A recent Columbus Dispatch article listed the number of private provides that can bill Medicaid, at 13,000 across the state of Ohio. Not all of these providers serve people with a developmental disability, but the idea of losing their non-agency provider is creating a lot of back lash from people with disabilities and their families. The precipitous action is in response to Federal Regulation. The Columbus Dispatch reported recently that communication was presented to Governor Kasich on March 20th 2015, with a very clear message.
“Federal Labor Secretary Thomas Perez sent Ohio Gov. John Kasich and other governors a letter yesterday warning them to make sure their upcoming budgets comply with a federal rule requiring minimum-wage and overtime pay for most home-care workers.”
So why the concern from people that their private provider has to now be hired on by an agency? Perhaps it goes without saying, but anyone who receives personal care support at almost any level is creating an intimate relationship with another person. Many people and their families have spent years cultivating a trusting and understanding relationship between themselves and the person or persons who are providing care in their home. Private provides have learned a persons favorite food, sports team, and tv show. They have shared, on a daily basis, the triumphs and disappointments of the person they care for, whether that be in learning, loving or grieving. Whether someone means to share these personal details it doesn’t matter in the end. A caretaker is there to feed, shop, cook, clean, bathe, transport and do all the daily things that a person may need support with. Whether a person or a family means to share, a service professional is going to get incorporated into the emotional swings that life creates. The thought of losing someone that you share or have shared so much with, can feel like losing a member of the family.
So what prevents a private provider from joining an agency and continuing that relationship with the person? I can think of three challenges that could create issues for when agencies are asked to do the heavy lifting and attempt to employ private providers and serve those contracts now left open.
Pay, Personality, and being Passed Over
It is clear that the reimbursement a person receives as a private provider is significantly more than the pay they would receive through an agency. The rate of reimbursement from Medicaid (IO WAIVER) is actually more for an agency when compared to a private provider by approximately 15%. However, the pay rate a private provider would expect to receive could be as much as 40% less when going to work for an agency. There are many good reasons an agency is priced the way that it is priced and why it’s pay structure is set up the way it is set up. This piece is not to walk through the merits of agencies and private providers or their down sides either. The point is, a professional having to consider even a 30% reduction in pay is unlikely to embrace that change and is unlikely to be able to continue in the field in the same capacity. The pay alone might be enough for a private provider to not continue services to someone under the umbrella of an agency.
Personality is the next reason agencies may have difficulty replacing a long standing private provider. As eluded to above, agencies have extensive infrastructures necessary to support large operations. Even small residential agencies can have over one hundred employees and some agencies operate nationally with thousands of employees. Staying in compliance with wage and hour laws and regulations from the department of labor( like the ones creating this predicament), sorting through ACA and HIPAA a few years back, as well as being the one to pay all of the required taxes for payroll, obligate agencies to create very extensive and deep operations as it pertains to administrative functions. More importantly, it can create a top down approach to care and care coordination. It is that top down approach that I believe creates the second dilemma for a private provider looking to make the switch. If you are a successful private provider, it is because of you. You have what it takes to connect with a person needing services and their family. It’s you who can coordinate your schedule, arrange for days off, address requests from your client and basically, manage all of the elements associated with the care that you deliver. That is not a personality that can make a change to a top down approach easily, in my opinion. A private provider will suddenly report into a manager, have policies and procedures that have been developed over the years, and may even comply with standards in other states. Asking permission for changes, sharing communication with the client, their family and their other supports will all be new for a private provider joining an agency.
The biggest concern, though, may be that people who need relatively fewer services for their care and support, may be passed over by an agency because it doesn’t work as well with their current model of service delivery. Many agencies are good at providing a large base of staff to serve a large of number of hours to multiple people who share an apartment or are renting a home together. Providing less than 40 hours, or even 60 hours a week of services that are flexible and may change based on a natural support structure is very different for many, but not all, agencies. Some agencies just may not have another page in their playbook.
The good news is that there are some agencies who, over the years, recognized this model of care and have figured out that not one size fits all. I also believe that good agencies will start considering how to serve this client base and adapt their customer service and program models in order to use the strengths that already exist in the care being received today.