House Aging & Long-Term Care Committee May 17, 2017

House Aging & Long-Term Care Committee May 17, 2017 Chairman Arndt and Ranking Member Howse and members of the House Aging and Long-Term Care Committee, my name is John Stacy and I am the director of advocacy with the Ohio Council for Home Care and Hospice. Our association represents more than 500 home care, palliative and hospice providers across the state. In the interest of time and in consideration of the other witness today, I will limit my remarks to two items of importance to our industry: Consideration of the state Medicaid reimbursement rate methodology by managed care organizations when negotiating rates with providers (ORC 5167) and designation of home health as an in-demand industry (ORC 6301.11). 1. Consideration of the state Medicaid reimbursement rate methodology by managed care organizations when negotiating rates with providers The Ohio Department of Medicaid has spent a considerable amout of time and energy creating a reimbursement rate methodology the state believes to be sufficient for home care services. As you may know, the state is required by CMS to document that Medicaid State Plan rates are consistent with efficiency, 1105 Schrock Road, Suite 120, Columbus OH 43229 614-885-0434 www.ochch.org

economy and quality of care and ensure sufficient beneficiary access to care, as required by the Social Security Act. These rates are created with input from the regulated industries and include factors such as base wage, employee related expenses such as insurance, FICA, workers comp, retirement, travel & time, training and supervisory costs. While we may disagree with specific inputs determined by the state and its consultant, for the first time we have a rate methodology that is based on something more than residual budgeting. We are very concerned about the state allowing MCO s to institute their own rates below what the state has documented as being required to ensure the efficiency, economy, quality, and access of care. Several other states, including high senior population states such as Arizona, Florida, and Michigan, require MCO s to provide reimbursement rates equal to or higher than those established by the state. With the expansion of managed care in Ohio for Medicaid receipts we are concerned that MCO s will focus more on following the lead of Buckeye Health Plan and institute a 15% across the board rate cut for home care providers rather than focus on care management and quality services. We recommend that Ohio should require that MCO s pay rates at least equal to the state methodology for all Medicaid providers to protect Ohioans from receiving substandard care. In addition we believe that the state should institute a policy to periodically review 1105 Schrock Road, Suite 120, Columbus OH 43229 614-885-0434 www.ochch.org

the rates to determine if they are sufficient to ensure quality care for Medicaid recipients. Specific Request: We respectfully request that ORC 5167: MEDICAID MANAGED CARE be amended regarding the state s reimbursement rate methodologies as follows: Require MCO s to provide reimbursement rates equal to or higher than those established by the state. We recommend that the Medicaid Rate Methodology be reviewed biannually to coincide with each state budget cycle. 2. Workforce development training and employee recruitment issues Tens of Thousands of Ohioan s have long-term care services and support needs that require not only nursing support but direct care workers as well, to help them perform routine daily activities, such as eating, dressing, and bathing. These caregivers are the backbone of ensuring Ohioans can remain in their homes with the supports and care they need rather than going to more costly institutional care. The Ohio Department of Job & Family Services ( ODJFS ) has identified homehealth services as the second fastest growing industry this decade. However, home health and community based care providers are already suffering from the shortage of available staff for entry-level positions. 72% of home health and 1105 Schrock Road, Suite 120, Columbus OH 43229 614-885-0434 www.ochch.org

community-based care providers reported that they had to limit admissions or reduce services due to a lack of staffing. More than 40% of hospice and home care providers report having no applicants for their open positions. (Please see attached workforce development information) While there are a number of reasons for this, including low Medicaid reimbursement rates which limit the rate of compensation providers can pay for home-health aide services, we respectfully request that the General Assembly make changes to state workforce development programs to help home health and community-based care providers. In the House passed version of HB49, an amendment was added at our request to designate home health care as an in demand industry as identified by the governor s office of work transformation (ORC 6301.11). In addition the amendment lowered the threshold for access to state workforce development dollars to 125% of the federal poverty level allow our members to potentialy avail themselves to these resources. I wanted to thank the House for this recognition of the struggle our industry faces recruiting and retaining a high quality workforce. We would like to recommend one additional change to the Ohio Administrative Code dealing with who can provide personal care services (OAC 173-32-02.11 (C) (2) (a) (ii)). This section has caused problems in hiring workers who have not had a competency test in the past 24-months or if they have a gap in service in that two-year period. We believe that the Department of Aging is misinterpreting 1105 Schrock Road, Suite 120, Columbus OH 43229 614-885-0434 www.ochch.org

Medicare Conditions of Participation (CoPs) as we are clearly not prohibited from hiring an individual in this situation. The agency must simply give the aide a new written competency and a return demonstration test to make sure they are able to fulfill the job responsibilities. Specific Request: We respectfully request that OAC 173-32-02.11 (C) (2) (a) (ii) be amended as follows: Amend Ohio Administrative Code Chapter 173-32-02.11 (C) (2) (a) (ii) to follow CMS CoPs for Medicare certified providers by striking out as follows: OAC 173-39-02.11 (C) (2) (a) (ii) Successfully complete the Medicare competency evaluation program for home health aides set forth in 42 C.F.R. Part 484., as a direct care health care worker without a twenty-four month lapse in employment as a home health aide or nurse aide; Thank you for your consideration of these requests. I would be happy to try to answer any questions you may have. 1105 Schrock Road, Suite 120, Columbus OH 43229 614-885-0434 www.ochch.org

HIGH WORKFORCE TURNOVER FROM STAGNANT WAGES HARMS PATIENT CARE Wages paid to home health and personal care workers in Ohio continue to lag behind those paid employees in comparable jobs, resulting in high workforce turnover which harms patient care. A Feb. 2017 study on Ohio s Long-Term Care Workforce Crisis showed dramatic caregiver shortages, with more than 5,000 unfilled positions reported by survey respondents. i In addition: 8 out of 10 home health aides who left their jobs, left for better pay. Home health workers in Ohio are mostly women, in their 40s and 50s, earning between $9-10 an hour. 57% of home health and hospice providers reported having fewer home health aides than planned. 1 in 5 providers has limited admissions or reduced services, creating access to care issues. Some Ohio homecare companies report workforce turnover in excess of 60% (see reverse). Ohio Dept. of Job and Family Services ranks home health and personal care aides in the top 5 fastest growing and most in-demand jobs between 2012-22, projecting them to increase 39.2% and 38.8% respectively. ii OHIO PROPOSES GREATER RELIANCE ON HOMECARE TO REBALANCE ITS BUDGET Homecare employees form the backbone of the State s efforts to rebalance Medicaid expenditures away from institutional care, but low wages are forcing homecare employees to leave the industry for higher paying jobs in retail, fast food and related industries. Despite stagnant wages, the number of Ohioans receiving HCBS has grown nearly 30% in the past 4 years (see graph). This process literally has rebalanced institutional care, saving the state ~$2.4m per month in State Medicaid dollars. iii Caregivers, however, are at the breaking point and are unable to sustain their efforts which yield these savings because of stagnant wages. iv BUILDING ON OUR PROGRESS In 2015-16, the General Assembly enacted the first rate increase for home health and personal care aides in over 12 years. Providers requested 15%. The House set aside 10%, but only 5% survived in the final budget. In this year s Executive Budget the Kasich Administration proposed a 5% increase in personal care aide rates for Ohio Home Care and PASSPORT waivers (est. cost is $23.1m/$8.6m state share in SFY 2019). v This increase would restore the amount proposed in 2015 and enable providers to compete in Ohio. We ve managed [Medicaid], but if people want to stay in their own home, rather than being put in a nursing home, they could do it. Gov. Kasich on CNN, 5/7/17 THE ASK We respectfully request the General Assembly to include Gov. Kasich s 5% increase for personal care aides in the final budget for SFY 2018-19. This will help homecare address employee turnover and advance Ohio s progress as a national leader in Medicaid transformation by providing greater access to HCBS to the elderly and disabled, the patient-preferred and least-costly setting.

i Survey of providers conducted by five Ohio associations operating in the field of long-term care (Leading Age, Ohio Association of Senior Centers, Ohio Health Care Association, Ohio Assisted Living Association and Ohio Council for Home Care & Hospice). Results published in a Feb. 2017 report called, The Long-Term Care Workforce Crisis: Caregivers Needed! A 2016 Report. ii Ohio Department of Job and Family Services, 2022 Ohio Job Outlook: Employment Projections. Dec. 2014. Retrieved from: http://ohiolmi.com/proj/projections/ohio_job_outlook_2012-2022.pdf. iii Ohio Department of Medicaid, MyCare Ohio: Progress Report 2017, page 21. Retrieved from: http://medicaid.ohio.gov/portals/0/initiatives/mltss/mycare_ohio_progress_report_2017.pdf. iv See footnote 1. Survey results from Feb. 2017 report, The Long-Term Care Workforce Crisis: Caregivers Needed! A 2016 Report. v Ohio Office of Health Transformation, Prioritize Home and Community Based Services, Jan. 30, 2017. Retrieved from: http://www.healthtransformation.ohio.gov/linkclick.aspx?fileticket=vyi4o1vy6qa%3d&tabid=254. SOURCE: Internal turnover data maintained by Almost Family and Home Care by Black Stone.

Bringing Health Care Home What is Home Care & Hospice? Home health care and hospice are health care options that allow individuals of all ages to remain in their home alone or with their families rather than in an institutional setting. Home care is available to individuals with acute, chronic or debilitating health problems. Hospice is not only caring for the terminally ill, but also a philosophy that affirms life, dignity, and choice until the end of life. Why Do People Choose Home Care & Hospice? Home health care services promote independence to individuals of all ages. Home care and hospice can provide a viable, cost-effective health care environment outside of the institutional setting of a hospital or nursing home. What Services Are Available? Advanced technologies now enable health care professionals to use sophisticated, high-tech medical equipment and procedures in the home to promote healing and/or comfort and pain relief. Home health care services include care provided by skilled professionals as prescribed and directed by the individual s personal physician, as well as supportive services including assistance with walking, bathing, dressing, meal preparation and light housekeeping. Choosing a Provider Finding an agency best suited for your needs requires research, but it is time well spent. Important factors include the quality of care, availability of needed services, personnel training and expertise, and coverage provided by the payor. Fortunately, most communities have a variety of agencies to choose from. Visit www.centerforcommunitybasedcare.org to search for providers. You can also contact the Ohio Departments of Health and Aging to obtain additional lists of agencies. Providing Solutions for You & Your Family. A Few Questions to Ask How long has the agency been serving the community? Is the agency certified by Medicare? Is the agency accredited? How does the agency select and train its employees? Does it run a criminal records check on new and current employees? Is the individual s course of treatment documented, detailing the specific tasks to be carried out by each professional caregiver? Does the agency assign supervisors to oversee the quality of care individuals are receiving? If so, how often do these individuals visit? Whom can you call with questions and complaints? How are problems followed up and resolved? Does it provide written statements that explain all the costs and payment plan options associated with home care? What procedures are in place to handle emergencies?

What is Home Care? Home care encompasses a wide range of health and social services that can be delivered at home to recovering, disabled or chronically ill persons in need of medical, nursing, social or therapeutic treatment and/or assistance with the essential activities of daily living. Home care is provided to families and individuals of all ages who are challenged by a variety of health and social problems, including short and long-term illness, injury, physical handicaps, mental health disorders and chemical dependencies. Who Provides Home Care? Home care services are provided by home health care agencies. These agencies generally fall into three main groups: home care agencies, home care aide agencies and hospices. These public and private non-profit and for-profit organizations center around a core of professional nursing and home care aide services. Home care agencies also provide a variety of other services, including physical, occupational and speech therapy, and social and nutritional care. Home care usually requires a team effort. Depending on a person s needs, it may involve professionals, aides, and volunteers. Before one receives home care, a specific plan of treatment should be designed by a physician, nurse, and/or medical social worker in cooperation with the people who will provide the care. The team of caregivers is usually comprised of: physicians social workers registered nurse (RNs) licensed practical nurses (LPNs) therapy specialists (physical, occupational, and speech therapists) dieticians and pharmacists home care aides and chore workers/ companions family members volunteers Who Pays for Home Care Services? Home health care services are reimbursed by both private and public sources. Public third-party payors include Medicaid, Medicare, and PASSPORT. A growing number of private insurance plans and other third-party payors also provide home health care reimbursement. Home health care may also be paid directly by the individual or the individual s family.

What is Hospice? Hospice provides care and support for persons in the last phases of incurable disease so they may live as fully and comfortably as possible. Hospice recognizes dying as part of the normal process of living and focuses on maintaining the quality of remaining life. Hospice is not only caring for the terminally ill, but also a philosophy that affirms life, dignity, and choice until the end. Who Provides Hospice? Hospice is provided in Ohio by licensed hospices. Most hospices in Ohio are also Medicare Certified. Care may be provided in the hospice s own in-patient facility, a nursing facility or in the individual s home. The hospice program has a variety of services provided by the hospice care team. The team is usually comprised of: registered nurses social workers physicians clergy and other counselors home health/hospice aides family members trained volunteers physical, occupational and speech therapists Who Pays for Hospice Services? Insurance coverage for hospice care is available through Medicare, Medicaid, and most private insurance plans. The individual and family can pay for hospice services out of pocket if no other payment option is available. The individual and family should discuss payment options with the physician and hospice staff. Additional Home and Community Services Home and community based care makes it possible for elders or individuals with disabilities to live independently at home. Services ranging from nursing, respite for primary caregivers, meal delivery, medication, and medical equipment are just some of the services provided to keep people where they want to be at home. To find out more about choosing an agency or to locate a home care or hospice provider in your area, visit the Center for Community Based Care (CCBC) website at www.centerforcommunitybasedcare.org. 1105 Schrock Rd, Suite 120 Columbus, OH 43229 www.centerforcommunitybasedcare.org