Tag: Medicaid

homelessness, Morning Fizz

Former KCRHA Leader Now Sees “Significant Issues” With Medicaid Funding for Homelessness; Lived Experience Coalition Weighs In on Report on Hotel Program It Ran

1. The city of Seattle has amended its $60,000 contract with former King County Homelessness Authority CEO Marc Dones, who was supposed to spend the latter half of this year coming up with ways to maximize the use of Medicaid funding for homelessness programs.

The latest iteration of the contract directs Dones to come up with “recommendations with respect to the local federal unsheltered initiative “All Inside” … [including] considerations for the local initiative’s statement of work, actionable workplan and performance plan,” in addition to the work Dones has already done on Medicaid. In an email on August 7 titled “Landscape to Date,” Dones concluded that there were several “significant” but “solvable” challenges to billing Medicaid for homeless services.

All Inside is a Biden Administration program that provides technical assistance to cities, including Seattle; it does not include additional funding for housing or services.

The pivot is particularly striking given Dones’ previous advocacy for using Medicaid Foundational Community Supports funds to pay for Partnership for Zero—a privately funded effort to end unsheltered homelessness downtown that folded, after housing 230 people, this month. Dones was so bullish on the program that they predicted it would pay for at least 85 percent of Partnership for Zero’s services by next year, brushing aside concerns from homeless service providers and elected officials that the program is complex, highly restrictive, and expensive to administer.

Providers raised every one of the issues Dones identified as part of their contract with the city when the KCRHA tied the future of Partnership for Zero to Medicaid funding earlier this year, but were largely ignored. 

In their latest update, Dones identified “four significant issues” with using Medicaid to fund homeless services. First, Dones wrote, agencies often have to spend a lot of time and staff resources documenting and administering programs in order to get reimbursed. Second, Dones wrote, agencies have to spend a lot of time “chasing” clients to collect billable hours, creating a “significant gap in what is called the ‘billable units of service’ and requir[ing] agencies to fund activities that are related to enrolled clients with no path to reimbursement.”

The third issue Dones identified is that FCS is not a reliable source of funds for behavioral health services. And the fourth was that Medicaid reimburses agencies slowly and often rejects claims for minor or technical reasons, making it hard for providers without large cash reserves to use it as a reliable source of funding.

Providers raised every one of these issues when the KCRHA tied the future of Partnership for Zero to Medicaid funding earlier this year, but were largely ignored.

Dones has completed approximately half of their 240-hour contract, according to a schedule of “deliverables” included in the contract document. So far, Dones has produced a timeline and scope of work, a 600-word email describing the “landscape to date,” a 450-word email containing a “Draft Assessment” of All Inside, and a list of five stakeholders to talk to about various topics, including the “intersection of public transit and homelessness,” “intersection of organized crime and encampments,” and “pro social public space activation to prevent encampments.”

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2. The final version of a report documenting what went wrong with a hotel program run by the Lived Experience Coalition reaches substantially the same conclusions as an early draft PubliCola covered back in August, but does include a number of notes contributed by the LEC, which has blamed budget missteps that led to the collapse of the program primarily on its then-fiscal sponsor, Building Changes, and the KCRHA.

As we reported last month, the report, by independent consultant Courtney Noble, concluded that the LEC was in over its head when it accepted $1 million in federal funding to run the hotel-based shelter program, which was the advocacy group’s first such contract. Noble also reported that other factors, including a lack of transparency from Building Changes and a hostile relationship with the KCRHA and Dones, contributed to the program’s failure.

In footnotes to the report, the LEC said the audit itself should go through a racial equity analysis “due to the fact that the audit was conducted by a single individual of a particular racial background and socioeconomic class” who may have unconscious bias. Additionally, the LEC objected to the consultant’s suggestion that conflict between “personalities”—at a minimum, Dones, LEC director LaMont Green, and Building Changes director Daniel Zavala—contributed to the collapse of the hotel program.  

The final report now emphasizes systemic issues and removes references to the LEC’s initial proposal, which included hot meals, mass shelter, and supplies in addition to the hotel rooms that were the core of the LEC’s final contract. It also softens suggestions that the Lived Experience Coalition should participate in the regional Homelessness Management Information, a central clearinghouse for information about people who interact with the homelessness system, in order to access federal Emergency Food and Shelter Program funds in the future.

The LEC has said that gathering the kind of data required to participate in HMIS would re-traumatize their clients; additionally, according to the final report, they “believed that KCRHA leadership was retributive, and wanted to punish them for stepping out of their advocacy lane to run the hoteling program. LEC maintained that they were still not a direct service provider, and believed that participating in HMIS would strengthen KCRHA’s argument that they were.”

In footnotes to the report, the LEC said the audit itself should go through a racial equity analysis “due to the fact that the audit was conducted by a single individual of a particular racial background and socioeconomic class” who may have unconscious bias. Additionally, the LEC objected to the consultant’s suggestion that conflict between “personalities”—at a minimum, Dones, LEC director LaMont Green, and Building Changes director Daniel Zavala—contributed to the collapse of the hotel program.

It has historically an issue when poor white, black, brown, and indigenous people come together to speak truth and organize to urgently improve failing systems resulting in the dehumanization, pain, suffering, and early death of our unhoused neighbors that the systems do not want to be accountable and then turn to tactics such as defunding, gaslighting, and mischaracterizing their work,” the LEC wrote.

Finally, the LEC said it’s inaccurate to call the hotel program a failure. “The program did not fail, it served over 400 people during a time period when we saw record deaths among those experiencing homelessness,” the group’s final footnote says.

Health, homelessness, housing, human services

Unreleased Report Highlights Funding Challenges for Program Aimed at Ending Homelessness Downtown
Tent removal in progress on a recent morning at Third and James in downtown Seattle.

By Erica C. Barnett

A report commissioned by the King County Regional Homelessness Authority, but never publicly released, highlights some of the challenges the regional agency will face as it attempts to use federal Medicaid funding to pay for Partnership for Zero, a marquee program that aims to eliminate homelessness in downtown Seattle by connecting people directly with housing.

The report, from the nonprofit Corporation for Supportive Housing, also lays out a potential road map for navigating the Medicaid reimbursement process, which is so byzantine that many King County providers have avoided using the program.

Currently, homeless service providers can seek funding through a Medicaid-based program called Foundational Community Supports, which provides benefits and services for people experiencing homelessness who are eligible for Medicaid and have chronic health conditions. The program, which has been around since 2018, treats homelessness as a health care issue and housing as a form of health care—a meaningful step that many advocates have applauded.

“FCS is a really unique revenue source, because it’s not a short-term grant or contract—it really is based on a person’s health and will stay with them as long as they need these services,” said Debbie Thiele, CSH’s western managing director. “It’s been a major breakthrough to have the health care system seeing supportive housing services as a part of health.”

But establishing clients’ eligibility for the program and securing payment for ongoing services has been a daunting and sometimes money-losing challenge for service providers, who often have to hire specialized administrative staff and train case managers to meticulously document encounters with clients. In conversations with PubliCola earlier this year, providers explained how challenging it can be to translate notes by front-line case managers into billable Medicaid hours; a case worker who isn’t fully trained and dogged in their efforts to enroll clients and “constantly generate [billable] service contacts” can cost an agency significantly more than they bring in, one provider said.

Back in April, Dones said the KCRHA was about to start billing some services to Medicaid in a series of experimental “dry runs” that will “give us ample time to correct anything that is going wrong” before transitioning Partnership for Zero into a mostly Medicaid-funded program next year. Those dry runs haven’t happened, and the reasons for the delay remain somewhat opaque.

“Once providers are up and running with Medicaid FCS, it is projected to cover gaps with increase revenue, but to get to that point, providers report their start-up costs to be far more than they can afford, in some cases in the hundreds of thousands of dollars,” the report says.

Thiele says one solution would be funding to help organizations, particularly smaller and BIPOC-led groups, set up the billing and other infrastructure they need. “If you want the nonprofit sector, which is reliant on grants and contracts and doing this incredibly challenging work in community, to make a major internal change to the way they operate, then they need investment in order to do that,” Thiele said. “With staff turnover being what it is right now, it’s a big risk for nonprofits to do new things,” she added.

The CSH report breaks down some of the primary issues that prevent homeless service providers from getting the most out of Medicaid funds, including administrative hurdles that force staff to work extra hours manually inputting data and doing duplicative work; denials and disenrollments for reasons that can feel capricious, such as minor technical errors; and difficulty knowing what services FCS will consider “supplemental” or new, as opposed to “supplanting” funding for services that already exists.

Many of the issues that exist at nonprofits are also relevant for KCRHA, which will have to train its system advocates—case managers with personal experience of homelessness who navigate Partnership for Zero clients into services and housing—to do all the things nonprofit service providers have identified as major challenges.

Earlier this year, KCRHA’s then-CEO Marc Dones told the agency’s implementation board that securing funds through FCS should be relatively simple, and expressed confidence that Partnership for Zero, which has fallen significantly behind schedule, would be at least 85 percent Medicaid-funded by next year. In fact, Dones called the agency’s 85 percent prediction “conservative,” adding that “if we are able to exceed that, then we will close the budget gap just on Medicaid reimbursement.” KCRHA baked this optimism into its 2024 budget, which assumes that Medicaid, through FCS, will provide about $5 million for Partnership for Zero, with KCRHA making up an estimated $900,000 gap.

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Dones resigned earlier this year. The city of Seattle is currently paying them $250 an hour to come up with recommendations for using Medicaid funds “to maximize the region’s resources available to address homelessness”—a portfolio that seems quite similar to the the work CSH is doing for KCRHA.

Back in April, Dones said the KCRHA was about to start billing some services to Medicaid in a series of experimental “dry runs” that will “give us ample time to correct anything that is going wrong” before transitioning Partnership for Zero into a mostly Medicaid-funded program next year. Those dry runs haven’t happened, and the reasons for the delay remain somewhat opaque.

According to Thiele, CSH was supposed to move into Phase 2 of their “engagement” with KCRHA as soon as they finished the initial report earlier this year: The “dry run, and convenings across King County.” But, she said, “we’ve been waiting on our contract with them for some time. … They did recently give us a small contract to get started, but we were seeing this as probably a good 18 months of process work” before Medicaid billing can start in earnest. “It’s in motion, but I just can’t tell how far we’ll get with it.”

KCRHA spokeswoman Anne Martens said the agency is “on track for a ‘dry run’ this fall. … My guess is that there will be some kinks to work out, and we’ll have to adjust and evaluate as we go.” Later, Martens clarified that the “dry run… is still expected to happen before the end of the year. So we’re still in the process of setting up the system, policies, tech configurations, and trainings required to test how Medicaid billing would work in practice.”

Partnership for Zero is funded by corporate and philanthropic donors through the nonprofit We Are In, which is also paying for the contract between the KCRHA and Corporation for Supportive Housing.

Had Partnership for Zero achieved its original targets, every person living unsheltered in downtown Seattle would now be housed, and the KCRHA would be working to rapidly house each new person who arrived in the downtown area as part of the final, “hold steady” phase of the project. After this phase, KCRHA planned to expand the Partnership for Zero effort into other parts of Seattle and other regions of King County.

Since launching, the downtown effort has encountered many challenges, including a reluctance among private landlords to rent to people in the program. One issue that arose early on, according to a January 2023 memo from Dones to We Are In director Felicia Salcedo, is that landlords wanted assurances that formerly homeless tenants would be able to pay fair market rent after the first 12 months, when their Partnership for Zero rent subsidy runs out.

In February, We Are In announced another million dollars in funding for the program, but the future of the overall program remains unclear. We Are In declined to comment for this story.

homelessness

Former KCRHA Director’s New $250-an-Hour Contract Focuses On Medicaid Funding for Homelessness
Regional Homelessness Authority CEO Marc Dones speaks at a press conference about the new public-private "Partnership for Zero" Thursday
Former KCRHA director Marc Dones at the “Partnership for Zero” announcement last year

By Erica C. Barnett

The Seattle Human Services Department released the details of former King County Regional Homelessness Authority director Marc Dones’ $250-an-hour contract with the city on Friday. PubliCola reported on the contract, which is widely viewed as a payment in lieu of severance (for which Dones, who resigned, was ineligible), in June. Real Change was first to report on the contract details on Friday. Dones’ contract began on June 20, the first business day after their final day at KCRHA.

Under the contract, Dones (through their company, Gray Sky Consulting) will receive $60,000—the equivalent of three months’ salary—for performing 240 hours of work, including 30 hours determining the scope the work to be performed and creating a timeline for deliverables.

City consulting contracts don’t generally require an exact accounting of hours—see, for example, former deputy mayor Tim Ceis’ own $250-an-hour contract to “build community consensus” on Mayor Bruce Harrell’s preferred light rail station locations—so it’s impossible to say how much actual time Dones will spend delivering on this contract. Coming up with or list of “stakeholders,” for example, is supposed to take the former KCRHA director five hours, and writing a final report accounts for another 60.

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The contract says Dones will do a “landscape assessment” of existing programs and come up with recommendations for using Medicaid funds “to maximize the region’s resources available to address homelessness.” As we’ve been reporting since February 2022, Dones planned to use a Medicaid-funded state program called Foundational Community Supports to pay for the downtown Partnership for Zero, an ambitious (and unrealized) plan to eliminate visible homelessness in downtown Seattle by as early as last year. The KCRHA’s adopted 2024 budget assumes$5.2 million from Medicaid reimbursement, an estimate Dones called “conservative.”

Providers who have used Medicaid funding to pay for programs addressing homelessness cautioned that Medicaid reimbursement is almost more trouble than it’s worth, because the use of the federal program is severely limited and documenting units of care, known as “encounters,” has proven extremely difficult. It’s unclear what additional research Dones is expected to provide beyond the work KCRHA did to justify the assumptions about Medicaid reimbursement that informed its 2024 budget.

The contract also includes 30 hours of research on the integration of existing “labor, public health, and violence prevention” programs, including violence prevention research with a “specific focus on the overlap between gang violence and encampments.”

Health, homelessness, housing, human services

Marquee Plan to End Unsheltered Homelessness Depends on Federal Funding Source Some Call Risky
Image via We Are In.

By Erica C. Barnett

Last week, the King County Regional Homelessness Authority’s implementation and governing boards approved a 2024 budget proposal that assumes the agency will receive significant future funding from Medicaid to keep the Partnership for Zero program, which aims to end unsheltered homelessness in downtown Seattle, going. Currently, the program is funded by corporate and philanthropic donations through a public-private partnership called We Are In.

The federal funding would come through a statewide program for Medicaid clients called Foundational Community Supports that funds “pre-tenancy” services for chronically homeless people—everything from getting an ID to negotiating an apartment lease.

“Based on current research, we estimate that Medicaid will reimburse 85% of Partnership for Zero (PfZ) costs,” or about $5.2 million, the KCRHA’s 2024 budget says. In 2022, a group of corporate and philanthropic donors pledged $10 million to fund the initial downtown Seattle “demonstration project,” which pays case managers known as system advocates to connect people living downtown to services, shelter and housing. Over the next five years, KCRHA plans to expand Partnership for Zero countywide.

Several members of both boards, including Auburn Mayor Nancy Backus, expressed reservations about relying on a federal program that the KCRHA has never used before to fund one of the agency’s marquee initiatives. “I’m just concerned about approving [a budget] where you don’t have the money,” Backus said. “As someone who provides our budget to the council every two years, we never put anything in the budget … that’s aspirational.”

“I think that there were some estimates that were like, ‘this will make it rain money,’ and then there were other estimates that were like, ‘this will get you two nickels.’ We feel confident that this is a capturable amount of revenue.”—KCRHA CEO Marc Dones

“I would love not to spend more money than we have,” KCRHA CEO Marc Dones responded. “So what we’re doing is a number of dry runs with Medicaid billing while we’re still entirely grant- funded”—essentially, submitting invoices for real services to see what gets rejected and approved.

“Our current conservative estimate [is] an 85 percent reimbursement,” Dones added. “I think that there were some estimates that were like, ‘this will make it rain money,’ and then there were other estimates that were like, ‘this will get you two nickels.’ We feel confident that this is a capturable amount of revenue.”

But providers and advocates familiar with Foundational Community Supports, speaking to PubliCola on background, said that although the concept behind FCS is extremely forward-thinking—the six-year-old program treats housing as a form of health care, which is new for Medicaid—relying so heavily on FCS to fund a costly, high-profile effort like Partnership for Zero is a significant risk.

To understand why, it’s helpful to understand a bit about how nonprofits use the program to fund services for unsheltered people in King County.

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Foundational Community Supports is a fee-for-service program; it pays $112 for every documented “encounter” between a service provider and a client, up to a maximum of six encounters a month. (In the case of KCRHA, the government itself, rather than a nonprofit, will be the service provider). If a case manager has a dozen clients and manages to document six encounters with each of them every month for a year, that adds up to about $95,000. The starting salary for KCRHA’s system advocates—formerly homeless peers who serve as case managers and outreach specialists for Partnership for Zero—is $75,000, so a $95,000 reimbursement would more than pay for both’ salaries and benefits, with some to spare for administration and other costs.

So far so good. Except, service providers say, that it’s almost impossible to “max out” on providing services to unsheltered people this way. Case managers must document each encounter with an unsheltered person in detail, with case notes that demonstrate what service they provided and how that encounter got the person closer to their housing goal.

Opportunities for “wasted” time abound. If a case worker goes out looking for a client and doesn’t find them—a common situation when trying to find unsheltered people, especially in a city that sweeps encampments—that time doesn’t count. If a case manager is new and still in training, or in the process of convincing someone to sign up for the program, that time doesn’t count. And if everything goes perfectly but the case notes are too short, or too long, or don’t include the right kind of details to convince the third-party administrator reviewing a person’s forms, that time doesn’t count either.

Because Foundational Community Supports isn’t a reliable source of funding, service providers don’t typically rely on it to fund entire programs; instead, they “braid” FCS with other funding sources to create a stable foundation for ongoing programs. The constant documentation and pressure to monetize every interaction with unsheltered clients can make it harder to build relationships with unsheltered people. According to one experienced homeless service provider, FCS is “just not really how rapport-based type outreach services relationships work, or how they’re usually delivered.”

Multiple people with Medicaid billing experience mentioned the concept of the “golden thread”–  a consistent narrative through every piece of documentation that explains why the person needs specific services and how each of those services are helping them achieve their self-determined goals. Failure to convincingly document that “thread” is “why a lot of claims get denied,” one former service provider said.

“We are comfortable that that’s a good number, but we’re not going to know until we start doing it and we’ll build a better and better understanding of what a successful reimbursement package is.”—KCRHA Chief Administrative Officer Meg Barclay

Facing pushback from board members last week, Dones pointed that the agency still has money left over from We Are In’s original $10 million commitment to pay for the program through 2023 and potentially beyond, if getting funds through Medicaid proves more challenging than the agency anticipates. And, KCRHA Chief Administrative Officer Meg Barclay noted, the KCRHA is consulting with the Corporation for Supportive Housing, which trains service providers to do Medicaid billing, to learn how to maximize their reimbursements.

Even so, Barclay added, Medicaid is “kind of a black box—sort of strange. So we are comfortable that that’s a good number, but we’re not going to know until we start doing it and we’ll build a better and better understanding of what a successful reimbursement package is.”

Debbie Thiele, CSH’s managing director for the western United States, told PubliCola last year that FCS is “designed to be as user-friendly as possible to a group of providers who are not health care providers.”

One implementation board member, Simha Reddy, said he saw the KCRHA’s effort to fund Partnership for Zero through Medicaid as an experiment that could be helpful to other nonprofit providers who could “jump on the bandwagon” and “learn alongside us.”

And Dones pointed out that the KCRHA won’t be the only government entity to rely on Medicaid funding to run a homelessness program—Spokane, they said, “funds a huge portion of their system” with Foundational Community Supports.

“I do think that the discussion around the difficulty of these dollars is not actually borne out by even our neighbors in Washington,” Dones told the implementation board last week. However, service providers who spoke with PubliCola said Spokane is both smaller (with a homeless population of around 1,800) and more affordable than King County, making it easier to house people in private-market housing and help them stay there.

The budget both boards approved last week isn’t a final spending plan. The KCRHA will send it to its two primary funders, King County and the city of Seattle, later this year, and adopt a finalized budget in December. What the votes represent is a bet on Dones’ plan to fund Partnership for Zero, which will otherwise run out of funding next year.

Editor’s note: Due to a transcription error by the author, the original version of this story incorrectly attributed Backus’ quote to Seattle Deputy Mayor Tiffany Washington.