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Costs, concerns rise on home healthcare

Abuse, fraud stir call for oversight

By David Abel
Globe Staff / March 28, 2009
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One personal care attendant was arrested last year in Boston, accused of leaving a quadriplegic with cerebral palsy undressed, lacking water, and without stockings that prevent blood clots. Last summer, another attendant allegedly charged thousands of dollars on the credit cards of her patient. A year before, an attendant in Brockton was charged with creating an alias and defrauding the state of more than $20,000 to treat himself.

As the state Medicaid program has significantly increased the amount of money it spends on personal care attendants over the past decade, reports of fraud, abuse, and neglect have tripled, state officials said. The correlation raises new concerns about a system that requires no training, certification, or criminal background checks for attendants and operates with minimal oversight over the low-paid home healthcare workers.

State officials say the rise in abuse and fraud cases is a result primarily of the program's growth, not an exploding rate of these crimes. But the problems are expected only to multiply in coming years, as the home healthcare program continues to expand. Those issues have drawn the attention of lawmakers on Beacon Hill, where at least one bill proposing tighter regulation has surfaced. Meanwhile, prosecutors seek to recoup losses, and even some advocates for home healthcare workers are voicing concern.

"There are definitely areas that need improvement," said Mike Fadel, executive vice president of Local 1199 SEIU, the union that represents personal care attendants. "Everybody is engaged in discussion to address these areas of concern. . . .. Whatever fraud or abuse exists needs to be looked at very closely and rooted out, but this is a low-cost, high-quality program. It's what consumers want."

The Medicaid program, which provides healthcare services to the poor and disabled, increased spending on personal care attendants in Massachusetts from about $100 million a decade ago to more than $330 million this year, growth that reflects the state's efforts to care for an increasingly older population in their homes, rather than at hospitals, where the costs are higher.

The state is trying to clamp down on fraud and abuse. In the first half of fiscal 2009, the state prosecuted cases worth more than $1 million, double what it collected during the same period over the last three years and more than it recouped in each of those years.

The questions about supervision of the state's growing number of personal care attendants - there are now about 23,000, more than double a decade ago - come as federal investigators released a report this month documenting a litany of problems nationwide. In a study of how states spent billions on home healthcare workers hired through Medicare, the federally administered program for the elderly, the Government Accountability Office found rampant abuse, including more than $200 million paid in fiscal 2007 for care never rendered.

The GAO report found that Medicare spending on the nation's home healthcare workers - who now treat about 3 million Americans every year, at a cost of more than $13 billion - rose by 44 percent between 2002 and 2006, even as the number of patients rose by less than 17 percent during the same period.

"This is certainly a high-risk program vulnerable to fraud, abuse, and wasteful spending," said James Cosgrove, the GAO's director of healthcare, who oversaw the recent report. "It's an area that's particularly hard to monitor."

In Massachusetts, a state audit last year estimated that MassHealth, the state Medicaid program, overpaid at least $610,000 for personal care attendant services in fiscal 2005. In its annual report, the state auditor's office noted "a significant increase in personal care attendant fraud referrals, cases in which falsified records enabled certain caregivers to receive payment for services that were not provided." One case referred to prosecutors last year involved filing of false time sheets amounting to $193,000.

As a result, the auditor's office, with the attorney general and federal health agencies, launched a Personal Care Attendant Task Force to investigate major fraud cases involving the home healthcare workers.

"We have worked closely . . . to maximize our collective resources in order to address fraud among personal care assistants," Attorney General Martha Coakley said in a written statement. "We are committed to rooting out fraud in the personal care assistant program."

Medicaid officials who oversee the program said that while they are monitoring the rising number of abuse and fraud cases, the numbers are no surprise, given the rising number of attendants and of people who use the service.

"The major reason for the growth of fraud referrals is because of the growth of the program, and the growth of the program is a good thing," said Tom Dehner, director of the state's Medicaid program.

Dehner is reluctant to increase regulation. "We believe that consumer control of this program and service is intensely personal," he said. "We think consumers are in the best position to direct when and how to receive these services and train people and supervise them."

Some lawmakers are calling for changes. State Representative Barbara L'Italien, an Andover Democrat, introduced a bill this year that would allow patients to run a free criminal background check on attendants they hire, create an online database to help consumers find attendants, and establish a surrogate program to help those who cannot oversee attendants on their own.

She said she is considering adding a provision that would require training or licensing attendants. "There should absolutely be a criminal background check required, and absolutely there needs to be more training," she said.

Advocates in the booming industry said they support the proposed legislation and are working to increase training for attendants, who often work in difficult conditions and earn a state-mandated $11.60 an hour. Yet some worry that too many regulations will make the program overly bureaucratic and curtail patients' ability to hire, fire, schedule, train, and pay attendants on their own, with money from the state.

"This is a program with inherent risks, and we would be happy to overhaul it in a lot of ways," said Bill Henning, director of the Boston Center for Independent Living, which provides home healthcare services to 1,000 people in the area. "But there's a lot of turnover in this field, and there's a real concern that we could choke off the supply of attendants."

But some of those receiving the care say the state should do better. Over three decades, Carolyn Wojcik said, she has been robbed, bullied, and intimidated by personal care attendants she has employed, some of whom have threatened, "If you don't have me, who are you going to get?" The 60-year-old from the Fenway, a spastic quadriplegic with cerebral palsy, says she has fired scores of attendants.

She's also well aware of the fraud, which she said can go both ways. She has heard that some patients hire illegal immigrants, pay them lower wages than the state mandates, and pocket the rest of the state's money.

In September, she accused an attendant of leaving her for hours without water, naked, and on her back, unable to move. After a pretrial hearing this week, the attendant, Rashidah Robinson, 24, of Dorchester, said she is not guilty.

"You can never be sure who you hire, and I check all their references," Wojcik said. "It would be nice, at the least, for the state to allow us to do a free criminal background check."

David Abel can be reached at dabel@globe.com.

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