Increased wages for pediatric home nurses can bring more hospitalized children back home to their parents.
ThinkAdvisor recently published an article about numerous cases across the country in which hospitalized children are cleared to return home but cannot due to the severe shortage of home care nurses. This means that these children must live in the hospital or other institution until they can get the nursing care they need at home. This lack of available skilled nurses has created a huge financial and emotional strain on these children’s parents and families.
So where are these nurses? Making higher wages in other settings and industries. Even though home nursing is almost always less expensive than hospital care, private insurance rarely covers the service and Medicaid pays very little for it. This leaves few nurses willing to work for these low wages, especially when they can receive higher pay in other settings or other industries entirely.
But it doesn’t have to be this way! Increasing the reimbursement rate for in-home nurses is possible, and increased wages increase parents’ access to in-home nursing care for their child. In Pennsylvania, for example, BAYADA home health care employees, clients, and clients’ family members advocated for a pediatric nursing rate increase and received a $5 per hour increase. BAYADA saw open hours for the program decrease by nearly 50% for one of our largest payors.
A parent coalition in Massachusetts successfully advocated for increased reimbursement rates after over a decade of stagnant rates. But in Massachusetts, the increase still is not enough—parents say that the wages remain too low to attract and retain enough home nurses for their state’s medically complex pediatric population.
In Pennsylvania, Massachusetts and in other states around the nation fighting an in-home nursing shortage, advocacy is the key. It’s important that we raise our voices about this issue so that legislators can understand what home care means to parents of medically complex children.
If you are interested in finding out what you can do to help bring these children home, let’s chat! Shoot an email to firstname.lastname@example.org.
Recent conversations with MCC Waiver Administrator Michelle White have revealed that the time is right to explore making significant changes in the nursing reimbursement model. GAO has formed two workgroups to analyze and evaluate options to address Medicaid policy and its reimbursement model for nursing.
First, we’ve formed a BAYADA technical expert group representing the relevant practices and leadership to help inform BAYADA’s recommendations. The second group is a larger provider workgroup within the SC Association for Home Care & Hospice. As a SCAHHC Board member, I have been asked to co-chair this workgroup to draft industry recommendations. BAYADA will draw from its internal workgroup to inform the conversation with the industry and Medicaid. This is a great opportunity to address the challenges and recommend a unified solution to DHHS that can be a win-win for providers, the state, and ultimately- clients.
Thank you to the SC Advisory Council and the workgroups! I look forward to working with you to develop recommendations that will lead to better outcomes for our staff, clients and their families!
Dave Totaro served as a panelist to inform Commissioners about lessons learned from Managed Care and MLTSS implementation in BAYADA states.
Last Thursday BAYADA Home Health Care’s Chief Government Affairs Officer Dave Totaro served as a panelist during the Medicaid and CHIP Payment and Access Commission’s (MACPAC) public meeting in Washington, DC. This opportunity was especially unique and important for BAYADA because MACPAC serves to provide policy and data analysis and make recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and CHIP. We are optimistic that Dave’s insights will help shape the Commission’s future recommendations on state and federal Managed Care and MLTSS policies and procedures.
MACPAC extended the invitation to Dave to serve as the panel’s provider representative due to BAYADA’s experience with Managed Long Term Services and Supports (MLTSS) and managed care implementation across a number of states. Dave accepted the opportunity and successfully delivered his presentation in front of the 17-person Commission and a public audience, which included a number of congressional staffers and CMS representatives.
Aside from Dave, participating panelists were Dennis Heaphy, a MLTSS beneficiary and expert on public health from Massachusetts’s Disability Policy Consortium, and Michelle Bentzien-Purrington, Vice President of MLTSS and Duals Integration at Molina Healthcare. Dave’s presentation focused on BAYADA’s experience in implementing Managed Care across multiple states, particularly the lessons learned that can translate to better implementation in future states looking toward managed care and MLTSS.
Dave presented MLTSS implementation as a three-legged stool: Adequate rates, state supports, and federal process changes must all be in place for a successful rollout. Should one of the legs be faulty, then the entire operation is set to fail. The presentation described for the Commission:
The need for the state to set adequate reimbursement rates and why inadequate rates affect providers’ ability to recruit, retain, and compete, which can lead to an unhealthy provider network and, ultimately, an access to care issue
The need for states to protect a set adequate rate via a rate floor, and the need to regularly review and adjust this rate
The need for state oversight and regulation of MCOs so that providers can focus on care delivery rather than managing the administrative burdens and variable practices of each MCO
The importance of the federal government equalizing Home and Community Based Services with nursing home care to solve for the institutional bias that currently allows LTSS individuals to access facility care more easily than home and community-based care
The need for the federal government to collect uniform data so that MCOs and providers can work together to close care gaps and save the state money
Each section was accompanied by BAYADA-state specific examples, and the presentation concluded with a series of recommendations related to each of the above points. Throughout Dave’s presentation, the Commissioners and audience were engaged and following along to the accompanying PowerPoint. After his presentation, Commissioner Leanna George—the mother of a child currently living in an Intermediate Care Facility—positively commented that rate floor setting was as avenue towards ensuring adequate reimbursement rates that she had not heard of before.
During the Q&A portion of the meeting, Commissioner Brian Burwell asked that each panelist state which area of MLTSS the Commission should focus their research and attention. The other panelists echoed Dave’s sentiments regarding federal changes to rebalance HCBS with nursing home care to remove institutional biases that continue to affect beneficiaries who wish to remain at home.
After the panel wrapped up, Commission Chair Penny Thompson approached Dave to compliment him on his presentation, and Dave has already been contacted by MACPAC’s Executive Director Anne Schwartz regarding his future support and counsel on MLTSS. GAO is ready to work with the Commission on next steps and is excited to be at the table to help recommend policies that are favorable to home care providers.
Thank you to all BAYADA colleagues that assisted Dave in the research and creation of this presentation:
At the end of June, 2017, through the efforts of our Ambassadors, our industry partners, our clients, and our legislative champions, the Rate Floor Bill passed the Delaware General Assembly.
This year, in the second year of Delaware’s two-year legislative session, our major legislative goal is to achieve an increase in the Medicaid fee schedule for RN and LPN hourly care. These two rates have stagnated since 2006. We are asking the legislature to update both according to the Consumer Price Index. Doing so would move LPN care from $46.14 to $56.01 and RN care from $51.50 to $62.51 per hour.
Our initial meetings with key members of the Joint Finance Committee have been very positive. We are working with them to include increased funding for this request in this year’s budget. If successful, our MCO contracts would have to be renegotiated so that reimbursement would be equal to or greater than the new fee schedule amounts.
This session, our major legislative goal in Maryland is to increase the Medicaid LPN rate across all programs and client groups from $34.16 to $42.81. It is an ambitious goal—initial budget estimates place the cost to the state at $26 million per year. With neighboring states reimbursing LPN care at $45, $46.14 and $50 per hour, it is easy to see why there is such a problem of access to care across Maryland. The low reimbursement simply does not support a sufficient wage to be able to consistently recruit and retain the skilled nurses that we need to be able to commit to serving a larger number of clients.
Problems within the Maryland Department of Health and a general lack of transparency have hindered this effort in past months. There have been a few targeted data points essential to such a large budget ask that BAYADA and Maryland-National Capital Homecare Association (MNCHA) through our best efforts, have been unable to obtain.
We started this session asking key legislative champions to help us get this information, using their political pressure to get information from the Department of Health or to introduce legislation that would establish an oversight working group to investigate the issue. Several legislators have been deeply troubled by the idea of children and adults with disabilities being unable to access the skilled nursing care they need to remain at home safely and have stepped up to help. This information, and the support we are gaining from those in key positions to move this effort through to becoming law, is a key step in increasing this LPN rate.
Thank you to Ambassadors Dan Guidebeck, Nikita Mutter, and Matt Paske for joining in legislative meetings and sharing the stories of how this issue impacts our clients and employees. Your commitment to advocacy reminds me of why we do what we do every day.
2017 proved to be another eventful year for home care in Pennsylvania. Notably, MCO implementation of the increased pediatric rate went into effect on January 1, 2017. As a result, our pediatric offices have been able to implement various programs for our nurses including increased wages, benefits, and bonuses throughout the year.
Early in 2017 the PA Government Affairs Office (GAO) worked with NJ GAO Director Louise Lindenmeier to lobby against New Jersey Governor Christie’s intent to end the NJ/PA tax reciprocity agreement. We were successful in getting the over 40-year agreement reinstated, thus saving BAYADA employees over $6 million in taxes.
Throughout the year we were active participants in PA’s move towards full implementation of Community Health Choices (CHC). Our participation, as well as that of others in the industry, resulted in a temporaryrate floor for personal assistance services. The rate floor ensures that implementation of CHC will not result in rate cuts for services within the program.
In May we submitted comments in favor of an “open” electronic visit verification (EVV) system, which would be more beneficial to our employees and to BAYADA than a closed system. The administration heard our concerns and is now planning to implement an open system. See our next article to learn more about PA’s EVV system.
Finally, PA took unprecedented steps by introducing legislation which would allow deemed eligibility for home care. This legislation takes a big step toward equalizing access to home and community based services as it would allow those who appear to financially qualify for nursing home services to be deemed eligible for home care services as well. After the legislation was introduced it was voted unanimously out of the House Public Health and Appropriations Committees and was voted out of the full House unanimously. Next up in the long and winding legislative process: The bill will now be considered in the Senate.
Towards the end of 2017 the PA GAO conducted a needs assessment with our PA division directors. Upon completion of the needs assessment our PA GAO Advisory Council met and recommended the following priorities for 2018:
Increase the personal assistance service rate by an average of 10%, creating a statewide reimbursement rate of $20.58 by 6/30/18.
Pass deemed eligibility for home care through legislation by 4Q18 (continuation of 2017 goal).
Allow physician signatures to be obtained within 30 days instead of 7 days.
Include requisite reimbursement increases in any state minimum wage increase.
Pass drug disposal legislation for Hospice.
Support the passage of Pennsylvania Orders for Life-Sustaining Treatment (POLST) legislation.
Lay the foundation for rate floor legislation in Pennsylvania.
Our PA legislative priorities have been approved by BAYADA’s Chief Executive Officer. We are looking forward to an exciting and challenging year ahead! Thank you to all PA staff, clients and families for your support and commitment to advocacy. Your efforts are paramount to our efforts to ensure that all Pennsylvanians can live a safe home life with comfort, independence, and dignity.
Last month the GAO Advisory Committee met to evaluate our 2017 efforts and to plan for 2018. The Advisory Committee is made up of representation of every practice in NC as well as representation from CMO and GAO. Below is a summary of their findings and the priorities for 2018.
2017 Legislative Accomplishments With your help we accomplished the following:
• Secured an increase for Medicaid aide services under the Personal Care Services (PCS) Program and the Community Alternatives Program for Children (CAP-C) from $13.88 to $15.52, effective August 1, 2017, and to $15.60 effective January 1, 2018. BAYADA impact: $300K annually. These increases will allow us to hire and retain more quality staff. • Protected Certificate of Need (CON) and prevented its elimination from health care. Also prevented the Continuing Care Retirement Communities (CCRCs) from operating a home health agency without a CON. The CCRCs were seeking a carve-out from CON statute. Four separate bills were filed to eliminate this statute. BAYADA impact: Protected 5 service offices that serve Medicare clients. This issue is likely to re-surface in 2018. • Secured a 7.5% tax exclusion for health care services on all revenue. BAYADA impact: All 54 NC service offices will save a collective $12.6M annually.
2018 Key Legislative Priorities:
• Amend the Community Alternatives Program for Disabled Adults (CAP-DA) budget neutrality language to allow the aide rate to be increased from $13.88 to $15.60 to align with the PCS and CAP-C rate increases effective Oct. 1, 2018, by Q4-2018. • Secure a $1.40 increase for all Medicaid aide services from $15.60 to $17.00 effective Jan. 1, 2019, by Q3-2018. • Prevent the elimination of Certificate of Need (CON) for home health or hospice by Q3-2018. • Ensure that the Medicaid Transformation waiver includes a rate floor provision and language that ensures access to quality care and minimal administrative burden by Q4-2018.
Submitted by Louise Lindenmeier, Director, NJ Government Affairs (GAO)
Chief Government Affairs Officer Dave Totaro, State Assistive Care Practice Leader Eric Thul, and Director, Strategy & Value-Based Partnerships Matt Lippitt met with New Jersey Governor Chris Christie to discuss the recently signed law which sets a floor for minimum reimbursement under managed Medicaid for Personal Care Assistant Care. Our team explained the challenges under managed Medicaid, how reimbursement is used to support personal care services, and the wage needs of the home health aides. The meeting was very informative for both the Governor and us, and served as an excellent start towards addressing the unintended consequences of the Governor’s conditional veto.
On July 13, Assemblyman Troy Singleton and Senate Majority Leader Loretta Weinberg introduced legislation A5089/S3400 which increases the New Jersey private duty nursing rate under State Fee-For-Service Medicaid by $10 per hour for registered nurses and licensed practical nurses. The last rate increase for private duty nursing was in 2008. BAYADA has been working with the Home Care Association and other providers discussing the need for a rate increase as it is difficult to recruit and retain nurses. BAYADA did an internal study and found of the scheduled hours, only 72% of those hours were filled, leaving clients and families without care.
Submitted by Lee Dobson, Area Director, NC Government Affairs (GAO)
On August 16, Representative John Fraley visited with staff from our Lake Norman adult office before heading to meet with his constituent, our client, Mr. Bachner. Associate Lauren Keys, the Hearts for Home Care Ambassador who organized the home visits, commented “Rep. Fraley came prepared with good questions about home care and Medicaid reform. While he doesn’t sit on a health committee, he wanted to learn about our issues.” Clinical Manager Mary Hope Milligan and Client Services Manager Lucas Reives both described our recruiting challenges.
Mr. Bachner, a 90-year old WWII, Korean, and Vietnam vet, was a delight. He shared many stories of his life, his children, and his service to our country. It was especially heartwarming to hear how he met his wife, Cora, and after a week proposed marriage – a marriage that lasted 60-year.
While Mr. Bachner is satisfied with his Veterans Administration (VA) benefits, we took this opportunity to share with Rep. Fraley the disparity between VA and Medicaid and how difficult it is to staff under Medicaid because the rates are so low. As a retired businessman, Rep. Fraley understood and said, “Thank you for opportunity to meet with BAYADA staff and Mr. Bachner. This was a good learning experience for me, as well as, a treat!“ As our meeting concluded, he commented that all he needed to remember was that we’re looking to get to $17.00 per hour next session.