minimum staffing standards that providers must meet, such as worker compensation.

By far the most prevalent mechanism for stimulating increased direct-care worker pay is the wage pass-through, a state-level allocation of Medicaid funds that are added to reimbursement rates for the specific purpose of increasing direct-care staff wages. A review and evaluation of state wage pass-through laws conducted in 2003 found that 21 states had implemented such programs; nine of those programs were for skilled nursing facilities only, while the others also included home health or personal care (PHI, 2003b). Most of these programs were mandatory, but participation was voluntary in at least six of the states, and some states allowed flexibility in exactly how the funds were to be used to improve staffing.

Evaluation data for wage pass-throughs are limited and show mixed results, especially in terms of the effect on recruitment and retention. The effects on actual wages were also unclear. One reason for the lack of clarity is that Medicaid is only one payer among several and workers are not payer-specific, so facilities with different proportions of Medicaid residents received different total amounts to be spent on wage increments. A variety of other obstacles to analyzing these programs also exist, including the use of differing measures of recruitment and retention, an inability to monitor how wages are actually transferred to the employees, and difficulty in separating the effects of the wage pass-through from other interventions. The lack of data suggests the need for careful monitoring and auditing of wage pass-through programs. The evidence that is available, however, indicates that the wage increases were often too small, were unreliable year to year, lacked accountability mechanisms, and were time consuming and expensive to implement. However, some states, such as Wyoming, have implemented programs that have been deemed successful by assessors (Seavey and Salter, 2006).

Increasing wages is only one step toward improving the recruitment and retention of direct-care workers; benefits also need to be improved. This is especially true of direct-care workers in home settings, who typically have very limited benefits (Howes, 2006). According to a 2005 study, nine states had developed or were in the process of developing programs that would address the lack of health insurance among health care workers (Harmuth and Dyson, 2005). State strategies for expanding access to coverage for these workers include subsidizing employer-sponsored insurance, designing innovative employer-based insurance packages, and, in the case of Massachusetts, including the workers in a near-universal state health coverage plan (Seavey and Salter, 2006). In states such as Wisconsin, wage pass-throughs have also been considered as an option for funding the health care benefits of direct-care employees (PHI, 2006).

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