Could New Not-for-Profit Requirement Limit Patient Access?

by David Gorn

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State health officials recently outlined new requirements for the transition of adult day health care centers into the nascent Community Based Adult Services program. They include the stipulation that centers must be not-for-profit to qualify for Medi-Cal funding.

Many centers are for-profit, particularly in Los Angeles County where the bulk of day care beneficiaries live. Advocates worry the change could decrease access to care if for-profits are unwilling or unable to make the conversion to not-for-profit status.

Elissa Gershon, a senior attorney for Disability Rights California, said the new not-for-profit requirement could make it difficult for some beneficiaries to find care.

"Our concern is that people have access to providers, you can't have a limitation that excludes providers," Gershon said. "It depends on how this is implemented, if it can allow enough for-profits to transition to CBAS (not-for-profit Community Based Adult Services centers) because right now there are very few open nonprofit slots."

Disability Rights California sued California over the state's transition plan after the state elected to eliminate adult day health care as a Medi-Cal benefit. The state Department of Health Care Services and Disability Rights California settled out of court last month. The CBAS program was created as part of that settlement.

According to Norman Williams of DHCS, there is a strong department effort to help convert for-profit ADHC centers into not-for-profit CBAS centers. He said the requirement will provide exceptions to the rule so that access will be ensured.

"We are concerned about access, that's at the top of our list," Williams said. "We consider access to these services vital. ADHC was founded as a nonprofit, so this takes it back to its original status, its original focus, and moves us toward more consistent accountability, more consistent documentation and better delivery of care."

There are three types of exceptions, Williams said. "One of the exceptions is specialization," he said. "If a center serves a specific health need that can't be met by other centers in the area, it may qualify for an exception."

The other exceptions can be made to ensure an adequate number of CBAS centers, or to mitigate delays in the nonprofit conversion process, Williams said.

There are an estimated 193 for-profit ADHC centers in California -- with a disproportionately high number of them in the L.A. area -- according to the California Association of Adult Day Services. There are about 99 not-for-profit ADHC centers in the state. It's too early to know how many of those for-profits can convert, state officials said.

Many centers have shown strong interest in making that conversion, Williams said. "We just announced this recently, so we are still hearing feedback from the centers themselves. But we were encouraged by the number of centers who were interested in this."

The question for Gershon is around how many exceptions will be made.

"The state does have these exceptions," she said. "They could be big enough to drive a truck through, or not."

If the number of eligible CBAS beneficiaries and the demand for CBAS slots exceeds the number of center slots available, then obviously the state would have an access problem, Gershon said. And one of the advocate concerns is that the assessments to determine CBAS patient eligibility might be compromised by a lack of available services.

"We will look really closely to make sure the assessments are done independently of any other circumstances," Gershon said. "A pure assessment process is core, it's the key to the whole thing."

The transition from ADHC to CBAS is a process, she said, and the new requirements ensure the state gets some of the accountability it wants, while the new CBAS centers are designed to maintain a level of service for ADHC patients and providers. "There has been a lot of collaboration between ADHC providers and the DHCS," Gershon said. "And people can file for hearings if they have problems [getting access]. So there are a number of these checks and balances in place."

susan smith
Let us hope that the outcome of this settlement is culturally and evidence-based appropriate care. Too often, low-income folks get the short end of the stick by not getting adequate care, and end up back in the ER. There has to be extra education taken to help recipients of the Medi-Cal benefit understand their treatments and medications, and to fully comprehend the options available to them at an affordable price.
Vladimir Yepishin
Hopefully the Administration has the strong enough reason for the conversion for-profit format to the non-profit one and will help the for-profit providers to do it. At the same time, hopefully the Administration takes into account that all extra tasks it puts on the providers are reducing the providers’ direct care ability. Therefore if there is some opportunity to avoid the conversion of for-profit to non-one it would help the providers’ healthcare quality and reduce the risk of conversion the cost effective CBAS healthcare to the expensive institutional one.

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