The Crisis in Home Care: How Medicaid and Medicare Advantage Are Failing America’s Most Vulnerable with Arya Rashidian - Episode 134

The latest episode of the Caregiver Relief podcast tackles a critical and escalating crisis in the home care industry. Host Diane Carbo, RN, speaks with Arya Rashidian from Arya Home Healthcare to unpack how systemic policy failures, specifically regarding Medicaid and Medicare Advantage reimbursement, are pushing the system to its breaking point and transferring an immense burden onto family caregivers.

This episode is a must-listen for anyone involved in healthcare—from providers and agencies to the family members holding it all together.

📝 Episode Outline & Key Takeaways

Here is a look at the major themes and alarming realities discussed in this crucial conversation:

1. The Growing Crisis and Unpaid Care Burden

• A Systemic Collapse: The crisis is fueled by years of continuously lowered Medicare reimbursement rates and the shift to cost-sharing models by Medicare Advantage plans.
• The Shocking Cost of Unpaid Care: Family caregivers now provide an estimated $1 trillion in unpaid care each year, highlighting the staggering time, energy, and sacrifice being transferred from the system to families.
• Caregiver Vulnerability: Many family caregivers struggle with low wages and depend on shrinking support programs like SNAP, which are further at risk during government shutdowns.

2. Understanding Home Care Services and Funding

• Defining Services: Arya provides clarity on the different types of home care:
  • Skilled Care (e.g., PT, IV therapy, wound care): Mostly covered by Medicare and private pay; generally not covered by Medicaid, though waivers apply.
  • Personal Care: Usually offered by Medicaid through its waiver process, or privately funded. Eligibility for Medicaid waivers is becoming more stringent.
  • Palliative Care: Specialized care usually done by a nurse and Medicare-funded; not offered by Medicaid.
• Virginia's Model: Virginia does pay family caregivers under Consumer Directed Services (CD) or Agency Directed Services (AD), though reimbursement rates differ, and not every state offers this benefit.

3. Financial Pressures and Quality of Care 📉

• Reimbursement Cuts Impact Quality: Quality of care is directly related to funding. Ongoing cuts, particularly in state-level Medicaid funding, are expected to significantly reduce rates, especially affecting providers in rural areas.
• The Volume-Based Model: Skilled nursing (nurses, therapists) is a fee-for-service/volume-based business, meaning providers are paid per visit (ranging from $20 to $200) rather than hourly. This forces them into a cyclical fashion, seeing many clients quickly to make ends meet.
• The Unfair Truth for Nurses: Nurses who perform critical duties like opening a case, doing six-month evaluations, recruitment, training, and complying with MCO/state requirements do not get reimbursed for this legwork; their salary comes out of the general reimbursement left after expenses. This creates a disincentive for quality assessments and follow-ups.

4. Administrative Burdens and Provider Survival

• Electronic Visit Verification (EVV): This mechanism was introduced to mitigate fraud by requiring GPS-enabled clock-in/clock-out tracking for Medicaid-funded services, replacing the old paper-based system.
• Managed Care Organization (MCO) Delays: New administrative requirements and the transition to the full EVV model are causing significant delays in reimbursement from payers, forcing small agencies to rely on loans and cash reserves to make payroll and pay vendors.
• Caregivers at Risk: The professional caregivers who often rely on SNAP and other federal/state subsidized programs to meet their needs are the first to feel the impact of government shutdowns and delayed funding.

5. The Bigger Picture and the Path Forward

• Government's Role: The co-hosts agree that government involvement, including the shift towards national healthcare models and partisan gridlock, has ultimately damaged the healthcare system, leading to higher costs and lower quality of care for most Americans.
• Managed Care as Gatekeepers: Tax dollars are funding MCOs (Managed Care Organizations) to act as gatekeepers, which for Medicaid, is often a "loss business" for the MCOs since any unused funds must go back to the government. This lack of financial incentive means MCOs focus on making their Medicare (commercial) models more lucrative.
• The Ideal Provider: Arya stresses that this industry is only sustainable for those who are dedicated and committed to building and maintaining quality of life, not for those solely focused on a for-profit business model.

🎧 Listen Now!

Hear the full conversation to gain an in-depth understanding of the legislative loopholes, administrative burdens, and financial realities threatening home care for America's most vulnerable.

Because caregiving is one of the hardest and most meaningful things you'll ever do, and no one should have to do it alone.

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