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Why home Care Costs So Much

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Institutional costs are eligible for Medicaid reimbursement to states. Home services aren’t. I wrote awhile ago about activists pushing the Medicaid Community Attendant Services Act in Congress. That bill proposes that in-home services be covered by Medicaid – not just by a “waiver” program the state may, or may not, choose to offer. But this bill has gone nowhere.

Another villain, say activists, are the nurse practice acts in force today in most states. Toby Olson explains nurse practice act this way: “They carve out a range of activists and say, ‘if a person is going to do this for pay, it’s going to be a nurse.’ Period.” Olson heads Washington state’s Governor’s Committee on Disability Issues and Employment.

No matter how they doll it up with terms like “quality of care” and “professional standards,” say disability activists, it’s really about money. Having to have nurses handle these tasks makes them very expensive. A nurse being paid to “suction” a Ventilator user is more costly than paying a personal attendant to do it. If the money comes from state Medicaid coffers, it becomes too expensive a proposition – -so expensive that a nursing home becomes a cheaper alternative for the state. This is the reason news reports often say home care is as costly as, or more costly than nursing home care: It’s because the services are being provided by nurses – – likely required by state law to be provided by a nurse – – at their professional fee level. President Clinton’s January 4 announcement of tax credits and other assistance for home care doesn’t deal with this issue at all.

When states seek waivers to use Medicaid funds to pay home care costs, they must prove it’s cost effective. Missouri activists have worked since summer with the state Medicaid office to develop a consumer-controlled “home- and community-based services Medicaid waiver”, said Missouri disability activist Heather DeMian. The biggest roadblock to designing a cost-effective waiver, she says, has been the Missouri Nurse Practice Act. Under many nurse practices laws, “it’s illegal to use your own judgment and rent a pair of hands,” as Olson puts it. “If you can tell someone, ‘pick up that blue pill – – not that light blue one, but the long blue capsule – – and put it in my mouth’ – – if you’re competent to do that, but you can’t put the pill in your mouth by yourself, then you’re not allowed to have just anyone working for you to do it, It has to be a nurse.” says Olson. “Disabled people can’t control their own care.”

Disability activists in Kansas amended their nurse practice act in 1989 to allow delegation of what’s termed “nursing-related tasks.” Last year Kansas Medicaid saw a savings of $52 million as a result of using a home-and community based waiver to provide “consumer-controlled” attendant services to disabled people, including those who use ventilators – – that group of disabled people whose nursing care is always touted as so extremely costly.

A revamping by legislatures of the state nurse practice act can realize similar cost-savings and the dignity of controlling one’s own care.

by Mary W. Johnson

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