Comments by John L. Painter

JOHN PAINTER's picture

I'm not certain where

I'm not certain where Superintendent Webster got that figure from, that's likely a quarter hour cost. Most private practice clinicians I know charge around $60/hr. However he and the Commissioner are correct that Maine's DHHS completely controls the cost of MaineCare rates, similar to how Congress controls Medicare rates - it has nothing to do with the free market.

Maine also discourages competition in healthcare emerging professions, since we do not let some of the newer professions which have developed over the past quarter century to practice in the state as they do in other states, e.g. in New Jersey, Pennsylvania, etc I'm recognized as a fully qualified mental health professional (QMHP), in Maine my (national) credential CPRP is only recognized as a para profession. I would argue, allowing some of the newer credentialed professions with solid evidence base to practice in Maine, likely would help drive down costs through market competition.

Regarding the drunk driving, because addiction is considered a form of mental illness, services meant to address the addition are considered a covered health service. I'm not certain that helps your feeling on the matter, but that's the reason it works the way it does. Personally I'd rather see the person in effective treatment than plowing into my wife or kid in a head on.

JOHN PAINTER's picture

I agree with the

I agree with the Commissioners data, it's fairly well known at least amongst healthcare provider community, that a very small percentage of MaineCare beneficiaries disproportionately drive the cost. However she did not go quite far enough in describing that the 5% who are driving over half the cost have complex co-occurring conditions e.g. mental illness, COPD, type 1 diabetes, substance abuse, etc. Many of these individuals, if earlier in their lives had easy access to services, would have been much easier to reduce or prevent those conditions. Though to some, that may sound too much like "welfare" to act upon.

I also agree that Maine is addicted to Federal Medicaid funds and does not utilize the funds well, primarily targeting the money towards expensive hospital based care to the virtual exclusion of evidenced based primary and preventative wellness services. Maine has on payroll very capable statisticians and actuaries under the governments direction, it's to entirely clear why we have tens of thousands of tax payer dollars to hire consultants to do the same work.

I also think the Commissioner is correct that a cookie cutter approach (single model trap) is expensive and unhelpful in our states health and human service system. Though, for example, Maine still requires people who can live in the community in their own homes which they pay for, but need rehabilitative services such as PNMI mental health rehabilitation to give up their homes and move into a state controlled residence, which they must move out of once they are better and try to find a new home. In this case the Legislature and Administration could immediately pass LD 87 and move to eliminate such costly and disruptive practices.

Unfortunately to date, we have largely the same system we had a decade ago, or for that matter somewhat digressed to several decades ago in the 1970's when Maine had a Department of Mental Health and Corrections. Though it seems ironically fitting as the Commission and Governor plan to move people from our states flagship mental health hospital into the prison system and effectively give up on patients healthcare providers in the hospital have a hard time understanding.

I hope that the Commissioner and LePage Administration now that they are looking at the data and articulating some of symptomatic problems of our Health and Human Services System, have the fire in their bellies necessary to look at what is really going on in actual peoples, lives and develop public policy to rebuild a system that focuses on the hope and wellness of our people, and not the demagoguery which has crept in to Maine.

JOHN PAINTER's picture

Beginning in 2014

Beginning in 2014 Disproportionate Share Hospitals, will begin to experience payment reductions from the federal government.

Disproportionate Share Hospitals like Riverview Psychiatric Hospital in Augusta, are facilities states designate as receiving high volumes of people without insurance, Maine has identified its psychiatric hospitals as such, and the federal government though CMS provides Disproportionate Share funds to the state which then reimburses those hospitals for care which would otherwise go unfunded.

The reason for the payment reductions is because as more people are covered by private insurance (or Medicaid) as called for under the Patient Protection and Affordable Care Act a.k.a. Obamacare, there is less money needed for federal Disproportionate Share Hospitals.

For Maine, like the other states which chose not to expand their Medicaid program, local tax payers will begin to pick up the cost of care at their hospitals which receive Disproportionate Share funds.

By choosing to not expand MaineCare, Maine's government knowingly chose to shift the cost of care at hospitals receiving Disproportionate Care Hospital funds onto the backs of local tax payers. The overall cost of Maine's Medicaid program while significant, is more of a red herring. Understanding how and why 20% of the MaineCare beneficiaries drive 80% of the cost, and who profits is more important to understand.

JOHN PAINTER's picture

Carol, As a fellow healthcare

Carol,

As a fellow healthcare professional, in behavioral health, I agree with your assertion that these problems did not arise overnight.

"I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” ~ Abraham Maslow

I also do not believe the paper is at all accurate in reporting this happened “After a series of violent outbursts by patients, the Center for Medicaid and Medicare Services conducted an unannounced inspection of the facility in March.”

The precipitating events were actually caused by the hospital, not the patients. Riverview and its predecessor, the Augusta Mental Health Institute have a long history of being structured as a punitive model. Our nearly quarter century old unresolved class action lawsuit, Bates v. Glover or the AMHI Consent Decree exemplifies that. Riverview, like much of Maine’s mental health system requires a cultural overhaul. I don’t see a problem of lack of money in the system, I do routinely see precious tax payer dollars allocated for high cost low outcome priorities.

I'll give an example. In 1847 Maine’s Legislature began dealing with the first complaints of violence in our state psychiatric hospital. At that time a former patient of the Maine Insane Hospital later renamed the Augusta Mental Health Institute brought his case of abuses he suffered at the hospital to Maine’s Legislature. While he was listened to, was able to present witnesses, about being physically abused, over medicated and under rehabilitated, denied access to family/friends and his community, the government was ultimately unable to resolve the factors contributing to his harm.

What has changed in the past 166 years?

“The end cannot justify the means, for the simple and obvious reason that the means employed determine the nature of the ends produced.” ~ Aldus Huxley

Maine has a long history of viewing violence, when committed by a person with a mental illness, as a failure of that individual. However when acts of violence are perpetrated upon an individual with a mental illness in a hospital setting, especially a government operated hospital it is regarded as a failure of the “system” from which the individual can experience little recourse to correct, or hope for recovery from their illness.

While I give Superintendent McEwen and Commissioner Mayhew and even Governor LePage some credit for some things they have implemented in attempting to improve Maine’s mental health system (some emphasis on evidence based practices), they have concentrated on ends, and in the case of Riverview Hospital virtually blind to the means towards the ends.

JOHN PAINTER's picture

It's not about the money, or is it?

While Commissioner Mayhew is certainly correct that CMS is concerned that staff are co-mingled between the certified, and decertified unit the hospital created, she also misses the other concerns CMS is raising in their response.

One of the core issues CMS undoubtably has with Maine's plan to address people being hurt in a hospital that was receiving federal Disproportionate Share Hospital (DSH) funds, was to decertify the unit where staff and patients were harmed so that CMS wouldn't have oversight of the conditions which are causing people to be harmed.

Another factor CMS is likely interested in is just how Maine uses/misuses DSH funds since Maine is just one of several states which use DSH funds exclusively for psychiatric hospitals which tend to have a high volume of Medicaid (MainCare) patients. This may be a matter of interest CMS has since it has already identified some systemic problems in Maine and might be questioning whether Maine is really target all or even most of its DSH funds (and federal match) on those hospitals as it should, or using the money for other purposes. A $20 million litmus test?

Another issue, one Maine (and other states not expanding Medicaid) should be paying attention to is the reduction in DSH funds as part of the Affordable Care Act (ACA). The ACA has a built in gradual but significant reduction in DSH payments, this will happen because as more people are covered by their own insurance less DSH funds will be necessary to cover unpaid expenses/charity care.

While I agree with Senator Craven's concerns that you get what you pay for, resolution to Riverview Hospitals problems are more closely tied to essential culture change and in treatment modalities used at Riverview not spending more money.

JOHN PAINTER's picture

Robert, There's a fair amount

Robert,

There's a fair amount off data on the concept of living wages in economics, sociology, etc probably not what this forum wants to wade through. On a more digestible level, MIT has done a fair amount of work on this topic to put the question into an easier (if you have computer access) to understand format http://livingwage.mit.edu/states/23/locations

JOHN PAINTER's picture

While Maine is not the first

While Maine is not the first or only state to experience the effects of an "hourglass" economy, http://www.bloomberg.com/apps/news?pid=newsarchive&sid=a5FkS3h6EfeM we are feeling and seeing it more starkly. We're an older population, have more health issues (and tend to address health when it's become a problem, not taking a wellness/prevention approach), we have a somewhat stable but overall lackluster economy.

To an extent the great heated discussions I'm reading through are probably just at the front end of a much larger public discussion, possibly, what are we as a society?

JOHN PAINTER's picture

I agree

In terms of why the health of our people is of highest importance to our security and prosperity... As Thomas Reid said in his "Essays on the Intellectual Powers of Man" in 1786 "In every chain of reasoning, the evidence of the last conclusion can be no greater than that of the weakest link of the chain, whatever may be the strengh of the rest."

JOHN PAINTER's picture

Jerry, I understand but don't

Jerry,
I understand but don't agree with your sentiment towards Republicans, but I do agree with your point on "affordable, guaranteed, regulated fair health care" though I think it could be helpful to describe why in more detail since I understand many people have questions about the Affordable Care Act.

A lot of people think the Patient Protection and Affordable Care Act or the Affordable Care Act (ACA), pejoratively called Obamacare is either another entitlement program or is free because their concept of universal healthcare is “free healthcare” or that it is “government run”. These are both assumptions, and both incorrect, I suspect you did not mean to imply "fair health care" was free.

Universal healthcare is a term politicians use because it sounds better than “a compulsory insurance mandate.” Healthcare under the ACA is not free. Under the ACA everyone is required to have (buy) insurance, so everyone is supposed to have “affordable healthcare coverage.” The more people buy in, the cheaper it gets for everyone. There are still entitlement programs like Medicare for the elderly and Medicaid for the poor and disabled, but they are quite different.

The Affordable Care Act is a law that requires compulsory or mandatory insurance – not healthcare though as you suggest. We are all required under the ACA to buy insurance that is subsidized by our employers and/or possibly the government. Employers are only required to pay up to 60% of the cost of insurance premiums. Thus, we’re still going to need to pay for the rest of the insurance cost.

Under the Affordable Care Act, private insurance that meets at least minimum coverage and cost guidelines is subsidized for those qualified! This means that the government is helping individuals and families cover substantial portions of their income. If you earn less than $46,000 dollars a year as a family household (4x the American Poverty Line), then you’d likely qualify for a subsidy or tax credit. The median household income for Maine is $47,898 according to the 2010 census, so this means that most Mainers who don't already have insurance or their insurance is more than 9.5% of their income, are going to be able to have at least some help paying their insurance. These are tax dollars coming back to the people, albeit targeted by the government (this is the part which smarts for some conservatives), similar in the same way home mortgage interest deduction is – though for me is welcome.

In my opinion, the ACA comes closer to inching us along towards Friedmans notion of a negative income tax (NIT) approach than Democrats admit or Republicans take credit for.

JOHN PAINTER's picture

Jeff, not exactly what you

Jeff, not exactly what you were looking for but is a place to start https://gateway.maine.gov/dhhs-apps/dashboard/Default.aspx