robert mollica national academy for state health policy and leslie hendrickson hendrickson...
TRANSCRIPT
Robert MollicaNational Academy for State Health Policy
And
Leslie HendricksonHendrickson Development
November 12, 2009
Goal 3: Financing StudyExamine laws, regulations, policies and payment
methodologies affecting long-term care in CaliforniaIdentify barriers and make recommendations to:
Improve access to home and community based servicesMore effectively manage funding for services that promote
community living optionsReport addresses older adults, adults with physical
disabilities and persons with developmental disabilitiesDoes not address persons with mental illness
FocusMedi-Cal services
IHSS HCBS waiver programs (MSSP, ALW, NF/AH, AIDS)Nursing Facility servicesADHC
Did not includeState general revenue programsOlder Americans Act
Challenges to Managing Long Term Care
Fiscal, geographicServices covered by multiple state and county agencies
Department of Social ServicesDepartment of Health Care ServicesDepartment of AgingDepartment of Public HealthDepartment of Developmental Services
General lack of streamlined accessNo common database across programs
Balancing: What Is It? No standard definition of balanceSystem enables consumers to choose services and settings
based on their preferencesDefined by state policyPossible measures
Percent of spending on HCBSPercent of people served in community settingsMonths in the community vs institutional settingsPercent of new users who receive HCBS
Comparing StatesCMS 64 expenditure data released annually by Thomson
ReutersUnder-reports HCBS spending in some states
Expenditures not included in rankingsState plan Adult Day Health CareTargeted Case ManagementState general revenue services
Defining “Institution” and Community Settings
Key Findings: RankingsParticipant rankings:
1st in number of personal care participants/1,00042nd in HCBS waiver participants/1,0006th in total HCBS participants/1,000
Per capita spending (all populations)Personal care 4th
Total HCBS 18thHCBS waivers 48th
Nursing facility 41st
ICF-MR 33rd
Percentage HCBS Spending
Population CA NAT AVE
Percent HCBS (all populations) 54% 42%
Older adults, individuals with 52% 31%physical disabilities
Individuals with developmental 62% 63%disabilities
Key Findings…Programs spread across multiple agenciesOnly DDS has a single entry point systemNo agency-wide long-term care strategic planInstitutional bias in financial eligibility for nursing facility
and HCBS waiver servicesLimited organizational base to build or expand new
programs (eg statewide transition program)
Key Findings…Progress relocating individuals from Developmental
CentersNursing home supply and Medi-Cal use declined from
2001 to 2008California National
Supply - 6.0% -1.6%Medi-Cal census -.4% - 8.3%
Nursing facility rate does not control for low occupancyRates exceeded inflation
Cost effectiveness/woodwork effectChange the service mix to meet expanding need
Reduce the spending growth rateSet aside waiver slots for persons relocating from
institutionsConduct a “break even” analysis“Cost avoidance” through diversion
Use of the ReportContinue status quoFormulate a transition planIncremental changesBroader changes
Recommendations: 28Time to implement
General Short-term (12 months) Medium-term (12 – 24 months)Longer-term (24 months or longer)
CategoryFinancingAccess/delivery systemState-level organization
General Recommendations Establish a philosophy and legislative intent for all long-
term services and supportsCurrently only described for specific programsNo overall statement of intent for the “system”
Develop a strategic plan for long-term services and supportsPopulations addressedTimetables, responsibilities and measureable goals
Budget FlexibilityCreate a unified long-term care budget for aged/disabled
servicesNursing facility servicesIn Home Supportive ServicesMultipurpose Senior Services ProgramOther HCBS waivers
Reinvest Savings in HCBSWaiver programs are cost effective and should be
expanded Transfer savings to HCBS programs from individuals who
transition from nursing facilitiesAllow appropriations for nursing facilities to pay for
HCBS for waivers with waiting lists
Rental Assistance VoucherAddresses need for affordable housing for individuals
who want to transition from an institutionConvert a portion of the state share of savings in a nursing
home to a temporary rental assistance subsidyIndividuals must be on a waiting list for a housing choice
voucher
Nursing Facility ReimbursementAdopt nursing facility case mix reimbursement system for
the staffing component of reimbursement rateCreates incentives to serve higher acuity residents and
divert lower acuity applicants to community programsReimbursement level for property costs seems too lowExamine reimbursement level for insurance which might
need cap on size of per diem costs
Reduce Payments for Vacant Nursing Facility Beds
Establish a nursing facility occupancy provisionBased on a flat percentage of licensed beds or the
statewide average occupancy rateGAO report on 19 states found the average nursing
facility occupancy provision used by other states was 88.6%
25% of CA nursing facilities have occupancy rates below 85%
Convert “labor driven operating allocation”
Now used as incentive or bonus for hiring staff instead of contracting for staff
Some or all of labor offset can be converted to support other policies:Incentivize homes to support transition effortsPromote “Culture Change”Pay for Performance for meeting quality of care and quality
of life goals, e.g. example of ColoradoRestructure physical plants, build residential optionsPromote more staff training
Managed Long-Term Care ASPE report – “most studies and officials report that
managed LTC reduces use of institutional services and increase use of HCBS relative to fee for service programs”
Consumer satisfaction is highImproves coordination of health and long term care needsReduce hospital use, emergency room visits, lower overall
costs
Increase Scope of Provider Fees
Add Medicare revenue to Quality Assurance Fee Added after study was completed
Identify provider groups interested in establishing QAFs for HCBS
Streamline Access to HCBSCreate single entry points for older adults and adults with
physical disabilitiesScope of programs and activitiesPossible entities
Regional or County based organizationsADRCMSSP sitesArea Agencies on Aging
Co-locate financial eligibility workers in SEPs/ADRCs
DiversionWork with hospitals to provide preadmission
screening/options counseling for individuals who:Seek admission to a nursing homeDischarged from a hospital with health & supportive service
needsProvided by single entry points, ADRCs, community
organizationsPriority groups
Medi-Cal beneficiariesLikely spend down within 3 or 6 months
Transition ProgramEstablish a statewide nursing facility case management
function to support residents who can relocate to the community
Support and expand Money Follows the Person project Provide funds to help Independent Living Centers, MSSP
sites, Area Agencies on Aging, other non-profits and counties to expand transition programs
Takes several years to build an effective infrastructure
Eligibility Changes to Increase HCBS Use
Addresses institutional biasAdd the 300% of SSI eligibility group to HCBS waivers
Allows people who would spend down in a nursing home to be eligible for HCBS waivers in the community
Establish maintenance allowance/share of cost
Help Individuals in Nursing Facilities Keep a Home
Increase the home maintenance allowanceAllows individuals admitted to a nursing home to retain
income to maintain their homeMust expect to return home within 180 daysCurrent allowance is $209 a monthOptions: Exempt up to 100% FPL; Percentage of the
SSI/SSP payment; Total SSI/SSP payment
Keep a Home…Maintain the SSI/SSP eligibility status for short-term
nursing home admissionsAllows individuals in a nursing home for less than 90 days
to receive their full SSI/SSP payment to maintain their home
Services in Residential SettingsOffers options for people who need access to services for
unscheduled needs, oversight and supervisionProgram options
Allow IHSS payments in RCFEsExpand assisted living waiver statewideAdd assisted living services to MSSP, NF/AH waiver
Expedite Financial EligibilityAllow case managers to presume financial eligibility and
enroll applicants in an HCBS waiver to avoid nursing facility admission
“Fast track” the eligibility processCo-locate financial eligibility workers with single entry
points/ADRCs
New Department Create a Department of Long-Term Services and SupportsLittle Hoover Commission recommendationPossible components
In Home Supportive ServicesMultipurpose Senior Services ProgramAssisted Living Waiver ProgramOther HCBS waiversNursing home level of careNursing home licensingRCFE licensing