13 December 2017

Home care packages and the tyranny of choice

TheHill

If there are three words which perhaps best summarise the philosophy behind Consumer Directed Care it is control, flexibility and choice.

Throw confusion, anxiety and uncertainty into the mix and, in the space of six words, you have pretty much encapsulated the reality of the current state of play in Australia.

First introduced locally in 2013, Consumer Directed Care (CDC) is a model of home care service delivery which, at its fundamental core, hands power to the consumer. It is an admirable and worthy approach, and one adopted by many health systems around the globe.

Since mid-2015 all new and existing home care packages (HCP) in Australia have been delivered under the CDC framework and given recipients greater say in who delivers services and what those services are. And earlier this year, CDC evolved again through Increasing Choice Reforms which, as the name suggests, aimed to further those core pillars of control, flexibility and choice.

Yet as laudable as the intentions have been, however well-meaning the concept, implementation has been far from flawless. Sweeping reforms of this nature rarely are.

It has, it seems, left many elderly, ill and frail consumers struggling to navigate the system and, as a consequence, unable to source the help they need.

Central to the reforms which came into force at the end of February was the allocation of the HCPs themselves. While people continue to be evaluated by My Aged Care through an Aged Care Assessment Team (ACAT, or ACAS in Victoria), packages are now assigned to, and held directly by individuals.

It is a step change from the old order. Previously, packages were distributed to providers and required consumers to find a provider with an available package. In many cases they were left with little more than Hobson’s choice.

Now, armed with their package – although that in itself can take more than 12 months – consumers seek out and negotiate with providers of their choosing. In addition, reforms have made it easier to switch providers and, critically, allowed consumers to take their package with them should they decide to change.

Under the previous system, not only did providers hold the packages in the first place, they retained any unspent funds if, for whatever reason, a consumer wanted someone new to supply their services. The financial disincentive to change was overwhelming.

What the legislation has created is a commercially-focused, market-driven environment where providers have needed to become more astute at selling their expertise and services to a consumer with the ability to shop around.

HUGE BACKLOG 

It has also laid bare the enormous disparity between supply and demand. Where previously there were hundreds of queues across a multitude of providers – making it impossible to reliably measure the size of the backlog – there is now a single, government-controlled central waiting list.

For the first time the backlog has been revealed. And it’s huge.

Data released in September showed almost 54,000 people who had been approved as needing care were waiting for a package. In addition, a further 35,000 had been allocated an interim package lower than they had been approved. It made for alarming reading.

Ian Yates, chief executive of COTA, the national organisation advocating for older Australians, said the sector had always suspected a backlog, but not of this magnitude.

“There are around 90,000 home care packages out there, and we now know, for the first time, that 54,000 people are waiting. If you think about that proportionally, that is a shock to the system,” he told The Medical Republic.

“It’s not a new problem, of course. It didn’t just happen overnight. We knew lots of people were waiting for home care but the quantum and proportionality was a surprise. It means all the stuff people like me have been going on about – that there is a preference for Home Care Packages – is true.”

The shortfall is particularly acute for level 4 packages – the highest level of care. Of the near 90,000 waiting for home care or allocated an interim package, 56,500 sit in this level, often for up to 18 months.

Unsurprisingly, calls are growing to alter the mix of packages by reducing the number of cheaper, less-in-demand lower level 1 and 2 packages and using the savings to fund more higher level 3 and 4 packages.

Such a move was among 38 recommendations included in David Tune’s review of aged care reform, released at the same time as the waiting list data emerged.

Tune also suggested temporarily redirecting funding from residential to home care – a plan supported by Yates – and introducing a level 5 package in order to allow people to stay at home longer.

The shock over the sheer scale of the waiting list did shake the government into life. It created 6000 high level packages to at least temporarily ease pressure. But what is abundantly clear is that a longer-term solution is required.

David Panter, chief executive of South Australia-based home services provider ECH, said he was “relieved” there was clarity around demand. “It’s the first time we have had any indication of the level of demand. The challenge now for government is how they will respond,” he said.

As daunting an issue as it, the backlog is far from the only challenge.

The shift to a market-driven model of home care has had far reaching implications for providers who have lost the protection of block funding. Now, as in any commercial environment, they must fight for business.

It has raised concerns – real or otherwise – that potentially vulnerable elderly consumers could be leaned on to sign contracts by under-pressure providers anxious to secure packages.

Not all older people have the capacity to process large amounts of information

Furthermore, no doubt spying a business opportunity, the number of providers of home care has jumped 40% in recent months, rising from 527 at the start of the year to 735 as at June 30.

MORE COMPLAINTS

Certainly the number of home care package complaints lodged with the Aged Care Complaints Commissioner has climbed sharply in the past year, rising 45% to 688, a little over half relating to fees and charges and a lack of consultation and communication.

Yet it would be unfair to draw a direct link between that increase and the shift in home care to a market model.

“Data demonstrates an increase in complaints regarding home care packages since February 2017 … but it’s important to note that an increase in complaints does not necessarily represent declining standards but may instead represent the empowerment of consumers,” a spokesman said.

“We have been working hard to increase the importance of speaking up about issues and firmly believe that complaints are one of the most effective tools to improve the quality of care.”

Writing in its annual report, Aged Care Complaints Commissioner, Rae Lamb, recognised that for consumers to make informed decisions “they must have good information”.

“Services that disclose how many complaints they get, and how they deal with them, will be more attractive,” she said.

“For the baby boomers, such transparency may be a selling point.”

This idea of a “selling point” goes to the heart of this new world for many providers, one that has forced them to adopt a more pro-active approach to attract consumers.

No longer are the elderly almost compelled to employ the first provider who has an available package. For the first time, the power rests with the consumer. Once they are notified their package is available – a process that is still lamentably long – they are free to take it to any provider they choose. They have 56 days of being assigned a package to start receiving services, extendable to 84 days on request.

The result of the consumer’s new-found choice, flexibility and control appears to have manifested itself in two key ways, one welcome, the other what might be described as an unintended consequence.

While there is clear merit in giving control to consumers – and some have embraced it with relish – the majority are simply confused.

Panter, from ECH, said: “We are finding there is an increasing delay between someone being allocated a package and putting it to use.

“What most providers experienced immediately after the February reforms was an absence of any new packages coming through the door for about two months. We dipped from about 712 to 650, through death or people moving to residential care, and it’s taken until now to get back to just over the 712 figure.

“People were trying to be good shoppers, and in our experience it’s almost entirely down to the eldest daughter or daughter-in-law phoning up providers and seeing what they can offer.

“We had an experience where ourselves and 12 other providers were invited to give a presentation in someone’s home. We’ve also had situations where people opened Excel spreadsheets and were tabulating every provider’s response in order to make an informed decision.”

While it indicates thorough planning, Panter estimated such an approach only related to one in 10 cases. The overwhelming majority of package holders have simply been too confused to take action, Panter suggested.

“They don’t know how to make a judgment between one provider and another,” he said. “People don’t quite know how to interpret information … and we have very poor information about how to judge the quality and effectiveness of many healthcare interventions.”

Lee-Fay Low, associate professor of ageing and health at the University of Sydney, said choice, while clearly welcome, had created its own complexities.

“Once you get your package, it’s up to you, and this is where it falls down,” she said. “The system offers people choice but it doesn’t really offer support to make decisions. Unless you have a tenacious family member negotiating with a provider, it can be very difficult.

“It can work brilliantly if you have someone who can negotiate fantastic services. But if you’re on your, are not internet savvy, don’t speak English very well or need specialist services, finding the right provider is extremely challenging.”

BAFFLING

One of the difficulties has been a fundamental lack of knowledge or understanding about what CDC means, according to Professor Andrew Beer, dean, research and innovation at The University of South Australia, who specialises in issues surrounding an ageing population.

He described the process as “baffling” for its target population, with people transitioned to CDC long before the system was sufficiently explained.

“That has been reflected in the very low rate of change in providers that individuals are using,” Professor Beer said. “And even within providers there has been very little change in the mix of services people have taken on board.”

Yet even when it was explained to consumers they had options over how their money was spent – it could even be used to buy pet food if dog walking was deemed beneficial to their well-being – it tended to go unheeded, he said.

“For many who receive packages, they are grateful for whatever they can get so they are not inclined to look for something better. They are happy if they are receiving services which meet 70% of their needs. And when it’s explained they have choice and can shape what they spend their money on, they are they are not exercising it in the way you would expect.”

Nevertheless, this shift towards a customer-centric model has forced providers to re-think how they market their services. They are building brand awareness through marketing campaigns, and looking to articulate points of difference. It’s even possible to envisage a price war erupting in the new competitive landscape with service providers potentially undercutting each other in search of a customer’s signature.

While such a notion was rejected by Fraser Douglass, managing director of Oxley Home Care in Sydney, he admitted value for money was an important component in any discussions with potential clients.

“All providers now need to attract customers through service, high quality communication, flexibility, high-quality care plans and value for money through lower fees and more hours,” he told The Medical Republic.

“But I would hesitate to say there will be under-cutting, and I am not seeing a race to the bottom on price. I am seeing value pricing.

“We all know that if you buy the cheapest pair of shoes they may not last long so I would argue the average consumer now understands the equation between quality and price. They are shopping around on reputation, looking at who their friend uses or who their doctor recommends.

“We are saying to everyone ‘talk to a number of providers and see who you like and who you build a rapport with’.”

Douglass acknowledged that with wider choice comes potential confusion for an elderly consumer who may be confronted with, and bamboozled by, a host of marketing messages from a variety of sources.  But the strong ethics of the sector, coupled with the regulatory framework around home care services, meant the public could select a provider with confidence, he stressed.

“Have we printed more brochures? Have we looked at our online communication? Of course. But for us the cultural step has not been huge because we have always responded to client needs. We have always been customer-centric,” Douglass added.

“But we are all approved providers working under acts and standards and procedures, so it should be well regulated, and overall I think it is. So no matter who the consumer chooses, they should be employing an organisation that will look after their needs.

“But yes, you still have to make a choice and choice can be confusing because there is everything from pricing and contracts, service and care plans to consider.

“To that end, providers are, I think, becoming better at simplifying things for consumers. They are making it easier to understand, offering simpler words and descriptions and that will be the trend. It will get better and easier for the consumer, not harder and more complex.”

UNETHICAL TERRITORY?

Panter, while agreeing that simplified language, breaking down complex pricing structures and spelling out the options available was crucial in easing the process for consumers, said that some providers were straying into what could be construed as unethical territory.

“I know there are providers who have clear targets and if a consumer doesn’t sign within 48 hours they are seen as someone who is not going to sign and the provider moves on to the next potential client,” he said.

“They are ruthless in terms of how much time they spend with people and that, in itself, will put pressure on someone.

“But my bigger concern is that people just don’t know their way around the system and are not even getting to a provider. They are not activating their package, don’t know how to choose and therefore do nothing. It is only if you have a pushy, assertive relative that gets you into the system.”

The issue is even more acute when it comes to those with dementia, according to Alzheimer’s Australia chief executive Maree McCabe.

While fully supportive of the philosophy of CDC, and the “voice” it gives consumers, too many people are feeling overawed at being handed a package and then left to their own devices. “What our consumers report to us is that they have significant trouble navigating the system,” McCabe said.

“We have advocated for CDC and want people to choose the providers they want based on who is best for their needs. It’s just that the execution is proving more complex than anyone imagined. It’s difficult enough for anyone, but you add some form of cognitive impairment or dementia and it really does create massive problems.

“We would encourage GPs to refer their patients to us so we can help them navigate the system and ensure they get the services they need.”

Lee-Fay Low agreed, adding: “The government wants people to take personal responsibility, and it’s great at providing choice. But it’s as though the system has been designed on the assumption that all older people have the capacity to make complex decisions and process large amounts of information. Of course some can, but there are many who need help and the system has not provided enough support for those people.”

What is clear in an era of consumer choice and flexibility is the need for a strong case manager who can guide someone through their options and draw up a personalised care plan.

Yet Panter said even that process had been devalued amid concerns it was nothing more than an “administration cost” which ate into an individual’s care funds.

Far from paying for highly paid CEOs and other “corporate costs” – a widespread perception – the process was integral to the success of a home care package, he said.

“There is a lot of focus placed on actual service delivery. It is seen as a good use of money, yet someone coming to your home, talking about your plan, discussing what the right services are to meet your goals, is devalued,” Panter said.

“There were stories of providers charging big administration fees and rorting the system when in fact those fees were about care management and paying for a nurse to discuss your options, understanding what your goals are working through what services fit best.”

Following the controversy, ECH developed four pricing levels “to be really explicit and place a value on care planning”.

“We have certainly upped our marketing to ensure people are aware of what we do and how we do it but the biggest change for us is our pricing and making is as clear as possible,” Panter said.

“Previously the consumer didn’t see any of those details. Now they receive an itemised invoice every month.”

So, given time, will the full consumer benefits of control, flexibility and choice be realised? And will the existing confusion, anxiety and confusion ease?

That’s the conclusion of Yates, from COTA. While conceding there were genuine problems to fix – the lengthy waiting list among them – he said foundations were in place to create a home care system that better met the needs of a population that, not unsurprisingly, wanted to stay in their own homes for as long as possible.

“We would like to see more consumer support services, and the My Aged Care gateway ought to have the capacity for face to face consultations and have more information in more diverse ways,” he said.

“That wasn’t there in the previous system either, so work needs to be done on that front.

“But the new system will drive change. I don’t think you’ll see the culture change in a few months but in two years’ time we’ll have much more of a consumer driven marketplace.

“Why? Because smart operators are working out what the consumer wants, which is flexibility and choice.”

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