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Guest MINDSETTER™ Nicholas Oliver: Intervention Needed on RI’s Home Care Access Crisis

Monday, April 25, 2016


For almost a decade, Rhode Island’s home care providers have faced a freeze in their Medicaid reimbursement rates for delivering healthcare services to many of our state’s homebound population. Many of these individuals receiving care are Rhode Island’s oldest, poorest, and sickest citizens. These patients, some of whom are otherwise nursing home eligible, have either been long-time or lifetime disabled or were part of the working poor that became chronically or terminally ill. 

Our state leaders have a profound history of turning their back from ensuring that the resources have been available in order to provide for their care. The last two increases were in fiscal years 2002 and 2008, in which there was a cut in fiscal year 2009 as a result of the state’s response to that period’s national economic recession. For home care providers to deliver healthcare services to a population that requires regular support for their activities of daily living, such as feeding, bathing, using the toilet, and homemaking, there are additional costs in which home care providers accrue beyond labor, such as medical supplies, workers compensation insurance, malpractice and professional liability insurance, medical practice accreditation, federal and state taxes, and general operating expenses, just to name a few examples. By the time these expenses are deducted from the reimbursement in which the state Medicaid office provides, the wages for nursing assistants, which deliver the bulk of care provided in the homes of Medicaid beneficiaries utilizing home care, many of whom are women, ethnic and cultural minorities, and single parents, are not dramatically higher above minimum wage. Many of these paraprofessionals are leaving home care provider agencies to work in other parts of the healthcare sector, such as hospitals and nursing homes, where reimbursement rates allow for higher wages and benefits, or are leaving the sector altogether to work in places such as fast food and retail. The revolving door of quality care staff due to the low wages and limited benefits has caused current patients to wonder if the nursing assistant that visited them today will be the same person at the next visit. In addition, the increased demand for services over the supply of qualified nursing assistants and other healthcare professionals have led to long waiting lists to onboard new patients and communities within our state that have limited or no providers available. Please do not take my word for it; just ask your local community action agency in which the state contracts many of its case management for those in need of home care services. Home care providers continually hear from caseworkers begging and pleading to accept a new patient, but at a cost in which has placed many home care providers in financial constraints that threaten to close their agencies. Many home care providers are no longer able to accept new Medicaid patients as a result of financial losses and those that do, because they primarily provide care through the Medicaid program, are knowingly accepting their fate. 

During the 2014 campaign, then-General Treasurer Gina Raimondo touted her experience as a successful venture capitalist. However, that level of business acumen seemingly never translated into understanding the total cost to deliver a service, including those delivered at taxpayers’ expense. Governor Raimondo’s fiscal year 2017 budget includes the first proposal by a Governor for a Medicaid reimbursement increase since 2008. However, the seven-percent proposal calls for a full wage-pass through, similar to 2002 and 2008. While home care providers believe that nursing assistants and other healthcare professionals that work in home care should earn wages competitive to their peers throughout the healthcare sector and receive employment benefits that include access to quality healthcare as they provide in the community everyday, home care providers cannot afford another wage-pass through without reimbursement for the additional expenses to deliver healthcare services that are not proposed in her state budget, nor were included in 2002 and 2008. With a wage-pass through, there are additional costs to home care providers that are contingent on their payroll, such as certain insurances and payroll taxes. Add the implementation of the employer mandate to provide access to health insurance for employees under the Affordable Care Act and the mandate for home care agencies to pay overtime wages and compensate for mileage reimbursement under a new U.S. Department of Labor rule, these additional unfunded mandates are causing home care agencies in Rhode Island to reconsider accepting patents based on their insurance. Thus, access to healthcare services in the home is diminishing to a crisis point regardless of whether the patients has Medicaid, Medicare, commercial insurance, or even privately pays, without meaningful response by our Governor or her Secretary of Health and Human Services Elizabeth Roberts. Home care providers need to cover their expenses and hire and retain the staff to deliver quality healthcare at home. This will mean that home care workers may never even see this small wage increase if it passes because it is less expensive to reject it and accept a ‘clawback’ on the increased reimbursement rate. 

In the absence of leadership from our Governor and the Secretary, it is my hope that the General Assembly will take action and reverse the effects of the access crisis before ending this legislative session.

Nicholas Oliver is the Executive Director of the Rhode Island Partnership for Home Care, the state’s association representing home care and hospice providers licensed by the Rhode Island Department of Health to deliver home-based healthcare services.


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