Maine could have avoided the rampant problems it has had with its non-emergency medical transportation system for Medicaid recipients by looking to Vermont, critics say.
But Maine officials say they have no plans to switch to a system similar to Vermont’s, even though that’s possisble if service problems persist.
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Vermont, like Maine, recently revised its Medicaid transportation system to satisfy federal requirements. But unlike Maine, Vermont maintained a system of local nonprofits to provide rides to low-income residents who have no other transportation. Vermont officials say the changes have generated hardly any complaints.
Maine hired contractors to coordinate rides, but not provide them, in a regional system that started Aug. 1. The result has been thousands of complaints about disjointed service and patients missing rides to medical appointments.
“We all look at the problems in Maine and say, ‘We really did the right thing,’ ” said Jim Moulton, chairman of the Vermont Public Transit Association.
Moulton helped state officials craft Vermont’s system, which started a year before Maine’s. He said Vermont considered a system more like what Maine ended up with, but ultimately decided to keep its local nonprofits operating the service.
Some Maine lawmakers say the state should switch to a Vermont-style system to extract itself from the mess that began Aug. 1, when two out-of-state companies started arranging rides for low-income patients across Maine.
“Vermont is exactly the model we should be using,” said Rep. Richard Farnsworth, D-Portland, House chair of the Legislature’s Health and Human Services Committee. “I’m not sure why (the Department of Health and Human Services) is being so stubborn about it. The only thing I can think of is, they made a decision and they can’t admit that they were wrong.”
Rep. Peggy Rotundo, D-Lewiston, said she has heard that Vermont’s system works well, and Maine should be looking at what that state is doing.
But Maine officials reiterated Friday that they are committed to the system they devised to comply with federal rules for accountability and transparency.
“We believe in the model,” said Stephanie Nadeau, director of MaineCare services, the state’s version of Medicaid.
Nadeau said about 20 states have systems similar to Maine’s and many work without major problems.
“We are seeing movement in the right direction,” she said, but Maine is in contact with Vermont officials, whose system could inspire some adjustments without a move to scrap the regional system.
“We are looking at any and all opportunities to improve on the delivery system that we have today,” Nadeau said.
One possibility is canceling the contracts with the companies that Maine hired to arrange the rides.
The contracts can be canceled for any reason, and the company that now arranges rides in most of Maine, Connecticut-based Coordinated Transportation Solutions, is on the equivalent of probation for subpar performance. The state has given the company until Dec. 1 to fix service problems, including missed rides and long wait times for people who call to arrange transportation.
But Nadeau said the state intends to keep its system, even if it cancels contracts.
The way states deliver such services is crucial to public health and to controlling medical costs, said Paul Hughes-Cromwick, senior health economist at the Michigan-based Altarum Institute, who studies non-emergency medical transportation.
“The evidence is unequivocal. You get a good value for what you’re spending,” he said. “When these folks have access to their appointments, what you’re really doing is offsetting a huge expense down the road. When you take it away, all hell can break loose.”
He said the people who are served by the transportation system can’t access health care if they can’t get to it.
CHANGES TARGETED ABUSES
The reason why many states overhauled or modified their Medicaid rides systems lies with the federal government, which is prodding states to operate systems that prevent fraud and abuse, such as people getting rides that aren’t related to medical issues.
States have wide latitude to devise their own systems to comply with federal rules. Maine’s overhaul and Vermont’s minor changes both won approval from the federal government.
Before the changes, Vermont’s and Maine’s transportation systems were similar in some ways, both relying heavily on local nonprofit agencies to coordinate and provide rides to a mostly rural population.
Both states changed their funding models so that contractors are paid flat fees to deliver service, which in the federal government’s view cuts down on the potential for fraud and abuse. If an agency has no financial incentive to provide more rides, then it won’t be tempted to give prohibited rides, such as rides to the grocery store or the beach.
Vermont, while changing its funding model, kept its local transit agencies to coordinate and provide the rides.
Maine split the two functions, hiring contractors to coordinate the rides. The local transit agencies lost that work but still provide the rides. Because of that change, those agencies had to lay off employees who coordinated and dispatched rides.
Nadeau noted that the local transit agencies were permitted to bid on the state contracts but most did not.
But agency officials have told the Portland Press Herald that a rule adopted by the state – again in an effort to satisfy the federal government – prevented any company that won a contract from providing more than 25 percent of the rides it dispatched.
That rule created a disincentive for transit firms to seek the state contracts, agency officials said, because they would have been forced to curtail their driving operations.
Transportation agencies such as the Regional Transportation Program in Portland and the Kennebec Valley Community Action Program have complained that the system was disastrous in its first two months, with MaineCare recipients waiting hours when promised rides, or having their rides canceled with little notice. The Press Herald has been flooded with similar stories.
FINANCIAL INCENTIVE TO CHANGE
Why did Maine overhaul its system instead of making modifications like Vermont’s? While there’s a myriad of reasons, some of it has to do with Maine seeking additional federal funding.
The MaineCare rides program costs $40 million a year, funded through a mix of federal and state dollars. The new system qualifies for a higher reimbursement rate from the federal government, which means an extra $6.1 million in federal money for the state.
Vermont, by contrast, has a waiver from the federal government that blends its reimbursement rates for all Medicaid services, so it had no incentive to create a wholly new system that could capture a higher reimbursement.
When asked whether the system they crafted would have captured the higher rate otherwise, Vermont officials said they didn’t know.
In Maine, Nadeau said she could not remember an explicit directive from the federal government for Maine to split up the functions of coordinating and providing rides to qualify for the higher reimbursement rate.
But she said state officials believed that they had to split them to capture the higher rate, and that keeping the local agencies in charge of every aspect of the program would have caused the state to lose out on the $6.1 million.
Farnsworth said he doubts statements by Maine’s DHHS on the reimbursement issue, and believes that Vermont’s system would qualify for the higher reimbursement rate because it limits the potential for abuse.
“If you meet the criteria set forth by the federal government, then you get the higher rate,” Farnsworth said.
In Vermont, at least, riders have barely noticed the changes.
Mark Larson, the state’s health commissioner, said, “It took some creative thinking, and compromises, but we’ve been able to figure out a system that works in a Vermont context.”
Joe Lawlor can be contacted at 791-6376 or at:jlawlor@pressherald.comjlawlor@pressherald.comTwitter: @joelawlorph@joelawlorph
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