Colorado VNA (CVNA) in Northern Colorado has been providing Medicaid Home and Community-Based Services (HCBS) services for over thirty years. Like many organizations that care for HCBS patients, our organization is struggling to care for these patients because the reimbursement is too low, well below our costs. In recent years, with the increase in home health care regulations; the cost to provide homemaking and personal care services has risen significantly. It is because of the gap between reimbursement and costs that CVNA is working to find other agencies to take on some of our patients. Additionally, CVNA will be kicking off a fundraising campaign to seek support from caring donors passionate about helping Colorado residents remain in their homes. The following is an overview of how CVNA came to this decision to decrease our HCBS census as well as a description of what other states are doing with HCBS.
A large challenge that CVNA and other HCBS providers struggle with is the low HCBS reimbursement rates. The rates have simply not kept pace with the increasing cost of living in Colorado. There was an increase from $15 per hour to $17 per hour in 2015 and then a 50 cent proposed increase for 2018. This increase is simply not enough and I fear that a growing number of agencies serving HCBS patients will decide to stop taking new HCBS patients and/or get out of HCBS altogether.
This is unfortunate because increased spending on attendant and homemaking care like HCBS has been shown to decrease institution costs, i.e. the more states increase and support HCBS services, the less funds are spent on skilled nursing. In fact Colorado has been a leader in supporting HCBS and as a result has had very limited to no growth in skilled nursing days for patients over 65 in the past ten years, however I fear that this trend may reverse in the near future if more money is not allocated for HCBS or other financial sources of support are not found.There is data that show systematic support for HCBS results in decreasing spending growth on institutional long-term care services. According to an article in Health Affairs “expansion of HCBS appears to entail a short-term increase in spending, followed by a reduction in institutional spending and long-term cost savings.” In fact “Nursing home spending grew by 3.4 percent in the low-HCBS states over the period, after adjusting for inflation, but declined by 15.3 percent in the high-HCBS states;” like Colorado. These findings match what CVNA hears from its own patients in Denver and Northern Colorado. Through our own patient surveys, over 93% of our patients report that the personal care and homemaking services provided by CVNA are critical to that patient’s ability to remain independent in the home. After the progress Colorado has made, I fear that there may be a decrease in patients remaining in the home and a move towards more patients returning to nursing homes. Not only that, recent success in transitioning patients from skilled nursing to the home will slow down or stall altogether. In a 2005 survey by the Centers for Medicare and Medicaid Services (CMS), 165,276 nursing home residents indicated that they would like to return to their communities; if they received HCBS waivers to do so, the public could see annual savings of $2.6 billion.
It does not have to be this way. In fact Arizona has a more expansive program called Arizona Long Term Care System (ALTCS) which emphasizes HCBS and rewards providers to keep people out of facility-based care. In addition to the higher level of incentive, Arizona also pays their HCBS providers dramatically more at $22 per hour vs. Colorado’s current $17. What is particularly telling is that Arizona has a significantly lower cost of living than Colorado; a salary of $36,000 in Phoenix needs to be $46,000 in Denver according to this cost of living calculator. Arizona is not the only state that pays more and has done more to coordinate HCBS services. Missouri pays $18.40 per hour for homemaking even though the cost of living in Missouri is much lower than Colorado and even lower than Arizona. Additionally, Missouri has rolled out its own program to keep people in their home called Aging-in-place which has seen improved outcomes by connecting HCBS services with nurse care management and traditional home health services like nursing and physical therapy services.
Colorado’s Department of Health Care Policy and Financing (HCPF), i.e. Colorado’s Medicaid organization; does know and even acknowledges that reimbursement for HCBS is too low. In fact, a recent HCPF analysis of HCBS rates recommended a new rate of $21.48 per hour, an increase of $1.12 per 15-minute “unit” of service or $4.48 per hour (Slide 11). This magnitude of increase would make a dramatic difference for providers assisting HCBS clients and in fact HCPF would likely have a backlog of new providers requesting to become HCBS provides. However, the real issue is not really HCPF, but rather the necessary budget to support HCPF’s recommendation (Slide 14).
As you can see, HCBS is an extremely important part of the care continuum that helps people remain in their homes. Colorado has been an extremely progressive state in its implementation and support for more HCBS services than many other states and as a result, Colorado’s skilled nursing admissions and overall census has either decreased or remained stable over the past decade. However, I believe these gains may be lost if Colorado does not invest more in its HCBS providers in the coming months and years. And, the problem is only going to get worse as Colorado’s minimum wage inches towards $12 an hour. In the meantime, CVNA will reduce our own HCBS patients in order to remain sustainable unless of course we find other funding sources to support our patients as it is our mission to help people remain independent in their homes.
Christopher J. Lee
President & CEO