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Paying Your Marketers Properly – Revisiting the Rabbit Hole

October 9, 2012 By paulhirsch Leave a Comment

Update: 12-06-2012 – This Article Series is not forgotten, it is still “in-the-works!” In our desire to compile an authoritative basis for our opinion on this matter we are still reviewing a massive amount of documents, from Legislative History of Congress all the way to state court litigation documents which address this topic. We have read most of it and have “digested” what we have read. However the creation process is taking a backseat to ongoing litigation. We are simply waiting for things to slow down a bit before we delve into writing this article series – after all client needs come first!

Of course, if you have specific questions about a current situation or questions about what you want to do in terms of your marketing approaches, we are more than willing to advise you on a particular circumstance! If in doubt – ASK US!-

Paying Your Marketers Properly – Revisiting the Rabbit Hole

Introduction – Part 1 (of 5)

After updating our website recently we have noticed that our article “Paying Your Marketers – Properly” and the issues covered within it have spurned many questions and comments both here on our site and from some of our clients. The health care industry is an ever-changing world, subject to ebb and flow of legislation, agency rules / regulations, court decisions and an ever-changing labor pool. Notably, Liz wrote this article almost ten years ago!

Many changes have occurred throughout the health care industry since the original article was written. Government agencies charged with oversight of the industry and its participants work differently then they did ten years ago. In fact, almost every facet of the industry has been affected by continual changes in the laws, rules, and regulations governing how agencies do business in this marketplace. It follows that the issue of paying marketers has changed also. Ultimately the crux of the original article remains in place, but none-the-less it deserves a fresh analysis.

One illustration of this change can be seen in the government’s focus (both on the state and federal levels) on strengthening and enforcing the prohibitions on fraud and abuse within the industry. The government’s new resolve in combating fraud and abuse has developed throughout many areas. One of the most visible examples of this new focus and resolve is the DOJ-HHS’s HEAT strike-teams, which actively combines and focuses the intelligence and resources of federal and state agencies towards the single inexorable goal of prosecuting businesses and people involved in Medicaid and Medicare fraud and abuse.

Moreover, beyond the health care industry itself, almost every industry (including health care) and every business, across the country, faces the perils and pitfalls of the changing environment of employer / employee relationships and employment laws. Federal and state agencies have promulgated new rules and regulations, and have adapted their methods and strategies in dealing with employment law. The “old-hat” areas of discrimination, retaliation, and harassment are as much of a concern as ever. However as technology advances and permeates the fabric of our society new questions are being raised such as: When can you run a criminal background check on a prospective employee? Can you ask a potential employee for their password to social media websites so you can better evaluate them? What are the limits you can place on employees’ use of social media both on the clock and off the clock (there is a surprising amount of controversy in this area particularly!)?

So how does all of this effect marketing strategies and payment structures for marketers in the health care industry?

In some ways many things are unchanged, but unfortunately that is not the whole story. Certain recent developments in the health care industry and employment law should give pause to health care providers when they decide to start or continue with marketing strategies and payment structures.

We have decided to start a multi-part series of articles which will shed new light on some old concepts, highlight certain techniques and approaches to structuring marketer training and payment, identify emerging issues and areas of concern, and suggest “functional adaptation methods” which can help health care businesses avoid potential pitfalls.

Please note: Many of the emerging issues about social media and employment law could be entire articles in and of themselves. So, this series will touch on some points of these emerging issues, but if there is interest in a more in-depth look we will consider putting together an article on these issues themselves.

Here are the planned segments:

Part 1: Introduction

Part 2: Health Care Laws (Anti-kickback and other federal rules & – Employee vs. Independent Contractor considerations)

Part 3: Employment Laws ( Fair Labor and Standards Act (FLSA) – wages paid and hours worked – payment structures – necessary documentation)

Part 4: Emerging Concerns

Part 5: “Functional Adaptation Methods” ®

(Please note regarding the phrase “functional adaptation methods:” some people might be looking for “best practices,” however we detest this catch phrase and purposefully choose to avoid it. As many successful business people can attest this phrase is one of the general corporate ear candy catch phrases which are in vogue. At the outset, this phrase in particular tends to over-simplify complex issues, because what might be best a best practice in one instance might not be what is best for every situation.)

What Can I Ask An Applicant?

March 30, 2012 By Pearson & Bernard Leave a Comment

Hiring employees is no longer a simple process of elimination or selection of the best applicant. In today’s legal climate, employers need to be equally concerned about what they ask applicants as well as what they fail to ask. The prudent employer should establish a well defined procedure for employee selection that includes steps for checking references and other qualifications and reflects the restrictions imposed by both state and federal law.

Hiring An Employee No Longer Means Fitting the Applicant into a Strictly Defined Position.

Employment applications and interviews are the primary methods of screening and eliminating unqualified or ill-suited persons from consideration for a position and as such can run afoul of the various state and federal anti-discrimination laws. Types of questions that have been found to unfairly discriminate include questions concerning arrests and conviction records. Additional problem areas for employment inquiries include age, sex or marital status, physical or emotional capacity, and even religious affiliation. With all these restrictions, how can an employer legally screen applicants for employment?

The anti-discrimination laws presume that all the answers to pre-employment questions will be used in making a hiring decision. In general, these law prohibit the use of job criteria or pre-employment questioning that disproportionally disqualify minorities, members of one sex, older persons, or disabled persons. Hiring employees no longer means fitting the employee into a strictly defined position. Rather employers must maintain a degree of flexibility in hiring, a willingness to accommodate individual applicants’ limitations, either real or “perceived” and either physical or emotional.

Hiring guidelines published by the Equal Employment Opportunity Commission, the EEOC, suggests establishing a job description for each position that outlines the primary responsibilities for the job, technically referred to as the “essential functions.” Applicants should be reviewed for qualifications that meet these essential functions. Any job criteria that could screen an applicant from eligibility employees must be directly “job-related” or justified as a business-necessity. Examples of necessary job related criteria include the ability to type or use a computer for a secretary position or a truck driver’s ability to drive an eighteen-wheel vehicle for a prolonged period. Example of criteria necessary for businesses are such things as licensor requirements for nurses or state and/or federal law requirements for criminal record checks or drug testing for certain employees.

In both the application and interview process, questions should reflect only the established job requirements, such as the working hours, job criteria, or the identified essential functions. General questions concerning the applicant’s age, marital status, physical health, religion or ethnic background should be avoided unless the subject matter of the question can be established as a necessary qualification.

Specific questions concerning an applicant’s ability to do a particular function should be posed only after an initial offer of employment is made, and, then the employer must be prepared to accommodate any disability, religious need, or other limitation. The overriding duty to accommodate such limitations is lifted only if the employer can prove that the accommodation would cause the company “undue hardship.”

Employers Need to Prepare Hiring Procedures & Policies Well in Advance of Placing a Want-Ad.

On the other side of the picture, employers should ask and verify several items in the application process. Many states require criminal record verification of employees. Although the process may be costly and impose additional paperwork, employers who have people in positions of confidence, or going into clients’ homes, or employees who must be bonded likely need to obtain this information. The business necessity in such cases is demonstrated by the criminal case example of the home health aide. Any request for criminal convictions information should be accompanied by a statement that a record will no necessarily bar employment and that factors such as the seriousness and nature of the crime, along with the time of the offense will be considered and evaluated.

Also, there are several screening procedures that employers can and should conduct. First, employers should conduct reference checks and ask applicants for an explanation of any “unemployed” time. Second, applications and any subsequent employment questionnaires should establish an enforceable policy that any false information is not only grounds for disqualification for a position, but, also cause for discharge if discovered after a hiring. Also, employers can require verification of basic information, perhaps with a drivers license or professional license or certification, or a follow-up telephone call. Finally, companies should establish a procedure checking list to assure that each of these procedures are followed, and, include this information in the applicant’s file.

In the end, to avoid legal liabilities in the screening and hiring of employees, it has become very important for employers to prepare hiring procedures and policies well in advance of placing the want-ad. It is certainly more costly in time, and in money, to face a lawsuit down the road either from some disgruntled applicant who did not get hired, or from a client injured in some way by the one who did.

Paying Your Marketers – Properly

March 22, 2012 By Pearson & Bernard 6 Comments

Since the advent of PPS in late 2001, home health agencies have moved to openly marketing their businesses to referral sources and to the public. No longer are marketing activities taboo and necessarily buried in the duties of patient coordinators or educators. As the marketing practices become more popular and likely more necessary, salesmen unfamiliar with health care are being attracted and or recruited into the health arena. These square peg employees from the unregulated business environment require education on the rules and requirements that govern health care providers.

The change from cost reimbursement to the PPS episode payment did not change the restrictions that exist on marketing health care services. As home health owners know, many marketing tricks used in the outside business world can land a health care provider in jail. In addition, the employment law requirements for minimum wage and overtime set specific rules for outside salespeople, which must be completely satisfied. Violations of any of these laws can be very costly. This article will address both the health law and employment law issues that must be addressed in your marketing pay practices.

The Problem with Paying for Referrals

Salespeople and marketers in non-healthcare business fields traditionally receive their wages in the form of a commission or draw against commissions. In other words, they are paid on the basis of the sales they produce. In the health care business, sales are generated through referrals from other health care providers or direct solicitation of patients. In either case, there exists a strict prohibition against any payment, solicitation of payment, or receipt of payment for a referral of Medicare or Medicaid business.

The Medicare and Medicaid Anti-Kickback Act, 42 U.S.C. § 1320A-7b(b), specifically prohibits “whoever (from) knowingly and willingly soliciting or receiving any remuneration…if one purpose” of the payment is “to induce a referral of business reimbursed under the Medicare and Medicaid programs.” This law therefore impacts how you pay your marketers for the referrals generated and also raises concerns about any traditional business perks your marketers may choose to offer referral sources. Similarly, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) included a prohibition against the use of gifts and other benefits to directly solicit patients for services. Both of these laws include criminal penalties in the form of jail sentences, huge penalties or fines, and mandatory exclusion from government program participation.

Clearly, the payment of a commission or even a sizeable bonus to your marketers has the express and exclusive purpose of inducing a referral of home health business, much of which is reimbursed by the Medicare program. As such, commission payments to your marketers violates the plain words of the Anti-Kickback Act. In addition, in the business world, salesmen often market to their prospective clients over lunches, golf games, or other perks. These are traditional business practices that in the health care field are prohibited “in kind” payments with at least one (1) purpose to induce referrals.

Several criminal prosecutions have arisen under the Anti-Kickback Act and the courts in those cases have found the law to be both constitutional and literal – that any payment, direct or indirect, in cash or in kind – is a violation if one purpose, and just one purpose, of the payment is to induce a referral of Medicare or Medicaid business. Soon after the law took effect, the OIG noted the concerns of health care providers that “many relatively innocuous or even beneficial commercial arrangements were technically covered by the statute” and were, therefore, subject to criminal prosecutions. Because of the overreaching breadth of the law, the government published rules for a few exceptions to the prohibited payment, which are intended to protect what are considered legitimate business relationships.

One of the recognized exceptions, or “safe harbors,” extends to employees. As stated in the rule, a payment to a “bona fide” employee will not be considered illegal remuneration for a referral as outlawed under the Anti-Kickback Act. 42 C.F.R. §1001.952(i). A “bona fide” employee is one for whom employment withholding and employment taxes are paid, technically an employee as defined under 26 U.S.C. §3121(d) (2) of the Internal Revenue Code. He or she does not have to be a full-time employee, but cannot be a 1099-type independent contractor. To simplify the definition, the employee must be what is called a W-2 employee. He or she must be subject to hiring and firing, supervision and other disciplinary action.

In the comments to the proposed Safe Harbor Employee rule, the OIG noted that the employer may pay the employee in any manner to “assist in the solicitation of Medicare or State health care program business.” The manner of payment may include a payment based on “the amount of business generated” as long as “these salespersons employees” are subject to “appropriate supervision. Thus, under the Employee Safe Harbor, home health agencies may pay their employee marketers on a commission, or draw against commission basis, or include wages based on productivity. Payment of this type does cross the line on the literal language of the Anti-Kickback law, but it falls squarely into the Safe Harbor and is therefore protected.

Although commission payments are protected, employers should be concerned about, and, alerted to their marketer’s sales practices on a day-to-day basis. At the time of hiring, each employee should be instructed on the prohibitions of the Anti-Kickback Act, and required to review and sign a code of conduct agreeing to not offer kickbacks or other indirect payments or benefits to referral sources. At a minimum, this requirement establishes a pattern of supervision that should be supplemented with regular performance reviews and ongoing supervision of activities. Although it is unlikely that the OIG would prosecute for a single lunch or box of donuts, the literal language of the Anti-kickback Act prohibits such conduct.

Finally, it is important to note that agencies should always scrutinize and identify any and all marketing costs, including the wages paid to marketers, to assure that no such costs are claimed on the annual cost report. Marketing costs are still unallowable on the cost report, and any claim for such costs could be construed to be a false claim.

Practical Problems with Commission Payments

There are, though, some practical problems that arise with commission payments, unrelated to fraud and abuse that must be considered and addressed before an agency enters into this type of compensation plan. First, in the realm of the PPS system, shear volume of referrals is not necessarily a good thing. Rather, it is the quality of the referral that is important. Paying a commission on an episode, which runs in the red financially, has no business advantage. Thus, any commission payment should be tied to the profitability of the actual home health episode. Creating the commission scheme therefore requires some time and considerable thought.

As an example, the commissions could be paid quarterly or every 62 days at the close of an episode depending on the speed of your billing procedures. At this point, there should be a realm of assurance as to the value of the episode. Tracking the referral to the marketer could be managed through some internal coding process or other recordkeeping system which identifies the marketer. Another possible commission payment basis is a pure productivity bonus that scales the business generated again on a quarterly or other time period basis to the overall productivity of the agency. This type of commission compensation encourages quality referrals which overall benefits the agency most.

Under the PPS payment model and with the aggressive claims review posture of the Medicare and Medicaid programs, it is necessary to create a commission payment plan that does more than generate just referrals, but also works to enhance real profit. Such a plan should take some time and consideration in implementation. In addition, use of a commission structure must be tempered with appropriate supervision and fraud and abuse controls to assure that inexperienced marketers perform in accordance with fraud and abuse laws and your agency’s ethical standards.

The Risk of Overtime Pay Liability

The other major hurdle in structuring a marketing payment plan is consideration of the requirements for minimum wage and overtime liability. For several years the home health and other health care industries have been prime targets on the Department of Labor hit lists for overtime violations. As the home health industry moves into the business world of marketing, agencies must review any payment plan to assure compliance with the overtime pay requirements.

Traditionally, home health marketers have been nurses or other professionals who were paid a salary and wore several hats. Most of these employees could qualify for an exemption from overtime pay under the professional or management exemptions due to their status and job duties. In the current time, with the use of actual business “marketers” rather than professionals, other exemptions must be considered to avoid payment of overtime.

As a brief review, employers must pay overtime to employees for all hours worked in a workweek in excess of forty (40) hours, unless the employee is a properly classified exempt employee. Overtime pay is to be calculated and one and one half times the employees’ regular rate of pay. Hours worked include all time an employee is suffered or permitted to work, including paper work and travel time other than to and from the worksite. The use of an “approved only” overtime policy is pointless and without effect if the employee’s job duties requires him or her to work in excess of forty (40) hours a workweek. A commission-payment system encourages marketers to be out in the field, pounding on doors many hours a day. Thus, there exists a risk of overtime pay unless the marketer is properly assigned and classified into an exempt job duty status.

The Fair Labor Standards Act, which imposes the overtime pay duty, includes an exemption for “outside sales employees.” As long as a home health marketer’s job is dedicated to “making sales, or to “obtaining orders or contracts for services,” and is performed “customarily” away from the agency’s office(s), the marketer can be considered an outside salesperson and exempt from overtime pay. As noted, the job duties must be dedicated to sales, with no more than twenty percent (20%) non-sales duties in any one (1) workweek. The non-sales work does NOT include clerical or other work that would be considered “incidental to or in conjunction with the employee’s own outside sales or solicitations.” Such incidental “sales” work would include telephone follow-up or paperwork associated with the actual sales duties.

Use of the Outside Salesperson exemption is foreign to home health agencies, but should be considered to avoid overtime pay exposure. It is important for any exemption to use the actual wording of the exemption s it is the employer’s duty always to prove that the employee is properly exempt from overtime. Therefore, a marketer’s job description and actual duties should replicate the exemption language and note that the employee will be considered an exempt outside sales employee. This helps to avoid any misunderstanding or disgruntled complaints from an employee after-the-fact.

Unlike other exemptions, an outside salesperson is not required to be paid in accordance with the salary or fee requirements of the Fair Labor Standards Act. Thus, a commission payment plan is permissible, if administratively functional for an agency. There is a basement level of wages that must be paid to qualify for the exemption. Of course, salary or fee payments are not otherwise precluded for outside salespersons and can still be used along with a performance bonus as long as the employee performs the outlined job duties for the exemption. Under the current rule, the minimum wage amount for the exemption is set at $155 a week, but the regulations for all exemptions are proposed to be changed.1

A Recommended Marketer’s Compensation Plan

With years of negative rhetoric about fraud in the home health industry and the overall climate against “inducement” of referrals, any compensation plan that is designed to induce referrals may still raise the hair on some agency owner’s head. Although a commission or other traditional “sales” compensation model is clearly protected for “bona fide” employees under the employee safe harbor, there are significant practical business problems in implementation. An alternative model is to pay a base salary that allows employees some wage security along with performance and productivity bonuses that are tied to their actual sales and the profitability of the company. Any salary model must comply with the salary rules and Marketers should be identified as outside sales people to assure the exemption for overtime pay. Yet it is possible to provide the sales incentive through a well-designed bonus program tied to growth and profitable referrals.

As a final note, it is necessary to train marketers intensely both on their specific duties and the PPS payment system so that they understand the profit potential of referrals. Moreover, each and every marketing employee should be educated on Anti-Kickback prohibition and other fraud and abuse laws to assure compliant conduct. Remember it is your job to supervise and oversee their activities. Your marketers will be your public face and must present themselves as knowledgeable of your business and, even more importantly, of your ethical standards for your business.

1. The proposed changes are extensive and as now written will reduce the overtime exposure greatly. The most important change to note is that LPN’s may be properly exempted as a learned professional employee. However, there is considerable debate and opposition to the proposals that make any substantive discussion too prospective. Agencies should stay alert during the upcoming year and consult legal counsel as legislation and regulations proceed.

Dealing With Investigations

March 15, 2012 By Pearson & Bernard Leave a Comment

Home care is once again the target of government efforts to reduce health care expenditures. The array of programs being used to financially and operationally confront agencies is extensive and daunting: focused medical reviews, compliance reviews, recoupments, denials, offsets, payment suspensions, ORT, program exclusion, civil monetary penalties, Wedge audits and criminal prosecutions, to name just a few. What can an agency do before, during and after an investigation?

WHAT TO DO PRIOR TO AN INVESTIGATION

Agencies must be prepared for unannounced investigations and audits at any time. The consequences of these investigations can be extreme, both financially and criminally. There are steps an agency can take now to minimize the potential damage of being the target in a government investigation:

Prepare for possible delays in payment or suspension of payment – review your lines of credit or other sources of cash flow to be sure they are adequate if you are caught up in the storm.

Begin to review your system of internal audit of claims to determine that there is adequate documentation of compliance with medical necessity and homebound criteria.

Maintain a separate file for your communications with legal counsel, since those documents can be protected from seizure by government agents under attorney-client privilege.

Contact your health law and criminal law attorneys now to ensure their availability to represent you when needed.

Only the reckless, daring or naive will not have a Fraud and Abuse Compliance Plan in place. A comprehensive plan may include all of the above.

WHAT TO DO DURING AN INVESTIGATION

If you are notified by a surveyor or a fiscal intermediary that your agency is being subjected to an audit, do not expected to be treated fairly, or with meaningful due process:

Make certain that you have copies of all documents that you provide to the surveyor so that you can conduct your own detailed audit of that case file;

Be certain that the intermediary has all of your documentation before the government renders an initial decision; and,

Contact legal counsel at the outset to achieve the greatest protection of attorney-client privilege and perhaps extend that protection to the activities of your accountant, consultant, etc.

If, however, government agents present subpoenas or search warrants, time is of the essence and you should remember to do the following:

Find out who is the agent in charge and ask to see the document. A subpoena requires the production of material, but the officer(s) presenting the documents may not search the premises and seize the material. A search warrant allows agents access to the premises and the authority to seize material described in the warrant, or accompanying affidavit.

Immediately contact your attorney and advise him or her of the situation. At this point, the call is probably being monitored and there are guards at all of the entrances to your agency. Ask the agent in charge to seal the area and delay the search until your attorney arrives. Have trusted supervisors or managers accompany agents to the areas covered by the search warrant to observe, not to interfere.

Advise your employees that they are under no obligation to answer any questions by the agents – Do not tell them that they cannot speak to agents, because that could be construed as obstruction of justice. It is the employee’s choice to answer questions or remain silent. Usually, government agents will not tell your employees that. Then send all non-essential personnel home and otherwise close the agency until the search is completed.

WHAT TO DO IN THE AFTERMATH

An agency must be very careful about agreeing to a settlement with the government without first reviewing all of the legal ramifications with its legal counsel.

Accepting an extrapolated damages claim by the government based on an audit, for example, can have many unforseen consequences. An agency that accepts a monetary settlement of an audit could still be subjected to any of the following:

Mandatory or permissive exclusion from the program;
Criminal prosecution;

Inclusion in the national database authorized by the Portability Act as an “abuser” (the so-called scarlet letter provision); and/or, Imposition of civil monetary penalties.

Remember, too, that positions your agency accepts as part of any settlement with the government can have collateral consequences under other federal laws, such as the Fair Labor Standards Act (FLSA), the False Claims Act (FCA), etc.

The government has maintained its position that Medicare/Medicaid fraud is public enemy #3, just behind drugs and violent crime, and is directing much of its efforts at home care.

504 Rehabilitation Act Grievance Policy

February 28, 2012 By Pearson & Bernard Leave a Comment

The Rehabilitation Act of 1973 was the predecessor of the American Disabilities Act of 1990 and imposed a duty upon federal contractors, or entities that participate in federally funded programs to accommodate persons with “handicaps.” In addition, Section 504 of the law prohibits a business which participates in a program that receive federal financial assistance from discrimination which affects the receipt of the federal benefit and in employment of individuals. Thus this law applies to home health agencies which participate in Medicare or Medicaid who, as outlined in the law, employ more then fifteen (15) persons.
The regulations adopted to implement section 504 provides that “no qualified Handicapped individual shall on the basis of handicap be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity which receive or benefits from federal financial assistance.” The law and regulations do not require an affirmative action policy. Yet, the regulations outline specific discriminatory actions which are prohibited including denial of a benefit or service, providing a less effective benefit of service or a different benefit or service either directly or through a contract, license or other arrangement if such acts are done on the basis of a person’s handicap. As previously stated, the prohibition extends to access to services or facilities as well as to employment opportunities.
Similar to the ADA, Section 504 of the Rehabilitation Act generally requires program participant to reasonably accommodate a qualified person with a handicap in the employment setting. Such a duty is not stated for accessibility to services. Instead, the regulations simply prohibit using the handicap as the basis of denial, restriction or limitation on services.
The regulations require that a covered entity appoint a specific person to coordinate is compliance. In addition, the covered entity must institute a grievance policy applicable complaints about possible discriminatory acts. The grievance policy should address employment grievance and patient grievance and include the following:

1. Adopt a written grievance procedure to be incorporated in clinical and employment policies. The grievance policy should be included in patient admission packets.

2. The grievance procedures should outline that complaints be in writing and addressed to a management level person and/or the identified Grievance Coordinator.

3. Establish specific time frames for filing the compliant and the investigation of the changes.

4. Outline the time frame and chain of command for decision_making on the complaint including identifying the person or the job title of the person who will oversee the investigation of the complaint.

5. Provide for a grievance hearing_ a meeting of the aggrieved party and the decision makers including the Chief Executive Officer of the company as a final step in the procedure.

Agencies also must maintain a log of grievances from patients or employee that fall under section 504, by disabled person who are either patient, applicants for employment, etc. In addition, agencies must post a notice of compliance with Section 504 of the Rehabilitation Act which includes the name of the Grievance Coordinator. Agencies who advertise, either for employees or for educational purposes, should also include reference to being non_discriminatory on the basis of race, sex, disability, religion, or ethnic background.

In light of the recent cases, home health agencies should make sure they are in compliance with Section 504 of the Rehabilitation Act and address the issues in admission policies. A grievance procedure should be adopted and incorporated in agency admission and compliance policies. Decisions on admission or discharge should be characterized as related to the agency’s ability to provide or reasonable expectation to be able to provide the care for patients, which may include whether or not the agency can afford to pay its employees to provide services.

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