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21 Oct

Balancing Reform and Sustainability: The Path Forward for New York’s CDPAP Program

New York’s Consumer Directed Personal Assistance Program (CDPAP) continues to be a concern for providers and New York State (NYS). This vital Medicaid program, which allows seniors and disabled individuals to hire, train, and manage their own caregivers—Personal Assistants—has seen explosive growth in recent years, from 140,000 participants in 2015 to over 250,000 currently enrolled. This level of growth indicates that there is a place for CDPAP; however, this rapid expansion has raised concerns about oversight, potential fraud, program appropriateness, and escalating costs now exceeding $9 billion annually. 

In response, Governor Kathy Hochul’s recent budget proposal for 2024-2025 financial year includes sweeping reforms aimed at reining in the program. Key changes involve eliminating wage parity for caregivers, altering the roles of consumers and fiscal intermediaries, empowering the Department of Health to revoke intermediaries’ authorization, and establishing work-hour limits. While the intentions are understandable, the proposed overhaul risks significant disruption. 

CDPAP faces several gaps and challenges, including the lack of robust vetting for authorization appropriateness, established training requirements, independent supervision of caregivers, and active oversight of CDPAP providers’ practices. These deficiencies have left the program vulnerable to abuse, fraud, and misuse, with reports of excessive billing, timekeeping issues, and insufficient care quality monitoring. Addressing these problems is essential for CDPAP’s sustainability. 

The program’s flexible work schedule is a major appeal for family members and friends. However, seniors or disabled individuals will have higher care needs, reflective of higher hours, and need more structured and supervised services, moving beyond light personal care services or housekeeping support. On average, CDPAP workers are providing more than 30 hours per week, raising questions about authorization appropriateness for this program. CDPAP was created in 1995 to allow chronically ill and physically disabled individuals with stable medical conditions greater flexibility and freedom of choice in-home care services with an individual often very with high sensibility with their care needs, playing a vital role in enabling independent living with dignity. 

It is imperative to identify and implement strategies to resolve program challenges while maximizing consumer benefits. While capping caregiver hours could curb overtime abuse and burnout, it does not address the core issues. New York State should consider capping permissible CDPAP service hours and clearly defining exceptions for exceeding this cap. For example, if a consumer with a stable medical condition requires more than a certain number of hours weekly, it might indicate a need for supervised care from a clinically trained team. NYS should provide objective guidelines for a “stable medical condition” and collaborate with the Department of Health and CDPAP stakeholders to define exceptions. 

He believes that, “this will be a positive step toward lowering associated direct care and administrative costs.”

For providers committed to quality care and the sustainability of healthcare in NYS, strengthening training, background checks, electronic visit verification, reporting, and respite care options should be welcomed. Adjusting wage parity for Personal Assistants performing CDPAP services is also contentious. However, a non-affirmative answer to these two questions should point all of us in the right direction: 

  • Given that CDPAP should be focused on individuals with stable medical conditions who can direct their care, should the same rate be paid as an agency that has to cover coordination, clinical assessment, monitoring, and supervision activities for a person who needs greater support and supervision?  
  • Should an unlicensed Personal Assistant get the same pay as a licensed Personal Care Assistant (PCA) or Home Health Aide (HHA)? 

Handpicking caregivers allows for highly personalized, culturally competent care tailored to unique needs. Dismantling this could lower care quality for unique populations, particularly disabled individuals with nuanced care needs. Radically altering CDPAP could cause significant disruption for over 250,000 New Yorkers currently enrolled. CDPAP has helped with labor shortages, reducing access and equity gaps in care. NYS should continuously answer three questions to ensure the true average total cost of care: 

  • Do CDPAP consumers have better health outcomes than clients with similar attributes receiving services through a licensed home care agency? 
  • Are CDPAP consumers overusing emergency rooms and being hospitalized at a higher rate than clients with similar attributes receiving services? 
  • Are CDPAP clients more adherent to medication management? 

As NYS explores issuing a request for a proposal for a fiscal intermediary, key measures should be considered to maximize reform benefits and sustain CDPAP. Fiscal intermediaries (FIs), who handle payroll and administrative tasks, have been considered valuable facilitators and burdensome rent-seekers. The state must establish clear criteria for a Lead FI to support consolidation, ensuring vetted and properly operated FIs can continue providing culturally sensitive care for the program’s 250,000 consumers.  States like California and Pennsylvania rely heavily on the County Health & Human Services Agencies and Area Agencies on Aging (AAAs) to support the Consumers in their application for services—the substitute for that in New York are the currently compliant CDPAP agencies. A Leas FI should provide the following functions: 

  • Evaluate the current CDPAP agencies, and establish ratings for agencies, and contract agencies above a certain rating. 
  • Design and manage a training network to support some mandatory training for PAs and Consumers. 
  • Execute audits and oversight like those done by HRA for the HRA home care program. 
  • Manage annual self-attestation by Consumers to adhere to their fiduciary expectations to deter fraud, waste, and abuse. 
  • Evaluate annual service quality levels leveraging clinical data to determine health outcomes for CDPAP consumers. 
  • Develop a family caregiver and robust respite care information hub to facilitate family caregivers taking breaks. 

Ultimately, CDPAP’s sustainability depends on managing deficiencies through enhanced accountability measures, not reducing services that allow vulnerable New Yorkers to live independently. The state must rein in overspending, crack down on bad actors, and establish higher standards for evaluating medical stability and the capacity of the consumer to self-direct their care, and vetting and training Personal Assistants. By addressing shortcomings through enhanced vetting, training, and targeted cost controls, the state can preserve CDPAP’s consumer-directed model, enabling thousands of New Yorkers with special needs to live life to the fullest. 

With more than 5.3 million New Yorkers projected to be at least 60 years old and require long-term care by 2030, CDPAP represents a vital alternative, allowing aging loved ones to receive care in their homes and communities. As the program evolves, public and private stakeholders must work collaboratively to uphold CDPAP’s spirit of empowering independence while fortifying its standards and fiscal sustainability. In the months ahead, lawmakers should approach CDPAP reform with an objective, nuanced lens to ensure the program’s transformative model continues to benefit New Yorkers. 

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