The Home Help Program audit conducted by the Michigan Office of the Auditor General looked at the criminal records of individual providers, direct care workers providing services in clients' homes. Of the approximately 70,000 individual providers, 3,786 had felony convictions prior to Jan. 2, 2013. "This included…572 convictions for violent crimes ranging from assault to homicide; 285 convictions for sex-related crimes; 1,148 convictions for financial crimes such as fraud, identity theft and embezzlement; and 2, 020 convictions for drug related offenses."
About 75% of the elderly or disabled clients employ family members or close friends to provide care. According to the audit report, it could not be readily determined how many of the providers with felonies were related to the clients they served. The report says, "…the client's ability to hire a relatives poses a unique circumstance in that clients may be fully aware of their relatives' criminal history. Although we concur that client choice should be encouraged and honored, it should be made with full disclosure, balanced with client safety and security, and consideration of the potential liability to the State."
The overall recommendation of the auditor is that, "DCH and DHS should consider conducting criminal history checks for individual providers and requiring agency providers to conduct criminal history checks for their employees and/or subcontractors. By not conducting criminal history checks, DCH and DHS may be unaware of unsuitable individuals who may harm to their vulnerable client population." [emphasis added]…"Of particular concern are providers who are not related to the clients they serve because the clients are less likely to be aware of the providers' criminal past."
In response, DCH and DHS agree that they should be conducting criminal history background checks for individual and agency providers.
According to the report, DCH has developed a criminal history background check policy. The draft policy is under review and will be impemented once the review process is complete. They will also seek legislative solutions "that potentially could warrant disqualification as a provider."
See also this article from USA Today, 6/17/14, "Felons on Michigan payroll as home caregivers"
"I read audits so you don't have to."
Reading reports such as the "Performance Audit of the Medicaid Home Help Program", is tedious at best, but they often reveal nuggets of useful and interesting information that you rarely find in one place. Below are some of those nuggets:
Home Help Services are a dual responsibility of the Michigan Department of Community Health (DCH) and the Michigan Department of Human Services (DHS) and are paid for by a combination of federal and state funds.
The overall conclusion of the report is that "DHS and DCH efforts to operate HHP consistent with selected laws, rules, regulations, and policies were not effective."
Findings in the audit include improper payments for Home Help Services of an estimated $160 million, 17.9% of the $893.7 million HHP expenditure from 10/1/10 to 9/30/13. Also, "…DCH and DHS could not ensure that clients timely received the most appropriate type and quantity of services for their conditions."
Qualifying for Home Help Services
According to the audit (page 9), services are available to people who have functional limitations resulting from a medical or physical disability or cognitive impairment who live in settings other than nursing homes, licensed group homes, mental institutions, or homes for the aged. They provide personal assistance to individuals with "activities of daily living" (ADLs) and "instrumental activities of daily living" (IADLs). ADL services include assistance with eating, toileting, bathing, grooming, and mobility. IADL services offer help with medication, meal preparation, shopping, and light housework. In addition, complex care services are available for clients with certain medical conditions.
To qualify for services (page 10), an individual must be an active Medicaid recipient, obtain a certification of medical need from a physician, and have a need for services indicating a functional need of 3 or greater for at least one ADL [activity of daily living]. A local DHS office must receive a referral for the prospective client. The DHS office contacts the client to obtain a certification of medical need. An adult services worker (ASW) from DHS conducts a functional assessment rating for each activity, with 1 being independent and 5 being dependent. The ASW allocates time for each task assessed at 3 or greater based on the actual time required for completion of the task. DCH and DHS can place limits on the amount of time allocable for each Instrumental Activity of Daily living, except medication.
(Having gone through this process many years ago with my older son and hearing from other parents who have done the same, the assigning of numbers and time allocations to various tasks can seem arbitrary and subjective, although the use of numbers provide a veneer of scientific objectivity.)
Lack of staffing likely contributed to many of the problems revealed in the report
This is brought up a number of times in responses to the audit by DCH and DHS. The state agencies were constrained by limited resources and staff to carry out functions required by Medicaid policies. Inadequate staffing and systems for cross-checking data from different departments in state government likely resulted in improper payments of Medicaid funds.
For example, on page 71 of the report, is Exhibit 6, showing Adult Services Clients and Adult Services Worker (ASW) Counts from 1999 through 2013:
The number of Home Help Services clients increased steadily from 46,309 in 1999- 2000. Adult Protective Services clients are also served by ASWs and the figures for both are combined to show a total increase in clients from 55,373 in 1999-2000 to 85,710 in 2012 - 2013.
While the number of clients served increased steadily from 1999 to 2013 by 54.8%, the number of Adult Services Workers decreased by 25.3%, from 541 in 1999 to 404 in 2013.
In 2013 there were 404 Adult Services Workers. As of March 2014,153 of the Adult Services Workers had caseloads of over 200 clients. 60 had caseloads of 300 or more clients.
[DCH and DHS note that not all caseloads are the same. Therefore the data cannot be used to compute meaningful average caseload sizes per ASW.]
Pay rates for Home Help Providers
During the audit period pay rates ranged from $8 to $11 per hour for individual providers and from $13.50 to $15.50 per hour for agency providers.
Perspective on Medicaid Expenditures for Home Help Services
Medicaid Expenditures by Category
October 1, 2010 through September 30, 2013
Page 65 of the report, Exhibit 3, shows a colorful pie chart of Medicaid expenditures. While the flaws in the Home Help Program are significant, it helps to put the program in perspective by comparing it to the total expenditures for Medicaid over the three year period that the audit covers:
- Hospital costs and Medicaid Health Plans make up 49% of Medicaid expenditures with over $5 billion spent on hospitals and over 12 billion for Medicaid Health Plans.
- Community Mental Health services constitute 18% of expenditures at over $6 billion.
- Long Term Care accounts for 14% of expenditures at over $5 billion.
- The Home Help Program constitutes 2% of expenditures at $894 million.
For my money, anything that can reduce costs for medical care through the Medicaid Health Plans and hospitalizations would offer the most bang for the buck, but it is often the case that there is less of an appetite to focus on spending that involves powerful political and financial interests than to concentrate on services to low-income people with disabilities.
Michigan's Medicaid-funded Home Help Program that provides services to elderly and disabled people in their own homes is fraught with problems, according to a perfomance audit by the Michigan Office of the Auditor General.
According to the Lansing State Journal from 6/17/14, "Audit: Michigan improperly spent $160M on Medicaid", expenditures on improper payments (where the state failed to obtain sufficient documentation from service providers) accounts for 18% of the $894 million spent on the Home Help program that served about 67,000 people per year over a three year period.
In addition, "...Auditors said nearly 3,800 of roughly 70,000 home health providers had felony convictions, including 572 convictions for violent crimes…"
According to the Lansing State Journal:
"The audit also found that the state:
- overpaid 80 agencies $6.8 million by not making sure they met requirements to get higher fees than individual aides.
- hired a contractor in 2008 for $1.4 million to visit DHS [Department of Human Services] county offices over three years to review home health cases, yet the case file reviews were not forwarded to the offices for corrective action on time. The Community Health Department blamed a lack of staff for the delay.
- inappropriately paid $3.5 million for home services when the patients were instead being hospitalized or in nursing homes.
- did not review thousands of W-2 forms returned as undeliverable, missing a chance to crack down on clients fraudulently getting services or their relatives providing a false address to avoid cuts in the clients’ authorized service level.
- failed to create a process for caseworkers to refer suspected fraud to the attorney general’s office."
What is the significance of a dysfunctional Home Help Program?
Home Help Services are mandatory under Medicaid, meaning that they must be available to all eligible individuals. Medicaid funding for Home Help Services, paid for by both federal and state governments, is a significant factor in allowing many people with developmental and other disabilities to live in their own homes. It is almost always a component of providing care in unlicensed supported living settings. The findings in the audit of Michigan's program, however, exemplify problems more generally with community care, especially for those with severe, profound, and complex disabilities: funding and the provision of services is so fragmented that the system of care is often unmanageable. This is aggravated in this case by cuts in funding to state government that, if they had not been a legislative priority, might have allowed more and better oversight, ultimately saving taxpayers money and improving the lives of people with disabilities.
Under these conditions, accountability for the provision of services and the expenditure of funds, in addition to assuring the health and safety of the people receiving services, is illusory at best. Federally-funded disability advocacy groups and the Centers for Medicare and Medicaid Services (CMS), the federal agency that regulates Medicaid and Medicare, are pressuring states to turn away from any kind of congregate care and service settings (settings that serve more than three people with disabilities together), just when innovative care in congregate settings and maintaining high quality care in settings that are considered "institutional", might be a solution to the problems of fragmentation, mismanagement, and lack of accountability. Those who choose and would benefit from care in congregate settings, usually people with more severe and complex disabilities, also cost more to care for regardless of where they live. Congregate settings that offer economies of scale contribute to cost-efficiency and better use of taxpayers' money.
