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Access to Independent Providers: OHT Finally Clarifies Proposal to Redesign Home Care Programs

The outcry over the Kasich administration’s proposed “elimination of Independent Providers (IPs)” has led finally to clarification, by the Ohio Office of Health Transformation, that their proposal “does not eliminate independent providers.”  

In February 2015, OHT announced that the budget “requires Medicaid to eliminate the ‘independent service provider’ option” as a means to “decrease programmatic fraud and abuse.” This announcement sent shockwaves through the disabilities, developmental disabilities and aging communities, especially among individuals and families relying on IPs for home care. For two weeks in March, the House Finance Subcommittee on Health & Human Services heard testimony from individuals and family members opposing theproposal. Many recounted their bad experiences using an agency and expressed their desire to maintain their choice of who provides their most intimate care – such as dressing, feeding, bathing, and toileting. In his testimony, John Lepley, MyCare Ohio enrollee and OCVIC Central Region member co-chair, said, “The Independent Provider program allowed me to find excellent quality home health aides who were loyal to me and not to an agency.  No longer did I have to worry if my aide was going to show up on time — or show up at all, for that matter.  As a student at The Ohio State University, this was instrumental in allowing me to attend classes and eventually graduate with my Bachelor’s degree.” (Testimony can be found on the House Finance: Health & Human Services Subcommittee’s website under March 18.)

However, despite OHT’s announcement, their proposal did not eliminate IP services, but rather make changes to comply with federal labor rules and expand Ohio’s “self-direction” program.  Self direction allows the consumer to act as the employer – recruit, hire, schedule, supervise and discharge their chosen home care providers. A financial management company is available to handle payroll, time sheets, paying workers’ compensation, and other administrative functions.

UHCAN Ohio and Ohio Consumer Voice for Integrated Care leaders learned from national experts that Ohio faced possible liability in its current system of reimbursing IPs as if they were contractors of services, when under federal law, they should be classified as employees. For that reason, OCVIC manager John Arnold asked the subcommittee:

  • That the provision eliminating Independent Providers be removed from HB 64 and be replaced with language creating a workgroup (comprised of consumers, advocates, community organizations, providers, legislators, state administrators, and other stakeholders) that is required to develop a consumer-directed option for long-term services and supports in the timeframe necessary to address the state’s concerns regarding state liability as the potential employer of record for Independent Providers.

On March 24, OHT hosted a stakeholder meeting at which they shared their goals for expanding self direction in Ohio’s Medicaid HCBS programs: Increase access to home and community based services, make self-direction an option in every HCBS waiver program, comply with federal fair labor standards, and improve quality of in-home direct care.  The state agreed that the budget language, including transition timetable would change, and that a workgroup will be created to work out details of the transition.

Don’t ever doubt the power of a strong consumer voice!


OCVIC’s other Budget Testimony

In testimony, OCVIC’s Project Manager had three other budget recommendations to help MyCare Ohio Consumers:

  1. That funding be included in the SFY 2016/2017 state budget to improve the capacity of the Office of the State Long Term Care Ombudsman, which has been designated as the place where MyCare members and families can go for help if they have concerns about their care.
  2. Ohio has developed the Aging and Disability Resource Network, (ADRN), administered by the Area Agencies on Aging, which is designed to help those individuals who need long-term services and supports remain at home or in the community rather than be admitted to a nursing facility. OCVIC recommends that additional funds be included in the SFY 2016/2017 state budget to be directed to the AAAs and their ADRN partners to assure that the front door works as it was designed.
  3. That language be added to HB 64 that would require the Department of Medicaid to contract for an independent MyCare evaluation. OCVIC is requesting that Ohio contract with an Ohio university to examine the processes that have been used by the state and the managed care organizations and to determine how those processes have affected the MyCare participants.

OCVIC coalition members are hopeful that, with these important funding additions, MyCare consumers will experience a smoother transition to receiving their acute care and long-term services and supports from Managed Care Organizations; that enrollees will have better health outcomes; and that Medicaid budget growth will be constrained.

Updated: The Choice of Self-Direction for People with Disabilities – A Big Step Forward, If Done Correctly

The disability rights movement  has long sought equal rights and opportunities, in areas such as transportation, education, and accommodations for people with physical or intellectual disabilities. The landmark 1999 US Supreme Court decision, Olmstead v. L.C., established that publicly funded programs must grant people with disabilities the choice to live in community-based settings, instead of institutions. For people with disabilities who rely on Medicaid to pay for assistance with the activities of daily living, one way to live independently is through the “self-direction option” available currently in MyCare Ohio and some Medicaid Waivers.   This includes serving as the employer of their home health aides (often with assistance from a third party to do payroll, taxes, and paperwork). With self-direction, the consumer is more in charge of their life, a key part of independent living.

Ohio has been slow to adopt real self-direction for people on Medicaid, (although many have been able to choose Independent Providers), but change is coming for all people receiving home care.

People self-directing their care often prefer to hire their own personal care assistants. Recent proposed changes in how Medicaid pays these Independent Providers  of home care catapulted the issue of self-direction to the forefront of Ohio’s budget and policy conversation. To recap, the Governor’s budget – House Bill 64, as introduced – proposed to eliminate payment of claims from Independent Providers (IPs), without adequately communicating the reason for the change (compliance with federal laws) or the alternative for retaining the choice of IPs. An uproar ensued from consumers and family members (and their IPs) who thought they would lose the right to hire IPs.  

Ohio Consumer Voice for Integrated Care (OCVIC), coordinated by UHCAN Ohio, has advocated strongly with the Kasich administration and other advocates to resolve the issue by offering consumers the option to self-direct and to do so through an open and transparent process with strong consumer representation. The Governor’s Office of Health Transformation (OHT) has stated its intention to expand “Self-Direction” by including that option in all Medicaid Waivers. OHT has convened a workgroup of stakeholders to help with the expansion of self-direction, with a key goal being to make it ‘do-able’ by consumers who choose it. The next step is for OHT to prevail upon the Senate to add its language to their version of HB 64. [Update: The Senate declined to add OHT’s language to the budget, so the workgroup, timetable, and guidelines for creating a self-direction option for all Ohioans is NOT in statute].

OHT’s amendment to HB 64 addresses most, but not all, stakeholder concerns. OCVIC is currently reviewing successful self-direction models in use in other states and will be sharing its findings with Ohio Medicaid officials and the workgroup. While the workgroup can make recommendations, OHT has the final say on the model(s) and funding. Thus, no guarantee exists that consumers will get the hours of care they need, that IPs will be paid a decent wage, or that self-direction will be affordable to consumers (given administrative costs). With existing federal law and pending implementation that require IPs to be paid as employees – with overtime, reimbursement for travel, and other protections – consumers and IPs face additional uncertainty about future pay and hours for IPs.

If OHT’s amendment becomes law and a workgroup is created to create a program on self-direction, advocates will have to remain well organized to make sure Ohio’s move to self-direction works for consumers and IPs. [Update: Since the amendment was not added, advocates for people with disabilities will have to gain a commitment from OHT to conduct a process with robust input from consumers and advocates.] In the meantime, MyCare Ohio, the integrated program for Ohio’s Medicare/Medicaid beneficiaries, has an existing requirement that all consumers have a choice of self-direction. But the choice is not real right now, because consumers requesting self-direction have found that plans do not have a smooth process or system in place. The MyCare plans have agreed to work with OCVIC – and allied stakeholders – to design a consumer-friendly self-direction program for MyCare that could become the model for all Ohio self-direction.

Working with Ohio and national experts, OCVIC hopes to make self-direction a genuine choice for all Ohioans in home care wanting to live independently.

Advocates Push for MyCare Ohio Evaluation in Budget

Legislators are well aware that last year’s MyCare enrollment into Medicaid managed care was chaotic for many of the 100,000 older adult and disabled Ohioans and that many problems persist. That’s why advocates for MyCare consumers were surprised that the Senate rejected a proposed amendment to authorize and fund an independent evaluation of Ohio, following the first year of the Medicaid enrollment.

Supported by Ohio Consumer Voice for Integrated Care, Area Agencies on Aging, and others, the proposed evaluation would examine consumer experiences with MyCare – their level of satisfaction, what choices they’ve made, how their lives have been impacted, whether they’ve experienced delays in getting needed services, whether they’re lives have been improved. Such an evaluation would allow advocates, consumers, and the managed care plans to both target areas of improvement and build upon aspects that are working well for consumers.

Given current debates over plans to integrate behavioral health services into Medicaid managed care, the evaluation of consumer experience during and after Medicaid managed care enrollment should offer perspective on potential risks and benefits, as well as safeguards to put into place. Many MyCare Ohio enrollees have multiple chronic health conditions or complex personal care needs, making disruptions in services potentially life-threatening. The same is true of people with serious mental illness, many of whom rely on a complex network of supports to remain stabilized.

MyCare Ohio is a three-year demonstration, at the end of which state and federal policymakers will have to make decisions on its future. Yet the federal evaluation of the demonstration will be conducted only after it has ended – too late to make mid-course corrections.

Ohio Consumer Voice for Integrated Care believes in the promise of MyCare Ohio – better care coordination across settings, better care, and better quality of life for dually eligible Ohioans who have received fragmented, often poor, care from two systems that were not designed to work together. But we know that much system and process improvement needs to happen before consumers realize the promise – and an early evaluation will help target those improvements.

OCVIC will continue to educate lawmakers about the benefits of the evaluation. Those who agree on the benefits of the evaluation can contact their state legislators to educate them as well.

Great News! National Accreditation Body Adopts Dental Therapy Education Standards

Ohio needs well-trained mid-level dental providers to improve our oral health so Ohioans can lead healthy, productive lives. But in order to introduce a new type of dental provider, we also need education standards (preferably national ones). Education standards guide community colleges and state universities in developing training programs for the new providers. Without education standards, colleges and universities have been unable to take the steps necessary to set up a program to educate and train Dental Therapists to practice in Ohio. But now the void has been filled.

Recently, the Commission on Dental Accreditation (CODA), the nationally recognized accrediting body for dental and dental-related professions, took a historic step to adopt Accreditation Standards for Dental Therapy Education Programs. That means Ohio educational institutions will now have the guidance they need to craft training programs to ensure the delivery of safe, effective routine dental care through Dental Therapists. Weighing in on this decision, Dr. Edward Sterling, DDS of Dublin, OH said, “The Commission on Dental Accreditation establishment of training standards for Dental Therapists is a critical step… Now, training goals and standards are established and can be measured to assure they are met – the same way it is done throughout all of dental education.”

We’re not in the clear yet, though. CODA is delaying implementation of the Standards while gathering more data on 2 remaining questions:

  • Has the allied dental education area been in operation for a sufficient period of time to establish benchmarks and adequately measure performance? and
  • Is there evidence of need and support from the public and professional communities to sustain educational programs in the discipline?

Community Catalyst, our national partner in this project, sent a letter in early June which included signers from over 100 organizations and individuals, including 38 from Ohio, providing CODA with documentation which addressed these questions and calling on CODA to implement the Standards. This information will be considered at the August 7, 2015 meeting of the Commission.

We’re hoping that CODA will vote to implement the education standards so Dental Access Now! can continue to work with Ohio community colleges to develop their programs to train end educate Dental Therapists here in Ohio.

Kasich Administration’s Rate “Modernization” and End of Collective Bargaining Threaten Consumers & Home Care Workers

While the administration has declared its intention to expand the choice of self-direction to all disabled Ohioans (see other article), their actions toward home care workers – rate “modernization” and ending collective bargaining rights – appear to undermine the promise of self-direction for consumers.

Ohio Consumer Voice for Integrated Care (OCVIC, led by UHCAN Ohio), is extremely concerned about adequate pay for home care workers because inadequate pay leads to worker turnover and poor quality services. The House version of the budget bill, HB 64, added a  pay raise to home care workers (it’s uncertain whether the Senate will retain it, and the Governor could veto it). But during May, the administration dealt a double whammy against home health aides.

Rate “Modernization”: On May 15, 2015, the Ohio Department of Medicaid held an administrative hearing on a proposed set of rules to “modernize the way Ohio Medicaid pays for nursing and aide services.” Although ODM claims that most provider types will see gains in certain circumstances, everyone speaking at the hearing – including Cathy Levine and John Lepley from OCVIC – decried the proposed cuts in pay for home health care workers, both those working for agencies and independent providers.

Several home health aides spoke of their commitment to their clients. One frail, elderly woman shuffled to the podium, leaning heavily on her walker, to tell the hearing officer that she would probably be dead if it weren’t for her home health aide. When she said the aide is like a daughter to her, the aide teared up – as did most people in the room. Every aide who spoke talked about the struggle to make ends meet on their current $9.00 an hour pay. One IP has to work over 70 hours a week to afford her prescription drugs.

Home health aides – whether working for agencies or as independent providers – are woefully underpaid.  Advocates for home care workers support a living wage for IPs – $15 an hour. If that seems like high pay for someone without a nursing degree, let’s consider what a home health aide does for frail older adults and other people with disabilities. Let’s also consider the value of their work – i.e., what benefit and savings do they provide?

Home health aides assist clients with personal activities of daily living, including dressing, bathing, eating, and toileting. It requires great skill to lift, assist, and move another adult without inflicting pain, humiliation, or injury. Trained home health aides prevent falls and pressure sores (“bed sores”), complications that lead to hospitalizations and further disability or death. (“Superman” star Christopher Reeves died from an infection stemming from a bed sore.) Home health aides prevent very expensive hospitalizations, surgery, rehab, and confinement to nursing homes. They are essential to reducing avoidable, undesirable spending for Ohio’s highest cost patients. Thus, IPs produce the highest-quality care at a comparatively modest cost. If you consider the cost of nursing home care, the state can afford to raise home health workers’ pay to $15/hour.

ODM developed the new formula with an actuary and “stakeholder” input (from nurses, for whom the rule addresses current concerns about overpayment for short visits). But it is not clear whether home health workers will fare better or worse.

Stripping Away Collective Bargaining: This rate process demonstrates why all home health aides need an organization that represents their interests. However, they are farther than ever from having representation. On Friday, May 22, 2015 (Memorial Day weekend), the Governor rescinded an Executive Order issued in 2007 by former Governor Strickland that gave  home health aides the right to organize and bargain collectively (negotiate) for their wages and working conditions. With Governor Strickland’s departure, a sunset of provisions giving the union bargaining power took effect, but the union (SEIU 1199) continued to negotiate a contract and provide healthcare (a much needed and rarely available benefit for this group of workers) – until the Governor’s action last week.  (Ironically, the Governor justified his action on the basis that IPs can now get their health care through the Marketplace – a shaky notion until we know the outcome of King v. Burwell – see other article).

To its credit, the Governor’s Office of Health Transformation preaches (correctly) the need to move Ohio from paying for volume of health care to value-based care.  However, efforts to restrict the ability of home care workers to bargain collectively for pay and working conditions and the confusing new rate structure call into question whether, in this case, they are practicing what they preach.

“I Owe How Much!?” Surprise Medical Bills: A Problem for Consumers

Have you or anybody you know received medical treatment that you thought was covered by insurance, only to receive a surprise bill that isn’t covered? If so, you’re not alone.

In the past two years, a whopping one out of three privately insured Americans received a “surprise” medical bill, according to a Consumers Union survey published May 5th. CU described a “surprise” medical bill as one you weren’t expecting or where the health plan paid less than expected.

CU surveyed 2,200 adult U.S. residents as well as additional persons in Ohio (622), Florida, California, and Texas. The survey also found that nearly nine out of ten consumers don’t know the state agency or department tasked with handling health insurance complaints.

To understand why surprise medical bills are a growing concern to consumers, you need to know a few insurance terms.

Providers who are “in network” vs. “out of network:” Most health insurance plans contract with providers of medical services, such as doctors, physical therapists, or hospitals. The providers with a contract are “in network” and have agreed to a discounted fee. The insured person knows that the in-network provider agrees to accept the insurance company’s payment as full payment — subject to any co-payment or co-insurance, once the deductible has been met. Providers who have not entered into a contract with the patient’s insurance company may charge the consumer their full fee.  How much of the fee the insurance company pays depends on the insurance policy, and the patient is stuck with the balance.

Why surprise medical bills happen: The problem of “surprise” bills often arises when consumers go to a doctor or hospital that is in their network, but that hospital or doctor uses another provider who is not in the network. Frequently this happens when an out-of-network anesthesiologist assists an in-network surgeon at an in-network hospital, an out-of-network radiologist reads the X-ray, or an emergency department at the in-network hospital is staffed by a physicians’ group that is not in the network. In all of these cases, patients are ending up with bills they didn’t expect and over which they had no control. And they aren’t happy about it!

What UHCAN Ohio is doing about “surprise medical bills”: Consumers Union heard many stories from the people surveyed, and some of them are from Ohio. UHCAN Ohio and Ohio Consumers for Health Coverage (OCHC) are reaching out to those who gave their permission to be contacted to further develop the case for legislation in Ohio to address this problem. According to the Ohio Department of Insurance, the problem cannot be addressed by regulation alone without legislation. Recently, the state of New York passed a law that protects consumers in this situation while it sets up a process to resolve the payment issue between the provider and the consumer’s insurance company. 

The OCHC ACA Implementation team is developing a letter to send to Ohio lawmakers.  We have also put together a survey to get more information from Ohioans about the problems with surprise medical bills they have seen. If you would like to take the survey, you can do so by clicking here.