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MHCD responded to Roland's letter with a flurry of phone calls. One doctor proposed a meeting with all parties concerned, an opportunity to do a fresh evaluation of Donald and his needs. The elder Roland declined.
"Donald's been evaluated so many times," he says. "They need to leave him alone."
For most of the fourteen months he worked at MHCD, Steve Thomas was known as a hardworking, conscientious case manager who cared more about his clients than the bottom line. Then he became a whistleblower, trying to get his supervisors to look into what he considered to be improper billing practices and possible Medicaid fraud. Now he is viewed in some quarters as a classic Disgruntled Former Employee.
A former child actor and model, Thomas says he still makes enough in residuals from his appearances on TV shows such as Police Woman and CHiPs to devote much of his adult life to volunteer work. The job at MHCD paid less than $25,000 a year and required little more than a bachelor's degree and rudimentary training, but he saw it as an opportunity to "make a difference in people's lives."
Thomas says he quickly became "obsessed" with the job, often working overtime without bothering to put in for additional compensation. On his eight-member high-intensity treatment team, case management involved everything from therapy sessions with clients to helping them find a place to live, taking them shopping, linking them to other health services, or simply lending a sympathetic ear. Given the critical needs of the Goebel clients, the job placed endless demands on Thomas and other members of his team.
Yet some aspects of the work rankled Thomas from the start. The team's performance was routinely evaluated, not on the basis of how many of their clients were faring well and staying out of the hospital, but on how many billable contacts with clients they were making. Each member was expected to meet weekly and monthly productivity goals; the entire team was supposed to be billing a total of around $61,000 a month.
"It was like a sales job--you had to make your quota," Thomas says. "I thought I was in the movie Glengarry Glen Ross."
In theory, all the Goebel clients are entitled to the same services. But because of the differences in their disability benefits, they couldn't all be billed the same way. Medicaid would pay for therapy and other case-management services, at a rate that averaged around $38 per "contact"--whether that contact was a five-minute phone call or a two-hour shopping trip. Medicare, though, would pay only for therapy. Services for indigent clients who had no benefits were paid through a special fund that was often exhausted before the end of the month, Thomas says.
Thomas soon discovered that Medicaid clients were highly prized by some MHCD staffers; one supervisor, he says, even referred to Medicaid clients as "cash cows." "There's no question, that was the terminology," he says. "Everybody knew she said it. And they would laugh. They'd make moo-moo sounds or say 'ka-ching!' when one of them walked in. I could clearly see who was Medicaid and who wasn't by how they were treated when they came through the door."
And what about those Goebel clients who weren't covered by Medicaid? "It was like, tough darts, buddy," Thomas says. "I had a client who was self-paid--which means he didn't have any benefits--and he was chronically homeless. I was told, 'Don't worry about him; he'll figure out a way to get by.'"
Other members of Thomas's team have echoed his charges. "When I first started, I was told to have more contact with Medicaid clients than [with those with] Medicare," says another case manager, who requested anonymity. "Who's to say the Medicare clients didn't need more help? One time I was called by a Medicaid client and I asked someone to take a message. I was told, 'You need to talk to this client. She's Medicaid. You can bill for this.' I was busy doing something else, but I lost a billable contact."
Deputy director McGuirk says that it's MHCD policy to treat all of its Goebel clients equally, regardless of their benefits, and that he's unaware of any supervisor using terms such as "cash cows" or "ka-ching!" in reference to the mentally ill.
"It's disappointing to me that staff have taken on that kind of perception," McGuirk says. Implicit in the Goebel plan, he explains, was the expectation that Medicaid revenue would play a large part in funding all the programs, and the concept of "billable contacts" was structured accordingly. "But somehow that gets translated down that the emphasis is on client contacts for revenue purposes. We want to de-emphasize the revenue-generation aspect of it, because there's opportunity for people to misinterpret what it means."
He adds, "If people are really using 'cash cow' language, that's extremely unfortunate. What we have, I think, is a team that has gotten, through whatever internal dynamics, into sort of a bad place."
In time, Thomas's dissatisfaction with what was going on at MHCD became focused on the activities of a colleague, case manager Michael Steinert. Steinert was considered one of the most productive members of the high-intensity team, but Thomas believed his productivity was achieved by billing for numerous brief phone contacts and that he wasn't spending as much time with clients as were other members of the team. On at least one occasion, he claims, Steinert's contact records reflect that he was conferring with clients at the same time that he was talking to Thomas.