When the Texas Health and Human Services Commission released its modified Medicaid rate cuts on September 4, they had no effect on Advocate Pediatric Home Care.
By then, the home care agency had already laid off all 15 of its speech, occupational and physical therapists and discharged 120 of those pediatric patients. It started doing so in June, up through August. And, according to the agency’s administrator and director of nursing, Brittany Brazell, it was in order to save them.
“We knew we wouldn't be able to provide the service,” Brazell said. “What we figured would happen if we waited for the cuts to go through was that either therapists would go without work, or patients would go without care. There was no way to make it a smooth, easy transition for anybody.”
So before the storm came, Brazell tried to help all of her therapists find new jobs and help her patients find new care before the industry was flooded with patients on waiting lists, stuck in a scramble.
On Friday, the storm touched down: The state announced revisions to the cuts proposed last spring. HHSC still has to implement the Legislature’s order to cut $350 million from Medicaid funding over the next two years, they'll just do so in a slightly different way then the agency had initially planned. Instead of cutting Medicaid reimbursement rates for physical and occupational therapists by, on average, 18 to 20 percent, it would cut them by roughly 10 to 13 percent—but as high as 25 percent in some cases. Speech therapists, instead of seeing rate cuts of roughly 30 percent, would see them fall roughly 16 to 18 percent—still, some could see Medicaid reimbursement cut by up to 27 percent.
Brazell said that, given the amount HHSC was told to cut, she anticipated no amount of modification could change her decision.
In June, she called a meeting and gathered her 15 therapists around the table to break the news that the agency wasn’t going to survive the cuts; it would have to only focus on nursing. In helping her therapists relocate, she urged them to go on to bigger agencies that would have a better chance at surviving the cuts. And since then, all of them have. But at the time there was only fear.
“It was horrible,” Brazell said. “It was a very somber meeting—nobody was talking.”
The therapists hadn't even been with Advocate Pediatric for a year. This September would have marked the one-year anniversary since the home-care agency began offering speech, physical, and occupational therapy to its patients. To lament the occasion, she wrote a letter on September 2 to several senators, telling them about the anniversary they wouldn't be having. “These are among your youngest and most vulnerable constituents,” she said of her patients, closing out the letter. “They deserve better.”
And then two days later: the new cuts—still large enough to dismantle agencies like Brazell’s, and according to others in the industry, even some of the big ones she sent her employees to.
Paige Kinkade, who runs five Medcare Pediatric Group outpatient centers, servicing 13 counties with 350 employees, said that her agency could have handled cuts between 1 and 3 percent. “And even with that,” she said, “we would have had to make some operational changes. We laid off 15 therapists last [legislative session]. There’s nothing else to cut. There’s no fat. Operations like us don't end up with double-digit profit margins, so there’s only so much you can do.”
Kinkade was troubled not just by the new rates, but the speed with which HHSC released them. After several families and care providers who sued the state succeeded in stopping the cuts from going through on September 1, HHSC withdrew its plans and said it was going to “start over.” As it promised, there was in fact public testimony, on August 31, to help inform the new cuts. But now Kinkade wonders: were they really listening? “We don't feel like they were. How do you go back and start from scratch, then two weeks later put out a modified rate?” she questioned. “Where’s the access to care study? Have they done any study on that to see what’s going to happen when they cut these rates?”
According to HHSC spokesman Bryan Black, the new cuts were based on comparisons to 11 unnamed states’ Medicaid rates. The previous cuts were based on comparisons to those states’ commercial rates—something critics strongly opposed, along with the controversial Texas A&M study those comparisons came from. That study was still used this time—just differently.
Bill Noble, a spokesperson for Texas Association for Home Care & Hospice, said that he and the organization’s executive director, Rachel Hammon, felt like the state’s withdrawal gave “false hope” to many in the industry, who thought that, maybe, the state was starting to see just how badly this was going to hurt patients and providers. “They didn’t even tap the brakes,” he said. “They’re really moving full speed ahead.”
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Even though the state will take additional public testimony on September 18 from stakeholders, Noble is hesitant to hang onto any ounce of optimism that it will matter. Pointing to agencies like Advocate Pediatric Home Care—a little microcosm of the effects these cuts may have on other agencies in the near future—Noble said, “We know that, at the end of the day, this is exactly what industry observers and experts pointed to with the risk of having such deep cuts. If you don’t ask people what kind of impact the actions of the Legislature would have in making a budget cut, you end up with unfortunate outcomes. De-access to therapy is already happening.”
When Advocate Pediatric began discharging its young homebound patients, Brazell said she did everything she could to find them new care providers; some, for example, were able to continue on with the Advocate Pediatric therapists who relocated to other agencies. But because 90 percent of the agency's patients were in rural areas—up to 20 miles north of Conroe—inevitably, many ended up on waiting lists. No one would take them with the threat of such low reimbursement rates looming overhead.
A couple such patients sprang to mind for Brazell. There was the teenage girl in Dayton, Texas, who, after suffering a severe brain injury, regressed back to the cognitive level of a toddler. Brazell made upwards of 20 calls for her, asking home care agencies if they might be willing to make the drive so the girl could continue making progress. No luck.
There was the young 20-year-old girl in Crosby, Texas, who was born with severe cerebral palsy. She can’t leave the home without ambulance transport, Brazell said, and is the kind of patient who needs continual care—otherwise she will rapidly regress and lose everything she gained working with therapists in every realm: speech, physical, occupational. Again, no luck.