Case, bill highlight need for state to act more efficiently

The state made the right call for disabled clients in its resolution of a court case concerning its evaluation methods, but it must pay heed to clients and taxpayers as well in this larger picture or draconian measures may cause more budgetary headaches.

In a case involving a severely disabled man, the state consented and as a result was released from being a defendant in a suit brought by the man’s family arguing his constitutional rights were being violated. Him being severely mentally retarded and prone to seizures, the state had cut back his in-home care hours from 24 to seven utilizing its recently-implemented resource allocation model (RAM). However, the state essentially admitted that the RAM had not correctly captured the full care implications of his conditions and will allocate him more hours.

The state has moved towards the RAM in the past couple of years because of spiraling home- and community-based care costs. A pair of court decisions mandated that the state provide approved federal waiver programs to use Medicaid money to provide this kind of care outside of institutions. However, it was done in a very uncoordinated way which poorly linked actual need to services received, wasting money. Further, federal regulation states that per client waiver costs over all recipients cannot exceed the average reimbursement paid to have that person in a nursing home, and use of the RAM is a tool to better align services to client that could remove unnecessary spending.

Thus, the concept of the RAM, used in many states, is not a bad idea. The problem has come in its execution, which the suit as it continues alleges, as well as that the state has not applied it to all venues – to date, mostly in home situations only. Doing so fails to identify where mismatches of services-to-need occur in institutions. There may be a number of people in nursing homes, for example, who could receive as good or better services at home or in a community-living setting at a cost less than the state’s reimbursement to nursing homes.

But we won’t know this until the RAM is applied to them and the state has been dragging its feet in applying it to them. As a result, state Rep. Walker Hines has introduced HB 959 which basically would place a moratorium on the use of the RAM until this issue is sorted out. While this is somewhat of a baby-with-bathwater approach, it would be unfortunate if these are the lengths that must be gone to in order to prod the state (which is facing tremendous pressure from overbuilt institutions almost entirely dependent on government revenues not to reallocate money away from them) to take the proper course.

Resolution of this case regarding the state should demonstrate to it that model use limited to the in-home segment cannot improve enough the efficiency in spending of health dollars. It must apply the RAM to all situations in order to realize maximal savings and to optimize resources. Further, it must tinker with its use to better fit exceptional situations; for example, while typical nursing homes provide a continuum of care for most disabled, for some people nursing home care would be far more expensive (such as people using mechanical ventilation) so, even if their home care costs exceeded the typical reimbursement, their actual costs in a nursing would be far higher and thus should justify receiving care at home despite it being higher than the typical reimbursement rate.

The state in effect has admitted the latter as a result of its settlement and presumably will work towards reassessment in exceptional cases. As for the former, it must commit itself to serve both clients and taxpayers by comprehensively applying the RAM as a moral imperative, but if it doesn’t a legal imperative may force it to do so.