Thursday, June 16, 2005

Aged and Disabled Waiver Renewal: The good, the bad, & the ugly

The Aged and Disabled Medicaid Waiver (A/D Waiver) program provides in-home Medicaid-funded services to low-income West Virginians who need help with activities of daily living. To qualify medically, the participant must have at least 5 "deficits" according to the Pre-Admission Screening, needing the same level of care required for Medicaid-covered nursing home admission. The program has 5,400 slots or participants, and there has been a 6 month waitlist in place for over a year. Basically this program helps people stay living at home and avoid having to move to a nursing home by providing help with activities of daily living, ie. walking, bathing, dressing, eating, toileting, as well as instrumental activites of daily living, ie. meal preparation, house work, and shopping. This program is one of the important pieces of the Olmstead puzzle, how the state discharges its duty to support community-based living.

The A/D Waiver is up for 5 year renewal through the Centers for Medicare and Medicaid Services (CMS). The renewal application includes some significant changes, both positive and negative, as well as some missed opportunities for change in leaving certain areas as is.

The Good
The self-directed option that is being funded through a Robert Wood Johnson grant will enable participants to take control over their own services. The option to self-direct will be entirely voluntary, only approximately 10% of participants are expected to try it, and participants can choose to go back to the traditional model any time. In a nutshell, the self-directed option will allow a participant to take a budget (which will be determined by the amount of $ the participant's level of service would have cost under the traditional model, minus a small adminstrative fee), and create a service plan within that budget designed to suit the participant's service needs. Self-directed participants will become the employers for individuals they choose to hire to serve their needs, or can contract with existing providers for staff. They can hire their spouses, family, and friends, if they choose. They can choose to bank some of the monthly budget to save up for home modifications, assistive technology, or other items they need. They won't just get the cash, approved costs will be paid through a fiscal intermediary.

This option will not only empower those participants to take control of their own lives, it can help address the serious staffing shortage that has plagued the program for years. This is the best part of the Waiver renewal changes, and I hope this program is so successful that we start incorporating the best aspects of consumer direction into all areas of Medicaid in West Virginia.

The Bad
The Waiver still has a 6 month waitlist, and still has no triage or prioritization to allow needier people to get on the program quicker. I know this is a contentious issue, especially for those who do not have the highest need, and therefore would not be prioritized. I think a priority system can address those folks, for example by having a person become a priority once he or she has been on the waitlist for a specified length of time. At any rate, we have had the heartbreak of telling a senior with Lou Gehrig's disease, who came home to West Virginia to die, that she had to wait at least 6 months for waiver services, though her prognosis gave her less than 6 months to leave. We missed a great opportunity to deeply help this woman, and her slot would have been available for the next person in less than the waitlist period anyway. Other states have prioritization that works, we could do it, too.

The Ugly
Though many providers who are just learning about the self-directed option are very worried about the impact it will have on their bottom line, the more worrisome aspect of the renewal application for them is the significant reduction in slots. While self-direction might move as many as 540 participants off provider roles (though many will doubtlessly still choose to contract with providers for services), by the 2d year the program proposes to cut 2,000 slots.

As an advocate for seniors and people with disabilities this is deeply disturbing to me. This is absolutely going backwards in our Olmstead efforts. This program helps people leave nursing homes to live back in the community, helps people in the community stay home longer, and is already so underfunded that we have a 6 month waitlist and very low maximum levels of service provided. Generally participants get 25 hours of services or less per week on the program, not even enough to allow a family caregiver to continue to work a full-time paying job in addition to caring for a person with a disability.

Though states may apply for changes before the expiration of their waivers (5 years in this case), renewal time is the best chance to try to progress. I think the reduction in slots on this waiver proposal is not outweighed by the improvement the self-directed option will bring, and overall the new proposed version of the waiver is worse for West Virginia rather than better.

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