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In the Finger Lakes region, three separate hospital case managers recently told us the same thing, Maxim is the only provider still taking private duty nursing cases.
Think about that.
In a state with one of the largest Medicaid programs in the country, hospitals are struggling to discharge medically fragile children because there are simply not enough home nursing providers left to take them.
This is not because the need isn’t there. It is because there aren’t enough nurses.
Private Duty Nursing (PDN), sometimes called Continuous Skilled Nursing (CSN), is a Medicaid benefit for medically complex children who require ventilators, feeding tubes, seizure monitoring or other round-the-clock clinical care in their home. These children are federally entitled to receive nursing services under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. That entitlement is not optional, but a federal right.
In New York, however, most children who are authorized for PDN do not receive anywhere close to their prescribed hours. For comparison, in neighboring Massachusetts, medically complex children utilize upwards of 70 percent of their authorized nursing hours. In New York, utilization rates are lower than 30 percent.
New York’s Medicaid PDN reimbursement rates fall far behind our regional counterparts. Neighboring states like Massachusetts reimburses agencies for PDN registered nurses at $94.44 per hour, New York’s fee-for-service rates range from $32.62 to $64.71 depending on whether patients are up-state or down-state, and if children qualify for specific rate add-ons.
When nurses are underpaid, they move on, and not because they want to, but because they cannot survive on these wages.
Home health care has seen up to 50 percent of registered nurses shift away from PDN in the past two to three years. Licensed practical nurses are also steadily moving into higher paying opportunities. The result is devastating for families that received authorized Medicaid hours for their child but cannot find coverage and are forced to remain in hospitals or cycle through repeated readmissions.
Parents are at the end of their ropes.
These children are already guaranteed skilled nursing services under federal law. The failure is not in parental devotion, but in the state’s reimbursement policy. Underfunded rates have hollowed out the provider network because there are simply not enough agencies in New York willing or able to take PDN cases due to the current reimbursement levels.
But investing in PDN is more than a politically moral obligation, it is also the fiscally responsible one. A California analysis conducted by California Health Policy Strategies found that increasing in-home nursing reimbursement rates could ultimately save the state of California $175 million annually by reducing unnecessary hospital stays.
Hospital care and long-term care facilities are the most expensive places to deliver long-term support to medically fragile children. When reimbursement rates are too low to attract nurses into home care, New York ends up paying far more for prolonged hospitalizations. The math does not change simply because the state line does.
New York lawmakers are currently considering S.7705-A and A.4162-B, legislation that would establish a more rational reimbursement method for PDN care. Additionally, this legislation, which we desperately need to reform PDN, would increase transparency in rate publication.
Maxim Healthcare provides services in 42 states. In some states, policymakers have recognized the value and importance of investing in PDN. In others, like New York, we are watching the provider network shrink to a breaking point.
When hospital discharge planners say that we are the only agency still consistently accepting PDN cases, that is not market competition. That is a warning. If reimbursement rates remain stagnant and workforce shortages worsen, providers have and will continue to make difficult decisions about where they can realistically sustain operations. No organization can operate indefinitely in an environment where it cannot recruit nurses because rates do not reflect market wages.
The question is not whether New York can afford to improve PDN reimbursement, but rather whether New York can afford not to.
Rachael Collichio
Area vice president New York, Maxim Healthcare
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