Colorado’s Office of the State Auditor has issued an odd performance audit of Colorado Medicaid’s Consumer-Directed Attendant Support Services Program (CDASS). In one sentence, the report says CDASS costs more than traditional Medicaid home care. In the next, it says there are no data to support this finding.
CDASS’ program structure makes the higher cost claim unlikely. Disabled Medicaid clients needing hired attendants to assist with bathing, toileting, dressing, eating, meal preparation, health maintenance and housekeeping first have their needs assessed by Medicaid case managers. The case managers determine the quality and amount of in-home care each client will require for the next year. Some basic tasks, like house cleaning, can be provided by less skilled, less expensive, home attendants. Other tasks, like feeding tube maintenance, might require more costly attendants with some medical training. Case managers determine the number of hours at each skill level the state will pay for.
After that, clients have a choice. If they choose to stay enrolled in traditional Medicaid, the state reimburses a home health agency for the allocated hours at standard rates.
The home health agency sends people to a client’s home to provide the care specified by the case manager.
If a client instead chooses CDASS, the allocated hours of care of each type are multiplied by standard rates used to reimburse home health agencies at given skill levels. The money for a year of care is put into an individual CDASS account with a fiscal management service, and the client hires his own care workers and draws on his CDASS funds to pay them.
Clients are eligible for CDASS only if they can either manage their own care or appoint someone else to do so.
By training home health assistants to do more complex tasks and being picky about who they hire, many CDASS clients can get the care they need for less. The report complains CDASS clients paid more skilled attendants an average of $16.68 an hour. The standard state rate for home care agencies is $28.36 an hour.
It concludes the difference shows clients “may not have needed the funding allocation they received for those services.”
But CDASS clients use their “savings” to buy more hours of care or to buy coverage on more expensive holidays, nights and weekends. Advocates for the disabled say more and more flexible care lowers overall health spending. The report mentions a 2013 state finding that CDASS clients may have had fewer “emergency room visits compared to clients receiving services through in-home health agencies.”
According to the audit report, CDASS enrollment grew by 75 percent between 2011 and 2014 to 3,124.
The audit’s main conclusions were arrived at using a judgmental sample of 30 of the 642 people enrolling in CDASS in 2014.
The report makes much of the potential “problem” created by clients whose monthly spending varies by 10 percent or more relative to the amount of care in their case manager plan. It worries CDASS client timesheets do not match the type of care in the case manager plan, and “the risk of fraud or abuse increases” because CDASS clients can hire family members, spouses and friends as attendants.
But the report does not identify any case in which an individual overspent his annual allocation, nor any case in which a person was not getting the care he needed because his hiring differed from that specified in the case management plan. It does not identify any case of fraud or abuse.
Even though the state was unable to provide the State Auditor’s Office with reliable data on overall health spending for CDASS relative to the rest of the home care population, the allocation of attendant care should be the same whether a client chooses traditional Medicaid or CDASS.
Clients choose CDASS because it gives them the freedom to buy the attendant care they need when they need it. This is something not even the most kindly and well-motivated bureaucrats can do, especially when planning a year in advance.
Linda Gorman directs the Health Care Policy Center at the Independence Institute, a free market think tank in Denver.
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