Ohio’s New Interest in Acuity-Based Provider Pay: What It Could Mean

Ohio may be moving a step closer to paying care providers based on the acuity of the individual served. But what does that mean, and why does it matter?

Acuity simply means “how much care or support a person needs.” If someone has a higher acuity, they need more help: more care hours, more hands-on assistance, and/or more specialized skills from their provider.

Acuity-Based Rates are a payment system for service providers based primarily on the acuity of the client. Providers caring for people with more intensive/complex needs would be paid more than providers caring for low acuity individuals.

HPC: How the Current System Works

Right now in Ohio, providers of Homemaker/Personal Care are paid different amounts depending on which county the client lives in. The lowest possible pay right now is $28.60 per hour for an independent provider in Athens County, and the highest possible pay is $34.68 per hour for an agency provider in Hamilton County. There are also some add-ons for people with higher acuity that can raise the pay a bit more:

• Behavioral add-on ($3.48 per hour)

• Complex care add-on ($3.48 per hour)

• Medical add-on (68 cents per hour)

What a Fully Acuity-Based System Could Look Like

Under a fully acuity-based system, it’s possible those add-on rates for high acuity could potentially be built in from the start instead of being an add-on. In theory, a person with a developmental disability would take the interRAI assessment, get a score, and that score would translate into both an funding amount and a pay rate for that person’s care workers.

This could be a big help for people with higher needs. Why? Because in Ohio, providers can choose their clients. Imagine a provider who needs to choose between these two possible clients:

• Low acuity client: Needs some assistance with paying and renting shoes during an outing to the bowling alley and needs help using the washing machine at home.

• High acuity client: Needs close, constant supervision at all times, all daily living tasks done for them, and also has aggressive behaviors, pica, and a serious seizure disorder. The provider is not able to sit down, eat, or use the restroom during their shift, and would need to pay their own medical bills if they are injured on the job.

Even with one or more of the add-ons, the high acuity client may not seem “worth it” to a provider when the pay for the lower acuity client is pretty decent and the job is straightforward and not dangerous or taxing. A truly acuity-based pay system could close that “Is it worth it?” gap by making the high-acuity client’s rate meaningfully higher.

Ohio Shared Living and the Parent Penalty

Ohio Shared Living already uses a daily rate that’s partly based on acuity. But there’s a big problem: the ODDP test’s scoring system heavily weights living situation. If the individual lives with relatives, their budget often gets bumped down to the level of a low acuity individual, even if their acuity is medium to high. We’ve analyzed the full scoring algorithm and dozens of ODDP tests and found many cases where a person would receive a score of 6-7 if they lived with strangers, but instead their score is 2 because they live with their parent. With a few exceptions, Ohio Shared Living parents receive lower pay for higher acuity work because they are related to the client.

This is part of what’s called the Ohio Parent Penalty, where family caregivers get paid less than non-family caregivers for doing the exact same work. The fix for this would be to base payment on the acuity of the person with a disability, not the identity of the care worker.

The Big Unknowns

We don’t yet know whether Ohio is truly moving toward a fair, fully acuity-based pay rate for direct care workers. Another question would be whether provider agencies would be required to pass any of the high acuity pay on to the actual worker. When Ohio raised pay rates across the board in early 2024, provider agencies were permitted to pocket the increase and keep paying their workers the old, lower wages.

These are the questions we’ll be watching:

• Will pay rates for high-acuity clients truly reflect the extra work?

• Will acuity-based rates be enough to convince providers to want to care for high acuity folks?

• If so, will those providers be in it for the right reasons? Or will they claim they are willing and able to do some very challenging work when they really are not?

• Will family caregivers finally be paid based on their loved one’s acuity instead of being penalized for being related to the client?

• Will the state require agencies to pass any higher rates on to the actual workers, or will the agencies keep the money for themselves?

For now, this is all still very hypothetical! But for families and providers alike, the way Ohio answers these questions could make a huge difference in who gets care and who is left without a provider.