Federal and State Regulations governing Medicare and
Medicaid have created a unique class of worker in the United States Healthcare
System. Personal Care Assistants (PCAs)
will comprise over 1.2 million workers by 2018 and currently provide over 1.2
billion hours of care to elderly, disabled, and chronically ill patients. By 2020 PCAs will be providing more hours of
care to a select group of patients with Disabilities, Diabetes, COPD,
Alzheimer’s, Parkinson’s, and conditions associated with old age, then ALL of
the physicians in the US providing care to the ENTIRE US patient population.
A majority of PCAs work as
”independent providers” employed by the patient and reimbursed under a Medicaid
consumer directed program. PCAs may also
be affiliated with a Medicare / Medicaid Intermediary (Home Health Agency).
It is
estimated that PCAs account for over $25 billion in direct payments from Medicare
and Medicaid. Furthermore, by providing
over 25 million hours of care per week, PCAs influence over $100 billion
annually in healthcare services (pharmaceutical, DME, etc…), shopping / dietary
decisions, personal care, and financial decisions for the patients under their
care. To date, the influence of PCAs on
patient decisions in the healthcare provider hierarchy has been overlooked and
underestimated.
Government regulations, an aging population, and increasing
incidence of chronic disease are driving the growth of the PCA workforce at an
unprecedented rate. As the number of hours of care provided to
patients by PCAs is increasing, so to, is the incidence of fraud. The FBI, State Agencies, and healthcare
organizations are attempting to address fraudulent Medicare and Medicaid
billing on behalf of PCA services. A
June 5, 2014 indictment in Illinois netted over 43 Medicare and Medicaid
beneficiaries as well as Personal Care Assistants that were billing for
services that never occurred.
According
to an Office of Inspector General report released in December 2012, Medicaid
costs for personal care services in 2011 totaled $12.7 billion, a 35 percent
increase since 2005. The U.S. Department of Labor projects that the employment
of personal assistants and home health care workers will grow by 46 percent by
2018. U.S Department of Health and Human Services, Office of Inspector General:
Personal Care Services, Trends, Vulnerabilities, and Recommendations for
Improvement, OIG-12-12-01 (November 2012). Home personal care is one of the
fastest growing job categories in the country. However, the OIG’s report points
to numerous problems in Medicaid personal care services that leave it
vulnerable to improper payments, abuse, and fraud, including lack of training
standards, uneven oversight of services provided, and failure to implement
prepayment controls to prevent improper or fraudulent payments.
Personal Care Assistants should receive better access to education and increased wages commensurate with experience to elevate outcomes in our healthcare system Fraud detection is a critical component.
The “personal choice option” also known as “consumer directed care” in
Medicare and Medicaid regulations allows PCAs to be chosen by patients. Fraud is a significant concern in care
provided by PCAs in consumer directed care. In fraud cases, a patient will select an in-direct
family member or a friend and agree to split some portion of the reimbursement.
The fraudulent “PCA” does not even have
to show up at the patient’s residence and time sheets are forged. The Medicare and Medicaid reimbursement
rates for PCAs are approximately $20 per hour.
Fraud remains a looming concern in home care; the US Government
Accountability Office reported “estimated improper payments for Medicare of
almost $48 billion for fiscal year 2010,” including expenditures for home
oxygen and other home health claims. To qualify for coverage from payers or to
generate incentives within insurance for individuals, home care technologies
may also offer new avenues to address home care fraud, in addition to improving
patients’ health and quality of life and saving money.
Franchised Home Health Care Agencies are fast
pace. The leading franchises in terms of
number of locations or “units” are Home Instead, Comfort Keepers, Home Helpers,
and Visiting Angels. These four brands account
for about 2,400 locations. The largest franchises in terms of corporate revenue
are Home Instead, Interim HealthCare, Visiting Angels and Comfort Keepers. Some of these organizations have expanded
their networks internationally. Home
Instead is considered to be not only the leading senior care franchise but also
the largest franchise system period in the U.S. And in 2010, Comfort Keepers
made it onto the Inc. 500 list of the top 500 fastest‐growing companies in the U.S. with a three‐year sales growth of 32 percent.
