Published on May 10, 2021
Six current and recent employees of InnovAge (INNV), the country’s largest provider of senior healthcare under the government’s Program for All-Inclusive Care for the Elderly (PACE), tell The Capitol Forum that the company is enrolling patients into its program at a rate that far exceeds its capacity to appropriately care for them. In the opinion of these employees, the company’s lapses in care have resulted not only in harm to patients, but in some cases premature death. There is, however, no indication of any investigation or charges in connection with the employees’ claims.
“My heart just breaks when I see people in the centers, because overall, these folks are not getting the care they deserve that they are paying for with their Medicaid and Medicare and that we are paying for with our tax dollars,” one current employee said.
While the pandemic exacerbated some of these problems, the employees all said that the issues existed before the pandemic, and, according to the employees, InnovAge currently has a patient population that is too sick, too complex, and too large for its staff to appropriately care for. These problems have only compounded with the high rate of recent staff departures, which has left some InnovAge facilities with almost no primary care providers, according to current employees.
The employees, who wished to remain anonymous because of their current or recent employment by InnovAge, all had patient-facing roles at InnovAge centers in New Mexico, California, and Colorado. Some employees also declined to have their roles at InnovAge published because the low number of staff in some departments could make them more easily identifiable.
At each of their centers, the employees detailed substantially high caseloads for each worker, a drive to enroll as many patients as possible in order to receive government funding, and organizational dysfunction that was resulting in delays in appointments and care that could stretch years. The employees told The Capitol Forum that they had raised these concerns internally with InnovAge management to little effect but had not reached out to authorities with them.
These delays include both primary care that should be provided by InnovAge as well as outside appointments with specialists that InnovAge is supposed to arrange, and the employees said that thousands of these outside referrals to see specialists were outstanding by more than 180 days.
Rather than scheduling these appointments, however, InnovAge is instead cancelling them in order to clear the backlog and make them appear more recent for compliance reasons. Emails obtained by The Capitol Forum reveal that the director at InnovAge’s facility in Pueblo, Colorado instructed staff in April to clear a backlog of outstanding orders by deleting them from the facility’s electronic medical records platform.
“We will need these cleaned up by the first week of May – I know this is aggressive but compliance is a major focus for all facilities right now – we cannot continue to have these orders outstanding. If they need to be cancelled and re-ordered then so be it – regardless we cannot have orders out 180+ days,” the center director wrote. According to the email, 305 orders for care were outstanding by more than 180 days.
This issue is not unique to the Pueblo facility, as other employees stated that they had also been asked to “clean up” their facility’s backlog of old, outstanding orders. While these orders could be outstanding for a long time, the care patients needed often could not wait.
“On any given date, someone’s chart would have five or six orders they were waiting on. Could be something like a podiatry appointment for someone with diabetes. A diabetic can’t wait on podiatry, and these would be months old,” a former social worker at InnovAge’s San Bernardino, California facility said.
These delays in care are having unfortunate but preventable consequences for InnovAge patients. One former doctor at the Pueblo facility stated that they believed there were three premature deaths due to the patients’ inability to see specialists or to organizational dysfunction, while other employees expressed their view that certain lapses in care resulted in patient death.
“One was a heart patient,” the doctor told The Capitol Forum, “I was trying to get them to see a cardiologist, but the schedulers were totally overwhelmed.”
“The way the system is set up is that the high utilizers drop off,” the doctor continued, adding that, in their opinion, the system “is favoring the low utilizers, which are less expensive to care for. People that have an actual need for the care are dying out of the system because of the slow pace of care and delays.”
A current nurse practitioner in Colorado said that lapses in care had, in their view, resulted in an easily preventable death, though they declined to discuss specifics, citing patient privacy concerns.
“We moved a patient from one medication to another but didn’t do any labs or follow up, and they ended up passing as a result,” the nurse practitioner said, adding that “it can take up to six months to get something as simple as blood work done. The quality of care here is just nonexistent, it’s just putting Band-Aids on stuff and praying you don’t go crazy.”
InnovAge did not respond to a request for comment for this article.
Prioritizing enrollment over patient care, employee safety. InnovAge receives over 99% of its funding from Medicaid and Medicare payments under the PACE program, which is designed to keep seniors living independently while also lowering the cost of care by focusing on preventative medicine and lifestyle changes.
To incentivize PACE operators like InnovAge to focus on cheaper preventative care, programs are paid a capitated rate for each patient in its system in return for paying for all care for that patient. If a patient ends up going over that capitated amount by having an expensive stay in a hospital, for example, InnovAge is responsible for covering that cost.
InnovAge estimates that it receives an average of $7,500 per member per month (PMPM) for each of the 6,400 InnovAge participants across the five states in which it operates. That fee varies from state to state as well as patient to patient, as patients with complex health issues receive additional payments from the federal Medicare program.
In its SEC filings, InnovAge told investors that growing enrollment at its existing centers is one of the primary drivers of its future growth, with each current center expected to have a target enrollment of 800 participants, several times higher than the national average of 184 participants per center, according to a 2018 report by Centers for Medicare & Medicaid Services (CMS).
InnovAge has grown the populations at its existing centers by about 12% each of the last four years. Additionally, the enrolled patients are sicker than the average PACE enrollee. The company estimates that the average InnovAge participant has nine chronic conditions as opposed to the national average of 5.8, according to the National Pace Association, creating a large and medically complex pool of patients.
Some centers have already surpassed that 800-participant target. According to a former social worker at InnovAge’s facility in San Bernardino, California, over 1,000 participants are enrolled at that site.
Asked why the center had so many participants, the social worker said that “we’re not stupid. It’s just for the money. That’s why there is such pushback whenever anyone wants to disenroll. It can take months to get them a simple blood test or medication change, but once management knows they want to disenroll, it immediately becomes ‘what can we do to keep them?’”
“Disenrollment is very frowned upon,” a former doctor said, “We’ve had patients threaten to kill and harm InnovAge workers and they would not disenroll them.”
Threats of violence against InnovAge employees are not uncommon. According to the employees, their jobs became significantly more difficult once InnovAge began targeting homeless people and drug addicts for participation in the program, with some of the employees being personally threatened.
“Now that we are advertising at the homeless shelter, we have been inheriting a lot more difficult patients,” a current employee said, adding that their center was enrolling homeless in order to hit upper management’s enrollment quotas.
“I have had to go to the homeless shelters to do checkups,” the employee continued, “Fist fights, fights in the hallways. I have been threatened by patients and I still have them assigned to me.”
A former doctor told The Capitol Forum that, in their opinion, InnovAge may be targeting homeless populations for enrollment because they utilize services less than an average PACE participant, saving InnovAge money.
“We have a patient population notorious for not following through,” the doctor said, “When we can finally schedule an appointment, 30% are no shows. That was told to me by management, but during the whole time I was there, there was never any discussion about how to improve our no-show rate, which would have obviously improved a patient’s care.”
Other employees questioned InnovAge’s decision to enroll homeless participants, given that the PACE program is designed to keep patients living in their homes.
“With PACE, you need to be stable in the community to join the program,” the former social worker in San Bernardino said, “That has gone totally out the window. They are enrolling people from homeless shelters, enrolling people in nursing homes that had no discharge plans. InnovAge would put them in one of their contract facilities, like an assisted living facility.”
“If someone is already in a nursing home, InnovAge basically moves them to another nursing home they have a contract with so they could get payments for them. If they are homeless, they get people to these assisted living homes for a month and then enroll them so that it looks like they are a part of the community.”
“When I first started at InnovAge, there was a rule that to qualify you had to have stable housing. That’s just not the case anymore, the guidelines and rules have deteriorated,” a current employee in Colorado said.
While the number of patients, as well as the complexity of the average patient, has grown, staffing to accommodate them has not.
“We just received permission to enroll 100 new people from the state government. We were capped at 400 but now we can have 500. InnovAge hasn’t hired a single new staff member” to help with patient care, a current employee said, though they did say that InnovAge hired more enrollment and marketing staff.
Other employees stated they had massive caseloads that have only been made worse by the high turnover that facilities have.
“With staffing shortages, it has left me responsible for 550-600 participants on my caseload for several weeks into months with limited assistance available in our department. InnovAge is working to hire people, but they cannot hire people fast enough to accommodate the losses,” a current employee said.
Each employee could recount several doctors, nurses, social workers, and other members of InnovAge’s care team that walked off the job within the last month, and two current employees told The Capitol Forum that one of the only things keeping them in their job was the knowledge of how their departure would place additional stress on their colleagues.
Staff turnover at some facilities has meant that staffing at those facilities has become “dangerously low,” according to a complaint made against the InnovAge facility in Thornton, Colorado to the state’s Department of Healthcare Policy and Financing (HCPF).
HCPF notified InnovAge of the complaints in a March 10 letter to the Company. According to the letter “acute medical issues were observed during several home visits prompting staff to contact the PACE clinic and EMS. The medical issues were described as ‘preventable or not caught by primary care.’ Issues included but were not limited to medication management, infection after surgery, pulmonary embolism, and failure to monitor participants who tested positive for COVID-19.”
HCPF’s letter did not relay any official findings—rather it summarized the complaints it received and asked InnovAge to provide detailed information related to the complaints within 15 business days. It is not known if the complaints have been resolved or if InnovAge and HCPF are still in discussions for a final resolution.
InnovAge appears to be aware of the staffing shortage at Thornton, as it recently sent a letter to area patients informing them that “while you may not have a formally assigned individual primary care provider at this time, we are here for you.”
“Ultimately, the level of acuity for these patients,” the nurse practitioner concluded, “is just too high for how many providers we have.”
Delays for patient care, thousands of orders outstanding. According to the employees, the high number of sick patients, the lack of staff and outside specialists, and general organizational dysfunction, particularly around the scheduling of appointments, is leading to long delays in providing care for patients. As previously mentioned, the director at one center instructed staff to delete outstanding orders to see specialists that were over 180 days old and reorder them to make them appear newer.
“I would put in an order and these would often not be touched for six months, and I have seen orders over a year old from other providers that had not been touched. There was this huge backlog of thousands of orders,” a former doctor said, “and I know that some of those orders were cleaned up and reuploaded to make them appear more recent before I got there.”
“Getting a colonoscopy, we can’t get that done, it just won’t happen,” one nurse practitioner said, “There are just these significant delays in care, and the patients get pushed to the side and six months later we’re still in the same spot.”
“I spoke with a participant’s power of attorney just yesterday and they were asking why they had yet to see the pain specialist” a current employee at the Albuquerque, New Mexico facility said, “A pain specialist! They’ve been waiting on an appointment to see a pain specialist for months and months. And this is with a patient who luckily has someone who can advocate on their behalf. Not a lot of our patients have that. And this happens a lot.”
By law, InnovAge is required to have contracts with third party specialists that allow patients to see them in a timely manner. However, according to the current employee, “we do not have enough specialists to satisfy our population. Nope, I say that without any hesitation.”
Scheduling appointments at some centers has gotten so bad that center directors are now asking patients to schedule their own appointments. According to a draft letter reviewed by The Capitol Forum, the director of the San Bernardino facility told participants that “we hear there are challenges around how we schedule outside specialty appointments for our participants.”
To fix those issues, “we are initiating a pilot program to allow our participants to schedule their own outside specialty appointments.”
According to the letter, patients will receive authorizations by text or email from InnovAge to schedule their appointments and will communicate status updates and transportation needs to InnovAge on their own.
“They wanted them to set this all up using text messages,” the former social worker said, “this is a geriatric population. What were they thinking?”
The backlog and organizational dysfunctions are resulting in major complications for patients, according to the employees. One current employee noted that delays in things like dental care, which the ombudsmen tasked with overseeing InnovAge’s Denver operations has previously told The Capitol Forum was a major concern, were having serious follow-on effects for patients’ health.
“The added amount of time it is taking to have dental work approved, not just scheduled, but approved, is just ridiculous,” the employee said, “these are people with no teeth or broken or lost dentures who are having a hard time eating, which leads to other issues. There is just a massive delay in care, and even once the SDR [Service Delivery Request] is processed or approved, whether something is then scheduled and they are seen, I don’t know.”
“I know patients that need surgery to excise a tumor and it’s been delayed by over a year,” a nurse practitioner said, “there just seems to be some breakdown in communication between the hospital and InnovAge.” According to the nurse practitioner, they also had a patient who suffered a medical complication but passed away before InnovAge could schedule an appointment with a specialist.
“One of my patients almost lost a leg. He had a bone infection and we had to send him to a nursing home because he developed gangrene on his leg and the family was very upset,” a former social worker told The Capitol Forum, “The doctor didn’t follow through, scheduling didn’t follow through. He just got lost in the shuffle.”
Other employees said that the number of patients often meant that care could not be individualized.
“The interdisciplinary team [a panel of 11 specialists that is required to meet at least every six months to revise care plans] would meet, but I never wrote any actual goals for my patients,” the former social worker said, “No doctor or social worker was going in and writing actual participant goals in the care plan. The care plans were just prepopulated with generic goals for each participant, like ‘will supply resources, monitor depression, etc.’ Nothing was ever closed out. We would just meet every six months and change the date on the forms to make them look current.”
Ultimately, according to a former doctor at InnovAge, caring for patients amounted to triaging the worst cases and hoping for the best for the others.
“Literally, if it was life, limb, or eyesight the provider would have to personally escort the order through the system and follow up day after day to make sure it was fulfilled,” a former doctor said, “otherwise, it sat on the pile.”
Financial decisions driving care plans. According to the employees, financial decisions regarding the cost of care often overrode medical decisions at InnovAge, despite the PACE program’s guidelines for providing “all-inclusive care” for seniors.
“It was always a little uncomfortable to have someone from the finance side of the business sitting in on our IDT meetings, making decisions based on money not medical care. He had no medical background, but was able to have a yay or nay on care plans,” a current employee said.
Employees stated that financial decisions often played a role in deciding even relatively small purchases for patients, and the time it took to resolve the decision often harmed patients.
“They like to push that money is not an issue when it comes to things, but if it is relatively expensive, it has to go up through legal, they have to do an investigation, and they will ultimately determine if legal, not medical, will pay for it,” a nurse practitioner said, describing an episode in which it took InnovAge long enough to sign off on the purchase of a medical device that the patient ended up going to the hospital several times while waiting for it.
According to the former social worker, cost considerations at InnovAge deprived participants of care that was seemingly fundamental to the PACE program.
“The whole point of PACE is to try to keep people living in their homes, right?” the social worker said, “but we didn’t want to hire homecare people because it was too expensive. People were begging for help around their house, and it was a constant tooth and nail fighting to get someone home care hours to help them in the home, which is the whole point of the program in the first place and we’re skimping on that.”
According to one current employee, patient diagnoses have been changed in order to place participants within InnovAge’s network of contracted assisted living facilities.
“You would think preventative care would be a priority, but we have people who have diabetes who may not have had great nutrition education and have no idea how to manage their diabetes.
They go from independent to assisted living and should be on what is known as a consistent carbohydrate diet (CCD). But there are so many assisted living facilities that InnovAge contracts with that don’t have CCD,” the employee said, adding that “Dietitians have been asked by social workers to change their diet from CCD to regular just to get them into the assisted living facility. Diet and lifestyle are huge with diabetes, but unfortunately, the diets were changed. I have a really hard time with that.”
Asked whether diabetic patients were harmed by these changes, the employee said that “honestly, there are so many participants that we can’t follow them closely. The caseload is so high that there is just no time for nutrition education or to follow up with them. Their diabetes ends up being predominantly managed with medications, which is treating the symptoms rather than the cause.”
RAF scores. Each employee said that they had seen a noticeable uptick in the number of patients with substance abuse issues enrolled at their facilities in the last few years, with some pointing towards recent changes in CMS policies that added reimbursement for patients with substance abuse disorders.
Previously, a diagnosis of substance addiction generally was not included in a patients Risk Adjustment Factor (RAF) score, which determines additional payments from CMS. A patient with kidney disease, for example, would have a higher RAF score in order to compensate a provider for dialysis treatments. In 2018, CMS revised its methodology for calculating patient acuity, resulting in expanded reimbursement to healthcare providers for patients with a range of opioid addictions.
“Once substance abuse was added and they started recruiting on that, we have seen an increased enrollment of substance abusers, and they are notorious for not showing up,” a former doctor said, “But we have no substance abuse or addiction counselor. We just got them a high RAF score and then there was no follow up.”
Other employees confirmed that their centers also had either few or no professionals qualified to deal with substance abuse issues, with most saying that the work was given to the existing social workers. One current employee also said that they had concerns about some of the diagnoses for their patients.
“If you give someone a diagnosis of dementia and this person didn’t have dementia, it could be damaging to the person,” the employee said, noting that a dementia diagnosis increased a patient’s RAF score, “There may be reasons for giving these diagnoses that I may not see, but if they are receiving medication for dementia that they don’t have, that’s really bad. I’ve had this concern several times.”
Each employee told The Capitol Forum that they and others had voiced concerns about problems to upper management, but that these concerns always seemed to fall on deaf ears.
“The people at the clinic level are working their butts off to make things work. Understaffing is an issue, and I think it may be intentional,” a former doctor said, “A lot of people trying to work under impossible circumstances to deliver some kind of care. Then there is a line that is crossed at the corporate level. They are just completely resistant to any change to make things actually better. Any suggestion for real improvement was just shut down.”
For some employees, the culture at InnovAge, with its focus on increasing revenues without fixing systemic staffing and care issues that were harming patients, made quitting inevitable despite worries that their departures could further harm patients.
“When I left, I had trouble thinking, is this person going to die because I’m not there to nag someone to get on the case because these people are super sick?” the former social worker said, fighting back tears, “I struggled, but I couldn’t work for somewhere that was profits over people, and that’s what it constantly felt like.”
Please note Capitol Forum had previously reported that the Colorado Department of Health Care Policy & Financing (HCPF) had raised a complaint with InnovAge. Rather HCPF contacted InnovAge to relay complaints it had received regarding InnovAge. We have updated articles from 3/29 and 4/23 to reflect this distinction.