From: Kenneth S Fink/Medicaid

To: Patricia Johnson/Medicaid@Medicaid, Patricia Bazin/Medicaid@Medicaid,

Lydia Hemmings/Medicaid@Medicaid, Ann Kinningham/Medicaid@Medicaid,
Noreen Moon-Ng/Medicaid@Medicaid

Date: Wednesday, April 01, 2009 08:26PM

Subject: Fw: HELP!

fyi. We've already had some high level meetings on DOH decisions that cost-shift to
MQD. This may come to a head again while I'm away, resulting in another high level
meeting. Not sure who Lillian would want at such a meeting, but wanted to make sure you
were all aware.
Kenny
-----Forwarded by Kenneth S Fink/Medicaid on 04/01/2009 08:24PM -----

To: linda.smith@hawaii.gov, Barry.Fukunaga@hawaii.gov,

Georgina.K.Kawamura@hawaii.gov, Chiyome.L.Fukino@hawaii.gov,
Susan.J.Jackson@hawaii.gov
From: Lillian.B.Koller@hawaii.gov
Date: 04/01/2009 03:38PM
cc: kfink@medicaid.dhs.state.hi.us, ATsark@dhs.state.hi.us
Subject: HELP!

Aloha Linda, Barry, Georgina, Doc and Susan:

I need your help! I am getting overwhelmed with alerts from my staff that DOH is taking actions or proposing to
take actions ASAP that will cause a huge cost-shift from DOH to DHS without DHS getting any extra resources to
handle the influx.

You all already know from our meeting on March 12th that AMHD's March 9th letter to all AMHD providers
(stating that AMHD had run out of money for SFY 2009 and had to shut down services and stop payments to
providers) greatly aggravated an already growing wave of AMHD refugees streaming into my Medicaid programs.

The latest from AMHD is a proposal by Dr. Bill Sheehan dated 02/25/09 that Michelle Hill forwarded last week to
Dr. Kenny Fink asking for his expedited approval. Dr. Sheehan explains that "The number of individuals who were
deemed eligible for [AMHD] services rose from approximately 4,200 in 2001 to approximately 15,000 in 2009" so
he proposes to "tighten the Eligibility Criteria for state funded mental health services so as to enroll only the
individuals who are most in need, most impaired, and have no other access to services." That's fine, but I have no
idea how many more AMHD clients this change will cause to seek Medicaid services on top of the thousands who
are already streaming into Medicaid due to AMHD's March 9th letter. Further, neither the design nor the funding of
my QUEST and QExA Medicaid programs can accommodate this transition at this time. We have a plan to make
this transition in October when I will be entering new contracts with my QUEST and QExA health plans, but that's
contingent on my obtaining both CMS and SPO approval to expand my Medicaid programs and contracts in this
way. And, I can't see how I can so substantially expand my QUEST and QExA contracts without increasing my
capitated payments to the health plans which means I'll need more money which nobody has to give me.

Additionally, last week I got an email from Patti Bazin saying: "I am hearing in the community that the nurses who
work in both the public health nursing and children with special health needs programs would like to transition all
of the work they do with disabled or aged Medicaid clients to the QExA health plans." Again, this transfer was not
anticipated in the design or funding of the QUEST or QExA Medicaid programs.

Finally, I just got an email today from Amy Tsark telling me that Dr. Sheehan said AMHD is "in the process of
changing their procedures to refer more self neglect cases to APS [my Adult Protective Services program] because
of the new law. He estimates there are thousands." The new law that Dr. Sheehan is referring to was last session's
expansion of APS to serve not only "dependent adults" as the law says now but also "vulnerable adults" who are
anticipated in the design or funding of the QUEST or QExA Medicaid programs.

Finally, I just got an email today from Amy Tsark telling me that Dr. Sheehan said AMHD is "in the process of
changing their procedures to refer more self neglect cases to APS [my Adult Protective Services program] because
of the new law. He estimates there are thousands." The new law that Dr. Sheehan is referring to was last session's
expansion of APS to serve not only "dependent adults" as the law says now but also "vulnerable adults" who are
subject to abuse, neglect, imminent harm or financial exploitation. DHS agreed to this expansion of the law on a
cost-neutral basis and completed a massive internal reorganization to free up the staff to absorb an expected
expansion of APS cases. But we weren't expecting this! We weren't expecting AMHD to deliberately change its
procedures to exploit a slight change in the law from "dependent" to "vulnerable" as yet another opportunity to off-
load more AMHD clients on DHS and I certainly can't afford Dr. Sheehan's "thousands" more in APS cases without
more resources. Besides, when did mental illness become self neglect anyway?

I'm having a very, very hard time with all of this, and so is my staff. May we please meet again, all of us, and put
all of our cards on the table this time? I'd like to know, for instance, if DOH is thinking of any other opportunities
than the ones described above to reduce its expenditures at my Department's expense. If I sound angry, I apologize,
but I am annoyed. We shouldn't be doing this on a piecemeal basis and I shouldn't be finding out about these things
through the grapevine.

Also, we need to coordinate all of this. For example, the capitated payments that I make to the QUEST and QExA
health plans are based on utilization data that expressly excluded the services that AMHD has been reducing and
intends to reduce further. AMHD can certainly do these reductions, but certain things must be done, in a certain
order, to make these transitions happen, including but not limited to DHS getting CMS approval to expand QUEST
and QExA, DHS getting SPO approval to make substantial changes to our existing contracts in QUEST and QExA
and, worst of all, DHS getting more State funds to match Federal funds to cover this cost-shift from DOH to DHS.
And the APS thing, well, I'm at a loss for words!

We need to figure all this out and how to cost contain it because nobody's got the money to pay for this -- not DOH
and not DHS either.

Thanks,

Lillian

Lillian B. Koller, Director

Department of Human Services
Phone: (808) 586-4997
Fax: (808) 586-4890
Email: lillian.b.koller@hawaii.gov