MONTICELLO, NY — Sullivan County Public Health Director Nancy McGraw painted a harsh picture: lost revenue for the county. The county’s long-term home health program might go away. And the most vulnerable, the sickest, and those who live in far-flung parts of Sullivan could suffer the most.

This was the picture she sketched out—again—about what it would mean for the county to lose its certified home health agency (CHHA). The presentation at the November 12 Health and Family Services committee meeting sparked acrimonious discussion. The issue ran up against the concern of at least one legislator that residents weren’t being served. Images of tax dollars lurked in the background.

While it was broadly similar to McGraw’s presentation in September, the public health director was also speaking on behalf of the Health Services Advisory Board (HSAB). She had new information and representatives from the HSAB added detail as well. 

The emphasis, over and over, was on how critical it was that the CHHA remain county-owned. 

It’s “a safety net for vulnerable residents and the uninsured,” McGraw said. It reaches out to all parts of the county; nurses can drive 50 miles or more between a day’s appointments. The CHHA serves everyone, no matter how complex the care. No one is turned down. 

Moreover, the nurses also work in response to the Public Health Department and public health needs. McGraw cited a tuberculosis outbreak in one of the adult homes. Public health nurses had to be out dealing with it, preventing community spread, within 48 hours. CHHA nurses also run vaccine clinics and assess people for nursing home placement. 

Privately-owned home health agencies, on the other hand, can cherrypick, McGraw said. They can sign on high-reimbursement patients rather than those with dementia or the uninsured. They can refuse complicated, high-tech cases that are too time-consuming. 

A public health nurse handles many complex cases, from tracheostomies to severe birth defects to vacuum-assisted closure of a wound. “Private companies don’t do these treatments,” one nurse testified during public comment. “Please stop looking at numbers and look at people.” Private companies can also refuse patients who live too far away. 

It is also a matter of dollars and cents. Moving the CHHA to a private manager would also cost the county money, McGraw said. “If the CHHA is privatized, the long-term home health program would have to be divested as well, unless it’s run by a nursing home,” McGraw said. 

At the moment, that program is down to five or six patients due to changes in Medicaid-managed care in New York. 

Even if that program is lost as well, public health would have to create a new home-care program for its maternal and child health clients who are now cared for by the CHHA. That move would require eight replacement nurses, McGraw said. 

Those nurses would also handle vaccinations (rabies, measles, flu, eventually COVID-19) but hiring and training new nurses “would be an additional cost to the county.” A rough estimate, she said, would be $500,000 to $800,000. 

No one put a cost on the care that residents who did not qualify for a private CHHA would potentially lose. Some wondered how that would affect the county’s improving health rankings. 

Higher-reimbursement care received through the CHHA also helps pay for overall public health costs. Without the CHHA, the department would lose $1.696 million in revenue.

Benchmarks

Legislative Chair Rob Doherty brought up national averages, pointing out that the county’s rural CHHA fell short in 2018 and arguing that a private manager would run it more efficiently. 

But Sullivan County is poor. “We have residents who can’t afford to pay,” McGraw argued back. 

Not hitting benchmarks means we’re underserving our communities, Doherty replied.

“We made a profit” before Medicaid-managed care, McGraw said. 

An argument ensued and emerged periodically during the rest of the meeting: legislators pointing out that this was a service and shouldn’t be expected to be profitable, and Doherty responding that it was about the CHHA not hitting national benchmarks, thus not caring properly for its clients. Health and Community Services committee chair Nadia Rajsz and legislator Ira Steingart argued that new management should be given time to turn things around, both in the care center and the CHHA. 

Recent numbers, Steingart said, “have been closer to the average that Rob’s looking to get.” Steingart has expressed dismay with the speed with which the county chose to outsource the management of the care center and CHHA. “It went right to having a company come in,” he said.

Some background points to consider:

Medicaid-managed care has been around since the 1980s and has slowly taken over the Medicaid program in New York. A majority of recipients now get their care through private companies that administer Medicaid. Advocacy groups argue that this has brought poorer health outcomes as managed care limits access to treatment, especially in the last few years. 

(More information on the problems with long-term care and advocacy can be found at www.cdpaanys.org, www.cssny.org and www.nursinghome411.org.)

Considering the aforementioned benchmarks, it wasn’t clear what rating system everyone was talking about. But Medicare.gov, whose star rating is used to compare nursing homes and home health agencies, points out, “These star ratings are different from the consumer ratings that you see on websites for products like books, restaurants, or hotels that reflect averages of consumers’ opinions. Since the star rating ranks all agencies from lowest to highest, some agencies will be ranked below others even though they’re providing good-quality care.”

However, McGraw, the HSAB and commenters said that comparing home health agencies is tricky. Some are municipally-owned, like the CHHA, some are not-for-profit, some are private. Are they serving the same people? Are the roads lousy and distances far? Does winter weather make traveling tough? 

The Health Services Advisory Board weighs in

Members of the HSAB are appointed by the legislature to advise the county health director with respect to the discharge of powers, responsibilities and duties. They took a turn to speak. 

Joan Patterson read a letter from Dr. Bruce Ellsweig, head of the board, who wrote that “eliminating the CHHA would have a profound and dangerous impact on our ability to care for our citizens,” and criticizing “a lack of appreciation for what Nancy McGraw has done.” 

Dr. Larysa Dyrszka talked about the care recipients who were unable to come in person and asked the legislature to consider the economic impact of poorer health.

Carol Ryan, former head of Public Health, asked how the legislature could cut the department in the midst of a pandemic. “I think it will have a chaotic, disruptive effect,” she said. “You can call and mobilize [the nurses] at a moment’s notice.”

Referring to the benchmarks, she said, “You realize, in a rural area, we’re always going to come up short compared to urban areas,” which have more resources and a higher patient density, so multiple visits can be accomplished within one building. That makes a home health agency look more productive. 

Public comment, sampled

Ken Walter: “We’re the boss, we vote for you. Why aren’t you telling us the information you’re supposed to be sharing?”

Sandy Oxford: “Anything you do in this community is a heavy lift” due to poverty. “We’re going to get the truth out, for our neighbors have relied on the public good.” She asked why, in this anxiety-filled time, it was necessary to lease the care center and CHHA. “I don’t understand.”

Lou Setren pointed out that sale language is still in the resolution and request for proposal. He addressed benchmarks and added that “we need to give those folks who are professionals in this area the opportunity to improve, and they have improved.”

Both Setren and Catherine Scott asked why their requests for a consultant to look into ways to improve the care center were ignored, but the county is hiring a consultant to look after its financial interests in the lease.

And legislator Luis Alvarez remembered the elderly he found dead at home when he worked for the sheriff’s department. He talked about one lady in particular. “Sometimes the only connection she had was that nurse... We are there for them and we are abandoning them.”