ANCOR Releases Findings from Recent PHE Unwinding Impact Assessment

With the public health emergency (PHE) set to expire on May 11, ANCOR recently fielded a survey of its members about the anticipated impact of the unwinding of emergency flexibilities on the direct support workforce crisis and access to services. From March 9 through March 31, ANCOR’s PHE Unwinding Impact Assessment garnered 242 responses across 21 states. 

Key findings from ANCOR’s newest survey include that: 

• 45.3% of respondents have been reliant on an increased reimbursement rate for one or more services to help stabilize the workforce. 
• 49.2% of respondents have been reliant on new remote support or telehealth services to help stabilize access to services. 
• 82.1% of respondents are concerned vacancy and turnover rates would increase when the Appendix K flexibilities terminate. 
• 77.9% of respondents are concerned that additional program closures will occur when the Appendix K flexibilities terminate. 

Significantly, nearly one in three (31.6%) of respondents stated that they did not have a clear understanding of when and how their state will discontinue or make permanent the use of its flexibilities. Without an understanding of what the next six months hold, providers are making decisions now to close services.  

Access to Services is Already Challenged

The longstanding direct support workforce crisis has been exacerbated by the COVID-19 pandemic, and emergency flexibilities were critical to stabilizing the direct support workforce. But even so, the workforce crisis has led to closures of critically needed services and a denial of access to community-based supports for people with I/DD. As found in ANCOR’s 2022 State of America’s Direct Support Workforce Crisis, 83% of providers are turning away new referrals; 63% of providers are discontinuing programs and services; and 55% of providers are considering additional service discontinuations. Additionally, 71% of case managers are struggling to find available providers.  

In this most recent survey of providers, ANCOR found that 42.2% of respondents indicated they provide services in an area where few other providers offer the same services. With decreasing access, people with disabilities are beginning to experience service deserts in rural areas where they need to travel far outside of their communities to access services.  

Providers are Reliant on Emergency Flexibilities to Stabilize the Workforce

In 2021, the median hourly wage for DSPs was $14.50 and the turnover ratio for DSPs ranged from 28.5% to 59% with a weighted average of 43.3%. During this time, full-time vacancy rates rose to 16.5% – a roughly 94% increase since 2019 (NCI 2021 State of the Workforce Survey). And, during the COVID-19 PHE, we know that 49 states used Appendix K to modify payment rates (CMS Unwinding HCBS PHE Flexibilities Webinar, February 8, 2023). 

In ANCOR’s most recent survey on PHE flexibilities, almost half, or 45.3%, of respondents indicated that they were reliant on an increased reimbursement rate for one or more services to help stabilize the workforce, with 40.1% saying they made a pass-through or wage-specific payment increase. As one survey respondent shared: 

“The rate increases we have received is what has kept us afloat. The overtime amounts we are paying [have] remained consistent throughout the pandemic. We have been [unable] to fill our vacancies, we will not be able to sustain the current [overtime] costs when we lose the funding. We cannot sustain the [overtime] we have to [incur] to maintain staffing levels.”  

Furthermore, 82.1% of respondents indicated they were concerned vacancy and turnover rates would increase when the Appendix K flexibilities terminate. As the results of ANCOR’s 2022 State of the Direct Support Workforce Crisis show, the workforce emergency is now to the point of denying access to services and further threatening the quality of services for people with I/DD. 

Providers are Reliant on Emergency Flexibilities to Stabilize Access to Service Offerings

Community-based providers of services for people with I/DD have been largely reliant on emergency flexibilities to stabilize access to service offerings. 49.2% of respondents to ANCOR’s PHE Unwinding Impact Assessment indicated they were reliant on new remote support or telehealth services to help stabilize access to services during the COVID-19 PHE. 

Additionally, 21.9% of respondents indicated they were reliant on paid family caregivers; 36.6% indicated they were reliant on waivers of administrative requirements; and 24.6% indicated they were reliant on retainer payments. As one respondent shared:  

“The use of telehealth services throughout the PHE has been instrumental in our service provision. It has also further increased many participants’ independence due to increased technology skills, communication skills, and using only verbal prompting [or] encouragement from the provider. Providers have truly always provided this type of support, but it was never reimbursed prior to the PHE.” 

Significantly, 77.9% of respondents indicated they were concerned that additional program closures will occur when the Appendix K flexibilities terminate. With access already challenged, additional program closures significantly increase the risk of hospitalization and institutionalization for people with intellectual and developmental services seeking support.  

Certainty About the Future of Appendix K Flexibilities is Critical to Stabilizing the Workforce and Access to Services

In response to a question about the certainty of the future of Appendix K flexibilities, a total of 74.3% of respondents indicated that they were either unclear or somewhat clear on when and how their state will discontinue or make permanent the use of its flexibilities authorized under Appendix K, with 31.6% stating they were unclear and 42.7% responding that they were only somewhat clear. 

One respondent stated that “We have been given very little information as to the unwinding process and what will be required and when,” while another shared that “No to very little information has been provided by state Medicaid representatives.” 

The future of home and community-based services is dependent on the ability of providers to access the tools and resources they need to maintain a sufficient workforce. With an overwhelming percentage of providers anticipating increases in vacancy rates, providers are making decisions now to reduce services and close programs.  

In order to begin addressing these issues, the government must invest in community-based services. Now is the time to tell Congress to support Medicaid-funded home and community-based services.