State of CDPAP

The Consumer Directed Personal Assistance Program (CDPAP) has long been a cornerstone of personal freedom and dignity for New Yorkers with disabilities, elderly and chronic illnesses. This vital program empowers individuals to choose their caregivers and dictate how their care is provided, ensuring autonomy and personalization. However, recent developments threaten to undermine the program’s foundational principles and jeopardize its future.

The Threat to Consumer Choice

At the heart of CDPAP lies the principle of choice. Consumers deserve the ability to select from multiple Fiscal Intermediaries (FIs) to ensure their needs are met by organizations that align with their preferences and circumstances. The move to appoint a single statewide FI—Public Partnerships LLC (PPL)—flies in the face of this principle. By centralizing the program, the state is effectively removing the competitive marketplace that has enabled tailored and high-quality care for decades.

Each FI offers unique benefits and services, accommodating diverse consumer needs. From language accessibility to specialized cultural knowledge, these differences enrich the program and support its diverse user base. A single FI cannot adequately replicate this diversity, and limiting choice removes a pillar of CDPAP, reducing it to a one-size-fits-all model that ignores individual preferences.

Economies of Scale: A Misguided Approach

While the concept of economies of scale may seem efficient on paper, its practical application in a program like CDPAP is both unfeasible and restrictive. Consolidating services under a single statewide FI fails to account for the inherent complexity and individuality of the program. CDPAP is not a mass-produced service but a deeply personal and customized system of care.

Different regions and communities have unique needs, and no single organization can effectively address them all. Attempts to centralize operations often result in bottlenecks, reduced service quality, and an inability to adapt to localized demands. Moreover, the "one-size-fits-all" model undermines the very essence of consumer-directed care, which thrives on flexibility and personalization. By prioritizing theoretical cost savings over real-world effectiveness, the state risks dismantling the program’s most valuable attributes.

The Fallacy of Cost Savings and the Risks of Monopoly

The promise of cost savings from centralizing CDPAP under PPL is both misleading and unsustainable. PPL is already demanding higher reimbursement rates from Managed Care Organizations (MCOs) than they currently pay providers, negating any claimed efficiencies. This move increases the financial burden on the state without delivering improved services to consumers or personal assistants (PAs).

Governor Hochul’s projection of $200 million in savings is based on reductions to PAs' benefits as outlined in her SFY 2025 briefing book—a decision that would directly impact the workers who are the backbone of this program. Furthermore, the question remains: what happened to the $400 million in savings promised for the current fiscal year? These unfulfilled savings underscore the risks of relying on theoretical financial models that fail in practice.

Creating a monopoly in a program as diverse and personalized as CDPAP undermines competition and stifles innovation. History shows that monopolies lead to inefficiencies, higher costs, and reduced accountability. By entrusting a single organization with such immense responsibility, the state jeopardizes the quality and accessibility of care for vulnerable populations. A competitive marketplace of multiple FIs is essential to ensuring the program remains adaptable, efficient, and consumer-focused.

While the concept of economies of scale may seem efficient on paper, its practical application in a program like CDPAP is both unfeasible and restrictive. Consolidating services under a single statewide FI fails to account for the inherent complexity and individuality of the program. CDPAP is not a mass-produced service but a deeply personal and customized system of care.

Different regions and communities have unique needs, and no single organization can effectively address them all. Attempts to centralize operations often result in bottlenecks, reduced service quality, and an inability to adapt to localized demands. Moreover, the "one-size-fits-all" model undermines the very essence of consumer-directed care, which thrives on flexibility and personalization. By prioritizing theoretical cost savings over real-world effectiveness, the state risks dismantling the program’s most valuable attributes.

The Positive Growth of CDPAP

The growth of CDPAP is not a challenge to be curtailed but a success story to be celebrated. For years, licensed agencies have raised alarms about the growing aging population and the urgent need to expand the workforce. Workforce shortages have long hindered the ability to meet care demands, leaving many New Yorkers without essential services.

When Governor Hochul expresses concern over the program's growth, it is important to remember that this growth addresses a long-standing crisis in home care. For years, cries from the industry about worker shortages fell on deaf ears. CDPAP emerged as a solution, enabling family members and friends to step in as caregivers while earning a paycheck. This approach not only filled gaps but also saved countless New Yorkers from institutional care, allowing them to remain in their homes and communities.

Importantly, CDPAP’s growth has not occurred in isolation but as part of a broader shift within New York’s home care system. While CDPAP has expanded, agency-model home care has declined, resulting in only modest overall growth in home care utilization. This shift reflects consumer preferences for greater autonomy, flexibility, and the ability to employ family members as caregivers. Additionally, rising costs in both CDPAP and agency-model care have been driven by wage parity requirements and increasing labor expenses, not solely by expanded utilization.

By empowering more New Yorkers to participate in caregiving, CDPAP has strengthened communities and ensured that countless individuals receive the care they need from people they trust. The expansion of CDPAP reflects its effectiveness in filling these gaps and should be viewed as a testament to its importance, not as a burden to be constrained.

Addressing Fraud, Waste, and Abuse (FWA)

Fraud, waste, and abuse are critical concerns for any program of this scale. Yet, it is disingenuous to paint the entire CDPAP system with a broad brush of misconduct. For years, “good actors” within the program have proactively worked to address these issues. Through associations like CDPAANYS, HCA, and HCP, stakeholders have engaged in continuous dialogue with policymakers, offering actionable solutions such as:

  • Enforcing annual cost report submissions by FIs.
  • Implementing a registration or licensure process to weed out non-compliant providers.
  • Certifying providers through Medicaid to establish accountability.

Despite these efforts, the concerns raised have often been met with acknowledgment but little action. Furthermore, allegations of fraud within CDPAP are frequently vague and unsupported by concrete evidence. When examples are cited, they often pertain to unrelated entities, such as social adult day programs or licensed home care agencies, not FIs.

Rather than constructing a costly new infrastructure, the state could focus on refining and strengthening the existing framework—a system that has already demonstrated its effectiveness.

Flawed Selection Process for PPL

The selection of PPL as the single statewide FI has been marred by controversy:

  • Lack of Transparency: The RFP has been amended many times to accommodate PPL
  • Expedited RFP Process: The subsequent Request for Proposals (RFP) was completed in an unprecedented one-month timeframe, raising questions about its fairness and objectivity.
  • Disregard for Stakeholder Expertise: Experienced New York-based organizations were sidelined in favor of an out-of-state contractor with a problematic track record in other states, including Pennsylvania, New Jersey, and Colorado.
  • Shown HIPAA Non-Compliance: PPL has demonstrated that its systems are not fully compliant with HIPAA, raising concerns about the security and confidentiality of sensitive information.

States Where PPL Has Been Removed

Public Partnerships LLC (PPL) has faced significant challenges in administering consumer-directed care programs in several states, leading to their removal or loss of contracts. Among these states are:

  • Pennsylvania: PPL faced severe operational issues, including unpaid workers and mismanagement, which led to additional state expenses and loss of trust.
  • New Jersey: Reports of fiscal and operational failures resulted in individuals being denied critical services, prompting the state to reconsider their involvement.
  • Colorado: Surveys revealed PPL received the lowest satisfaction scores among financial management service agencies, further contributing to their removal.
  • Georgia (Their HQ): Operational inefficiencies and non-compliance with program requirements led to significant dissatisfaction and the eventual termination of PPL's role in the state.

These examples underscore concerns about PPL’s ability to effectively manage large-scale programs and raise questions about its selection as the sole fiscal intermediary for CDPAP in New York.

The PCG, SSO, and PPL Conflict

A significant conflict of interest underlies the current centralization of CDPAP under PPL. Public Consulting Group (PCG), which holds a substantial ownership stake in PPL, has also maintained longstanding contracts with the New York State Department of Health (DOH). These contracts have enabled PCG to exert influence over Medicaid program administration, raising questions about the fairness and objectivity of PPL’s selection (see office state comptroller open book).

Support Services Organization (SSO), another entity linked to PCG, provides back-office support and operational services to healthcare programs. This arrangement creates a financial web where PCG profits from both its consulting contracts with the state and its ownership stake in PPL. Critics argue that this setup incentivizes decisions that prioritize profits over the interests of CDPAP consumers and providers.

The interconnected roles of PCG, SSO, and PPL highlight a troubling concentration of power and profit in a system meant to serve vulnerable populations. This conflict underscores the need for transparency and accountability in the administration of CDPAP and other Medicaid programs. Stakeholders and advocates have called for independent investigations to uncover the full extent of these relationships and their influence on policy decisions.

|| || |Entity|Role/Action|How PCG Makes Money| |PCG Public Consulting Group|Owns SSO & PPL|Collects profits from State Consulting Contracts, SSO & PPL| |SSO Support Services Organization|Places employees in State Health Departments|Earns Staffing fees; PCG benefits from SSO revenues| |State Health Departments|Influenced by SSO employees to favor PPL|PCG earns indirectly through consultancy and lobbying| |PPL Public Partners LLC|Wins state contracts due to favorable policies|Revenues from contracts; PCG profits as owner|

Union Influence and the Role of 1199 SEIU

The union influence of 1199 SEIU also plays a pivotal role in shaping the CDPAP landscape. This powerful labor union has long sought to unionize the CDPAP workforce to expand its Health Benefit Fund, which has faced financial challenges in recent years. The State of New York has provided over $250 million in bailouts to 1199 SEIU’s Health Benefit Fund, including $49 million in 2022 alone. Critics argue that this latest push for unionizing CDPAP workers represents a “buy back” opportunity for the union to bolster its membership and stabilize its financial position.

Unionizing CDPAP workers would provide 1199 SEIU with additional revenue streams, reducing its dependence on state funding while consolidating its power within the home care sector. Critics argue that 1199 SEIU’s lobbying efforts and political influence have disproportionately shaped policy decisions, including the selection of PPL. The union’s significant campaign contributions and ability to mobilize its vast membership have made it a major player in New York politics. There are also concerns about neutrality agreements between 1199 SEIU and PPL, which may facilitate the unionization process while limiting oversight and transparency.

While unions can play a valuable role in protecting workers, the influence of 1199 SEIU raises questions about whether policy changes prioritize the needs of consumers and caregivers or the financial interests of the union. Ensuring that CDPAP remains consumer-focused and flexible is essential to preserving its mission.

Implications for Workers and Consumers

The transition to PPL has already revealed troubling operational issues:

  • Violations of regulatory guidelines, such as terminating PAs without consumer consent.
  • Significant delays and discrepancies in payments, disrupting care for thousands of consumers as seen throughout their history.
  • Non Competitive pay
  • HIPAA violations
  • Being forced into a union

These are the facts. If you want me to site my sources, I would be happy to walk you through everything and point you to everything. Chances are I missed a whole lot also, but the bigger question is, who is the one really taking advantage?