Editorial: Home-care a challenge

Ohio has made tremendous progress in reforming an inefficient and often-ineffective system of public health care into one that better focuses the state’s resources on helping the poor and disabled.

But far more wrinkles remain to be ironed out of the Medicare and Medicaid systems, and Gov. John Kasich’s budget proposal illustrates some of the challenges.

As the recent Dispatch series “ Home-care crisis” outlined, home health care for elderly, infirm and disabled adults is an industry exploding in growth but lacking in oversight.

Most people prefer living at home to living in nursing homes, and in-home care is far less expensive. But with services being delivered by thousands of providers in thousands of locations, effective oversight naturally is harder. While home health care takes up less than 5 percent of state Medicaid spending, it has generated more than half of the improper payments to providers in the past three fiscal years.

Worse, the lack of oversight, and of enforcement of what few standards exist, puts people who need in-home care at risk of abuse by their supposed caregivers.

Kasich’s budget proposal seeks to address this by phasing out the hardest-to-regulate type of home-care, in which individuals — not employed by agencies — provide care and bill Medicaid directly for the services. More than half of Ohio’s in-home care is provided this way. Caregivers working as independents can bill Medicaid as much as $18 per hour for the first hour and $13 an hour after that. Those working for agencies rarely make more than $10 per hour.

Independent caregivers like the higher wages and autonomy; clients feel they’re likely to have a more-loyal caregiver, likely to stay on the job longer.

The problem, state officials say, is the difficulty of keeping track of independents. “ Accountability and safety are our top priorities,” said Greg Moody, director of Kasich’s Office of Health Transformation. Plans in the works to tighten oversight of agency-provided care — for example, requiring GPS-based verification that providers really are with clients when they bill for services — would be impossible or too expensive to apply to independent providers, Moody said.

Kasich’s solution is to beef up oversight of agencies and to phase out the use of independent providers other than for clients who receive Medicaid waivers allowing them to be the “employers of record.” Such waivers commonly are used by Ohio patients using home care through programs in the Department of Developmental Disabilities. That type of waiver doesn’t exist yet for most other types of home care, but Moody said the state will ask federal Medicaid officials to allow it.

This could be a sensible solution. Part of the reason independent home-care providers won’t be entirely phased out until July 2019, Moody said, is to allow time for a new employer-of-record waiver to be established. An important question will be whether such a waiver process will be simple enough for most clients to navigate.

Moody also said his office would like to see Medicaid rates raised in some areas; this could allow for higher caregiver wages, which could be critical to ensuring that competent, trustworthy people remain in the field.

The challenge of providing acceptable-quality public health care without bankrupting taxpayers remains one of government’s hardest tasks. The Office of Health Transformation is helping Ohio make progress in this difficult arena.

http://www.dispatch.com/content/stories/editorials/2015/02/07/1-home-care-a-challenge.html