Fraud and abuse in the Medicaid Personal Care Services program

“Stunning” is the word that comes up most often to describe this week’s election. 

The GOP has promised to repeal Obamacare with few detailed plans, as yet, to replace it or preserve parts that have worked and are generally popular. This uncertain future makes it hard to comment on policy regarding Medicaid-funded healthcare and caregiving for people with DD. Nevertheless, an article, “Report Finds Caregiver Fraud Widespread” by Melissa Bailey, 11/8/16, that examines Medicaid in-home Personal Care Services is relevant for now and will continue to be relevant as long as these services are publicly funded. [The article appeared in Kaiser Health News (KHN) and was republished by Disability Scoop.]

According to the article, the Medicaid Personal Care Services program (known as Home Help Services in Michigan) is “rife with financial scams, some of which threaten patient safety…” A report from the Office of Inspector General (OIG) for the US Department of Health and Human Services recommends that the federal Centers for Medicare and Medicaid Services (CMS) improve oversight and monitoring of the program "...to prevent and detect improper payments, facilitate enforcement efforts, and reduce the risk of beneficiaries being exposed to substandard or otherwise harmful care.” 

Personal Care Services “provide non-medical assistance to the elderly, people with disabilities, and individuals with chronic or temporary conditions so that they can remain in their homes and communities. Typically, an attendant provides PCS. In many States, PCS attendants work for personal care agencies, which are enrolled in the Medicaid program and bill for services on the attendants' behalf…”

More from the KHN article:

“The OIG has investigated over 200 cases of fraud and abuse since 2012 in the program, which is paid for by the federal government and administered by each state. These caretakers, often untrained and largely unregulated, are paid an average of $10 per hour to help vulnerable people with daily tasks like bathing, cleaning and cooking.

“The report exposes vulnerabilities in a system that more people will rely on as baby boomers age. Demand for personal care assistants is projected to grow by 26 percent over the next 10 years — an increase of roughly half a million workers — according to the U.S. Department of Labor.

“‘This type of industry is ripe for fraud,’ warned Lynne Keilman-Cruz, a program manager at Alaska’s Department of Health and Social Services who has investigated widespread fraud. The risks increase because the care takes place out of view in people’s homes, and because neglected patients may not advocate for their own care.”

The OIG report calls on CMS to “establish national qualifications, including background checks, and ensure every claim identifies the worker and time of service. It also called on CMS to require states to enroll all personal assistants, so they can be tracked by unique numbers.” These are all sensible recommendations to reduce fraud and protect Medicaid beneficiaries. 

CMS, however, is “treading lightly” in deference to disability groups who fear that stricter regulations may limit beneficiaries’ access to caretakers. This fear is not unfounded, but why are disability advocates willing to trade access to caretakers for the perpetuation of abusive and fraudulent practices that undermine the program and risk the safety of people with disabilities? Is it too much to ask advocates who claim to represent our family members with disabilities to take a stand in favor of both access and high quality care? 

Instead of mandatory background checks and training for Personal Care Services, CMS has opted to give $50 million in grants to 26 states to set up background check programs. Instead of requiring mandatory training, CMS has offered states the option of offering basic caretaker training “without usurping beneficiary decisions on what skills are most appropriate for their home care workers”. These measures may be a step in the right direction, but why not require training specified in a plan of care based on individual need and preference, rather than leaving it up to chance as to whether the home care worker has the skills to do the job he or she is hired to do?

Here are excerpts from another article from Kaiser Health News on California’s In-Home Supportive Services Programs,  “Lots Of Responsibility For In-Home Care Providers — But No Training Required” by Anna Gorman, 1/6/15:

“No overall training is required for the more than 400,000 caregivers in California’s $7.3 billion In-Home Supportive Services Program (IHSS) for low-income elderly and disabled residents. Without instruction even in CPR or first aid, these caregivers can quickly become overwhelmed and their sick or disabled clients can get hurt, according to interviews with caregivers, advocates and elder abuse experts.”

…

"IHSS was never intended to be a medical program. The caregivers are distinct from visiting nurses and the certified home health aides often dispatched after a hospital stay. IHSS caregivers are not certified or licensed and are hired to do personal care and household tasks.

“But more than a quarter of IHSS clients are 80 or over, and many have chronic health conditions or dementia. In these and other cases, caregivers can end up providing basic medical care–helping to administer insulin shots, manage other medication or dress wounds, for instance.”

Here again the issue of training is controversial:

“A union that represents caregivers ... sees advantages to a minimum level of training.

“SEIU-United Healthcare Workers West proposed a statewide initiative last year that would have required 75 hours of training, but the union didn’t get enough signatures to put the measure on the ballot. SEIU plans to try again for the 2016 ballot.

“Requiring training would ‘save lives,’ said Loretta Jackson, who serves on the union’s executive board and is an IHSS caregiver in Sacramento. It would also reduce the risk of injuries to caregivers, she added.”

But disability advocates balk at requirements that might threaten access to caregivers. 

“Eileen Carroll, the deputy director of the California Department of Social Services, said the program doesn’t have a lot of training requirements because it was set up to give clients the choice of how they want their care delivered.”…

“Carroll said the state is in a tough situation. Training is a positive thing, she said, 'but you have a very strong adult disabled community in this program who … oppose any mandatory training.’

"Many disability rights advocates say a training mandate would make it more difficult for IHSS consumers to find caregivers, chip away at clients’ autonomy and drain resources from the program.

“‘The idea of choice is really paramount,’ said Deborah Doctor, legislative advocate at Disability Rights California. ‘Anything that puts a requirement that erodes that choice is a problem.’”

Again, why not tie the training for the home care worker to the individual needs of the person receiving care with that person’s participation in determining what is needed? That way the appropriate level of training would be provided leading to both access and higher quality care without compromising the beneficiary's right to choice.

The cost of improving the Personal Care Services program is the unspoken issue influencing the CMS decision on whether to impose higher standards on states to better ensure the safety of people needing care. These costs also stoke the fear of disability advocates that access to caregivers will be adversely affected. 

Is it too much to ask of federal regulators, state agencies, and especially disability advocates to take a more nuanced approach to the costs and benefits of a system that reduces abuse and delivers better care to those receiving services? It may be that having higher standards reduces many costs over time. And if it costs more to deliver better care and avoid the tragic consequences of allowing abuses of the system to continue, this may be a cost that the public is willing to bear. After all, more and more families are affected by the responsibility of taking care of aging and disabled family members and would rather see a system that provides higher quality care that they can rely on, than one that limps along failing to provide even a basic level of care that protects their loved ones from harm.