‘We’re teetering on the edge.’ Are Medicaid rates making it harder to age at home?
Instead of living in nursing facilities, nearly 3,800 Granite Staters are in their own homes and communities thanks to the help they receive with basic needs like bathing, transferring from a wheelchair to bed, managing medications, making meals, and getting to medical appointments.
Approximately 600 of them risk losing that care in July if the state doesn’t increase what it’s paying providers through the Medicaid-funded Choices for Independence (CFI) program, which covers the cost of housekeeping and personal care services for people who want to age at home and qualify for Medicaid.
The heads of Ascentria Care Alliance and Waypoint of New Hampshire, who have 600 CFI clients between them, said they will leave the program in July if lawmakers do not increase their Medicaid payments. They said they’ve stayed in the program this long only by fundraising to cover their losses.
It’s still early in state budget negotiations, but their rate requests far exceed the 3.1 percent increase Gov. Chris Sununu has proposed in his two-year budget. Their departure would leave their clients few options; the state has a massive shortage of direct care workers, and long-term care nursing facilities are full.
“It’s turned into, we used to subsidize (the care) somewhat, to now, it’s going to break the organization if it continues at this rate,” said Angela Bovill, president and CEO of Ascentria. “It’s not that we don’t care. We haven’t stopped caring or we wouldn’t have been subsidizing it the last bunch of years. But the subsidy numbers are getting so high, that it’s no longer even a viable question.”
It’s been a moral and practical decision, Bovill and Borja Alvarez de Toledo, president and CEO of Waypoint, said.
Even with fundraising and temporary American Rescue Plan money, Ascentria and Waypoint said they can’t pay their direct care workers more than $13.50 an hour, so little that in 2020, 32 percent of those in New Hampshire relied on some kind of public assistance, according to PHI, a national policy organization focused on elder care and disability services.
“I can’t go to sleep at night and continue to treat the staff that we hire this way because it’s not right,” said Alvarez de Toledo. “And we’ve been doing it because we care about the seniors. And who’s going to take care of them? At some point, I’m like, ‘Wait a minute, is this our responsibility? Do I have to, year after year, raise half a million dollars to just break even in this contract?’”
Amy Moore, director of in-home care at Ascentria, said it has become so hard to recruit staff at that salary that her agency is turning down 100 client referrals a month and increasingly relying on families or close friends to provide CFI services.
About four years ago, about 40 percent of the agency’s care givers were family members and friends caring for a loved one. Now it’s 90 percent, Moore said.
“Those people have all had to leave careers, move, and uproot their lives,” she said. “Those family members are the only reason, frankly, we still have a program going, and we’re teetering on the edge. That’s a very broken system.”
The fragile finances are hurting clients, too, Alvarez de Toledo said.
Unable to recruit or retain workers, Waypoint is providing clients fewer services than what they’ve qualified for. “They’re authorized for 25 hours, and you say, ‘Well, I can only give 12. That’s what they’re getting from us,” Alvarez de Toledo said. “And that’s not OK either.”
Services approved versus services provided
A 2021 federal lawsuit against the state Department of Health and Human Services alleges it paid for only 55 percent of the services it approved for CFI clients in 2018 and 2019. New Hampshire Legal Assistance, Disability Rights Center – New Hampshire, AARP Foundation, and the Nixon Peabody law office, who brought the case on behalf of four plaintiffs, have asked a judge to certify it as a class action lawsuit.
Jake Leon, spokesman for the Department of Health and Human Services, said there are a number of reasons why CFI participants do not receive all their authorized services. They often don’t request the transportation services they could, or they don’t receive them because they are in the hospital or a short-term rehabilitation center for a surgery, illness, or some other reason, he said in an email. Concerns about COVID-19 have led some to forgo services, he said. Others have very specific preferences about which worker delivers services in their home.
The New Hampshire Fiscal Policy Institute identified additional reasons in a 2022 analysis.
The workforce shortage was a big one but not the only one. Determining financial eligibility for Medicaid can be very complex, it said. There can be long waits for documentation and approval, and finding the right information or methods for applying for Medicaid can be difficult. And getting approval for services for in-home care can take longer than those for provided in nursing homes.
In Oct. 2021, the median processing time for Medicaid application approval was 36 days for nursing facilities and 45 days for CFI services, the analysis found. In some cases, the wait was 90 days, it said. “These long delays mean people may not receive critically needed services,” the report said.
$153.2 million in lost funding
CFI services are available to people who are over 18, have a chronic illness or disability, qualify for nursing-home level care, and are eligible for Medicaid. The state sets the reimbursement rate and splits the cost with the federal government.
It’s a much less expensive way to care for people who would otherwise go to a nursing home.
A year of CFI services costs less than $20,000 compared to $80,000 to $100,000 for a nursing home, Alvarez de Toledo said. And nursing homes can’t accommodate hundreds of new patients. As it is, the state’s hospitals say they are unable to discharge patients to long-term care, sometimes for weeks, because nursing homes have so few available beds.
But the state has not funded the CFI program as generously as it has nursing home care, according to the New Hampshire Fiscal Policy Institute analysis.
It found that the state’s Medicaid payments to nursing facilities kept better pace with inflation than its CFI payments for in-home care did. Between 2011 and 2021, the CFI providers would have received an additional $153.2 million had the state adjusted their Medicaid rates for inflation the same way it did for nursing home services, the institute found.
‘If I said to you, ‘We’re going to develop a program that makes the client happy, keeps the client in their home, saves the state money, benefits the hospitals, and benefits the nursing homes,’ you would say, ‘Where can we implement this program?’” said Keith Kuenning, director of advocacy at Waypoint. “We have that program. Right now. It’s ongoing in New Hampshire, except the program is on the verge of collapse because they won’t fully fund it the way that they need to.”
‘I’m not sacrificing the people who work for us’
Leon said his agency supports the kind of comprehensive review of CFI rates that’s called for in Senate Bill 86. The bill would also put $40 million each of the next two years into Medicaid rate increases, but it is not yet determined how that will be divided up.
There’s lots of competition for that money. The state’s 10 community mental health centers, which rely on Medicaid for 70 percent of their budgets, requested a 21.5 percent to 23 percent increase in their rates.
Leon noted that the department requested and received funding from the Legislature to increase what it pays for CFI services over the last five years. He said in fiscal year 2022, payments for personal care services increased 15 percent, while payments for homemakers services rose by 6 percent. Leon said rates have increased since 2018 by 3 percent or 4 percent each year.
Kuenning characterized those numbers as accurate – but misleading.
For at least a decade, the state has paid CFI providers less than the cost of delivering CFI services, he said. A 6 percent increase on an underfunded system is not sufficient, he said.
“If those were adequate, why is Ascentria losing $1.5 million a year? Why are we losing $500,000 a year?” said Kuenning of Waypoint’s work with its 200 clients. “It’s true that they’ve given us the raises, but honestly, it doesn’t do enough to make a difference to keep our program running.”
Leon said the department has invested $30 million in federal money into increasing the workforce with retention and hiring bonuses and stipends. The agency also worked with the state Department of Employment Security to recruit and train additional service workers, he said.
Providers like Ascentria and Waypoint argue that solving the workforce shortage must begin with an increase in their $13.50 hourly wage, which would require rate increases, not only temporary stipends and bonuses.
When asked about potentially losing Waypoint and Ascentria in the CFI program, Leon said, “A loss of provider may impact the provision of service to New Hampshire’s most vulnerable citizens, but a thorough analysis would be necessary to determine the extent of that impact.”
It looks certain that Medicaid rates will increase in the next budget. Sununu’s proposed 3.1 percent annual increase won’t be enough, according to Medicaid-funded organizations.
Ascentria and Waypoint said their requested 11 percent increase for homemaker services would bump that hourly payment from $21.60 to $24. The 33 percent increase they are seeking for personal care services would bring that hourly payment from $22.48 to $30.
It would be enough just to break even, Bovill and Alvarez de Toledo said. It wouldn’t be enough to pay a competitive wage or give clients all the services the state has said they qualify for, they said.
“As mission driven organizations, we can’t say, ‘Well, we’re delivering our mission to seniors because we’re really not’,” said Bovill. “I’m not sacrificing the people who work for us on behalf of an attempt to care for some other people, because then everybody fails. And I can’t see how that’s an acceptable answer to anything.”
This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations, and the John A. Hartford Foundation.