Wyoming health officials are exploring ways to make a Medicaid program for the developmentally disabled less prone to conflicts of interest.
But the effort is causing concern among nonprofit groups that care for people with disabilities. They worry the changes, however well intended, will lead to a system that’s slower to respond to the needs of a vulnerable population.
The changes focus on case managers who help nearly 2,300 people navigate the state’s Home and Community-Based Waivers Program. Officials want them to operate more independently of the organizations that provide services to people with intellectual disabilities and brain injuries.
Under the state’s existing rules, case managers can work for the same organizations that provide services such as adult day care and job training. They can also provide the services themselves.
Case managers are not supposed to recommend a specific service provider. But some might be guiding clients to their employer’s programs, even when another organization might be a better option, said Chris Newman, who oversees the state’s waiver program.
Officials also worry that some case managers hesitate to raise concerns about a client’s care when it involves a service provide by their employer. Making case managers more independent would result in a more responsive system, Newman said.
“I think people will see concerns and frustrations will be addressed more quickly and appropriately,” she said.
Others aren’t as sure. Laura McKinney is president of Magic City Enterprises, a Cheyenne-based organization that serves people with developmental disabilities. She’s found her case managers interact with clients more often than independent ones. It’s also easier for them to address a concern.
“Our case managers know if there is an issue, they can come to me … if they don’t feel it is addressed, they can go to the state,” she said.
Wyoming is in the midst of an overhaul of its waiver program, spurred by a desire to reduce wait times for services without spending more money. Wringing conflicts of interest from the system is one part of that effort.
Health officials believe they can reduce the number of conflicts by making case managers more independent. Those managers play a key role in the waiver program. They work with clients to develop plans for care and then help connect them to services in the community.
Case managers are also responsible for ensuring their clients are properly cared for. If a client is staying at a group home without enough nurses, it would be the case manager’s job to approach management about the situation, Newman said.
But what happens when a case manager’s employer runs the group home?
“What we have seen consistently from across the state, it is very difficult for a case manager who is working for the organization to go to the organization and say, ‘You need more staffing there. My person is not being served appropriately,’ ” Newman said.
It’s possible such a scenario has played out somewhere in Wyoming, said Chris Boston, executive director of NOWCAP Services, a Casper-based disability service provider. But in his view, it’s far from a given.
“I will tell you flat out: That doesn’t happen in our organization,” he said. “We have weekly staff meetings where we work out issues and concerns.”
Other conflicts might not be so overt. Reform advocates worry that case managers might direct clients to their own employer’s services — even if their motivations aren’t financial.
“They are familiar with their own program,” said Rep. Elaine Harvey, R-Lovell, who chaired the legislative committee that sponsored the overhaul. “They feel their program is valuable.”
Case managers who work for larger disability providers insist they can still give fair counsel to clients. Tony Scoville, a case manager with Magic City, said he doesn’t have any difficulty giving his clients options beyond his own organization.
Case managers are taught to avoid potential conflicts of interest in the system, he said.
“There are choices,” he said. “I tell my folks that.”
Health officials expect to complete a draft plan for the conflict-free system sometime next month. They haven’t determined the details of the plan, or when it might actually go into effect.
That ambiguity has sparked some anxiety among people who rely on services, said McKinney, the Magic City president. Some of her clients are worried they might lose their case manager in the transition to a new system. Case managers themselves are also concerned they might have to leave their employer, either for a new agency or to go independent.
Even after the transition is over, McKinney doubts people in the waiver program will be better off. She says in states with other systems, clients only interact with case managers a few times each year.
“I understand the idea behind [the conflict-free system], but I think some of the problems that have been brought up are not as big as some people say they are,” she said.
There are options besides making case managers more independent. Heavier monitoring is one. But Newman argues that such an approach isn’t feasible in Wyoming.
There are 239 case managers in the system, and it’s difficult to catch one who is not providing appropriate services based on a conflict of interest, Newman said. She believes it’s better to craft a system that minimizes the chances a conflict could develop.
“It would give the case manager the authority and the power to be independent and work independently,” she said. “They aren’t being pulled in three different directions.”