More on the Michigan Audit of Home Help Services

"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.