been very hesitant – maybe a sign of this being the state’s announcement that it will start forthwith in the upcoming budget this transition from institution to home and community, particularly in the area of mental health services.

Both paths must be followed – making sure that dollars are efficiently used and getting them to a proper consideration of real need – or the state will find scarce dollars inefficiently used and demands, through courts and otherwise, that they be used correctly. Avoiding both of these outcomes will stretch dollars in tight times and serve the unfortunate among us.