Predictably, no veto override session will occur in 2013, confirmed at the end of last week. But that doesn’t mean that what emerged as the highest-profiled of the matters vetoed, more money to fund permanently expansion of the New Opportunity Waivers program, cannot be altered to serve more people and make better use of taxpayer dollars. And an important first step was taken last week to do this.
The Legislature this year passed a $4 million in line items to mandate new ongoing spending for 200 additional slots for this. Waiver programs let states use federal Medicaid dollars to give services to the developmentally disabled or elderly who would not otherwise qualify for the program on the basis of income or assets, as long as the average cost per client does not exceed what the state would spend on paying for them to live in nursing homes.
With a waiting list of approaching 11,000 for NOW, at least a small dent could have been made in that, where some on the list with severe disabilities have waited for eight or more years. But citing legislative directives that produced a health care budget $40 million in the red ordering the executive to make cuts, Gov. Bobby Jindal vetoed those line items.
The resources involved aren’t trivial. In Fiscal Year 2012, $457 million was spent on 8,425 NOW recipients while another $206 million for 8,241 clients was spent on other waiver programs. NOW differs from the others because it provides skilled nursing services and as much as around-the-clock care, which the others separately do not. However, not all hours given have to be skilled nursing, and many on the waiting list already receive a high level of services from the other waivers at an intense level. Nor at the time of offering do all applicants have need of services at the NOW level; for this and other reasons, fewer than half of NOW offers are accepted.
Several reasons explain the list’s length. First, Louisiana’s previous strategy, before court decisions forced it to shift emphasis to home- and community-based services, was to warehouse the elderly and disabled into nursing homes, so the abrupt transition meant a lot of catching-up (as well as reducing wasteful spending to nursing homes that seems set to continue for some time, dollars which otherwise could have gone to waiver services). Second, in that rush Louisiana overcompensated in terms of people made eligible for NOW and in the level of services provided across all waiver programs, with the rebalancing beginning only after Jindal took office. Third, with the creation of the several programs beginning with NOW in 2003 (each is petitioned to the federal government, which then must approve them and any changes made after), it was difficult to stitch them together in a way that provided an efficient continuity of care.
For an example of this, a child under 18 qualifies either for NOW or a Children’s Choice Waiver depending on the need for skilled nursing. But what if prior to the child’s 18th birthday a change in health conditions causes a need for skilled nursing where one previous did not exist? Under current regulations, NOW is first-come-first-served, so a coverage gap would exist. This then creates an incentive to get the child placed initially on the NOW waiting list in anticipation, whether the need ever manifests, of such needs, while in the interim the child uses CCW.
Going to a need basis in determining NOW recipients largely solves for this, and that’s what happened last week as advocates called upon legislators to back an override session and then to override the NOW item veto when the Department of Health and Hospitals said that standard could start within the year. This would deliver NOW services to more people more quickly, although some adjustment should be made to allow long-time waiters of lower need not to have to wait several more years to receive services. This would make the awarding process more responsive and create incentives to match program to genuine need.
But more can be done. Revamping of rules can create more seamless ability to transit from one kind of waiver to another as ages (some differ between children and adults) and needs change, to eliminate incentive to clog the NOW list, and to make sure nobody falls through the cracks (such as when turning 18 and becoming ineligible for one program only to be faced with a waiting list for another similar one for adults for which then they would have to apply).
Rules revision also can allocate personnel resources more efficiently; currently, the one-size-fits-all staffing model for providers does not induce incentives for matching staff capabilities to client needs. For example, reimbursement levels by the state to providers could depend upon demonstrated competencies of employees, which then could pay more skilled workers higher wages for households whose clients have greater demands; this is something DHH already is reviewing.
Technology also can assist. To ensure that contracted providers are meeting service commitments, using verification systems that indicate employee arrival and departure can be mandated for all providers, not just for skilled nurses. Personnel even may not be necessary for low needs individuals, where electronic monitoring can suffice.
Finally, although vilified by some when introduced a few years ago, the resource allocation model approach that identifies needs that then on a rational basis can be fit to resources required, perhaps in concert with the move to need-based allocation of NOW, can be extended in its discriminatory power to make sure that the appropriate amount and level of services are being provided. This will stretch dollars and get more clients services and more quickly.
In other words, it’s not just a matter of money needed to increase service levels. While advocates do well to call attention to a gap in service, policy changes can accomplish closing at least some of this gap. And it’s to DHH’s credit that increasingly it’s open to making, if not implementing, these changes.