Care in questionAfter years without cost-of-living adjustments, some community-based residential care providers are considering not signing contracts with the managed care organization that oversees care for some of their residents.
By: Shelley Nelson, Superior Telegram
After years without cost-of-living adjustments, some community-based residential care providers are considering not signing contracts with the managed care organization that oversees care for some of their residents.
For Norm and Darlene Groehler of rural Superior, it’s a service that is essential to her mother’s safety. And the threat of losing that care is troubling.
As an only child, Darlene Groehler said her mother, living with Alzheimer’s disease, is her responsibility. While she was able to keep her mother at home for three years as the disease progressed, it was becoming dangerous to do so.
“I’d come home from work and there would be burned pots on the stove,” Darlene said. She posted notes around the kitchen to remind her mother not to leave the kitchen when the stove was on, but her mother couldn’t process the information, she said. So Darlene made the decision to admit her mother to Cedar Ridge Assisted Living and Memory Care.
“Cedar Ridge has been wonderful; she’s been there for almost a year,” Darlene said. “I haven’t had to worry at all about her care.”
She’s worried now, though because seven of the facility’s eight residents are members of NorthernBridges, the managed care organization that took over management of long-term care in 2009 for 11 northwest counties, contracted by the Wisconsin Department of Health Services.
Long-term care is managed differently than it was when it was a county-run program, said John McMahon, chief executive officer of NorthernBridges. It is those differences, he believes, that are the source of the current strife.
With long waiting lists and the high cost of providing long-term care, the state shifted its efforts to a new care model, Family Care to end long waiting lists and provide more cost-effective support to aging and disabled people.
“We haven’t gotten a raise in several years,” said Greg Swanson; he and wife Jennifer own Northern Residence in Hawthorne. “Now we’re facing cuts; it’s like a compound hit. My wife and I own a small seven-bed place and there wasn’t much profit margin before … I just don’t know how we’re going to keep doing it unless we get a raise eventually,” Swanson said.
Over the last seven years — only two working with NorthernBridges — Greg Date estimates keeping up with the cost of living should have raised rates from $130 when he opened Stardusk House in the village of Superior to $159.01 today, based on the Consumer Price Index. Yet he has employees who have gotten more in raises in the seven years since he opened the assisted-living facility than he did this year with the highest rate NorthernBridges offered, he said. The highest rate offered only $2.42 more than his starting rate.
Before this year, he said, “we never received a penny in raises.” When those were due, Douglas County froze its rates while planning for managed care; since managed care entered the picture, he said increases were held off because the organization was new. The rate range he was offered started at $111.24, he said.
“Now the rates are lower than when they started,” Date said.
McMahon said under county-run programs, care providers negotiated with the county to set their rates. Under managed care, rates are based on each members’ acuity — the level of care, support and supervision they need to live independently, he said.
McMahon said after two years of developing the rate-setting system with input from providers, what they found is they were paying for more care than some members needed.
“Family Care is predicated on the premise that the member is at the center of all decision-making,” McMahon said. But the organization is also responsible to provide support to its members in the most effective and cost-efficient manner, he said.
Care providers said their rates were initially cut 30 to 50 percent, then, they were raised a level 15 percent below the original rate. Some rates were restored to previous levels, some reported.
NorthernBridges made a decision not to cut rates more than 15 percent to bring costs in line with the level of care and supervision members need, McMahon said.
Rates are just one problem that is frustrating caregivers. In homes that provide care to the aging, hospitalization is inevitable, and under the old system, care providers were paid a portion of their rates to hold the bed open until the patient returns.
That partial payment has been eliminated, which could leave providers without any income and no ability to place another person in their facility during an extended absence from the residential care facilities.
It’s not like care providers can ask the families to come and pick up their loved one’s belongings to make their room available to another resident when they are hospitalized, said Sharon Kotter, who partnered with Pam Clark to open Harmony Houses in the village of Superior.
“This is their home,” Kotter said.
“They’re supposed to have a bed-hold because they are supposed to have a place to return to,” Date said. He said even at 80 percent — the rate providers were paid to hold open beds — the business takes a hit when a resident is hospitalized “but I take a bigger hit if that’s zero … That bed hold rate just means I get a little something to keep that bed available while that person’s in the hospital.”
Part of the problem, Date said, is conflicting federal and state rules concerning the partial payment.
Medicaid rules won’t allow NorthernBridges to pay for care in a hospital or nursing home at the same time it’s paying for care in a residential care facility for an individual, McMahon said. Medicaid will not pay twice for services, he said.
Residential-based care providers are required to make transportation available to residents for medical care and other activities.
For facilities with wheelchair-bound residents, that means hiring specialized transportation services to accommodate them.
Kotter said there are not many who own a van capable of transporting wheelchair-bound residents to their appointments, and specialized transportation services can be quite expensive, particularly for facilities in outlying areas.
While she and other providers have provisions in their contracts with families to pay those costs, a change in the contracts with NorthernBridges prohibits the facilities from billing families to recoup those costs.
“It wasn’t costing the state anything,” Kotter said. “It wasn’t costing NorthernBridges anything. It just cost us. It came directly from our pocket and not anyone else’s.”
McMahon said it’s not true that NorthernBridges won’t pay for transportation in extraordinary circumstances, however, care providers are responsible for providing transportation and that cost is part of the rate the managed care organization pays.
“It’s part of the scope of services we contract for,” McMahon said. “It’s part of the scope of services they agree to. We will pay for transportation in exceptional circumstances,” such as transportation for treatment in the Twin Cities.
Kotter said it’s never been her practice to bill a family for those costs when she knows they can’t afford it. However, she can no longer bill families who can and are willing to pay to ensure that service for the quality of life for their loved one.
The plights caregivers are facing have some elected officials concerned about the future of Family Care and the ability to find providers in the future.
Currently, NorthernBridges contracts with 700-800 providers for a variety of services in its 11-county region.
“The crux of the issue is that we have providers that simply can’t make it, and a lot of them are looking at potentially closing their doors with this new contract,” said Rep. Nick Milroy, D-South Range, who is working with care providers to try to solve the problems. “If that happens, not only the human factor, where you’re throwing people out onto the street — this is what they consider home — but it’s going to cost us more because they are going to end up in other facilities that cost the government more. So it’s really penny-wise, pound-foolish.”
Milroy said his goal is to find a solution that at least allows care providers a “small enough profit” to keep their doors open.
“These are facilities that provide health care for individuals, the step between their homes,” said Douglas County Supervisor Mary Lou Bergman said. “These are people still capable of taking care of themselves, somewhat. They might need to have assistance when they have medications, some of them have physical problems … some of them may have Alzheimer’s.
“I think it’s just a shame that they’re being cut and cut and cut, and it seems the cuts are affecting their clients or members as they refer to them. The members that need the most attention are the ones that are being cut the worst.”