Ted Nagel’s arms and legs don’t work. He has a congenital condition that makes him completely dependent on others to perform the most basic tasks — eating, grooming, going to the bathroom. He must be carried to and from his bed, bathroom, and motorized wheelchair.
These days he’s challenged to find a home care worker who will accept the meager Medicaid reimbursement the government pays, after the agency who employs the worker takes a cut.
Home care workers, also known as personal care aides (PCAs), perform non-medical tasks such as light cleaning and meal preparation. They earn a median national wage of $12, according to the Labor Department.
“You can’t find people who want to do personal care and deal with bodily functions for $10 an hour,” says Republican state Sen. James Settelmeyer, Nagel’s representative and neighbor.
Settlemeyer has watched for two and a half years as Nagel makes his way each night in his motorized wheelchair to the local hospital, where he can find the help he needs, given the dearth of qualified and willing personal care aides.
Senate Bill 93, sponsored by Settlemeyer, would allow Nagel and others who have the mental capacity to manage their own care to pay their personal care aides more, in an effort to recruit and retain quality help.
Nevada currently allows Medicaid recipients to direct their own home care by managing an employee provided through an agency, such as Visiting Angels, or choose the personal care assistant and act as managing employer, while an Intermediary Service Organization (ISO) is the actual employer — handling taxes, pay and paperwork.
SB93 would cut out the middleman by allowing the client to receive funds directly from Medicaid “and use that money to pay for services provided by a personal care assistant.”
“The consumer directed movement has been around for a long time,” says Vicki Hoak, Executive Director of the Home Care Association of America. “Medicaid will give a range to the consumer and the consumer decides what the pay is going to be for that employee.”
“It’s something we recognize as a choice,” Hoak says. “Usually states don’t provide a lot of training and don’t have a lot of oversight on this model.”
How it works
Each state offers some type of self-directed personal care assistance program, according to Medicaid. Many states, including Nevada, allow the client to pay a friend or relative to provide care.
Some states allow spouses to be paid as caregivers, but Nevada is not one of them.
The self-directed client’s budget is determined by an assessment of their needs, as well as average home care wages in the area, according to the American Council on Aging.
Under state and federal laws, clients with money could pay caregivers more, as long as it does not exceed federal and state caps. A PCA could receive as much as $17 or $18 an hour, Settelmeyer says, as long as its within the guidelines.
But should quality care be available only to those Medicaid recipients who can afford to pay for it?
“Do I think they should be able to utilize the Medicaid money and only the Medicaid money? No,” says Settelmeyer. But he says the crux of the bill — and the bulk of higher reimbursement to caregivers — is achieved by cutting out the middleman.
“Without the agency taking their cut, the client can direct more pay to the PCA,” he says.
What about the Medicaid recipients who lack the cognitive ability to manage their PCAs, or the financial wherewithal to augment their caregiver’s income? Are they destined to endure inferior care?
“Fair question,” says State Sen. Joe Hardy, a physician who moonlights as a legislator. “We have to start to show how this may be a good example and maybe show what else we could do.”
“A rate of pay that would guarantee everyone access to robust services would obviously be an ideal solution, but ideal is rarely possible and might be impossible in this space,” says State Sen. Ben Kieckefer, also a Republican and a member of the Senate Health and Human Services committee. “Providing greater opportunity for consumer-driven healthcare solutions is generally a good thing, I think.”
“I wish there was a way we could try to find more resources for those people, as well,” Settelmeyer says. “Is it right to say just because we can’t give it to everybody, should we not give it to anybody?”
Some experts suggest a uniform assessment tool and a tiered rate of reimbursement based on the level of care provided would benefit clients, as well as providers.
“There’s not a gigantic pot of money the state currently has or I’d gladly vote for that,” says Settelmeyer, who says the Department of Health and Human Services shot down the concept of tiered reimbursement. “We talked with the Division about that and they said it would be too problematic and that this had the least fiscal impact.”
Personal care aides make up 2.2 percent of the workforce in the U.S. New York has the highest share of PCAs in the workforce at 4 percent. Nevada has the lowest share of all states at .9 percent.
A policy report from the Guinn Center says Nevada will need to almost double its workforce of 13,000 personal care aides to meet demand by 2040.
Industry advocates say caregivers left the market during the pandemic for a variety of reasons, including to take advantage of CARES Act unemployment benefits, which paid more than their wages.
Home care is recognized as a means of allowing seniors and the disabled to remain in their homes. The monthly consumer cost of hiring a personal care aide to perform homemaking services (shopping, laundry, and cleaning) was $4,481 in Nevada, according to Genworth’s 2019 Cost of Care survey — roughly half the monthly cost of a private room in a nursing home, which runs $8,800.
Settelmeyer says his bill would allow more Nevadans to remain at home and provide a higher wage to caregivers. The bill projects that based on current participation in self-directed care, some 338 Medicaid clients would take advantage of the bill’s provisions in fiscal year 2022 and 352 the next year.
“Anybody I can keep out of the hospital, I should do it,” Settelmeyer says, including his neighbor Nagel. “Should we worry about the world? Yes. Right now I have to worry about what I can get passed.”