Charlene Harrington Slides 7 24

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Information about Charlene Harrington Slides 7 24
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Published on October 29, 2007

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Slide1:  UCSF Medicaid Long Term Care: Changes, Innovations and Cost Containment Charlene Harrington, Ph.D. and Martin Kitchener, Ph.D. Slide2:  Levit, et al. Health Affairs 2003 US Medicaid Long Term Care Participants, 2000 Total Participants: 7.37 million:  US Medicaid Long Term Care Participants, 2000 Total Participants: 7.37 million Source. CMS, 2003. Medicaid Statistical Information System, 2000. Washington, DC. US Medicaid Expenditures, 2002 Total: $82 billion:  US Medicaid Expenditures, 2002 Total: $82 billion Source: Burwell, 2003. CMS Form 64 Expenditure Data. Cambridge, MA: MedStat Nursing Home and ICF-MR/DD Expenditures in Billions, 1997 – 2002 :  Nursing Home and ICF-MR/DD Expenditures in Billions, 1997 – 2002 Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Waivers. SF: UCSF. Trends in LTC Bed Supply, 1990-2001 :  Harrington et al. 2003. Do We Have An Adequate Supply of LTC. SF: UCSF. Trends in LTC Bed Supply, 1990-2001 Percent Occupancy Rates in US Nursing Homes, 1995-2001:  Percent Occupancy Rates in US Nursing Homes, 1995-2001 Harrington, et al., 2002. Nursing Facilities, Staffing, Residents & Facility Deficiencies, 1995-2001. www.nccnhr.org Provider Supply:  Provider Supply Oversupply and slow growth in Nursing Homes (17,458 facilities with 1.81 million beds) Decline in Intermediate Care for the Mentally Retarded/Developmentally Disabled Doubling of Residential Care and Assisted Living in last decade Possible Oversupply of Residential Care/ Assisted Living Percent of States with LTC Certificate-of-Need/Moratoria, 2002:  Percent of States with LTC Certificate-of-Need/Moratoria, 2002 Harrington, et al., 2003. Trends in Certificate-of-Need and Moratoria. San Francisco: UCSF Regulation of LTC Provider Supply:  Regulation of LTC Provider Supply CON/Moratoria is used to control Medicaid costs & improve distribution of services CON does limit nursing home growth States are trying to shift to residential care/ assisted living and home and community based services (HCBS) State CON controls on home care/ hospice may create access problems Medicaid Nursing Home Reimbursement Rates :  Medicaid Nursing Home Reimbursement Rates Medicaid reimbursement rates vary widely across states – Average $124 per day in 2002 Range - $83 in LA to $323 in AK States are limiting NH reimbursement rates to keep costs down Can have a negative impact on quality Results in low wages/benefits and an unstable workforce Swan, J. 2003. Medicaid Reimburement Rates. Wichita: Wichita State University, Medicaid Nursing Home Screening Programs:  Medicaid Nursing Home Screening Programs Have not been effective in lowering NH admissions - screening is often not done before placement Many LTC users are not given a choice of HCBS upon admission so some are inappropriately placed in institutions States are trying to improve the effectiveness of their screening programs Toner and Harrington:, 2003. Nursing Home and HCBS Need Criteria. SF: UCSF LTC Screening:  LTC Screening 31 states use a combination of nursing, medical, functional, or other psychosocial criteria for nursing homes and HCBS 25 states have explicit criteria and 7 have point systems Problems NH assessment is generally shorter and less comprehensive than HCBS screening Some states use a higher need criteria for HCBS than for nursing homes Tonner and Harrington, 2002. LTC Screening Programs, Home Health & Community Services. LTC Coordination Problems :  LTC Coordination Problems Fragmentation of LTC services, programs, and agencies Fragmentation and inequity across LTC groups within states Lack of central entry point Multiple different screening/assessment programs, tools, and criteria Poor data tracking & information systems Harrington et al 2000. HCFA study. Pressures to Provide HCBS:  Pressures to Provide HCBS Poor quality of nursing home care and increasing costs Consumer demand for alternatives to nursing homes especially by the disabled community Pressures from CMS to increase Medicaid access to HCBS Olmstead v. L.C. Supreme Court Decision:  Olmstead v. L.C. Supreme Court Decision Individuals living in institutions have the right to live in the community if they are able to do so and choose to live in a community setting Litigation against states and settlement agreements Three Types of Medicaid Home and Community Based Services:  Three Types of Medicaid Home and Community Based Services Home health care – Only required for those who would be in an institution Personal care state plan option available in only 28 states HCBS waiver programs Must be nursing home eligible Can limit slots & expenditures Medicaid Home Health, Personal Care and Waiver Participants, 2001 (2,117,948 participants):  Medicaid Home Health, Personal Care and Waiver Participants, 2001 (2,117,948 participants) Kitchener, Ng, & Harrington, 2003, Medicaid Home Care Participation. San Francisco: UCSF Expenditures for Home Health, Personal Care & HCBS Waivers, 2001 Total: $22 billion:  Expenditures for Home Health, Personal Care & HCBS Waivers, 2001 Total: $22 billion Source: Kitchener, Ng, and Harrington, 2003. Medicaid Home Care. San Francisco, CA: UCSF Waiver Participants vs. Waiver Expenditures in Billions, 1992 – 2001 (832,915 participants/$14 billion, 2001):  Waiver Participants vs. Waiver Expenditures in Billions, 1992 – 2001 (832,915 participants/$14 billion, 2001) Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Waivers. SF: UCSF. Waiver Expenditures in Billions and Expenditures per Participant, 1992 – 2001 ($17,070 per participant, 2001):  Waiver Expenditures in Billions and Expenditures per Participant, 1992 – 2001 ($17,070 per participant, 2001) Kitchener, Ng, & Harrington, 2003. Medicaid Home Care. SF: UCSF. Waiver Participants by Recipient Type: 2001 (832,915 Participants):  Waiver Participants by Recipient Type: 2001 (832,915 Participants) Source: Kitchener, Ng, and Harrington, 2003. Form 376. San Francisco, CA: UCSF Medicaid Waiver Expenditures by Recipient Type, 2001 Total: $14 billion:  Medicaid Waiver Expenditures by Recipient Type, 2001 Total: $14 billion Source: Kitchener, Ng, and Harrington, 2003. Medicaid Home Care. SF: UCSF. Waiver Expenditures by Service Category, 2001 Total: $14 billion:  Waiver Expenditures by Service Category, 2001 Total: $14 billion Kitchener, Ng, & Harrington, 2003. Medicaid Home Care. S: UCSF Cost Control Policies:  Cost Control Policies Limits on waiver eligibility for those who are otherwise eligible for institutional care Ceilings or caps on expenditures per recipient Limits on waiver slots Kitchener, Ng, & Harrington, 2003. Medicaid Home Care Policies. SF: UCSF Waiver Financial Eligibility Limits as a % of SSI or Poverty Level, 2002 (N = 171 Waivers or 78%):  Waiver Financial Eligibility Limits as a % of SSI or Poverty Level, 2002 (N = 171 Waivers or 78%) Kitchener, Ng, and Harrington, 2003. Medicare Home Care. San Francisco: UCSF. States with “Ceilings” of “Caps” on Waiver Expenditures, 2002 :  States with “Ceilings” of “Caps” on Waiver Expenditures, 2002 Kitchener, Ng, and Harrington, 2003. Medicaid Home Care. SF: UCSF. Medicaid HCBS Waiver Waiting Lists by Recipient Types, 2002 Total - 157,640 :  Medicaid HCBS Waiver Waiting Lists by Recipient Types, 2002 Total - 157,640 Kitchener, Ng, & Harrington, 2003. Medicaid Home Care, 2002. SF: UCSF. Waiting Lists for HCBS Waivers in Selected States in 2002:  Waiting Lists for HCBS Waivers in Selected States in 2002 Kitchener, Ng, & Harrington 2003. Medicaid Home Care. SF: UCSF. Unmet Needs for HCBS in 2002:  Unmet Needs for HCBS in 2002 Only 28 states offer Personal Care Option States are limiting the number of waiver slots Large and long waiting lists in some states Most states report shortages of funds for HCBS HCBS slots not keeping up with the need Kitchener, Ng, & Harrington, 2003. Medicaid Home Care. SF: UCSF. Undersupply of HCBS Providers:  Undersupply of HCBS Providers 7,880 certified home health agencies in 2000 2,288 certified hospices in 2000 3,344 adult day care centers in 2001 Severe shortages of home and personal care workers Inadequate Medicaid rates to pay for wages and benefits Harrington, 2003. Home health, hospice, and adult day care. SF: UCSF Quality of Care Oversight for HCBS:  Quality of Care Oversight for HCBS Lack of regular audits or reviews of casement agencies, waiver providers and direct-care staff Failure to provide authorized or necessary services Inadequate assessment of care needs Inadequate care management Need better and more detailed quality assurance systems GAO, 2003. Home health, hospice, and adult day care. SF: UCSF Summary - Medicaid LTC :  Summary - Medicaid LTC Shift from Institutional to HCBS States spend less on HCBS than institutional care ($17,000 for HCBS compared with $45,000 for NH) HCBS is in demand by recipients States are trying to make HCBS a substitute for institutional care rather than an add on service Still a great need for HCBS Need more HCBS providers Need to improve quality oversight

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