Woods Services (Woods) and Homestead Smart Health Plans (Homestead) have been working collaboratively with Homestead serving as Woods’ employee health benefits vendor using a cost-effective reference-based pricing methodology (RBP), an alternative to how insurance carriers pay claims. Instead of paying hospitals based on “discounted” inflated list prices, RBP bases reimbursement on national references including Medicare rates. The benefits of RBP include significantly lower costs for employers and employees; no network restrictions, which enables employees to choose any doctor or hospital; and fair, reasonable, and transparent pricing. When Woods adopted the RBP approach, it was considered innovative and disruptive and Woods faced challenges finding a benefits broker or consultant that would support the approach. Two benefits consultants that support reference-based pricing are Johnson, Kendall, and Johnson (JKJ) and Connor Strong and Buckelew. In order to survive in the intellectual disabilities sector, being brave and innovative are a must. In a post-COVID-19 world, the sector will have no choice but to implement this kind of alternative to traditional employee health benefits. Woods has laid the groundwork for other human services providers, which often struggle to pay direct support professionals a living wage and offer solid employee benefits packages.
What’s unique about this collaboration is the population health focus of each entity and the willingness on the part of each to continually develop creative ways to enhance benefits for employees, improve their health, and optimize health care savings so that Woods can continue to deliver on its core mission. This is critically important because the majority of Woods employees are direct support professionals provide 24/7 hands-on direct care for children and adults with intellectual disabilities, autism, brain injury, psychiatric disorders, and severe behavioral and medical challenges. Woods provides population health services in campus- and community-based settings for 675 individuals. Savings that Woods has realized through Homestead Smart Health Plans have been reinvested into a robust employee engagement strategy, which includes improved benefits. Now more than ever, a population health approach is critical for both Woods clients and the employees who care for them, in order to address the COVID-19 pandemic and prevent a worst-case scenario.
Woods Workforce and National Labor Trends
Consider Woods’ workforce:
- Woods has more than 1,900 employees in its Langhorne-based residential treatment, school, and day programs.
- Approximately 1,400 (65 percent) of its employees are direct support professionals, classroom aides, or some other form of direct care worker, most with no education beyond a high school diploma.
- Woods’ workforce is very diverse racially, culturally, and socio-economically.
- Many direct support professionals live at or below the poverty level, work two jobs or excessive overtime to make ends meet.
- Many employees experience high stress levels related to a variety factors: financial concerns, transportation issues, chronic and acute health issues, access to good health care, etc. These are all social determinants of health.
Consider the national landscape for this workforce, which is already in a deep crisis. The workforce crisis is relevant to thousands of disability and elderly service organizations, to their staff, and to service recipients and their families – in short, to almost everyone in the country. The workforce crisis is driven by numerous labor market and demographic trends. Three million direct care workers nationally serve older adults and people with disabilities. The need for these jobs is projected to increase 40 percent over the next 10 years and growth for these occupations exceeds growth for other low wage occupations1. Demographic pressures contribute to the increasing need to fill these positions. By 2020 the population over age 65 will reach 55 million and by 2050 it will reach 88 million2; many older adults will need long term support services provided by the same workforce3. Further complicating the matter is that increasing numbers of children are diagnosed with autism spectrum disorder; now 1 in 68 children receive an autism diagnosis4. Increasing numbers of people with intellectual disabilities or autism will require supports. By 2025 this number will total nearly 1 million, up from 720,000 in 2015, while at the same time, nearly 900,000 people with intellectual disabilities currently live with family caregivers over the age of 60, who will require supports in the future when aging family members can no longer care for them at home.5 Finally, the pool of qualified workers is not large enough. The population of working age adults is shrinking, now at 32 adults for every adult aged 85 and over, to only 12 adults for every adult 85 and over by 20506.
What do direct support professionals do every day? Tasks include personal care such as bathing, assisting with toileting, dressing, feeding, and home health care such as monitoring health status and behaviors, administering medication, and changing bandages.7 Direct support professionals may work under the supervision of licensed staff such as nurses, or relatively independently.8 Settings where direct support professionals provide care include individual homes, group homes, continuing care retirement communities, assisted living communities, nursing homes, hospitals, residential treatment programs, and places of employment or centers which provide vocational rehabilitation service and supported employment.9 Wages – and rates paid to providers to deliver services – have not kept up with the cost of living, which contributes to 25 percent of the workforce qualifying for public benefits, and also to high turnover and vacancy rates across the industry.10
Woods’ Strategy to Address the Social Determinants of Health
Because of these challenges, Woods turned the population health lens already in place for the population it serves on its workforce. In the last two years, Woods has implemented the following as part of its employee engagement strategies, made possible in significant part by the savings realized by using Homestead’s reference-based pricing benefits methodology as part of Woods’ benefits plan:
- No-cost on-site health care to all employees
- No-premium health benefits for employees; no referrals needed and protection against balance billing
- A 403B plan with company contribution and match
- Onsite college degree programs at significantly reduced tuition
- Greater tuition reimbursement and a student loan payment benefit
- New career ladders, identifying advancement opportunities for employees
- New training and professional development on key areas of service provision, including trauma-informed care that benefits staff and clients
- Social supports for staff, including financial education and housing counseling
- An Equity, Diversity, and Inclusion initiative
Results of the employee engagement strategy are promising – retention among degree program participants has skyrocketed; employees have received significant funds for loan repayment of prior student debt and access to discounted educational programs; and usage of the free on-site health center is up. For a nonprofit that self-funds its employee health care benefits, increasing access to care for employees who often lack primary care providers is key to improving their health and potentially reducing overall costs of health care.
What Does All This Mean Now, In Light of the COVID-19 Pandemic?
Woods and Homestead are in a unique position to protect and support employees, and prevent the spread of the virus for both the vulnerable population receiving services as well as the employees who provide the direct, hands-on care for this population. As the administrator of a self-funded health benefits plan regulated by ERISA (Employee Retirement Income Security Act), Woods was not required to waive member responsibility (copays, coinsurance, deductibles) for COVID-19 testing. However, in the interests of public health and on-going support of its employees, Woods waived these member responsibilities, which Homestead encouraged for all of its employer clients. (Now all health plans are mandated to waive these costs under the recently enacted Families First Coronavirus Response Act.) Woods and Homestead have worked closely together to encourage testing when needed, and to remove barriers such as co-pays to telemedicine instead of in-person office visits where possible. This further helps to prevent unnecessary exposure for both patients and health care providers alike. These benefits are integrated into the health plan.
Woods continues to offer free on-site health care, and has instituted a number of protocols as a result of its emergency preparedness plan. These include frequent communications to staff, families, and funders, on-going education on COVID-19 and ways to prevent its spread, mandatory temperature screening as staff report to work, as well as CDC-recommended procedures, and protocols that align with regulatory body recommendations for residential care programs for keeping people healthy and safe. Woods has the luxury, unlike many providers of similar services, of an on-site health center for both clients and employees, and a robust team of physicians, nurse practitioners, and nurses to help ensure the health and safety of clients and employees.
Woods knows that under ideal circumstances, improving the lives of our employees will lead to higher quality care for the 675 individuals with intellectual and developmental disabilities that it serves. In this period of national emergency, it is more important than ever. After the COVID-19 pandemic is over, the intellectual disabilities sector must look to innovative approaches such as the ones implemented by the Woods and Homestead collaboration in order to survive.
Liz Hayden, MPH and MS Ed, is the Strategy Development Director at Woods Services (Woods). She is responsible for providing strategic guidance in program and resource development to Woods and its family of affiliate organizations, identifying funding opportunities and writing grants, concept papers and policy papers. She brings more than 25 years of program development and management in social services, public health, adult literacy, ESL, intergenerational programming, and higher education to her role.
Nancy De Leon Link, MGA, is the Chief of Staff at Homestead Smart Health Plans, an innovative health benefits company serving self-funded employers looking for quality, lower-cost health care solutions. An experienced public health and health care leader, Ms. Link served as the COO and then CEO of the National Nurse-Led Care Consortium, where she oversaw the doubling of its growth to a $10M national organization. Ms. Link worked with the CDC on public health preparedness efforts including a national triage phone line for pandemic influenza, and also managed the five-county Southeastern Pennsylvania regional public health preparedness program. She has more than 20 years of public health and managerial experience.
1 U.S. Bureau of Labor Statistics (2018).
3 Landers, S., Madigan, E., Leff, B., Rosati, R. J., McCann, B. A., Hornbake, R., ... & Lee, T. (2016). The future of home health care: a strategic framework for optimizing value. Home health care management & practice, 28(4), 262-278.
4 Autism and Developmental Disabilities Monitoring Network Surveillance Year 2010 Principal Investigators. (2014). Prevalence of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2010. Morbidity and Mortality Weekly Report: Surveillance Summaries, 63(2), 1-21.
5 Braddock, D. L., Hemp, R., Tanis, E. S., Haffer, L., & Wu, J. (2017). The state of the states in intellectual and developmental disabilities. Washington, DC: American Association on Intellectual and Developmental Disabilities.
6 Spreat, S. (2019). 2018 Pennsylvania Direct Support Professional Wage Study. Langhorne, PA: Alliance of Community Service Providers (ACSP), Moving Agencies toward Excellence (MAX), Pennsylvania Advocacy and Resources for Autism and Intellectual Disability (PAR), Rehabilitation and Community Providers Association (RCPA), Arc of Pennsylvania (Arc/PA), The Provider Alliance (TPA), United Cerebral Palsy of Pennsylvania (UCPA).
7 U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2017. Long-Term Services and Supports: Direct Care Worker Demand Projections, 2015-2030. Rockville, Maryland.
9 U.S. Home Care Workers Report (2018). PHI: Quality Care Through Quality Jobs. Bronx, NY
10 Spreat, S. (2019). 2018 Pennsylvania Direct Support Professional Wage Study. Langhorne, PA: Alliance of Community Service Providers (ACSP), Moving Agencies toward Excellence (MAX), Pennsylvania Advocacy and Resources for Autism and Intellectual Disability (PAR), Rehabilitation and Community Providers Association (RCPA), Arc of Pennsylvania (Arc/PA), The Provider Alliance (TPA), United Cerebral Palsy of Pennsylvania (UCPA).