Letter to the Editor
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
