Episode Transcript
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Speaker 1 (00:01):
And good morning everyone. Welcome to Life Happens Radio. Thank
you for joining us on this very sunny fall Saturday,
eleven am every Saturday here in WGY. We bring you ideas,
information and news to help you navigate through the very
complex aging process, your working years, your retirement years, how
(00:22):
to stay healthy, wealthy and wise and what are the
things that you need to do and think about From
an estate planning perspective. We talk a lot about wills
and trusts and powers of attorney and healthcare proxies. We
talk about businesses. If you own a business, how do
you make that business work for you and when you're
ready to retire, keep working for you in the way
(00:43):
of a payment and business succession planning is a big
part of what we do special needs planning. Today, we're
going to focus on a topic that is near and
dear to my heart and something that most of you
think about but don't really want to face because it
involves health, and it involves failing health and chronic conditions
(01:06):
and an ability to get care where you want it,
when you need it. And where is that, folks, Where
would you want to get care if you had an
illness that required people to come in and help you
you needed help, just doing the things. They call them
activities of daily living, taking a bath, taking a shower,
(01:29):
getting dressed, getting meals, getting all the things done that
you need to get done. Some people just getting up
and down, in and out of bed. Can you transfer?
Can you get to the bathroom? These are activities of
daily living. Nobody wants to think about that until you
need to. But when you need to, you want to
make sure that you have a plan in place to
(01:50):
help you get care. And we call that home health care.
And the home health care marketplace has boomed because so
many people are aging and wanting to live in their
own homes. Services need to be developed and wrapped around
those needs. And what we see in the healthcare system,
which I affectionately call a sick care system, is that
(02:13):
you have episodic care in and out of emergency rooms, hospitals,
doctors' offices, but no real health care plan that follows
people into their home. And we're very fortunate today to
have a special guest, someone I've known for a number
of years who has been in state government and for
the last several years has served as the president and
(02:34):
CEO of the Home Care Associate Association of New York State.
And where would you want to get better information than
the President and CEO of the Home Care Association of
New York State, none other than Al Cardillo. Good morning, now,
good morning, Thanks very much for having us here today and.
Speaker 2 (02:49):
Thank you as always.
Speaker 1 (02:51):
We could talk for days about the issues that face
home healthcare, but before we jump in, just tell our
listeners there's a little bit about the Home Care.
Speaker 2 (03:02):
Association of New York.
Speaker 1 (03:03):
Who are your constituents, your members, who you represent and
how you represent them?
Speaker 2 (03:09):
Thank you, lou Yes. The Home Care Association in New
York State is comprised of hospitals, hospital systems, long term
care systems, community health agencies, health plans, all of whom
are federally and state licensed to provide care in the home.
We represent over three hundred of those organizations in the state. Combined,
(03:34):
they serve somewhere between a half a million and a
million individuals in the state and employ over two hundred
thousand individuals in the field nurses, home health aids, physical therapists,
social workers, and others.
Speaker 1 (03:47):
That's a lot of employees in the healthcare system and
a very diverse set, from hospitals to home health agencies
and kind of everything in between.
Speaker 2 (03:57):
Yes, and in that representation all of the various models
that New York hosts for care at home, Medicare, Medicaid,
what are called certified home health agencies, which are the
skilled services that are provided very often upon a discharge
from the hospital or when someone has a medical complication
(04:18):
like diabetes or congestive heart failure to manage those right
to addressing chronic illness and individuals, individuals with disabilities, and
really more permanent needs for daily care, but also at
the front end of the spectrum new moms and infants
coming home that are in need of services. So our
(04:38):
providers really represent that full scope.
Speaker 1 (04:41):
So, Al, you've been doing this for how many years now,
over forty years, Over forty years. I've been practicing law
over forty years, and for a good part of that
I've been involved in long term care and Medicaid, medicare,
elder law planning, and been involved with the Bar Association
and a number of legis lative initiatives over the years
that we've worked on together. And today what we see
(05:07):
when our clients walk in the door is a glazed
look because they've pinballed through the healthcare system and are
now looking and saying, you're just on the way in here.
You said, somebody called you this morning. You said, how
do I get my mom care? She's ninety five? So
where do I start? How do I get care? What
are the big problems? And this is a big question,
(05:28):
what are the big problems that you see in healthcare
and translate that into home healthcare?
Speaker 2 (05:34):
Well, I think you know, the entire healthcare system is
really struggling with securing sufficient workers in the field, nurses,
physical therapists, home health aid, social workers, staff in nursing
homes and the hospitals. The entire healthcare system is really
focused on trying to secure the base of workforce support
(05:55):
to deliver the services that people need. And that's the
case whether you're in the emergency room or whether or
in the home. The other real fundamental issue is that
and this is more unique in long term care and
in home healthcare. Is that different from how most people
have their hospital services or the physician services covered. There's
huge gaps between Medicare, Medicaid, and commercial and private coverage
(06:19):
when it comes to covering services like home health care.
People generally find that if they have a condition that
requires restoration, rehabilitation follows a hospitalization. There's some very good
coverage under the Medicare program, although we're facing some of
the most serious cutbacks in decades. But then once you're
through completed that episode, if you need ongoing care, the
(06:41):
system has a gigantic hole. There's a cliff. There's a cliff,
and you fall right off.
Speaker 1 (06:45):
And that's where our firm comes in. Yes, because we
do elder law, Medicaid planning, we do healthcare planning. We
work with an agency locally that we helped establish called
ever Home Care Advisors, and we've had them on the
show a number of times, and that's physical therapist, occupational therapists,
social workers arens who work for individuals. They're not working
for a hospital system, they're not working for a healthcare system.
(07:08):
They're working for you and helping navigate through this and
ever Homecare Advisors is a company that I think we
need so many more of those types of entities to
help guide people through this system. And I do want
to get into a little bit of history because this
is how we got where we are, but I want
to focus really on some of the current issues. The
(07:30):
labor shortage and I've seen your presentation now a dozen times.
It's phenomenal the information that your agency, the Homecare Association,
puts out. If you want to get a real feel
for the data, get their report. How can people access
to Homecare Association report?
Speaker 2 (07:44):
They can? They can contact the Homecare Association or our
website is www dot hcashys dot org. Or they can
contact our office at five one eight four two six
eight seven sixty four.
Speaker 1 (08:00):
You can access this information and folks, data talks, it's
real data. And I've seen you illustrate the shortages in
healthcare workers and home healthcare workers and the number of
job openings that are existing currently in New York State
with a with a dice diametrically opposed number of people
(08:21):
coming into the workforce as needing care. What's that number?
Speaker 2 (08:25):
Well, when you look at the at the numbers that
are are researched by the state, by labor, by others,
I mean we're talking really a projected need for well
over a million jobs you know in this field. Where
are we going to find them? Well? I think that's yes,
and that and that's really been the struggle. We've really
been trying to work, not just us in home care,
(08:46):
but on the hospital side, the nursing home side, especially
since the pandemic, but even before to try to have
really concrete programs that can be offered to support people
coming into the pipeline. But then also once people are
working in the field to retain the turnover rate and
healthcare is very substantial, it's very costly eighty it's very
(09:09):
very high. Well, for example, on the nursing side, the
home health aid side, it's over thirty percent in the
field to replace a home care nurse, for example, because
of the specialization and training, even if you took an
experienced nurse who works in the hospital, and may take
six to nine months to a year for that person
to really really get up to speed to be able
to do that. So we have wage disparity, wage and
(09:32):
also conditions. It's very difficulty. The level of layers of
administration and regulation and documentation drives nurses from the field,
and the wage issue obviously creates a tremendous amount of
pressure on individuals who work as home health aids, who
are wonderful and what they do, they make the difference
in people's lives every day.
Speaker 1 (09:52):
Yeah, and you talk about nurses, but in the home
healthcare field. One in one hundred people working in the
home is a nurse. The other ninety nine are either
social workers or just uncertified home health aids. And that's
those are the people that for twenty four hours a
day will take care of someone if they need that
(10:13):
twenty four hour a day care and our end may
be in and out of there in half an hour.
Speaker 2 (10:18):
They're not going to be there all day.
Speaker 1 (10:19):
Yes, So it's and the RNs come from a whole
different set of providers.
Speaker 2 (10:25):
Well, the one thing is that for the RNs, for example,
you need a nurse to open a case, manage the case.
One nurse equals about twenty five patients. So for example,
you know, and there's an agency in this air, very
prominent agency that for months, months, maybe the last several years,
has had seventeen nursing vacancies and their agency unable to fill.
(10:49):
It's not because they're not a tremendous agency. It's because
of the competition and also just the shortage of people
staying in the field.
Speaker 1 (10:57):
And we have a call. Theyn't open up the lines,
but we have a call. Billin's can the good morning bill?
How can we help you?
Speaker 3 (11:01):
This good morning. I have a question that's a little
bit beyond the long term care, but I am interested
in long term care in terms of I have an
irrevocable trust, and I'm trying to protect my assets, and
I'm also trying to protect myself from a healthcare situation.
Do I have to pay taxes on money before I
(11:26):
can move money into an irrevocable trust.
Speaker 1 (11:30):
It depends on what money you're moving.
Speaker 3 (11:33):
So you have something a virus and follower one K
my wife and.
Speaker 1 (11:37):
I Okay, good news. Well, let me start with bad
news and then the good news. When you do what
we call the Medicaid Asset Protection Trust, which is an
irrevocable trust, It's designed for very very particular purpose, and
that is to keep as much control and flexibility as
you have over those assets, but still have them sheltered
if you do need nursing home or home health care
(11:58):
in the future. So when we look at moving assets
in and out, the bad news is that any movement
of a retirement account an IRA or four oh one
K is a taxable event. The good news is that
New York State exempts those accounts without putting them in
the trust, so you don't have to transfer your IRA.
(12:18):
You don't have to transfer your four oh one K.
Even a wrath under current rules, maintains an exempt status
in your name alone, so you don't have to transfer those.
At some point when you access medicaid, you have to
start drawing on them like you would when you hit
your required beginning date at age seventy three. But those
accounts are fine. If you move stocks, if you move
(12:40):
real estate, if you move any other assets into the trust,
there is no taxable event. It's only those types of
assets that have income and respect of a deceed ird
we call it, and that's tax deferred income in them.
Speaker 3 (12:55):
So so base and can you move a partial amount
of of We'll say, let's just say I had five
hundred thousand dollars, could I move an effect We'll say
four hundred thousand, and I left one hundred thousand for
my wife to live on.
Speaker 1 (13:10):
Absolutely absolutely, Because a spouse, if she's healthy and you
need medicaid, she can keep seventy four thousand, eight hundred
and twenty dollars. You can keep thirty one thousand, one
hundred and twenty five dollars. So together you can actually
keep with one of you on medicaid one of you
living in the community. You can actually keep around one
(13:31):
hundred thousand dollars.
Speaker 3 (13:34):
But if I wanted to transfer more, could I do
a partial disclaimer and pass it by her to my children?
Speaker 2 (13:45):
You could, sure.
Speaker 1 (13:48):
I'm not sure at what point you're thinking of doing
that now or in the future.
Speaker 3 (13:54):
Well, we're both in our early eighties, so we're thinking
about trying to make it's the correct move, I guess
at this point in time. And also whether or not
are we to really too well now to seek long
term care at.
Speaker 1 (14:11):
Our age insurance? Yes, the long term care insurance policies
would not be written beyond now aage seventy for most companies,
and there're only a couple of companies left selling long
term character That's.
Speaker 2 (14:22):
A whole other topic.
Speaker 1 (14:23):
But for you, we do this when we sit down
with our clients.
Speaker 2 (14:27):
We draw it up.
Speaker 1 (14:28):
We do a diagram, because clients come in and they
have heard a lot of things, and they have a
lot of thoughts. And when it goes down on a
piece of paper and we put your trust, your other assets,
your retirement assets, your income, your kids, your beneficiaries, how
they inherit from the trust. All of that goes into
a diagram, and it makes sense once you see it
that way. But in your case, keep the retirements, retirement accounts,
(14:51):
separate your other assets, your home, your other assets. Put
a good chunk of that in the trust. If you
want to keep one hundred thousand dollars out, that's a
good place.
Speaker 3 (15:02):
Okay, that sounds very good. Thank you very much.
Speaker 1 (15:06):
Oh you're very welcome. And now we're gonna have to
take a short break. When we come back, I really
want to dig into the home healthcare marketplace because.
Speaker 2 (15:14):
Our clients walk in the door.
Speaker 1 (15:15):
As I said, they have this look because they've been
phone calling, and I call it the eternal loop. You
make one phone call, you get referred to another number,
You make another phone call. And I did this with
my mother twenty five years ago, and I got the
first number that I called was the last number that
I received, And I said, this isn't working. You got
to have better answers. And we're gonna come back. We're
gonna talk about how to unwind this and kind of
(15:38):
solve the riddle. How do you get care in your home?
How do you make sure that you're ready for this?
How do you prepare for it? And we're going to
talk to al Cardilo about what's being done to try
to bolster back this home healthcare marketplace. I'm Lou Piro,
your host for this morning. You're listening to Life Happens Radio.
We'll be right back after this short break. You're your
host for this morning from Pierre O'Connor and Strauss or
(16:00):
a law from here in Latham, New York, New York City.
We have office in Garden City, New Long Island. We
are up in Lake Placid, and we work with clients
helping to shape their legal plans. We work with their
financial advisors, their tax advisors, because you want to have
a comprehensive plan. And one of the main issues, folks,
that people are thinking about and planning for is when
(16:21):
I age, if I need care, where do I get it,
how do I get it, and how do I pay
for it? And now going back, let's take this and
peel apart the major healthcare legislation of our lifetimes. And no,
it's not the Affordable Care Act. It's the Great Society
Program of Lyndon Johnson in nineteen sixty five, which gave
us Medicare and Medicaid. And I've had Mike Burgess on
(16:43):
we celebrated the fiftieth anniversary of Medicare and we explored
the history and the preamble when Lyndon Johnson said in
his preamble, never again will seniors in America have to
worry about healthcare. He just didn't see what was coming.
Where do we have today with Medicare and Medicaid, Well.
Speaker 2 (17:01):
That's for sure in terms of not seeing what was coming,
because nobody in nineteen sixty five would have imagined a
world today where when an individual goes into the hospital,
if they go they're coming out with tubes and drains
and all sorts of very complex needs, fresh surgical wounds,
the whole thing. Where it's a very very different world.
(17:21):
People are living so much longer, and then especially in
terms of the ability to be supported and have a
long life if you've got a chronic or serious condition.
So the world is very different. On the Medicaid side,
Medicaid has evolved in very creative ways in that period
of time. Medicare, however, seems stuck in nineteen sixty five.
(17:45):
There's still a homebound requirement. There are other requirements that
are not realistic for what a person needs when they
receive care. At home. That's been a pressure point that
we've been working on at the federal level to try
to open up the system and allow it to really
flow more freely with state of the art medicine. We're
facing right now some of some of the most dramatic
(18:07):
Medicare costs in home health care services in a generation.
Speaker 1 (18:11):
And this is Medicare. Nineteen ninety seven was the last time,
and that was something called the balanced budget acting. Guess what,
They balanced the budget and they cut all across the board,
including Medicare. There were severe Medicare changes in nineteen ninety seven,
and that was President Clinton and Nut Gingridge, and they
did their job. They cut the budget, but they took
(18:32):
what was a fabric of home health care under Medicare,
where you had a doctor, a nurse, a social worker
on a team under Medicare, and you had home health
aids up to thirty five hours a week through Medicare.
That was obliterating with the stroke of a pen.
Speaker 2 (18:50):
Fifty percent of the home health agencies in the country
closed yes, following that. So we're in the situation now
where the projections are very very similar. They're really dire.
These cuts really have nothing to do with the merit
of reimbursing at one level or the other. They all
relate to arcane requirements of the federal bureaucracy when they
move from one payment year to the next to maintain
(19:12):
something called budget neutrality. And this is right now unraveling
in the billions as it relates to home care over
this period of time.
Speaker 1 (19:21):
And there's a New York Congressional delegation. You've given me
a lot of literature and a letter from the Congress
of the United States to the President to the CMS
heads because the Center for Medicare Medicaid Services what used
to be HICCLA, which is now CMS, is in charge
of both Medicare and Medicaid and they're changing the reimbursement system.
(19:43):
They're changing the way that providers can provide care, the
amount of money that providers can put back into their infrastructure,
eighty twenty rule, and a lot of other things that
are happening. This all Alan, and this has been the
case since I started even looking at this issue, and
it was very clear to me it's about dollars. It's
(20:04):
never about care. It's about dollars. How do we and
no one ever wants to say the ration word, But
how do we allocate resources in the appropriate way with
the amount of money that we have available without inflating
the budget.
Speaker 2 (20:19):
Well, I think one thing is that Medicare and those
who administered have to wake up. You know. Part of
the narrowness of the system is that home care is
viewed sort of as its own somewhere out, you know,
apart from the mainstream system. But the reality is home
health services work still work functionally with physicians, hospitals, pharmacists,
(20:40):
other community partners, but it is not covered and reimbursed
that in that kind of way.
Speaker 1 (20:47):
Nor is it integrated fully with the healthcare exactly.
Speaker 2 (20:49):
So as an example, there was an experiment that Congress
authorized called the value based payment mechanism for home care.
It's saved hundreds of millions of diyars.
Speaker 1 (21:00):
Was under that other major healthcare legislation, the Affordable Care Well.
Speaker 2 (21:04):
And since then, yes, and since that time, building on that,
So it saved hundreds of millions of dollars. So what
did Congress do? They said this should apply across the country.
So the projection is that value based home health care
will save three to four billion dollars over this limited
period ahead. How does it do it. It improves the outcome
(21:25):
with reduction in hospitalizations, emergency services, and other high cost services.
None of those savings was predicated on shrinking the services,
but making them indispensably accessible to the individual.
Speaker 1 (21:39):
Yeah, so providers, you achieved this result for us with
a lot less money.
Speaker 2 (21:44):
Yes, exactly, that's and that's the smart way to do things.
If we got this major problem in the country in
terms of even the future solvency of Medicare, you need
to look at home care as an integral partner. So
while while at the same time you have Congress forecasting
billions and savings, you have the federal bureaucracy making billions
of cots. On the other side, you can't bring in staff,
(22:07):
you can't cover those home health a hours that you said,
and you can't provide continuity to patients if you're now
cutting the services beyond the ability to retain the staff.
Speaker 1 (22:17):
And so Medicare is in my mind an illusion for
home health care. It doesn't and I don't think we'll
ever have the budget necessary.
Speaker 2 (22:27):
Well, again, it needs to open up and it needs
to recognize the fact that we're talking about caring for
a person, not a thing that fits between the parameters
of some insurance plan, that is that which Medicare is
an insurance plan. You know. One of the things that
has been happening in recent years is a growth in
what's called Medicare advantage or a medic Medicare managed component
(22:52):
for the system. You know, part of that vision is
to is to create flexibility to be able to cover
services more broadly. But Medicare itself remains a very rigid
model and is very underpaid, and as I said, it
doesn't recognize the full flow of services that patients need.
Speaker 1 (23:11):
Yeah, and we're going to take a break shortly. But
a top down bureaucracy does not deliver services efficiently into
someone's home.
Speaker 2 (23:21):
No, No, it just does not.
Speaker 1 (23:22):
You need a bottom up system that looks at the
patient and the whole patient. What is the patient's resources
in the home, What can family provide because families are
being asked to do a lot more in this system
of home healthcare, and what resources does that individual need
in their home. You have these things that say, okay,
(23:43):
you need this, Well maybe they do, maybe they don't,
but it's not based on the individual's care plan.
Speaker 2 (23:48):
No, that's absolutely the case. And you know, new York
really sort of low, I think, departed from what was
a very solid way. In nineteen seventy seven, a state senator,
Senator Taki Lombardi, was the chair of the Committee on Health,
and he envisioned a program that would function around the
patient individually, customizing services in a plan called the Nursing
(24:12):
Home Without Walls Program, also the Lombardi also the Lombardi
program after the great Senator to Lombardi, and the state
sort of departed from that course when it got so
heavily focused on the money side, not the patient sign
And let's come back and talk about that, because we're
facing an avalanche as seniors age out in New York State.
We have one of the fastest growing senior populations and
(24:33):
one of the slowest growing employee populations. And this is
a disaster waiting to happen, folks, So stay with us.
Al Cardillo, CEO, President of the Home Care Association of
New York State, Lupiro from Pierre o' connor and Strauss,
We're going to continue to dialogue. We will open up
the phone lines if you have a question, we'll be
right back. Home Care Association of New York State President
CEO who has been in healthcare.
Speaker 1 (24:54):
In New York State for over forty years. And we
do more talking in between the show than we do
on the show because we are both so deeply entrenched
in these issues. And if you have a question, you
want to be part of this conversation. We're talking about
home healthcare in New York State. You can give us
a call. It's eight hundred talk WGY eight hundred eight
(25:14):
two five five nine four nine again eight hundred eighty
two five fifty nine forty nine and out. Everything comes
down to the money. And you were mentioning earlier that
that there are programs that are agnostic as to dollars.
Now we're gonna have Rebecca Prevy on. We do something
(25:34):
called Medicaid Mondays and Becky Preview runs the New York
State Area Association on Aging, so all the counties and
the Home the HRA Human Resource Administration New York State.
Becky leads each of those agencies. She represents them statewide.
And we're going to talk about services that are available
without medicaid. Now, why should we have to have a
(25:57):
separate show to talk about service that are available without medicaid?
Because what most of their money comes from, is the
Older Americans Act and grants that come from the federal government,
and they combine with the Medicare program. So you have
these silos. Medicare money going in one direction, people saying, oh,
we're going to expand Medicare, and on the other hand,
(26:19):
CMS is cutting the ribbons on Medicare. You have Medicaid,
which is supposed to be the payer of last resort,
which has become the only payer. It's not the payer
of last resort anymore. That was what Medicaid was intended
to be in nineteen sixty five. It was women and
babies who needed healthcare. That's what Medicaid was invented for.
But what has happened is Medicare has retrenched from any
(26:41):
services like this in the home, and Medicaid has had
to pick up because you can't leave people and let
them die in their homes, which is kind of what's
happening in some cases. So it's getting a bit drastic.
I don't mean to overdee the seriousness of the problem,
but we have a serious problem in New York State.
Speaker 2 (26:59):
Album Oh, we absolutely do. And I think that especially
with relate with respect to coverage New York for many
years was a leader in looking at alternatives to Medicaid
to provide coverage. Lou you were at the ground floor
of a lot of it, trying to really expand the
system to make it be more sensible for the coverage
(27:21):
of the services people needed apart from Medicare and Medicaid.
We currently are advocating a piece of legislation called the
New York home Care First Act. Part of that is
to direct the Commissioner of Health and the state to
look at what the current parameters are in the private
market and across all programs to ensure that home care
coverage is optimized for everybody that needs it. We're certainly
(27:44):
hopeful that we can get the legislature to pass this
in the coming session, but it really takes the vocal
voice of all, for example, the listeners on this line
and other advocates that are concerned about this area to
press that point to the legislature and governor.
Speaker 1 (27:58):
Yeah, but the data is really the key, because people
need to be told the truth. They don't get the truth.
They get some broad policy statements, they get you know, fluff, Oh,
we're going to expand services, we're gonna make it better,
and then they cut the ribbons out of the programs
that are essential to people, and I'm gonna pick on
(28:19):
one Medicaid program. We just had a guy named Brian
O'Malley who's the head of the Consumer Directed Agencies in
New York State, because the governor just took six hundred
agencies that administer home healthcare and just took them out
of existence and brought in one provider from the state
of Georgia who's going to administer this for the whole
state of New York. And that's called the Consumer Directed
(28:39):
Personal Assistance Program or cd PAP. We talk about it
all the time on the show because it has become
the lifeline for people to survive and get care that
they need.
Speaker 2 (28:51):
Talk a little bit about how that fits into the system. Yes,
So that's a program that actually grew out of the
nineteen eighties from a really an experiment in New York
City that was run by the disabilities community and really
has grown into being a very prominent program in New
York State. It allows a person to be able to
designate a caregiver someone that they've identified. It could be
(29:13):
a family member, could be a friend, or someone that
they know and trust, and that person can provide the
services at their direction. It's available under Medicaid, so you
have to qualify for Medicaid in order to have it accessible.
But Medicaid covers the service and the program because it's
grown so much. And part of the reason it's grown
is because there's really been an under investment in the
(29:36):
regulated part of home care. Individuals turn to the program,
identify their caregiver, and then it's covered.
Speaker 1 (29:43):
So this gets back to the first premise that we
were talking about, and that is the staffing shortage. Yes,
in New York State and I have clients. We work
with our clients very closely in trying to find home healthcare.
And as I said, ever home care advisors, when this
issue arises, we or to them. They pick up the
phone and they're now nuanced, knowledgeable, they know all the agencies,
(30:06):
they know the people and say, Okay, we have a
need for sixteen hours a day of home health care
in colony New York. Can you staff the case?
Speaker 2 (30:13):
No?
Speaker 1 (30:15):
They call the next agency. We have a need for
sixteen hours a day of home care in colony New York.
Can you staff the case?
Speaker 2 (30:20):
No?
Speaker 1 (30:20):
No, no, no, no, no, what.
Speaker 2 (30:22):
Do you do?
Speaker 1 (30:24):
You can't get the care, and so the consumer directed
program says, Okay, you know, I'm gonna call my cousin
who's got some time for you. Got laid off from
her job. She can come in and do eight hours
a day and spend this with my mom and.
Speaker 2 (30:36):
Be a paid caregiver.
Speaker 1 (30:38):
I have a neighbor who is going to be doing this,
but needs to have some income, so the neighbor can
fill this gap. It's the chasms, the enormous gaps in
care that cd PAP has been filling. And of course
once you open the door to that and people see
that there is a solution, now, they're going to slam
that trap door and try to cut the program.
Speaker 2 (30:59):
Because it's too success. Yeah, that's exactly what's happening. It
has been the single largest growing area in the Medicaid program.
But also we know population wise, the elder population is
the most significantly growing part of our demographics, including those
eighty five and older. So it's like you can't have
it all ways. Over the course of the nineteen eighties,
(31:21):
the federal government and the state constrained the reimbursement for
the hospital system to shorten stays and constrain the reimbursement
for nursing homes on the basis that the underlying layer
of home and community based services was the best place
for the patients. Even the Supreme Court ruled that under
cases involving the Americans with Disabilities Act.
Speaker 1 (31:41):
The own steadcase, Yes, which we've talked about a lot
on this program.
Speaker 2 (31:44):
But if you're going to do that, you then have
to provide those services concurrent with what the expected demand
is going to be. It doesn't happen by magic. There's
got to be support. I just on the area of workforce.
I want one thing I'd like to point out is
that the the way in which the workforce is treated
is almost that it's a responsibility of the providers to
(32:06):
find and hire people. But when does it really become
more of a societal obligation to recruit people into the field,
much the way we do with teachers, with physicians, you know,
and others, where there is a broad public good component
to that occupation. So the system can't just function on
the magic of a provider or another provider. There's got
(32:30):
to be some broader ownership and participation for what this
is all about.
Speaker 1 (32:34):
Yeah, it isn't a field that people go into to
get rich or to scam the system. It's something that
the caregivers that we see that are paid caregivers in
this system do it for the reason that they want
to care for someone. They want to help another human being.
And that's the vast majority of people that I see
in this area. Home health aids are heroes. They are
(32:57):
heroes because this is not an easy job. We talk
about this. You can go to you know, I guess
both the presidential candidates have worked at McDonald's.
Speaker 2 (33:06):
But you can go to McDonald's and make.
Speaker 1 (33:09):
It now twenty two dollars an hour flipping a burger
giving out a bag of French fries. If what are
the home healthcare wages under medicaid? What does a home
health aid make under cd PAP.
Speaker 2 (33:21):
Well, really, when you add everything together, you're talking in
the low twenties, but it also varies. There's the minimum
wage for home care, but then there's the wage that
providers attempt to pay in order to compete in the market.
But the reimbursement methodologies, whether they're under Medicare or Medicaid,
do not really reflect the real cost of recruiting and
(33:44):
maintaining a base. And I think in there is really
part of the fallacy. One of the areas of the
system that we're very concerned about is this high skilled
home health component where individuals come home from the hospital
or are managed with very complex conditions. That program is
right now suffering in terms of the loss of the
(34:04):
closure of agencies and the scale back of services because
for over ten years there's been no real adjustment in
the way in which the program works.
Speaker 1 (34:13):
So we have a program that our law firm has sponsored.
Speaker 2 (34:16):
We started it thirty years ago.
Speaker 1 (34:19):
It'll be our thirtieth next May, called the Elder Law Forum.
You've spoken at it several times.
Speaker 2 (34:24):
We had the.
Speaker 1 (34:25):
Lieutenant Governor, we had Assemblyman MacDonald's, Senator Ashby, Senator Rivera,
and heads of agencies, Greg Olsen from Naisofa. We had
people from Department of Health. And it's a full day
where we try to really get to the root of
the problems and what are some of the solutions, and
(34:45):
we get kind of in a circle and circle the wagons.
But each year it's okay, well, here are ten great ideas,
but we don't have the money to do anymore, and
they just fall by the wayside. You remember the compact
for Long Term which my good friend Gail Holabinka conceived of.
And Gail, who recently passed away, was in New York State,
(35:09):
the head of the Partnership for Long Term Care, which
was an insurance program, that had this great idea, let
people pay their fair share. That's all my clients want.
It's an all or nothing game. Let them pay their
fair share, spend something down on care, take the burden
off the state, but don't have to go bankrupt to
get help. And that's what the system calls for today, bankruptcy.
(35:30):
You need to be bankrupt to get Medicaid? Is that
what our system, our government wants people to think that
the only way you can get help and care through
our healthcare system is to be bankrupt.
Speaker 2 (35:42):
That's Medicaid.
Speaker 1 (35:43):
And so the compact said, well, even if you don't
have insurance or can't get it, you can pay a
fair share, you can private pay for two or three years,
depending upon how much money you have, and then Medicaid
comes in and subsidizes your long term care. Again you
mentioned and the Lombardi program. The guy that helped write
that was GUI named Bob Hurs, who also we lost recently,
(36:06):
and Bob wrote the Compact legislation, and he did it
in a didn't even know he was doing it, and
he sent us the bill and it was we went
two years and he said, find every way that this
system could be gamed, every every possible pera mutation that
we need to address. And we brought it up and
we took it to the Senate and the Senate passed
it unanimously, and we couldn't get it out of committee
(36:29):
in the Assembly, never got out of the Health Committee
in the Assembly. But the Compact was a rational way
to do this. There's another program that looks at Medicare dollars,
looks at Medicaid dollars, looks to the needs of the patient,
what's the team that they need. It's called the PACE program.
And you represent I think some of the PACE organizations
we do the EDDIE.
Speaker 2 (36:50):
The EDDI in this area is one of the premier
PACE programs in the state. And that's a that's a
very unique model.
Speaker 1 (36:55):
The program for all inclusive care for the elderly.
Speaker 2 (37:00):
Don't that sound good? It does? And and and the
way in which the program is organized. That is also
a program that really revolves around the needs of the patient.
A plan of care that is really a patient first
plan of care, and the the part to the the
the care coordinators within the program are really able to
arrange for services across an array of care that meet
(37:23):
that person's needs again in a plan of care that
is reflective of that person.
Speaker 1 (37:29):
And that's patient centered care. There was also a dollars
follow the Patient program in New York which was kind
of great. You know, wherever the patient needed to be,
the dollars went with them, and that hasn't really money
follows the person. Money follows the person that was in
New York City. Primarily, I think, I don't know what's
left of that program.
Speaker 2 (37:46):
Well, it's it's like these programs are all very positive
as they start out, but as I was saying earlier,
there really needs to be a commitment to that course
of action. When for example, when Senator Lombardi created the
public health law in New York that governs home health care,
the preamble to it was that home healthcare was a
priority focus of the state and needed to and the
(38:09):
accessibility and availability of that service had to be an
integral part of the healthcare system. Really, since the state
went on a track of being this very narrow focused
Medicaid models. Really there has lost sight of the importance
of that very mission, which is really what as I
mentioned earlier, the New York Home Care First Act would
(38:33):
bring us back to the more holistic, integral involvement of
home health as part of the delivery system.
Speaker 1 (38:41):
Because hospitals discharge, as we like to say, sicker and quicker,
or they try to if they can find a safe discharge.
But we see hospitals and their emergency rooms overloaded with
patients that shouldn't be in emergency rooms. And then do
you get admitted to the hospital, you know, is there
a place where they can safely discharge you home? Do
(39:03):
they put you on observation status in which case none
of your Medicare benefits trigger for the skilled care component,
and no patient knows what's going on behind the scenes
when they walk into that emergency room door, and it's
not something that is a pretty picture.
Speaker 2 (39:21):
And so there's some innovative things going on to try
to address that. One thing, for example, is the EDDY,
which is part of the Saint Peter's Partner system, has
implemented an emergency room diversion program where the home care
staff the emergency staff, primary care physicians all work together
so that when a person goes to the er, if
(39:42):
it's possible for them to be redirected and supported back home.
That can happen without the stay. We're also working the
Home Care Association and the Iroquois Healthcare Association, which is
the Upstate Hospital Association. We are working under a very
generous philanthropic grant from the Mother Cabrini Health Foundation, and
(40:03):
under this grant we are piloting these models called community
medicine and paramedicine where we integrate together the hospital, the
home health agency, primary care physicians, and EMS technicians to
work together to bridge those gaps on discharge, to make
visits for people that are vulnerable, and really all in
(40:25):
all to try to better coordinate care so that people
are vulnerable are not left to one provider or the
other or the other, but by bringing the system together
trying to provide that safety net for patients.
Speaker 1 (40:36):
And my hope is these are all bright lights. You
know that a thousand points of light I think was
George H. W.
Speaker 2 (40:42):
Bush.
Speaker 1 (40:44):
But there are islands of excellence out there great. You know,
EMS would love to do more for people, the home
health agencies would love to do more for people, but
they're all on their own individual island. What happens, unfortunately,
is you run a pilot program funded as a pilot,
it shows great results, and then the pilot funding ends
(41:05):
and it doesn't become part of the mainstream of our
healthcare system.
Speaker 2 (41:09):
And so we're facing that issue actually where we're now
entering about to enter our fourth year of financing. So
we've talked I talked recently to the Governor's Healthcare Commission
about this program and there was a lot of interest
in looking at it for potential sustainability past this point. Also,
we've talked to the insurers who are very interested in
this model to see whether or not it gives them
(41:31):
a cost effective option to interrupt the rehospitalization, rehospitalization an
emergency room revolving door process. Right now, the program has
grown to seven regions of the state, from the far
side of the Finger Lakes right down to the Hudson
Valley and north all the way to the border. So
we're hoping that the experience of this model will contribute
(41:55):
to some important policy decisions and to support for individuals
that other worse are caught in this fragmented system of
coverage and all of.
Speaker 1 (42:03):
That until then, care coordination, care management, private care management
is a way to navigate through the system. But these things, folks,
it's up to you. Guess what this season is. It's
legislative season. There's an election in ten days. And have
you heard it detailed or nuanced discussion about aging and
(42:24):
long term care from any candidate. They have a concept
of a plant maybe, or they're not even thinking about
it because it's not the number one priority. It doesn't
get a lot of media attention. It's not a sexy issue,
but it's an issue that is taking an ever increasing
portion of our government budget for Medicare and Medicaid. And
(42:45):
until we get some of these programs that you're talking
about ol off the ground and into the permanent mainstream
of healthcare, we're going to be spinning the wheel in
as Gaale used to say, rearranging the deck chairs on
the Titanic. But these are the programs and they're there, folks,
they're not fantasy. We have some technology that we've been implementing.
We have pilot programs with a company called Viva Links
(43:07):
that brings technology into the home and helps coordinate all
of those services that you're talking about. And gives the
consumer and the caregiver or platform to participate in that care.
It's a lot going on out there. Talk to your
legislators when they knock on your door and say can
you get my vote, Tell them you need to think
about aging and long term care. You need to take
some of these programs seriously and make a difference. We
(43:30):
need to take one more short break. We're gonna come
right back.
Speaker 2 (43:33):
You're listening.
Speaker 1 (43:33):
I get all ripped up when you're here out you're
listening to Life Happens Radio every Saturday morning here on
talk radio WGY. We'll be right back for this morning's
Life Happens Radio show. We're here a Saturday morning on WGY,
and we bring you information, ideas, and thoughts to help
you shape your future and aging and healthcare. As I
(43:54):
said at the top of the hour, it's not something
that we think about on a day to day basis
because it just leads into a very dark place because
there are no real good solutions and good answers out there.
But you have to fight your way through this. Get
the right help, get the right advice, get a plan
in place. And we're going to have a webinar coming
up that I invite everyone who's listening to attend. It
(44:18):
is our Medicaid Monday webinar, and it's going to be
on November eighteenth. It's Monday, November eighteenth. We're gonna have,
as I said earlier, our guest Becky Prevy, and we're
going to be talking about how to get care without Medicaid.
What are the resources available to you to keep you
healthy at home, get service in the home, integrate that
(44:42):
care that we've been talking about, and make sure that
you're receiving essential services and that you're being cared for
in a way that's to your best interests, and that
you can have your family involved in that care. So
Rebecca Preview. It's going to be at twelve noon on
November eighteenth. We hope that you can join us and
you can sign up as always on our website, which
(45:02):
is purolaw dot com. That's p I E R R
Law dot com. We hope that you can join us
on the eighteenth at noon. Al we have about eight
minutes left and I just want to kind of come
back to the work of the Home Care Association.
Speaker 2 (45:19):
Your efforts, these.
Speaker 1 (45:20):
Pilot programs are essential. They have to get traction they
have to be funded. We have to get the government's attention.
But Medicare right now is the Washington issue, and there's
a lot going on there cms changing rules, cutting home
care benefits. But we also have a Governor's master Plan
(45:41):
for Aging that's been going on for the last two
years or more. I've been part of a work group
on home and community based services. There are hundreds of
people that have participated in this. I understand they got
something like one hundred and eleven recommendations, and I know
you're involved in it and your agency, the Home Care
Association of New York State, is involved in it. What
(46:02):
is the Governor's master Plan?
Speaker 2 (46:04):
So the governor created this master plan by an executive
order and has has attempted to bring together knowledgeable people
a stakeholders meaning you know, organizations that are that are
deeply involved in the field, to try to cultivate recommendations
that really cover all of the essential areas from prevention
(46:25):
to palliative care and everything in the middle that can
better support the aged community within New York State. And
that is co chaired by Greg Olsen, who's the who
is the Commissioner of the Director of the State Office
for aging the best one in the country as a
matter of fact, UH and the State Department of Health
and so so. Over this time, there's really an entire
(46:47):
scaffold of these of these recommendations. I think the one
thing that's going to be really critical is they move
toward a final report that they're supposed to be issuing,
is what is the reality of the ability to implement
the many recommendations that are there related to the health workforce,
to technology, to support for informal caregivers. All of those
(47:08):
require funding, or many of them require funding. They also
require rethinking the regulatory structure, which right now is very
confining within the system. If you look at the state budget,
our state budget, the medicaid component itself is over one
hundred billion dollars. It's something like forty two percent of
(47:29):
the entire state budget is on Medicaid. Surely, within the
way in which we spend one hundred plus billion dollars
on medicaid, we can rethink the flexibility that needs to
be placed into this field to adequately support what is
really the entire underlayer of the healthcare delivery system. If
we're trying to keep people out of hospitals, out of
(47:50):
nursing homes and keep them healthy in their surgeries and
in all of their medical management. You've got to have
the flow of funds that aligns with that purpose.
Speaker 1 (47:59):
Amen, and the flow of not just Medicaid funds. And
this is where, absolutely, this is where I think we
all who in our silo get distracted because I'm holding
in my hand the interim report of the Master Plan
for Aging, which came out about two weeks ago, and
they're moving toward final report, or that's what we've been told,
(48:21):
and there'll be specific recommendations. But the Medicare dollars that
we're talking about are scarce dollars. The Medicaid dollars that
we're talking about are scarce dollars. The dollars in people's
own bank accounts are scarce dollars. When you think about
today's nursing home cost is two hundred thousand dollars a year,
and if you need twenty four to seven private agency care,
(48:43):
it's about two hundred and fifty for twenty four to
seven care, two hundred and fifty thousand dollars a year.
So individuals can't afford to pay for this. Medicare probably
can't afford to pay for this, and Medicaid is facing
the same kind of budget constraints. But private and insurance
has to play a role. Both Medicare, Medicure advantage, Medicure supplement,
(49:04):
and some long term care component of that has to
be built into this. So we have insurance dollars, we
have a risk pool, true true risk management. You have
individuals who can utilize their own resources to maximize the
care that they receive and the benefits that they receive.
You have Medicare, the federal programs, Medicare, Medicaid, and federal
and state program and Medicaid. Those dollars have to be
(49:25):
rationalized and brought together. Is there any movement to pull
all of these private and.
Speaker 2 (49:33):
Public resources together? You know, really that's exactly what we
need because the system is fragmented, and in its fragmentation,
it doesn't really organize the coverage so that the coverage
of services fits the person and that it's all affordable.
You know, there were there have been efforts, For example,
in the in the late nineteen eighties, President Reagan champion
(49:53):
the Medicare Catastrophic Act. Yeah, it passed. It would have
really expanded coverage for these severe needs. It was repealed
by Congress. The very next year, in conjunction with the
Obamacare Act, Senator Ted Kennedy sponsored what was called the
Class Act, which was supposed to create an infrastructure for
long term care financing outside of Medicaid and outside these services,
(50:16):
really bringing the system together. After several years, it never
launched off the ground and has been repealed. There needs
to be the will to not only examine the issue,
but to bring those carriers together in models where all
of the financing is integrated. I think one hundred percent
that needs to happen.
Speaker 1 (50:35):
And now thank you for your leadership over the last
forty years. Your phone number one more time for the
Home Care Association.
Speaker 2 (50:41):
Five one eight, four two six eight seven sixty four.
Speaker 1 (50:46):
And you can always call us at Pierre Conor and
Strauss at four nine twenty one hundred here in the
five one eight. Thank you for listening today. We hope
that you enjoyed today's program. It is deeply educational and
very very important. Talk to your legislators when the knock
on your door. Tell them to think about long term
care and find some answers
And good morning everyone. Welcome to Life Happens Radio. Thank
you for joining us on this very sunny fall Saturday,
eleven am every Saturday here in WGY. We bring you ideas,
information and news to help you navigate through the very
complex aging process, your working years, your retirement years, how
(00:22):
to stay healthy, wealthy and wise and what are the
things that you need to do and think about From
an estate planning perspective. We talk a lot about wills
and trusts and powers of attorney and healthcare proxies. We
talk about businesses. If you own a business, how do
you make that business work for you and when you're
ready to retire, keep working for you in the way
(00:43):
of a payment and business succession planning is a big
part of what we do special needs planning. Today, we're
going to focus on a topic that is near and
dear to my heart and something that most of you
think about but don't really want to face because it
involves health, and it involves failing health and chronic conditions
(01:06):
and an ability to get care where you want it,
when you need it. And where is that, folks, Where
would you want to get care if you had an
illness that required people to come in and help you
you needed help, just doing the things. They call them
activities of daily living, taking a bath, taking a shower,
(01:29):
getting dressed, getting meals, getting all the things done that
you need to get done. Some people just getting up
and down, in and out of bed. Can you transfer?
Can you get to the bathroom? These are activities of
daily living. Nobody wants to think about that until you
need to. But when you need to, you want to
make sure that you have a plan in place to
(01:50):
help you get care. And we call that home health care.
And the home health care marketplace has boomed because so
many people are aging and wanting to live in their
own homes. Services need to be developed and wrapped around
those needs. And what we see in the healthcare system,
which I affectionately call a sick care system, is that
(02:13):
you have episodic care in and out of emergency rooms, hospitals,
doctors' offices, but no real health care plan that follows
people into their home. And we're very fortunate today to
have a special guest, someone I've known for a number
of years who has been in state government and for
the last several years has served as the president and
(02:34):
CEO of the Home Care Associate Association of New York State.
And where would you want to get better information than
the President and CEO of the Home Care Association of
New York State, none other than Al Cardillo. Good morning, now,
good morning, Thanks very much for having us here today and.
Speaker 2 (02:49):
Thank you as always.
Speaker 1 (02:51):
We could talk for days about the issues that face
home healthcare, but before we jump in, just tell our
listeners there's a little bit about the Home Care.
Speaker 2 (03:02):
Association of New York.
Speaker 1 (03:03):
Who are your constituents, your members, who you represent and
how you represent them?
Speaker 2 (03:09):
Thank you, lou Yes. The Home Care Association in New
York State is comprised of hospitals, hospital systems, long term
care systems, community health agencies, health plans, all of whom
are federally and state licensed to provide care in the home.
We represent over three hundred of those organizations in the state. Combined,
(03:34):
they serve somewhere between a half a million and a
million individuals in the state and employ over two hundred
thousand individuals in the field nurses, home health aids, physical therapists,
social workers, and others.
Speaker 1 (03:47):
That's a lot of employees in the healthcare system and
a very diverse set, from hospitals to home health agencies
and kind of everything in between.
Speaker 2 (03:57):
Yes, and in that representation all of the various models
that New York hosts for care at home, Medicare, Medicaid,
what are called certified home health agencies, which are the
skilled services that are provided very often upon a discharge
from the hospital or when someone has a medical complication
(04:18):
like diabetes or congestive heart failure to manage those right
to addressing chronic illness and individuals, individuals with disabilities, and
really more permanent needs for daily care, but also at
the front end of the spectrum new moms and infants
coming home that are in need of services. So our
(04:38):
providers really represent that full scope.
Speaker 1 (04:41):
So, Al, you've been doing this for how many years now,
over forty years, Over forty years. I've been practicing law
over forty years, and for a good part of that
I've been involved in long term care and Medicaid, medicare,
elder law planning, and been involved with the Bar Association
and a number of legis lative initiatives over the years
that we've worked on together. And today what we see
(05:07):
when our clients walk in the door is a glazed
look because they've pinballed through the healthcare system and are
now looking and saying, you're just on the way in here.
You said, somebody called you this morning. You said, how
do I get my mom care? She's ninety five? So
where do I start? How do I get care? What
are the big problems? And this is a big question,
(05:28):
what are the big problems that you see in healthcare
and translate that into home healthcare?
Speaker 2 (05:34):
Well, I think you know, the entire healthcare system is
really struggling with securing sufficient workers in the field, nurses,
physical therapists, home health aid, social workers, staff in nursing
homes and the hospitals. The entire healthcare system is really
focused on trying to secure the base of workforce support
(05:55):
to deliver the services that people need. And that's the
case whether you're in the emergency room or whether or
in the home. The other real fundamental issue is that
and this is more unique in long term care and
in home healthcare. Is that different from how most people
have their hospital services or the physician services covered. There's
huge gaps between Medicare, Medicaid, and commercial and private coverage
(06:19):
when it comes to covering services like home health care.
People generally find that if they have a condition that
requires restoration, rehabilitation follows a hospitalization. There's some very good
coverage under the Medicare program, although we're facing some of
the most serious cutbacks in decades. But then once you're
through completed that episode, if you need ongoing care, the
(06:41):
system has a gigantic hole. There's a cliff. There's a cliff,
and you fall right off.
Speaker 1 (06:45):
And that's where our firm comes in. Yes, because we
do elder law, Medicaid planning, we do healthcare planning. We
work with an agency locally that we helped establish called
ever Home Care Advisors, and we've had them on the
show a number of times, and that's physical therapist, occupational therapists,
social workers arens who work for individuals. They're not working
for a hospital system, they're not working for a healthcare system.
(07:08):
They're working for you and helping navigate through this and
ever Homecare Advisors is a company that I think we
need so many more of those types of entities to
help guide people through this system. And I do want
to get into a little bit of history because this
is how we got where we are, but I want
to focus really on some of the current issues. The
(07:30):
labor shortage and I've seen your presentation now a dozen times.
It's phenomenal the information that your agency, the Homecare Association,
puts out. If you want to get a real feel
for the data, get their report. How can people access
to Homecare Association report?
Speaker 2 (07:44):
They can? They can contact the Homecare Association or our
website is www dot hcashys dot org. Or they can
contact our office at five one eight four two six
eight seven sixty four.
Speaker 1 (08:00):
You can access this information and folks, data talks, it's
real data. And I've seen you illustrate the shortages in
healthcare workers and home healthcare workers and the number of
job openings that are existing currently in New York State
with a with a dice diametrically opposed number of people
(08:21):
coming into the workforce as needing care. What's that number?
Speaker 2 (08:25):
Well, when you look at the at the numbers that
are are researched by the state, by labor, by others,
I mean we're talking really a projected need for well
over a million jobs you know in this field. Where
are we going to find them? Well? I think that's yes,
and that and that's really been the struggle. We've really
been trying to work, not just us in home care,
(08:46):
but on the hospital side, the nursing home side, especially
since the pandemic, but even before to try to have
really concrete programs that can be offered to support people
coming into the pipeline. But then also once people are
working in the field to retain the turnover rate and
healthcare is very substantial, it's very costly eighty it's very
(09:09):
very high. Well, for example, on the nursing side, the
home health aid side, it's over thirty percent in the
field to replace a home care nurse, for example, because
of the specialization and training, even if you took an
experienced nurse who works in the hospital, and may take
six to nine months to a year for that person
to really really get up to speed to be able
to do that. So we have wage disparity, wage and
(09:32):
also conditions. It's very difficulty. The level of layers of
administration and regulation and documentation drives nurses from the field,
and the wage issue obviously creates a tremendous amount of
pressure on individuals who work as home health aids, who
are wonderful and what they do, they make the difference
in people's lives every day.
Speaker 1 (09:52):
Yeah, and you talk about nurses, but in the home
healthcare field. One in one hundred people working in the
home is a nurse. The other ninety nine are either
social workers or just uncertified home health aids. And that's
those are the people that for twenty four hours a
day will take care of someone if they need that
(10:13):
twenty four hour a day care and our end may
be in and out of there in half an hour.
Speaker 2 (10:18):
They're not going to be there all day.
Speaker 1 (10:19):
Yes, So it's and the RNs come from a whole
different set of providers.
Speaker 2 (10:25):
Well, the one thing is that for the RNs, for example,
you need a nurse to open a case, manage the case.
One nurse equals about twenty five patients. So for example,
you know, and there's an agency in this air, very
prominent agency that for months, months, maybe the last several years,
has had seventeen nursing vacancies and their agency unable to fill.
(10:49):
It's not because they're not a tremendous agency. It's because
of the competition and also just the shortage of people
staying in the field.
Speaker 1 (10:57):
And we have a call. Theyn't open up the lines,
but we have a call. Billin's can the good morning bill?
How can we help you?
Speaker 3 (11:01):
This good morning. I have a question that's a little
bit beyond the long term care, but I am interested
in long term care in terms of I have an
irrevocable trust, and I'm trying to protect my assets, and
I'm also trying to protect myself from a healthcare situation.
Do I have to pay taxes on money before I
(11:26):
can move money into an irrevocable trust.
Speaker 1 (11:30):
It depends on what money you're moving.
Speaker 3 (11:33):
So you have something a virus and follower one K
my wife and.
Speaker 1 (11:37):
I Okay, good news. Well, let me start with bad
news and then the good news. When you do what
we call the Medicaid Asset Protection Trust, which is an
irrevocable trust, It's designed for very very particular purpose, and
that is to keep as much control and flexibility as
you have over those assets, but still have them sheltered
if you do need nursing home or home health care
(11:58):
in the future. So when we look at moving assets
in and out, the bad news is that any movement
of a retirement account an IRA or four oh one
K is a taxable event. The good news is that
New York State exempts those accounts without putting them in
the trust, so you don't have to transfer your IRA.
(12:18):
You don't have to transfer your four oh one K.
Even a wrath under current rules, maintains an exempt status
in your name alone, so you don't have to transfer those.
At some point when you access medicaid, you have to
start drawing on them like you would when you hit
your required beginning date at age seventy three. But those
accounts are fine. If you move stocks, if you move
(12:40):
real estate, if you move any other assets into the trust,
there is no taxable event. It's only those types of
assets that have income and respect of a deceed ird
we call it, and that's tax deferred income in them.
Speaker 3 (12:55):
So so base and can you move a partial amount
of of We'll say, let's just say I had five
hundred thousand dollars, could I move an effect We'll say
four hundred thousand, and I left one hundred thousand for
my wife to live on.
Speaker 1 (13:10):
Absolutely absolutely, Because a spouse, if she's healthy and you
need medicaid, she can keep seventy four thousand, eight hundred
and twenty dollars. You can keep thirty one thousand, one
hundred and twenty five dollars. So together you can actually
keep with one of you on medicaid one of you
living in the community. You can actually keep around one
(13:31):
hundred thousand dollars.
Speaker 3 (13:34):
But if I wanted to transfer more, could I do
a partial disclaimer and pass it by her to my children?
Speaker 2 (13:45):
You could, sure.
Speaker 1 (13:48):
I'm not sure at what point you're thinking of doing
that now or in the future.
Speaker 3 (13:54):
Well, we're both in our early eighties, so we're thinking
about trying to make it's the correct move, I guess
at this point in time. And also whether or not
are we to really too well now to seek long
term care at.
Speaker 1 (14:11):
Our age insurance? Yes, the long term care insurance policies
would not be written beyond now aage seventy for most companies,
and there're only a couple of companies left selling long
term character That's.
Speaker 2 (14:22):
A whole other topic.
Speaker 1 (14:23):
But for you, we do this when we sit down
with our clients.
Speaker 2 (14:27):
We draw it up.
Speaker 1 (14:28):
We do a diagram, because clients come in and they
have heard a lot of things, and they have a
lot of thoughts. And when it goes down on a
piece of paper and we put your trust, your other assets,
your retirement assets, your income, your kids, your beneficiaries, how
they inherit from the trust. All of that goes into
a diagram, and it makes sense once you see it
that way. But in your case, keep the retirements, retirement accounts,
(14:51):
separate your other assets, your home, your other assets. Put
a good chunk of that in the trust. If you
want to keep one hundred thousand dollars out, that's a
good place.
Speaker 3 (15:02):
Okay, that sounds very good. Thank you very much.
Speaker 1 (15:06):
Oh you're very welcome. And now we're gonna have to
take a short break. When we come back, I really
want to dig into the home healthcare marketplace because.
Speaker 2 (15:14):
Our clients walk in the door.
Speaker 1 (15:15):
As I said, they have this look because they've been
phone calling, and I call it the eternal loop. You
make one phone call, you get referred to another number,
You make another phone call. And I did this with
my mother twenty five years ago, and I got the
first number that I called was the last number that
I received, And I said, this isn't working. You got
to have better answers. And we're gonna come back. We're
gonna talk about how to unwind this and kind of
(15:38):
solve the riddle. How do you get care in your home?
How do you make sure that you're ready for this?
How do you prepare for it? And we're going to
talk to al Cardilo about what's being done to try
to bolster back this home healthcare marketplace. I'm Lou Piro,
your host for this morning. You're listening to Life Happens Radio.
We'll be right back after this short break. You're your
host for this morning from Pierre O'Connor and Strauss or
(16:00):
a law from here in Latham, New York, New York City.
We have office in Garden City, New Long Island. We
are up in Lake Placid, and we work with clients
helping to shape their legal plans. We work with their
financial advisors, their tax advisors, because you want to have
a comprehensive plan. And one of the main issues, folks,
that people are thinking about and planning for is when
(16:21):
I age, if I need care, where do I get it,
how do I get it, and how do I pay
for it? And now going back, let's take this and
peel apart the major healthcare legislation of our lifetimes. And no,
it's not the Affordable Care Act. It's the Great Society
Program of Lyndon Johnson in nineteen sixty five, which gave
us Medicare and Medicaid. And I've had Mike Burgess on
(16:43):
we celebrated the fiftieth anniversary of Medicare and we explored
the history and the preamble when Lyndon Johnson said in
his preamble, never again will seniors in America have to
worry about healthcare. He just didn't see what was coming.
Where do we have today with Medicare and Medicaid, Well.
Speaker 2 (17:01):
That's for sure in terms of not seeing what was coming,
because nobody in nineteen sixty five would have imagined a
world today where when an individual goes into the hospital,
if they go they're coming out with tubes and drains
and all sorts of very complex needs, fresh surgical wounds,
the whole thing. Where it's a very very different world.
(17:21):
People are living so much longer, and then especially in
terms of the ability to be supported and have a
long life if you've got a chronic or serious condition.
So the world is very different. On the Medicaid side,
Medicaid has evolved in very creative ways in that period
of time. Medicare, however, seems stuck in nineteen sixty five.
(17:45):
There's still a homebound requirement. There are other requirements that
are not realistic for what a person needs when they
receive care. At home. That's been a pressure point that
we've been working on at the federal level to try
to open up the system and allow it to really
flow more freely with state of the art medicine. We're
facing right now some of some of the most dramatic
(18:07):
Medicare costs in home health care services in a generation.
Speaker 1 (18:11):
And this is Medicare. Nineteen ninety seven was the last time,
and that was something called the balanced budget acting. Guess what,
They balanced the budget and they cut all across the board,
including Medicare. There were severe Medicare changes in nineteen ninety seven,
and that was President Clinton and Nut Gingridge, and they
did their job. They cut the budget, but they took
(18:32):
what was a fabric of home health care under Medicare,
where you had a doctor, a nurse, a social worker
on a team under Medicare, and you had home health
aids up to thirty five hours a week through Medicare.
That was obliterating with the stroke of a pen.
Speaker 2 (18:50):
Fifty percent of the home health agencies in the country
closed yes, following that. So we're in the situation now
where the projections are very very similar. They're really dire.
These cuts really have nothing to do with the merit
of reimbursing at one level or the other. They all
relate to arcane requirements of the federal bureaucracy when they
move from one payment year to the next to maintain
(19:12):
something called budget neutrality. And this is right now unraveling
in the billions as it relates to home care over
this period of time.
Speaker 1 (19:21):
And there's a New York Congressional delegation. You've given me
a lot of literature and a letter from the Congress
of the United States to the President to the CMS
heads because the Center for Medicare Medicaid Services what used
to be HICCLA, which is now CMS, is in charge
of both Medicare and Medicaid and they're changing the reimbursement system.
(19:43):
They're changing the way that providers can provide care, the
amount of money that providers can put back into their infrastructure,
eighty twenty rule, and a lot of other things that
are happening. This all Alan, and this has been the
case since I started even looking at this issue, and
it was very clear to me it's about dollars. It's
(20:04):
never about care. It's about dollars. How do we and
no one ever wants to say the ration word, But
how do we allocate resources in the appropriate way with
the amount of money that we have available without inflating
the budget.
Speaker 2 (20:19):
Well, I think one thing is that Medicare and those
who administered have to wake up. You know. Part of
the narrowness of the system is that home care is
viewed sort of as its own somewhere out, you know,
apart from the mainstream system. But the reality is home
health services work still work functionally with physicians, hospitals, pharmacists,
(20:40):
other community partners, but it is not covered and reimbursed
that in that kind of way.
Speaker 1 (20:47):
Nor is it integrated fully with the healthcare exactly.
Speaker 2 (20:49):
So as an example, there was an experiment that Congress
authorized called the value based payment mechanism for home care.
It's saved hundreds of millions of diyars.
Speaker 1 (21:00):
Was under that other major healthcare legislation, the Affordable Care Well.
Speaker 2 (21:04):
And since then, yes, and since that time, building on that,
So it saved hundreds of millions of dollars. So what
did Congress do? They said this should apply across the country.
So the projection is that value based home health care
will save three to four billion dollars over this limited
period ahead. How does it do it. It improves the outcome
(21:25):
with reduction in hospitalizations, emergency services, and other high cost services.
None of those savings was predicated on shrinking the services,
but making them indispensably accessible to the individual.
Speaker 1 (21:39):
Yeah, so providers, you achieved this result for us with
a lot less money.
Speaker 2 (21:44):
Yes, exactly, that's and that's the smart way to do things.
If we got this major problem in the country in
terms of even the future solvency of Medicare, you need
to look at home care as an integral partner. So
while while at the same time you have Congress forecasting
billions and savings, you have the federal bureaucracy making billions
of cots. On the other side, you can't bring in staff,
(22:07):
you can't cover those home health a hours that you said,
and you can't provide continuity to patients if you're now
cutting the services beyond the ability to retain the staff.
Speaker 1 (22:17):
And so Medicare is in my mind an illusion for
home health care. It doesn't and I don't think we'll
ever have the budget necessary.
Speaker 2 (22:27):
Well, again, it needs to open up and it needs
to recognize the fact that we're talking about caring for
a person, not a thing that fits between the parameters
of some insurance plan, that is that which Medicare is
an insurance plan. You know. One of the things that
has been happening in recent years is a growth in
what's called Medicare advantage or a medic Medicare managed component
(22:52):
for the system. You know, part of that vision is
to is to create flexibility to be able to cover
services more broadly. But Medicare itself remains a very rigid
model and is very underpaid, and as I said, it
doesn't recognize the full flow of services that patients need.
Speaker 1 (23:11):
Yeah, and we're going to take a break shortly. But
a top down bureaucracy does not deliver services efficiently into
someone's home.
Speaker 2 (23:21):
No, No, it just does not.
Speaker 1 (23:22):
You need a bottom up system that looks at the
patient and the whole patient. What is the patient's resources
in the home, What can family provide because families are
being asked to do a lot more in this system
of home healthcare, and what resources does that individual need
in their home. You have these things that say, okay,
(23:43):
you need this, Well maybe they do, maybe they don't,
but it's not based on the individual's care plan.
Speaker 2 (23:48):
No, that's absolutely the case. And you know, new York
really sort of low, I think, departed from what was
a very solid way. In nineteen seventy seven, a state senator,
Senator Taki Lombardi, was the chair of the Committee on Health,
and he envisioned a program that would function around the
patient individually, customizing services in a plan called the Nursing
(24:12):
Home Without Walls Program, also the Lombardi also the Lombardi
program after the great Senator to Lombardi, and the state
sort of departed from that course when it got so
heavily focused on the money side, not the patient sign
And let's come back and talk about that, because we're
facing an avalanche as seniors age out in New York State.
We have one of the fastest growing senior populations and
(24:33):
one of the slowest growing employee populations. And this is
a disaster waiting to happen, folks, So stay with us.
Al Cardillo, CEO, President of the Home Care Association of
New York State, Lupiro from Pierre o' connor and Strauss,
We're going to continue to dialogue. We will open up
the phone lines if you have a question, we'll be
right back. Home Care Association of New York State President
CEO who has been in healthcare.
Speaker 1 (24:54):
In New York State for over forty years. And we
do more talking in between the show than we do
on the show because we are both so deeply entrenched
in these issues. And if you have a question, you
want to be part of this conversation. We're talking about
home healthcare in New York State. You can give us
a call. It's eight hundred talk WGY eight hundred eight
(25:14):
two five five nine four nine again eight hundred eighty
two five fifty nine forty nine and out. Everything comes
down to the money. And you were mentioning earlier that
that there are programs that are agnostic as to dollars.
Now we're gonna have Rebecca Prevy on. We do something
(25:34):
called Medicaid Mondays and Becky Preview runs the New York
State Area Association on Aging, so all the counties and
the Home the HRA Human Resource Administration New York State.
Becky leads each of those agencies. She represents them statewide.
And we're going to talk about services that are available
without medicaid. Now, why should we have to have a
(25:57):
separate show to talk about service that are available without medicaid?
Because what most of their money comes from, is the
Older Americans Act and grants that come from the federal government,
and they combine with the Medicare program. So you have
these silos. Medicare money going in one direction, people saying, oh,
we're going to expand Medicare, and on the other hand,
(26:19):
CMS is cutting the ribbons on Medicare. You have Medicaid,
which is supposed to be the payer of last resort,
which has become the only payer. It's not the payer
of last resort anymore. That was what Medicaid was intended
to be in nineteen sixty five. It was women and
babies who needed healthcare. That's what Medicaid was invented for.
But what has happened is Medicare has retrenched from any
(26:41):
services like this in the home, and Medicaid has had
to pick up because you can't leave people and let
them die in their homes, which is kind of what's
happening in some cases. So it's getting a bit drastic.
I don't mean to overdee the seriousness of the problem,
but we have a serious problem in New York State.
Speaker 2 (26:59):
Album Oh, we absolutely do. And I think that especially
with relate with respect to coverage New York for many
years was a leader in looking at alternatives to Medicaid
to provide coverage. Lou you were at the ground floor
of a lot of it, trying to really expand the
system to make it be more sensible for the coverage
(27:21):
of the services people needed apart from Medicare and Medicaid.
We currently are advocating a piece of legislation called the
New York home Care First Act. Part of that is
to direct the Commissioner of Health and the state to
look at what the current parameters are in the private
market and across all programs to ensure that home care
coverage is optimized for everybody that needs it. We're certainly
(27:44):
hopeful that we can get the legislature to pass this
in the coming session, but it really takes the vocal
voice of all, for example, the listeners on this line
and other advocates that are concerned about this area to
press that point to the legislature and governor.
Speaker 1 (27:58):
Yeah, but the data is really the key, because people
need to be told the truth. They don't get the truth.
They get some broad policy statements, they get you know, fluff, Oh,
we're going to expand services, we're gonna make it better,
and then they cut the ribbons out of the programs
that are essential to people, and I'm gonna pick on
(28:19):
one Medicaid program. We just had a guy named Brian
O'Malley who's the head of the Consumer Directed Agencies in
New York State, because the governor just took six hundred
agencies that administer home healthcare and just took them out
of existence and brought in one provider from the state
of Georgia who's going to administer this for the whole
state of New York. And that's called the Consumer Directed
(28:39):
Personal Assistance Program or cd PAP. We talk about it
all the time on the show because it has become
the lifeline for people to survive and get care that
they need.
Speaker 2 (28:51):
Talk a little bit about how that fits into the system. Yes,
So that's a program that actually grew out of the
nineteen eighties from a really an experiment in New York
City that was run by the disabilities community and really
has grown into being a very prominent program in New
York State. It allows a person to be able to
designate a caregiver someone that they've identified. It could be
(29:13):
a family member, could be a friend, or someone that
they know and trust, and that person can provide the
services at their direction. It's available under Medicaid, so you
have to qualify for Medicaid in order to have it accessible.
But Medicaid covers the service and the program because it's
grown so much. And part of the reason it's grown
is because there's really been an under investment in the
(29:36):
regulated part of home care. Individuals turn to the program,
identify their caregiver, and then it's covered.
Speaker 1 (29:43):
So this gets back to the first premise that we
were talking about, and that is the staffing shortage. Yes,
in New York State and I have clients. We work
with our clients very closely in trying to find home healthcare.
And as I said, ever home care advisors, when this
issue arises, we or to them. They pick up the
phone and they're now nuanced, knowledgeable, they know all the agencies,
(30:06):
they know the people and say, Okay, we have a
need for sixteen hours a day of home health care
in colony New York. Can you staff the case?
Speaker 2 (30:13):
No?
Speaker 1 (30:15):
They call the next agency. We have a need for
sixteen hours a day of home care in colony New York.
Can you staff the case?
Speaker 2 (30:20):
No?
Speaker 1 (30:20):
No, no, no, no, no, what.
Speaker 2 (30:22):
Do you do?
Speaker 1 (30:24):
You can't get the care, and so the consumer directed
program says, Okay, you know, I'm gonna call my cousin
who's got some time for you. Got laid off from
her job. She can come in and do eight hours
a day and spend this with my mom and.
Speaker 2 (30:36):
Be a paid caregiver.
Speaker 1 (30:38):
I have a neighbor who is going to be doing this,
but needs to have some income, so the neighbor can
fill this gap. It's the chasms, the enormous gaps in
care that cd PAP has been filling. And of course
once you open the door to that and people see
that there is a solution, now, they're going to slam
that trap door and try to cut the program.
Speaker 2 (30:59):
Because it's too success. Yeah, that's exactly what's happening. It
has been the single largest growing area in the Medicaid program.
But also we know population wise, the elder population is
the most significantly growing part of our demographics, including those
eighty five and older. So it's like you can't have
it all ways. Over the course of the nineteen eighties,
(31:21):
the federal government and the state constrained the reimbursement for
the hospital system to shorten stays and constrain the reimbursement
for nursing homes on the basis that the underlying layer
of home and community based services was the best place
for the patients. Even the Supreme Court ruled that under
cases involving the Americans with Disabilities Act.
Speaker 1 (31:41):
The own steadcase, Yes, which we've talked about a lot
on this program.
Speaker 2 (31:44):
But if you're going to do that, you then have
to provide those services concurrent with what the expected demand
is going to be. It doesn't happen by magic. There's
got to be support. I just on the area of workforce.
I want one thing I'd like to point out is
that the the way in which the workforce is treated
is almost that it's a responsibility of the providers to
(32:06):
find and hire people. But when does it really become
more of a societal obligation to recruit people into the field,
much the way we do with teachers, with physicians, you know,
and others, where there is a broad public good component
to that occupation. So the system can't just function on
the magic of a provider or another provider. There's got
(32:30):
to be some broader ownership and participation for what this
is all about.
Speaker 1 (32:34):
Yeah, it isn't a field that people go into to
get rich or to scam the system. It's something that
the caregivers that we see that are paid caregivers in
this system do it for the reason that they want
to care for someone. They want to help another human being.
And that's the vast majority of people that I see
in this area. Home health aids are heroes. They are
(32:57):
heroes because this is not an easy job. We talk
about this. You can go to you know, I guess
both the presidential candidates have worked at McDonald's.
Speaker 2 (33:06):
But you can go to McDonald's and make.
Speaker 1 (33:09):
It now twenty two dollars an hour flipping a burger
giving out a bag of French fries. If what are
the home healthcare wages under medicaid? What does a home
health aid make under cd PAP.
Speaker 2 (33:21):
Well, really, when you add everything together, you're talking in
the low twenties, but it also varies. There's the minimum
wage for home care, but then there's the wage that
providers attempt to pay in order to compete in the market.
But the reimbursement methodologies, whether they're under Medicare or Medicaid,
do not really reflect the real cost of recruiting and
(33:44):
maintaining a base. And I think in there is really
part of the fallacy. One of the areas of the
system that we're very concerned about is this high skilled
home health component where individuals come home from the hospital
or are managed with very complex conditions. That program is
right now suffering in terms of the loss of the
(34:04):
closure of agencies and the scale back of services because
for over ten years there's been no real adjustment in
the way in which the program works.
Speaker 1 (34:13):
So we have a program that our law firm has sponsored.
Speaker 2 (34:16):
We started it thirty years ago.
Speaker 1 (34:19):
It'll be our thirtieth next May, called the Elder Law Forum.
You've spoken at it several times.
Speaker 2 (34:24):
We had the.
Speaker 1 (34:25):
Lieutenant Governor, we had Assemblyman MacDonald's, Senator Ashby, Senator Rivera,
and heads of agencies, Greg Olsen from Naisofa. We had
people from Department of Health. And it's a full day
where we try to really get to the root of
the problems and what are some of the solutions, and
(34:45):
we get kind of in a circle and circle the wagons.
But each year it's okay, well, here are ten great ideas,
but we don't have the money to do anymore, and
they just fall by the wayside. You remember the compact
for Long Term which my good friend Gail Holabinka conceived of.
And Gail, who recently passed away, was in New York State,
(35:09):
the head of the Partnership for Long Term Care, which
was an insurance program, that had this great idea, let
people pay their fair share. That's all my clients want.
It's an all or nothing game. Let them pay their
fair share, spend something down on care, take the burden
off the state, but don't have to go bankrupt to
get help. And that's what the system calls for today, bankruptcy.
(35:30):
You need to be bankrupt to get Medicaid? Is that
what our system, our government wants people to think that
the only way you can get help and care through
our healthcare system is to be bankrupt.
Speaker 2 (35:42):
That's Medicaid.
Speaker 1 (35:43):
And so the compact said, well, even if you don't
have insurance or can't get it, you can pay a
fair share, you can private pay for two or three years,
depending upon how much money you have, and then Medicaid
comes in and subsidizes your long term care. Again you
mentioned and the Lombardi program. The guy that helped write
that was GUI named Bob Hurs, who also we lost recently,
(36:06):
and Bob wrote the Compact legislation, and he did it
in a didn't even know he was doing it, and
he sent us the bill and it was we went
two years and he said, find every way that this
system could be gamed, every every possible pera mutation that
we need to address. And we brought it up and
we took it to the Senate and the Senate passed
it unanimously, and we couldn't get it out of committee
(36:29):
in the Assembly, never got out of the Health Committee
in the Assembly. But the Compact was a rational way
to do this. There's another program that looks at Medicare dollars,
looks at Medicaid dollars, looks to the needs of the patient,
what's the team that they need. It's called the PACE program.
And you represent I think some of the PACE organizations
we do the EDDIE.
Speaker 2 (36:50):
The EDDI in this area is one of the premier
PACE programs in the state. And that's a that's a
very unique model.
Speaker 1 (36:55):
The program for all inclusive care for the elderly.
Speaker 2 (37:00):
Don't that sound good? It does? And and and the
way in which the program is organized. That is also
a program that really revolves around the needs of the patient.
A plan of care that is really a patient first
plan of care, and the the part to the the
the care coordinators within the program are really able to
arrange for services across an array of care that meet
(37:23):
that person's needs again in a plan of care that
is reflective of that person.
Speaker 1 (37:29):
And that's patient centered care. There was also a dollars
follow the Patient program in New York which was kind
of great. You know, wherever the patient needed to be,
the dollars went with them, and that hasn't really money
follows the person. Money follows the person that was in
New York City. Primarily, I think, I don't know what's
left of that program.
Speaker 2 (37:46):
Well, it's it's like these programs are all very positive
as they start out, but as I was saying earlier,
there really needs to be a commitment to that course
of action. When for example, when Senator Lombardi created the
public health law in New York that governs home health care,
the preamble to it was that home healthcare was a
priority focus of the state and needed to and the
(38:09):
accessibility and availability of that service had to be an
integral part of the healthcare system. Really, since the state
went on a track of being this very narrow focused
Medicaid models. Really there has lost sight of the importance
of that very mission, which is really what as I
mentioned earlier, the New York Home Care First Act would
(38:33):
bring us back to the more holistic, integral involvement of
home health as part of the delivery system.
Speaker 1 (38:41):
Because hospitals discharge, as we like to say, sicker and quicker,
or they try to if they can find a safe discharge.
But we see hospitals and their emergency rooms overloaded with
patients that shouldn't be in emergency rooms. And then do
you get admitted to the hospital, you know, is there
a place where they can safely discharge you home? Do
(39:03):
they put you on observation status in which case none
of your Medicare benefits trigger for the skilled care component,
and no patient knows what's going on behind the scenes
when they walk into that emergency room door, and it's
not something that is a pretty picture.
Speaker 2 (39:21):
And so there's some innovative things going on to try
to address that. One thing, for example, is the EDDY,
which is part of the Saint Peter's Partner system, has
implemented an emergency room diversion program where the home care
staff the emergency staff, primary care physicians all work together
so that when a person goes to the er, if
(39:42):
it's possible for them to be redirected and supported back home.
That can happen without the stay. We're also working the
Home Care Association and the Iroquois Healthcare Association, which is
the Upstate Hospital Association. We are working under a very
generous philanthropic grant from the Mother Cabrini Health Foundation, and
(40:03):
under this grant we are piloting these models called community
medicine and paramedicine where we integrate together the hospital, the
home health agency, primary care physicians, and EMS technicians to
work together to bridge those gaps on discharge, to make
visits for people that are vulnerable, and really all in
(40:25):
all to try to better coordinate care so that people
are vulnerable are not left to one provider or the
other or the other, but by bringing the system together
trying to provide that safety net for patients.
Speaker 1 (40:36):
And my hope is these are all bright lights. You
know that a thousand points of light I think was
George H. W.
Speaker 2 (40:42):
Bush.
Speaker 1 (40:44):
But there are islands of excellence out there great. You know,
EMS would love to do more for people, the home
health agencies would love to do more for people, but
they're all on their own individual island. What happens, unfortunately,
is you run a pilot program funded as a pilot,
it shows great results, and then the pilot funding ends
(41:05):
and it doesn't become part of the mainstream of our
healthcare system.
Speaker 2 (41:09):
And so we're facing that issue actually where we're now
entering about to enter our fourth year of financing. So
we've talked I talked recently to the Governor's Healthcare Commission
about this program and there was a lot of interest
in looking at it for potential sustainability past this point. Also,
we've talked to the insurers who are very interested in
this model to see whether or not it gives them
(41:31):
a cost effective option to interrupt the rehospitalization, rehospitalization an
emergency room revolving door process. Right now, the program has
grown to seven regions of the state, from the far
side of the Finger Lakes right down to the Hudson
Valley and north all the way to the border. So
we're hoping that the experience of this model will contribute
(41:55):
to some important policy decisions and to support for individuals
that other worse are caught in this fragmented system of
coverage and all of.
Speaker 1 (42:03):
That until then, care coordination, care management, private care management
is a way to navigate through the system. But these things, folks,
it's up to you. Guess what this season is. It's
legislative season. There's an election in ten days. And have
you heard it detailed or nuanced discussion about aging and
(42:24):
long term care from any candidate. They have a concept
of a plant maybe, or they're not even thinking about
it because it's not the number one priority. It doesn't
get a lot of media attention. It's not a sexy issue,
but it's an issue that is taking an ever increasing
portion of our government budget for Medicare and Medicaid. And
(42:45):
until we get some of these programs that you're talking
about ol off the ground and into the permanent mainstream
of healthcare, we're going to be spinning the wheel in
as Gaale used to say, rearranging the deck chairs on
the Titanic. But these are the programs and they're there, folks,
they're not fantasy. We have some technology that we've been implementing.
We have pilot programs with a company called Viva Links
(43:07):
that brings technology into the home and helps coordinate all
of those services that you're talking about. And gives the
consumer and the caregiver or platform to participate in that care.
It's a lot going on out there. Talk to your
legislators when they knock on your door and say can
you get my vote, Tell them you need to think
about aging and long term care. You need to take
some of these programs seriously and make a difference. We
(43:30):
need to take one more short break. We're gonna come
right back.
Speaker 2 (43:33):
You're listening.
Speaker 1 (43:33):
I get all ripped up when you're here out you're
listening to Life Happens Radio every Saturday morning here on
talk radio WGY. We'll be right back for this morning's
Life Happens Radio show. We're here a Saturday morning on WGY,
and we bring you information, ideas, and thoughts to help
you shape your future and aging and healthcare. As I
(43:54):
said at the top of the hour, it's not something
that we think about on a day to day basis
because it just leads into a very dark place because
there are no real good solutions and good answers out there.
But you have to fight your way through this. Get
the right help, get the right advice, get a plan
in place. And we're going to have a webinar coming
up that I invite everyone who's listening to attend. It
(44:18):
is our Medicaid Monday webinar, and it's going to be
on November eighteenth. It's Monday, November eighteenth. We're gonna have,
as I said earlier, our guest Becky Prevy, and we're
going to be talking about how to get care without Medicaid.
What are the resources available to you to keep you
healthy at home, get service in the home, integrate that
(44:42):
care that we've been talking about, and make sure that
you're receiving essential services and that you're being cared for
in a way that's to your best interests, and that
you can have your family involved in that care. So
Rebecca Preview. It's going to be at twelve noon on
November eighteenth. We hope that you can join us and
you can sign up as always on our website, which
(45:02):
is purolaw dot com. That's p I E R R
Law dot com. We hope that you can join us
on the eighteenth at noon. Al we have about eight
minutes left and I just want to kind of come
back to the work of the Home Care Association.
Speaker 2 (45:19):
Your efforts, these.
Speaker 1 (45:20):
Pilot programs are essential. They have to get traction they
have to be funded. We have to get the government's attention.
But Medicare right now is the Washington issue, and there's
a lot going on there cms changing rules, cutting home
care benefits. But we also have a Governor's master Plan
(45:41):
for Aging that's been going on for the last two
years or more. I've been part of a work group
on home and community based services. There are hundreds of
people that have participated in this. I understand they got
something like one hundred and eleven recommendations, and I know
you're involved in it and your agency, the Home Care
Association of New York State, is involved in it. What
(46:02):
is the Governor's master Plan?
Speaker 2 (46:04):
So the governor created this master plan by an executive
order and has has attempted to bring together knowledgeable people
a stakeholders meaning you know, organizations that are that are
deeply involved in the field, to try to cultivate recommendations
that really cover all of the essential areas from prevention
(46:25):
to palliative care and everything in the middle that can
better support the aged community within New York State. And
that is co chaired by Greg Olsen, who's the who
is the Commissioner of the Director of the State Office
for aging the best one in the country as a
matter of fact, UH and the State Department of Health
and so so. Over this time, there's really an entire
(46:47):
scaffold of these of these recommendations. I think the one
thing that's going to be really critical is they move
toward a final report that they're supposed to be issuing,
is what is the reality of the ability to implement
the many recommendations that are there related to the health workforce,
to technology, to support for informal caregivers. All of those
(47:08):
require funding, or many of them require funding. They also
require rethinking the regulatory structure, which right now is very
confining within the system. If you look at the state budget,
our state budget, the medicaid component itself is over one
hundred billion dollars. It's something like forty two percent of
(47:29):
the entire state budget is on Medicaid. Surely, within the
way in which we spend one hundred plus billion dollars
on medicaid, we can rethink the flexibility that needs to
be placed into this field to adequately support what is
really the entire underlayer of the healthcare delivery system. If
we're trying to keep people out of hospitals, out of
(47:50):
nursing homes and keep them healthy in their surgeries and
in all of their medical management. You've got to have
the flow of funds that aligns with that purpose.
Speaker 1 (47:59):
Amen, and the flow of not just Medicaid funds. And
this is where, absolutely, this is where I think we
all who in our silo get distracted because I'm holding
in my hand the interim report of the Master Plan
for Aging, which came out about two weeks ago, and
they're moving toward final report, or that's what we've been told,
(48:21):
and there'll be specific recommendations. But the Medicare dollars that
we're talking about are scarce dollars. The Medicaid dollars that
we're talking about are scarce dollars. The dollars in people's
own bank accounts are scarce dollars. When you think about
today's nursing home cost is two hundred thousand dollars a year,
and if you need twenty four to seven private agency care,
(48:43):
it's about two hundred and fifty for twenty four to
seven care, two hundred and fifty thousand dollars a year.
So individuals can't afford to pay for this. Medicare probably
can't afford to pay for this, and Medicaid is facing
the same kind of budget constraints. But private and insurance
has to play a role. Both Medicare, Medicure advantage, Medicure supplement,
(49:04):
and some long term care component of that has to
be built into this. So we have insurance dollars, we
have a risk pool, true true risk management. You have
individuals who can utilize their own resources to maximize the
care that they receive and the benefits that they receive.
You have Medicare, the federal programs, Medicare, Medicaid, and federal
and state program and Medicaid. Those dollars have to be
(49:25):
rationalized and brought together. Is there any movement to pull
all of these private and.
Speaker 2 (49:33):
Public resources together? You know, really that's exactly what we
need because the system is fragmented, and in its fragmentation,
it doesn't really organize the coverage so that the coverage
of services fits the person and that it's all affordable.
You know, there were there have been efforts, For example,
in the in the late nineteen eighties, President Reagan champion
(49:53):
the Medicare Catastrophic Act. Yeah, it passed. It would have
really expanded coverage for these severe needs. It was repealed
by Congress. The very next year, in conjunction with the
Obamacare Act, Senator Ted Kennedy sponsored what was called the
Class Act, which was supposed to create an infrastructure for
long term care financing outside of Medicaid and outside these services,
(50:16):
really bringing the system together. After several years, it never
launched off the ground and has been repealed. There needs
to be the will to not only examine the issue,
but to bring those carriers together in models where all
of the financing is integrated. I think one hundred percent
that needs to happen.
Speaker 1 (50:35):
And now thank you for your leadership over the last
forty years. Your phone number one more time for the
Home Care Association.
Speaker 2 (50:41):
Five one eight, four two six eight seven sixty four.
Speaker 1 (50:46):
And you can always call us at Pierre Conor and
Strauss at four nine twenty one hundred here in the
five one eight. Thank you for listening today. We hope
that you enjoyed today's program. It is deeply educational and
very very important. Talk to your legislators when the knock
on your door. Tell them to think about long term
care and find some answers
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