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NY Capitol Building in Albany

Recently the New York State Department of Health (DOH) announced the members of some of the workgroups for Governor Andrew Cuomo‘s Medicaid Redesign Team (MRT) effort.

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.

PHI Role within Reform

PHI New York Policy Director Carol Rodat 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 Long Term Care (MLTC) Implementation and Waiver Redesign 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 for the greater use of care management models. Both of these provisions were in the blueprint (pdf) they presented to the MRT.

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 with New York City residents in April 2012, all adults over the age of 21 covered by Medicaid — or “dually eligible” for Medicare and Medicaid coverage — 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. A 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).

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

– by Meghan Shineman, PHI New York Policy Analyst

Texas state capitol building in Austin

After several months of debate, potentially devastating cuts to Texas’s Medicaid reimbursement rates have been deleted from the state budget proposal, which was approved by a House-Senate committee on May 17.

The cuts — which had been supported primarily by the Republican-dominated Texas House — would have slashed Medicaid reimbursement rates for nursing homes by up to 10 percent. With the loss of matching federal funds factored in, the overall cut would have been closer to 33 percent.

Health care advocates had argued that as many as 80 percent of Texas’s nursing homes would have been forced to shut down as a result of the proposed cuts.

In a statement, the Texas Health Care Association said that, by maintaining the current Medicaid reimbursement rate, the latest budget proposal “will bring the Texas nursing home profession back from the brink of disaster and avert significant nursing home closures and job losses” if it is signed into law.

Concerns Remain

Health care advocates say they still have concerns about the latest version of the budget proposal, however.

Although the current Medicaid reimbursement rates are maintained in the next budget, advocates say they are still not high enough to genuinely influence the quality of care in Texas.

“We should never let ourselves become convinced that current reimbursement rates to nursing homes or home care providers are truly adequate to cover costs or entice direct-care workers to seek employment within this sector,” said Jane Bavineau, the executive director of Care for Elders, a Houston-based organization that focuses on eldercare issues.

“It is difficult now, and it will surely become more difficult in the years ahead,” Bavineau continued.

Indeed, the decision to maintain the current reimbursement rate for nursing homes will create an instant shortfall of $4.8 billion, which lawmakers will have to reckon with in 2013, the next time Texas has to submit a budget.

Community-Based Care Targeted

Additionally, the House-Senate committee agreed to cut $15 million from Community Based Alternatives (CBA), Texas’s Medicaid waiver program.

CBA coordinates the delivery of home care to Medicaid-eligible older adults and people living with disabilities who would otherwise have to live in a nursing home.

The cut represents approximately half of CBA’s budget.

The proposed $15 million cut “will harm home care agencies, which by definition harms consumers and direct-care workers,” said Dennis Borel, executive director of the Coalition of Texans with Disabilities.

“The tighter the belt, the harder it is for us to provide the care needed,” said Renee Tillman, a direct-care worker in Texas and the founding president of the Texas Association of Nurse Assistants.

Borel also said that he suspects that some home health agencies — particularly those in Texas’s sparsely populated rural areas — would not survive such a severe reduction in funding.

Health care advocates — including the Coalition of Texans with Disabilities — successfully fended off an attempt by the legislature to also cut CBA home care workers’ wages to the federal minimum of $7.25 an hour, from approximately $8.

– by Matthew Ozga

In an April 26 letter to the Centers for Medicare and Medicaid Services (CMS), PHI filed its comments to the proposed rule (pdf) on the implementation of the Community First Choice Option (CFC).

PHI recommended that CMS recognize the impact of the direct-care workforce on the cost and quality of home- and community-based services (HCBS), as well as consumer access to those services, by incorporating specific direct-care workforce criteria in the draft rule.

The CFC program is an optional state Medicaid program created under the Affordable Care Act to provide individuals with disabilities who are eligible for nursing homes and other institutional settings with options to receive community-based services.

It also expands the definition of attendant care and allows for payment of other services, such as one month’s rent, if it helps the individual with their transition from an institution to the community.

Invest in Workforce Compensation

In a letter (pdf) to CMS Administrator Don Berwick, PHI Government Affairs Director Carol Regan raises concern that the proposed CFC rule does not explicitly recognize “the building of a far more stable and available home care workforce” as an “essential component” of efforts to expand home- and community-based services to a broader population.

Beginning in October 2011, states that choose to participate in the CFC will receive a 6 percent increase in federal Medicaid matching funds. PHI advises that “a portion of these funds should be invested in workforce compensation, an investment that has been shown to improve recruitment and retention and thus quality of care.”

Building a Workforce to Meet Program Goals

PHI recommends that CMS include provisions in the CFC regulations that will enable states to take on responsibility for building a consumer-directed workforce that is sufficient to meet the program goals, by:

• Ensuring adequate compensation for direct-care workers;
• Establishing consumer-workforce labor market intermediaries or registries;
• Implementing data systems to monitor the direct-care workforce; and
• Including workers and their representatives on the Development and Implementation Councils.

PHI’s comments include the growing body of evidence about how the lack of available direct-care workers is already limiting access to HCBS; how poor compensation is a leading barrier to recruitment, retention, and quality; and how policy steps are needed to fill our nation’s “care gap.”

PHI’s comments (pdf) on the proposed rule for the implementation of CFC are available on the PHI PolicyWorks site.

– by Deane Beebe

The Friday Morning Collaborative is hosting the third webinar in its “Medicaid Home- and Community-Based Services” series for state advocates.

The next webinar, “Implications of Medicaid Block Grants and Spending Caps for Seniors and People with Disabilities,” will take place on May 6, 2:00-3:30 PM EST.

Speakers include:

• John Holahan, Urban Institute
• Edwin Park, Center on Budget and Policy Priorities
• Patricia Nemore, Center for Medicare Advocacy

Registration is required. Space is limited; participants are urged to share phone lines.

The first two webinars in the series, “State Budgets: Challenges and Opportunities for Home and Community-Based Services” and “Cost-Effectiveness of Home and Community-Based Services,” are available online.

The Friday Morning Collaborative is a coalition of national aging and disability organizations working together to protect and strengthen Medicaid home- and community-based services.

The webinar series is made possible with support from The SCAN Foundation.

– by Deane Beebe

NY Capitol Building in Albany

The New York State Budget for 2011-2012, passed on March 31, includes sweeping legislation that will dramatically alter the way New York pays for and delivers Medicaid services, particularly in home- and community-based settings.

Most of the recommendations of Governor Andrew Cuomo’s Medicaid Redesign Team (MRT), which was charged with identifying the best ways to reduce costs and improve the health delivery system, were incorporated.

PHI has been an active proponent for two key measures that were included in the budget:

• Wage parity for home health aides: Organizations providing Medicaid services in the downstate area — New York City and Westchester, Nassau, and Suffolk counties — are required to compensate their home health aides using the living wage of that geographic area, which will result in an hourly wage increase of $2. As a result, home health aides will earn the same wage as personal care aides.
• Care management models and the integration of services within capitated models of care: Beginning in April 2012, consumers who need more than 120 days of community-based long-term care will transition into care management models. And personal care will be incorporated into the Medicaid managed care benefit once the state gets approval from the federal government.

PHI and Independence Care System Provided Blueprint for Reform

PHI and its affiliated managed long-term care organization, Independence Care System, advocated for the 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.

Once implemented, these provisions will increase efficiency and address a long-standing inequity in the pay for home health aides.

“Home health aides have always been underpaid for the difficult, sensitive, and important work they do,” says Assembly Member Richard N. Gottfried.

“At some home health agencies, the under-compensation has been shocking. The living wage provision in the state budget, together with other reforms, will bring more fairness to home health aides, reduce costly turnover that reduces quality, assure more appropriate services, and reasonably contain costs. However, it is important that these reforms be implemented carefully, to avoid disruption and unintended damage to good providers,” Gottfried said.

Living Wage Implementation

In New York City, parity with the personal care aides, who currently earn $10 an hour, would be implemented over a 3-year period. Home health aides will begin the transition to parity starting March 1, 2012.

Although Westchester, Nassau, and Suffolk counties have living wage laws in effect, the home health aides working in these counties will not receive an increase until March 1, 2013. However, aides in these counties may reach 115 percent of total compensation required under the New York City living wage law by March 2016.

Health care benefits and paid time off are determined by the collective bargaining agreement (CBA) in effect on January 1, 2011 or by the terms of the Living Wage law in the county in which care is delivered, if there is no union contract.

“This budget finally corrects an injustice that’s been in place for many years,” says PHI New York Policy Director Carol Rodat. “It’s not only good economic policy given the size of the home care aide workforce, but wage parity ensures continuity of care as it makes it possible for aides to remain with their clients when they transition to care management models.”

PHI Longtime Supporter of Wage Parity

PHI has been a strong advocate of improving jobs for home care workers as a means of reforming the Medicaid system. PHI has published several papers that detail the size, training, and health coverage of the home care workforce, including the inequities in the home health aide wages.

“The United Hospital Fund has long supported analytic work that focuses on the direct-care/home care workforce, beginning with the 1994 report, ‘Better Jobs, Better Care: Building the Home Care Work Force,’ and more recently through the support of three PHI reports on the aide workforce,” says UHF Senior Vice President for Program David Gould.

“We’re pleased that the state’s budget recognizes the importance of this workforce by providing a movement towards parity for the home health aides. This provision promises to encourage continuity of care while creating better jobs, and we applaud PHI for its work in this arena,” Gould added.

– by the PHI New York State Policy Team

The Friday Morning Collaborative is hosting the second webinar in its series to provide information and resources that may assist state advocates in preventing cuts to home and community-based services (HCBS), while promoting the adoption of new options in the Affordable Care Act.

“Cost Effectiveness of Home and Community Based Services” will take place on March 25 from 2:00 to 3:30 PM EST.

Speakers will include:

• Stephen Kaye, Center for Personal Assistance Services, University of California San Francisco;
• Lisa Alecxih, The Lewin Group;
• K. Charlie Lakin, Research and Training Center on Community Living, University of Minnesota; and
• Dee Mahan, Families USA.

Due to limited space, anyone interested in participating should register early and share lines when possible. The webinar will also be recorded and made available for viewing following the event.

A recent AARP Public Policy Institute report documents how state budget cuts caused by the economic recession pose a serious threat to long-term care services for elders and individuals with physical disabilities.

The webinar series was kicked off in February with “State Budgets: Challenges and Opportunities for Home and Community Based Services.” The series is made possible with support from The Scan Foundation.

The Friday Morning Collaborative — of which PHI is a member — is a national coalition of aging and disability organizations working together to protect and strengthen Medicaid Home and Community Based Services (HCBS).

– by Deane Beebe