SB 693 will create Michigan’s Exchange, the MiHealth Marketplace.  Although there are some concerning things in the version that was passed, we are very pleased that consumers will have be in the majority on the Marketplace Board.  It now moves on to the full Senate for a vote.

The ACA requires states to create an Exchange, the a new marketplace where individuals and small businesses will be able to find out information about health insurance plans and access tax credit subsidies to reduce the cost of health insurance.  Health insurance plans on the Exchange will have to meet specific quality and cost requirements and won’t be able to use health status to determine premims. This video explains what is in the ACA and what exactly an Exchange does.

By passing legislation to create the Exchange,  Michigan will be to apply for federal grants to pay for the development of the Exchange.  If the state does not create its own Exchange, it will have to participate in the federal Exchange.

PHI provided testimony (pdf) in the House and the Senate in support of Michigan creating our own Exchange and letting legislators know how the MiHealth Marketplace will help many direct-care workers and long-term care employers across the state.   We have also been very active with the Michigan Consumers for Healthcare in talking with legislators urging their support for moving forward with implementation.  Last month, PHI-Michigan participated in a press conference with MCH to outline our priorities in what a Michigan Exchange should look like, including the following:

• Consumer representation on the Exchange Board and not allowing the insurance industry to have a voting seat on the Board.
• Move beyond the “Orbitz for Healthcare” model by providing other ways for workers to get information about their health care options, including allowing community organizations to act as Navigators.
• Seamless enrollment in Medicaid to allow workers to move between Medicaid and private insurance to do so without gaps in coverage.

Even with the victory in the Committee, we still have long road ahead to creating a Michigan Exchange.  Many  legislators are opposed to the Exchange or even implementing the ACA  in Michigan.  It is important for them to hear from you about how the it will help make quality health coverage more accessible and affordable.  If you would like to get involved or contact your legislature, please contact Tameshia Bridges at tbridges@phintional.org.

The Alzheimer’s Association, New York City Chapter (AlzNYC), is offering a free monthly newsletter, ADvancing Care, to people who work in nursing homes and other residential care settings as well as to the families and friends of those who reside there.

To subscribe and read the current and past issues, visit the AlzNYC website.

New York City Council Speaker Christine Quinn

New York City Council Speaker Christine Quinn outlined her vision for how the city can both create jobs and build long-term economic security in an October 18 speech.

Among the initiatives intended to help recent immigrants and low-income workers improve their job prospects is an expansion of training for home care workers to help them get jobs in the growing health care sector.

The City Council is working with PHI and 1199 SEIU to train an additional 200 New Yorkers per year in home health care and to also address stabilization efforts across the home care sector.

“PHI thanks Speaker Quinn and the City Council for investing in the home care workforce to ensure quality jobs for low-income workers and better care for elders and people with living with disabilities in New York City,” said PHI President Steven Dawson.

Increase in Demand for Home Care Workforce

Quinn says that the following recent state changes are expected to have a large impact on the home care workforce, making it an ideal time to support this vital industry:

• As the population ages, there will be an increased demand for health professionals who care for disabled or home-bound individuals.
• New York State has mandated that all home care workers serving Medicaid recipients within geographic areas that have local living wage laws be paid a living wage (to be phased in beginning in 2012).
• New Yorkers who need more than 120 days of home and community-based long term care services — mostly dual eligibles — will be required to enroll in Managed Long Term Care (MLTC) plans beginning in April 2012, pending federal approval. Most MLTC plans will likely employ home health aides to ensure compliance with federal regulations and because these workers can perform health-related tasks.

“An enormous amount of upgrade training will be necessary to ensure that tens of thousands of personal care aides do not become unemployed due to these changes,” Quinn said.

Initiative Specifics

The City Council’s partnership with PHI will fund a RN-certified trainer to make it possible for PHI and its affiliate, Cooperative Home Care Associates (CHCA), to train new home health aides and help transition personal care aides who might not otherwise retain their jobs.

CHCA guarantees a job to any trainee who successfully completes the entry-level training.

Through the City Council’s partnership with 1199 SEIU, the 1199 SEIU Bill Michelson Home Care Education Fund will provide additional training and education services to support all home care workers — including individuals from CHCA — to achieve higher levels of education and employment by providing extensive ESL training, preparation for college enrollment, and other skill-building initiatives.

“By partnering with 1199 SEIU and PHI, the City Council is supporting a field that will see increased growth due to demographic shifts, and an agency that is committed to improving the quality of the profession and the stabilization of this field,” Quinn said.

Both the Massachusetts House and Senate have passed surplus reserve bills that would provide some direct-care workers in the state with a one-time wage supplement if the state has reserve tax revenues of at least $20.6 billion by January 15, 2012.

Eligible direct-care workers and human service workers who earn less than $40,000 a year would benefit from the legislation, which earmarks $10 million for a Direct-Care Worker’s Salary Reserve.

The wage supplement was included in the surplus reserve bills because the direct-care workers who will likely be eligible have not received a wage raise in three years, explained PHI Massachusetts Policy Director Amy Robins.

While the language in the bill does not provide much detail, Lisa Gurgone, executive director of the Massachusetts Council for Home Care Aide Services, said that the language tracked previous legislation that made clear which workers would be eligible for the salary reserve wage supplement.

The direct-care workers who were eligible in 2009 were:

• homemakers and personal care homemakers who provide long-term services and supports to clients enrolled in the Massachusetts Home Care Program administered through the state’s Executive Office of Elder Affairs and the Massachusetts Rehabilitation Commission;
• direct-care workers who are employed by social service agencies that contract with Commonwealth’s Executive Office of Health and Human Services; and
• home health aides who work as homemakers and personal care homemakers for agencies that have contracts with Aging Services Access Points, which provide case management services and long-term services and supports to elders.

Direct-care workers who are employed in settings such as nursing homes, certified home health agencies, and assisted living facilities that are paid “class-rates” (set by the state’s Health and Human Services Division of Health Care Finance and Policy) would most likely not be eligible for the bonus.

In fiscal year 2009, direct-care workers received a one-time salary reserve bonus, but the subsequent state budgets lacked adequate funding for a salary reserve.

According to the Associated Press, 30,000 direct-care workers would be eligible for the salary reserve bonus should the bill be signed into law.

It is anticipated that Massachusetts Governor Deval Patrick will sign the supplemental budget proposal, but he could still veto the Direct-Care Worker’s Salary Reserve provision.

– by Deane Beebe

PHI Michigan Senior Workforce Advocate Tameshia Bridges (at podium) with fellow MCH members

The Michigan Consumers for Healthcare (MCH) coalition held a press conference on October 11 to announce its support for a Senate bill to establish a state health insurance exchange and to offer recommendations on how to improve the legislation.

Under the Affordable Care Act (ACA), every state is required to create a health insurance exchange by 2014; the federal government is responsible for creating an exchange for states that do not comply with the law.

The MCH coalition, of which PHI Michigan is a member, is urging that the bill (SB 693) be modified to ensure that the proposed exchange’s governing board has a “dominant pro-consumer presence and culture,” and that there is “streamlined access to healthcare coverage for the state’s poor and underinsured.”

MCH is calling for the legislation’s proposed “opt-in” provision for Medicaid, MIChild, and other state-supported programs to be replaced with a “presumptive eligibility clause.”

“As the consumer voice for affordable, accessible, quality healthcare in our state, Michigan Consumers for Healthcare wants to see the proposed MIHealth Marketplace expand access, increase competition, reduce premium costs, be customer-service oriented and work for small businesses and individuals alike,” said MCH Director Don Hazaert.

Seamless Interaction with Medicaid Important to Direct-Care Workforce

Speaking at the press conference, PHI Michigan Senior Workforce Advocate Tameshia Bridges, a MCH board member, reported that 32 percent of Michigan’s 156,000 direct-care workers are uninsured (pdf). Direct-care workers in Michigan are three times more likely than the state’s general population to lack insurance.

“Seamless interaction between Medicaid and the proposed MIHealth Marketplace is important for the direct-care workforce,” Bridges said.

“Due to the low-wage and largely part-time work status of these workers, it is likely they will churn between Medicaid and private coverage, or that their families will get coverage from both sources,” she added.

Must Be a Reliable and Trusted Resource

The coalition also recommends that the bill’s language state that community organizations can serve as “navigators” for the exchange, and that specialized training be mandated for anyone serving as a navigator.

“Having credible and reliable people to explain health care options to both workers and employers has been shown to play an important role in boosting enrollment in other states with health care expansion programs,” Bridges said.

“The MIHealth marketplace must be seen as an accessible and trusted resource that direct-care workers can turn to for the health coverage options available to them, as well as for information that will help them determine the plan that best meets their needs.”

– by Deane Beebe

MRT Managed Long Term Care Implementation and Waiver Redesign Workgroup

Carol Rodat, PHI’s New York Policy Director, sits on the Managed Long Term Care Implementation and Waiver Redesign workgroup, which has been asked to advise DOH on the development of care coordination models to be used in the mandatory enrollment of persons in need of more than 120 days of community-based long term care services.  Specific areas that are of interest include but are not limited to:  care coordination model draft principles; enrollment processes; integration of consumer direction; transition from fee for service; and consumer protections.  The workgroup has met three times this year, and established separate subcommittees on Fair Hearings and Quality Metrics.   Final recommendations will be presented and voted on at the November 1 MRT meeting.

MRT Workforce Flexibility and Change of Scope of Practice Workgroup

Peggy Powell, PHI’s National Director of Workforce Development and Curriculum Design, was recently appointed to the Workforce Flexibility and Change of Scope of Practice Workgroup, which will meet at least three times before making recommendations to the MRT, which will be voted on December 13.

This workgroup will develop a multi-year strategy to redefine and develop the workforce, to ensure that the comprehensive health care needs of New York’s population are met in the future. The proposed strategy will include redefining the roles of certain types of providers and aligning training and certification requirements with workforce development goals.

Smaller groups within this work group will focus on several issues:

• Permit nurses (under their scope of practice exemption) to orient/direct home health aides (HHAs) and primary care workers to provide nursing care as is currently allowed in the consumer-directed personal assistance program;
• Allow licensed practical nurses (LPNs) to complete assessments in long-term care settings;
• Extend the use of medication aides into nursing homes;
• Expand the scope of practice of HHAs to include the administration of pre-poured medications to both self-directing and non-self-directing individuals; and,
• Expand the scope of practice to allow dental hygienists to address the need for services in underserved areas.

Many of the provisions within the New York State budget for fiscal year 2011-2012 included moving long-term care services into some form of managed care, the first of which began to be implemented this year.

Governor Cuomo and New York State legislative leaders agreed to a budget for fiscal year 2011-2012 on March 31, 2011 that eliminated a $10 billion deficit and cut total Medicaid spending by $2.8 billion.

Personal Care Carve-In to Managed Care

Starting August 1, 2011, personal care services became part of the Medicaid Managed Care (MMC) benefit package.  At this time, most personal care agencies have signed contracts with the managed care plans. However, a client that has an existing relationship with a personal care agency that is non-participating (does not have a signed contract) with their managed care plan shall be permitted to continue receiving personal care services up to 60 days from August 1, with extensions by the plan as appropriate. These policies were put in place to ensure continuity of care.

This change does NOT affect personal care clients who are:

• dually eligible for Medicare and Medicaid,
• required to “spend-down” in order to be eligible for Medicaid, or
• currently in a Consumer Directed Personal Assistant Program (CDPAP).

Dual beneficiaries who require more than 120 days of care will receive their personal care services through another form of managed care –managed long-term care plans (MLTCs), a PACE program, or Medicaid Advantage Plus – beginning April 2012.  CDPAP services are expected to be included as a benefit in both MMC and MLTC as of July 2012.

Positive Impact on Home Care Workers

Included in the appendix of all standard clauses between the managed care plans and personal care agencies is language reflecting the living wage law that is in place in New York City, Westchester, Nassau and Suffolk counties.  Plans must reimburse agencies at the rates previously negotiated with the New York City Human Resource Administration (HRA) between August 1, 2011 through February 29, 2012.  These rates support the living wage level of reimbursement, currently at $10 per hour, for all home attendants employed by these personal care agencies.

Effective March 1, 2012, all personal care agencies in New York City shall be required to comply with the parity provisions that were included in the budget. Personal care agencies in Nassau, Suffolk and Westchester must also comply with the living wage requirements set in statute, starting March 1, 2013.  All providers will certify to their contractors – the managed care plans – that they reimburse all home attendants as required by this section.

PHI supports the transitional policies and living wage language laws currently implemented, as they ensure continuity of care for both the personal care client and the worker.

A recent Op-Ed by Charles Blow in The New York Times describes blue-collar and low-wage workers in simple yet powerful words. Direct-care workers are counted among those that he describes as, “They are honest people who do honest work — crack-the-bones work; lift-it, chop-it, empty-it, glide-it-in-smooth work; feel-the-flames-up-close work; crawl-down-in-there work — things that no one wants to do but that someone must.”

He rightly points to what many of who care about this workforce know – that though they are invisible to many policymakers, they are part of backbone of this country.

PHI’s Michigan’s Direct-Care Workforce: A Smart Target for Creating Better Opportunities and Better Jobs sheds light on the direct-care workforce as a critical part of Michigan’s economy. It also shows areas where both the Michigan Department of Community Health and Michigan Economic Development Corporation can make investments that will the improve quality of jobs and long-term supports services and the ability of employers to attract and retain qualified, trained staff.

Suggested investments include:

• Develop a system to regularly assess the volume, stability, and compensation of Michigan’s direct-care workforce.
• Update the state’s training program for certified nursing assistants (CNA) beyond the federal minimum of 75 hours.
• Include incentives that support employers’ ability to provide training and develop sector-specific strategies to enhance this workforce.

Massachusetts State House in Boston

PHI Massachusetts lent its support to two bills at a July 19 hearing on home and community health care provider policies, held by the Joint Committee on Public Health.

“An Act Relating to Training for Certified Nurses’ Aides and Direct-Care Workers,” Senate Bill 1121, calls for a review of current training standards for home health aides and certified nurse aides (CNAs) in the state.

“An Act Relative to Home Health Aides,” Senate Bill 1138, would expand the current role of home health aides (HHAs) in the state and, with appropriate training and oversight, allow them to administer some medications.

Facilitating a Career Lattice

Passage of the training standards bill would be well-timed: Massachusetts is one of six states to receive a Personal and Home Care Aide State Training (PHCAST) demonstration grant from the Department of Health and Human Services.

“The PHCAST demonstration grant will position Massachusetts as a leader on training standards for personal care attendants and personal care aides nationally — and also lay the foundation for a portable credential in the state,” said PHI Massachusetts State Director Amy Robins in her hearing testimony.

“A close examination of training standards for CNAs and HHAs could help facilitate the creation of a clearly articulated and intentional career lattice among direct-care occupations. This would allow workers to advance to new positions and move across settings — keys to cultivating, recruiting, and retaining the direct-care workforce Massachusetts will need in the coming years,” Robins’ testimony (pdf) concluded.

Medication Administration

Senate Bill 1138 provides a very attainable advancement opportunity for HHAs who are interested in medication administration.

“The experience of others demonstrates that this can be done safely and effectively — and that this strategy also helps ensure the best value for our health care spending, with all working to the top of their training and licensing,” Robins’ testimony (pdf) said.

The bill “would send a clear signal that the state recognizes the importance of this vital workforce and the need to do more to improve these jobs and create meaningful advancement opportunities,” her testimony continued.

There are nearly 100,000 direct-care workers in Massachusetts. Direct-care jobs are the second largest occupational grouping in the state and are expected to grow by 22 percent by 2016, dramatically outpacing the growth of other jobs.

Home and community-based direct-care jobs are among the state’s lowest-paying jobs, paying wages that fall below the state’s low-wage threshold.

“Quite simply, the state must do more to cultivate a high-quality, well-trained and stable workforce,” Robins says. “These two bills are important steps in the right direction.”

For more information on the direct-care workforce in Massachusetts, see State Facts: Massachusetts’ Direct-Care Workforce (pdf).

– by the PHI Policy team

Recently the New York State Department of Health (DOH) announced the names of some of the members of the workgroups for Governor Andrew Cuomo’s Medicaid Redesign Team (MRT) effort.  Three of the nine workgroups that are charged with the work to implement key provisions of the MRT proposal are:

• Managed Long Term Care (MLTC) Implementation and Waiver Redesign;
• Behavioral Health Reform; and
• Program Streamlining and State/Local Responsibilities. 

The MRT was charged with identifying the best ways to reduce costs and improve the health delivery system in the state. Most of the team’s 79 recommendations were incorporated into the 2011-2012 New York State Budget, which passed on March 31.  The budget included sweeping legislation that will dramatically alter the way the state pays for and delivers Medicaid services, particularly in home- and community-based settings. 

Profound Impact of MLTC Reforms

Included in the New York State budget is a proposal to expand the use of capitated care management models, which – combined with reimbursement cuts – has the potential to change the landscape of home care.  

Beginning in New York City in April 2012, all people with Medicaid and the “dually eligible” — people with Medicare and Medicaid coverage — over the age of 21 who need community-based long-term care services for more than 120 days will be required to enroll in a MLTC plan or another care coordination program. New York State will first need the federal government’s permission to implement its plan.

DOH anticipates transitioning approximately 2,000 clients a month into a MLTC plan over a period of three years. MLTC plan is a term that applies to New York’s Medicaid Managed Long Term Care plans, Medicaid Advantage Plus, or the Program of All-inclusive Services for the Elderly (PACE).

PHI Role within Reform

Carol Rodat, PHI New York policy director, and Marilyn Saviola, director of advocacy at Independence Care System (ICS) – the PHI-affiliated managed long-term care organization – were both named to the MRT Managed LTC workgroup. 

The MRT Managed LTC workgroup is charged with, among other things, the task of advising DOH on:

• the development of care coordination models to be used in the mandatory enrollment;
• processes to ensure patient protections and access;
• continuity of services; and
• avoidance of nursing home placement and hospital stays.

PHI and ICS have been active proponents for wage improvements for home health aides as well as the greater use of care management models. Both of these provisions were in the blueprint (pdf) they presented to the MRT.

The New York State MRT website contains a list of all participants and meeting dates for the three MRT workgroups, as well as additional MRT information.