Staff Shortage Gets Worse

Acute shortages of home care workers are occurring all over the country, threatening care for people with disabilities and older adults. Many agencies are struggling with retention and scheduling as a smaller pool of workers are increasingly moved around to cover open positions.

In Minnesota and Wisconsin, nursing homes have denied admission to thousands of patients over the past year because they lack essential staff, according to local long-term care associations. In New York, patients living in rural areas have been injured, soiled themselves, and gone without meals because paid caregivers aren’t available, according to testimony provided to the state Assembly’s health committee in February. In Illinois, the independence of people with severe developmental disabilities is being compromised, as agencies experience staff shortages of up to 30 percent, according to a court monitor overseeing a federal consent decree.

The emerging crisis is driven by low wages, mostly funded by state Medicaid programs, and a shrinking pool of workers willing to perform physically and emotionally demanding work. It portends even worse difficulties to come. America’s senior citizen population will swell to 88 million people in 2050, up from 48 million currently, and requires more assistance with chronic health conditions and disabilities, experts warn.

“If we don’t turn this around, things are only going to get worse,” said Dr. David Gifford, Senior Vice President of quality and regulatory affairs for the American Health Care Association, which represents nursing homes across the U.S.

Rising Demand, Stagnant Wages

For years, experts have predicted that demand for services from a rapidly aging population will outstrip the capacity of the direct care workforce.

The U.S. Bureau of Labor Statistics estimates an additional 1.1 million workers of this kind will be needed by 2024 — a 26 percent increase over 2014. Yet, the population of potential workers who tend to fill these jobs, overwhelmingly women ages 25 to 64, will increase at a much slower rate. Falling immigration and refugee rates may make the situation worse.

After the recession of 2008-’09, positions in Medicaid-funded agencies were relatively easy to fill. Now, however, the improving economy has led these workers to pursue other higher-paying alternatives. Turnover rates have soared.

At the same time, wages for nursing assistants, home health aides, and personal care aides have stagnated, making recruitment difficult. The average hourly rate nationally is $10.11 — a few cents lower than a decade ago, according to PHI, an organization that studies the direct-care workforce. There is a push on now in a handful of states to raise the minimum to $15 an hour.

Hardest to cover are people with disabilities or older adults who live at some distance from a city center and need only one to two hours of help a day. Workers prefer longer shifts and less time traveling between clients, so they gravitate to other opportunities.

Hard Times in Wisconsin

Some of the best data available comes from Wisconsin, where long-term care facilities and agencies serving seniors and people with disabilities have surveyed their members over the past year.

One of seven caregiving positions in Wisconsin nursing homes and group homes remain unfilled, one survey discovered; 70 percent of administrators reported a lack of qualified job applicants. As a result, 18 percent of long-term facilities in Wisconsin have had to limit resident admissions, declining care for more than 5,300 vulnerable residents.

“The words ‘unprecedented’ and ‘desperate’ come to mind,” said John Sauer, president and chief executive of LeadingAge Wisconsin, which represents not-for-profit long-term care institutions. “In my 28 years in the business, this is the most challenging workforce situation I’ve seen.”

Sauer and others blame inadequate payments from Medicaid — which funds about two-thirds of nursing homes’ business — for the bind. In rural areas, especially, operators are at the breaking point.

“We are very seriously considering closing our nursing facility so it doesn’t drive the whole corporation out of business,” said Greg Loeser, chief executive of Iola Living Assistance, which offers skilled nursing, assisted living, and independent living services in a rural area about 70 miles west of Green Bay.

Like other short-staffed operators, he’s had to ask employees to work overtime and use agency staff, increasing labor costs substantially. A nearby state veterans home, the largest in Wisconsin, pays higher wages, making it hard for him to find employees. Last year, Iola’s losses on Medicaid-funded residents skyrocketed to $631,000 — an “unsustainable amount,” Loeser said.

Wisconsin Gov. Scott Walker has proposed a 2 percent Medicaid increase for long-term care facilities and personal care agencies for each of the next two years, but that won’t be enough to make a substantial difference, Loeser and other experts say.

The situation is equally grim for Wisconsin agencies that send personal care workers into people’s homes. According to a separate survey in 2016, 85 percent of agencies said they didn’t have enough staff to cover all shifts, and 43 percent reported not filling shifts at least seven times a month.

These staff shortages are making it more important that agencies have the right workforce management tools to help with employee retention and manage the changing schedules of a shrinking workforce. To learn more about how workforce management can help your agencies minimize turnover and improve retention rates, contact MITC.

Richard Edley Reflects On What Managed Care Means for Pennsylvania Providers

Managed Care is coming to Pennsylvania, like it or not. Many agencies in Pennsylvania will shortly be required to interact with Managed Care organizations for the first time. Providers are going to need to get authorized, acquire new technology, introduce new systems and work with new organizations. This is uncharted water for many providers. Richard Edley, President and CEO of RCPA, has been working with the state, MCOs, and agencies regarding the expansion of Managed Care in Pennsylvania. Since 1994, Richard has been working to support health care in Pennsylvania.

When asked what challenges he foresees when adapting to Managed Care, Richard notes that Managed Care isn’t actually new to Pennsylvania. “Behavioral and physical health care providers have had Managed Care for a long time. It is the move toward Managed Long Term Services and Support (LTSS) that is a new initiative. You’re now talking about social services, rather than medical services. The expansion of Managed Care does not apply to the Intellectual/Developmental Disabilities agencies, even though there has been a lot of talk over the years. It’s bound to come back.”

“However, while Managed Care isn’t new to Pennsylvania, there are new challenges presented by Managed Care for LTSS. Physical health has its challenges, but it is much more standardized. If a patient has symptoms that meet a certain criteria, and the treatment suggested is criteria based, the process of submitting for approval is fairly straightforward. With long term care, you’re talking about such things as in-home services, supports for people to get employment, or care for the elderly, so applying criteria and authorizing services is a grey area. It is much harder to manage.”

“Managed Care Organizations (MCOs) have to learn about how the system works to focus on efficiency and services. It’s a very complex system, and MCOs will have a learning curve.”

“In the previous structure, clients would seek out agencies. The agencies would then get authorization through the state. Now, clients will seek out the MCOs or an agency. If the client contacts an MCO, the MCO will put the client in touch with an agency and work directly with the state. If the client contacts an agency, the agency will have to contact the MCO to get an authorization.”

“For many of the affected agencies, this is the first time they’ll be touching managed care in any way. This is the first time they are dealing with the notion of getting credentials/accreditations, submitting for authorization, tracking, submitting claims that match, need for appeal, or the need to submit for additional services. This is a whole new world.”

“From the IT standpoint, many providers are still very much paper and pencil. A few may have relied on a very basic system or the state system to help them. Now, these providers are going to need Electronic Visit Verification (EVV), electronic health records, and need to get the data to the MCOs in real-time. It will be stressful for small providers, and they’re going to face a real struggle.”

“The way it works right now for agencies without EVV, a person goes into the home and there is no way to verify the visit. If the provider sees a problem with the time, they have someone go back to the office, fill out some things in a system, submit a fax, and eventually authorization happens. If that’s the situation, you are losing valuable time. Technology can be given to attendants to verify the presence of the caregiver and submit requests online. It speeds everything up, saves money, and prevents delays in receiving necessary treatment. Agencies need to be better prepared to take on the technological burden.”

“There is an additional pressure on agency providers: this is the first time the state Community Health Choices has released a procurement where the MCOs are not required to have an Any Willing Provider Network. If a Pennsylvania service area starts with ten providers, after the six month transition period the MCO may only use two.”

“We have to ask providers, ‘How are you going to differentiate yourself?’ We’ve looked at raising the bar on credentials and standards as well as data outcomes. If agencies could track in real-time, it could help them survive the transition period. There is an uncertain future for providers. There is risk for personal attendant services and service coordination entities; some might not survive.”
“In terms of resources, no one is talking about funding as of yet. The state and MCOs are going to be hosting a lot of trainings and meetings, but providing resources for agencies to learn about managed care is also the role of the associations.”

“RCP-SO is being organized to represent the providers who are affected. In the mid-1990s, the precursor to RCPA founded Community Behavioral HealthCare Network of Pennsylvania, Inc. I worked there as CEO for many years before coming to RCPA. It was a provider owned company, and it proved that if you have managed care coming to a state, providers can come together and manage it themselves, rather than wait what MCOs are mandating.”

“With that background, it wasn’t out of left field for RCPA to meet with providers, or suggest building a company managing CHC. However, we aren’t competing against large physical health plans. Community HealthChoices has billions in expenditures; that wouldn’t be feasible. We are coming together to create specific products to improve quality and be more cost-effective proving viability in the long-term for MCOs.”

“We’re seeking to help providers in four fields: Brain Injury, Service Coordination, Personal Attendant Services, and Vocational and Day Programs.”

“All of the products, at a high level, streamline administration and work toward alternative reimbursement and unified quality indicators. As an example, with Brain Injury providers, we represent all the post-acute care providers in the state. They have their own outcomes measure and tools, and are all CARF accredited. It wasn’t hard to go to the MCOs and tell them we can manage Brain Injury services for them.”

“It would be more difficult for MCOs to manage Brain Injury providers on day one because they aren’t familiar with how they operate, and there are so many competing interests and priorities (e.g., nursing home admissions). MCOs are contracting with us to standardize quality outcomes, and define quality reimbursement services.”

Agencies and Association Speak Out on EVV in Louisiana

The State of Louisiana has not had a lot of success with EVV. Having previously attempted to mandate the use of first, Sandata for EVV in 2013 and secondly First Data for EVV in 2015, the state ended up cancelling both. On April 18, 2017, the state announced its third EVV mandate plan.

The state and providers have wasted an enormous amount of money, time, and energy with nothing to show for it to date. All mandates have involved the state selecting a single vendor. The third mandate offers a state system, but leaves the providers to pay all the technology with no freedom of choice! The Louisiana approach was very different than that taken in other states, such as Missouri, where providers were allowed to choose the vendor that worked best for the provider, as long as the vendor complied with general regulations for Medicaid electronic documentation. Over 600 providers in Missouri have successfully been using EVV for billing and payroll since 2015.

On April 18th, the Louisiana Department of Health released a memo outlining the EVV requirements that will take effect on January 1, 2018. The plan requires providers to use GPS verification via tablets which are kept in the client’s homes. The cost of the tablets and data plans will be incurred by the providers. This memo contains misleading information regarding the use of GPS as it pertains to the Cures Act and the perceived monetary neutrality to providers. True costs are wildly underestimated and savings exaggerated according to providers. As evidenced from the testimony of Louisiana providers in this article, there are many concerns with the selected technology and the cost burdens that will be placed on providers that the state has not adequately addressed.

In this article Laura Brackin, Ph.D. with Brackin & Associates, along with representatives from Care, Inc., The Arc of Baton Rouge, and Options, Inc. share their thoughts on EVV in Louisiana. Many providers in Louisiana have been using EVV systems for years, and hope their experiences and feedback will be helpful to their state and others in making the best decision regarding implementing EVV.

The Community Provider Association (CPA) represents many providers in Louisiana. In 2015 the CPA wrote a letter to the state outlining their questions and concerns regarding the state’s plans for implementing EVV, writing:

“The Community Provider Association supports the implementation of an EVV system, as it has the potential to streamline billing and other administrative processes; and reduce waste, fraud, and abuse. However, if the system is not an appropriate system for Louisiana and/or is implemented inappropriately, it will not achieve the desired outcomes and could harm a system that is already on the brink of collapse.”

Dr. Laura Brackin is the former head of the Louisiana Office for Citizens with Developmental Disabilities and current President of Brackin and Associates, a disability consulting firm. Dr. Brackin represents the Community Provider Association and they have been actively involved with Louisiana’s EVV considerations for the past few years.

Our team wanted EVV, and felt it would be helpful to providers because a lot of the processes with the state were time consuming and labor intensive. We also knew some providers across the country were billing for things they wouldn’t have been billing for with EVV, either intentionally or unintentionally. That money could be better redirected toward services for individuals and increases in reimbursement rates.”

“Data from 2012 indicated EVV saved states money due to a reduction in ineffective or inappropriate billing. The cost savings could range between 10 and 20 percent. The cost of Louisiana’s largest DD waiver is well over $400 million per annum, which would mean there could be cost-savings of $40-$80 million per annum. Even a more conservative estimate of 5% in cost savings would still yield significant results of $20 million. That’s a lot of money and we need to make sure we’re spending it appropriately in our service system.”

“Several providers in the state were already using an EVV system; however the state wanted to implement a single system for all providers. We did not think this was not a good idea. We pushed for the state to allow providers to choose their own EVV vendor from a state approved vendor list, but the state had already made the decision to hire the first vendor.”

“There are several benefits for the state to use an approved EVV vendor list, as opposed to trying to implement a single EVV system.”

“First, when the state contracts with one entity, it’s very labor intensive for the state. It takes a lot of time and resources for state staff to understand the complexities of an EVV system in order to develop the Request for Proposals (RFP). It then takes time to evaluate those proposals, initiate a contract, and manage that contract. It is much easier and faster for a state to implement EVV statewide by setting criteria and then approving the vendors who meet that criterion. With the deadline for the Cures Act in 2019, allowing for multiple vendors is the fastest way for states to get an EVV system in place.”

“Another benefit to the state is that allowing multiple EVV vendors means that the state isn’t tied to one vendor. Therefore, if the state has a problem with one particular EVV vendor they can eliminate that vendor from the list without threatening the entire EVV system for the state. Whereas if the state uses one vendor and then has problems with that vendor, they are stuck until they can develop a new RFP, go through the selection process, and implement a new system. “

“Using multiple vendors is also a benefit to the state financially. It takes the state much longer to implement a single system than it does to use multiple vendors. And time is money. EVV saves states money by reducing fraud, waste, and abuse in the system. The longer it takes the state to implement EVV, the longer it will takes the state to reap the cost-saving benefits of EVV. Think of the money the state could have saved over the past four years if Louisiana would have implemented EVV in 2013. We are now four years down the road, facing a state budget crisis year after year, when we could have been saving millions of dollars. It doesn’t make sense. “

“Louisiana is again proposing the use of one state-wide system. However, the state has agreed to build a bridge between the EVV systems providers are currently using and the state’s system. But it is my understanding that providers who are not currently using an EVV system will be required to use the state’s EVV system. The state will only allow exceptions for those providers who are already using an EVV system. That may have changed.”

“Providers initiated EVV legislation several years ago to push the state to move forward with EVV. The bill passed and became law, but implementation has not been what we expected. We’re now considering whether we need legislation to ensure that providers be allowed to choose the EVV solution that works best for them, because that’s best practice.”

Some providers in Louisiana have been using EVV systems for years, and know what works best for them. Sue Bush, CFO at Options, Inc. based in Hammond, Louisiana has used multiple electronic timekeeping systems (EVV). Options, Inc. manages community home, family support, supported independent living, and vocational programs.

Since 2009 Options, Inc. has used MITC for EVV. Sue Bush has many years of experience with multiple vendors which has made her very aware of the benefits and costs of EVV.

“We had electronic timekeeping (EVV) prior to MITC. It was not Caller-ID based. Using 100% Caller-ID based has changed how we do everything. It always codes to the right client, whereas before using MITC our staff had to enter a 6 digit pin for each client. It was frequently wrong because staff would enter the wrong client’s pin. Our records would show staff at one location and time & attendance would show they were at another. The biggest advantage of using MITC for our EVV system is during audits. Anytime we use MITC and another entity uses paper timesheets and there is an overlap within the state, we don’t have a problem because our records are electronic. That means we get paid.”

“Close to 100% of our clients have landline phones, so all 300 of our staff uses a client landline, with the exception of a very few people serving clients who don’t have phones. We do paper timesheets for the handful who don’t have phones.”

EVV in conjunction with a comprehensive workforce management solution provides other benefits to agencies as well. Options, Inc. is able to automate pay differential calculations and integrate directly from MITC into payroll.

“MITC classifies shifts as different pay types before records are exported to payroll. We have many shift differentials, including reduced rates for nights, shift differentials for weekends, and premium pay for certain participants that are a higher level of care. Those are in addition to the regular rate, holiday pay, and PTO,” says Sue Bush, CFO at Options, Inc.

The Arc of Baton Rouge helps improve the quality of life for children and adults with intellectual and developmental disabilities and their families through advocacy, services, and support. Karen Monroe, Business Manager at the Arc Baton Rouge agrees that EVV has benefitted her agency:

“Our data is accurate now that we are using MITC. It resolves problems we encountered spending hours and hours on paper timesheets. Shift differentials are also automated, which saves a lot of manual calculating time.”

Bridgette Wilson, Billing Coordinator at Care, Inc. has been using MITC Time & Attendance for their 600 employees since 2014. Care, Inc. has offices in Hammond, Covington, LaPlace, and Baton Rouge. Care, Inc. has provided In-Home Care, Emergency Response, Personal Assistance, Medicaid Services, and Special Needs services to residents of Louisiana since 1991.

Prior to using MITC, Care, Inc. used paper timesheets for all employees. Bridgette knows they’ve benefitted from EVV, saying, “EVV helps us when people are admitted into the hospital because as soon as we are made aware of the hospitalization, we can go and check and make sure there’s no duplication between administration and admission and discharge. We can see that nearly in real-time or a matter of days, rather than weeks. We can handle things in a timely manner. That’s the same with drop in visits. Knowing where people are in real time helps you manage your employees.”

“All of our staff use a phone for EVV, usually clients’ landlines and cell phones. For clients that have neither, employees use their own phone, especially when picking up clients in the community. Clients and staff pay for own cell phones because calls are free. Clients with government phones often overuse their minutes. If that is the case, staff can use their own phones.”

Bridgette Wilson at Care, Inc. says, “The state plan is going to be a problem for everybody that has a payroll process. EVV changes your payroll process; it’s not just time & attendance. How will payroll and time & attendance work together in the state’s solution? I don’t see how the state is going to do that.”

Louisiana estimates the cost of EVV will be non-existent to the state in the long term, with a 2014 studying claiming that “the savings of implementing a statewide EVV system will more than offset the associated costs of implementation and administration.[1]” and the April 18th memo stating that the, “EVV system already in place for center-based, vocational, and transportation providers and utilizing smart devices with internet access is at least cost neutral, and in many cases will represent a cost savings to providers.”

Bridgette Wilson at Care, Inc. disagrees.I don’t know where they get the idea that agencies won’t incur any costs. The costs of the tablets are a cost, and my experience is that there isn’t any administrative savings with EVV. At Care, Inc., we certainly don’t spend 2/3 of our time on data entry like the state claims providers do in the memo, and we aren’t processing timecards every day. I don’t know where the state got those ratios regarding time spent on data, but they aren’t accurate for Care, Inc.”

Providers are concerned about the costs they will be forced to incur when the state mandates EVV from a single provider chosen by the state, especially those pertaining to technology.

Like Care, Inc., the Arc of Baton Rouge has begun to see a reduction in clients with landline phones, and is already facing some of the challenges and costs of using smartphones.

“We started using MITC three or four years ago for Time & Attendance. We have 150 employees using MITC for Time & Attendance. Some of our clients do not have landline phones and it has started to become an issue for us. Our staff use landlines where available, or the staff use their personal cell phones. We have supervisors using online timesheets, instead of clocking in and out.”

“The real difficulty is that staff have to engage GPS, otherwise they can be anywhere and you don’t know where they’re clocking in from. I can’t understand why the state would prefer smartphones, because the landline provides actual proof that the staff were there.”

Following the release of the Louisiana Department of Health Memo (LDH) on April 18th, questions remain regarding the required use of technology and the cost burden placed on providers.

Sue Bush, CFO at Options, Inc. had many questions after reading the memo, “LDH initially sent the memo without the part indicating we could choose our own provider. It was quite concerning. I’m still confused about that because the memo says we will be required to use tablets. Cell phones or landlines will not be allowed.”

Bridgette Wilson from Care, Inc. also felt the memo lacked clarity. “The memo failed to address the specific language in the Cures Act and what is actually required for EVV. The state is complicating this beyond the federal requirements when EVV is already complex enough.”

“I was really happy to see the state approving rounding. I think that’s going to help a lot of other issues within the state and EVV. I wish we had a little more information. I know they have 40 agencies out testing the software, but I don’t know who they are or their size. Whether an agency has 20 clients or 500 is a big difference.”

“I don’t understand why the state wouldn’t want providers to use a landline phone. I have a bigger concern with tablets. The cost is my biggest concern, but I have other questions. Who replaces a tablet when a client’s grandchild comes and breaks it? Who is accountable for that piece of equipment? Many people in rural areas don’t have Wi-Fi or computers. How do I, as a provider, get Wi-Fi in a home where there isn’t any? Louisiana Department of Health in their memo says data plans, and that the provider will pay for them. I don’t see how that is going to work.”

“Providers have questions about what technology will be mandated for the state’s EVV system and how the technology will be paid for. Providers are also concerned with not only the cost of each device, but also the cost for internet service on each device. There are also costly administrative burdens to take into consideration, especially in light of the fact that the DSP workforce has such high turnover rates. It will be extremely time consuming for providers to issued to DSPs, train DSPs on how to use the smartphone for EVV purposes, and then ensuring that the smartphones are returned when the DSP is no longer employed. A lot of providers have expressed to me that there are DSPs who just quit without returning anything,” according to Dr. Brackin, adding, “Who pays for that?”

Bridgette Wilson from Care, Inc. knows exactly how much it would cost her agency to purchase the tablets, “$68,000 for the initial tablet purchase alone. The state also estimates the tables will last for three years, which doesn’t seem realistic. The $68,000 does not include data plans, replacement hardware, or tracking the hardware.

Sue Bush at Options, Inc. agrees, especially if EVV is restricted to smartphones only.

“The cost would be ridiculous. There is no way we could absorb the costs for providing tablets to 150 clients in addition to the data plans.”

When asked for an estimate of what the proposed tablet EVV solution would cost her agency, Sue said, “I don’t even know. The biggest thing I took away from the requirements is that their claim that it will not have a cost is built on faulty logic. The LDH is saying that we can get rid of people who process billing because the automated system will eliminate data entry. What the state doesn’t recognize is we still have to do all the quality control by matching daily logs with shifts that were billed. The state has said that a service not properly documented is a service not provided. Automating billing completely is frightening to me because we need to make sure we do not bill anything that is an error. The state’s system doesn’t eliminate anything as far as we’re concerned. Whether you’re keying data in or checking it, you still have to employ that person.

Bridgette Wilson at Care, Inc. agrees, “Fundamentally, implementing EVV did not result in a reduction in staff. It changes the work. In my experience, implementing EVV does not generate a cost savings from eliminating positions.”

Sue Bush at Options, Inc. is also concerned about the plan to integrate LaSERs with payroll, “I’m not sure how the system is going to interface with payroll. Our payroll is very complicated with shift differentials. How are our records going to be imported into a payroll system? How are we able to ensure people are paid correctly?”

Sue thinks Missouri’s EVV model, which allowed providers to select their own vendors for EVV, would be a better option.

“So many providers are already using MITC for EVV. We were one of the first, I think, and we had success. A lot of our peer group has gone to EVV because of our success.”

Karen Monroe from The Arc of Baton Rouge hopes the state does not go to a single provider.

“We put one of our vocational/day habilitation programs on LaSRS because of a mandate, there is no way our in home services could go to the state provider because it cannot provide us with the information we need on the backend. I’m talking about things like the payroll reports and other items MITC provides, like tracking training and leaving messages. It just doesn’t have that ability, and it would cost us more money if we used the state program, because we would have to hire someone else to convert data for payroll purposes and tracking training.”

“We’ve talked to them about LaSRS being able to provide an hours report, but with LaSRS the breakdown of hours can’t be given by shift. They can’t give us that information. If they can’t provide that information, we have to stay with our current program. It’s becoming so cost ineffective for us.”

Sue Bush also has concerns about the accuracy of GPS and other limitations of the state’s technology,

“Caller ID is a tremendous help. If you’re calling from a landline in a participant’s house and it’s their Caller ID, you are 100% guaranteed that someone is there with the client. With a device, we’d have to check GPS coordinates. The other variable is that a lot of times, staff are picking the participants up at other locations. So it’s not a GPS at one location. It could be anywhere. It’s all over the place. I think it would be way more difficult. Messaging capability is another concern. If the state doesn’t have messaging capability that would be an issue. We know staff is obligated to hear messages in MITC before they clock in or out or via online alerts. We are sure staff receive our messages. We use that all the time and depend on it.”

Karen Monroe at Arc of Baton Rouge hopes that Louisiana providers are heard by the state as Louisiana considers how to proceed,

“I think EVV is great because there is so much fraud going on, there just needs to be a single way to streamline EVV and get the state on board to allow the parameters to be known to providers. Providers need to be able to choose our own vendor and get the information as we need it. Going to sole provider, I can’t see how that would work. “

Laura Brackin has advice for other states based on her experience.

“My recommendation for other states is to decide what the state needs from an EVV system, develop a list of approved EVV vendors, and then allow the providers to choose their own system. Providers are all different. Some offer only one service to a small number of individuals, whereas others may operate in multiple states offering multiple services to a large number of individuals. Each provider’s EVV needs could be met differently. As long as the EVV vendors all meet the state requirements, a state should be able to give providers the flexibility to choose the EVV system that works best for them. The advice I would give every state is to start advocating now to be allowed to use multiple vendors. I would tell other states to learn from Louisiana’s experiences from the last 4 years. It’s not just a provider issue.”