Start where you are. Use what you have. Do what you can . - Ar - - PowerPoint PPT Presentation

cdChoices.org Facebook.com/CDChoices

Making the Most of Employer Authority:

Optimizing Consumer Control & Management of Their Staff Setting Wage Rates & Saving for Bonuses

Start where you are. Use what you have. Do what you can.

• Ar

Arthur As Ashe

Session Agenda

• 1. Who are we?
• 2. What is happening in New York State?
• 3. Revisiting purpose; Looking ahead
• 4. Getting creative with what you have
• 5. First Year Results: Survey and data review
• 6. Challenges and the future
• 7. First person experience: Cindy & Dan share their experience
• 8. Q&A

Session Goal: To inspire participants to think creatively about even the most restrictive self-direction programs in order to further empower consumers and respond to the ever- changing regulatory and funding environment.

Before we begin…

“Yes t they c y can!” !”

Do not doubt the capabilities of the consumers (or their representatives) you serve!

(…or how the workers they employ will respond)

Part I: “Who are we?”

Consumer Directed Choices, Inc.

 Non-profit FMS founded by consumers in 1997  Based in Albany, NY  FMS for approx. 1,000 individuals in 16 Capital Region & Hudson Valley counties

• Medicaid: Consumer Directed Personal Assistance

(CDPA)

• Aging Funds (OAA): Consumer Directed Expanded In-

Home Services for the Elderly

• NYS Grant: Alzheimer’s Caregivers’ Consumer Directed

Respite Program  Board of Directors: Almost 50% are consumers/representatives and other persons with disabilities  Founder, Constance Laymon, served as CEO from beginning until her death in September 2012 – leader in development and growth of CDPA in New York

Part II: What’s Happening in New York?

CDPA in NYS: Structure & Financing

 NYS has multiple self-direction programs: Today is focused on Consumer Directed Personal Assistance (CDPA)  Established in state law in 1995

• Originally only found under New York’s Medicaid State Plan for Personal Care Services
• Included in NYS 1115 Medicaid Waiver for Managed Long Term Care in 2012
• Also now part of the Community First Choice Option

 Employer Authority only  Division of responsibilities:

• County local social services district/managed care plans: determines eligibility, approves

individual’s care plan, authorizes services in weekly hour allotments (e.g. 40 hrs./week)

• Consumer (or designated representative): responsible for implementing care plan including

recruiting, hiring, training, supervising, scheduling, terminating their workers (“Personal Assistants”)

• Fiscal Intermediary (“FI”): payroll, benefits coordination, compliance monitoring, employer

resources

CDPA in NYS: Structure & Financing (continued)

 FI is prohibited by statute from engaging in consumer responsibilities

• But responsible for “establishing the amount of wages” for

workers

 CDPA is currently (changes are anticipated in the future) financed via a single hourly reimbursement to FI for every hour the consumer uses services

• Pre-2012: Reimbursement rates determined by state formula
• 2012: Managed care/Managed Long Term Care (i.e. health

plans) negotiated rates introduced

• 2019: Approximately 74% of CDPA services are paid for by

managed care using negotiated reimbursement rates (re: CDChoices)

Managed Care 74% State Rates 25%

CDPA in NYS: Structure & Financing (continued)

 Impact of managed care on CDPA “system”:

• Significant program growth
• Significant growth in # of FIs operating as well as # of managed care plans
• Greater disparity in reimbursement rates across funders

 Other big Medicaid change: Value-Based Purchasing

• Health plan premiums impacted by performance on quality measures
• Traditional licensed & clinical providers required to participate in value-based contracting

with health plans

• CDPA is currently exempt from value-based contracting (but not exempt from health plan’s

quality measures)

We needed to change!

What did all this change mean?....

Part III: Revisiting Purpose & Looking Ahead

Our Purpose & the Future…

 Our Why: CDChoices exists to ensure that people with disabilities have the maximum freedom and control over the care, their lives & their destinies  Mission & Values = Consumer control & freedom:

• Consumers in the best position to determine what

is best for their care and independence

• Dignity of risk – consumers are capable of making

informed decisions & accepting the results

 Experiencing increased competition (need to differentiate)  Observing increased reimbursement rate differences among managed care plans

• Worker wage increases typically pushed during negotiations

Our Purpose & the Future (continued)…

 Growing need to control program costs…but don’t want to interfere with consumer responsibilities  Increasing emphasis on value and performance (aka: Value-based Purchasing or VBP)

• VBP in Traditional Care: Service provider is incentivized to deliver better quality care in

exchange for higher revenues

• VBP Challenge in CDPA: FMS providers are not responsible for nor have control over

consumers’ care

• Theory on how VBP can work in CDPA: consumers given more resources, greater control –

and eventually incentives – to achieve better personal health outcomes

Part IV: Getting Creative with What You Have

The Idea…

 Build in budget authority

• Consumer controlled wages & benefits
• Potential to address every challenge
• Strengthens missions and purpose
• Vision: consumers have full control over their workers’ wages & benefits within the fiscal,

legal, programmatic parameters defined by government and health plans

 Biggest challenge: How?

• Limited flexibility with program & funding
• Infrastructure not set up for consumer controlled wage/benefits
• Financial risk – needed to minimize

 Solutions:

• Don’t fight program structure – design around it (KNOW THE REGULATIONS/STATUTES)
• Phase in/Test concept – don’t try implementing too much at once

How did we start?

 Tested consumer capacity and acceptance of control over compensation

• Surplus funds allocated into

individual budgets for consumers to distribute to their workers

• Individuals’ overtime costs

factored into budgets

• Consumers given control over

funds for wage increases for their workers

 Both initiatives were successful, well-received

What came next?

 Outlined multi-phased concept

• Phase I – basic cash/wage compensation
• Phase II – budgeting premium & non-billable pay
• Phase III – budgeting nonmandatory benefits & vendor purchases
• NOTE: phases & order not set in stone

 Currently in Phase I - Spent 3 years planning & preparing for implementation:

• Organizational philosophy and values – from board/owners to staff
• Financial capacity/feasibility
• Informational system capacity
• Process & procedural structures

Where are we now?

 Each consumer has a per-hour “wage band”

• Same concept as a pay range – “minimum” and “maximum” pay rate
• “Minimum” is minimum wage
• “Maximum” is called a ceiling – the highest pay rate the consumer can set

 Wage band ceiling is dependent on the reimbursement rate of the consumer’s payer

• Results in consumers having different wage bands, different wage ceiling due to variations in

reimbursement levels

 Consumers are responsible for setting the specific wage rate their PAs’ will earn:

• Can change a PA’s wage rate at any time
• Can “save” for bonuses for any of their PAs

Where are we now? (continued)

 Consumer can change a worker’s pay rate at any time

• Up or down (but if “down,” must follow state

regulations)

 Consumer can “save” for bonuses for PAs

• Set pay rate for one or more workers below

the wage band ceiling

• Each hour that worker works, a “savings” is

accrued

• Bonuses can be distributed to any currently

employed worker

 Started: March 24, 2018

Part V: First Year Results

Consumer Survey Results

 Surveymonkey questionnaire – Summer 2018 (Initial Reaction)

• Targeted to all consumers – completed online or hard copy
• 12.3% of all active consumers at the time

 Generally representative of consumer population:

Self-Directing 54.5% Non-Self Directing 45.5%

Self-Directing?

State Rates 29% Managed Care 69% Other 3%

Who are their payers?

1 Worker 45.5% 2 Workers 23.2% 3+ Workers 32.1%

How many employees?

Survey respondents’ payers a little off: General consumer population =74% MCO/MLTC, 25% FFS

Consumer Survey Results

 What is the relationship between consumers and workers?

NOTE: Percentages add up to more than 100 due to “select all that apply” question

All 1 Worker 2 Workers 3+ Workers Family member 42.86% 45.10% 30.77% 47.22% Friend(s) 27.68% 15.69% 42.31% 33.33% Boyfriend/Girlfriend 4.46% 1.96% 11.54% 2.78% No relation 53.57% 39.22% 38.46% 86.11% Consumer-Worker Relationship

Consumer Survey Results

 Almost 63% of respondents stated they changed workers’ pay rates  11% of respondents stated they did not change workers’ pay rates

Consumer Survey Results

What changes in pay rates were made?

“Lowest ½” are the 7 wage bands with the lowest wage rate ceilings. “Highest ½” are the 8 wage bands with the highest wage rate ceilings.

Lowest 1/2 of Wage Bands 1 Worker 2 Workers 3+ Workers I put all of my workers' at my wage ceiling. 88.89% 33.3% 56.3% I set different wages for each worker. 11.11% 44.4% 31.3% Same wage rate between min wage & ceiling 0.00% 11.1% 6.3% Other 0.00% 11.1% 12.5% Highest 1/2 of Wage Bands 1 Worker 2 Workers 3+ Workers I put all of my workers' at my wage ceiling. 83.33% 28.6% 33.3% I set different wages for each worker. 0.00% 42.9% 33.3% Same wage rate between min wage & ceiling 0.00% 14.3% 33.3% Other 16.67% 14.3% 16.7%

Consumer Survey Results

What factors did consumers use in setting wage rates?

• 1. Past performance (75.7%)
• 2. Longevity (42.9%)
• 3. # of Hours Worked (22.9%)
• 4. Saving for bonuses (8.9%)
• 5. Other reasons cited: job responsibilities,

consumer complexities

Consumer Survey Results

“I like the idea.”

“Well, for one thing, I think I get a better employee.”

“A better sense of control over another aspect of the employment relationship.”

“I am I am sav saving ng to aw awar ard a bo a bonus nus - it hel elps k s keep eep t the e PAs s I I hav ave. e.”

“I feel this gives me as the employer increased responsibility, but also increased freedom to assess someone's ability to perform the job before rewarding them with more pay.” “It has allowed me to feel more in control of the management of my PAs.”

“Much better when it comes to giving increases and leaving room to give more. In a nut shell, It works much better.” “Me being able to set wage shows them I am the boss - I am in charge and I value them.”

Quantitative Data Results

Does CDChoices data match survey responses?

 Data indicates “Yes”  Data indicates consumers differentiate their workers with wage rates:

• # of workers employed is primary indicator that a consumer possibly differentiates
• Significant majority of consumers with 1 worker set their wage rate to the ceiling
• Level of wage band ceiling is also an indicator, though appears not as much as # of

workers

Pay Rate Differentiation

Consumers with the lower wage band ceilings

% No 47.8% % Yes 52.2%

2 Workers - Lowest 1/2 of Wage Ban Ceilings Likely Wage Rate Differentiation?

% No 29.3% % Yes 70.7%

3+ Workers - Lowest 1/2 Wage Band Ceiling Likely Wage Rate Differentiation? “Lowest ½” are the 7 wage bands with the lowest wage rate ceilings.

Pay Rate Differentiation

Consumers with the higher wage band ceilings

% No 36.2% % Yes 63.8%

2 Workers - Highest 1/2 of Wage Band Ceilings Likely Wage Rate Differentiation?

% No 24.1% % Yes 75.9%

3+ Workers - Highest 1/2 of Wage Band Ceilings Likely Wage Rate Differentiation? “Highest ½” are the 8 wage bands with the highest wage rate ceilings.

“Saving” for bonuses

 68% of all consumers had bonus balances as of March 2019  Average bonus balance = $401

• Lowest balance = <$1
• Highest balance = $9,500

 Consumers with higher wage ceilings and more employees tended to have higher bonus balances  Future: full consumer control over timing of bonus distribution to employees

Bonus “Savings” Balances April 2018 – March 2019

$300 or less (68.7%) $301 - $700 (14.4%) $701 - $1100 (7.1%) $1101 + (9.7%)

Bonus Savings Balance Consumers with balances

Wage Band Impact?

Is there an impact on quality of consumers’ workforce and programs?

 Too soon to tell for certain and need more data collection  One statistic that is intriguing: Turnover

Wage Band Impact on Turnover

Turnover change

 Measured each consumer’s individual turnover rate from April 2017 – December 2018

• “Before”: April 2017 – December 2017 (pre-wage band launch)
• “After”: April 2018 – December 2018 (post-launch)

 Only consumers active for the entire period were measured

• New consumers referred; consumers terminated – not included

 Consumers with at least 1 worker employed and at least 3 authorized hours per week included

• Removes a couple of extreme outliers that could skew results

Wage Band Impact on Turnover

Turnover change – almost one year later April – December 2017 & 2018

1.9% 19.0% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0% Lowest 1/2 of Wage Ceilings Highest 1/2 of Wage Ceilings

Pre/Post Wage Band Change in # of Consumers with Zero Turnover

6.5%

• 33.8%
• 40.0%
• 35.0%
• 30.0%
• 25.0%
• 20.0%
• 15.0%
• 10.0%
• 5.0%

0.0% 5.0% 10.0% Lowest 1/2 of Wage Ceilings Highest 1/2 of Wage Ceilings

Pre/Post Wage Band Change in Consumers' Ave Worker Turnover Rates “Lowest ½” are the 7 wage bands with the lowest wage rate ceilings. “Highest ½” are the 8 wage bands with the highest wage rate ceilings.

Part VI: Challenges & Future

Challenges & Future

 Tying turnover and other data to positive health/quality outcomes

• In some cases, successfully used first year data with our rate negotiations

 Keeping reimbursement rates ahead of minimum wage

• Possibility that eventually no consumer will have room to make wage rate decisions

 Next phases:

• “Savings” bonuses paid out at anytime upon consumer/DR direction
• Incorporating heavy overtime costs into wage bands (i.e. budgeting for overtime)
• Other premium pay budgeting (e.g. holiday, shift differentials)

Part VII: Cindy Hill & Dan Loomis

First Person Experience

Questions?