[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
COMBATING WASTE, FRAUD, AND ABUSE IN MEDICAID'S PERSONAL CARE SERVICES
PROGRAM
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
MAY 2, 2017
__________
Serial No. 115-29
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
__________
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COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
TIM MURPHY, Pennsylvania ELIOT L. ENGEL, New York
MICHAEL C. BURGESS, Texas GENE GREEN, Texas
MARSHA BLACKBURN, Tennessee DIANA DeGETTE, Colorado
STEVE SCALISE, Louisiana MICHAEL F. DOYLE, Pennsylvania
ROBERT E. LATTA, Ohio JANICE D. SCHAKOWSKY, Illinois
CATHY McMORRIS RODGERS, Washington G.K. BUTTERFIELD, North Carolina
GREGG HARPER, Mississippi DORIS O. MATSUI, California
LEONARD LANCE, New Jersey KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky JOHN P. SARBANES, Maryland
PETE OLSON, Texas JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia PETER WELCH, Vermont
ADAM KINZINGER, Illinois BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York
GUS M. BILIRAKIS, Florida YVETTE D. CLARKE, New York
BILL JOHNSON, Ohio DAVID LOEBSACK, Iowa
BILLY LONG, Missouri KURT SCHRADER, Oregon
LARRY BUCSHON, Indiana JOSEPH P. KENNEDY, III,
BILL FLORES, Texas Massachusetts
SUSAN W. BROOKS, Indiana TONY CARDENAS, California
MARKWAYNE MULLIN, Oklahoma RAUL RUIZ, California
RICHARD HUDSON, North Carolina SCOTT H. PETERS, California
CHRIS COLLINS, New York DEBBIE DINGELL, Michigan
KEVIN CRAMER, North Dakota
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
7_____
Subcommittee on Oversight and Investigations
TIM MURPHY, Pennsylvania
Chairman
H. MORGAN GRIFFITH, Virginia DIANA DeGETTE, Colorado
Vice Chairman Ranking Member
JOE BARTON, Texas JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas KATHY CASTOR, Florida
SUSAN W. BROOKS, Indiana PAUL TONKO, New York
CHRIS COLLINS, New York YVETTE D. CLARKE, New York
TIM WALBERG, Michigan RAUL RUIZ, California
MIMI WALTERS, California SCOTT H. PETERS, California
RYAN A. COSTELLO, Pennsylvania FRANK PALLONE, Jr., New Jersey (ex
EARL L. ``BUDDY'' CARTER, Georgia officio)
GREG WALDEN, Oregon (ex officio)
(ii)
C O N T E N T S
----------
Page
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 3
Hon. Diana DeGette, a Representative in Congress from the State
of Colorado, opening statement................................. 4
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 6
Prepared statement........................................... 7
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 9
Prepared statement........................................... 10
Witnesses
Christi A. Grimm, Chief of Staff, Office of Inspector General,
Department of Health and Human Services........................ 12
Prepared statement........................................... 14
Answers to submitted questions............................... 94
Katherine M. Iritani, Director, Health Care, Government
Accountability Office.......................................... 26
Prepared statement........................................... 28
Answers to submitted questions............................... 99
Tim Hill, Deputy Director, Center for Medicaid and CHIP Services,
Centers for Medicare and Medicaid Services, Department of
Health and Human Services...................................... 55
Prepared statement........................................... 57
Answers to submitted questions............................... 103
Submitted Material
Subcommittee memorandum.......................................... 89
COMBATING WASTE, FRAUD, AND ABUSE IN MEDICAID'S PERSONAL CARE SERVICES
PROGRAM
----------
TUESDAY, MAY 2, 2017
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:16 a.m., in
Room 2322, Rayburn House Office Building, Hon. Tim Murphy
(chairman of the subcommittee) presiding.
Members present: Representatives Murphy, Griffith, Brooks,
Collins, Walberg, Walters, Costello, Carter, Walden (ex
officio), DeGette, Schakowsky, Tonko, Clarke, Ruiz, and Pallone
(ex officio).
Staff present: Jennifer Barblan, Chief Counsel, Oversight
and Investigations; Ray Baum, Staff Director; Elena Brennan,
Legislative Clerk, Oversight and Investigations; Lamar Echols,
Counsel, Oversight and Investigations; Blair Ellis, Press
Secretary/Digital Coordinator; Emily Felder, Counsel, Oversight
and Investigations; Jennifer Sherman, Press Secretary; Julie
Babayan, Minority Counsel; Jeff Carroll, Minority Staff
Director; Christopher Knauer, Minority Oversight Staff
Director; Miles Lichtman, Minority Policy Analyst; Kevin
McAloon, Minority Professional Staff Member; Jon Monger,
Minority Counsel; Dino Papanastasiou, Minority GAO Detailee;
and C.J. Young, Minority Press Secretary.
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Murphy. Good morning. The subcommittee convenes this
hearing today to examine Medicaid Personal Care Services, a
critical lifeline for our Nation's most vulnerable populations.
Medicaid is the largest provider of long-term care services
for disabled and elderly individuals. Lately, long-term care
has shifted from nursing homes and institutional settings to
services provided to beneficiaries in their homes.
Personal care services, or PCS, provides essential services
to Medicaid beneficiaries with significant needs so that they
can stay in their homes. As they enter this ever more
vulnerable stage of life, most elderly persons prefer to live
in familiar surroundings.
These are not health services, but rather they assist
beneficiaries with daily activities they can no longer do
without assistance such as meal preparation, laundry, and
transportation so that they can continue to live in their
communities.
PCS now makes up a large component of home- and community-
based care and continues to grow rapidly. In 2015, Federal and
State expenditures for PCS amounted to $15 billion, up from
$12.7 billion in 2011. The actual figure is probably
significantly higher because this number only reflects fee-for-
service claims, and does not include managed care.
The U.S. Department of Labor projected that employment of
personal and home health aides will grow by 46 percent between
2008 and 2018, which far exceeds the average growth of 10
percent for all occupations.
While the move toward home care has undoubtedly improved
the lives of Medicaid beneficiaries by allowing them to stay at
home and saves money for taxpayers, we cannot turn a blind eye
to waste, fraud, and abuse in the Personal Care Services
program.
More than 29 reports by the HHS Office of Inspector General
have uncovered systemic fraud in PCS. The OIG has uncovered
schemes between PCS attendants and Medicaid beneficiaries to
submit claims for services that were not provided. This type of
fraud is difficult to detect because attendants can often be a
beneficiary's spouse, child or friend.
Even more troubling is the abuse that HHS OIG's
investigations found. Stories like that of a beneficiary in my
home State of Pennsylvania dying of exposure to the cold while
under the care of a PCS attendant. This beneficiary had autism
and a history of running away, but the attendant left her alone
in a crowded shopping mall and waited an hour to call
authorities.
In Maryland, a disabled woman was left alone in a locked
car on a hot and sunny day, while her attendant went shopping
with a friend. This woman was unable to open the car door. A
concerned citizen noticed her in distress and called the
police.
In Vermont, an attendant stole the opioid painkillers
prescribed for the beneficiary, even though the beneficiary was
in significant discomfort and pain. This same attendant was on
probation for drug possession at the time.
These are just some of the many stories of abuse uncovered
by the OIG and other authorities. We will discuss them more
today.
We talk about program integrity and high improper payments
a lot on this subcommittee. We are used to getting into the
weeds on error rates, methodology, and data collection.
To help curb fraud in PCS and protect vulnerable
beneficiaries, Congress acted in the Helping Families in Mental
Health Crisis Act of 2016 to require the use of an electronic
visit verification system for Medicaid-provided PCS and home
health services. This became law as part of 21st Century Cures,
and when implemented, will help ensure that information
regarding the services provided are verified.
Having verified data that will help identify waste, fraud,
and abuse is important because there are real people at risk.
Those who use the PCS program include our friends and
neighbors, who may not have the resources or ability to speak
up when they encounter abuse. This subcommittee and this
Congress will not tolerate these abuses.
While it is undoubtedly good policy to keep beneficiaries
in their homes, it also raises difficult questions which must
be addressed.
How do we protect vulnerable people from abuse in their
homes, when no one else is around to assess an attendant's
performance?
What changes can we make, by both Congress and CMS, to
improve the program while maintaining access for Medicaid
beneficiaries who need these services?
Both the HHS OIG and the Government Accountability Office
have done excellent work to highlight the problems within PCS.
These offices have also suggested ways to solve these problems,
such as additional beneficiary safeguards, higher standards for
attendants, and pre-payment controls.
I am grateful for your work and look forward to hearing
more about your findings.
I understand that CMS has already acted to address some of
these, but not all, these findings, and we will discuss what
CMS is doing to address our concerns.
So thank you to all of our witnesses today for your
dedication, and great work to protect Medicaid beneficiaries
and root out waste, fraud, and abuse. I look forward to a
productive discussion today.
[The prepared statement of Mr. Murphy follows:]
Prepared statement of Hon. Tim Murphy
The subcommittee convenes this hearing today to examine
Medicaid Personal Care Services--a critical lifeline for our
Nation's most vulnerable populations.
Medicaid is the largest provider of long-term care services
for disabled and elderly individuals. Lately, long-term care
has shifted from nursing homes and institutional settings to
services provided to beneficiaries in their homes.
Personal care services, or PCS, provide essential services
to Medicaid beneficiaries with significant needs so that they
can stay in their homes. As they enter this ever more
vulnerable stage of life, most elderly persons prefer to live
in familiar surroundings.
These are not health services, but rather they assist
beneficiaries with daily activities they can no longer do
without assistance such as meal preparation, laundry, and
transportation so that they can continue to live in their
communities.
PCS now makes up a large component of home- and community-
based care, and continues to grow rapidly. In 2015, Federal and
State expenditures for PCS amounted to $15 billion, up from
$12.7 billion in 2011. The actual figure is probably
significantly higher because this number only reflects fee-for-
service claims, and does not include managed care.
The U.S. Department of Labor projected that employment of
personal and home health aides will grow by 46 percent between
2008 and 2018, which far exceeds the average growth of 10
percent for all occupations.
While the move toward home care has undoubtedly improved
the lives of Medicaid beneficiaries by allowing them to stay at
home--and saves money for taxpayers--we cannot turn a blind eye
to waste, fraud, and abuse in the Personal Care Services
program.
More than 29 reports by the HHS Office of Inspector General
have uncovered systemic fraud in PCS. The OIG has uncovered
schemes between PCS attendants and Medicaid beneficiaries to
submit claims for services that were not provided. This type of
fraud is difficult to detect because attendants can often be a
beneficiary's spouse, child or friend.
Even more troubling is the abuse the HHS OIG's
investigations found. Stories like that of a beneficiary in my
home State of Pennsylvania dying of exposure to the cold while
under the care of a PCS attendant. This beneficiary had autism
and a history of running away, but the attendant left her alone
in a crowded shopping mall and waited an hour to call
authorities.
In Maryland, a disabled woman was left alone in a locked
car on a hot and sunny day, while her attendant went shopping
with a friend. This woman was unable to open the car door. A
concerned citizen noticed her in distress and called the
police.
In Vermont, an attendant stole the opioid painkillers
prescribed for the beneficiary, even though the beneficiary was
in significant discomfort and pain. This same attendant was on
probation for drug possession at the time.
These are just some of the many stories of abuse uncovered
by the OIG and other authorities--We will discuss them more
today.
We talk about program integrity and high improper payments
a lot on this subcommittee. We are used to getting into the
weeds on error rates, methodology, and data collection.
To help curb fraud in PCS and protect vulnerable
beneficiaries, Congress acted in the Helping Families in Mental
Health Crisis Act of 2016 to require the use of an electronic
visit verification system for Medicaid-provided PCS and home
health services. This became law as part of 21st Century Cures,
and, when implemented, will help ensure that information
regarding the services provided are verified.
Having verified data that will help identify waste, fraud,
and abuse is important because there are real people at risk--
those who use the PCS program include our friends and
neighbors, who may not have the resources or ability to speak
up when they encounter abuse. This subcommittee, this Congress,
will not tolerate these abuses.
While it is undoubtedly good policy to keep beneficiaries
in their homes, it also raises difficult questions which must
be addressed.
How do we protect vulnerable people from abuse in their
homes, when no one else is around to assess an attendant's
performance?
What changes can we make--by both Congress and CMS--to
improve this program while maintaining access for Medicaid
beneficiaries who need these services?
Both the HHS OIG and the Government Accountability Office
have done excellent work to highlight the problems within PCS.
These offices have also suggested ways to solve these
problems--such as additional beneficiary safeguards, higher
standards for attendants, and pre-payment controls.
I am grateful for your work and look forward to hearing
more about your findings.
I understand that CMS has already acted to address some--
but not all--of these findings, and we will discuss what CMS is
doing to address our concerns.
Thank you to our witnesses today for your dedication and
great work to protect Medicaid beneficiaries and root out
waste, fraud, and abuse. I look forward to a productive
discussion today.
Mr. Murphy. I'll recognize Ms. DeGette for 5 minutes. Our
main clock is not working, so as a reminder, I will just tap
this when you reach 5 minutes. Thank you.
OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thanks, Mr. Chairman. Today, thanks to
Medicaid, 74 million vulnerable Americans including seniors,
children, adults, and people with disabilities have access to
quality healthcare. And despite what we often hear from our
colleagues on the other side of the aisle, the Medicaid program
delivers this care efficiently and effectively. In fact, not
only are Medicaid's costs for beneficiaries substantially lower
than that of private insurance, but they have also been growing
more slowly per beneficiary. What is more, we know that the
Medicaid program literally saves lives.
Last year, more than 12 million low-income adults had
healthcare coverage because of the Affordable Care Act Medicaid
expansion, something I think is an astonishing achievement.
Coupled with other important provisions of the ACA, the
Medicaid expansion has helped drive the uninsured rate to the
lowest level in our Nation's history.
One of the key components of Medicaid is the Personal Care
Services program. Personal care services which include
assistance with activities like bathing, dressing, and meal
preparation are an important part of long-term care that
Medicaid offers to beneficiaries. This allows beneficiaries to
hold on to their independence longer and to stay in their homes
with dignity. Furthermore, personal care services can save the
Government money because they can be cheaper than enrolling
patients in a nursing home, a lot cheaper.
However, just like other home healthcare services, personal
care services can be susceptible to improper payment or even to
fraud. Fraud, abuse, and mismanagement happen wherever large
amounts of money are spent, both in the public sector and in
the private sector, and we need to always look for ways to
address this. But that doesn't mean the program is ill-
conceived or should be drastically cut. Instead what it means
is we need to focus our efforts on ensuring that the program
receives more effective oversight and that we prevent and
address these issues.
As I pointed out before, the ACA provided the Department of
Health and Human Services and its Office of Inspector General
with a wide range of new tools and authorities to fight fraud.
For example, the ACA provided nearly $350 million in new funds
for fraud control efforts, as well as new means for screening
potential providers and suppliers. It also provided the HHS and
OIG with new authorities to impose stronger penalties on those
who commit fraud and gave the Centers for Medicare and Medicaid
Services the ability to temporarily halt payments to those
suspected of fraud. These new tools allow program
administrators to better protect tax dollars and to move away
from the pay-and-chase model by preventing bad providers from
ever entering the program. These are positive developments.
But today, we are going to hear from the agencies that
there are still vulnerabilities related to the PCS program, as
well as additional actions that CMS should better take to
oversee this program. For example, an October 2016
investigative advisory from HHS OIG detailed some disturbing
cases of PCS fraud and beneficiary neglect. These bad actors
not only defrauded the program, they harmed the patients they
were supposed to serve. That advisory follows other HHS OIG
reports highlighting PCS program vulnerabilities that
contributed to questionable care services and improper
payments.
The OIG continues to recommend that CMS use its authorities
more effectively to oversee PCS programs across all States to
improve program integrity and help the risk of beneficiary
harm.
Similarly, GAO has also found areas for improvement in the
PCS program. Specifically, the State-reported data that CMS
relies on for oversight lacks key investigation and there are
variations in the program requirements across different States.
This is an important point because States are ultimately
responsible for overseeing their programs.
Along these lines, the GAO is also going to testify that
some States continue to provide inaccurate or untimely data to
CMS. We need to explore the challenges that States are facing
in collecting this data and determine why States don't have
additional resources to better oversee the program. We need to
make sure the program is fully resourced and that includes
sufficient money to collect and analyze data. Given that the
States are on the front lines of running this important
program, I think we need to hear from the States about what
they are doing.
And finally, Mr. Chairman, as we talk about waste, fraud,
and abuse, we should be mindful that the President's budget
blueprint threatens agencies like HHS OIG to oversee these
programs. The OIG said on average it has one full-time employee
to oversee more than $680 million a year. So I think we need to
remedy that if we want to stop waste, fraud, and abuse.
So anyway, in conclusion, thanks for having this hearing. I
think we are all against waste, fraud, and abuse and we all
need to work together to make sure that it ends. I yield back.
Mr. Murphy. I thank the gentlelady. She yields back. I now
recognize the chairman of the full committee.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. I thank the gentleman for holding this hearing
and for our witnesses' good work and good testimony. We are
here today to talk about this program which serves our Nation's
most vulnerable individuals. Through Medicaid, personal care
services provide essential care to millions of elderly people,
disabled children and adults, and those who need long-term care
to cope with crippling diseases. It used to be that many of
these people ended up having to be institutionalized or cared
for in a nursing home. Instead, personal care services provide
an attendant to help people do the things like shop for
groceries, do the laundry, make sure that they are taking their
medications right on the schedule.
Without personal care services and home healthcare at
large, these folks would not be able to live at home in their
communities. Personal care services are quite literally a life
saver for many.
I truly believe in programs like personal home services and
home healthcare. Oregon experimented in these types of programs
a long time ago. The vast majority of personal care workers are
really solid people who work hard and take care of people and
they care, especially they care for these vulnerable
populations. They make their lives better, healthier, brighter,
and easier.
That is why it is so disturbing when the Office of
Inspector General reported these instances of fraud, abuse, and
mismanagement in this very essential program. Stories of
attendants stealing pain meds, abandoning mentally ill
beneficiaries in public places, leaving elderly folks alone for
weeks at a time. This is outrageous and it is unacceptable.
What's worse is that OIG has made clear that these are not
just some isolated individual bad actors. The OIG
investigations have uncovered more than 200 cases of fraud and
abuse in the program just since 2012. And as we learned from
witnesses earlier this year, the Government Accountability
Office has Medicaid designated as a high-risk program since
2003. So we have an obligation to get to the bottom of this for
the taxpayers and for patients alike.
Late last year, GAO released a report on the need to
harmonize requirements for personal care services across
various States. GAO reviewed the policies and procedures in my
home State of Oregon and three other States while performing
this work. While I was heartened to learn about the safeguards
Oregon has in place to prevent this fraud, the audit made clear
there is more work to be done.
More recently, GAO released a second report on the need for
better data on PCS. The most recent data at the time of the
audit released in 2017 was from 2012. That was 5 years ago. And
the data GAO did release was incomplete. Without complete and
up-to-date data, those who are tasked with rooting out waste,
fraud, and abuse in this program are frankly hamstrung.
So both the OIG and GAO sounded the alarm for years. This
fraud and abuse is happening because the States and the Federal
Government failed to put in safeguards to protect these
beneficiaries. It is sickening to see hard-earned tax dollars
going to people who take advantage and mistreat the elderly and
disabled in their own homes. And these beneficiaries are
particularly suspect to harm because they are often lack the
physical or mental ability to speak up. Many times a personal
care worker is the only person a beneficiary may see for weeks
at a time, so they go along with the fraud or abuse because
they are so dependent on that person for help.
We can do better for them. Our citizens deserve to know the
attendant they allow into their home, the attendant paid by
State and Federal taxpayers, will take good care of them and
have their best interests at heart. And while most do--and most
do--it is clear we have a serious problem in the program.
Today, we are here to talk about the steps we're going to
take to correct the problems identified for us by the good work
by the Office of Inspector General and the GAO.
I would like to thank Ms. Grimm from the OIG, and Ms.
Iritani from the GAO, for your extraordinary work that exposed
this fraud, abuse, and mismanagement in the program. You have
done a good job. Your decades of work culminated in some
common-sense recommendations for CMS that will better protect
beneficiaries and taxpayers. So I look forward to discussing
those recommendations today and also learning about how
Congress can do its part to solve these problems.
Mr. Hill, I especially appreciate your testimony today,
too. I understand CMS has taken steps to implement some of the
recommendations and is working to make other improvements in
the program. That is encouraging. I look forward to hearing
more about your work as well.
With that, Mr. Chairman, and with apologies to our
witnesses, we have a couple of subcommittees going on at the
same time and my duties as full committee chairman drag me
between the two. So thank you for your good work. I have your
testimony. It is most helpful. And I return the balance of my
time.
[The prepared statement of Mr. Walden follows:]
Prepared statement of Hon. Greg Walden
We are here today to talk about a program that serves our
Nation's most vulnerable individuals. Through Medicaid,
personal care services provide essential care to millions of
elderly people, disabled children and adults, and those who
need longterm care to cope with crippling disease.
It used to be that these folks had to be institutionalized
or cared for in a nursing home. Instead, personal care services
provide an attendant to help people do things like shop for
groceries, do the laundry, drive to the doctor and take
medication on the right schedule.
Without personal care services--and home health care at
large--these folks would not be able to live at home, in their
communities. Personal care services are quite literally a life-
saver for many.
I truly believe in programs like personal care services and
home health care. The vast majority of personal care workers
are good people who serve vulnerable populations and make the
lives of others healthier, brighter and a little easier.
That's why I was so disturbed when the Office of Inspector
General reported instances of fraud, abuse, and mismanagement
in this important program. Stories of attendants stealing pain
medication, abandoning mentally ill beneficiaries in public
places, leaving elderly folks alone for weeks at a time--this
is outrageous and unacceptable.
What's worse, is that OIG has made clear that these are not
just individual bad actors. The OIG investigations have
uncovered more than 200 cases of fraud and abuse in the program
just since 2012. And as we learned from witnesses earlier this
year, the Government Accountability Office has Medicaid
designated Medicaid as a ``high risk'' program since 2003. We
have an obligation to get to the bottom of this, for the
taxpayers and for the patients, alike.
Late last year, GAO released a report on the need to
harmonize requirements for Personal Care Services across the
various States. GAO reviewed the policies and procedures of my
home State of Oregon and three other States while performing
this work. While I was heartened to learn of the safeguards
Oregon has in place to prevent this fraud, the audit made clear
that there is more work to be done.
More recently, GAO released a second report on the need for
better data on PCS. The most recent data at the time of the
audit-released in 2017-was from 2012. Five years ago. And the
data GAO did receive was incomplete. Without complete and up-
to-date data those who are tasked with rooting out waste,
fraud, and abuse in this program are hamstrung.
So, both the OIG and GAO have sounded the alarm for years.
This fraud and abuse is happening because the States and
the Federal Government failed to put in safeguards to protect
these beneficiaries.
It is sickening to see hard-earned taxpayer dollars going
to people who take advantage of and mistreat elderly and
disabled people in their own homes.
And these beneficiaries are particularly susceptible to
harm because they often lack the physical or mental ability to
speak up.
Many times, a personal care worker is the only person a
beneficiary will see for weeks, so they go along with fraud or
abuse because they are dependent on their attendant for help.
We can do better. Our citizens deserve to know that the
attendant they allow into their home, the attendant paid by
State and Federal taxpayers, will take good care of them and
have their best interests at heart. And while most do, it's
clear we have a serious problem in this program.
Today, we are here to talk about the steps we are going to
take to correct the problems identified for us by the Office of
Inspector General and others.
I would like to thank Ms. Grimm from the OIG and Ms.
Iritani from GAO for your extraordinary work that has exposed
fraud, abuse, and mismanagement in this program. Your decades
of work have culminated in some common-sense recommendations
for CMS that will better protect beneficiaries.
I look forward to discussing those recommendations today,
and also learning about how Congress can do its part to solve
these problems.
Mr, Hill, I appreciate your testimony today too. I
understand that CMS has taken steps to implement some of these
recommendations and is working toward improvements. That's
encouraging, and I look forward to learning more about your
work as well.
Thank you, Mr. Chairman, for holding this important hearing
today. I yield back the remainder of my time.
Mr. Murphy. The chairman returns the balance of his time
and yields back. I now recognize the gentleman from New Jersey,
Mr. Pallone, for 5 minutes.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman. This committee has a
long-standing history of examining fraud and abuse in Medicaid
and we should continue to find ways to improve the vital
programs, including the Personal Care Services program. But it
is important to keep these issues in context. Medicaid is a
critical program that provides essential healthcare to more
than 74 million Americans, including seniors, children,
pregnant women, and people with disabilities. Now with the
expansion of Medicaid under the Affordable Care Act, more than
12 million people gained health insurance coverage last year.
Additional achievements under the ACA have helped improve the
quality, accessibility, and affordability of healthcare for
millions of Americans.
We have made historic gains and we must not roll back this
progress by cutting essential health programs such as Medicaid.
The Republican Trumpcare bill which the Republican leadership
is still trying to convince members to support, drastically
cuts and caps the Medicaid program. It rations care for
millions in order to give giant tax breaks to the wealthy and
corporations. By allowing a State to arbitrarily cap coverage
or provide a block grant for certain enrollees, Trumpcare would
result in mass rationing of care for seniors in nursing homes,
pregnant women, working parents, and people living with
disabilities.
Instead, it is imperative that we make every effort to
ensure Federal and State dollars are spent effectively. While
Medicaid is already an incredibly lean program that has among
the lowest improper payment rates of any Federal health
program, we should always be looking at ways to prevent any
fraud, waste, or abuse in any Federal program. The HHS Office
of Inspector General has reported on improper payments,
questionable care quality, and fraud in the PCS program and I
am particularly concerned by OIG's investigative advisory that
highlighted stories of vulnerable patients who were neglected
and even harmed by the PCS providers entrusted with their care.
So I am committed to working with my colleagues to address
these issues and the root causes of fraud, waste, and abuse.
However, any solution we consider to address the problems in
the PCS program should be designed primarily to serve one
constituency, and that is vulnerable Medicaid patients. We must
root out fraud and abuse, but we should not use potential fraud
and abuse as an excuse to harm the people these programs are
intended to serve. In other words, the answer to Medicaid fraud
is not to cut coverage or reduce benefits. The answer to
beneficiary harm and neglect is not to institute work
requirements and the answer to abusive providers is not to drug
test low-income beneficiaries. Instead, we should be
strengthening oversight so that bad actors are not allowed into
the program, all beneficiaries get the care they need, and the
American tax dollars are protected.
The PCS program is a great example of the type of crucial
services that we should be protecting and strengthening. PCS
attendants help patients with daily activities such as bathing
and dressing which gives Medicaid patients more freedom and
dignity by allowing them to stay in their homes. Medicaid is
the majority payer of long term care services and supports for
seniors and individuals with disabilities and personal care
services are a critical benefit for these populations.
The HHS OIG has done important work on this issue that has
benefitted the committee's past bipartisan work and no doubt
will continue to benefit this committee if given the proper
resources and that is one of the many reasons why I'm so
concerned about President Trump's budget blueprint which
threatens to undermine the important work of agencies like the
HHS OIG.
We will also hear from GAO about the challenges posed by
various PCS program requirements across different States and
how the States have not provided accurate data on the PCS
program. Because Medicaid is a Federal-State partnership, we
need both CMS and the States to do their part in conducting
oversight.
And finally, Mr. Chairman, I would like to thank the
witnesses today for their commitment to strengthening the
Medicaid program and serving its beneficiaries. Instead of
rolling back the progress we've made, we must continue to find
ways to improve oversight of these vital programs and I don't
think anybody else wants my time, so I will yield back, Mr.
Chairman.
[The prepared statement of Mr. Pallone follows:]
Prepared statement of Hon. Frank Pallone, Jr.
Thank you, Mr. Chairman. This committee has a longstanding
history of examining fraud and abuse in Medicaid. We should
continue to find ways to improve these vital programs,
including the Personal Care Services (PCS) program. But it is
important to keep these issues in context.
Medicaid is a critical program that provides essential
health care to more than 74 million Americans--including
seniors, children, pregnant women, and people with
disabilities.
Now with the expansion of Medicaid under the Affordable
Care Act (ACA), more than 12 million people gained health
insurance coverage last year. Additional achievements under the
ACA have helped improve the quality, accessibility, and
affordability of health care for millions of Americans.
We have made historic gains, and we must not roll back this
progress by cutting essential health care programs such as
Medicaid. The Republican Trumpcare bill, which the Republican
leadership is still trying to strong-arm Members into
supporting, drastically cuts and caps the Medicaid program. It
rations care for millions in order to give giant tax breaks to
the wealthy and corporations. By allowing a State to
arbitrarily cap coverage or provide a block grant for certain
enrollees, Trumpcare would result in mass rationing of care for
seniors in nursing homes, pregnant women and working parents,
and people living with disabilities.
Instead, it is imperative that we make every effort to
ensure Federal and State dollars are spent effectively. While
Medicaid is already an incredibly lean program that has among
the lowest improper payment rates of any Federal health
program, we should always be looking at ways to prevent any
fraud, waste, or abuse in any Federal program.
The HHS Office of Inspector General has reported on
improper payments, questionable care quality, and fraud in the
PCS program. I am particularly concerned by OIG's investigative
advisory that highlighted stories of vulnerable patients who
were neglected and even harmed by the PCS providers entrusted
with their care.
I am committed to working with my colleagues to address
these issues and the root causes of fraud, waste, and abuse.
However, any solution we consider to address the problems in
the PCS program should be designed primarily to serve one
constituency: vulnerable Medicaid patients. We must root out
fraud and abuse, but we should not use potential fraud and
abuse as an excuse to harm the people these programs are
intended to serve.
In other words, the answer to Medicaid fraud is not to cut
coverage or reduce benefits. The answer to beneficiary harm and
neglect is not to institute work requirements. And the answer
to abusive providers is not to drug test low-income
beneficiaries.
Instead, we should be strengthening oversight so that bad
actors are not allowed into the program, all beneficiaries get
the care they need, and Americans' tax dollars are protected.
The PCS program is a great example of the type of crucial
services that we should be protecting and strengthening. PCS
attendants help patients with daily activities such as bathing
and dressing, which gives Medicaid patients more freedom and
dignity by allowing them to stay in their homes. Medicaid is
the majority payer of long-term care services and supports for
seniors and individuals with disabilities, and personal care
services are a critical benefit for these populations.
The HHS OIG has done important work on this issue that has
benefitted the committee's past bipartisan work, and no doubt
will continue to benefit this committee if given the
appropriate resources. That is one of the many reasons why I am
so concerned about President Trump's budget blueprint, which
threatens to undermine the important work of agencies like the
HHS OIG.
We will also hear from GAO about the challenges posed by
varying PCS program requirements across different States, and
how the States have not provided accurate data on the PCS
program. Because Medicaid is a Federal-State partnership, we
need both CMS and the States to do their part in conducting
oversight.
Mr. Chairman, I would like to thank the witnesses today for
their commitment to strengthening the Medicaid program and
serving its beneficiaries. Instead of rolling back the progress
we have made, we must continue to find ways to improve
oversight of these vital programs.
Thank you, and I yield back.
Mr. Murphy. The gentleman yields back. So let's begin. I
ask unanimous consent that the Members' written opening
statements be introduced into the record, and without objection
the documents will be entered into the record.
I now would look to introduce our panel of Federal
witnesses for today's hearing. First, we welcome Ms. Christi
Grimm, Chief of Staff of the Department of Health and Human
Services, Office of Inspector General. With nearly 2 decades of
leadership and expertise in HHS programs, Ms. Grimm manages the
operation and resources of the immediate Office of Inspector
General and is responsible for effective execution of OIG
priority initiatives, advising on a wide variety of policy and
operational matters.
Next, we welcome Ms. Katherine Iritani. Have I said that
right? Good. Director of Healthcare Issues at the U.S.
Government Accountability Office. In her 36-year career with
GAO, Ms. Iritani has helped lead a wide variety of programs and
evaluation assignments for Congress. In recent years, she has
overseen Medicaid financing, payment, access, and long-term
care issues, including program oversight issues contributing to
Medicaid being designated as a high-risk program.
And last, we would like to welcome Mr. Timothy Hill, Deputy
Director for the Center for Medicaid and CHIP Services, CMCS,
and the Centers for Medicaid and Medicare Services at HHS. As
Deputy Director at CMCS, Mr. Hill leads activities related to
national Medicaid and CHIP policy and program operations and
works closely with States in the implementation of their
Medicaid and CHIP programs.
So I thank all the witnesses for being here today and
providing testimony. We look forward to productive discussion
on how we can strengthen and combat waste, fraud, and abuse
reform in the PCS program.
As you are aware, the committee is holding an investigative
hearing and when doing so has the practice of taking testimony
under oath. Do any of you have objection to testifying under
oath?
Seeing no objections, the Chair then advises you that under
the rules of the House and the rules of the committee, you are
entitled to be advised by counsel. Do any of you desire to be
advised by counsel during testimony today? And seeing none
there, then will you please rise and raise your right hand. I
will swear you in.
Do you swear the testimony you are about the give is the
truth, the whole truth, and nothing but the truth?
[Witnesses sworn.]
Thank you. All of you are now sworn in under oath and
subject to the penalties set forth in Title 18 Section 1001 of
the United States Code.
We will have you each give a 5-minute summary of your
written statement and we'll begin with Ms. Grimm, you are
recognized.
STATEMENT OF CHRISTI A. GRIMM, CHIEF OF STAFF, OFFICE OF
INSPECTOR GENERAL, DEPARTMENT OF HEALTH AND HUMAN SERVICES;
KATHERINE M. IRITANI, DIRECTOR, HEALTH CARE, GOVERNMENT
ACCOUNTABILITY OFFICE; AND TIM HILL, DEPUTY DIRECTOR, CENTER
FOR MEDICAID AND CHIP SERVICES, CENTERS FOR MEDICARE AND
MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
STATEMENT OF CHRISTI A. GRIMM
Ms. Grimm. Good morning, Chairman Murphy, Ranking Member
DeGette, and other distinguished members of the subcommittee. I
am Christi Grimm, Chief of Staff of the Office of Inspector
General for the U.S. Department of Health and Human Services.
Thank you for the opportunity to appear before you to
discuss the importance of protecting Medicaid personal care
services from fraud, waste, and abuse and protecting
beneficiaries from abuse and neglect. The Personal Care program
has been one of OIG's top management concerns for the past 8
years. My testimony today will highlight our work overseeing
the Personal Care program and progress the Department has made
in implementing our recommendations.
In the last 5 years, often with our State partners, OIG has
opened more than 200 investigations involving fraud and patient
harm in the Personal Care program. For example, as the chairman
pointed out in his opening, in Pennsylvania, a personal care
attendant who was hired to provide close supervision to a
beneficiary lost her while shopping in a department store. The
attendant waited an hour before notifying the authorities. The
beneficiary was found the next day dead from exposure to the
cold. This harm is something no one should ever have to
experience. Systemic problems must be rectified so that the
Federal and State Governments can prevent similar tragedies.
In the past decade, OIG has issued more than 30 reports
pertaining the Personal Care which recommended the recovery of
almost $700 million. OIG's November 2012 Personal Care
portfolio summarized the findings of OIG's body of work which
found that Personal Care payments were often improper because
the services did not comply with basic requirements.
OIG's October 2016 Investigative Advisory documented common
fraud schemes including payments for services that were
unnecessary or not provided and resulted in death,
hospitalization, and less degrees of beneficiary harm.
Collectively, our work demonstrates the persistent
vulnerabilities in personal care that contribute to high
improper payments, significant fraud, and that place vulnerable
beneficiaries at risk. Bad actors are exploiting policy
vulnerabilities and diverting Personal Care resources.
OIG's long history of oversight and enforcement has
consistently demonstrated that basic pillars of program
integrity prevention, detection, and enforcement are lacking in
the Personal Care program. We must prevent bad actors from
participating in our programs, detect potential fraud, waste,
and abuse and beneficiary harm, and enforce the laws through
Federal and State investigations and prosecutions.
When these basic safeguards are in place, they have a
dramatic effect on our ability to identify and stop fraud,
waste, and abuse. For example, Alaska implemented a requirement
that all Personal Care attendants enroll with the State
Medicaid Agency. Attendant enrollment data helped Alaska detect
potential patterns of fraud and help strengthen cases for
prosecution. In 2 short years, that data helped Alaska to
investigate and obtain 108 criminal convictions and recover
$5.6 million.
CMS has concurred with our top recommendations for
improving the Personal Care program. In 2016, CMS issued a
request for information, guidance, and provided training to
States and providers resulting in improvements to the Personal
Care program. Notwithstanding this progress, much remains to be
done. As of today, four OIG recommendations from the 2012
portfolio remain unimplemented.
First, CMS should establish minimum Federal qualifications
and screening standards for all personal care attendants.
Second, CMS should require States to enroll or register all
personal care attendants and assign them unique identification
numbers.
Third, CMS should require that Personal Care claims
identify the dates of services and who provided those services.
Finally, CMS should consider whether additional controls
are needed to ensure that Personal Care Services are allowed
under program rules and are provided.
OIG work has demonstrated that Personal Care is subject to
persistent fraud and beneficiary harm. CMS, in partnership with
States, must implement basic safeguards to protect this
critical benefit that allows millions of beneficiaries to
remain in their homes and communities. Combating fraud and
patient harm in Personal Care not only protects beneficiaries
and programs, but also elevates the many honest, professional,
and dedicated care attendants that enable beneficiaries to live
independently.
Again, thank you for the opportunity to testify this
morning. I am happy to answer any questions you have.
[The prepared statement of Ms. Grimm follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Ms. Grimm.
Ms. Iritani, you are recognized for 5 minutes.
STATEMENT OF KATHERINE M. IRITANI
Ms. Iritani. Chairman Murphy, Ranking Member DeGette, and
members of the subcommittee, I am pleased to be here to discuss
GAO's work on Medicaid personal care services. The number of
people receiving these services is significant and growing.
Medicaid is the Nation's primary payer of long-term services
and supports including those provided in homes and community
settings.
Personal care services are critical to helping people age
in place, maintain independence, and participate in community
life to the fullest extent possible. These services are not
without risk, both for beneficiary safety and for improper
payments. Regarding safety, beneficiaries receiving these
services include older adults and individuals with
disabilities, some of whom could be vulnerable.
Regarding improper payments, personal care services are
among the higher types at risk of being improper. One known
concern is with Medicaid being billed for care that was never
provided to the beneficiary.
My testimony today is based on two recent GAO reports that
examined Federal requirements for programs providing personal
care services and data available for oversight.
Now, typically, I would start my statement with some key
facts about these services, such as the Federal requirements in
place to protect beneficiaries from harm and to ensure that
services billed to Medicaid were actually provided, and basic
facts about these important services, such as the number of
beneficiaries receiving them in States and at what cost. But as
you'll hear today, these key points of fact are not easily laid
out.
I have three key observations from our work. First, there
are multiple different program authorities under which States
can provide personal care services in Medicaid. Since the
program's inception in 1965, States have been required to cover
institutional, but not home and community-based care. Since
1975, several different options to provide home and community
services have been provided to States. All States have adopted
one or more different programs to varying degrees. How States
screen, train, and monitor attendants and ensure billed
services are provided varies, not only between States, but even
within States, by program.
A second key finding in our work: the Federal requirements
CMS has in place for oversight of beneficiaries' safety and
provision of services vary significantly between the different
types of programs. Approaches for measuring quality assurance,
defining and monitoring critical incidents, screening
attendants to ensure they are not bad actors and then ensuring
billed services are provided can and do vary significantly
between programs. These differing requirements result in uneven
safeguards for beneficiaries, depending on the program they are
enrolled in; uneven assurances regarding oversight of billed
services; and complexities for States and others administering
and overseeing services.
A third key finding of our work relates to the data CMS
needs for oversight. Our work found that data available to CMS
on the provision of and spending on personal care services are
not always timely, complete, consistent, or accurate. For
example, data lags caused by late submissions from States and
other problems can mean CMS lacks good data for years on the
services States have provided.
At the time of our work conducted in 2016 largely, the best
available data were for 2012 and only available for 35 of the
States that provided these services. For those 35 States where
we had data, 15 percent, amounting to nearly $5 billion in
claims, lacked provider identification numbers; 34 percent,
amounting to over $5 billion in claims, lacked information on
the quantity of services provided; and more than 400 different
procedure codes were used by States to identify personal care
services.
Without good data, CMS cannot effectively perform key
management functions such as ensuring State claims are
appropriate, ensuring appropriate Federal matching, identifying
program risks, and monitoring access and spending trends.
In recent years, Congress has directed HHS to improve
coordination of home and community-based programs in Medicaid.
CMS has taken steps to do so, and more can be done. In view of
the growth in, the demand for, and the cost of Medicaid home
and community-based services and the importance of these
services to the beneficiaries who rely on them, Federal
leadership to improve data and better harmonize requirements
among different types of programs is needed.
Mr. Chairman, this concludes my statement. I'm happy to
answer any questions.
[The prepared statement of Ms. Iritani follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Ms. Iritani.
Mr. Hill, you're recognized for 5 minutes.
STATEMENT OF TIM HILL
Mr. Hill. Thank you. Good morning, Chairman Murphy, Ranking
Member DeGette, and members of the subcommittee. Thank you for
the invitation and the opportunity to discuss personal care
services in Medicaid.
Speaking as a career executive with over 25 years of
experience to Medicare and Medicaid service, to Medicare and
Medicaid beneficiaries, I can state with confidence that CMS
shares your commitment to protecting beneficiaries and ensuring
the taxpayer dollars are spent on legitimate items and
services. This fiduciary commitment is the forefront of all of
our activities. In that regard, we greatly appreciate the
ongoing work done by the IG and the GAO to highlight potential
vulnerabilities in these important programs and we rely on
their recommendations to inform our program improvement
activities across all our programs.
As you know, States are primarily responsible for day-to-
day operation of the Medicaid program and for designing
programs that best serve the needs of the beneficiaries in any
particular State. While we at CMS have an important role to
play in terms of providing overall guidance and direction,
States are in charge of administering the Medicaid programs and
have significant flexibility to choose options that enable them
to deliver high quality, cost effective care for their
residents.
Perhaps nowhere in the Medicaid program is that flexibility
more important than in designing and administering home and
community-based service programs including the provision of
personal care services. Personal care services provide vital,
person-centered care that allows individuals to remain in their
homes or community instead of a nursing facility or other
institution. In Medicaid, coverage of these important services
is generally optional for States. However, because States see
the value in these services, nearly all 50 States provide some
level of coverage.
It's hard to overstate the ways in which maintaining home
and community based service programs benefits both the
communities and the beneficiaries they serve. These programs
cost less for both States and beneficiaries. They empower
patients to have more control over their daily lives and the
management of their health and they provide essential and
culturally appropriate support to patients and their families.
It's precisely because of the importance of these programs
to Medicaid that it's paramount that we do all we can to
protect these programs from fraud, waste, and abuse. Not solely
to protect against financial losses, but as we've heard this
morning, but more importantly to protect against abuse or
neglect of vulnerable beneficiaries, many of whom are elderly
or individuals with disabilities and may have no other
practical alternative to institutionalization.
Even one case of fraud, abuse or neglect is too many. In
our efforts to protect these programs and the beneficiaries
they serve, we pursue a balanced approach that recognizes the
unique needs of every State while preserving their flexibility
to design programs that will best serve their residents, while
at the same time analyzing when and where to use national
standards or guidance.
We take a number of actions and we'll continue to help
States safeguard their Medicaid beneficiaries and program
resources by providing them with the tools they need to be
successful. For example, to help States better understand
requirements and share best practices, we publish guidance that
highlights suggested approaches to strengthening and
stabilizing the Medicaid home care workforce and other options
to strengthen program integrity in Medicaid Personal Care
Services programs.
We've provided training for State officials and other
stakeholders creating space for them to collaborate, share best
practices, while staff is simultaneously staying up to date on
emerging program vulnerabilities.
CMS also uses focused program integrity reviews, assessing
State program integrity effectiveness related to their
administration of personal care services, providing States with
feedback on vulnerabilities and possible corrective actions.
This year, we plan to conduct focused reviews on PCS in
five additional States.
We also use our Medicaid Integrity Resources to work
collaborative with States to identify improper payments through
review of claims. Using these resources, we've conducted over
40 audits on personal care services in 8 States. In one recent
audit of PCS services in one State resulted in over $500,000
being returned to the Treasury.
Even as we continue to work with States to help them
implement their programs, we are interested in understanding
what changes need to be made at the Federal level. That is why
last November, we published a request for information to gather
stakeholder feedback on a provision of HCBS services. We are
particularly interested in the benefits and consequences of
implementing standard Federal requirements for personal care
services and what these standards could include and how they
could be developed.
We're reviewing the comments we received to inform our
approach to supporting States and their program integrity
efforts in a way that maximizes State flexibility while
protecting personal care service programs and beneficiaries
from fraud, waste, and abuse.
As we continue our efforts for PCS, we must also work to
ensure that any additional oversight requirements do not create
administrative burden, increase costs or impact beneficiary
choice or control. The successful delivery of PCS in Medicaid
ensure that both individual needs and preferences are met and
that the program has adequate safeguards in place.
We look forward to continuing our work with States, our
oversight partners, and other stakeholders. This concludes my
statement. I'm happy to take any questions.
[The prepared statement of Mr. Hill follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Mr. Hill. I'll recognize myself for
5 minutes. First of all, Ms. Grimm, Ms. Iritani, I want to
commend you and your offices. It doesn't happen a lot in
Congress, but in terms of a branch of the Federal Government
that do their job, we thank you for doing that. We are
absolutely indebted to you for these discoveries, and there's a
real trust we have in this committee for the work you do. So
please pass that compliment on to your other workers as well.
That being the case, it bothers us about the stories you're
telling us, the fraud and abuse and how it really hurts the
beneficiaries, the elderly, and disabled individuals.
And there's certain elements of this, Ms. Grimm, that you
talked about, the PCS, that make it more susceptible to fraud
for the vulnerable. You mentioned in some of your testimony
some of the stories that beneficiaries often feel reliant on or
loyal to their attendant--it sort of reminds you of the
Stockholm Syndrome here--but even if that attendant is
committing fraud or abuse and harm. So why is that, and what is
in the system inherent in that that leads to that and, of
course, how do we change it?
Ms. Grimm. Thank you for your question. I think inherent to
personal care services is sort of the intimate nature of those
services, going into beneficiaries' homes and providing
services like bathing, dressing, light housekeeping, food
preparation. And in many of those instances, as you point out,
the beneficiary becomes very reliant on those services, and in
their mind services, even if they're suboptimal, are better
than no services, and we have found apprehension on having
fraud and abuse reported by beneficiaries. Often referrals come
to us from families or loved ones that are witnessing neglect.
Mr. Murphy. Are there threats made, subtle threats in terms
of--that sometimes occur under these circumstances?
Ms. Grimm. I'm not aware of a specific instance where the
beneficiary was told they could not report, but we certainly
have plenty of examples of harm that's resulted from fraud.
Mr. Murphy. And I'm wondering in these cases, too, at times
maybe a family puts up a hidden camera in the home, too, and
also records events. Have those occurred? Have you seen
anything like that?
Ms. Grimm. Hidden cameras in beneficiaries----
Mr. Murphy. Families many times do that with their
babysitters, too, that may actually record some instances where
a PCS worker was causing some problems. Have you seen any
instances of that yet?
Ms. Grimm. I don't have any instances of that, but we do
have examples of family members that are perpetrating the harm
and neglect with the beneficiary, so even in those scenarios
where it's self-directed PCS, we are still seeing instances of
family members committing that harm.
Mr. Murphy. So given all of these stories and the heart-
breaking nature of them, if you could choose a recommendation
you think would make the biggest impact, what would it be?
Ms. Grimm. We want to know who we're doing business with at
the attendant level. So the number one recommendation that I
would put forward is that you enroll and register attendants
and make sure that those identifiers are on the claims.
Mr. Murphy. And background checks, full background checks
on them, too?
Ms. Grimm. We do recommend background checks. Many of the
instances that we included in our investigative advisory would
have revealed a history of criminal conduct, including drug
diversion.
Mr. Murphy. And what other kinds of backgrounds would be in
this besides drugs? Felonies, burglaries?
Ms. Grimm. We do have another example of a case in Illinois
where a nurse had lost her licensure because she was stealing
drugs from her employer. And in that instance, she was excluded
from all Federal healthcare programs and a check, like we
recommend for other programs and looking at the exclusions
list, would have revealed that.
Mr. Murphy. OK, thank you. Ms. Iritani, what impact does
CMS have? How is it, in fact, not getting data on time? You
made references to this data. How does this affect the
oversight ability for CMS on PCS workers?
Ms. Iritani. Data is critically important to really
overseeing the program. CMS needs data to ensure that payments
are appropriate and to assess trends and to ensure that the
Federal matching is appropriate for what States are claiming
from the Federal Government in terms of provided services.
Mr. Murphy. Thank you. And Mr. Hill, given the kind of
things here, what steps do you see moving forward that you
could use to improve this whole process?
Mr. Hill. So I think I would focus on two areas that have
been highlighted. First, on the policy side and the
recommendations with respect to standards. We've talked to the
IG. We issued our RFI last year. For us, it's a balance, right,
so every State is a little different. The requirements in one
State may not be the requirements we want to have in every
State, so we're anxious to continue our analysis there to
determine whether or not we should be putting more requirements
on States that internally have their own set of standards or
whether we should be doing that nationally at the Federal
level.
Second, and I couldn't agree more, I think, with our
colleague from the GAO that the dearth of data in the Medicaid
program is a problem. We've done a lot over the last year to
get data in in a much more timely way in a way that will let us
do analysis, not only for our own selves, but also to give
information back to the States about how their programs are
operating and so continuing our effort to get data in to make
that data timely and accurate I think is very important.
Mr. Murphy. Thank you. I'm out of time. Ms. DeGette, you're
recognized for 5 minutes.
Ms. DeGette. Thank you, Mr. Chairman. I'm gratified to hear
that members on both sides of the aisle recognize the
importance of the Personal Care Services program to Medicaid
beneficiaries and also the potential cost savings that we can
get. But I do think that we can work together to address where
controls need to be improved.
A little note, one of the many little known provisions in
21st Century Cures which, of course, this entire committee
worked together on, required an electronic visit verification
system for personal healthcare services and home healthcare
services under Medicaid. What this requirement said is by 2019
all personal care visits have to be electronically verifiable
and that standard background information would be collected on
every claim which I think would help. That would be a help.
I just want to ask the panel some of the questions about
the scope of the Personal Care Services program and what we can
do.
Mr. Hill, you heard Ms. Grimm talk about some of these
services, particularly to the elderly who can stay in their
homes. I think we all agree this program can be very beneficial
to people like that, is that right?
Mr. Hill. It's incredibly beneficial. For every example and
every conversation we have with the IG about abuse and the
horrible things that are going on, I think there's also as
unreported sort of hundreds of examples of folks who are now
living in their home, in their community with attendants and
workers who make their lives fulfilling in a way that would not
be if they were in an institution, people who have suffered
broken limbs, broken back or where they have intellectual
disabilities or any number of medical conditions that normally
keep them in an institution are keeping them in their
communities.
Ms. DeGette. And not only that, but it also is more cost
effective than putting them in nursing homes, is that correct?
Mr. Hill. Absolutely, even as the GAO has noted, the
highest spending State for PCS is close to $30,000 per
beneficiary. Nursing homes are easily three to four times that
amount.
Ms. DeGette. Thank you. Now Ms. Iritani, I think you
testified to this, your January 2017 audit found that the CMS
data is of limited value for oversight purposes because it's
often not timely and it's inconsistent across State lines and
has errors. Is that correct?
Ms. Iritani. That's correct.
Ms. DeGette. And also, this is important. Although there
are problems with the quality of data, it doesn't necessarily
mean there's widespread fraud in the program, is that right?
Ms. Iritani. That's correct.
Ms. DeGette. And so why do you think the States are having
such a hard time providing accurate and timely data to the CMS?
Ms. Iritani. There are a host of different reasons and we
didn't look at that specifically. We have on-going work
actually looking at challenges that States are having with
implementing T-MSIS, the utilization claims system. More work
needs to be done. But some of the things that we are aware of
in terms of some reasons States haven't submitted is related to
new systems that they're putting in, maybe to comply with T-
MSIS and other reasons.
Ms. DeGette. Don't you think it would be a good idea to
work with the States so that we can get the data that we need
because we can't really even begin to get our arms around the
extent of the problem until we have that data?
Ms. Iritani. Yes.
Ms. DeGette. Can anybody testify what efforts we're making
to standardize and to get that data? Mr. Hill?
Mr. Hill. I'll speak briefly on where we are with the data
collection. As GAO has pointed out, historically, the Medicaid
data that we've gotten into CMCS has not been timely. It's not
been accurate. Beginning 4 years ago, we began implementing a
transformed system, a new system to collect use data,
utilization data, claims data from States in a much more timely
and standard format. We now have requirements in terms of what
data the States have to submit, how it has to be submitted and
the timeliness of that.
We now have 35 States representing more than 60 percent of
the beneficiaries and expenditures in the country reporting
data into that system. We're beginning to share that data with
our partners to do quality assessment and be sure that it's
useable and it has fixed a lot of the vulnerabilities that have
been identified by the GAO and are hoping, we, CMS, will be
ready to accept data from all States by the end of the summer.
Ms. DeGette. Great. Let me stop you there because I'm out
of time.
Mr. Hill. Yes.
Ms. DeGette. Let me just say I think this would be a
perfect hearing for the fall, Mr. Chairman, to bring the States
in to talk about are they complying with that deadline of this
summer and to see what else they need.
Mr. Murphy. Right, and we also had that briefing before
that most States are not even getting data.
Ms. DeGette. Right.
Mr. Murphy. So we're kind of flying blind. So appreciate
it.
Ms. DeGette. OK, thanks. I yield back.
Mr. Murphy. I recognize the chairman of the committee for 5
minutes.
Mr. Walden. Thank you, Mr. Chairman. Ms. Iritani, in your
report on PCS data, you were only able to analyze 35 States
because 15 had not reported the data yet, as you all are having
this discussion from 2012. So you conducted this audit from
July 2015 to January of 2017 and as of then, 35 of 50 States
had enough data from 2012 to analyze, correct?
Ms. Iritani. Correct.
Mr. Walden. Why were the data so late? Is this a common
problem? Once it gets there, it just seems like it can take
several years for CMS to process it, and why is that?
Ms. Iritani. And I think there are two issues. One is that
States submit data late, and it could be because they are
largely managed care, and managed-care plans may submit data
late or may not submit data at all.
The other problem is that when the data comes in, it is not
good and so CMS needs to go through a lengthy validation
process which is part of why we only had data for 35 States
several years later, is that the data had not been validated
for those other States.
Mr. Walden. Makes is it pretty hard to do appropriate
oversight and reconciliation and everything else then?
Ms. Iritani. Yes.
Mr. Walden. Mr. Hill, GAO's January 2017 report raised
concerns about these processing times. What's the average time
it takes to process 1 year's worth of data, if there is such a
thing as an average time?
Mr. Hill. Right, so as identified, the data that the GAO
looked at in the system that they were looking at was the
system that is prior to the one we're using now. So for a
State, for example, that's what we call live, submitting data
into our system. For the 35 that I've identified that are
processing, we have up-to-date data within a month current to
the year, right, so if it's March and they submitted the data
on the 1st of--from January and it's consistent, current for
January.
Mr. Walden. All right.
Mr. Hill. Now as I said, we've built in a lot of the front-
end control to be sure that we don't have to take as long as we
were taking in the prior system to do the quality check. Those
quality checks are built in upfront. So we're confident and
hopeful, I should say, and confident that this new system will
both provide data much more timely, much more consistently, and
in a way that will allow us to do the analysis and the
oversight in a way that we could not.
Mr. Walden. OK. Ms. Iritani, a question back to your
comment about the managed-care plans, could the States or the
Federal Government make a condition of the contract with the
managed-care plans that they have to submit data on a regular
basis in a format that works for the expedited review and do we
do that?
Ms. Iritani. Yes, they are required to. It's more a
question of enforcement.
Mr. Walden. What's the penalty if they don't?
Ms. Iritani. I think that will depend on the contract that
the States have put in place with the managed-care
organization.
Mr. Walden. And we could probably weigh in on that contract
requirement since we're a partner in this process?
Ms. Iritani. That would be a policy decision.
Mr. Walden. Yes. OK. Ms. Grimm, I understand a beneficiary
in Pennsylvania died of exposure to the cold while under the
care of a PCS attendant according to some of the reports. In
another case, a hot July day, a PCS attendant in Maryland left
a beneficiary with developmental disabilities in a locked car
while shopping with a companion.
What's the most important thing CMS can do to prevent
beneficiaries from being subject to neglect and abuse by PCS
attendants?
Ms. Grimm. Move to require States to enroll or register a
care attendant so that we're able to keep track of what's
happening at that attendant level.
Mr. Walden. OK, and what reaction, if you get any, from the
States when this is suggested?
Ms. Grimm. We have a report coming out at the end of the
summer that provides survey data from the Medicaid Fraud
Control Unit Directors on the recommendations that we have put
forward, also fraud trends related to personal care. We know
that that group very much endorses the recommendation that
we've put forward related to enrollment and registry. And the
report will also have some other solutions States have
explored.
Mr. Walden. OK, perfect. How do you investigate fraud when
it involves beneficiaries' family members because we understand
that's a problem, too?
Ms. Grimm. One thing that I think this committee could also
do is to give our Medicaid Fraud Control Units the authority to
investigate stand-alone harm in patients' homes. They currently
only have the authority to investigate when it's associated
with billing fraud. So it does become challenging to
investigate harm when it is not linked to some of those other
billing issues.
Mr. Walden. My time has expired. Thank you again for the
good work that you are doing and your counsel to us. We
appreciate it.
Mr. Chairman, I yield back.
Mr. Murphy. All right, I now recognize Mr. Tonko for 5
minutes.
Mr. Tonko. Thank you, Mr. Chair. It's good to see CMS here
today to talk about improvements that CMS can make and should
make to this program. But let's not forget that the Medicaid
program and PCS, in particular, is a partnership between the
Federal Government and the States. States are given flexibility
to design their given programs to fit the needs of their
populations, but in exchange they have to do their part to
ensure the integrity of the programs.
States are the first line of defense in protecting Federal
and State Medicaid dollars. So with that being said, Mr. Hill,
in your testimony you stated, and I quote, ``Both the Federal
Government and States have key roles as stewards of the
program.''
So is it accurate to state that CMS cannot perform
effective oversight without cooperative State partnerships?
Mr. Hill. I think oversight is always more effective when
there's cooperation between us and the States. We have our
role. The State has their role. Sometimes there will be
tension, right, between what we view as a direction the State
needs to be or whether or not they're in compliance with
Federal rules. But we always prefer to be working--particularly
on issues of beneficiary harm and abuse--working hand in glove
to make sure that we mitigate those.
Mr. Tonko. So what does CMS need from the States to improve
this whole outcome?
Mr. Hill. As I've indicated earlier, I think in any
oversight context, the more data we have and the better data we
have with States and States being up to date with submitting
that data is going to give everybody a leg up in terms of
understanding what our problems are and how we meet those gaps.
Beyond that, I think States as identified by the IG, each have
their own requirements for how they oversee and maintain the
integrity, in particular, of personal care attendants and how
those services are being delivered. And we need to make sure
that States are following through and enforcing those
individual State compliance, right?
We don't have the resources, nor is it our job, to on a
day-to-day basis be monitoring claims and understanding how the
benefits are being delivered in any particular State. So the
State really needs to be in a position to step up and be doing
that work on behalf of those beneficiaries.
Mr. Tonko. Thank you. And Ms. Iritani, would you agree that
the responsibility for program integrity falls on both CMS and
the State Medicaid programs?
Ms. Iritani. Yes.
Mr. Tonko. So the OIG has done a lot of excellent work
looking at different State programs and pointing out
vulnerabilities and short comings. I understand that OIG's
audits of some States have found problems with PCS claims such
as providers claiming more hours than were recorded.
And again, that being said, Ms. Grimm, it seems clear that
States need to make improvements. Do you believe that the
provision passed by the last Congress which does require States
to ensure PCS visits are electronically verified will help
address some of the issues that have been raised by the OIG?
Ms. Grimm. Thank you for that question. We very much
appreciate some of the protections and collection of data
that's offered by that provision in 21st Century Cures. We know
that that does not currently include managed care and, with the
high percentage of services in Medicaid being provided through
a managed-care model, it definitely does not sort of wrap
around those services, but it is a terrific step forward and it
does collect some of the information that would allow our
criminal investigators to detect potential patterns of fraud.
Yes.
[The HHS Office of Inspector General submitted the
following amended portion of Ms. Grimm's response:]
We know that that may not currently include managed care and,
with the high percentage of services in Medicaid being provided
through a managed-care model, it may not sort of wrap around
those services, but it is a terrific step forward and it does
collect some of the information that would allow our criminal
investigators to detect potential patterns of fraud.
Mr. Tonko. Thank you. And what additional resources do
States need in order to conduct better oversight of the PCS
programs?
Ms. Grimm. I think having uniformity in the kinds of
standards that are required, the qualifications, some floor
requirements for the care attendants upon which States can
build and customize according to the special needs of those
States. I think that would better put States in a good position
to make sure care being rendered to their beneficiaries is of a
high quality.
Mr. Tonko. Thank you. And Mr. Hill, what steps is CMS
taking to encourage or require States to do more in this area?
Mr. Hill. So we've taken a number of steps in terms of
working with States on education, giving them best practices
and feedback about program integrity, methods and standards, be
it through review of claims, how to put edits in place to
review claims for high-dollar or unsubstantiated services,
helping them think about putting together registries or
enrollments for PCS attendants. But beyond that, we're also
working with States to provide direct training. We have a
facility where we can bring States in and bring our law
enforcement partners in to do hands-on work to understand
better how to do investigations around PCS types of work and
what kind of policies to put in place to prevent those types of
abuses from occurring.
And finally, we're doing our own work to understand whether
or not more Federal requirements are needed beyond just
requiring States to have their own internal policies,
particularly around enrollment of attendants should there be a
Federal standard, should we have nationwide standards for how
these attendants ought to be monitored and overseen.
Mr. Tonko. And that training is up and running now?
Mr. Hill. Yes, we had training back in February. We had 36
States, a number of our partners from law enforcement and the
oversight community, and we'll continue to do that.
Mr. Tonko. Thank you very much, Mr. Chair. I yield back.
Mr. Murphy. Thank you, Vice Chairman Mr. Griffith is
recognized for 5 minutes.
Mr. Griffith. Thank you very much. Ms. Iritani, it's my
understanding that States can receive more Federal money in the
form of a higher match for some activities related to
collection and compliance with Federal reporting requirements.
Am I correct in that?
Ms. Iritani. Yes, that's correct.
Mr. Griffith. And so you're having difficulty getting
States to get some of the reporting and so forth. And I'm going
to switch gears in a minute on that. But do you have a stick?
You've got the carrot. Do you have a stick that they might
receive a lower match if you they're not collecting some of the
data that you want?
Ms. Iritani. CMS does have authority to reduce the Federal
matching for system areas that are experiencing problems from a
75 match to a 50 percent match.
Mr. Griffith. Now let me switch gears a little bit because
I am worried about the States and I think that some of the
resistance from the States may come from a fear that they'll
chase some folks out of this industry, particularly when you're
dealing with family members and we all want to stop the abuse,
but when you're talking about family members I heard, I believe
it was you who earlier said that some States had 400 different
codes, and so it was hard to get the coding straight. And I can
see a family member who is trying to take care of their loved
one is receiving some monies for bathing or doing some daily
activity where the mom or the dad of theirs needs help and then
they're faced with having to learn 400 codes. So I think if
we're going to do something, we have to make it simple. Would
you not agree?
Ms. Iritani. Yes, we would agree with the harmonization of
requirements. The 400 codes was actually at the Federal level
in terms of how PCS was coming in in terms of the coding.
Mr. Griffith. So if we're going to require electronic
verification which I think is fine as long as it can be done on
the phone because most people will have their electronic phones
with them, their little gadgets, and this is where tele stuff
can be of great help, technology can be of great help to us,
but it needs to be simplified because you're going to have a
hard time--if you're just a 50-some- or 60-some-year-old child
trying to do the best you can for your parents because Mr.
Hill, you did point out earlier, we see in the news all the
horror cases. What we don't see are the thousands of people,
whether they be the professionals who are coming in or the
agencies that are sending people in or whether it's a family
member, where that person's life is greatly enhanced by having
a PCS individual helping them out through one of these programs
and I get that.
It also raises some concerns for me that not only do we
have to simplify it, but we have to be careful because there's
a difference between somebody who's working for an agency that
sends in folks and that family member. Because while we want
family members monitored to a certain degree, I'm not sure we
want to create a whole new bureaucracy to monitor them. We have
the Department of Social Services, at least in the Commonwealth
of Virginia that already is aware of that and if something is
going on a neighbor can report and they go out just like they
would with a child, for child abuse, and look for that.
Then we also have this whole thing where everybody is like
let's do background checks. The question is if we're going to
do background checks and I'm not against that, but we need to
make sure that we're not throwing the baby out with the bath
water. Because absolutely, if you've got a history of child
abuse or spousal abuse or abuse of a parent, even if you're a
family member, you ought not be involved. But a theft--I was a
criminal defense attorney, by the way, for 28 years--so a theft
of four tires off of an automobile when you're 18, it's a
theft, Mr. Chairman raised that issue and he was right to do
so. It's a theft. It may want to be something that you take a
look at, but I'd hate to see a son who's now in his 40s or 50s
being precluded because he came back with a felony conviction
20-some years ago on stealing tires or doing something that,
when you look at the facts, it's a whole different case than
just running it through.
And the problem is when Government gets a hold of a
criminal background check, oftentimes they come up with hard
and fast rules. If you've been convicted of X, you can't be
involved. And I think we need to set that bar fairly high. I'm
not sure it shouldn't be our responsibility. What do you all
have to say about that?
Go ahead, Ms. Grimm. I think you're the right person to
start on that.
Ms. Grimm. OK, I very much appreciate the question and that
context absolutely matters. We believe that those background
checks can reveal information that consumers can use and their
family members can use to make informed decisions about the
care that's provided.
Mr. Griffith. OK, so you would look for if we were going to
craft some language along those lines to say have the
background check done, but then it would be the family members
who would decide or it would be forwarded to Department of
Social Services, something along those lines? Would that be
your proposal?
Ms. Grimm. I think we would want there to be guidance to be
accompanying the types of convictions and histories that are
revealed through those background checks, but we have not gone
forward with a recommendation that says this specific kind of
crime should preclude them from providing personal care. CMS
can provide some exemptions and we've had those conversations
with CMS.
Mr. Griffith. And if you all decide to go with guidance,
I'm happy to assist in any way I can to have you come up with
ways that you may be able to ferret out the bad actors without
throwing out the folks who might have made a mistake at one
point in time. Likewise, maybe you all can help us come up with
the proper guidelines to put into the legislation that would
give you that authority.
With that, Mr. Chairman, I yield back.
Mr. Murphy. I recognize the gentleman from California, Dr.
Ruiz, for 5 minutes.
Mr. Ruiz. Thank you very much, Mr. Chairman. I think
everyone can agree that we must do all that we can to maintain
program integrity in the Medicaid Personal Care Services
program and continue to work to eliminate fraud and abuse, and
we must continue to identify common sense improvements to this
program such as better data collection and Federal baseline
standards, but we must do so by maintaining patient access to
this critical program that allows individuals to remain at home
and live independently when they might otherwise be forced to
move to a nursing home or assistive living facility.
Data collection is integral in evidence-based policy
development. And I think many of you had mentioned that there
are some exciting opportunities here and if we don't use data,
then we're at the whims of ideological partisanship that then
kind of makes the wrong decision, contrary to what's best for
the patient and for the American people.
One of the problems we've seen regarding this program
integrity in the Personal Care Services program is inadequate
data. A GAO report stated that CMS is developing an enhanced
Medicaid claims data system known as the Transformed Medicaid
Statistical Information System pronounced as ``T-MISSIS,''
right? Under T-MSIS, States will be expected to report claims
data that are more timely and more complete.
Mr. Hill, it's clear that T-MSIS is a critical tool to
ensure timely, accurate, and complete data from States, and it
is my understanding States have been working for years to
implement the new system. What steps has CMS taken to complete
T-MSIS this year?
Mr. Hill. So this year, we've actually had a good year this
year. As I mentioned earlier, we've now got 35 States reporting
and I think most of them are current with their data reporting.
We're working with the remainder of the States to meet them
where they are, to make sure that they have everything they
need in place to begin reporting and will be ready to take
their data by the end of the summer. Whether they can meet that
deadline or not is something we'll continue to work with them
on.
Mr. Ruiz. How many States? What's the percentage? And what
year do you think we'll have everybody on board?
Mr. Hill. I'm hopeful that by the end of this year we can
have all States in. Now again, that all depends on whether
States are going to be able to internally meet their own
deadlines. As you know, Medicaid is incredibly complex at the
State level and they're integrating State data from many State
systems. And so it's a challenge for them to be able to put it
into a common core.
Mr. Ruiz. So what additional claims information will be
included under T-MSIS, and how will this improve the integrity
of the Medicaid claims data?
Mr. Hill. I think the single biggest piece of information
that we'll have out of--and this is where--it's hard to know
when you're supposed to correct a congressman, but it's ``T-M-
SIS.''
Mr. Ruiz. ``T-M-SIS.''
Mr. Hill. When we have the T-MSIS data in, particularly
data around providers, right, so there's just a statutory
requirement now to be providing, referring, and ordering
information on a claim so we'll know who referred, who ordered
a service and we'll know more information about the providers
that are submitting claims. Under the old prior information, we
didn't have that enrollment information and we didn't have the
ordering and referring information from providers.
Mr. Ruiz. Ms. Iritani, how will any further delay impact
the integrity of the Medicaid claims data in the near future?
Ms. Iritani. Significantly. Reliable data is really
important for overseeing improper payments and other functions,
and we have recommendations to CMS on personal care services in
particular that CMS should issue guidance that is standard on
reporting of personal care services and, with regard to T-MSIS,
should really prioritize the data that CMS needs for oversight.
Mr. Ruiz. So I understand that while there are reported
benefits of implementing T-MSIS, it is not a cure-all, correct?
Ms. Iritani. Correct.
Mr. Ruiz. For example, in your report, you stated that CMS
will need to develop plans for how it can be used for
oversight. Can you give me some examples of how that can be
used for oversight?
Ms. Iritani. Well, ensuring, for example, that the Federal
matching for what States are claiming as expenditures is
appropriate. Our work found, for example, that 17 percent of
the expenditure line reporting for personal care services was
incorrect.
Mr. Ruiz. Would you say this is the number one most
impactful way to start providing oversight for potential fraud
and abuse, is if we were to focus on one thing would it be the
data collection system, Mr. Hill?
Mr. Hill. For me, I mean we are focusing on it now and it
continues to be a priority. You can't run a program of the size
and scope of Medicaid without good, accurate data.
Mr. Ruiz. So what do you need to finish this in a timely
manner?
Mr. Hill. We need the continued cooperation of States to
get their data in and to do the work they need to do to get the
data in a timely way and we have that and we'll continue to
work with them.
Mr. Ruiz. Thank you very much.
Mr. Murphy. Mr. Collins, you're recognized for 5 minutes.
Mr. Collins. Thank you, Mr. Chairman. I want to thank the
witnesses also.
Now I'm a private-sector guy. I spent 30 years in the
private sector and at one point I also was the county executive
of the largest upstate county in New York. It was bankrupt. I'm
a Lean Six Sigma guy. I brought Lean Six Sigma into a large
municipal government for the first time in the United States
about 8 years ago. And it worked. But we also had a program
called Just Do It. We would put together a team of a lot of
different commissioners and we'd deep dive some issue that
touched on a lot of different departments and it would take us
6 months. And then every once in a while we'd come up with what
we'd called the Just Do It. It was so obvious, so direct. We
knew the problem. We really knew 90 percent of the solution. We
said why are we going to waste our time with this 6 months'
program. Let's just do it.
And kind of sort of what I'm hearing today is a lot of just
do it. So what am I missing here? The Federal Government sends
money out to the States. In the case of New York, our program
is $60 billion a year. So with 6 percent of the Nation's
population, we spend 12 percent of the Nation's Medicaid money
and it just keeps flowing.
In the private sector, if I have a vendor and he sends me
an invoice and he doesn't have the proper numbers on it, I
don't pay it. If he sends me an invoice and whatever
requirements that I've had aren't there, I don't pay it. So
here's my just do it.
Now no disrespect intended, but why are we wasting our time
analyzing 2012 data? It's worthless. Completely, utterly
worthless. There's nothing to compare 2012 to 2017. If we've
got a bunch of people crunching 2012 data, if I'm Tom Price or
Seema Verma, I'd go what? Are you joking me?
So if we've got the power of the purse strings, why don't
we just stop paying people, sending money to States who don't
adhere by our responsibilities? The requirements. Why don't we?
Why don't we?
OK, there's my just do it. I call you and I say we're just
going to do it. No money goes out without the data in a timely
fashion. Thirty-five States--well, 15 States--just wouldn't be
getting any more money. If you start cutting off the flow of
cash, you will get their attention and you will get your data.
You'll get your data in a timely fashion. And if you have--I'm
just somewhat dumbfounded by this. The solution is staring us
in the face and we're sitting here talking about something. I
don't get it. What am I missing?
Ms. Iritani. Well, we agree that CMS needs to take
immediate steps to----
Mr. Collins. So why don't we do it? Do it today. Is there a
reason? We can do it today.
Ms. Iritani. To improve the data, yes.
Mr. Collins. Today.
Ms. Iritani. And to issue guidance to States on standard
elements that they should be reporting.
Mr. Collins. Require that the attendants register. And if
there's not a number, they don't get their money.
Ms. Iritani. There has been a longstanding, also, interest
in making sure that there is access to services.
Mr. Collins. We do. But money talks.
Ms. Iritani. Yes.
Mr. Collins. The minute you cut off the funds, I mean,
that's what I find. When we talk about waste, fraud, and abuse,
and we find that the Federal Government is sending this money
out and then we're finding out after the fact through data
that's 5 years old when in the case of 15 States they don't
submit data, you know where the problem lies, in CMS, for
sending the money out, for approving the voucher. Don't we have
to approve payments?
Mr. Hill. So a couple of issues to unpack there, and I
think it's a fair comment and it's a true comment that the
money speaks. Right? And if we withhold funds, States are
definitely going to get somebody's attention much quicker than
other corrective actions. I think for us to consider, as we
talk to States and try to--particularly on their compliance
issues, not so much now talking about program abuse of
providers, billing inappropriately.
Let's talk about States meeting our requirements, for
example, for submitting data. We try very hard, recognizing
it's a complex system to get States to get into compliance in a
way short of having to withhold the funds. It's sort of
nuclear, right, to say we're immediately going to go to
withholding funds from the State of New York or any other
particular State without first going through as much as we can
with the State to be sure they've got all the TA, all the
information they need, all the help they can get from us to get
into compliance. If after that, they still are unwilling or
unable to come into compliance, then the purse strings is
definitely the place that we go to sort of make sure that we
have their attention.
Mr. Collins. And I do agree. You want to give somebody at
least a glide path, 3 months, even 6 months, but to hear that
we're analyzing 2012 data, I mean what a tragic waste of time.
2012 doesn't tell you anything about 2016, '17. I mean truly
not to be insulting here, I think we could get there very
quickly. I'm certainly hoping that Tom Price and Seema Verma
get there quickly and this has been kind of eye opening again
in a frustrating way.
Thank you, Mr. Chairman. I yield back.
Mr. Murphy. Thank you. I now recognize the gentlewoman from
Illinois, Ms. Schakowsky from Illinois.
Ms. Schakowsky. I want to thank all of our witnesses. First
of all, care services are incredibly important and I really
want to emphasize that, even as we try and make it better, I
hope all of us are really committed to making sure that those
services are provided.
In Illinois, we have the Community Care program which is
one of the home and community-based care services provided by
the Medicaid benefit, to Medicaid beneficiaries and provides
services to about 84,000 individuals.
We also know that these are the very programs that often
are slated for huge cuts. In Illinois, unfortunately, we
haven't had a budget for 2 years and Governor Bruce Rauner
proposed cutting $200 million from the Community Care Program
in his budget proposal which is one of the many reasons
Illinois hasn't had a budget.
In addition to funding for those programs, a high quality
personal care workforce is absolutely critical to ensuring that
beneficiaries have access to the services they need. As GAO has
reported, many of the personal care service programs differ
from State to State. We know that. And that includes the
training or lack thereof that service agencies provide to the
workforce. In some States, training is offered or required,
either for new entrants into the workforce or for continuing
education of existing workers. In other States, there's
actually little or no guidance on training or continuing
education for those workers.
Mr. Hill, let me ask you, have you investigated what
percentage of agencies providing personal care services in
Medicaid have orientation or training programs that are in
place?
Mr. Hill. So as I sit here, I couldn't give you statistics
by State where those requirements lie, which States require
that and which particular agency.
Ms. Schakowsky. Let me ask Ms. Iritani, do you know that or
either one of you know that?
Ms. Iritani. We know that it varies, yes.
Ms. Schakowsky. OK. But you don't know.
Ms. Iritani. No.
Ms. Grimm. An analysis that we did in 2010, we did find 301
sets of qualifications across States.
Ms. Schakowsky. OK, and that would include the kind of
orientation and training programs?
Ms. Grimm. It would include that in the qualifications.
Ms. Schakowsky. Back to Mr. Hill. Do you know what
percentage--or any of you know what percentage of those
specifically educate their employees and what constitutes
waste, fraud, or program abuse?
Mr. Hill. As I indicated earlier in response to a question,
we have issued guidance to States on best practices. While I
can't say which States require it as I sit here, I could not
tell you which States require that level of training. We have
identified for States that training, particularly around
compliance issues, is the best practice for attendees. And we
would expect that States would require that of particularly the
attendant agencies to be sure that the folks that are coming
into those agencies are properly trained, not just for patient
safeguards, but also on the compliance side.
Ms. Schakowsky. Well, what it seems to me is that the word
has gone out that this would be important, but nothing has been
done really to enforce that or to even survey that to find out
who's doing exactly what when it comes to worker training.
Finally, I just want to note that when a worker comes
forward to report cases of waste, fraud, or neglect on behalf
of the personal care agency they work for, I really think that
it's critical that they are provided whistleblower protections.
And again, to any of you, I'm just wondering if
whistleblower protections are built in.
Mr. Hill. Speaking for CMS--and I'm sure the IG and others
would have it--we review tips and whistleblower complaints as
valuable sources of information as we conduct investigations in
concert with our law enforcement partners. I think the
whistleblower protections vary by State in State law and that's
something that--we value those sorts of activities highly, and
it's something that we would encourage States to continue to
support.
Ms. Schakowsky. Well, again, are they protected by law if
they were to come forward?
Mr. Hill. On the whistleblower side, I think it's a State-
by-State determination as to how the State whistleblower laws
apply.
Ms. Schakowsky. Well, then let me just say I think we need
to standardize that because one of the ways that I think that
we can make the program operate effectively without waste,
fraud, and abuse is to protect the out front, the upfront
workers that are doing it because they are the most likely to
see it.
In my experience with those home care workers is that these
are really dedicated people who are doing often for very little
money some of the most important work in our country and I
yield back.
Mr. Murphy. Thank you. I now recognize Mr. Walberg for 5
minutes.
Mr. Walberg. Thank you, Mr. Chairman. Thanks to the panel.
My wife and I were extremely concerned when a personal care
worker stole a credit card from my mother and that was a deal
from that point on dealing with the bank and then dealing with
the court system. But I was disturbed, as I read the released
investigative advisory coming from OIG, that there are
significant number of instances where PCS workers steal
painkillers and other medications from their beneficiaries.
In the case, Ms. Grimm, that you noted in 2016 in Vermont
specifically, how did OIG discover that?
Ms. Grimm. So Vermont, that involved the husband. It was a
wife, the beneficiary was a husband and the wife was splitting
payments with the care attendant and as part of that scenario
she would get or he would get pain pills as a form of payment.
I don't know how that came into our office, but that was the
scenario that was uncovered.
Again, going back to some of the recommendations that we've
offered, had there been a background check in place, it would
have revealed a pattern of drug abuse.
Mr. Walberg. How often is this happening? Is this a common
occurrence that you're finding?
Ms. Grimm. I think fraud is very common in personal care.
We've opened 200 investigations since 2012 and our Medicaid
Fraud Control Units, it comprises one third of their criminal
convictions and have upward of 8,000 cases that have been
opened in that time frame.
Mr. Walberg. Are the painkillers that are stolen generally
used by the individual themself or are they selling this?
Ms. Grimm. We've seen patterns of both of them using
painkillers for themselves and then also selling those. Drug
diversion is a big issue in the fraud that we see.
Mr. Walberg. Yes, and that's a concern when we see about
the opioid problems, etcetera. The OIG recommended establishing
some minimum Federal qualifications and screening standards for
PCS workers. What kind of minimum qualifications do you have in
mind?
Ms. Grimm. We have recommended minimum age requirements,
background checks, and we endorse training. Just to sort of de-
mystify things, all of those things right now are voluntary.
They're not something that's required at the Federal level, so
to the extent that it's happening, it's the State sort of
acting on it. It is not currently required at the Federal
level.
Mr. Walberg. With the screening and the background checks,
it makes sense to prohibit individuals with felony convictions
for drug-related crimes and social services fraud. Is that part
of your recommendation?
Ms. Grimm. We have not specified, but there are guidelines
in place for care workers that have direct interaction with
patients in the home health context. And I think some good
parameters could be taken from that context.
Mr. Walberg. OK. It seems like that would make sense.
Mr. Hill, is CMS able to enact stricter standards?
Mr. Hill. We can certainly regulate. The question is how to
regulate. As you know, we issued our request for information
last fall, asking all the affected stakeholders on these very
particular issues about whether or not Federal standards for
enrollment or background screening or any number of things that
the IG has recommended should be put in place.
As you know, it's a tension between State flexibility and
the flexibility of any particular program in terms of who it is
and how it is they're overseeing those programs and the
imposition of a Federal requirement. So before we were to
implement a Federal requirement, we want to be sure that it's
going to meet the needs of all the States, both from a program
integrity standpoint and also from the service delivery
standpoint as well.
Mr. Walberg. Well, I appreciate that. I guess I would echo
some of Mr. Collins' statements as well that it's time to push.
And as you indicated as well, the financial push is sometimes
the best way to get these recommendations dealt with and the
States to get on board. Because it's one thing for an elderly
lady with dementia to lose her credit card. That can be fixed.
When you get into in this particular area of medications,
painkillers, getting out and misused, it impacts lives and
maybe get a good handle on that.
Thank you. I yield back.
Mr. Murphy. Thank you. I now recognize Ms. Clarke for 5
minutes.
Ms. Clarke. Thank you, Mr. Chairman. Mr. Chairman, I'm glad
that we've had the opportunity to talk about the Medicaid
program and how many people it helps across the country.
Roughly 74 million Americans depend on Medicaid for healthcare
coverage and the program is a lifeline to these individuals.
The Affordable Care Act authorized States to expand
Medicaid for low-income adults, helping to fill a major gap in
insurance coverage. As a result, more than 12 million low-
income adults were able to gain coverage last year.
As Republicans are contemplating repealing the Affordable
Care Act's Medicaid expansion and making sweeping changes to
Medicare, I'd like to put this program in context.
Mr. Hill, CMS has reported that the ACA's Medicaid
expansion has helped reduce the rate of uninsured to its lowest
level in our Nation's history. Is that correct?
Mr. Hill. That's correct.
Ms. Clarke. And in a report this past January, CMS stated,
and I quote, ``Medicaid is the most efficient healthcare
program we have, covering people at lower costs than commercial
insurance coverage or even Medicare. And at the same time
Medicaid has that proven track record of enabling access to
care, improving health, and helping children succeed in life.''
Mr. Hill, do you agree that Medicaid is an efficient
program and that is covers people at lower costs than Medicare
and commercial coverage?
Mr. Hill. My judgement is that Medicaid is an important
program doing a lot of good for the 74 million people that we
cover.
Ms. Clarke. In CMS' January report, the Agency stated,
``Research has shown that Medicaid expansion has helped improve
quality, access, and affordability of care.''
Mr. Hill, can you briefly explain how the Medicaid
expansion has improved the healthcare coverage of its
beneficiaries?
Mr. Hill. Without speaking directly to the January report,
let me just say that as a general proposition somebody who is
covered, whether they're covered through the marketplace or
whether they're covered by their employer, they have coverage
through Medicaid. If you have health insurance coverage, you
generally are going to be in a better place vis-a-vis be
uninsured, particularly if you get sick.
Ms. Clarke. So in addition to expanding Medicaid coverage
to millions, the ACA also created the Community First Choice
program. This program encourages more States to offer personal
care services by providing an additional six percent Federal
matching payment to these services. Unfortunately, in addition
to gutting the entire Medicaid program, one provision of
Trumpcare would actually repeal this option.
Ms. Iritani, I understand from your report that States have
begun to participate in the Community First Choice program, is
that correct?
Ms. Iritani. That's correct.
Ms. Clarke. Can you tell me more about States'
participation in this program?
Ms. Iritani. Well, we know from our work that eight States,
as of the time of our report, were participating in the
Community First Choice program. And one of the concerns we have
leading to our recommendation about harmonizing requirements is
making sure that for those people who are in that program who
require institutional level of care that the safeguards are in
place to ensure beneficiaries' safety are similar to other
programs that have served similar beneficiaries, because many
States are moving their beneficiaries from waiver programs that
have really strong or stronger safeguards into the Community
First Choice program.
Ms. Clarke. So you're saying that the Community First
Choice program doesn't have strong safeguards?
Ms. Iritani. I think that it doesn't have the same level of
safeguards as others, other programs' authorities.
Ms. Clarke. Are you saying that you believe that that may
put some of its participants at risk?
Ms. Iritani. We recommend that CMS actually needs to
harmonize the requirements in place between programs to ensure
that common risks for beneficiaries, depending on their level
of need, are addressed in common ways across the programs.
Ms. Clarke. And the Community First Choice program, do you
believe that their services are less than traditional?
Ms. Iritani. No, we did not do that work, no.
Ms. Clarke. OK. Mr. Chairman, I hope my colleagues
recognize the importance of this program, how many people rely
on Medicaid for their insurance. Trumpcare proposes to
dismantle the Medicaid program as we know it, capping coverage
for children, pregnant women, individuals with disabilities,
and of course, those who have gained coverage from the Medicaid
expansion, not to mention Medicaid is the primary insurer of
long term care services and support in this country.
I hope my colleagues will reflect on that point and the
immense responsibility we have to strengthen Medicaid and not
tear it down. And I yield back.
Mr. Murphy. Thank you. I now recognize Mr. Costello for 5
minutes.
Mr. Costello. Thank you, Mr. Chairman. Ms. Grimm, Mr. Hill,
between 2014 and 2015, the improper payment for personal
support services which includes PCS, as you know, nearly
doubled from 6.3 percent in 2014 to 12.1 percent in 2015.
That's a lot. Why did the error rate increase at such a level
in your opinion?
Mr. Hill. So some of it will have to do with measurement,
right. That's not necessarily a statistically significant way
to measure those services. I'm not discounting the fact that
there's an error rate meaning to worry about it, but just as a
technical matter, it's hard to make comparisons year to year
the way the PERM rate is put together.
I also think that the roll out of requirements around
requiring ordering and referring physicians on claims began to
get implemented over that time period. And so while in PCS that
may not be an issue that category of services you had
identified, there are claims in there that require ordering the
referring physician to be on the claim. And I know States have
had a struggle coming into compliance with that requirement.
Ms. Grimm. I missed it, did you say Ms. Iritani or Ms.
Grimm? I'm sorry.
Mr. Costello. Ms. Grimm.
Ms. Grimm. So the work that we've done, so we've looked at
error rates in personal care services across eight States, and
we have consistently found very high error rates in personal
care services.
Looking at recent information, Missouri, upwards of 47.8
percent in error rate; New Jersey, 30.9 percent; New York City,
18 percent. And this is consistent across States. So I think
the core point there is that we do find high error rates in
personal care services, so it's unsurprising that the error
rate in PERM is what it is for personal care.
Mr. Costello. Thank you. The Electronic Visitation
Verification piece of the Cures Act I think holds great
promise, and I would ask you to share, for those watching, the
EVV captures exact time, date, location, and duration of each
visit.
The question--and there are several, so I'm just going to
go through them and then open up to all three of you--is, where
is CMS in the process of implementing that change and how much
flexibility do States have? How much flexibility should States
have in how they choose to use EVV? What enforcement mechanisms
will CMS use to ensure State compliance with implementation by
2019? Have you see any success stories so far? And finally, how
can Congress be helpful?
For GAO and OIG, do you believe EVV implementation will
help curb fraud and result in more complete, accurate, and
timely data and do you care to elaborate on any GAO or OIG
recommendations to ensure smooth EVV implementation?
So Mr. Hill and then right on down the line with those
questions.
Mr. Hill. Let me take these in turn. In terms of State
flexibility and what we need to do to implement the provision,
as you know, the effective date is 2019 with respect to the
financing of EVV. And so between now and then we'll be
regulating and as part of that process we'll have to make a
determination as to how much flexibility, if flexibility is
given to States in terms of how we implement. So there's a lot
of policy work that we need to do in terms of the State
flexibility on EVV.
The enforcement here is withholding FFP. As you know, the
statute articulates if the State doesn't have a program, we can
reduce the Federal share. In terms of success stories, we know
there are two States, Missouri and Texas, already who have
begun rolling out EVV. We're working with them and learning all
we can for how those particular States are rolling this out so
that we can expand those successes and lessons learned in our
oversight activity.
Ms. Iritani. I can't speak to the implementation of EVV,
but what I can speak to are the benefits. We spoke to four
States, two have EVV in place. They spoke of cost savings when
they implemented it, improved timekeeping, more accurate
timekeeping, more accurate data, and absolving the beneficiary
of the responsibility of having to record time charges.
Additionally, EVV can help ensure that there is a process
for notifying the agencies if an attendant doesn't show up.
Mr. Costello. Have you offered any--will GAO be offering
any recommendations as it relates to implementation?
Ms. Iritani. We don't have current work on that.
Ms. Grimm. Implementation is going to be key. I think that
we've heard that just because the requirement exists doesn't
necessarily mean that the data are going to be collected and
that they're going to be reported and that there are any usable
time or usable way to be used. Reduction in--so in that
enforcement mechanism, the reduction in FMAP for EVVS is also
going to be important. The enforcement authority, without the
willingness to act on that enforcement authority, I think poses
a little bit of an issue. But certainly the data that EVVS
collects, that verification of services will go a very long
way. A lot of our fraud schemes show that they're billing for
services that were never rendered.
Mr. Costello. Have you or will you be sharing your
recommendations on usability with CMS to make sure that the
data is in a workable manner for you to be able to audit?
Ms. Grimm. We don't have any work specifically devoted to
EVVS right now, but we do have a report looking at T-MSIS that
is very close to completion that will point out issues related
to complete list, accuracy, and timeliness.
Mr. Costello. Thank you.
Mr. Murphy. Thank you. I now recognize Ms. Brooks for 5
minutes.
Ms. Brooks. Thank you, Mr. Chairman. It was actually 2012
to Mr. Collins' point earlier relying on data, but in 2012 it
was when HHS Office of Inspector General released the portfolio
highlighting waste, fraud, and abuse in the PCS program and to
date, CMS has yet to implement four of the recommendations. And
I'm not going to list all of them or read through all of them
because I want to get to the questions, but they include
reducing significant variation in the State PCS attendant
qualifications and improving CMS' and States' ability to
monitor billing and care quality.
I can go into greater detail if you don't know which four,
but you know which four. So rather than spend my time on that
since it's been nearly 5 years since these recommendations for
improving PCS were suggested and while I appreciate that CMS
has adopted some of the recommendations, there are still these
four.
So Mr. Hill, why has CMS not adopted all of the HHS OIG
recommendations after nearly 5 years? And do you disagree with
any of the recommendations?
Mr. Hill. So obviously the controls that the
recommendations are articulating are controls we'd like to see
States have in place.
The question for me is, it's not--so there are four
recommendations, but overarching all of them is CMS is showing
a Federal standard and regulating here and requiring States and
holding States accountable to those four standards. And it's
that balance that we're trying to strike here as to whether or
not we should regulate and create a Federal standard or whether
or not we should be allowing States as they are now or
requiring States to have more stringent standards at the State
level. So it's not a disagreement necessarily with the fact
that we ought to have standards for attendant qualifications.
The question is should that be a Federal standard or should
that be a standard that's left to the State with us ensuring
that the State is following through on that and complying.
Ms. Brooks. And while I understand that that's what the
differences are, it's been 5 years since the recommendation
came out and so what is the problem? Is there an internal
deadline at this point for CMS to adopt these recommendations?
Mr. Hill. So we issued a request for information last fall
after a lot of conversation with the IG to gather more
information on the question that I just articulated, in terms
of Federal standards or not. We're going through that
information and the data that we gathered as part of that RFI
and we'll be considering that as we move forward in the
regulatory agenda for Medicaid generally.
I should just be very clear, there's not an internal
deadline for when we have to have a reg out or not. We're going
through those comments now.
Ms. Brooks. Would you agree that a lot of people work best
when there are deadlines?
Mr. Hill. I do. I understand the point, yes.
Ms. Brooks. So that might be something you might consider
at this point after 5 years is setting a deadline?
Mr. Hill. I will be sure to raise that. I can't set the
deadlines. I'm a deadline follower, but I do report to the
folks who set deadlines.
Ms. Brooks. And you talked about the qualification issue,
what about is that a similar problem with respect to the
monitoring of the billing and care quality?
Mr. Hill. The data and information on claims, all the
controls that the IG has quite appropriately identified, we
have to regulate if we were going to have to require a State to
implement those.
Ms. Brooks. Ms. Grimm, and so Mr. Hill has talked about
have there been conversations between OIG and Mr. Hill and
others at CMS regarding the length of time that's passed since
you've issued these recommendations and have there been any
reasons as to why you believe there's been a delay that we
could maybe address in implementing the recommendations?
Ms. Grimm. We have a number of processes in place for all
of our unimplemented recommendations to follow up on the status
of those recommendations. We have met beginning in November
2015 with CMS leadership in person many times to talk about
options and possible solutions.
Ms. Brooks. So you're following your processes for
following up on recommendations. What has been the primary
reason for delay in moving forward since it's been years and
you've been following your process since November of '15?
Ms. Grimm. We certainly have provided a lot of technical
assistance to CMS. I think that's a great question for my
colleague, Mr. Hill.
Ms. Brooks. Mr. Hill, so we'll bring it back to you.
Mr. Hill. I fear I will not have a satisfactory answer for
you to be able to say exactly why a reg hasn't been
implemented. As you know, we sort of went through sort of a set
of conversations last year. We've now had a transition. We have
a new administration and we're beginning to think about what
that agenda looks like.
Ms. Brooks. I'll be anxious to see with respect to those
that you work with at CMS that we've set an internal deadline
and move forward on many of these recommendations. With that I
yield back.
Mr. Murphy. The gentlelady yields back. And I now recognize
Mr. Carter for 5 minutes.
Mr. Carter. Thank you, Mr. Chairman, and I thank all of you
for being here. You know, I think we've established the fact
that the personal care services are extremely important. Before
I became a member of Congress, I was a practicing pharmacist,
so I had some experience with this, particularly in the way of
medication management and drug therapy. I was also a consultant
pharmacist, as well as being a community pharmacist. And one of
the primary reasons that people are admitted to a nursing home
or to a personal care home is medication management. It's one
thing that we have to be careful of.
Representative Walberg alluded to some of the abuse and
certainly I have witnessed some of the abuse that can take
place with that, but I've also witnessed a lot of the benefit
that it can have. And the benefit of allowing someone to stay
in their home and not having to be institutionalized, it's a
great benefit to them personally and it saves money for a lot
of us, but obviously, there is a lot of room in that particular
scenario for abuse and for fraud. And it's difficult. I get it.
I understand it's difficult to identify that and hopefully our
healthcare professionals such as pharmacists are helping us
with that. And whenever they might see a trend or a tendency
there where medication goes missing or someone is not getting
their medication, maybe a physician can identify why is your
blood pressure going up, you know? Are you getting your blood
pressure medication or something and why is your pain level
going up? Perhaps they're not getting it like they're supposed
to. But nevertheless, I agree it is a good program, but it is a
program that obviously we wouldn't have you here today if we
weren't looking into the fraud, the waste, and the abuse that
exists in the program.
I want to start by very quickly talking just about the
self-directed Medicaid service models because as I understand
it a lot of the fraud that's involving the personal care
services is conspiracy, if you will, between the PCS and the
beneficiary.
Tell me, Mr. Hill, what has CMS done to combat that? What
can you do and what's been beneficial and what's worked?
Mr. Hill. So self-direction--I think, particularly for
those of us, myself included, who have sort of spent a lot of
time thinking about the medical model and how we do insurance
and provide services, self-direction is sort of the most out-
of-the-envelope way to think about how people are getting
services. You know, having a beneficiary pick and understand
and have a lot more control over who's coming into their home
and how that service is being delivered is a challenge.
Sometimes, as we've identified a family member or a friend, so
there is a range of things that we've done to help, not just
beneficiaries, but States and agencies who are sometimes
involved in that model to build in practices and policies to
mitigate against abuse.
We've talked about training. We've talked about compliance
work with the folks who are doing the service work. Some
States--and many States--have requirements for enrollment and
background checks, all of the things that we've talked about
work in self-direction as well as they're going to work in
agency. But again, because the beneficiary will be at the
center of that planning, at the center of identifying who is
coming into their home, the self-directed model is one that
provides, presents unique challenges.
Mr. Carter. Ms. Grimm, let me ask you, it's my
understanding that most of the fraud is proven through by
showing--most of the fraud is by people who have come and
actually testified and through referrals from individuals who
have turned them in, if you will. How can Health and Human
Services do a better job with that? Is there anything? How can
we incentivize people to report these types of abuse or fraud?
Ms. Grimm. I appreciate your question. I think yes, it is
true that a lot of the fraud that we see is in self-directed
models. They've shored up a number of different requirements
for self-directed so that things like the flow of cash isn't as
easily sort of shared with others. So CMS has taken steps in
that regard. But it would be easier, consistent with our
recommendations for us to know who we're doing business with.
Right now, we don't know the identities and the dates and the
types of services being provided at the attendant level. So
that's something that I think is critically needed for
oversight.
Mr. Carter. Great. Well, my time is about up. But again, I
want to stress that I've seen the benefits of this program. The
benefits are good. But I hope that we can do something to
address some of the problems that we have because I've also
seen the fraud that exists in there and it does exist. And
trying to get those bad actors out is difficult, but we need to
get them out. Thank you very much and I yield back.
Mr. Murphy. The gentleman yields back. I want to thank our
panel here. This has been very enlightening for us, and I want
to follow up on my friend and colleague's recommendation that
we bring the States in. We would look forward to hearing from
you if you have suggestions of what States that might be, so we
can hear about what's working, what's not working. And in the
meantime, please let us know if there's other things we need to
pay attention to.
I thank all of the witnesses and all the Members who
participated in today's hearing. I will remind Members they
have 10 business days to submit questions for the record, and I
ask that the witnesses give us timely responses to those and
respond promptly to those questions. And with that, this
subcommittee is adjourned.
[Whereupon, at 12:04 p.m., the subcommittee was adjourned.)
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