Counties, Texas Association of Counties Paying Attention

It is clear that the Texas Department of Transportation has some legitimate concerns regarding any major reform of the MTP program and the impact the reforms might have on their public transit systems. And why not? The state has invested mightily in the renown rural and small urban systems over the last 40 years or so. But they are not alone in their concerns.  Local officials are paying attention as well. Counties, cities and councils of government (COGs) invest in their local public transit systems as well.

We are not certain the health and human services policy folks have adequately gauged the impact that local officials might have on the debate. For example, state Rep. Drew Darby, R- San Angelo and Rep. Harvey Hilderbran, R-Kerrville are affiliated with their public transit agencies through their COGs.

County judges and commissioners courts have begun asking the Texas Association of Counties (TAC) for legislative help regarding NEMT.  Here are some examples of letters by county judges.

We are not aware at this moment that counties have been invited to the table on the medical transportation issue. If they haven’t, it might be prudent to do so. Soon.

Every Now and Then Leadership Happens

Phil Wilson, Executive Director TxDOT

Every now and then but not very often true leadership happens. It’s sad but it’s the way of the modern world - leadership stifled by today’s suffocating political climate. But when leadership does emerge it commands attention - more indelible due to its rarity. Phil Wilson, Executive Director of TxDOT, is that rare bird and Texans should be grateful for his skilled work, superior intelligence and his leadership acumen.

Phil’s efforts at TxDOT are truly transformative. He is succeeding in changing the culture of an agency that was ossified to the point of rigor. He is doing something that most experts thought could never be done. He has brought to TxDOT  an energetic, creative and entrepreneurial spirit with an ever-vigilant eye on improving the agency’s business processes.  That he is navigating this culture transformation in an agency the size of TxDOT is unique in the annals of Texas government.

When meeting with Phil Wilson one must be prepared for him to lead with a solution to your problem. He is assiduously prepared and will often surprise the most seasoned Capitol participant by his ability to zero in on the core of the issue presented him.

Let us put it like this: you will never have a vacuous meeting with Phil Wilson. If you are looking for polite platitudes, vacant gazes, clock watching countenances and hollow promises then Phil Wilson is not your guy. If you want something done and done the right way – by all means – call Phil Wilson.

Many observers were skeptical when the Texas Transportation Commission first hired Phil.  He was a political operative who spent some time as a staffer for Sen. Phil Gramm. What would he realistically be able to accomplish? Apparently a great deal – an up side with no discernible ceiling. Any skepticism about Phil has been dashed on any rock you might find whether your interests lie in multi-million dollar highway construction or bicycle education. He treats all issues big and small with equal vigor.

We are not alone in our opinions about Phil. Our opinions are shared by hundreds of Texans all over the state. We chose to make our opinions public.

We are quick to criticize our leaders. We neglect to express our gratitude (gratitude is in such short supply we might want to consider removing the word from the dictionary.)

Well, thanks Mr. Wilson for a job well done. Keep up the great work!

 

If the Private Sector Isn’t Getting it Done Turn Toward …

 the Private Sector?

In times of financial woes it is easy for policymakers looking for government savings to be seduced by the siren calls of privatization. The private sector can do it better, more efficiently, and cheaper than government. Right? But what happens when the solution is replacing the private sector with the private sector?

In Brooklyn, New York, broker Logisiticare replaced about 200 private fleets. Two hundred locally owned fleets. Things have not gone all that well. Logisticare says, “Hey, forget about it.”

“It is a mess,” said Gary Farberov, head of the recently formed Ambulette Para-Transit Coalition. “They are robbing us of patients, they are not paying us on time, and the call center isn’t even operating,” Farberov said. Here’s the link to the article in the NewYork Post:

In Texas, Logisticare took over an area in the Dallas area that had been managed by Irving Holdings (Yellow Cab). The complaints in that area are excessive and well documented. Meanwhile, broker MTM, which was awarded the Houston – Beaumont area under the pilot program, has been systematically punishing Yellow Cab of Houston for the egregious act of complaining to HHSC that Yellow Cab had not be been paid for 3 months worth of  legitimate trips.

In the spirit of capitalism and the American way, maybe a system can be devised where the public and private sector compete head to head  allowing competition and the marketplace to determine the NEMT contractor. This system would rely on competition to  drive down costs.

Oh yeah, we forgot --- that is the system we have NOW in Texas.

Private companies such as LeFleur, AMR and Irving Holdings are the Medicaid transportation providers in several regions. Public transit agencies such as the Brazos Transit District (The District), Capital Area Rural Transit System (CARTS) and Hill Country Transit manage the Medicaid trips in the rest of the state. ALL the aforementioned organizations were awarded their contracts on a competitive basis.

The implementation of a statewide broker in Texas would in effect create a monopoly. It doesn’t take John Kenneth Galbraith to figure out what will happen to quality and costs if that is permitted to happen. And it doesn’t take LBJ to figure out what to do with this public policy Trojan horse.

Part One: What the Heck is a Full-Risk Broker?

The full-risk broker concept slithered from the primordial ooze in 2005 as part of President George W. Bush’s Deficit Reduction Act of 2005 (DRA). DRA was primarily aimed at reducing the growth of entitlement programs such as Medicaid, Medicare, and Temporary Assistance for Needy Families (TANF).

The Senate's version passed after a tie-breaking vote was cast by Vice President Dick Cheney. The bill passed the chamber with no Democrats and five Republicans voting against the bill. The House version passed by a vote of 217-215, with all Democrats, fourteen Republicans, and one Independent voting against. And they say votes don’t count.

Dick Cheney’s vote unleashed full-risk brokers into the nonemergency medical transportation gene pool. But what are full-risk brokers exactly?

Full-risk brokers are private transportation companies that agree to do the following:

• Handle the call center duties (currently HHSC handles the call centers);

• Operate under a captitated system (so whether they coordinate 20 or 20,000 rides they are reimbursed by Medicaid the same;

• Contract with providers (public or private) for the actual trips (by law they cannot own and operate their own vehicles.)

So what’s so wrong with that?

First, the federal law was fundamentally and irrevocably flawed. The enabling legislative language was clearly written by health policy wonks. The prohibition on brokers from owning and operating vehicles was taken out of what is known as the Stark Law. Named after Con. Pete Stark, (D-California), that 80s law prohibited physicians from referring Medicare and Medicaid patients to their own clinics or hospitals. The broker law is based on Stark.

Problem? At the risk of sounding absurdly self-evident: nonemergency medical transportation is not a healthcare program. It is a transportation program. It is the fundament that policymakers have missed since since day one (and continue to miss today).

The transportation provider does not check Medicaid eligibility. It has no HIPAA ramifications. No treatment. No diagnosis. The drivers are not EMTs. They are not allied healthcare professionals of any kind.

The transportation provider is told by HHSC who to pick up and where to go. They drive the patient to the doctor, hospital, clinic or pharmacy. And then they take the Medicaid patient back home. It’s not rocket science. Heck, it’s not even science.

Having health policy experts devise a transportation program is like asking a physician to run a bus company. The full-risk broker model was flawed from the get-go. Like all things built on a weak foundation it dramatically misses the mark. The problems mount, however, as the model destroys the systems it touches. More on that later….