Life Happens

March 9th, 2024

Episode Transcript

(00:02):
Good morning everyone, Welcome to LifeHappens. We are here live in studio
today and we're bringing you today someinformation as we try to do each week
that will help you kind of shapeyour thoughts, your ideas, and help
you plan for your future. Andwhen we talk about planning for the future,
we look at wills, trusts,a state planning, tax planning,

(00:26):
business planning, all the things thatwe do at our firm, but we
also look at how people are goingto live throughout their lifetime. And successful
aging is a big part of whatwe talk about. And when you talk
about successful aging, you want tomake sure you maximize your Social Security,
your IRA for when K distributions,your income, protect your assets. But

(00:49):
at some point in time, thediscussion and the thought process turns to healthcare.
What if I'm the one who getsdiagnosed with Alzheimer's, or I get
diagnosed with Parkinson's, or I havean injury or a brain injury that puts
me in a position where I needhelp, or you know what, I'm

(01:12):
ninety five years old and I justneed help because things slow down, Our
bodily functions slow down as we age. So how do we plan for that?
How do we protect ourselves, tomake sure that we have a good
place to age and that it's ourown home or a nice facility, an
independent living place where I can sharewith others and have amenities. Or we

(01:36):
may need more serious care, butif we want to be at home,
we need to plan for that.Being at home and staying at home throughout
your lifetime is no accident. Ittakes careful planning and you need to have
resources available to you. And todaywe're going to focus on home care and
home healthcare. And I have aguest with me today who has been on

(01:57):
the show many times. He's beena friend for about thirty years now,
and we'll talk about the history andwhere that all started. But Al Cardillo
is our special guest who is theCEO of the Home Care Association of New
York State. And Al, goodmorning, Good morning Lou, and welcome
to the show. Our listeners shouldknow a little bit about the Home Care

(02:17):
Association and just tell them you havemany, many different types of constituents,
not just home health agencies, andyou represent a lot of the industry home
health in New York State. Yes, we do, thank you so much,
Lou. And really, before weget started, I just want to
acknowledge and thank you for the greatvalue of the information that this show brings

(02:38):
to the listeners each and every week. This is one of the most difficult
areas to understand and the healthcare system, and it impacts often multi generations within
the same family. So again,really appreciate what you do and thanks again
for having us on. Well,thanks and thanks for taking your time to
be with us and to educate ourlisteners. And don't turn this off,

(03:00):
folks, this discussion is going tobe about a season we're in. Not
baseball season, not Basketball's not MarchMadness season. It's budget season. And
your future and the services available toyou are being shaped right now here in
Albany, New York. So staytuned and listen how this is panning out.
But I'll start with your organization,the Homecare Association will do thank you.

(03:23):
So the Homecare Association of New YorkState represents a very broad array of
healthcare providers, health plans, andother organizations that are federally or state licensed
and certified to provide healthcare to individualsand their homes. And that really covers
the wide array of services. Professionalservices like nursing, physical therapy, social

(03:45):
work, on health aid services,respiratory therapy, speech pathology, and also
very much also covers the long term, chronic, day to day services that
individuals need if they have disabilities orsome of the conditions that Lou talked about
earlier Parkinson's disease, dementia, andso on. There's no age limit to

(04:09):
people who participate in the program.We have individuals who are newborns, and
individuals who are maternal patients who areexpecting, all the way to individuals that
are over one hundred years old.Care for individuals coming out of hospital that
have had major procedures, as wellas individuals that have complex medical conditions like

(04:30):
heart failure, chronic obstructive pulmonary disease, diabetes, and other conditions that just
need day to day management. Soreally it's that full spectrum of services and
providers, and it also includes hospiceand end of life care. So how
many members does the Home Care Associationof New York He We have about three
hundred members within the organization, butthose members comprise, for example, on

(04:55):
the home health side, nearly fivehundred thousand patients in the state. And
again that covers the very broad arrayof individuals and services that are provided.
So put that number touck that infive hundred thousand people in New York State
receiving services through the Home Care Associationmembership. And this is very much tied

(05:17):
to the New York State budget.We'll get back to that. But how
did you get to where you arein terms of your background and your expertise
and you are as deep into thestate government as anyone I know, especially
in this area of home care.Well, my entrance into this field is
well, it goes back a longtime though. I actually was in my

(05:39):
graduate program and it was a timewhen the state and society were beginning to
take a look at the focus ofwhat the healthcare field was going to be.
And there was a lot of concernthat there was going to be no
way to provide for the services thatwere needed, relying only on facilities on

(05:59):
hospitals and nursing homes. And sowe had a champion at that time in
the legislature and the health names TarkyLombardi, Senator Lombardi from Syracuse, and
Senator Lombardi was way ahead of histime nationally as well as in New York
and really took the long look andsaid, we really need a very robust
home health system to cover everything frompublic health to long term care. And

(06:24):
I had the opportunity initially to workon the administrative side in New York State,
working to implement the home care programsthat Senator Lombardi was legislating, worked
with many communities all over the statehelping them set these services up, and
then after a number of years ofdoing that, I received the invitation from

(06:46):
Senator Lombardi to come and work forhim, and that brought me into the
legislature where I worked very extensively onthis area as well as all health areas,
being the director of the Health Committee, the director of the Council on
Healthcare Financing, which oversaw hospitals.And from there I've been with the Home
Care Association now probably fifteen years plusand as a president now. And Tracia

(07:11):
Lombardi is a name that if you'vebeen around Albany, you know the name,
and it's when you have a programnamed after you, the Lombardi Program,
it's an acknowledgement that you made law, you created things that never existed
before. So just talk a littlebit about that, and I just want
to mention a good friend of minewho worked there, to Bob Hers who
passed away recently. So we'll givea shout out to Bob and his family.

(07:33):
Bob was phenomenal and we're shoulder toshoulder with all of us in this
field, and God bless Bob.Yeah, we worked together in that office
for Senator Lombardi well at the time. So I'll go back just a little
bit more because it will be intriguingon the finance side if you go all
the way back to nineteen seventy two. Actually, Senator Lombardi sponsored the very

(07:56):
first law in the country requiring thehealth insurance programs cover home care as a
as a mandatory benefit. It wasn'ta thing yet, No, it wasn't.
And Lou I can tell you thatthat here we are all these years
later and that law is almost thesame as when it was enacted. So
what it tells you is there's alot of modernization that needs to happen.
Later on in the decade, heactually established the first structural law within New

(08:22):
York State to bring all of homecare into certification regulation support, created grant
funding and just other mechanisms to supportthis. And the prime one of the
prime pieces of it was a programcalled the Long Term Home Healthcare Program or
the Nursing Home Without Walls Program,which was really a landmark program not only

(08:43):
in New York State, but ledthe country into the home movement of home
and community based care for individuals thatwould otherwise require care in a facility.
And this was a national phenomenon aswell. It absolutely was. It kind
of attracked people with disabilities in thealmost that Act and the almost decision of
the US Supreme Court that people havea right to live as independently as possible

(09:07):
and the government has an obligation toprovide service to them in the most independent
setting possible. And that was avery very much a shift in public policy
and thinking and mindset as people agedfurther and people had to live further into
their eighties, nineties, hundreds andbe at home, yes completely. And

(09:28):
one of the main drivers in thedesign of the program was to provide something
that could provide all of the sameservices that someone would get if they were
in a nursing home, but intheir own home, and that would include
the socialization, the modification of theenvironment, all the therapies and everything,
and the financing under Medicaid and evencontribution from Medicare was all consolidated in that

(09:52):
program. And it was novel.It was unique, and it hasn't really
been bested, I don't think byany new programs that are out there,
and we're in a very different worldtoday, no, we are. What
happened during the years of Governor Cuomois that is that there was a one
the second Governor Cuomo. What evolvedin that era around twenty eleven twenty twelve

(10:16):
was a Medicaid redesign that really functionalong the philosophy that everybody should be in
a managed care type of model.So imagine like an HMO, but for
Medicaid for healthcare, and so whetheryou needed primary care or long term care,
everybody was transitioning into that model.And I could talk about this for
days. Yes, and that's theprimary. Yes, that Medicaid redesign team

(10:39):
had one mandate and that was Ithink six billion dollars had to come out
of the budget. Yes, Sothey had to figure out a way to
do it. So they thought managedcare would be the way to improve services.
But as you and I know,the managed long term care program doesn't
really get into care management. Itreally is billing and contracting and hiring.

(11:01):
Well. The way in which theplans, the effective plans work is is
they work with the home care providersand together they work to try to manage
the care of individuals. It's generallyvery complicated because not only do you have
the primary health services, but youhave transportation, pharmaceuticals, adult daycare,
if somebody needs care in the community, the physician services. Everything really needs

(11:26):
to be managed and coordinated. It'sa tall task to do. And if
you go into certain regions of thestate, rural inner city regions where there's
a lot of challenge, the managementchallenge for a person at home is very
very complex. Say as opposed toa hospital or a facility where everything is
within a hallway or two away andfef service is how it used to be

(11:48):
delivered. So the government would simplycontract directly, yes, as opposed to
having a middleman and that managed longterm care company that gets a kind of
a capitated payment and then has contractwith your providers to provide all the services
that that person needs in home.So when you need twenty four to seven
care at home, they're in thered because they don't get enough money on

(12:09):
a capitated payment. So it createsa very hostile environment and a dynamic tension
between the applicant for medicaid and theMLTC and the agency because they have to
pay for twenty four to seven careout of a fixed budget, which creates
very bad results in a lot oflitigation. Lou, that is so well
said, and I think it's importantfor consumers to appreciate the fact that because

(12:33):
so much of this care has tocome from the medicaid side, and that
is because there's such a lack onthe private side of coverage, which Lou,
you certainly have been, you know, one of the champions of it,
as was Bob Hers in his day. But because of that, that
means those funds largely come from thestate and federal government. New York State,

(12:54):
as of the last budget spend overninety six billion dollars in medicaid,
which is like forty one of thetotal budget. And let's let's pause right
there, because we have to takea short break. Ninety six billion dollars
and forty one percent of the entireNew York State budget, yes goes to
medicate. Sit on that for acouple of minutes. We're gonna come back
and talk about where the state budgetis today, where home healthcare is today,

(13:18):
and where it's going in the future, because we have to innovate this
whole system, and we'll talk alittle bit about that when we come back.
You're listening to Life Happens Radio.I'm Lou Piro, your host for
this morning from Pierre o'connoran Strauss instudio live with Al Cardillo of the Home
Care Association of New York State.We're gonna take a short break and we
will be right back. Hold earnsme as we go. Hold on to

(13:52):
these thoughts because this is important andit's all of our futures. How do
we take care of our elders today, How do we take care of ourselves
as we age? What is theplan for tomorrow? I'm sixty five at
this point. I don't know howold you are, as I say,
you look young. So we've bothbeen kind of scratching at this for forty
plus years, and what's our future. What's my future going to look like

(14:16):
when I'm eighty five, ninety five, if I make it that far,
what's going to be available to mein terms of care? So the New
York State budget is a place wherethese debates happen because ninety six billion dollars
is a really big number. Sohow does New York and the taxpayers of
New York continue to fund the carethat people need? And it's a very

(14:39):
complex question and an answer that's ariddle that no one has really solved at
this point. But what's the currentstate of play out in the budget.
Well, it's a very very seriousbudget in terms of what the situation is
for healthcare and for home health carespecifically. Within that, I think most
of us who right now are lookingat the healthcare system in terms of services

(15:03):
that one would want to access,whether it's an elective procedure, a doctor
appointment, or going to the er. The weights are phenomenal and they're really
not conducive to the kind of decisionmaking that has to happen for good health.
So we know we're working from that. The system is reeling very much
still from COVID, the impact onthe workforce and service capacity. So in

(15:24):
this budget, home care, hospitals, nursing homes, the system is really
looking to try to have a fundingreset to support what needs to happen in
order to be able to deliver care. I attended a breakfast power breakfast on
Thursday sponsored by the Albany Business Review, and they had the CEOs of both
Saint Peter's and Albany met and theyhad the CEO of MVP Healthcare and of

(15:48):
my senior vice president of CDPHP Healthcare, and they talked about where the current
state of play in true healthcare,not home healthcare, but healthcare. In
the hospitals are on their backfoot.They are in the red and they are
getting under reimbursed for the services thatthey provide. The better paying services are
being done in outpatient clinics. Youknow, orthopedists and everyone, have cardiologists,

(16:11):
they have their own equipment, theyhave their own businesses outside of the
hospitals. So the things that hospitalscan make enough money on to survive are
being overshadowed by the flood of peoplein emergency rooms and the beds where they're
holding people and can't discharge them andthere's no real reimbursement for that. So

(16:32):
hospitals are struggling with this whole thing, and there's I'm talking to more and
more families because this is what wedo. You know, we're elder law
attorneys and when families come in andthey have a loved one that just went
forty eight hours sitting in the er, maybe four hours in the ambulance outside
the er, waiting to get inforty eight hours before they get a bed,
and they get a bed, andthen they can't be discharged because there's

(16:52):
no one that'll take them for rehab. So this whole situation is just a
dire situation right now in healthcare.So keeping people at home has to be
part of the logic of this.But the budget's going the other way,
yes, exactly. And that then, and you're driving right to the point
that I was setting up, whichis the fact you've got this crisis like

(17:15):
a train, you know, rushingright down at the tracks at everybody,
and yet you have a budget thatcuts over a billion dollars in Medicaid,
probably closer to two billion dollars atthis point, we're waiting for the legislature
on Monday to show the public andus within the field, you know,
what its response would be to thegovernor's cots. I mean again, you're

(17:37):
talking about over a billion dollars inthe home health side. You said it
perfectly. If you're in the hospitalor you're in the community and you need
medical care, your goal is tostay out of the hospital. That's not
the place to be. And thehospitals are again right now, the demand
is an overburden with regard to theircapacity. I just want to say I

(17:57):
just spent an entire day last weekin Washington with my colleagues in the State
Hospital Association with their federal people,and we went to probably half a dozen
a dozen congressional offices and talked aboutthe important relationship and the healthcare system between
hospitals and home health and how thesymbiotic relationship is very, very important to

(18:19):
support because we need each other inorder for care to be accessible in quality
within the system. And one ofthe things that was missing from the conversation
at that Power Breakfast meeting was anydiscussion of home healthcare. It's all institution
based. Yeah, and you know, when you look at the pyramid.
I'm glad you said that. Whenyou look at the pyramid and think about
and I would ask the listeners,think about where you spend the majority of

(18:42):
your time in your life and whereyou experience most of your health. It's
not in a facility, thankfully,it's in the community. And you don't
want to be right. But thething is is that when you think about
what's covered in the insurance world,when you think about what the focal points
are, it's almost in the focusis hospitals are critical. We've got to

(19:03):
have them. When we got anemergency, that's where we need to be,
an acute episode. But when wethink about where the time is spent,
that's the substantial place. And weneed a system that supports and recognizes
the pillar that is the home healthsystem, along with the pillar that is
the hospital side, and the pillarthat is the physician and primary care side.

(19:23):
Yeah, there's a program in thegovernment funding stream, and there are
so many different angles at this andso many different nuances and different programs.
But money follows the person, yes, and that just to me should be
the guiding principle of healthcare. Moneyfollows the person. But that's not the

(19:44):
way the real healthcare system works.No, and that's so well said.
The patient needs to be in thecenter of the system for the funding,
for the delivery of services for theorganization. And too often, and again
i'm sure the listeners, this resonateswith you. Very often you're ping,
poking around the different places of thesystem, you know how many times filling

(20:07):
out the same paperwork, realizing thatthe the you know, the connections haven't
been made between different parts. Andultimately the system has to be really based
on something where the patient is thecenter and the providers are all collaborating around
that goal of the patient. Andwe talked about the Medicaid Redesign Team one
and money that flowed from that disriptmoney that came in and there were twenty

(20:30):
five I think, yes, accountableCare organization I think eight billion dollars billion
came into New York State. Andwhat did we have to show for it?
That's a whole other topic. Butwho did they put in charge of
reinvigorating the community based care system hospitals? Does that make sense to you?
Yes, that's that And that wasexactly one of the concerns that we all

(20:51):
had, and certainly in the metaphorI was just given about the pyramid.
If you think, if you thinkabout it, the organizations which which generally
are those in which constituents are engagingyour doctors, your home health agencies,
your clinics, and so on,that needs to have the primary place in
defining how those funds go and whatthe system looks like, because they're the

(21:14):
ones that are generally involved most frequentlyin what your day to day healthcare needs
are. Yeah, and I thinkone of the CEOs and they were brilliant
people and well meaning and missioned people, all of them fighting a fight that
is just not a fair fight.But they're Medicaid reimbursements. They lose.

(21:36):
They're getting seventy cents on the dollars. Hospitals, yes, for Medicaid reimbursements.
How do you survive on that?Yeah? And nursing homes as well.
Nursing homes are somewhere around seventy centson the dollar. The data that
we just compiled based on certified reportsto the state shows that over fifty percent
of home health agencies are substantially ina negative position. Home health agencies are

(21:57):
also similarly way underfunded by Medicare andby Medicaid, and in fact, there
are some historic cuts that are stillcoming down from Medicare on the home house
side. We have a couple ofminutes to the news, let's just unpack
Medicare and Medicaid for a minute.Nineteen sixty five Great Watershed year, Lynn
Johnson's Great Society Program. He enactedMedicare and Medicaid. Why did he name

(22:19):
them so similarly, because everybody confusesthem and mixes them up. Medicare you
get when you're sixty five, andyou get a bundle of services parts ABCD,
and you get hospitalization coverage, youget physician coverage. You probably want
to look at a supplemental policy becauseMedicare has a lot of gap, so
they call it metic gap insurance.But why doesn't Medicare play into the long

(22:41):
term care world? It's so verymuch needs to. I often say that
Medicare is stuck in nineteen sixty fivewhere the age limits were what they were
then. Of course it's way differentnow. So many procedures are provided in
the community people living longer and withvery complex illnesses. Medicare really needs to
be modern and also to recognize astandard of eligibility for coverage that follows the

(23:04):
person. Just like you said,Lou, money needs to follow the person,
and the Medicare program needs to bebecome flexible to doing that. And
we had Alicia Kelly sitting in yourseat a few weeks ago. She is
with CDPHP and she's part of theMedicare Advantage plan. There she runs the
Medicare Advantage Plan and Medicare advantage isan area where insurance companies are innovating and

(23:26):
they have something called papapals, whichis thirty hours of companion service and assistants
through a Medicare advantage program. Sothere's a big shift towards the Medicare advantages
pluses and minuses, but that's somethingthat Medicare and Medicaid have to work better
together. And as the Home CareAssociation, we are reaching out to advance

(23:47):
our partnership with the Medicare Advantage plans. Actually recently had an outreach with CDPHP
and we're looking forward to a meetingwith them to talk about how can we
support the community services that they're nowtrying to expand and provide. And it's
a great development and there's a communicationgap there and we're gonna talk a little

(24:07):
bit about technology filling some of thesevoids. Electronic medical records was a big
topic of conversation on Thursday morning,and they're finally getting their systems. It's
a big lift, but a uniformelectronic medical records so that when you go
to one hospital another hospital, doctorthat would solve a lot of that problem
of bad medication management, improper diagnosis, and a collaboration and communication among healthcare

(24:30):
providers. So there is some lighton the horizon, folks, and we're
going to talk about that in thesecond half of the show, So stay
with us. Al Cardillo, greatto have you here. As always,
I'm Lupiro, your host for thismorning. We're gonna take a short break
for the news and when we comeback, we're going to talk more about
home healthcare. Be right back,Welcome back. Tops Prepared. We hope

(25:06):
you are if you listen to ourshow each week eleven am here on WGY.
And we also hope you are ifyou take advantage of some of our
other educational opportunities. Our firm isPierre, o' connor and Strauss. We
are right here in Latham, NewYork. We're also in New York City
and Garden City. We practice acrossNew York State and into Massachusetts, New
Jersey, Connecticut, and down toFlorida, and we represent clients and families

(25:30):
and that's what we do. Wetry to do things like prepare them for
retirement, prepare them for incapacity.If that were to happen to make sure
they have a plan in place tomake sure that upon death things are done
properly for them. And we havea seminar coming up. We have some
seats available, a few left,which is coming up this Tuesday, March

(25:52):
twelfth. It's going to be oneto two pm and my partner Aaron Connor,
and I are going to be speaking, So you can join us on
Tuesday from one to two at theColony Town Library. Love to see you
there. Come out and learn moreabout estate planning, revocable trusts, irrevocable
trusts, medicaid and we'll be coveringall of those things on Tuesday, March
twelfth, This coming Tuesday, oneto two pm at the Colonytown Library and

(26:18):
you can sign up right now bygoing on our website at perrolaw dot com.
That's p I E R R Ol a w dot com. You
can call our our office and leaveus some messages at five one eight four
five nine two one zero zero againfive one eight four five nine twenty one
hundred, or just email us infoat purolaw dot com. Any of those

(26:41):
things work. You can go onour website and get a lot more information.
We have our webinars up there,our guides up there, a lot
of substantive information because our firm believesthat you, as an educated consumer,
are the best clients we can have. So join us on Tuesday, or
just check out our website and keeplistening. Because I'm live in studio right

(27:02):
now with Al Cardillo, who headsup the Home Care Association of New York
State. We're talking about the seasonof the budget. April one is the
soft target. I guess it gotoverrun I think a little bit last year,
but certainly Andrew c Como was prettygood at coming in on April first.
He held the feet to the fireto make sure that happened. But

(27:23):
we'll see. And right now we'restill waiting to hear numbers. And the
budget affects all of you. Everylistener of the New York State that is
listening to this show is impacted directly, whether you know it or not,
by the results of this New YorkState budget. And that has been happening
for years, the Medicaid program.And I'll just throw those numbers out there
one more time because I want ourlisteners that didn't hear them to hear them.

(27:45):
This is why this is such animportant issue, thank you, LOUI.
Yes, so in the current statefinancial year, which runs from April
one to March thirty first, Sofor the two thousand and three two thousand
and four year, Medicaid is overninety six billion dollars of the total budget.
That's forty one percent of the entirebudget. And so it's a very,

(28:07):
very definitional service for the people ofthe state juxtaposed to all of the
other spending categories, whether it's education, transportation, public protection, all of
the important areas for New Yorkers.And we talked about the five hundred thousand

(28:27):
people that are served by this system, what percentage of them are Medicaid?
So actually the numbers closer to ninehundred thousand plus five hundred thousand was really
just the one category that I mentionedall health agencies. The other individuals are
in other categories, principally Medicaid.Of the five hundred thousand, I would

(28:52):
say the vast majority of those aredual medicare Medicaid recipients, and the others
are substantially on the Medicaid. Yeah, we haven't even touched the disability population
yet. Right there's there's like overthree hundred thousand people and managed long term
care, so really in a wayon top of the nearly five hundred thousand
that I mentioned before. And NewYork State. People think of New York

(29:17):
if you're not from New York asthe city, the Empire, State Building,
and the rest. But New YorkState is a very diverse state.
A lot of rural areas, alot of rustbelt type cities that are struggling,
and no home health agencies in manyof these locations anymore. So you
just can't find an agency to staffa case. But when we're looking at

(29:37):
planning for people and trying to guideour families through this maze, the financing
of long term care becomes just thismystery, a riddle. How do you
get money to pay for care?Most people start out in this system in
a gray market, and it's anissue that I try to bring up that

(29:57):
no one really wants to talk about. But when you start and you go
to a home health agency and theydon't have anybody that can staff your case,
and they're going to charge thirty fivedollars an hour. If it's a
private pay agency a lot of them, you hire somebody off the street.
Oh, I have a neighbor whohad somebody and doesn't need them anymore,
or my brother in law knew someone, and you start making phone calls and

(30:22):
you start paying people under the table. And so many of our clients come
to us and say, well,we hired you know, Rosie, and
she's great. We paired twenty fivedollars an hour. I say, okay,
so you're doing unemployment, you're doingworkers comp, you're doing payroll tax
and oh no, maybe writing acheck or maybe giving them cash, depending

(30:42):
but address that because I would say, if nine hundred thousand people are in
the formal care system, there's anothernine hundred thousand in the informal care system.
Yeah. No, that's very true. And you know it's just like
a building with walls has its capacity. Our services, which are without walls,
because our professionals and pair of professionalsgo to people's homes, has their

(31:06):
capacity limits as well. You haveto be able to attract and bring in
and support a workforce that is ableto mobilize and reach people in their homes,
whether they're in the mountains living alongthe lakes, or whether they're in
the whether they're in the urban areas. So all of that is really critical.
I think one of the things thatmakes this very stark contrast with the

(31:27):
budget that you're talking about is thathere we are, there's this issue where
there's understaffing and folks have to turnto the gray market, which we don't
encourage, but we understand the realities. But yet a state budget that's cutting
a billion dollars out of the system, a federal budget that's on track to
cut over three billion dollars from thehomehouse system nationally, and yet you have

(31:49):
this incredibly urgent need that's out thereand for individuals whether they're coming home from
the hospital or individuals who need theseservices because because you need to support every
day. This is a profoundly serioussituation for you and for our families that
we represent. We have a caremanagement arm ever home Care Advisors, that

(32:10):
helps people find caregivers. The searchfor caregivers is the holy ground at this
point in time. Finding somebody thatyou trust, somebody that's competent, somebody
that you're going to put in yourhome or your parents' home, who's going
to be there for eight hours,hands on with your frail mom and dad,

(32:30):
showering them, bathing them, transferringthem, getting them in and out
of bed doing things in that homethat are very, very sensitive and they're
making sixteen bucks an hour. Yeah, and they could make eighteen bucks flipping
a burger at McDonald's. So talkabout it, and I know this is
your issue, so I want youto expound on it. The workforce issue,

(32:50):
the shortage and the number of jobsthat are unfilled and the percentage of
vacancies in the home healthcare marketplace.So both in New York and nationally,
one of the greatest fields for longterm job growth is exactly in the in
the occupation that lou is talking about. It's it's for individuals that would be

(33:12):
working to support patients and families andtheir homes predominantly, but also at the
facility level. And this is whenyou look at the workforce and you look
at the future labor trends, that'swhere it is. Go back to the
financial picture. We spend ninety sixbillion dollars on Medicaid and we're dealing with
yet further cuts. There needs tobe a way to really change the equation

(33:34):
of house services are financed so thatindividuals can be offered a level of compensation
and a level of support that thatmirrors the value and the importance of that
work in the entire system. Ifwe think about this, most often individuals
who are working in a home healthaid capacity are are both supporting the individual

(33:55):
who needs the care, but alsosupporting the entire healthcare system because those supports
keep individuals from going into hospital,from requiring nursing home care, from falls
that require catastrophic costs. So thatkind of cost effectiveness and that value needs
to be recognized and how this systemis supported, and that's really one of

(34:15):
the big holes. It's kind ofthe irony within the process. And we
have to get to a risk sharingbilling system. Yes, value based payments
they call it, and I knowit's coming into home health care and it's
in healthcare in general. But whenyou have an insurance company, a hospital,
and a home health agency all onthe hook for a person's care and

(34:38):
going to get reimbursed more for bettercare and for better health and creating a
wellness system as opposed to a setcare systems, A lot of talk about
that, but it's hard to do. How do we rationalize all of these
different funding streams and get it toa point where everybody's working for that patient
the patient should be at the hubof this. You've got all the providers,

(35:00):
they all have their own silo.So Lou, we can actually bring
this back to an earlier part ofthe discussion. So Congress has required the
Federal Centers for Medicare and Medicaid Servicesto implement a national program in value based
payment in home health care, whichis now in force as of the last

(35:22):
year or so. That program isprojected to save between three and four billion
dollars nationally, but not through cutbacks, not through stinginess in the system,
but actually through improved outcome that results. There was a pilot project of just
a few sample states that in afew years saved over six hundred million dollars

(35:45):
and predicated on that experience. Thisis now being done nationally. But part
of making it work and go toyour wellness point is modernizing the Medicare program.
I mean, this is one step, but if you're not going to
cover the preventive and wellness services,if you're not going to cover any long
term care really under Medicare in homecare, then you're really leaving all that

(36:06):
stuff on the table. You're leavingthat on the side when people really need
those services. Medicaid has also beenmaking major advances into value based payment,
but really the support to make itwork, the financing and the technical support,
is still a long way off.The state just got approved for a
seven and a half billion dollar newwaiver, So that's seven and a half

(36:29):
billion dollars over the next three years, and part of which is to invest
in value based care. But itreally needs to be a realistic process of
implementing this so that the supports arereally there to make it real for patients.
So let's talk because this is talkingturkey, because that's two and a
half billion dollars a year that's goingto be spent on trying to build out

(36:49):
systems. Well, we wasted eightbillion dollars trying to build out systems.
Now we have another seven and ahalf billion. Yes, how do we
get a different result is really thequestion. So this is what we call
the eleven fifteen waiver, which isa federal waiver in New York State has
this kind of largess if you will. While they're cutting the budget on this
side, they get a seven anda half billion from the federal government.

(37:13):
On the other side, how isthat money is that money's not allocated yet
correct. So this is where thelobbyists are working their magic, and contractors
are trying to get the contracts fromthe state to do the things that need
to be done. And the governorhas a master plan on aging that I
think is going to be shaping someof this going forward. So how do

(37:34):
those dollars get allocated? Where wouldyou spend that money? Well, what
the focal point is in this newwaiver is on what the state calls social
care networks, really recognizing the factthat some of the social related needs that
people have are very instrumental to theirhealth and ultimately the healthcare that they use.

(37:59):
And so the focal point is reallygoing to be on trying to create
like thirteen regional social care networks wherecommunity organizations and hospitals are all anticipated to
work together to try to address ina coordinated way the major health services and
then all of these related social careservices. There are some specific populations that

(38:21):
are also in focus. One areindividuals that have mental health and behavioral health
needs. Another part of it isthe maternal health population and in New York
sadly, New York's track record withregard to maternal health, maternal mortality,
and morbidity is really not so great, not when you think about what we
convey, so that's another population withinit. And then also a major investment

(38:44):
in primary care, what physicians do, what clinics do, and so on.
So looking at this, we workvery closely with the New York State
Office for Aging, which has sixtyor sixty two counties. There are agencies
in each county run by Greg Olsonand the agency I need agencies on aging
by Rebecca Prevy. They provide alot of these services too, and I

(39:07):
don't think they're getting a lot oftime at the table with the governor's staff
yet. But there is already anetwork. Why are we going to recreate
this? And who's going to doit? The hospitals? I mean,
your question is just so on target, and you're right, a tremendous amount
is done by the State Office forAging and all of the local all of

(39:29):
the county offices for aging. Andand actually we work very closely with both
Greg and with Becky because really onthe idea that bringing the aging network into
a collaborative relationship with a healthcare systemaddresses so many of these gaps, and
the expertise is so very much thereto do that. One of the things

(39:50):
that we actually have done is that, working with our hospital partners and with
Greg and with Becky, we actuallyput together really a statewide report which shows
pathways for how to collaborate with agingoffices for aging and their services, home
health and hospitals. And there's somereally great models there that we're working to

(40:13):
promote. But I absolutely agree thatthat really should be more of a focus
of what's supported under the waiver.But the waiver is so traditionally Medicaid and
Medicare I'm sorry, not Medicare,but Medicaid. Really hoping that that aging
component will be made part of it, I think that's right on the money.
Well, we're going to talk whenwe come back. We're to take
another short break about some of thethings that are going on across New York

(40:36):
State. We have a pilot programthat I'm part of down in Columbia County,
and that's pulling together all of theresources that you just mentioned, the
hospital, the Office for Aging,ems, local physicians, other companies that
do home medicine. So we'll talka little bit about that, but also
the one program that has pulled ourclients out of the fire and allowed them
to convert people that are maybe offthe books to people on the books,

(40:59):
which is the consumer directed Personal Assistanceprogram. And this is something that got
put in place maybe ten years agoand really promoted. And they're a victim
of their own success because it becameso successful that it's the largest fastest growing
item in the budget. So now, of course, what do they want
to do and biggest cuts on theMedicaid side right now, they are the
biggest focal point for Medicaid cuts.We'll talk about that, explain it and

(41:22):
give you all of what's going tobe happening on Monday down at the state
Capitol. So stay with us.You're listening to Life Happens Radio Lupiro Liven
Studio with Al Cardillo from the HomecareAssociation of New York State. And we'll
be right back after the short break. We're back. Thanks for keeping with

(41:49):
us and just joining us. I'ma Lupiro, your host with this morning,
Al Cardillo from the Homecare Association ofNew York State. We're talking about
home healthcare in New York State,the state budget, the cuts of a
billion dollars coming out of home healthcareand for families that we work with at
Pure O'Connor and Strauss. This isthe number one issue. How do I
find a caregiver, how do Ipay that caregiver? How do I make
sure that my parents are safe intheir own home. All of those things

(42:14):
that would normally be done by atraditional home health agency that has umpteen regulations
and a lot of oversight is doneby people that are off the books,
coming in the house without any kindof supervision. But New York enacted this
program, consumer directed Personal Assistance.What is it, how does it work?
And why is it on the choppingblock? So actually this is the

(42:37):
program actually goes back to nineteen eightyfive, but just under a different name.
And the first governor Cuomo had proposeda model, an experimental model that
was based on a pilot program inNew York City called Concepts for Independence,
where individuals, largely who had quadriplegia, wanted the opportunity to be able to

(42:57):
direct their own AI aid to providefor the assistance that they felt they were
in the best position to articulate.So based on that, there was a
small demonstration in the eighties called theVoucher Demonstration program, which tried to test
the model in other areas. Ihappened to be the director of the Health
Committee when that program then was transitionedto something called patient managed home care,

(43:22):
and that's the way it was called. And under that we had some expansion
of scope of services and some greatnew pieces to add to it, included
the geriatric population and others. Andthen by the end of the end of
that decade, by the end ofthe nineties, it was renamed the consumer
directed program and mandated in every countyof the state. One of the reasons

(43:44):
it is so successful is number one, an individual gets to pick who they
want to be their caregiver. Theyget to train and orient that person,
and then that person gets paid forthe services that they provide. In addition,
when the system, the formal systemreaches capacity, like the home care
agency reaches capacity, an individual stillhas the opportunity to designate their own person

(44:07):
to provide their services. So oneof the reasons it's now really on the
chopping block and the Governor's budget isbecause the program has grown so rapidly that
the governor and the Division of Budgetare trying to bring it in. We're
very concerned about the cuts because ifyou can't. You can't just turn off
the support the supply of services onone end and then assume that people are

(44:30):
going to get care through the otherpart where you're proposing to cut a billion
dollars out. I mean, it'sjust the math doesn't work, and the
numbers of caregivers just don't match that. They don't, they don't. How
big of a shortfall do we have. Well, really in terms of what
caregivers and the number of caregivers peravailable that would fill an available spot.

(44:51):
Well, one thing that we knowis that the percentages, it depends on
the part of the system. Sofor example, on the hospital side,
the percentages are starting to reach thirtyforty percent of the inability to serve a
patient coming out, it's probably inthe teens maybe twenty percent of cases where
they're referrals. So I can expressit to you by that, I would

(45:12):
just say for any listener that isconcerned about home healthcare, concerned about access,
now's an important time to call yourassemblyman, yes, to call your
senator from the area and say,please reject these cuts to home care that
are in the governor's budget and restorethe funding if there needs to be reforms.
Let's have sensible ways of finding thepathway. But the kind of cuts

(45:35):
that are in the budget are veryblunt and they're going to have a major
impact in all communities of the state. So call your senator, call your
assemblymen. This is public policy advocacy. It works, folks. They listen.
They listen to people that are inthe halls at the New York State
Legislature, and those are called lobbyists, and those are people with money and

(45:58):
they're paid to advocate for certain groups. But you're your own group and band
together, do the work, representyourself, represent your community. Call your
legislator, advocate for note for thesecuts to be removed from the governor's budget,
because this is going to impact everyone of us as we age,

(46:19):
and we all worry what's going tohappen. There are very few bright lights
in terms of the number of people. Immigration is a mess. We don't
have people coming in that fiel Traditionally, many of these jobs are your kids?
Are my kids going to be homehealth AIDS? I don't think so.
So where are we going to getto laborpool ten twenty thirty years from
now when this demand just skyrockets andyou talk about that. Yeah, and

(46:44):
that's really I mean, we reallyare are and at the point where we
have a structural issue, a generationalissue within the healthcare system. And you
know, this really needs a prioritylevel of attention on a societal basis because
we need to have individual that aregoing to be able to provide these services.
Otherwise really the whole system becomes compromised, you know. And one of

(47:06):
the things, you know that Louwas talking about how this affects everyone,
but Lou, you know, itaffects the taxpayer too, you know,
so whether you have a relative,friend or it's yourself that has the medical
need, but also as taxpayers,we want to be able to have a
system that is smart, that worksin the way that we can support it.
And you know, one of theso one of the things is that
we there needs to be a completea structural program from the academic side,

(47:32):
the training side, and the compensationside that support people coming into this field.
That's very important. And technology isalso a very important bridge. And
I know you want to talk abouttechnology, Well, thank you for that
lead in because AI is changing theworld. It's changing everything that we do,
it's changing the practice of law andthe way that we serve clients and

(47:53):
utilizing AI to do things that wouldtake hours and hours before that are done
now in a matter of seconds.But AI is also being utilized to manage
health and we're working with companies thathave something called facial scanning technology. In
a forty five second facial scan,they monitor blood pressure, glucose, heart

(48:15):
rate, and a whole series ofother data points and they've created algorithms that
are predictive of stroke, heart attack, fall risk, all the things that
you need to monitor and manage inthe home. And this is a couple
dollars a month that it costs toadd on to a healthcare plan. We're
working on an app that we've developedhere called Viva Links and it's a part

(48:36):
project that I've been working on fora number of years with our team here
in Albany, and it's starting toget some traction. Our pilot in Columbia
County, we have fifty people whoare utilizing this technology with the children,
the caregivers, the responsible relatives thatare going to be cut out of the
consumer directed program. One of thecuts who are managing the care we have
seen yourself directing at home or onespouse managing for the other, and a

(48:59):
communication at work that includes telemedicine,It includes transportation. It includes a whole
host of social determinants of health thatcan be managed. Medication management all being
done through an app, a tabletin the home, and some devices that
can be put in the home.One of the other devices that we're talking
to this week is a device thatgoes into a home and manages and monitors

(49:20):
falls and heart rate and blood pressurethrough radar. A sixteen hundred square foot
home could be monitored to people throughthis one unit and data brought back so
that you know in advance when thingsare starting to change and shift. So
all of this should be used byhome health agencies in managing their staff and

(49:42):
managing their patients. So that levelof care brings down the cost of management
because you don't have to have asmany in person visits. You can manage
your care and your caregivers and yourstaff in a better way and rationalize the
use of your staff. For peoplewho need a check it, they need
a check in, it's a visualcheck in on a monitor through a system

(50:02):
that has their medical records right thereand all the data that's being inputed on
a day to day basis, andthat's fantastic and when you think about what
that does for the efficiency of theworkforce, because now you're able to provide
services and provide coverage and really optimizeeveryone's time and everybody's contribution towards trying to

(50:23):
coordinate all that care for the patient. You know, one of the things
that we've been really emphasizing and workingwith our hospital partners on is in multiple
regions of the state creating what wecall these community health community medicine collaboratives where
we put together the hospitals, thedoctors, ems, technology, physicians and

(50:44):
really bring it all together with homehealth to make it really to create the
glue for the community. And they'vealways said it takes a village to raise
a child, Well, it takesa village to care for an aging senior.
Al Cardillo, thank you so much. The Home Care Association of New
York State great advocates for all ofour listeners out there across New York State.
This is Life Happens Radio. I'mLou Piro. We're glad you could

(51:04):
join us today. We hope youenjoyed this conversation. We hope you can
join us on Tuesday at one o'clockfor the seminar on State Planning. And
of course we'll be back next weekwith more of life Happens