Louisiana Voice

Gov. Bobby Jindal may be about to deliver another $800 million kick in the teeth to Louisiana’s working poor with the same tactic he employed in losing that $80 million broadband internet grant: doing nothing.

But then, doing nothing seems to be what he does best these days (see: Bayou Corne; see: gaining traction as a viable presidential candidate for 2016), although he was rather decisive in cancelling the CNSI contract once word of a federal investigation became public knowledge—nearly three months after Jindal became aware of it.

The Louisiana Department of Health and Hospitals (DHH), already laboring under the cloud of a federal investigation, is running out of time to qualify for approval of the administration’s sweeping plan to privatize state-run hospitals or risk losing additional federal matching Medicaid funding.

That was the word contained in a letter of Jan. 30 from the Centers for Medicare & Medicaid Services (CMS) to Ruth Kennedy, director of the DHH Bureau of Health Services Financing.

State Rep. Jerome “Dee” Richard (I-Thibodaux) said Friday that DHH has never responded to a list of questions submitted by CMS in its letter to Kennedy.

“I just talked to the CMS representatives this week and they have received absolutely nothing from the state,” Richard said. “If they don’t respond to the questions and get approval before the budget is approved by the legislature, the state stands to lose another $800 million—and we’re already a billion dollars in the hole.”

Richard said he encountered DHH Secretary Bruce Greenstein recently and Greenstein assured him that everything had been approved.

“Somebody’s lying,” Richard said, “and I don’t think its CMS.”

At the same time, LouisianaVoice has received a copy of a March 18 letter from State Rep. Regina Ashford Barrow (D-Baton Rouge) to the LSU Board of Supervisors “to express grave concerns” over what she described as the failure of the LSU Health Sciences Center (LSUHSC) to receive necessary approval for certain elements of the cooperative endeavor agreement (CEA) facilitating the closure of Earl K. Long (EKL) Hospital in Baton Rouge.

“The clinics receive federal reimbursement for uninsured care, including payment of physicians and physicians in training who deliver that care,” she said. “CMS requires that the clinics be attached to a hospital for the funding stream to flow to cover outpatient care.

“While (DHH) has taken the position that CMS approval is not necessary and is moving forward with plans for Our Lady of the Lake (OLOL) Medical Center to operate the provider-based clinics, there remains the potential to lose significant federal funding for noncompliance with CMS requirements.”

Barrow said states “must meet certain requirements relative to decisions involving any provider, including outpatient clinics, of services under the Medicaid program. The failure to receive CMS approval for the transfer of the EKL attached outpatient clinics and the medical education program may result in loss of services to those most in need.”

Barrow then addressed several questions to the board:

• Has CMS approved the plan for OLOL to operate the clinics? If not, why?

• By proceeding forward without CMS approval, can this result in a disallowance that the state will have to repay?

• If CMS doesn’t approve this endeavor, how will the state satisfy its portion of the contract since the state is already facing a financial deficit?

• Who will provide care for uninsured women since the deal with Woman’s Hospital fell through?

• Who will monitor the entire CEA to ensure that it saves money and meets the benchmarks stated in the contract?

• Could there be any legal ramifications to LSU-HSC board members?

“It is imperative that all parties involved are fully apprised of all the details prior to moving forward with the CEA,” Barrow said. “The process continues to evolve and CMS has indicated that they have not been a part of any recent developments.

It turns out that CMS has a few questions of its own.

“The state plan must be comprehensive enough to determine the required level of federal financial participation (FFP) and to allow interested parties to understand the rate setting process and the items and services that are paid through these rates,” the six-CMS letter said.

Among the requests and questions submitted to the state by CMS were:

• No financial impact was noted due to the proposed revisions. Please provide a detailed analysis of how this determination was made and provide supporting documentation of the calculation;

• Please explain why the state proposed an effective date of Nov. 1, 2012, when no agreements have been signed (note that the CMS letter was written on Jan. 30, 2013).

• CMS must have copies of all signed standard cooperative endeavor agreements. In addition, please provide copies of all signed intergovernmental transfer (IGT), management agreements, MOUs (memorandums of understanding), management contracts, loan agreements and any other agreements that would present the possibility of a transfer of value between the two entities;

• Did the state receive any feedback or complaints from the public regarding the CEA? If so, what were the concerns and how were they addressed and resolved?

• Please provide information demonstrating that the changes proposed (in certain documents) comport with public process requirements. Please provide copies of the legislation authorizing the proposed changes.

• How many entities does the state anticipate will participate in this arrangement? Please submit a list of all participating hospitals, all transferring entities doing the IGT, and the dollar amount that the transferring entities will IGT. Please describe how the hospitals are related/affiliated to the transferring entity and provide the names of all owners of the participating hospitals.

• What is the source of all funds that will be transferred?

• What are the sources of IGT funds?

• Does the state agree to provide certification from the transferring entities that the IGTs are voluntary?

• The Social Security Act provides that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope or quality of care and services available under the plan. Please explain how this proposal complies with this provision.

• Please provide an Upper Payment Limit demonstration applicable to the payments for the current rate period for all classes.

• Please include a detailed narrative description of the methodology for calculating the upper payment limit in the state plan language.

• Please clarify if the state or a hospital service district has issued any proposals or enacted any legislation to support the public-private partnerships. Please submit that documentation for our review.

• Are the hospitals required to provide a specific amount of health care service to low income and needy patients? Is this health care limited to hospital only or will health care be provided to the general public? What type of health care covered services will be provided?

• How did the state determine that the Medicaid provider payments are sufficient to enlist enough providers to assure access to care and services in Medicaid at least to the extent that care and services are available to the general population in the geographic area?

• How were providers, advocates and beneficiaries engaged in the discussion around rate modifications?

• Is the state modifying anything else in the state plan which will counterbalance impact on access that may be caused by the decrease in rates?

• Please provide a list of facility closings and services that are being cut by LSU.

• Please describe how the state share of each type of Medicaid payment is funded. Please provide an estimate of total expenditure and state share amounts for each type of Medicaid funding.

That’s quite a to-do list.

Keep in mind the CMS letter was written on Jan. 30. At that time, LSU and DHH were in negotiations with St. Francis Medical Center in Monroe and Willis-Knighten for their takeover of E.A. Conway Hospital and LSU Medical Center, respectively.

Subsequent to that letter, the state abruptly pulled out of the negotiations and is now on the verge of consummating a deal with Biomedical Research Foundation (BRF) of Shreveport whose incoming president and CEO, Dr. John George, also serves on the LSU Board of Supervisors.

Jindal said that George, who presently serves as vice president of BRF, is not being paid a salary by BRF, so there is no conflict of interest. Current President and CEO John Sharp, however, is paid $275,400 and it is assumed that when George ascends to that position, he will be paid as well.

Greenstein, you may remember, refused to tell a Senate Committee in June of 2011 that his old employer, CNSI, had won a contract with his agency worth more than $184 million.

Faced with not being confirmed as DHH Secretary, he finally relented and told the committee that CNSI was the winner of the contract but then said that he had built a “firewall” between him and the selection process and that he had no contact with CNSI representatives during the selection process.

The committee later learned that he had indeed had ongoing discussions with CNSI executives during the bid process and that Greenstein was even responsible for rewriting the request for proposal (RFP) that made CNSI eligible to submit a proposal.

The circumstances surrounding the awarding of that contract are now being investigated by a federal grand jury.

Now Greenstein tells Richard everything was already done and all is well with CMS.

CMS told Richard it had received nothing from Greenstein or DHH.

And now the FBI and Louisiana Attorney General are investigating Greenstein’s agency.

And the health care of hundreds of thousands of Louisiana’s poor hangs in the balance.

It all comes down to one simple question:

Who do you believe?

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