Streams

Medicaid: US vs. NYC

Wednesday, January 19, 2011

Maha Attieh fills out a Medicaid application for Halima, an immigrant from Yemen. Halima signs her name on the form in English letters, which she learned through an ESL class. Maha Attieh fills out a Medicaid application for Halima, an immigrant from Yemen. Halima signs her name on the form in English letters, which she learned through an ESL class.

Welcome to Politics Bites, where every afternoon at It's a Free Country, we bring you the unmissable quotes from the morning's political conversations on WNYC. Today on The Brian Lehrer Show, New York Times reporter Anemona Hartocollis looked at the federal government's accusation that New York City is keeping too many Medicaid patients at home as a way to cut expenses.

The federal government has charged that New York City over-billed Medicaid by improperly approving 24-hour home care for thousands of patients, rather than assigning them to nursing homes and other long-term care facilities.

If the early reports are any indication, we are in for a long bout of he-said-she-said between Washington and New York. Anemona Hartocollis, who has been following this story for the New York Times, said that the lawsuit takes issue with the city's management of Medicaid funds and practices following a technical rule change in 2006. 

There's some dispute over the meaning of this change. The US attorney says that as of 2006, personal care in the home—feeding, grooming, toileting—was paid for by the federal and state governments. Before 2006 the city had to make a contribution. The implication of the lawsuit is that the motivation of the city in running this Medicaid mill and defrauding the feds, allegedly, was that if it put people in personal care the city didn't have to pay.

The city is pushing back. According to Hartocollis, the mayor's office and health advocates have expressed satisfaction with the way patient care is assigned in New York, making the point that it's better and cheaper to keep people in their homes than move them to facilities permanently.

The US attorney's office stepped into a hornet's nest they weren't expecting here. Not only Mayor Bloomberg, but advocates for the disabled as well have come out and said, "Gee, we want  people to stay at home; that's the optimal thing and in general it's less expensive." Although the US attorney alleges in this case that the personal care, because it was around the clock, was approximating nursing home care. Even the federal government, the advocates are saying, has a policy which it has pursued of keeping the disabled in the community, so why are they doing this? Their answer of course is, we're not taking sides on policy, this is just out-and-out fraud.

If this isn't going to be a policy debate, then the only questions are whether or not the city allocated Medicaid funds inappropriately, and whether or not the city benefited from doing so. The lawsuit would in effect settle confusion about what the 2006 rule change mandated, whether the city was indeed given a pass on contributing to home care costs, and if it then abused that privilege. Hortocollis said that city advocates are standing their ground, rebuffing the federal government and charging that the rule change is being mischaracterized.

Although the US attorney makes this stark distinction between personal care and other programs, he doesn't say what other programs he's referrring to. It's strongly implied that if you need something more intensive than 24-hour home care, it has to be a nursing home, but the city actually pays the same for nursing homes that it does for personal care. The advocates say that what happened wasn't that the city no longer had to pay anything, but that the city's contribution was capped, both for personal care and nursing homes, so essentially they're saying there's no benefit to the city of sending people to the nursing homes. This has gotten a little opaque.

Opaque is right. Not only do the city and the federal government disagree about the fundamental terms of the 2006 rule change—whether the city's home care contributions were nixed or capped—they can't seem to find common ground on how much the allegedly excessive home care costs, and who's had to foot most of the bill. What's more, the city recently released statistics showing that the number of patients entering the home care program had actually declined over the past decade. Hartocollis has reported that in the federal government's original complaint, they cited no such statistic about home care enrollment rising or falling since the rule change.

The city released those statistics because they seem to undermine the motivational aspect of the lawsuit. What you've got here is a lawsuit based perhaps on technical rule violations that inadvertently raised certain broader policy issues.

Although this debate is shaping up to be a lot of finger-pointing and prolonged bureaucratic confusion, Hartocollis said that there may be a silver lining to the unfortunate spotlight New York City now finds itself in.

For years there have been rumblings that home health care and aides and those kinds of programs are sort of handed out like candy, often done when they don't need to be done. In a way this falls into that background, but on the other hand, for a state like New York, which has the highest rate of Mediacaid spending in the country and that has budget problems, cracking down on a very expensive program may help control those costs.

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Comments [20]

My aunt, who has arthritis and dementia, was in a nursing home considered one of
the better ones yet she was utterly miserable while there. Yes, they fed her
and kept her clean. But she had no autonomy. Cast into an unfamiliar and not
very friendly environment, she ate when they told her to eat, had almost no
choice in what was available to eat, slept and woke when they told her to sleep
and wake, played when they let her play, had only the little bit of money they
allowed her to have.... I could go on and on! Forced from being an adult into
a childlike state, she had nothing to look forward to but death. And most of
the residents I spoke with at that place felt the same way. But now she's home
and receiving homecare after a long, hard and complicated struggle with the
bureaucracy.
Since her return to the home and autonomy she loves her health has improved
dramatically and lives each day more fully and productively. After all, it's
been well established that emotional well-being leads to physical improvement.
What's tragic is that it's far easier to be sent to a nursing home than to
receive homecare even though homecare is far less expensive (when my aunt was in
the nursing home, the charge to Medicaid was $550.00 per day. Her current
homecare cost is $152.00 per day and will be even less when she gets accepted
into a consumer-directed program).
And so it's beyond ridiculous to claim that New York City is giving people with
disabilities some kind of break as they fight for their right to live and thrive
at home with families and friends in a comfortable though sometimes challenging
environment. Believe me, it was a long and expensive struggle to bring her
home.
The physician "whistle blower" who is making these absurd allegations that NYC
is cutting corners to bring more people into homecare is likely nothing more
than a greedy souless crybaby who should him or herself be prosecuted for
abusing the legal system in order to unjustly enrich him or herself as well as
his or her employers.
As a taxpayer as well as human being, I demand that the United States abandon
this stupid lawsuit.

Jan. 20 2011 11:31 PM
Steven Sheppard from Manhattan

The vast majority of people would be happier and more comfortable if they stayed in their own home.

This lawsuit is misguided and cruel.

Jan. 19 2011 04:53 PM

I am reading a lot of talk about people remaining in their homes with familial support. As a Registered Nurse for 30 years in two different states, I can state unequivocally that families are the ones who take great advantage of the situation as often as the benefits serve to support the family. Only NY provides opportunity for 24 hour live in home attendant services. No other state comes close. I have seen too many able families allow the state to care for people who require 24 hours of supervision to remain in their two and three bedroom apartments living only a mile or less away form their loved one and unwilling to bring them into their home to care for them for at least half the day. There is this sense of entitlement they feel they deserve with comments like, "My mother worked her whole life for this and her taxes will pay for it." But I have seen too many families renege on their responsibilities to care for their loved ones and instead, let a stranger into the home at great expense to all tax payers.

I agree people should remain at home as a home care RN, but families need to do their part, stop griping about government intervention which is what this is and chip in for the cost, not just out of taxation revenues, but in time and heart.

As for cost? If you are a certified home health agency, the cost to provide a HHA until the Home Attendant agency kicks in is greater than the cost of reimbursement. There are two sides of the same coin.

Jan. 19 2011 04:27 PM

I am reading a lot of talk about people remaining in their homes with familial support. As a Registered Nurse for 30 years in two different states, I can state unequivocally that families are the ones who take great advantage of the situation as often as the benefits serve to support the family. Only NY provides opportunity for 24 hour live in home attendant services. No other state comes close. I have seen too many able families allow the state to care for people who require 24 hours of supervision to remain in their two and three bedroom apartments living only a mile or less away form their loved one and unwilling to bring them into their home to care for them for at least half the day. There is this sense of entitlement they feel they deserve with comments like, "My mother worked her whole life for this and her taxes will pay for it." But I have seen too many families renege on their responsibilities to care for their loved ones and instead, let a stranger into the home at great expense to all tax payers.

I agree people should remain at home as a home care RN, but families need to do their part, stop griping about government intervention which is what this is and chip in for the cost, not just out of taxation revenues, but in time and heart.

Jan. 19 2011 04:22 PM

@Jason from New York:

You are unfair to Mr. Lehrer (a fault I also share sometimes) and unrealistic in your expectations of what WNYC is offering (emotionally soothing programing for believers in "progressive" policies - the mirror image of Mr. Limbaugh over on WABC)
That said, regardless of the guest, and whatever view you think you may have on the topic, it is impossible to feel satisfied with the "information" being presented because of the apparent lack of preparation.
Mr. Lehrer's inability to clearly state the nature of the claims being made is, as usual, the first hint that the discussion will go no deeper than the superficial claims of the parties involved.
Why do we continue to listen?

Jan. 19 2011 11:53 AM
Don from New York City

When people need care, to the extent possible they prefer to receive it in the confines of familiar surroundings.
As a result of personal care, my 87 year old mother was able to stay in her home following a stroke, rather than require a much more expensive nursing home. This is what she wanted and with the aid she received this was possible for several years. It would appear that the federal government should devote more resources going after providers who illegally bill them for services they do not provide rather than forservices which reduce costs and serve peole in need in a manner which maximizes their sense of dignity and independence.

Jan. 19 2011 11:37 AM
Greg Otten from New York City

It is less expensive to help people remain at home than to wait for them to worsen and be institutionalized. If people don't get the care they need at home, they will end up needing expensive emergency room visits for falls and other emergency medical conditions. The assumption that living in an institution is safer than one-on-one care at home is absurd.

My grandmother, who lived her last years in a nursing home, severely mourned the loss of her home. While our family visited as frequently as possible, we could not be there all the time. She unfortunately spent many hours alone in her room and was very, very lonely. She could have used the attention she would have gotten at home.

On the other hand, my aunt, who has Alzheimers, is well cared for at home by 24-hour home health aides. Because of that, she has lived many happy years with the love of friends and family. She is never alone and has a lot of emotional support.

What kind of society are we if we don't care for our elders and disabled with the same compassion we would want for ourselves?

Not only is forced institutionalization cruel, but it is also irrational to expect taxpayers to bear the burden of costly institutionalization when a preferred alternative is available, especially in the current economic climate. The Supreme Court's Olmstead decision is clear that people have a right to live in the most integrated setting.

Jan. 19 2011 11:33 AM
Sandy Weiss from NYC

I work with people with disabilities. It is plainly wrong to assert that people with disabilities who are in need of 24 hour care would be better served in a nursing home than their own home. People prefer to remain in their own homes, within their own communities. In fact, it is less expensive to help people remain at home, and in many instances safer. Remember Willowbrook, Walter Reed and reports of inadequate staffing of nursing homes, reports of abuse and neglect of patients, etc.

Jan. 19 2011 11:03 AM
Gisell Claudio from New York City

As a counselor for people with disabilities and a daughter of one, i can vividly say that people prefer to remain in their own homes and in the community. It is less expensive to help people return home after a hopital stay than to wait for them to worsen and be institutionalized. If people don't get the care they need at home--they will end up needing expensive emergency room visits for falls, etc. The assumption that living in an institution is safer than one-on-one care at home is absurd--consider institutions like Willowbrook where there were inadequate staffing and abuse of patients.
It is irrational to expect taxpayers to bear the burden of costly institutionalization when a preferred alternatives are available--especially in the current economic climate. The Supreme Court's Olmstead decision is clear that people have a right to live in the most integrated setting.

Jan. 19 2011 10:57 AM
William from Manhattan

Terrific conversation on an important topic. Anemona Hartocollis clearly has done her research and presents the facts and her analysis clearly and fairly. It seems clear that home health care has a place in our health and elder care system. Incidentally, "home" health care aides often are also necessary in institutional settings - many residents in assisted living institutions must have an aide to attend to daily activities of living, sometimes for as long as 24 hours a day. I wonder how those aides are accounted for in the federal/state calculations.

Jan. 19 2011 10:52 AM
Jason from NY

Way to go Brian. You had an elder law attorney call in who knows the ins and outs of Medicaid (both on the federal and the state level) and you boot her off in five seconds in favor of a reporter who knows little about the matter. While in your previous segment, you let a Tunisian who hasn't been in the country for 13 years talk ad naseam about the current political climate in Tunisia at the expense of spending more time questioning a reporter who is assigned to and currently in Tunisia. Good moderating! Also nice try to establish a link between the U.S. and the Tunisian revolution via WikiLeaks. Bad bad meddling U.S. ...!

Jan. 19 2011 10:52 AM
Sharon

I wish the station would discuss the real reason why the state wants to discourage home health workers. At least for the state of New Jersey, there is a 7 year look back at the elderly or disabled person's assets so that anything the person requesting to go into a nursing home owned within the last 7 years, will go to the state automatically. Its just another way for the state to rape its citizens!

Jan. 19 2011 10:44 AM

Federal Gov. is showing how out of touch they are by making that statement. Individuals that are disabled and are receiving Medicaid should be given the right to make the choice to live independently in the community with the necessary supportive services. This is generally more cost effective than being institutionalized.

Jan. 19 2011 10:39 AM
Nick Lento from NJ

It's clearly cheaper AND more HUMANE to take care of people in their own homes!

This is just a BS reaction fueled from the nursing home industry.

Jan. 19 2011 10:37 AM
Mel Tanzman from Yonkers NY

I am shocked that the US Attorney is pursuing a suit which challenges the basic right under the ADA that people should receive services in the most integrated setting. To me it seems to be simply put a financial shakedown of NYC- the whistleblower stands to get 50% 0f the damages. One thing that is missing from the complaint is what the consumers and their families wanted- How many would prefer institutional care? Shame on the Department of Justice!!!

Jan. 19 2011 10:29 AM
Lourdes Rosa-Carrasquillo

People prefer to remain in their own homes and in the community. It is less expensive to help people return home after a hopital stay than to wait for them to worsen and be institutionalized. If people don't get the care they need at home--they will end up needing expensive emergency room visits for falls, etc. The assumption that living in an institution is safer than one-on-one care at home is absurd--consider institutions like Willowbrook where there were inadequate staffing and abuse of patients.
It is irrational to expect taxpayers to bear the burden of costly institutionalization when a preferred alternatives are available--especially in the current economic climate. The Supreme Court's Olmstead decision is clear that people have a right to live in the most integrated setting.

Jan. 19 2011 10:26 AM
marianne from Staten Island

Why do Republicans and some Democrats deny universal coverage (Medicare for all)?

If the social safety net isn't good enough for the same taxpayers who involuntarily fund congressional pensions, congressional health insurance premiums and congressional health care costs, then such "out of control big government socialism" shouldn't be good enough for the clearly overpaid, underworked elected "deficit hawks".

Isn't it interesting how our elected officials don't have to worry about either going bankrupt due to health issues, or are unable to afford medications and treatments, yet don't want their own constituents to have that same peace of mind, involuntarily provided at taxpayer-expense for our Congress?

Jan. 19 2011 10:25 AM

The U.S. District Attorney has gotten this wrong. I work with people with disabilities and very few that I know about need to be in or get better care in nursing homes than they do at home with an attendant. Most who have been able to come back to their communities are living productive, active lives. Those in institutions are often stripped of their dignity, their right to make decisions about their care and their lives and their rights under Olmstead. People in their communities are living their lives as independently and actively as they can and taxpayers are not faced with excessive costs.

Jan. 19 2011 09:57 AM
Susan Dooha, J.D. from New York

More than 75 local, state and national organizations, including the Center for Independence of the Disabled, NY have joined together to demand that the U.S. Attorney withdraw this litigation. The complaint reflects fundamental misunderstandings of the home care program and ignorance of the Supreme Court's decision establishing a right to live in the most integrated setting. New York City should be rewarded--not punished--for helping people remain in the community. This is not only good for people with disabilities of all ages--it is good for taxpayers because it costs less.

Jan. 19 2011 09:35 AM
Robert Fasano from Brooklyn

The U.S. Attorney's position is on a collision course with the Supreme Court's Olmstead decision--requiring that people with disabilities be able to live in the most integrated setting. A study by the United Hospital Fund demonstrates that programs that keep people at home are less costly and are preferred by most. From my perspective, the federal government has lost its way on this one.

Jan. 19 2011 09:14 AM

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