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Richard's story is the perfect example of just how difficult researching an agency can be. According to his court testimony from May of 2009, he received Alingog through Quality Home Care Service. Listed as Quality Nursing Service in the phone book, Quality Home Care doesn't have a website, but its contact is listed on Google Maps. Reached by phone, a spokesperson for the San Rafael agency confirmed that Alingog had worked there in the past, but insisted she did not work for them at the time of the loan. The spokesperson repeatedly claimed that she couldn't remember which years Alingog had been employed by Quality Home Care, adding, "I don't want to talk about her. I can't help you."
"The home-care agency industry is mushrooming in Marin," says Michele Boudinot, owner of North Bay Elder Care Options. She cites the county's relative age—21 percent over 62, compared to 14 percent statewide—and high median income—$89,000 in 2010—as potential incentives for the growth.
Boudinot is a certified geriatric-care manager through the National Association of Professional Geriatric Care Mangers, and she's also a member of the Marin County Elder Abuse Task Force. She cautions that this explosion in services should make Marin-based elders wary.
"People are buying franchises who, quite frankly, should probably be buying restaurant franchises," she says. "They don't realize what they're getting into, that now they're responsible for someone's healthcare. Sometimes the clients are very frail individuals; they're vulnerable with complex, chronic health conditions. These novice owners may not know anything about hiring good caregivers, and there are very few good caregivers around, so they put in caregivers without a lot of experience."
As Novato agency-owner Blount put it, in Marin "seniors are sometimes looked at as an easy way to make a buck."
With no centralized data source on the home-care industry, it's difficult to measure its growth. Census data on county business patterns from 2009 lists 24 home healthcare businesses, including medical centers. Boudinot says she's heard of more than 70. A survey of the Marin County website, several networking rosters and the yellow pages reveals over 50 nonmedical agencies, with at least four operating under multiple names. To quote Richard on his experience with Alingog's agency, this is an industry where it's easy to operate "under the radar."
Boudinot acts as a consultant to her elderly clients, charging an hourly fee ranging from $125 to $150. She gathers data on their needs, preferences and finances, and then refers them to either medical outpatient centers, self-employed care providers or agencies that fit their situation. She does not collect a referral fee from those she recommends, so in an industry where agencies and independent caregivers are often at odds, she has a unique view.
Still, she's cautious of businesses that take a large cut of a caregiver's pay, speculating that the worker's skill and experience might drop with his or her hourly rate. Some independently contracted caregivers that she uses have decades of experience and charge upwards of $20 an hour. And while that's comparable to most agencies' rates—a survey of businesses collected from the various sources described above revealed that the majority charge between $21 and $29 an hour for nonmedical caregiving—caregivers themselves only take a portion of that hourly fee.
Exactly what that portion looks like is debatable. According to the Federal Bureau of Labor Statistics, the average "home health aide" who is not self-employed in the metropolitan area encompassing Marin, San Francisco and San Mateo counties makes $11.50 an hour, or $24,450 a year. Marin agencies that would disclose their caregivers' earnings gave me quotes that generally ranged from $11.50 to $16 an hour.
But agency owners, particularly those that employ their caregivers ("full-service agencies") as opposed to simply referring them to clients for a fee ("referral agencies"), say that payment gap is built-in insurance.
Hourly care for Hired Hands, an agency operating out of Santa Rosa and Novato, is $24 an hour, with "live-in" round-the-clock care starting at $310 per 24-hour period. President Mark Winter declined to state how much the agency pays its caregivers, but he points out that companies like Hired Hands take on the responsibility of being their caregivers' employers—supervising them, providing them with insurance and workers' compensation and paying state and federal taxes, all of which figure in to the client's hourly or daily fee.
Hired Hands is a member of the statewide business association California Association for Health Services at Homes, which certifies members based on the evidence that they provide these regulations and a fee. "As a full-service industry, we provide many consumer protections," he says.
Sharon Smith of the San Rafael branch of national franchise Home Helpers reports that the agency charges between $26 and $30 an hour, and pays caregivers $14 per hour. Between workers' comp, insurance and franchise fees, the agency's profit margin is not the bloated 50 percent cut it looks like, but between 12 and 17 percent, she says.
As the head of Marin's public Division of Aging and Adult Services, Nick Trunzo oversees Adult Protective Services. He says there is no available data for reported incidents of abuse that can determine whether agencies or independent contractors are more adequate. "I personally would not say that one model is better than another; there are areas of concern in both," he says.