Advocates, Health Plans, State Eyeing ADHC Hearing

The lawsuit name has changed a couple of times. It first was filed in August 2009 under the name of plaintiff Lillie Brantley. Then it was Harry Cota. Now it’s Esther Darling.

The fact that Brantley and Cota died during the lawsuit’s two-year life underscores the fragility of the adult day health care population.

The 2009 lawsuit originally challenged ADHC cutbacks. The suit’s scope grew earlier this year when the state decided to eliminate ADHC as a Medi-Cal benefit altogether. Medi-Cal is California’s Medicaid program. The lawsuit doesn’t seek to reverse that elimination; it claims the state’s transition plan for the 35,000 ADHC beneficiaries is inadequate.

Both parties are trying to work out a settlement. If that effort fails, a federal court hearing is scheduled for Nov. 8.

Settlement talks apparently still are moving forward, but the points of view on either side seem far apart.

“We will make sure we will meet the medical needs of everyone in this population,” said Norman Williams, deputy director of the Office of Public Affairs at the Department of Health Care Services. “That’s what the state is committed to do, and that’s what we’re working to do.”

It’s not enough, according to Elissa Gershon, attorney for Disability Rights California, which is the group bringing the lawsuit.

“The bottom line is, the state has taken away a valuable and critical service, and has not expanded the array of services to replace it,” Gershon said. “This whole thing has been done hastily. We’ve seen some bad consequences so far, but nothing like what’s going to happen when ADHC is gone and people are left with nothing.”

Anne Hinton, executive director of the Department of Aging and Adult Services in San Francisco, has no stake in the court battle. She works in government and is familiar with the need to cut services to balance the budget.

This move, Hinton believes, will not be a big money saver and actually could cost the state money in the long run.

“These are enormously compromised people,” Hinton said. “They have multiple diagnoses, multiple medications, many with dementia. They’re older adults who are really sick.”

Hinton made it clear that she is working hard to help implement the state’s transition plan. But she also knows how at-risk this particular population is, and said this move puts these people in a perilous position.

“I think this shows a profound disregard for older adults,” Hinton said. “To me, it’s the most appalling thing. It’s just appalling. I don’t know who gave the governor advice. I don’t know why they selected this particular group, but however they did it, this is wrong. This can only produce a bad outcome.”

Timeline of Events

The state is working on a relatively short timeline. It needs to line up other care choices for this population by Dec. 1, when Medi-Cal coverage of ADHC services is set to expire.

The state’s first step was to offer managed care choices to ADHC beneficiaries, with the intent to shift beneficiaries into managed care programs. The next step — assessing the health needs of those ADHC beneficiaries — is more involved.

The state set a 45-day window, from Oct. 1 to Nov. 15, to contact and assess all of those 35,000 ADHC beneficiaries.

As of Oct. 21, about halfway into the effort, about 3,785 assessments had been completed, Williams said, but that estimate is rough and includes a wasted week where some data weren’t available. Also, Williams said, the pace of those assessments recently picked up and that trend isn’t reflected in the total number.

If the assessments can be completed on time by Nov. 15, the next challenge is to make some sort of plan for those people before the Dec. 1 elimination date.

Health Plans’ Concerns

There are two big issues to watch with the ADHC transition, according to Bradley Gilbert, CEO of the Inland Empire Health Plan.

The first is that most ADHC beneficiaries — many of whom are eligible for both Medi-Cal and Medicare — historically have been in fee-for-service plans that worked well with the ADHC benefit. However, when the benefit disappears, the only way for plans to offer similar services is through managed care, he said.

“If they’re in fee-for-service, how much are we going to be able to do?” Gilbert said. “The Medi-Cal [payment] is really not a lot. There’s not a lot of care delivery there. So I’m not quite sure how much a role we will play with care coordination with fee-for-service patients.”

Because the Inland Empire Health Plan has a special needs component, it can take on a lot of the care coordination for ADHC beneficiaries, he said.

The second dynamic to understand, according to Gilbert, is that the ADHC world has changed. He said health insurers like the Inland Empire plan will not be able to provide coverage for the services ADHC beneficiaries had been receiving, such as socialization, protective services and a constant level of monitoring.

“These people have been in this social situation, where nurses and health care workers are seeing them almost every day, intervening, checking on their health, and that’s going away,” Gilbert said.

“We’re not going to be able to do anything like that. There’s no way I can provide a three-day-a-week benefit, I just can’t,” he said.

Gilbert said the state’s proposed supplemental reimbursement of $60 per person per month is an important piece of the transition but will not provide the same level of services.

“Sixty bucks, which may or may not be the final figure, but whatever it is, that won’t cover a $1,200-a-month benefit,” Gilbert said.

The good news, according to Gilbert, is that what managed care can supply is a high level of care coordination and other services.

Plans Evolve

According to Abbie Totten, policy expert at the California Association of Health Plans, it’s a little early to pass judgment on the transition, given how little time DHCS has had to deal with elimination of the ADHC benefit. That means people need to cut the department a little slack, she said, and know that not all questions will be resolved right away.

“The plans want to work with the state to help serve this population, as long as we work together on this,” Totten said. “The plans are trying really hard to work cooperatively to find an equitable solution.”

A few of the questions still open, she said, are: “exactly what services we’re going to need, what the take-up rate will be, what’s the profile of the population, how long a person remains in your plan. Those things all need to be worked out.”

John Grgurina, CEO of San Francisco Health Plan, said the health assessments will help frame the upcoming task.

“Once we do the health risk assessments, once we see what they need in terms of care coordination, once we figure out the payment for these folks,” Grgurina said, “then we can take a really close look at it. Right now, it’s too early to tell how [successful] we are, how we’re doing with it.”

A Busy Month

The dominoes all start to move based on the settlement effort — or on the judge’s ruling. If the judge issues a preliminary injunction to temporarily extend ADHC services until the state can develop another transition plan, the state Legislature could get back in the mix when it reconvenes in January.

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