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California County Profiles of Medi-Cal Beneficiaries Who Use Long-Term Services and
Supports in 2008 ________________________________________
Prepared for
The SCAN Foundation
and
The California Department of Health Care Services
December 10, 2013
By CAMRI, University of California
Andrew B. Bindman, M.D.
Charlene Harrington, RN, Ph.D.
Sei J. Lee, M.D.
Robert J. Newcomer, Ph.D.
Chi Kao, Ph.D.
Taewoon Kang, Ph.D.
Philip Chu, M.A.
Denis Hulett, M.S.
2
Acknowledgments
This report is supported by funds received from the California Department of Health Care
Services and from a grant from The SCAN Foundation. The SCAN Foundation is dedicated to
creating a society in which seniors receive medical treatment and human services that are
integrated in the setting most appropriate to their needs. For more information on The SCAN
Foundation please visit www.TheSCANFoundation.org.
The authors wish to acknowledge the contributions of Jim Watkins and his colleagues in the
Research Analytic and Statistical Branch within the California Department of Health Care
Services in preparing some of the data files used for this study. We would also like to thank Julie
Stone for her editorial contributions and Lena Libatique for assisting with the formatting and
copy editing of this report.
CAMRI
CAMRI is a multi-campus research program of the University of California that promotes the
development and dissemination of evidence to improve policy decision-making in California’s
Medicaid program. For more information, please visit http://camri.universityofcalifornia.edu/.
3
TABLE OF CONTENTS
GLOSSARY ............................................................................................................................................ 5
INTRODUCTION .................................................................................................................................... 6
BACKGROUND ...................................................................................................................................... 8
METHODS ............................................................................................................................................. 9
RESULTS ............................................................................................................................................ 10
DISCUSSION ....................................................................................................................................... 16
FIGURES
Figure 1
Home and Community Based Services (HCBS) Users per 10,000 Medi-Cal Beneficiaries, CY
2008............................................................................................................................................ A-1
Figure 2
Nursing Facility Only (No Home and Community Based Services) Users per 10,000 Medi-Cal
Beneficiaries, CY 2008 .............................................................................................................. A-2
Figure 3
Percent Age 65 Years and Older among Medi-Cal Home and Community Based Services
(HCBS) Users, CY 2008 ............................................................................................................ A-3
Figure 4
Percent of Non-White Medi-Cal Home and Community Based Services (HCBS) Users, CY 2008
.................................................................................................................................................... A-4
Figure 5
Mean Number of ADL Limitations among Medi-Cal Home and Community Based Services
(HCBS) Users, CY 2008 ............................................................................................................ A-5
Figure 6
Percent of Cognitive Limitations among Medi-Cal Home and Community Based Services
(HCBS) Users, CY 2008 ............................................................................................................ A-6
Figure 7
Mean Total Medi-Cal Annual Spending per Medi-Cal Only Long Term Services and Support
(LTSS) User, CY 2008 .............................................................................................................. A-7
Figure 8
Mean Total Medi-Cal Annual Spending per Medi-Cal Only Nursing Facility Only (No Home
and Community Based Services) User, CY 2008 ...................................................................... A-8
Figure 9
Mean Total Medi-Cal and Medicare Annual Spending per Medicare-Medicaid Enrolled Long
Term Services and Support (LTSS) User, CY 2008 .................................................................. A-9
Figure 10
Mean Total Medi-Cal and Medicare Annual Spending per Medicare-Medicaid Enrolled (MME)
Nursing Facility Only (No Home and Community Based Services) User, CY 2008 .............. A-10
4
Figure 11 Percent of Medi-Cal Long-Term Services and Support LTSS Spending Over Total Medi-Cal
Spending, CY2008 ................................................................................................................... A-11
Figure 12 Percent of Medi-Cal Long-Term Services and Support (LTSS) Spending on Home and
Community Based Services (HCBS), CY 2008 ..................................................................... A-12
Figure 13
Annual Mortality Rate among Home and Community Based Services (HCBS) Users, CY 2008 ..
.................................................................................................................................................. A-13
Figure 14
Annual Nursing Facility Admission Rate among Medi-Cal Home and Community Based
Services (HCBS) Users, CY 2008 ........................................................................................... A-14
5
GLOSSARY
ADHC Adult Day Health Care
ADL Activity of Daily Living
CAMRI California Medicaid Research Institute
CMIPS Case Management Information Payrolling System
COHS County Organized Health System
FFS Fee-for-Service
GMC Geographic Managed Care
HCBS Home and Community Based Services
HH Home Health
IHSS In-Home Supportive Services
LTSS Long-Term Services and Supports
MME Medicare-Medicaid Enrollee
NF Nursing Facility
OASIS Outcomes Assessment and Information Set
SNF Skilled Nursing Facility
TCM Targeted Case Management
6
INTRODUCTION
Medicaid is the single largest payer for long-term services and supports (LTSS) for low-income
seniors and certain individuals with disabilities in the United States. It constitutes the only safety
net coverage of comprehensive LTSS in the nation. Medicaid is jointly financed by federal and
state governments. Within broad federal guidelines, each state designs and administers its own
Medicaid program. California’s Medicaid program, Medi-Cal, is administered by the California
Department of Health Care Services (DHCS).
Medi-Cal’s coverage of LTSS recipients, like in many other states, can be characterized by a
long history of fragmented financing and service delivery. In part, this fragmentation is due to a
lack of coordination and financial alignment among the multiple entities responsible for
delivering Medi-Cal’s LTSS. For example, in California, DHCS is responsible for directly
contracting with nursing facilities across the state on a fee-for-service (FFS) basis. Home- and
community-based services (HCBS), on the other hand, are administered by multiple state
departments under sub-contract with DHCS. These departments include the California
Department of Aging (CDA), the California Department of Public Health (CDPH), and the
Department of Developmental Services (DDS). Through subcontracts with the California
Department of Social Services (CDSS), counties also play a significant role. They are
responsible for administering California’s personal care benefit, In-Home Services and Supports
(IHSS).1 Each of these entities has a separate financing stream to operate its part of the Medi-Cal
LTSS program.
Additional fragmentation is added for Medi-Cal’s LTSS recipients who are also enrolled in
Medicare (referred to as dual enrollees and/or Medicare-Medicaid enrollees, MMEs). MMEs
participate in Medi-Cal for their LTSS while relying upon Medicare for a majority of their acute
and post-acute care services. Medi-Cal also pays for those acute and post-acute care services not
paid for by Medicare.
Not only does California’s financing and delivery system vary by county, but so too does its
geography and demographics. While some of California’s counties are densely urban, others are
highly rural. Differences in the per capita income and prevalence of older persons also exist by
county. These county differences likely contribute to decisions providers make about where to
locate nursing facilities, the supply of HCBS workers and providers, and the demand for LTSS
by county.
Amidst significant fragmentation in the Medi-Cal and Medicare programs and a diverse county
landscape, there is a growing demand for LTSS. With an aging population and an increase in
1 For further explanation of these distinct administrative rules in LTSS, see Tables 5 and 6 in the following report,
Julie Stone, MA, Robert J. Newcomer, PhD, Arpita Chattopadhyay, PhD, Todd P. Gilmer, PhD, Phillip Chu, MA,
Chi Kao, PhD, and Andrew B. Bindman, MD “Studying Recipients of Long-Term Services and Supports: A Case
Study in Assembling Medicaid and Medicare Claims and Assessment Data in California,” California Medicaid
Research Services, University of California, November 2011. See, http://thescanfoundation.org/california-medicaid-
research-institute-studying-recipients-long-term-care-services-and-supports-case or
http://camri.universityofcalifornia.edu/documents/data-case-study.pdf.
7
individuals under age 65 living with disabilities,2 the need for Medicaid coverage for LTSS and
Medicare for MMEs is expected to grow. Increased demand will likely result in increased
spending, unless significant programmatic changes can be made.
Policy-makers, counties and plans are now preparing to test the effectiveness of such
programmatic changes that will streamline the administration and financing of care across the
full range of acute, post-acute and LTSS for MMEs. DHCS and eight California counties are
participating in a federal demonstration for MMEs, entitled Cal Medi-Connect.3 Starting in
January 2014, Alameda, San Bernardino, San Mateo, Orange, Los Angeles, Santa Clara,
Riverside, and San Diego counties will begin enrolling MMEs, including those with LTSS needs,
into capitated Medi-Cal/Medicare managed care plans.4 Their hope is that improved coordination
and aligned financial incentives across the full range of services used by this population might
help curb expenditures and result in better care and outcomes.5
This report provides an analysis of Medi-Cal and Medicare data provided to the California
Medicaid Research Institute (CAMRI) by DHCS and Medicare. Specifically, it shows the
demographics, expenditures, and certain outcomes of California’s LTSS population in 2008 by
county. It is intended to support policy-makers in their effort to improve care coordination and
financial incentives for care delivery across California’s counties. It can also be used by policy-
makers, health plans, and advocates to identify programmatic strengths and areas that warrant
improvements.
This report is another in a series that presents findings from CAMRI’s integrated database. The
first report in this series, “Recipients of Home-and Community-Based Services in California,”
describes the demographic characteristic, HCBS use, functional level-of-care needs, and rates of
nursing facility admissions and mortality for recipients of HCBS in California.6 A second,
“Medicaid and Medicare Spending on Acute, Post-Acute, and Long-Term Services and Supports
in California,” describes the full range of medical expenditures for Medi-Cal only and MMEs
with LTSS needs. 7
A third, “Extended Stay Nursing Facility Admissions for California’s Dual
2 Carol O’Shaughnessy, Julie Stone, Thomas Gabe, Laura and Shrestha, Long-Term Care: Consumers, Providers,
Payers, and Programs,” Congressional Research Service, Library of Congress, March 15, 2007. 3 Under the authority of the Patient Protection and Affordable Care Act of 2010 (ACA), the Medicare and Medicaid
Coordination Office and the Medicare and Medicaid Centers for Innovation established a demonstration
opportunity for states to experiment with a capitated approach to aligning Medicare and Medicaid dollars for MMEs. 4 For more information on this demonstration, see http://www.calduals.org/.
5 It is also anticipated that beginning in 2014 that Medi-Cal managed care beneficiaries residing in these eight
counties will have payment for LTSS services transitioned from fee-for-service into the capitated payment to a
managed care plan. 6 Robert N. Newcomer, Ph.D., Charlene Harrington, R.N., Julie Stone, M.P.A. Arpita Chattopadhyay, Ph.D.
Sei J. Lee, M.D., Taewoon Kang, Ph.D., Phillip Chu, M.A.,Chi Kao, Ph.D. and Andrew B. Bindman, M.D.
“Recipients of Home and Community-Based Services in California,” California Medicaid Research Services,
University of California, June 2012. See, http://camri.universityofcalifornia.edu/documents/hcbs-report-dhcs.pdf or
http://www.thescanfoundation.org/california-medicaid-research-institute-recipients-home-and-community-based-
services-california. 7 Robert N. Newcomer, Ph.D., Charlene Harrington, R.N., Julie Stone, M.P.A. Arpita Chattopadhyay, Ph.D.
Sei J. Lee, M.D., Taewoon Kang, Ph.D., Phillip Chu, M.A.,Chi Kao, Ph.D. and Andrew B. Bindman, M.D.
“Medicaid and Medicare Spending on Acute, Post-Acute and Long-Term Services and Supports
8
Eligible and Medi-Cal-Only Beneficiaries, 2006-2008,” describes the demographic, health, and
functional status of adult Medi-Cal beneficiaries who are admitted to nursing facilities for
extended stays in California and examines whether these beneficiaries received any form of
Medi-Cal covered HCBS prior to entry.8 CAMRI also published a report entitled “Medi-Cal
Beneficiaries Who Use Long Term Services and Supports: Profiles of Utilization and Spending
in Eight Dual Eligible Integration Counties, 2008.” 9 This report expands upon the eight-county
report to include comparative information for all 58 counties in the state.
BACKGROUND
LTSS refers to a broad range of health and social services needed by people with a limited
capacity for self-care due to a physical, cognitive, or mental disability or condition that results in
functional impairment and dependence on others for an extended period of time. Formal services
to assist people with LTSS needs may be provided either in an institutional-based setting, such as
a nursing home, or in a home- or community-based setting such as a private home, group home,
or assisted living facility.
At the time of this study in 2008, almost all Medi-Cal beneficiaries received their LTSS services
through fee-for-service arrangements reimbursed by DHCS. However, some beneficiaries
depending on their eligibility category and county residence were required to receive acute and
post-acute care services through managed care arrangements delivered by county specific health
plans. In 2008, most of the Medi-Cal beneficiaries required to receive services in managed care
were low-income children and their parents, a group that does not make extensive use of LTSS
services. However, disabled Medi-Cal beneficiaries, a group much more likely to use LTSS,
were required to receive acute and post-acute care through a County Organized Health System
(COHS) managed care plan in nine of California’s 58 counties in 2008. These counties were Monterey, Napa, Orange, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Solano, and
Yolo.10
in California,” California Medicaid Research Services, University of California, December 2012. See,
http://thescanfoundation.org/california-medicaid-research-institute-medicaid-and-medicare-spending-acute-post-
acute-and-long-term or http://camri.universityofcalifornia.edu/publications.html. 8 Robert Newcomer, Charlene Harrington, Julie Stone, Denis Hulett, Taewoon Kang, Phillip Chu, Todd Gilmer,
Arpita Chattopadhyay, Andrew B. Bindman. “Extended Nursing Facility Stays Among California’s Dual Eligible
and Medi-Cal-Only Beneficiaries, 2006-2008,” California Medicaid Research Services, University of California,
September 2013. See, http://www.thescanfoundation.org/california-medicaid-research-institute-extended-nursing-
facility-stays-among-californias-dual or
http://camri.universityofcalifornia.edu/documents/camri_extended_nf_stays_among_california_dual_eligibles_medi
-cal-only_beneficiaries-9-25-13.pdf. 9 Sei J. Lee, Chi Kao, Denis Hulett, Taewoon Kang, Philip Chu, Robert J. Newcomer, Charlene Harrington, Arpita
Chattopadhyay, Andrew B. Bindman. “Medi-Cal Beneficiaries Who Use Long-Term Services and Supports:
Profiles of Utilization and Spending in Dual Eligible Integration Counties, 2008”, May 2013. See,
http://thescanfoundation.org/updated-california-medicaid-research-institute-medi-cal-beneficiaries-who-use-long-
term-services-and. 10
Since the time of our study, California’s counties have increased their use of Medi-Cal managed care. In 2011,
California expanded the mandatory enrollment of Medi-Cal beneficiaries who are eligible on the basis of being
aged, blind or disabled into managed care. Currently, 14 counties operate COHS plans, 14 counties operate two-plan
models in which Medi-Cal participants enroll in either a county-operated managed care plan (referred to as local
9
METHODS
This report provides summary data in 14 figures for each of California’s 58 counties on the
demographics, expenditures, and outcomes of Medi-Cal recipients ages 18 or over who were
LTSS users during Calendar Year (CY) 2008. The LTSS user population is not defined by an
eligibility category, but instead by service use. For this study, the services defining LTSS include
Medi-Cal reimbursed nursing facility services, home health (HH), IHSS, Adult Day Health Care
(ADHC)11
, Targeted Case Management (TCM), and any of the Medi-Cal HCBS waiver
programs (Section 1915(c) of the Social Security Act).
We identified the study population by using Medi-Cal's enrollment and claims files as well as the
state's Case Management Information Payrolling System (CMIPS). CMIPS includes recipients of
IHSS, the most common HCBS service, some of whom are not reflected in the individual claims
files.
We excluded from our analysis two groups of Medi-Cal LTSS users for whom we do not have
individual claims records: participants in the Program for All-Inclusive Care for the Elderly
(PACE) and individuals who qualify for Medi-Cal based on a diagnosis of a developmental
disability. For the 2.4% of Medi-Cal LTSS recipients who resided in more than one county in
2008, we assigned them to the county where they spent the majority of Medi-Cal eligible
months.
Comparisons of all 58 California counties are summarized in a series of bar graph figures
described in greater detail below. In each figure, we have arrayed the counties by the magnitude
of the measure of interest from highest to lowest value. The order of the counties in the figures
varies depending on the measure. In each figure we also included the state average weighted by
the population in each county.12
Demographics Figures
Figures 1- 6 focus on the number and characteristics of Medi-Cal LTSS recipients enrolled in
Medi-Cal in 2008 in each county. All of these recipients used Medi-Cal covered nursing facility
services and/or HCBS. These figures describe the characteristics of Medi-Cal LTSS users. We
identified our study population using 2008 Medi-Cal enrollment, claims and CMIPS files. For
additional information on the methodology for these Figures, see “Recipients of Home and
Community-Based Services in California.”13
initiative) or a commercial managed care plan, and 2 counties operate GMC models in which Medi-Cal participants
choose from one of several commercial plans. 11
Adult Day Health Care is currently known as Community-Based Adult Services (CBAS). 12
More detailed information on each county’s LTSS recipients, service use, expenditures, and outcomes is available
at http://camri.universityofcalifornia.edu/HCBS-County-Tables.pdf. 13
Robert N. Newcomer, Ph.D., Charlene Harrington, R.N., Julie Stone, M.P.A. Arpita Chattopadhyay, Ph.D.
Sei J. Lee, M.D., Taewoon Kang, Ph.D., Phillip Chu, M.A., Chi Kao, Ph.D. and Andrew B. Bindman, M.D.
“Recipients of Home and Community-Based Services in California,” California Medicaid Research Services,
University of California, June 2012. See, http://camri.universityofcalifornia.edu/documents/hcbs-report-dhcs.pdf or
10
Expenditure Figures
Figures 7-12 show program expenditures for LTSS users age 18 years and above in FFS by
county in 2008. For the analysis on costs we used social security numbers to link the Medi-Cal
LTSS population with Medicare’s enrollment file to identify those Medi-Cal recipients who were
also enrolled in Medicare during any month of the study year. Those participating in both
Medicare and Medi-Cal for at least one month in 2008 are considered MME in our analysis.
Since complete costs are not available for those beneficiaries who received services through
Medi-Cal managed care, the cost estimates included in the figures reflect only those Medi-Cal
beneficiaries who were LTSS users in FFS care delivery; we excluded Medi-Cal beneficiaries
who were ever in Medi-Cal managed care in 2008. In 2008, nine California counties - Monterey,
Napa, Orange, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Solano and Yolo – were
COHS. The vast majority of Medi-Cal recipients residing in COHS counties are enrolled in
managed care. The relatively small number of beneficiaries who receive Medi-Cal services only
through a fee-for-service payment arrangement in COHS counties include those who receive
exemptions because of special needs that cannot be met by the managed care plan,
undocumented immigrants who qualify for emergency Medi-Cal benefits, pregnant women
receiving limited Medi-Cal benefits, and others who qualify for limited benefits related to rare
clinical conditions such as tuberculosis. Since the expenditure data in these counties are among a
limited and potentially atypical group of Medi-Cal beneficiaries, readers should exercise caution
in making comparisons between COHS and other counties when it comes to the expenditure
results.
We report on three broad categories of health care expenditures using Medi-Cal and Medicare
claims data linked to our study population. These health care expenditures are for acute and other
medical care services, post-acute care, and LTSS for Medi-Cal funded state plan and HCBS
waiver services. Because we did not have comprehensive data for prescription drug expenditures,
we did not include them in our analyses.
Outcomes Figures
Figures 13-14 focus on two outcomes: mortality and nursing facility admission rates.
Specifically, the report shows county-specific mortality and nursing facility admissions rates for
the LTSS recipient population. These analyses largely followed the methodology outlined in the
above mentioned report, “Recipients of Home and Community-Based Services in California.”
Please refer to the Methods section of that report for details of this methodology.
RESULTS The following 14 figures describe the demographics, service expenditures, and outcomes of
Medi-Cal’s LTSS users during 2008 by California’s 58 counties.
http://www.thescanfoundation.org/california-medicaid-research-institute-recipients-home-and-community-based-
services-california.
11
Demographic Figures
Figure 1. HCBS Users per 10,000 Medi-Cal Beneficiaries, CY2008
In California, there were 1,121 HCBS users age 18 and older for every 10,000 Medi-Cal
beneficiaries (Medi-Cal only and MME) in CY 2008. Figure 1 shows how the proportion of
HCBS users per Medi-Cal beneficiaries varies by county.
Among all California counties, San Francisco had the highest number of HCBS users per 10,000
Medi-Cal beneficiaries (~2,300). San Francisco’s utilization of HCBS among LTSS recipients is
nearly 50% higher than the county with the second highest number of HCBS users per 10,000
Medi-Cal beneficiaries (Imperial).
Larger, more urban counties tended to have higher numbers of HCBS users per 10,000 Medi-Cal
beneficiaries. California’s two largest urban counties - Los Angeles and San Diego - also had an
above average number of HCBS users.
Other counties, such as Alameda, Marin and Sonoma were also above the average. Mono,
Tulare, Kern, Inyo, Del Norte, Modoc, and Ventura had the lowest ratios of HCBS users across
California counties.
Figure 2. Nursing Facility Only Users per 10,000 Medi-Cal Beneficiaries, CY2008
Figure 2 details the number of beneficiaries (Medi-Cal only and MME) who used nursing
facility care per 10,000 beneficiaries in 2008 by county. This count excludes any nursing facility
users who also used HCBS in 2008. On average, 210 Medi-Cal recipients per 10,000 used
nursing facility care as their only LTSS.
There was substantial variation across counties in the number of beneficiaries who used nursing
facility care as their only LTSS in 2008. Some of this is due to small numbers of cases in some
counties but even among some of the most populous counties there is variation. For example,
San Diego, San Francisco, San Clara, and Los Angeles have rates of nursing facility only use
that are above the state average while San Bernardino, Sacramento and Orange counties have
rates that are below the state average. Furthermore, San Diego and San Francisco which were
counties with among the highest numbers of HCBS users among Medi-Cal beneficiaries (Figure
1), also have some of the highest rates of nursing facility only users as well. This may reflect a
high level of need for LTSS among Medi-Cal beneficiaries in these counties.
Figure 3. Percent of Age 65 Years and Older among Medi-Cal HCBS Users, CY2008
Figure 3 details the percentage of HCBS users (Medi-Cal only MME) who were age 65 and
older in each county. In California, 61% of HCBS users were age 65 and older.
12
There was greater than two-fold difference between the counties with the highest percentage of
HCBS users age 65 years and older (Santa Clara, 78%) and the counties with the lowest
percentage (Alpine, 23% and Humboldt, 32%).
Only seven counties had a percentage of HCBS users age 65 years or older that was higher than
the state average; however, these were some of the states largest counties. They were Santa
Clara, Imperial, San Francisco, Los Angeles, Yolo, Orange, and Ventura.
Figure 4. Percent of Non-White Medi-Cal HCBS Users, CY2008
Figure 4 describes the percentage of HCBS users (Medi-Cal only and MME) who were non-
white in 2008 in each county in California. The statewide average share of HCBS users who
were non-white was 66%.
Nineteen counties had percentages of non-white HCBS users that were greater than 66%. The
counties with the highest share of non-white HCBS users were Imperial, Alameda, Monterey,
San Mateo, Santa Clara and Orange.
Counties with the largest share of white HCBS users tended to be in the northern section of
California: Sierra, Trinity, Mariposa, Nevada, Modoc and Tuolumne.
Figure 5. Mean Number of ADL Limitations among Medi-Cal HCBS Users, CY2008
Figure 5 shows the mean number of limitations in Activities of Daily Living (ADL) among
Medi-Cal HCBS users (Medi-Cal only and dually enrolled in Medicare) with assessment data
from OASIS (Outcome and Assessment Information Set) related to the use of home health or
CMIPS (Case Management, Information and Payrolling System) related to the use of IHSS.
ADLs refer to activities such as eating, bathing, using the toilet, dressing, walking across a small
room, and transferring (getting in or out of a bed or chair). The average number of ADL
limitations across all Medi-Cal LTSS recipients in California was 2.6 in 2008.
Excluding small counties with less than 1,000 HCBS users, there was less than a two-fold range
in mean ADL limitations (e.g., Tehama was 1.7; San Mateo was 2.9). The more densely
populated counties all had mean ADL limitation scores greater than 2.
The counties with the highest mean number of ADL limitations among its LTSS recipients were
San Mateo, Solano, Fresno, Butte, San Bernardino, Madera, Kern, and Los Angeles.
Figure 6. Percent with Cognitive Limitations among Medi-Cal HCBS Users, CY 2008
Figure 6 shows the percentage of HCBS users (Medi-Cal only and MME) with cognitive
limitations based on their CMIPS or OASIS assessments in 2008. An average of 37% of all
HCBS recipients in California’s counties had cognitive limitations. Butte, Alpine, Monterey,
Solano, Mariposa, and Imperial had the highest percentage of HCBS users with cognitive
limitations.
13
Los Angeles had the lowest percentage of cognitive limitation with 26% of HCBS users reported
as having cognitive limitations. Other counties with relatively lower percentages of HCBS users
with cognitive limitations were Colusa, Ventura, San Luis Obispo, Riverside, and Madera.
Service Expenditure Figures
Figure 7. Mean Total Medi-Cal Annual Spending per Medi-Cal Only LTSS User, CY2008
Figure 7 shows the mean total fee-for-service Medi-Cal spending for Medi-Cal only LTSS users
by county in 2008. The average spending per LTSS user across all counties in California was
$24,493.
There was a substantial range in the amount of spending per LTSS user across counties that
could partially be explained by a small number of cases in some the counties. In general, the
larger urban counties were near or above the state average while smaller, more rural counties
tended to have somewhat lower costs. The eight counties with the lowest spending were
delivering Medi-Cal services through a COHS, and even the one COHS county not in this group,
Yolo, had costs substantially below the state average. However, it should be noted that these
estimates are among fee-for-service Medi-Cal only beneficiaries, which are a small and
somewhat atypical group in COHS counties where the norm is for Medi-Cal participants to
receive acute and post-acute care services through mandatory managed care.
Figure 8. Mean Total Medi-Cal Annual Spending per Medi-Cal Only Nursing Facility
Only (No HCBS) User, CY2008
Figure 8 shows the Medi-Cal annual spending per Medi-Cal only beneficiary whose only LTSS
use in 2008 was nursing facility care. Total spending includes expenditures for Medi-Cal-
covered acute, post-acute, and nursing-facility care and averaged $71,635 across California.
There was a substantial range in the amount of spending per nursing home only LTSS user
across counties that could partially be explained by a small number of cases in some the
counties. Excluding small counties with less than 100 nursing facility only users, there was an
approximately two-fold variation in Medi-Cal spending, with Tulare spending greater than an
average of $100,000 per user and Riverside spending closer to an average of $60,000 per user.
There are very small numbers of fee-for-service users of only nursing facility care among Medi-
Cal only beneficiaries in COHS counties making it difficult to draw clear conclusions about the
expenditures in these counties.
Figure 9. Mean Total Medi-Cal and Medicare Annual Spending per MME LTSS User,
CY2008
Figure 9 shows the Medi-Cal and Medicare spending for MME LTSS users in 2008 by county.
The California average was $54,672. The bar chart for each county is sub-divided to show the
Medi-Cal and Medicare portions of total acute, post-acute and LTSS spending. Five of the seven
counties with the highest combined Medi-Cal and Medicare spending were delivering Medi-Cal
14
services through a COHS. However, the total number of MME users in COHS counties with
fee-for-service claims was with the exception of Orange county fewer than 100 cases per county.
Among non-COHS counties, San Benito and Alameda had the highest spending, with both
counties spending over $60,000 per MME LTSS user. Excluding counties with fewer than 100
cases, Imperial, Humboldt, Del Norte, Siskiyou and Madera counties had the lowest average
spending.
On average, Medi-Cal contributed 33% and Medicare 67% to the overall cost of acute, post-
acute, and LTSS for MME users of LTSS. At the county level, the proportion of the spending
that was contributed by Medi-Cal versus Medicare did not appear to be a major determinant of
whether a county tended to spend a relatively high or a relatively low amount on Medi-Cal LTSS
users.
Figure 10. Mean Total Medi-Cal and Medicare Spending per MME Nursing Facility Only
(No HCBS) User, CY2008
Figure 10 shows Medi-Cal spending per MME whose only LTSS use in 2008 was nursing
facility care. The average per beneficiary spending across all counties for this population was
$89,144. The bar chart for each county is sub-divided to show the Medi-Cal and Medicare
portions of acute, post-acute, and LTSS spending.
Excluding the COHS counties, which had relatively few and somewhat atypical fee-for-service
MMEs, the highest average spending was in large urban counties including San Francisco,
Alameda, Los Angeles, San Bernardino, Contra Costa, Santa Clara, San Diego, and Riverside.
The lowest spending counties on average were more rural: Amador, Madera, Mendocino,
Calaveras, and Del Norte.
On average, Medi-Cal contributed 44% and Medicare 56% to the overall cost of acute, post-
acute and LTSS for MMEs whose only LTSS use in 2008 was nursing facility care. At the
county level, the proportion of the spending that was contributed by Medi-Cal versus Medicare
did not appear to be a major determinant of whether a county tended to spend a relatively high or
a relatively low amount on Medi-Cal nursing facility only users.
Figure 11. Percent of Medi-Cal LTSS Spending Over Total Medi-Cal Spending, CY2008
Figure 11 shows the percentage of total Medi-Cal spending for all Medi-Cal beneficiaries
(Medi-Cal only and MME) in 2008 that was spent on LTSS by county. LTSS includes spending
for both nursing facilities and HCBS. Across California, LTSS accounted for 74% of the total
Medi-Cal spending for LTSS users.
Eight of the 10 counties with the lowest percentage of Medi-Cal spending on LTSS were COHS.
Yolo, which is also a COHS county had the highest percentage of spending on LTSS (90%)
among all California counties; however, the number of cases was relatively small (54). Other
counties with relatively large percentages of Medi-Cal spending on LTSS were Modoc, Sierra,
Mariposa, Santa Clara, and San Francisco.
15
Figure 12. Percent of Medi-Cal LTSS Spending on Home- and Community-Based Services,
CY 2008
Figure 12 shows the percentage of Medi-Cal LTSS expenditures (HCBS and nursing facility
care) spent on HCBS for all (Medi-Cal only and MME) by county. While on average, just over
half of Medi-Cal’s LTSS spending is on HCBS, there is a wide range across counties. Some of
the difference is explained by small numbers of observations in some counties. However, even
among counties with at least several thousand cases, there is a range in the percentage of Medi-
Cal LTSS spending for HCBS from a high of more than 70% in Imperial to a low of just over
20% in Tulare. Among the largest counties, Sacramento, Los Angeles, and San Francisco had a
percentage of LTSS spending on HCBS that was above the state average of 51%. San Diego is
the largest county below the state average in HCBS spending, which is somewhat surprising
given it had a rate of HCBS users that was above the state average (Figure 1).
Outcomes Figures
Figure 13. Annual Mortality Rate among Medi-Cal HCBS Users, CY2008
Figure 13 shows the annual mortality rate among HCBS Users (Medi-Cal only and MME) by
county in 2008. The average mortality rate of HCBS users across all counties was 5.4%.
Counties with higher mortality rates relative to other counties among the LTSS were Mariposa,
Inyo, Sierra, Siskiyou, Mono, and Colusa. Counties with lower mortality rates were Alpine,
Santa Barbara, Tuolumne, Sutter, Monterey, Los Angeles, San Francisco, and Orange.
Figure 14. Annual Nursing Facility Admission Rate (%) among Medi-Cal HCBS Users,
CY2008
Figure 14 shows the annual nursing facility admission rates for Medi-Cal HCBS users (Medi-
Cal only and dually enrolled in Medicare) in 2008. The average rate of nursing facility
admission for HCBS users across California was 8%. Of note, the analysis does not distinguish
the order of the events, but in the majority of cases nursing facility admission occurs after use of
HCBS services.
There was nearly a four-fold variation in nursing facility admission rates across counties.
Counties with the highest nursing facility admission rates relative to other counties were Inyo, El
Dorado, Sierra, Colusa, Mariposa, Nevada, Napa, and San Mateo. Counties with the lowest
nursing facility admission rates among HCBS users were Imperial, Mono, Santa Barbara, Yuba,
Sacramento, and San Benito.
16
DISCUSSION
We have previously reported on the size, demographics, health status, social support, use
patterns, expenditures, and outcomes of California’s LTSS population on a statewide basis.14,15,16
This report builds upon those findings by demonstrating the substantial variation in each of these
characteristics across all California counties.
With some exceptions, urban counties tended to outpace rural counties in their number of HCBS
users per 10,000. Counties also varied in the amount of their LTSS expenditures that were
directed toward HCBS rather than nursing facility care. This was partially but not fully explained
by the number of HCBS users among Medi-Cal beneficiaries in a county suggesting that some
variation in the type and amount of HCBS service may be contributing to the total costs of these
services.
We also found county variation in the average number of ADL and cognitive limitations among
Medi-Cal LTSS recipients. The documentation of cognitive limitations in CMIPS and OASIS
assessments can be subject to underreporting. However, the eligibility for Medi-Cal’s LTSS
services is the same across the state, and therefore suggests that counties either differ in their
prevalence of Medi-Cal beneficiaries with these needs, their accuracy in reporting on these
measures, or their ability to identify and meet the needs of beneficiaries that could be addressed
through LTSS services.
The significant variation by county also raises the question about whether individuals with the
same level of care needs are receiving the same level of services in each county, as is required by
Medicaid law. Although our findings are not adjusted for demographic and need differences
across counties, they suggest that Medi-Cal beneficiaries in some counties have significantly less
access to HCBS than Medi-Cal beneficiaries in other counties.
14
Robert N. Newcomer, Ph.D., Charlene Harrington, R.N., Julie Stone, M.P.A. Arpita Chattopadhyay, Ph.D.
Sei J. Lee, M.D., Taewoon Kang, Ph.D., Phillip Chu, M.A.,Chi Kao, Ph.D. and Andrew B. Bindman, M.D.
“Recipients of Home and Community-Based Services in California,” California Medicaid Research Services,
University of California, June 2012. See, http://camri.universityofcalifornia.edu/documents/hcbs-report-dhcs.pdf or
http://www.thescanfoundation.org/california-medicaid-research-institute-recipients-home-and-community-based-
services-california. 15
Robert N. Newcomer, Ph.D., Charlene Harrington, R.N., Julie Stone, M.P.A. Arpita Chattopadhyay, Ph.D.
Sei J. Lee, M.D., Taewoon Kang, Ph.D., Phillip Chu, M.A., Chi Kao, Ph.D. and Andrew B. Bindman, M.D.
“Medicaid and Medicare Spending on Acute, Post-Acute and Long-Term Services and Supports
in California,” California Medicaid Research Services, University of California, December 2012. See,
http://thescanfoundation.org/california-medicaid-research-institute-medicaid-and-medicare-spending-acute-post-
acute-and-long-term or http://camri.universityofcalifornia.edu/publications.html. 16
Robert Newcomer, Charlene Harrington, Julie Stone, Denis Hulett, Taewoon Kang, Phillip Chu, Todd Gilmer,
Arpita Chattopadhyay, Andrew B. Bindman. “Extended Nursing Facility Stays Among California’s Dual Eligible
and Medi-Cal-Only Beneficiaries, 2006-2008,” California Medicaid Research Services, University of California,
September 2013. See, http://www.thescanfoundation.org/california-medicaid-research-institute-extended-nursing-
facility-stays-among-californias-dual or
http://camri.universityofcalifornia.edu/documents/camri_extended_nf_stays_among_california_dual_eligibles_medi
-cal-only_beneficiaries-9-25-13.pdf.
17
Differences in nursing facility admissions among HCBS users by county (i.e., the range of 4.1%
to 16.2%) might be partly explained by differences in the numbers of nursing home beds by
county and the degree of access to HCBS. The number of HCBS users per 10,000 varied from
less than 500 to about 2,300, showing that some counties were more generous with HCBS
services than others. These variations might lower the threshold for nursing home admission in
some counties but also create an effect whereby Medi-Cal beneficiaries from counties with no or
limited numbers of nursing home beds and HCBS are placed in institutions outside of the
counties where they were living in the community. Future work might examine the relationship
between the supply of nursing home beds and the pattern of service use.
Finally, the following proposes some additional possible explanations for some of the differences
across counties. They warrant further analysis to evaluate the extent of their explanatory value.
County Demographics and Geography. California’s counties vary in their prevalence
of individuals age 65 and over, wealth levels, ethnic and racial diversity, and geography
(i.e., rural versus urban), among other factors.
Differences in program implementation by county. The fragmentation of
responsibilities for various components of Medi-Cal’s LTSS benefit package might lead
to county differences in program implementation and the availability of HCBS as an
alternative to nursing facility care. The lack of a systematic and standardized approach
for assessing Medi-Cal beneficiaries’ need for LTSS and for involving them through
shared decision-making in the process of selecting available resources may contribute to
county differences in the number of LTSS users and the types of services they receive.
Provider Supply. Variation in use rates of nursing facilities and HCBS, including IHSS
services, may partially reflect differences in the availability of certain types of providers
and workers in each county.
Managed Care versus FFS. County differences about whether LTSS recipients are
enrolled in managed care plans or in FFS may play a role in explaining differences across
counties. While LTSS services were and are currently paid on a fee-for-service basis even
in counties where Medi-Cal beneficiaries are mandatorily enrolled in managed care, the
coordination of acute and post-acute care services through managed care may have an
impact on how providers in these counties initiate evaluations for and use of LTSS
services. The planned inclusion of LTSS services within Medi-Cal managed care in some
demonstration counties beginning in 2014 will offer an opportunity to evaluate whether
the integration of financing is associated with integration of service delivery for Medi-
Cal’s beneficiaries whose needs require LTSS services.
Although our analysis cannot determine which programmatic decisions contributed to which
county differences, the presence of variation suggests that further studies are needed to identify
common programmatic traits of counties that have good outcomes at modest cost.
A1
0 500 1,000 1,500 2,000 2,500
MONO (N=22) TULARE (N=3,234) KERN (N=5,741) INYO (N=134) DEL NORTE (N=333) MODOC (N=107) VENTURA (N=5,085) EL DORADO (N=830) SISKIYOU (N=517) MADERA (N=1,715) SAN JOAQUIN (N=7,083) COLUSA (N=219) MERCED (N=3,385) TRINITY (N=162) LASSEN (N=289) FRESNO (N=13,083) AMADOR (N=215) NEVADA (N=559) SOLANO (N=3,460) SAN MATEO (N=3,922) CALAVERAS (N=346) SAN BERNARDINO (N=19,758) MONTEREY (N=4,301) TUOLUMNE (N=488) SAN BENITO (N=488) STANISLAUS (N=6,969) RIVERSIDE (N=16,809) KINGS (N=1,790) ORANGE (N=21,578) SANTA CRUZ (N=2,427) SANTA CLARA (N=15,865) YOLO (N=1,827) PLACER (N=1,770) NAPA (N=915) YUBA (N=1,319) SUTTER (N=1,436) SANTA BARBARA (N=4,495) BUTTE (N=3,439) TEHAMA (N=1,098) MENDOCINO (N=1,569) SACRAMENTO (N=20,251) SAN LUIS OBISPO (N=2,278) GLENN (N=513) MARIPOSA (N=223) ALPINE (N=13) CONTRA COSTA (N=9,695) SIERRA (N=48) ALAMEDA (N=19,244) SHASTA (N=3,320) SAN DIEGO (N= 28,016) HUMBOLDT (N=2,350) LOS ANGELES (N= 193,652) SONOMA (N= 4,889) PLUMAS (N=308) MARIN (N=2,117) LAKE (N=1,732) IMPERIAL (N=5,429) SAN FRANCISCO (N=24,235)
Figure 1: Home and Community Based Services (HCBS) Users per 10,000 Medi-‐Cal Beneficiaries, CY 2008
Results for fee-‐for-‐service LTTS users age 18 and above excluding those who enrolled in PACE or had developmental disabilities. N = number of users in county. California State Average = 1,121
A2
Figure 2: Nursing Facility Only (No Home and Community Based Services) Users per 10,000 Medi-‐Cal Beneficiaries, CY 2008
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE or had developmental disabilities N = number of nursing facility only users in county Alpine and Mono Counties had 10 or fewer observations and are not displayed to protect against the risk of patient identification. California State Average = 210
0 100 200 300 400 500 600 700 800
MONTEREY (N=30) SOLANO (N=63) SANTA BARBARA (N=64) SANTA CRUZ (N=58) ORANGE (N=1,282) YOLO (N=105) IMPERIAL (N=379) YUBA (N=170) DEL NORTE (N=83) MERCED (N=688) NAPA (N=146) KINGS (N=319) KERN (N=2,054) FRESNO (N=2,774) TULARE (N=1,457) SISKIYOU (N=123) MADERA (N=407) SACRAMENTO (N=3,276) MENDOCINO (N=255) SAN BERNARDINO (N=4,326) TRINITY (N=40) HUMBOLDT (N=346) SUTTER (N=274) COLUSA (N=58) GLENN (N=89) SAN BENITO (N=112) RIVERSIDE (N=3,942) TEHAMA (N=219) LOS ANGELES (N=31,198) VENTURA (N=1,576) STANISLAUS (N=1,710) LAKE (N=257) SAN LUIS OBISPO (N=464) SAN JOAQUIN (N=2,229) SANTA CLARA (N=3,950) LASSEN (N=92) ALAMEDA (N=4,239) CONTRA COSTA (N=2,268) SAN FRANCISCO (N=2,943) SHASTA (N=778) CALAVERAS (N=129) BUTTE (N=1,039) MARIPOSA (N=62) EL DORADO (N=389) SAN DIEGO (N=7,470) SONOMA (N=1,156) SAN MATEO (N=1,708) MARIN (N=548) MODOC (N=71) INYO (N=105) PLACER (N=836) PLUMAS (N=104) AMADOR (N=137) TUOLUMNE (N=288) NEVADA (N=382) SIERRA (N=28)
A3
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ALPINE (N=13) HUMBOLDT (N=2,350) YUBA (N=1,319) SANTA BARBARA (N=4,495) SUTTER (N=1,436) SAN LUIS OBISPO (N=2,278) PLUMAS (N=308) SHASTA (N=3,320) BUTTE (N=3,439) MARIN (N=2,117) AMADOR (N=215) TUOLUMNE (N=488) LAKE (N=1,732) TEHAMA (N=1,098) NEVADA (N=559) LASSEN (N=289) SONOMA (N=4,889) TRINITY (N=162) SANTA CRUZ (N=2,427) GLENN (N=513) DEL NORTE (N=333) CONTRA COSTA (N=9,695) MENDOCINO (N=1,569) MARIPOSA (N=223) SIERRA (N=48) SOLANO (N=3,460) NAPA (N=915) MONTEREY (N=4,301) MODOC (N=107) CALAVERAS (N=346) EL DORADO (N=830) KINGS (N=1,790) SAN BENITO (N=488) SISKIYOU (N=517) INYO (N=134) SAN BERNARDINO (N=19,758) PLACER (N=1,770) STANISLAUS (N= 6,969) RIVERSIDE (N=16,809) MERCED (N= 3,385) COLUSA (N=219) SACRAMENTO (N=20,251) ALAMEDA (N=19,244) SAN JOAQUIN (N=7,083) KERN (N=5,741) TULARE (N=3,234) SAN DIEGO (N=28,016) MADERA (N=1,715) FRESNO (N=13,083) MONO (N=22) SAN MATEO (N=3,922) VENTURA (N=5,085) ORANGE (N=21,578) YOLO (N=1,827) LOS ANGELES (N=193,652) SAN FRANCISCO (N=24,235) IMPERIAL (N=5,429) SANTA CLARA (N=15,865)
Figure 3: Percent Age 65 Years and Older among Medi-‐Cal Home and Community Based Services (HCBS) Users, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE or had developmental disabilities N = number of HCBS users in county California State Average = 61%
A4
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
SIERRA (N=48) TRINITY (N=162) MARIPOSA (N=223) NEVADA (N=559) MODOC (N=107) TUOLUMNE (N=488) EL DORADO (N=830) PLUMAS (N=308) TEHAMA (N=1,098) SHASTA (N=3,320) LASSEN (N=289) AMADOR (N=215) LAKE (N=1,732) CALAVERAS (N=346) SISKIYOU (N=517) HUMBOLDT (N=2,350) PLACER (N=1,770) MENDOCINO (N=1,569) DEL NORTE (N=333) INYO (N=134) BUTTE (N=3,439) SONOMA (N=4,889) SAN LUIS OBISPO (N=2,278) GLENN (N=513) YUBA (N=1,319) STANISLAUS (N=6,969) YOLO (N=1,827) MONO (N=22) SANTA CRUZ (N=2,427) NAPA (N=915) MARIN (N=2,117) SUTTER (N=1,436) COLUSA (N=219) MADERA (N=1,715) SACRAMENTO (N=20,251) TULARE (N=3,234) KERN (N=5,741) RIVERSIDE (N=16,809) MERCED (N=3,385) SANTA BARBARA (N=4,495) KINGS (N=1,790) VENTURA (N=5,085) LOS ANGELES (N=193,652) SAN BERNARDINO (N=19,758) SAN DIEGO (N=28,016) ALPINE (N=13) SAN JOAQUIN (N=7,083) CONTRA COSTA (N=9,695) FRESNO (N=13,083) SOLANO (N=3,460) SAN FRANCISCO (N=24,235) SAN BENITO (N=488) ORANGE (N=21,578) SANTA CLARA N=15,865) SAN MATEO (N=3,922) MONTEREY (N=4,301) ALAMEDA (N=19,244) IMPERIAL (N=5,429)
Figure 4: Percent of Non-‐White Medi-‐Cal Home and Community Based Services (HCBS) Users, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE or had developmental disabilities N = number of HCBS users in county California State Average = 66%
A5
0.0 0.5 1.0 1.5 2.0 2.5 3.0
SIERRA (N=48)
PLUMAS (N=301)
ALPINE (N=12)
TUOLUMNE (N=383)
COLUSA (N=180)
MARIPOSA (N=209)
LASSEN (N=278)
MONO (N=21)
SISKIYOU (N=493)
TEHAMA (N=1,032)
SAN LUIS OBISPO N=1,556)
AMADOR (N=175)
MENDOCINO (N=1,409)
INYO (N=116)
EL DORADO (N=702)
TRINITY (N=158)
SUTTER (N=833)
HUMBOLDT (N=1,676)
SHASTA (N=2,758)
MERCED (N=3,041)
SANTA CRUZ (N=2,031)
SANTA BARBARA (N=2,624)
NEVADA (N=522)
MARIN (N=1,447)
KINGS (N=1,651)
YUBA (N=753)
SANTA CLARA (N=14,941)
CALAVERAS (N=328)
SONOMA (N=4,371)
IMPERIAL (N=5,097)
YOLO (N=1,712)
STANISLAUS (N=6,049)
MODOC (N=106)
TULARE (N=2,814)
RIVERSIDE (N=14,781)
DEL NORTE (N=305)
SAN JOAQUIN (N=6,687)
ORANGE (N=15,208)
VENTURA (N=3,468)
SACRAMENTO (N=18,727)
SAN FRANCISCO (N=21,498)
SAN BENITO (N=379)
PLACER (N=1,564)
ALAMEDA (N=16,088)
SAN DIEGO (N=23,241)
NAPA (N=685)
GLENN (N=409)
CONTRA COSTA (N=7,406)
LAKE (N=1,548)
MONTEREY (N=3,258)
LOS ANGELES (N=173,884)
KERN (N=5,057)
MADERA (N=1,602)
SAN BERNARDINO (N=17,846)
BUTTE (N=2,910)
FRESNO (N=11,543)
SOLANO (N=2,703)
SAN MATEO (N=2,763)
Figure 5: Mean Number of ADL Limitations among Medi-‐Cal Home and Community Based (HCBS) Services Users, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
Results for Medi-‐Cal HCBS users age 18 and older with assessment data from CMIPS or OASIS excluding those who enrolled in PACE or had developmental disabilities N = number of HCBS users in county with CMIPS or OASIS assessment California State Average = 2.6
A6
0% 20% 40% 60% 80% 100%
LOS ANGELES (N=173,884) COLUSA (N=180) VENTURA (N=3,468) SAN LUIS OBISPO (N=1,556) RIVERSIDE (N=14,781) MADERA (N=1,602) KERN (N=5,057) CALAVERAS (N=328) SAN JOAQUIN (N=6,687) SIERRA (N=48) YOLO (N=1,712) YUBA (N=753) SISKIYOU (N=493) DEL NORTE (N=305) SAN BERNARDINO (N=17,846) MODOC (N=106) TRINITY (N=158) SAN DIEGO (N=23,241) KINGS (N=1,651) STANISLAUS (N=6,049) SAN BENITO (N=379) MERCED (N=3,041) PLUMAS (N=301) TUOLUMNE (N=383) SACRAMENTO (N=18,727) SUTTER (N=833) SANTA BARBARA (N=2,624) FRESNO (N=11,543) ORANGE (N=15,208) SONOMA (N=4,371) LAKE (N=1,548) SAN MATEO (N=2,763) NEVADA (N=522) SHASTA (N=2,758) ALAMEDA (N=16,088) SAN FRANCISCO (N=21,498) PLACER (N=1,564) MARIN (N=1,447) SANTA CLARA (N=14,941) GLENN (N=409) INYO (N=116) HUMBOLDT (N=1,676) MENDOCINO (N=1,409) SANTA CRUZ (N=2,031) LASSEN (N=278) EL DORADO (N=702) CONTRA COSTA (N=7,406) NAPA (N=685) TEHAMA (N=1,032) TULARE (N=2,814) MONO (N=21) AMADOR (N=175) IMPERIAL (N=5,097) MARIPOSA (N=209) SOLANO (N=2,703) MONTEREY (N=3,258) ALPINE (N=12) BUTTE (N=2,910)
Figure 6: Percent with Cognitive Limitations among Medi-‐Cal Home and Community Based Services (HCBS) Users, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
Results for Medi-‐Cal HCBS users age 18 and above with assessment data from CMIPS or OASIS excluding those who enrolled in PACE or had developmental disabilities N = number of HCBS users in county with CMIPS or OASIS assessment California State Average = 37%
A7
$0 $10,000 $20,000 $30,000 $40,000 $50,000
SAN LUIS OBISPO* (N=290) SOLANO* (N=204) ORANGE* (N=2,637) SANTA BARBARA* (N=1,536) MONTEREY* (N=426) SANTA CRUZ* (N=204) SAN MATEO* (N=650) NAPA* (N=105) MARIPOSA (N=57) GLENN (N=202) HUMBOLDT (N=1,039) SUTTER (N=780) MARIN (N=866) PLUMAS (N=96) YUBA (N=743) COLUSA (N=58) SHASTA (N=1,281) MENDOCINO (N=452) VENTURA (N=1,409) LASSEN (N=91) MERCED (N=1,015) AMADOR (N=72) YOLO* (N=11) IMPERIAL (N=876) STANISLAUS (N=1,509) TEHAMA (N=334) MADERA (N=432) BUTTE (N=1,347) CONTRA COSTA (N=2,870) KINGS (N=518) LOS ANGELES (N=39,586) SAN DIEGO (N=7,009) SACRAMENTO (N=4,103) DEL NORTE (N=129) SAN BENITO (N=169) TUOLUMNE (N=188) SONOMA (N=1,423) SISKIYOU (N=130) RIVERSIDE (N=3,575) SAN BERNARDINO (N=5,166) CALAVERAS (N=102) PLACER (N=472) LAKE (N=533) NEVADA (N=157) SAN JOAQUIN (N=1,561) EL DORADO (N=225) FRESNO (N=2,552) SAN FRANCISCO (N=4,429) SANTA CLARA (N=1,930) ALAMEDA (N=4,417) KERN (N=1,164) TRINITY (N=50) TULARE (N=742) MODOC (N=24) INYO (N=41)
Figure 7: Mean Total Medi-‐Cal Annual Spending per Medi-‐Cal Only Long-‐Term Services and Support (LTSS) User, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE or Medi-‐Cal managed care or had developmental disabilities N = number of Medi-‐Cal only fee-‐for-‐service LTSS users in county Alpine, Mono, and Sierra Counties had 10 or fewer observations and are not displayed in order to protect against the risk of patient identification. *Medi-‐Cal managed care delivered through County Organized Health System (COHS) California State Average = $24,493
A8
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE or Medi-‐Cal managed care or had developmental disabilities N = number of Medi-‐Cal only fee-‐for-‐service nursing facility only users in county Alpine, Amador, Calaveras, Colusa, Glenn, Inyo, Lassen, Mariposa, Modoc, Mono, Monterey, Napa, Nevada, Plumas, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, Sierra, Siskiyou, Solano, Tehama, Trinity, Tuolumne, Yolo, and Yuba counties had 10 or fewer observations and are not displayed in order to protect against the risk of patient identification. *Medi-‐Cal managed care delivered through County Organized Health System (COHS) California State Average = $71,635
Figure 8: Mean Total Medi-‐Cal Annual Spending per Medi-‐Cal Only Nursing Facility Only (No Home and Community Based Services) User, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
$0 $25,000 $50,000 $75,000 $100,000
MENDOCINO (N=15)
DEL NORTE (N=13)
SHASTA (N=49)
ORANGE* (N=33)
MADERA (N=43)
HUMBOLDT (N=43)
SUTTER (N=19)
IMPERIAL (N=45)
SAN MATEO* (N=26)
RIVERSIDE (N=423)
EL DORADO (N=16)
MARIN (N=38)
SAN DIEGO (N=914)
SACRAMENTO (N=251)
PLACER (N=33)
STANISLAUS (N=124)
SAN JOAQUIN (N=217)
LOS ANGELES (N=4,906)
KINGS (N=23)
BUTTE (N=52)
LAKE (N=17)
MERCED (N=28)
VENTURA (N=104)
SANTA CLARA (N=312)
SAN BERNARDINO (N=594)
SONOMA (N=75)
KERN (N=133)
FRESNO (N=232)
CONTRA COSTA (N=185)
ALAMEDA (N=587)
SAN FRANCISCO (N=532)
TULARE (N=106)
A9
$0 $20,000 $40,000 $60,000 $80,000 $100,000
SAN LUIS OBISPO* (N=80)
IMPERIAL (N=4,698)
MONO (N=20)
HUMBOLDT (N=1 621)
DEL NORTE (N=271)
SISKIYOU (N=496)
MADERA (N=1 446)
TRINITY (N=151)
CALAVERAS (N=350)
TEHAMA (N=948)
SAN FRANCISCO (N=17,857)
AMADOR (N=251)
SHASTA (N=2,649)
SUTTER (N=878)
FRESNO (N=9,816)
PLACER (N=1,548)
LASSEN (N=284)
MENDOCINO (N=1,342)
MODOC (N=152)
SONOMA (N=3,645)
SACRAMENTO (N=11,767)
YUBA (N=690)
VENTURA (N=4,640)
SANTA CLARA (N=13,945)
PLUMAS (N=307)
LOS ANGELES (N=146,958)
NEVADA (N=746)
GLENN (N=390)
SANTA CRUZ* (N=33)
BUTTE (N=3,016)
INYO (N=194)
MARIPOSA (N=218)
TULARE (N=3,391)
MERCED (N=2,953)
SAN DIEGO (N=21,346)
STANISLAUS (N=5,150)
YOLO* (N=43)
MARIN (N=1,340)
RIVERSIDE (N=11,815)
COLUSA (N=211)
SIERRA (N=66)
LAKE (N=1,403)
EL DORADO (N=849)
KERN (N=5,089)
SAN JOAQUIN (N=5,866)
KINGS (N=1,523)
SAN BERNARDINO (N=13,258)
TUOLUMNE (N=573)
CONTRA COSTA (N=5,725)
ALAMEDA (N=13,532)
MONTEREY* (N=25)
ORANGE* (N=247)
SAN BENITO (N=408)
SANTA BARBARA* (N=39)
SOLANO* (N=34)
SAN MATEO* (N=72)
Medi-‐Cal Medicare
Figure 9: Mean Total Medi-‐Cal and Medicare Annual Spending per Medicare-‐Medicaid (MME) Enrolled Long-‐Term Services and Support (LTSS) User, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in Medi-‐Cal managed care or had developmental disabilities N = number of dual enrolled fee-‐for-‐service LTSS users in county Alpine and Napa counties had 10 or fewer observations and are not displayed in order to protect against the risk of patient identification. *Medi-‐Cal managed care delivered through County Organized Health System (COHS) California State Average = $54,672
Figure 9: Mean Total Medi-‐Cal and Medicare Annual Spending per Medicare-‐Medicaid (MME) Enrolled Long-‐Term Services and Support (LTSS) User, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
A10
$0 $20,000 $40,000 $60,000 $80,000 $100,000 $120,000 $140,000 $160,000
SAN LUIS OBISPO* (N=45)
SANTA CRUZ* (N=11)
AMADOR (N=119)
MADERA (N=319)
MENDOCINO (N=233)
CALAVERAS (N=119)
DEL NORTE (N=67)
PLACER (N=541)
TEHAMA (N=204)
HUMBOLDT (N=298)
SUTTER (N=245)
BUTTE (N=966)
SHASTA (N=703)
SISKIYOU (N=111)
INYO (N=96)
NEVADA (N=362)
EL DORADO (N=304)
YUBA (N=151)
TULARE (N=1,300)
FRESNO (N=2,120)
YOLO* (N=28)
COLUSA (N=56)
KINGS (N=285)
LASSEN (N=90)
LAKE (N=230)
SONOMA (N=824)
MERCED (N=649)
MARIN (N=342)
IMPERIAL (N=328)
TUOLUMNE (N=270)
KERN (N=1,590)
GLENN (N=79)
SAN JOAQUIN (N=1,655)
SACRAMENTO (N=1,923)
MODOC (N=66)
STANISLAUS (N=1,258)
VENTURA (N=1,230)
PLUMAS (N=98)
MARIPOSA (N=60)
TRINITY (N=35)
RIVERSIDE (N=2,554)
SIERRA (N=26)
SAN DIEGO (N=4,840)
ORANGE* (N=103)
SANTA BARBARA* (N=33)
SANTA CLARA (N=2,788)
CONTRA COSTA (N=1,422)
SAN BERNARDINO (N=2,753)
LOS ANGELES (N=21,831)
ALAMEDA (N=2,878)
SAN FRANCISCO (N=2,088)
SAN BENITO (N=102)
SOLANO* (N=20)
SAN MATEO* (N=35)
Medi-‐Cal Medicare Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE, Medi-‐Cal managed care, Medicare managed care, or had developmental disabilities N = number of dual enrolled fee-‐for-‐service nursing facility only users in county Alpine, Monterey, Mono and Napa counties had 10 or fewer observations and are not displayed to protect against the risk of patient identification. *Medi-‐Cal managed care delivered through County Organized Health System (COHS) California State Average = $89,144
Figure 10: Mean Total Medi-‐Cal and Medicare Annual Spending per Medicare-‐Medicaid (MME) Enrolled Nursing Facility Only (No Home and Community Based Services) User, CY 2008; Medi-‐Cal Beneficiaries, CY 2008
A11
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
SANTA BARBARA* (N=1,575) NAPA* (N=113) MONTEREY* (N=451) ORANGE* (N=2,884) SANTA CRUZ* (N=237) MONO (N=26) SAN LUIS OBISPO* (N=370) SAN MATEO* (N=722) YUBA (N=1,433) SOLANO* (N=238) SUTTER (N=1,658) HUMBOLDT (N=2,660) TEHAMA (N=1,282) DEL NORTE (N=400) KINGS (N=2,041) LAKE (N=1,936) SHASTA (N=3,930) COLUSA (N=269) TRINITY (N=201) MERCED (N=3,968) BUTTE (N=4,363) IMPERIAL (N=5,574) CONTRA COSTA (N=8,595) KERN (N=6,253) ALPINE (N=13) SISKIYOU (N=626) MARIN (N=2,206) SAN BERNARDINO (N=18,424) GLENN (N=592) SONOMA (N=5,068) TULARE (N=4,133) MENDOCINO (N=1,794) LASSEN (N=375) RIVERSIDE (N=15,390) MADERA (N=1,878) SAN DIEGO (N=28,355) CALAVERAS (N=452) PLACER (N=2,020) FRESNO (N=12,368) STANISLAUS (N=6,659) ALAMEDA (N=17,949) SAN BENITO (N=577) EL DORADO (N=1,074) LOS ANGELES (N=186,544) INYO (N=235) SAN JOAQUIN (N=7,427) AMADOR (N=323) VENTURA (N=6,049) SACRAMENTO (N=15,870) TUOLUMNE (N=761) NEVADA (N=903) PLUMAS (N=403) SAN FRANCISCO (N=22,286) SANTA CLARA (N=15,875) MARIPOSA (N=275) SIERRA (N=76) MODOC (N=176) YOLO* (N=54)
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE, Medi-‐Cal managed care, Medicare managed care, or had developmental disabilities N = number of Medi-‐Cal LTSS fee-‐for-‐service users in county *Medi-‐Cal managed care delivered through County Organized Health System (COHS) California State Average = 74%
Figure 11: Percent of Medi-‐Cal Long-‐Term Services and Support (LTSS) Spending Over Total Medi-‐Cal Spending, CY2008
A12
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
SIERRA (N=76) TUOLUMNE (N=761) MODOC (N=176) YOLO* (N=54) INYO (N=235) PLUMAS (N=403) AMADOR (N=323) TULARE (N=4,133) NEVADA (N=903) SAN MATEO* (N=722) SANTA BARBARA* (N=1,575) SOLANO* (N=238) EL DORADO (N=1,074) SAN BENITO (N=577) TRINITY (N=201) COLUSA (N=269) MARIPOSA (N=275) SAN LUIS OBISPO* (N=370) SISKIYOU (N=626) LASSEN (N=375) CALAVERAS (N=452) ORANGE* (N=2,884) PLACER (N=2,020) SUTTER (N=1,658) KERN (N=6,253) SAN JOAQUIN (N=7,427) STANISLAUS (N=6,659) VENTURA (N=6,049) SHASTA (N=3,930) BUTTE (N=4,363) SAN DIEGO (N=28,355) SANTA CRUZ* (N=237) MADERA (N=1,878) MERCED (N=3,968) CONTRA COSTA (N=8,595) MARIN (N=2,206) TEHAMA (N=1,282) DEL NORTE (N=400) SAN BERNARDINO (N=18,424) SANTA CLARA (N=15,875) ALAMEDA (N=17,949) RIVERSIDE (N=15,390) KINGS (N=2,041) SONOMA (N=5,068) GLENN (N=592) FRESNO (N=12,368) SAN FRANCISCO (N=22,286) HUMBOLDT (N=2,660) YUBA (N=1,433) LOS ANGELES (N=186,544) MENDOCINO (N=1,794) SACRAMENTO (N=15,870) MONO (N=26) LAKE (N=1,936) NAPA* (N=113) IMPERIAL (N=5,574) MONTEREY* (N=451) ALPINE (N=13)
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE, Medi-‐Cal managed care, Medicare managed care, or had developmental disabilities N = number of Medi-‐Cal LTSS fee-‐for-‐service users in county *Medi-‐Cal managed care delivered through County Organized Health System (COHS) California State Average = 52%
Figure 12: Percent of Medi-‐Cal Long-‐Term Services and Support (LTSS) Spending on Home and Community Based Services (HCBS), CY 2008 Medi-‐Cal Beneficiaries, CY 2008
A13
0% 3% 5% 8% 10% 13% 15%
ALPINE (N=13)
SANTA BARBARA (N=4,495)
TUOLUMNE (N=488)
SUTTER (N=1,436)
MONTEREY (N=4,301)
LOS ANGELES (N=193,652)
SAN FRANCISCO (N=24,235)
ORANGE (N=21,578)
MARIN (N=2,117)
GLENN (N=513)
CONTRA COSTA (N=9,695)
ALAMEDA (N=19,244)
IMPERIAL (N=5,429)
YUBA (N=1,319)
SANTA CLARA (N=15,865)
SAN DIEGO (N=28,016)
YOLO (N=1,827)
SANTA CRUZ (N=2,427)
HUMBOLDT (N=2,350)
SONOMA (N=4,889)
VENTURA (N=5,085)
MERCED (N=3,385)
SAN BENITO (N=488)
STANISLAUS (N=6,969)
SACRAMENTO (N=20,251)
SAN MATEO (N=3,922)
SAN LUIS OBISPO (N=2,278)
RIVERSIDE (N=16,809)
NAPA (N=915)
NEVADA (N=559)
TEHAMA (N=1,098)
SAN BERNARDINO (N=19,758)
SOLANO (N=3,460)
FRESNO (N=13,083)
AMADOR (N=215)
KINGS (N=1,790)
PLACER (N=1,770)
CALAVERAS (N=346)
MADERA (N=1,715)
SHASTA (N=3,320)
TRINITY (N=162)
BUTTE (N=3,439)
MENDOCINO (N=1,569)
SAN JOAQUIN (N=7,083)
LASSEN (N=289)
PLUMAS (N=308)
EL DORADO (N=830)
TULARE (N=3,234)
LAKE (N=1,732)
DEL NORTE (N=333)
KERN (N=5,741)
MODOC (N=107)
COLUSA (N=219)
MONO (N= 22)
SISKIYOU (N=517)
SIERRA (N=48)
INYO (N=134)
MARIPOSA (N=223)
Figure 13: Annual Mortality Rate among Medi-‐Cal Home and Community Based Services (HCBS) Users, CY 2008
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE or had developmental disabilities N = number of HCBS users in county California State Average = 5.4%
A14
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
IMPERIAL (N=5,429) MONO (N=22) SANTA BARBARA (N=4,495) YUBA (N=1,319) SACRAMENTO (N=20,251) SAN BENITO (N=488) HUMBOLDT (N=2,350) MARIN (N=2,117) FRESNO (N=13,083) SUTTER (N=1,436) KINGS (N=1,790) SAN LUIS OBISPO (N=2,278) SAN FRANCISCO (N=24,235) CONTRA COSTA (N=9,695) LOS ANGELES (N=193,652) LAKE (N=1,732) ALAMEDA (N=19,244) SOLANO (N=3,460) MONTEREY (N=4,301) ALPINE (N=13) SANTA CLARA (N=15,865) MADERA (N=1,715) SONOMA (N=4,889) LASSEN (N=289) SISKIYOU (N=517) STANISLAUS (N=6,969) GLENN (N=513) SAN BERNARDINO (N=9,758) YOLO (N=1,827) SANTA CRUZ (N=2,427) ORANGE (N=21,578) VENTURA (N=5,085) MENDOCINO (N=1,569) DEL NORTE (N=333) PLUMAS (N=308) TEHAMA (N=1,098) TRINITY (N=162) MERCED (N=3,385) BUTTE (N=3,439) CALAVERAS (N=346) SAN DIEGO (N=28,016) KERN (N=5,741) RIVERSIDE (N=16,809) TULARE (N=3,234) SAN JOAQUIN (N=7,083) AMADOR (N=215) TUOLUMNE (N=488) SHASTA (N=3,320) MODOC (N=107) PLACER (N=1,770) SAN MATEO (N=3,922) NAPA (N=915) NEVADA (N=559) MARIPOSA (N=223) COLUSA (N=219) SIERRA (N=48) EL DORADO (N=830) INYO (N=134)
Figure 14: Annual Nursing Facility Admission Rate among Medi-‐Cal Home and Community Based Services (HCBS) Users, CY 2008 Medi-‐Cal Beneficiaries, CY 2008
Results for fee-‐for-‐service LTSS users age 18 and above excluding those who enrolled in PACE or had developmental disabilities N = number of HCBS users in county California State Average = 8%