Too Many Cooks in the Kitchen!

March 24, 2020

As I was sorting through the various issues which arose today, I began to see a pattern emerging – there are too many cooks in the kitchen!  In normal times providers must cope with conflicting interpretation and implementation of regulations and what is frequently seen as contradictory terms between the licensing agency (DBHDS) and the payment agency (DMAS); if you provide behavioral health services you also had the added confusion of six MCOs who had different practices, etc.  That was in “normal times!” Up until, roughly, two weeks ago all the “cooks” were at least working toward preparing the same menu, knew whether it was a luncheon or dinner, and how many guests to expect.  Now we are not in “normal times,” and we have a chef for the entire chain of 50 restaurants (in the White House) with helpers (in Congress) trying to give direction; a local chef (named Northam) who is very calmly trying to manage his kitchen, and multiple cooks (DBHDS, VDH, DSS, DOE, CSA, and DMAS) all scrambling to figure out what they are serving, to whom, how and when. There has not been a day recently, when there has not been a major shift in the factors which influence the outcome. As every cook knows, the real trick is to get the meal on the table still hot and properly presented – very tough to do if you do not know the menu, etc.  But enough of the metaphor . . .
  • Congress has thrown a bill  (HR6201) at us that allocates a lot of money to ease the sudden pain of loss of the school nutrition program for children now out of school, provide flexibility for states in the SNAP program, and provide paid leave for employees in certain circumstances.  What has not been clear in all of the promotion of this bill is that many of the provisions are “permissive” if a state applies, others are to be defined by regulations developed by a Federal Agency.  In the amendment to FMLA, for example, there is explicit language permitting the Secretary of Labor to issue regulations “to exclude certain health care providers and emergency responders from the definition of eligible employee.”  Those regulations are being written, but have not yet been issued.  ANCOR is working very hard on your behalf to be sure that we are explicitly included in the exception.
  • There are also a number of documents floating around with various definitions of “essential personnel.”  Nothing in Executive Order #53 threatened our services or staff; in fact, the Governor has been very clear that he intends to protect the health of all Virginians and insure they get good care – that’s what we do!   If you listen to the news, you hear a lot about states being “locked down.” (An unfortunate term, and not the reality in any state. We are not there yet, and if we all behave by keeping our distance, washing our hands and cleaning high touch surfaces every day, we will not be there!  And consider the alternative, if staff are not permitted to work, the commonwealth will have to come up with an alternative method/location for care; I do not think they are anxious to implement a Plan B!
  • DBHDS is doing an excellent job of putting out their FAQ document every day with a focus on what they are able to do to relieve the restrictions of their regulations.   Sometimes being helpful turns out to be a bit more burdensome than expected, but our reality is changing daily!
  • DMAS has released a lengthy and fairly comprehensive memo which covered a range of issues with a variety of services.  Many of the flexibilities that DMAS would like to offer do require CMS approval either through an 1135 Waiver or an Appendix K which modifies only a 1915c Waiver (DD Waivers or CCCPlus Waiver); they can submit either multiple times. The problem, of course, is that these are critical times and providers need options to protect both individuals and staff immediately if not sooner!  I think we can be certain that DMAS staff are working as fast as they can, if not fast enough for the provider who may not be able to meet payroll next week.
We are ONLY twenty days into this new normal – it just seems like twenty years!  Our first Pandemic related post was on March 4th – – today in March 24th.   The menu will get sorted, the cooks will try to work together, the table will be set and dinner will be served.  It will be chaotic and messy – but we will get there!