State seeking to curb in-home care costs

JEFFERSON CITY, Mo. -- Missouri officials fear the state may be overpaying in-home care providers millions of dollars to help disabled residents bathe, cook, clean and perform other daily activities.

Legislation recently passed by the Senate -- and now pending in the House -- could impose a pair of cost-cutting curbs on the more than 300 businesses and not-for-profit organizations that provide in-home services to about 50,000 low-income Missourians.

But some in-home care recipients and their advocates fear the changes will result in fewer services, making it more difficult for them to remain at home and more likely they will need to move into nursing homes.

At issue is the method by which Missouri determines whether residents' income makes them eligible for Medicaid, whether their physical conditions make them eligible for home care and, if so, how many hours of care they should receive.

Missouri has experimented during the past decade with several approaches, including conducting assessments through contracted nurses and state employees. Since July 2007, Missouri has allowed client assessments to be done by the same organizations that ultimately provide the home care services.

During that time, the number of people receiving home services has risen 15 percent while the annual cost has grown by one-third, according to figures for the Department of Health and Senior Services. At its current pace, the program will cost more than $1 billion annually within seven years, the department estimates.

"Basically, the program is unsustainable the way it is," said department spokesman Kit Wagar, who describes the current system as an "inherent conflict" of interest.

Legislation that passed the Senate 27-7 last week would allow the department to seek bids for an independent entity to conduct the needs assessments. It also would require all in-home care employees to eventually use a telephone-based time clock to record the hours they work.

Both provisions are based on an assumption that Missouri currently is paying too much for in-home services because providers -- either intentionally or unintentionally -- inflate the hours of personal care necessary for their clients.

To the contrary, some residents say they already need more hours of care than they are approved to receive from the state.

Janet Wilson, 63, of St. Joseph, uses a walker and an oxygen system to cope with a variety of disabilities. Wilson said she is authorized to receive four hours a day of paid care to help her bathe, do laundry, clean her home, cook and transport her to doctor's appointments.

"But it's not really enough to do what has to be done," Wilson said. So "our attendants give us more time than what they're allowed" -- often voluntarily staying for an extra hour or more.

A recent analysis by The Lewin Group, based in Falls Church, Va., estimated Missouri could save 5 percent of its Medicaid costs for in-home care services by requiring workers to log their hours electronically over an automated telephone system. That could amount to $25 million of savings in state and federal funds, according to a Missouri legislative research office.

The Lewin Group estimated Missouri could save $3.4 million annually by using a neutral entity to assess people's need for in-home care services. It predicted the change "would modestly increase future denial rates."

But the Missouri Home Care Union, which represents many in-home care workers, estimates it would cost the state $2 million a year to contract with a company for the assessments.

"In terms of state financial responsibility, it's irresponsible," said union spokesman Joe Lawrence. "In terms of the assistance thousands of Missourians need to live a life of some dignity, it gets wiped out, and they are in danger of being placed in nursing facilities."

The Department of Health and Senior Services currently reviews the needs assessments conducted by in-home care providers for their clients. A sampling of several hundred assessments last fall found they were more than twice as likely to overstate the clients' needs than to understate the hours of care necessary, the department said.

If department staff would have simply accepted the assessments performed by providers, Missouri would have paid an additional $8.5 million to $15.1 million a year, the department said.