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Missouri Auditor Finds Changes To Home Health Care Saved Far Less Than Expected

Jennifer Ludden | NPR

Controversial changes to Missouri's home health-services program by former Gov. Eric Greitens and the Republican-controlled legislature saved one fourth of the $43 million lawmakers had expected, accordinga state audit.

The Republican governor and state lawmakers didn’t take rising costs and sicker patients into account, concluded the report from State Auditor Nicole Galloway, a Democrat. 

Home-based services allow patients to stay out of nursing homes and keep a portion of their independence. To decide how much money it will allot each patient for such services, the state Department of Health and Senior Services uses a needs-based scoring system to determine a “level of care” score. Prior to 2017, patients with a score of over 21 were eligible for state-funded home care.

To rein in increasing costs, lawmakers voted to raise that score to 24 in 2017 and placed a cap on how many units of services some people could receive.

But the state didn’t take into account that a patient’s level of care score often rises over time, said Kim Lackey, policy director at the disability-rights advocacy organization Paraquad. 

State officials should have realized that, because when the eligibility requirement was first raised more than 10 years ago, patients’ scores steadily rose, Lackey said. As Missouri’s population ages, the needs of those needing such services will increase. As a result, they need more help.

“It seems like it’s something they could have had a handle on, in my opinion; All this historical data related to level of care scores shows they do increase,” she said.

That lack of foresight meant savings for the last year were only $11 million, and that the extra money needed to be added from other parts of the budget to pay for services, Galloway said.

“More realistic estimates would have helped avoid these problems,” she said.

Disability advocates say the cuts have meant many people need to make difficult choices when it comes to what care they receive in their home, Lackey said. Calling the services “crucial,” she said state officials should look elsewhere when making cuts.

“They have to choose between getting a bath one day and getting their kitchen cleaned,” Lackey said. “We’ve even talked to one individual who didn’t have enough hours, so she ended up having to sleep in her wheelchair at night.”

The audit identifies several other reasons for the state’s inaccurate projections. It notes the state is spending more per person for home-based services — partially because of the rising costs to reimburse providers for care.

And the scores of people who receive home care went up drastically after the new rules went into effect, Galloway found.

The state and contracted providers periodically reevaluate patients’ needs and re-work their eligibility scores. Between July 2017 and May 2018, 74 percent of the 5,500 people who the state reassessed had higher eligibility scores that kept them receiving services. That’s compared with 41 percent the year before.

That increase “creates questions as to whether some participants were improperly found to remain eligible for services under the higher … threshold,” the report reads.

Additionally, the scoring system the state uses to dole out home-based services, which include services such as adult daycare, nursing and housekeeping, doesn’t always accurately reflect how much help a patient needs, concluded the audit.

“For example, transportation significantly impacts services needed and authorized, but that’s not taken into account during the scoring process,” Galloway said.

The state Department of Health and Human Services plans to change the way it calculates participants’ scores. The system has not been updated since 1982, but state officials say they seek to improve it.

The department is seeking public comment from people who use home-based services online through the end of March.

Follow Sarah on Twitter: @Petit_Smudge

Sarah Fentem is the health reporter at St. Louis Public Radio.