The call from Connecticut Children’s Medical Center on Monday was supposed to be routine.
A case manager at the hospital in Hartford had a 14-year-old patient ready to go home. She needed to make sure the preferred home health agency, Pediatric Services of America, had nurses ready to visit the youth’s home.
Medicaid covers the cost of the home visits. But it’s been 10 years since agencies such as PSA have seen an increase in those basic rates — $37 an hour for a licensed practical nurse, $45 for a registered nurse.
A small add-on fee, less than $2 an hour, also covered by Medicaid, was tacked on a few years ago for some of the most severe cases. But, starting Aug. 11, with no state budget adopted, Gov. Dannel P. Malloy ended those add-on payments in an executive order — to save the state $1.9 million a year.
With that change, PSA could no longer make the numbers work. The Atlanta-based, for-profit company works with about 300 patients at a time, including some of the toughest home-care cases in Connecticut. The company decided it wouldn’t take on new patients as of this week.
That shocked the case manager at Connecticut Children’s.
“She was irate,” said Jeanne Silverwatch, the PSA vice president overseeing Connecticut and Massachusetts. “They wanted to discharge this child. … She’s angry, she’s upset and she said she was going to take it up the administrative ladder.”
She can take it all the way up to Malloy. She might find that this latest cut was too much to bear in a crisis that’s been brewing for more than 15 years as Medicaid payments to private health care providers have squeezed tighter and requirements have ballooned.
The result: Suddenly, hospitals are unable to discharge some patients for lack of home-care arrangements because agencies such as PSA are pulling back. It’s no longer a threat. It’s happening now. A long-term crisis is becoming an emergency and it is costing taxpayers the difference between inpatient treatment and home care, which is huge.
Officials at one Connecticut hospital told William Sullivan, CEO of Visiting Nurse Services of Connecticut, with 1,900 Medicaid patients, that it had patients ready for discharge who remain in beds as of Wednesday. One option: Send patients to nursing homes.
Sullivan’s agency, based in Bridgeport, lost $4.5 million on Medicaid last year. It has now stopped taking new patients under one large program and will cut services further, perhaps even ending home care for some or all of its current clients, Sullivan said.
As of Tuesday, PSA alone had requests from four hospitals to care for 25 children, covered by Medicaid, whose doctors said they could go home — but the company said it couldn’t take those new patients. Ten were at Connecticut Children’s, Silverwatch said. And PSA is just one of six home health agencies affected by the add-on cut, most of them serving older adults.
As of midday Wednesday, officials at Connecticut Children’s were unable to say whether they had discharged all the patients who were ready to leave. The two largest hospital systems, Yale New Haven and Hartford HealthCare, were checking on the issue Wednesday and did not immediately have comments.
Even a very small number of patients lingering in hospitals, nursing homes or inpatient rehabilitation facilities would quickly wash out the entire $1.9 million annual savings, and then some. A few, if they are in intensive care, could end up costing taxpayers more than $7,000 a day — for want of an average of $20 for a home nursing payment add-on.
And it’s tense for the families worried about keeping the home care they have. Also Monday at Connecticut Children’s, 5-year-old Ariella Botts, who suffers from a rare muscle disease that forces her to use a ventilator, was ready to go home — with as much as 23 hours a day of nurses from PSA — after three weeks in intensive care. And she did. Ariella is not a new patient for the agency, so she was able to return home with her family to East Hartford.
Rachel and Charles Botts both have good jobs, and they receive Medicaid help for Ariella under a waiver that recognizes they would quickly sink into poverty without it — or lose Ariella to a medical foster home. “With private insurance, there is zero chance we would be able to keep her alive,” said Rachel Botts, who works for a consulting firm helping schools and libraries obtain federal grants.
How long will PSA and other agencies keep nurses at the homes of families such as the Botts? Some, including PSA, say they’re already cutting back service and might exit the business in Connecticut or curtail their business sharply as soon as this summer.
“It’s a corporate decision; it’s out of my hands,” said Silverwatch, whose agency received $1.2 million in add-on payments last year, out of a total of $6 million, including the federal share. “The numbers are not looking good. And it’s killing me to say that.”
Locally based nonprofit agencies, some of which get the add-on payments, are in the same bind. “We’re trying to accommodate as many people as we can but it may be with less service,” said Janine Fay, CEO of VNA Community Healthcare, which is based in Guilford and serves mainly elderly clients in 36 towns. The agency received $550,000 in add-on payments last year.
“We have an obligation to keep our organization solvent,” she said.
VNA Community Healthcare has about 1,000 Medicaid clients, mostly older, out of 6,000 clients in total. In the past, the agency could subsidize Medicaid with higher profits from Medicare and private insurance, but those days are gone. “There are no increases coming from any of the payers,” Silverwatch said.
This is exactly the opposite of what the state Department of Social Services has spent countless hours trying to achieve. Through programs with names such as “Money Follows the Person” and “Community First Choice Initiative,” the department had helped 4,447 people move out of nursing facilities, according to a presentation to the legislature in May. The idea is to keep people home.
At the state Department of Social Services, which administers the $5.9 billion Medicaid program (with a state share of $2.4 billion), the logic is that agencies can do without the add-on payments.
“These ‘add-ons’ are not an absolutely critical factor. They are a way to provide extra compensation to providers who apply for them,” David Dearborn, the department spokesman, said in an email. Agencies traditionally have stayed afloat without the add-ons, he said. “They enhance a provider’s capacity, but they don’t necessarily make or break a provider’s ability to serve clients.”
Dearborn added that the state “is in the beginning stages of looking at alternative ways to modify payments for special complex care services.”
That needs to happen stat. We’ve been watching this crisis grow since the 2001-02 recession, when payments to the agencies flattened out. Now it’s 2017. The problem is not a threat — it’s happening now. The agencies can’t find nurses at the pay they’re offering.
These are not generic home care workers who watch clients and help with housework. In East Hartford, where Ariella Botts has a condition known as nemaline myopathy, the quality of the nurses has been inconsistent, Rachel Botts said, because the pay has not kept up — though she’s very happy with the current group of nurses.
“They need to be really able to see the subtle changes in her breathing to be able to know if she’s going to have a significant respiratory event,” she said. If the system collapses because of budget cuts, she said bluntly, “children are going to die because they will not get the care they need.”
With the add-on payments, Pediatric Services of America pays LPN’s $23 to $26 an hour and RN’s $27 to $30 — with no benefits. The flexibility is good and the nurses get a lot of overtime, which can be good for them, but it drives up the cost. The RNs can make much more in hospitals, and the ranks of LPNs are dwindling in Connecticut.
Also dwindling is the menu of options for the hospitals. “We may know in the next two weeks if any of the home care agencies are going to make a decision on whether they can continue to provide skilled nursing services to Medicaid pediatric patients,” said Sherry Greifzu, nursing director of ambulatory services. If it goes the wrong way, she said, “it will be an emergency.”
Here’s yet another reason for lawmakers to pass a damn budget and vote up or down on services like this one. Besides extended-hours nursing, the add-on covers services such as care for AIDS patients and security to escort nurses to patients’ homes in high-risk areas.
The situation is already an emergency, as Deborah Hoyt sees it. She’s CEO of the Connecticut Association for Healthcare at Home, which represents 65 of the agencies. The state is saving $103 million a year on care for Medicaid clients who are not in institutions, she said. “That’s great but all those savings are on the backs of the home health agencies, who haven’t had a raise in 10 years.”