Some Weeded Out, But at What Cost?
In an effort to make the state and federally funded Personal Care Assistant (PCA) program more accountable, the Minnesota Department of Human Services (DHS) has implemented a new registration process to track PCAs and home health aides who perform PCA services in the community. As of April 30th, 2006, approximately 21,000 PCAs will have been assigned a new identification number. As a part of this process, DHS has found over 230 people unfit to be providing services. The reason individuals are denied a PCA identification number is either that they haven’t passed the criminal background check or they have outstanding debts to the government, such as unpaid student loans or back taxes. The Department of Human Services believes that as such people have been removed from the work pool, the integrity of the PCA service program is enhanced. Billing requirements have also changed. In order for a Personal Care Provider Organization (PCPO) to bill for services performed by any PCA, they must now submit the new ID number for that PCA along with the consumer’s ID number and their own PCPO ID number.
The new registration process makes it more difficult to register as a PCA. Until recently passing a DHS approved criminal background check has been all that was needed to qualify as a personal care attendant. Now individuals must have a PCA ID number. To do so, they fill out an application, clear a DHS criminal background check and sign an agreement to abide by federal and state regulations for PCAs. This last step may be problematic. It is unclear how PCAs are expected to abide by the myriad of state and federal regulations when they are not involved in the direct billing process. For instance, a PCA simply bills the PCPO for an eight hour shift. The PCPO must then parse that eight hours into 15 minute task increments, each of which must meet stringent regulations. The PCA appears to have no control over, much less knowledge of, how this billing happens, and what regulations it is constrained by.
Although this new process is meant to ensure better quality care for members of the community who rely on PCA services, the time delays and paperwork increases will place new burdens on the PCPO’s and consumers of personal care services. Consumers who need immediate care will face a three or more week time delay in getting a new PCA— the time it takes to assign an ID number to a new PCA. The more complicated billing procedures may also hinder access to PCAs when they are needed most. “Implementing this cumbersome, new system will likely cause disruptions in payment to agencies employing PCAs,” said Jeff Bangsberg, Government Relations Director for the Minnesota HomeCare Association. “My fear is that after the April 30th mandatory billing date to use the new PCA identification numbers, access to care will be compromised. Agencies might find it too expensive to serve clients with multiple PCAs because of this new bureaucracy.”
PCPOs are being pulled in many directions as a result of this new process. Chief among them may be the risk of providing immediately needed PCA service to a client before knowing if the PCA will pass the background checks and thus be eligible for reimbursement. In order for an agency to be successful they must provide the disability community with PCA services in a timely manner. This is now very difficult because the ID number they must have from DHS to bill for services takesa minimum of 21 days to receive if the enrollment packet is submitted with no errors. The risk of providing immediately needed care with no assurance of later reimbursement has many agencies worried. Brenda Hicks, the PCA program assistant manager with the Metropolitan Center for Independent Living said simply, “We won’t be able to provide services to people if we’re not getting reimbursed.”
Many PCPOs can ill afford yet another bump in internal costs. They already face staggering administrative costs to ensure that they, their PCAs, and the consumers they serve stay in compliance with frequently updated state and federal regulations. Any delay in their cash flow from reimbursement could spell disaster for PCPOs. Kevin Sullivan of In Home Personal Care recognizes the benefits of the process, saying “These changes are intended to make the PCA program safer and more efficient. In the end they will prevent some of the fraud we see happening in the PCA program.” However, he also sees the dangers of added administrative hurdles to an already overworked staff. “Our profit margin is so slim that we are barely keeping our heads above water right now.”
Beyond PCPOs staying solvent, these higher administrative costs may also have a direct effect on hiring and retaining reliable, quality PCAs. Successfully employing an extremely diverse PCA population requires PCPOs to meet a diverse set of challenges. In order to appeal to potential employees, some agencies provide incentives like scholarships and tuition reimbursement. Very few can afford to offer perks like health benefits or child care. Should small agencies fall short in meeting the needs of their employees, their turnover rates—already high—will likely go up. Higher turnover rates would mean more new PCAs to submit paperwork for, and the cycle of rising administrative costs and time delays continues.
Perhaps most important is a PCPO’s commitment to providing a high quality of care—when it is needed—to a population with an extremely diverse set of needs and lifestyles. Failing to provide timely care to an individual with a disability can be extremely dangerous, if not illegal. For some consumers, a PCA does little more than provide light housekeeping and companionship. For others, any risk in interruption of services means they may not be able to retain their independent lifestyle. At the very least this interruption causes a large amount of stress for that person, their family, and the community.
Assisting people with disabilities to live independently in the community rather than placing them in institutions such as nursing homes is a relatively new philosophy. Recent experience has shown that pegging consumers and PCAs into a traditional healthcare-based models is ineffective. Everyone benefits from each member of society having access to the tools they need to live a full, rich, independent life. In turn, everyone has a responsibility to find creative solutions to problems within the current PCA program. DHS is charged with providing for the safety and well-being of people who depend on PCAs to help them live full, active, independent lives. “The former system of approving PCAs needed to be addressed.” Jeff Bangsberg said, “In bringing forth these changes last year, DHS clearly did not think through all of the unintended consequences this system has caused to PCAs, PCPOs and those who use the program to live independently in the community. They would have a better plan with more buy-in from the PCPOs, PCAs and clients using this service if they had included them in the develop-ment of a new registration system.” Working out the details of this latest change will take patience, communication and mutual respect for the needs of all parties involved.