Kansas legislators question plan to retool case management system for people with disabilities

TOPEKA — Dustin Winfrey enjoys his job at McDonald’s and remains confident in Johnson County’s delivery of community-based career and personal services for people with intellectual or developmental disabilities.

He told members of the Kansas Legislature that he wanted to avoid disruption that could result from the federal government’s directive that state officials remove or mitigate conflicts of interest among organizations that assess, develop and provide disability services to thousands of Kansans enrolled in Medicaid, including Johnson County Developmental Services or JCDS.

One proposed fix would be to create a Kansas network of stand-alone, independent organizations dedicated exclusively to case management.

“I like the current case management system, and do not want it to change,” Winfrey said in written testimony to a special legislative committee. “I like my job at McDonald’s and my job coach at JCDS and don’t want to have to choose between having a job and keeping my case manager.”

JCDS offers a single point of entry for individuals seeking disability services, including administrative work to determine eligibility for assistance and coordinating a network of 70 Johnson County providers.

Officials in the administration of Gov. Laura Kelly said the U.S. Centers for Medicare and Medicaid Services, or CMS, directed Kansas to come into compliance with federal rules on conflict of interest that were created in 2014. There are 8,500 Kansans with intellectual and developmental disabilities receiving targeted case management through Medicaid, and 37% receive other services from organizations that raised potential conflicts of interest.

CMS has leverage to compel states to act, because billions of dollars spent on disability services in Kansas come from the federal appropriations.

In response, the Kansas Department for Aging and Disability Services, or KDADS, launched a planning effort to transition service organizations to models that adhered to CMS’ rules.

Some members of the Legislature appeared willing to call CMS’ bluff, while others said they were skeptical Kansas could choose which federal mandate to ignore.

“To make a decision like this so quickly, I think, is very dangerous,” said Sen. Chase Blasi, a Wichita Republican. “I think we’re being bullied by the federal government.”

Sen. Mary Ware, D-Wichita: “Can we say, ‘Oh, we’re not going to pay any attention to what the feds want?'”

Dozens of Kansas organizations engaged in serving people with disabilities, the parents or guardians of individuals receiving Medicaid services and other advocates for the disabled objected last week to KDADS’ movement toward overhauling case management. KDADS said the objective was to end the practice of providing case management through entities that also provided other home- or community-based services.

Seth Kilber, assistant commissioner of long term services and supports at KDADS, said the conflict was evident when looking through the eyes of a Medicaid client.

“When the organization helping me plan my care is also providing my services it creates a conflict of interest,” Kilber said. “Even if it’s not said out load, there may be subtler ways in which they guide me to choose their services, even if those services may not be the best for me. Over time, this subtle pressure can build up.”

Kilber said separation of case management and service delivery would allow clients to know advice they received was focused on their interests rather than the financial status of a service organization. He said CMS was “unequivocal” in its communication with Kansas that the state must catch up with states that had complied.

“By eliminating conflicts of interest,” Kilber said, “we ensure that every person has the freedom to shape their own future with their voice guiding them every step of the way.”

El Dorado GOP Rep. Will Carpenter, chairman of the joint committee on targeted case management, said he was concerned CMS didn’t send Kansas a formal letter ordering the state to adhere to conflict of interest provisions within Medicaid rules. He joined others on the Legislature’s special committee who questioned why there was such urgency to reform operations a decade after implementation of the federal edict.

“We’d like them to put in writing what we’re actually trying to solve here,” Carpenter said. “It is just mindboggling to me to not have a letter from CMS that is spelled out, you know, ‘You’re in violation and you need to do this.'”

He said the state government should work with interested parties to address the 2014 standard, but action could await results of a statewide survey of disability providers and recipients. He said the level of satisfaction among 8,000 Kansans receiving intellectual and developmental services through Medicaid could be useful in persuading CMS that radical change was unnecessary. He said it wasn’t clear whether CMS was aware of state-imposed rules on conflict of interest.

“I do think because we are talking about 8,000 people in our state, that we don’t need to do anything to jerk the rug out from underneath anybody,” Carpenter said.

Rachel Neumann, chief operating office of COF Training Services, said the work of targeted case managers was critical for people with disabilities who would otherwise struggle to navigate the complex system tied to Medicaid.

She said COF Training Services responded in the past to CMS’ guidance on conflict of interest by establishing an independent limited liability company to offer case management services.

“The business model I developed would barely break even. It required the CEO to carry a full caseload, provided uncompetitive wages, outsourced all administrative functions and offered no benefits,” she said.

A case manager at Cottonwood Inc. in Lawrence said she wasn’t in this line of work to become an entrepreneur who owned a startup business.

“I did not get into this field to operate a case management organization, to handle finances, to hire and fire staff, or to advertise my services,” said Zoe Surprise-Murphy of Cottonwood. “I got into the field because I love helping people access the community, find resources they need to meet their goals and create plans that reflect the supports and preferences of the people I serve.”