A program which helps keep elders and the disabled in their homes grew 573 percent from 2002-07 in Beltrami County usage, the highest in the state.
It's also a state program that the legislative auditor, in a January report, called "unacceptably vulnerable to fraud and abuse."
The report on the Personal Care Assistance Program showed that the largest growth from 2002-06 was in northwest Minnesota at 275 percent, and statewide saw spending rise from $153 million in 2002 to more than $400 million in 2007.
The legislative auditor's report "states that the services have been subject to minimal state regulation and oversight, even though expenditures have grown significantly and the program is vulnerable to fraud and abuse," Mary Marchel, director of Beltrami County Health and Human Services, told county commissioners last week.
Personal Care Assistance is a home care service benefit under Medicaid available to people of all ages, accounting for less than 10 percent of Minnesota's total Medicaid spending, Marchel said.
Eligible people include individuals with physical disabilities, chronic diseases, behavioral diagnoses and mental illness, she said. A medical doctor must authorize the services.
People receiving PCA services might get help bathing, dressing and grooming, or help with home activities such as meal preparation and housekeeping, or some sanctioned health-related tasks, or redirection and intervention for behavior, including observation and monitoring, Marchel said.
The state Department of Human Services has overall administrative responsibility for the program, but PCA providers have played a larger role in day-to-day administration of PCA services, the report states. In fiscal 2008, more than 500 provider agencies were paid to administer PCA services.
Marchel, who said she was among those interviewed by the Legislative Auditor's Office staff, said that Beltrami County deals with 23 PCA providers. The state does not require them to be licensed, and many are not licensed.
"We have a unique set of circumstances and population that we serve and perhaps that is what has attracted services providers to the area," Marchel said. "We see a significant increase in utilization on the Red Lake Reservation."
Currently, of a total number of PCA clients of 520 in Beltrami County, 259 are Red Lake clients and 261 outside the reservation and in Beltrami County, she said.
"Public health nurses who conduct the initial assessments and authorizations believe that because Red Lake severely lacks more traditional home care providers, and options for elderly or disabled adults are limited - no adult day care - this type of available community support has filled the gap," she said.
"Many residents strongly value the PCA services they receive, although there has been little systematic analysis of outcomes," Marchel said.
Other reasons for the exploding usage of PCA, she said, include:
E Increased consumer information about PCA services, through promotion of services by parents and advocacy groups, marketing by provider agencies and simple outreach.
E Unusual concentrations of people with challenging service needs, such as former residents of regional treatment centers who now live in their communities.
E Availability of alternatives to PCA services may affect demand for PCA services, as some counties may have more extensive resources than others for providing home and community-based services bedsides PCA to disabled recipients.
The county contracts with providers for PCA services, but it is the providers who hire the in-home care staff, Marchel said. "These are generally unlicensed people."
Among the legislative auditor's recommendations are to establish a mandatory training program for PCA assessors and the provider agencies that administer PCA services, that all Medical Assistance State Plan PCA recipients have their services periodically supervised by a "qualified professional" and set up procedures for maltreatment complaints and identify topics that PCA assistants need training.
Also, the state Department of Human Services "should promptly and regularly analyze claims data to identify improper payments. It should also conduct more quality assurance reviews and investigations of PCA agencies."
Commissioner Jim Heltzer called PCA an important services, especially with a "welfare to work" philosophy that leaves the most vulnerable to public services.
"We're one of the poorest counties in the state, and we have more numbers of vulnerable that need these services," Heltzer said. "With the economy we have, we'll see those numbers get worse."
The legislative auditor's report highlights the need for increased standards and state oversight, Marchel said. "Because the state faces significant budget constraints, more cost effective mechanisms for improving compliance - namely PCA enrollment process, training, quality assurance reviews of PCA organizations - as opposed to beginning a new licensing process is being recommended."
The call for more training, more quality assurance will be less expensive than licensing, she said.
No host county contract is needed, she added, as the state Department of Human Services pays PCA providers directly. "For us they only have to pass a background check."
"While the report goes on to highlight the many changes in Minnesota laws and rules that have broadened PCA eligibility, access and consumer choice, as the concern persists about the escalating use of PCA services that until such a time basic program eligibility requirements become part of the discussion, it is my belief that we will continue to see escalating expenditures regardless of enhanced state oversight and accountability," Marchel said in a letter to Sen. Mary Olson, DFL-Bemidji, a member of the Senate Health and Human Services Committee.