Letter to the Editor - June 2006

To the Editor:I’m concerned regarding ongoing PCA Program changes that may disempower consumers and jeopardize their health and safety. Most consumers rely upon the Minnesota PCA Program for assistance with life’s basic activities (e.g. bathing, using the restroom, dressing, preparing meals, eating). I offer a few examples to support my fears about the changes recently implemented by the Department of Human Services (DHS).

First, during the past few years, DHS and public health nurses have scrutinized virtually each and every minute of PCA service approved; there is no blood left in that turnip.

Second, the “2003 PCA Consumer Survey” points out that consumers feel PCA wages, which directly relate to DHS reimbursement rates, are too low and create difficulty recruiting and retaining quality PCAs. I believe the wages are not only uncompetitive-they are far below a living wage. Many PCA agencies cannot even offer affordable health insurance for employees. Additionally, PCAs aren’t compensated for travel time or expenses between consumers or consumer-requested errands, which further decrease competitiveness; most community-based service providers reimburse for these expenses.

Third, a backlog in DHS background check processing last summer/fall created a significant bottleneck to accessing new PCAs for some consumers. Some consumers needed to wait to replace unreliable staff or depend on family and friends. Consumers seeking PCAs and not having an available family/social network may have postponed or been deprived of these essential life-sustaining activities; DHS doesn’t offer safety nets for consumers lacking adequate access to qualified and available PCAs.

Fourth, in response to the “Health Care Services Study: Findings and Strategies for Savings,” DHS implemented requirements that PCAs must have PCA provider numbers in order for personal care provider organizations [PCPOs] to be reimbursed for services. This process is intended to catch consumers and PCAs committing fraud–well-intentioned but poorly timed. The new PCA provider number process may delay reimbursement to PCPOs for services provided by new PCAs. This may cause cash flow concerns (i.e. being required to pay employees for services performed before receiving payment from DHS). Some PCPOs may respond by waiting to deploy new PCAs until their PCA provider numbers have been received, thereby ensuring timely payment from DHS for services provided. This process may take up to three weeks, thereby creating an industry labor-supply bottleneck. Many PCA candidates seeking work may be unable to wait three weeks to begin and instead choose other opportunities; an industry labor-supply diversion. Here again, consumers may lack adequate access to qualified and available PCAs.

Fifth, more recently, DHS has altered the flexible use option to reduce the time period consumers can use their approved PCA Program hours. Before, consumers could flexibly use their approved hours throughout a 12-month period. Perhaps they would save hours for extra help needed during illnesses, vacations, winter, or summer. Now, consumers’ flexible use period is only six months. Basically, DHS has disempowered consumers in an attempt to recapture unused hours every six months-weakening a consumer-driven safety-net and forcing consumers to alter their lifestyle. Sadly it is more likely that consumers will “dump” hours twice a year (i.e. pre-pay PCAs for anticipated future needs). It is important to note that “dumping” is considered fraud. Ironically, DHS has increased the likelihood of such activity by nature of their new policy-consumers and PCAs will attempt to cope as best as possible in order to protect their health, safety, security, and liberty. The cost to DHS and taxpayers will increase not only due to “dumping,” but also due to increased enforcement, investigation, and prosecution costs-the potential costs far outweighing any savings.

Sixth, DHS recently conducted an audit of PCPOs and is cracking down on the lack of current physician orders in consumers’ files. DHS requires PCPOs to have current physician diagnosis documentation justifying PCA Program eligibility and utilization. However, DHS already requires annual consumer care plan reviews by independent public health nurses. They review past year diagnoses, condition changes, and service utilization and then decide upcoming year service allowances. Public health nurses spend about an hour and a half with consumers; much more time than traditional physicians spend with consumers discussing PCA needs. Perhaps DHS or the public health nurses would be more appropriate keepers of physician statements? After all, they’re the ones charged with determining eligibility. It seems like a more efficient system avoiding additional administrative burden upon

PCPOs and audit, investigation, enforcement, and correction duties for DHS.

As I alluded to earlier, consumers lacking timely, consistent, and competent services may experience a number of costly and dangerous physical and emotional complications. In an environment where consumers have virtually no PCA service cushion approved, PCAs are not paid competitively, PCAs are not paid a living wage, PCAs are not reimbursed for travel costs or time between consumers, PCA candidates are delayed or diverted from entering an industry already plagued by labor shortages, and consumers are desperately attempting to recruit and retain qualified PCAs, conditions are ripe for problems.

First, frequent and systemwide fraud will occur during attempts to merely survive. Consumers may try to innovatively utilize very limited resources to protect their health, safety, and security. PCAs may inflate hours or steal toward achieving a “living wage”. I do not condone or trivialize these acts. I simply think the frequency and scale are symptoms of more complex issues that remain unaddressed. Attempts to detect, document, and prosecute will only increase costs.

Second, consumers will likely be forced to accept less reliable, consistent, and quality services. Extended staffing transition, continued staffing turnover, inconsistency, instability, and insecurity will likely cause significant emotional distress (e.g. anxiety, depression, panic, and repeated exposure could lead to learned helplessness). Some consumers may cope via alcohol or drug use or other risky behavior. The risk for physical ailments will greatly increase. These risks appreciably increase the chances a consumer will access acute medical care (e.g. treatment for pressure sores, infections, anxiety, panic, depression, learned helplessness, addiction). Additional ongoing case management, counseling, and medication may also be needed. These secondary services could dramatically increase costs.

Third, consumers lacking adequate access to qualified and available PCAs may require expensive admissions to an inpatient mental-health unit until more stable community-based support systems are redeveloped. Such crisis admissions would ensure available and consistent assistance with activities of daily living plus help managing anxiety, panic, and depression. It is important to distinguish between inpatient mental-health versus other inpatient services, which are typically unavailable to consumers unless they can demonstrate acute physical ailments requiring hospital-based skilled nursing. However, these improvised, informal, yet effective safety nets are much more costly and less efficient than services delivered via the PCA Program.

In essence, DHS is unintentionally driving up its own, and taxpayers’, overall costs by virtue of their chosen policies and procedures.

In my opinion, the lack of attention on more relevant service access and quality factors, lack of understanding and consideration for systemwide dynamics, lack of coordinated communication and participation among PCA Program stakeholders toward identifying and resolving factors impacting efficiency and quality, and lack of more effective policies and procedures increases the risk of abuse, neglect, and physiological harm for consumers. I believe these factors and DHS’s response have created-and are bound to exacerbate-at least patterned, if not widespread, actual and immediate jeopardy to consumer health and safety throughout the program. Not to mention increasing the chances of inefficiently using taxpayer money. Bottom line: I fear DHS may be risking class-action legal liability, its own integrity, the program’s integrity, and the very foundation of the independent living movement–consumers’ rights to life, liberty, and equality.

Sincerely,
Lance H. Hegland
Consumer, Advocate, and Consultant