HCA-NYS’ New President Weighs in on 13-Hour Rule, Home Care Investigation

One of the busiest state-level home care associations in the country has a new leader.

At the end of October, the board of directors for the Home Care Association of New York State (HCA-NYS) appointed Al Cardillo as the organization’s next president and CEO.

HCA-NYS is a statewide health and advocacy organization comprised of nearly 400 member providers and organizations delivering home and community-based care to several hundred thousand New Yorkers each year. Among HCA-NYS’ members are hospitals, nursing homes, free-standing agencies and health systems that operate home health, home care and hospice businesses.


In his new role as president and CEO, Cardillo will be tasked with helping New York’s home-based care providers navigate a complex web of state and federal regulatory hurdles. On the state level, New York providers face a confusing Department of Labor battle related to compensation for live-in aides, as well as rising minimum wages.

Plus, in September, New York City officials came out with findings from a major investigation into area home care agencies following reports of widespread noncompliance with labor laws and regulations. The investigation involved more than three dozen home care agencies and more than 50,000 workers.

Cardillo — a longtime health care policymaker who worked in the New York State Senate — spoke to Home Health Care News about his state’s unique challenges and his plans for HCA-NYS in a recent interview.


Below are some highlights of HHCN’s conversation with Cardillo, edited for length and clarity.

HHCN: You’ve been with the Home Care Association of New York State for several years now — more than a decade. Before that, you worked in the New York State Senate. Can you tell HHCN a little bit about the path that has gotten you to this point?

Cardillo: I’ve been working either directly in home care or in some capacity that encompasses the field for over 35 years.

My background is as a social worker. But over the course of my career, I’ve worked at the program level, working with providers and communities across the state of New York to implement home care when a good part of the system was still in its formative phase. The roots of home care go back 200 years, 150 years. So, not that formative of a phase, but in terms of how the system has really taken shape in the contemporary era.

In my early work, I worked at the community level with interested providers — hospitals, county health departments, local public health bodies, nursing homes and other entities — to actually develop [home care] programs and services. Back then, the state was looking to innovate, to bring home care very solidly into the realm of long-term care, really as the first consideration of a patient that was facing long-term care needs.

The program New York was advancing early on was something called the Nursing Home Without Walls program, which was really an underlying model for the national home care program we have today. I’m talking close to 40 years ago when this was a very innovative way of looking at patients, assessing them and planning for care.

Was this when you worked in the New York State Senate?

This was all when I worked for the State Division of Medical Assistance. That was the name of the unit supported by both the state and federal government that had special responsibility to implement these programs.

I did that for a number of years and then was recruited by the New York State Senate. I worked for the chairman of the New York State Senate Health Committee, Tarky Lombardi. He was a very renowned leader of health care nationally, but also he was a leader of home care for New York. He strongly believed in the service and his legislation was very pioneering.

In those years, I worked as the coordinator for long-term care for the Senate Health Committee. After a period of years doing that, the committee changed … then I became executive director.

As the years went on, I became the executive director of the Council on Health Care Financing, which had an official role in overseeing and recommending the financing system for hospitals in the state. It also extended to the broader public health system and further encompassed important negotiations in our state budget and in areas that directly touched the home care field.

So, to put that much of it together, I have background as a practitioner in social work, then working at the program level with providers and administrators, working to nurture the structure of home care in the state. Then I had a close to 20-year stint in state legislature in my other roles.

And I’ve always had a relationship with the HCA-NYS. In all my roles, there was always this collaborative nature with HCA-NYS to understand and receive guidance from the community in terms of how the system should be shaped, how important issues should be addressed, how we could innovative new directions in the field.

When did you first join HCA-NYS officially?

That was in 2007. I came in as executive vice president.

And now you find yourself appointed to lead the association as president.

I have a lot of ideas and a lot of energy for where the field goes forward from here. The health system is obviously going through a number of changes, especially if you just look at the last 10 or 15 years. There’s an obvious emphasis on home- and community-based care, on avoiding hospitalizations and emergency room visits.

That’s a premium for all the state and federal reforms. The other thing is that there’s a premium for integrating services, having services be aligned in the care and support of the patient, rather than services being silos.

What are your big-picture goals? What do you hope to accomplish?

 We’re in the middle of great challenges associated with actions taken at the government level. There are changes on the industry side as well.

What are those challenges on the government level? And are we talking state level or federal?

Both. State and federal. New York has been a state that’s been immersed in structural reform. It’s really important for the association to lead the vision for the role that home care plays in that changing system.

There’s the vision aspect, which is very important on an immediate and long-term basis. But I think with the kind of changes we’ve seen, there are immediate concerns on the budget process, reimbursement methodologies … and in the workforce.

The demand for care and service outstrip what the capacity is in many areas. As the system is changing, we need to make sure agencies have a regulatory structure and a finance structure that actually supports what they’re doing.

And the federal government has proposed a major change in the reimbursement system for home health agencies. Our state is in the process of enacting laws to try to affect labor standards.

When you say that the federal government has proposed a major change in the reimbursement system for home health agencies, you’re referring to the Patient-Driven Groupings Model, correct?

Yes. It’s one of the biggest changes to the home care industry in years.

HHCN has covered PDGM pretty extensively, so I don’t want to focus on that singular issue, though important, while we’re connecting with a state-level expert. What’s going on in New York? What are some of those labor reforms that you mentioned?

Going back to 2011, New York enacted a comprehensive series of Medicaid reforms. They call them Medicaid Redesign Team Reforms. The main corpus of that was to move all patients in the Medicaid system into managed care models — nursing home patients, home care patients, patients who had primary or specialty needs.

That’s been on an accelerated process.

In order to make that work, providers and health plans have to find approaches to the authorization of services, the right types and volumes of services that the patient needs. Then, of course, to be able to negotiate rates that are financially sustainable for both health plans and providers.

New York has also enacted increases in the minimum wage. The state has enacted wage parity laws for home care workers. There have been other changes that affect the workforce and the cost profile as well.

While that’s been happening, New York implemented a DSRIP initiative. One of the performance standards that the federal government held out to New York in the DSRIP model is … to have reduced avoidable hospital use by 25%. Obviously, what that means is shifting 25% into care into the community.

Another big change is our state is moving the entire Medicaid program into value-based payment.

At the federal level, there are nine states that have been selected for the value-based Medicare model, called valued-based purchasing. In New York, it’s referred to as value-based payment, and virtually all the home care agencies under Medicaid have to be in a value-based contract with a health plan.

We hear so much about value-based payment and about shifting from volume to value. What are your high-level thoughts on that? Good for the industry? Bad for the industry?

I think it affords the industry an opportunity to actually demonstrate and gain.

Right now, if a home care agency admits an individual that has had, let’s say, five to 10 hospitalizations within the past year … and through the work of that agency, the hospitalization rate drops to zero, or drops to a minimal level … then that agency has improved the outcome of the patient and saved an enormous cost to the Medicare program. But they receive no share in those savings, no acknowledgement or reward.

I think the opportunity is very significant there. But it has to proceed at a pace that’s in line with not only the home care industry, but with partners that have to be involved. The physician has to order the services. The managed care plan has to be a cooperating partner. All those partners have to be in line.

I think it’s an important for home care to demonstrate that value that it does provide — and to be rewarded with support for operations.

While we’re keeping it local, I know that home care in New York City received some bad press recently. The Department of Consumer of Affairs released findings from a big investigation. What did you think about that?

As an organization, one of the things that we really stress is excellence in compliance. We just had a major compliance conference covering everything from labor to operations.

We don’t know the details yet, exactly what the issue was in New York City. We do know it was along the labor law lines. There are many, many requirements that are very detailed and not always easy to understand … or where the provider’s action may be misconstrued.

It’s a little difficult to pass judgment on any specific instances like that when you don’t know the details.

Last time HHCN connected with HCA-NYS, it was about the 13-hour rule. Any updates?

The Department of Labor adopted regulations on an emergency basis that basically codified the longstanding practice that reimbursement for a live-in [aide] was at the 13-hour level, as long as there was appropriate time for meals and for sleep.

Emergency regulations were challenged in the court. The court basically ruled that the emergency basis didn’t exist for that regulation, so now you have a situation where the Department of Labor would be contemplated an appeal of that action by the court.

An appeal form the department stays that court ruling and leaves the 13-hour rule in effect. Meanwhile, the Department of Labor would be in a position to refile in the normal regulatory process … maintain the longstanding standard that it has had.

It’s sort of still out there. I think the expectation is that, if and when the Department of Labor repeals, it will sort of stay status quo until everything is finally adjudicated. But until you have that final adjudicated, there’s always the possibility that could change.

The has major implications both retrospectively and prospectively with the industry.

What are two or three things you’re looking forward to most or you’re most excited about when it comes to home-based care — on a state or national level?

Home care has important, critical roles across the entire continuum of care, from support for a new mom — maternal and child care — right through to end-of-life care. Very often in discussions, home care will be pigeonholed as post-acute or long-term care when it can fulfill important roles across the entire continuum.

I think promoting that in state and federal policies is very important and something we’ll be focused on.

There’s also a lot of opportunity for collaboration in new models of care, whether it’s integration with ACOs, hospitals, even providing hospital care in the home. There’s all sorts of opportunity areas for collaboration, which ultimately leads to better quality care, more coordinated care and, I think, reduced costs.

Telehealth is exciting. Home care’s involvement in public health and in primary care is exciting. I could keep going on and on.

Written by Robert Holly

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