I H S ti S iIn-Home Supportive Services

D i ti D t C t d C tDescriptive Data, Costs and Cost-Containment

St t i /Alt ti PStrategies/Alternative ProgramsPresentation by:

Kathy Harwell and Egon StammlerSan Joaquin County Human Services

12/2004

Age of Recipients

0-17 years0 yea s4%

18-64 years37%37%

65+ years59%

Ethnicity of Recipients

Hispanic22%

White44%

American Indian44%

Black

1%

Asian

17%

Asian16%

Primary Language by Ethnicity

1%6%

90%

100%

63%

36%

70%

80%

90%

85%

99%94%50%

60%

Non-English

64%30%

40%

gEnglish

15%

37%

10%

20%

0%

Asian Black Hispanic AmericanIndian

White

Primary Language of Recipients

Other

English57%

Other43%

57%

45000

Other Languages Spoken by Recipients

40000

Recipients

30000

35000

20000

25000

15000

5000

10000

0Spanish Armenian Russian Farsi Cantonese Vietnamese Tagalog Mandarin Cambodian Korean Hmong

Consumer Type of Recipients

Aged47%

Disabled50%

47%

Blind3%3%

Change in Consumer Type from 1996 to 1998

51.3%50 0%

60.0%

5 3%48.8%

44.9%47.5%

40.0%

50.0%

20.0%

30.0% 19961998

3.7% 3.7%0 0%

10.0%

0.0%Aged Blind Disabled

Distribution of County IHSS Cases by Program

90%

100%

70%

80%

50%

60%

%

30%

40%Residual/Split

% PCSP

10%

20%

0%Fresno Kern Kings Madera Mariposa Merced San

JoaquinSan LuisObispo

SantaBarbara

Stanislaus Tulare

Total IHSS Caseload by County800000

y y

600000

700000

400000

500000

300000

400000

100000

200000

0Fresno Kern Kings Madera Merced San

JoaquinSan LuisObispo

SantaBarbara

Tulare Stanislaus Mariposa

IHSS Cost DriversFrom FY 1998-99 to 2002-03, IHSS program costs nearly doubled (from $1.4 billion in 1998 99 to $2 3 billion in 2002 03)1998-99 to $2.3 billion in 2002-03).Due to Realignment pressures, counties are being forced to transfer revenue (up to 10%)being forced to transfer revenue (up to 10%) from the Mental Health Account and the Health Account to subsidize the Social Service A tAccount.The overall cost per authorized case has increased 27% on a statewide level from FYincreased 27% on a statewide level from FY 1996-97 to 98-99.

Costs for Authorized Cases, FY 96/97 to FY 98/99

$1 400 000 000

98/99

$1,224,354,859$1,200,000,000

$1,400,000,000

$879,469,434$800,000,000

$1,000,000,000

$400 000 000

$600,000,000

$200,000,000

$400,000,000

$0FY 96/97 FY 98/99

Percent Change in Average Monthly Cost Per Authorized Case from FY 96/97 to FY 98/99Authorized Case from FY 96/97 to FY 98/99

40%

35%

33%

37%

30%

35%

Statewide, 27%

22%

27%28%28%26%

28%

20%

25%

Statewide, 27%

15%

17%15%

20%

5%

10%

0%Fresno Kern Kings Madera Mariposa Merced San Joaquin San Luis

ObispoSanta

BarbaraStanislaus Tulare

Cost-Related Concerns1. Caseload growth/Overall population

growthg2. Provider wage increases/Addition of

provider benefitsprovider benefits3. Lack of uniform assessment process

1 Caseload Growth/General1. Caseload Growth/General Population Growth

In 1995-96, IHSS consumed 2.7% of the Realignment funds. In 2001-02, g ,IHSS consumed 52% of the Realignment funds.gOverall population growth has increased IHSS caseloadsIHSS caseloads.

IHSS paid cases have increased 58% from July 98-99 to June 03-04.July 98 99 to June 03 04.

IHSS Paid Cases, July 1998 - January 2004

300000

350000

250000

1 0000

200000

100000

150000

50000

0July

98/99June98/99

July99/00

June99/00

July00/01

June00/01

July01/02

June01/02

July02/03

June02/03

July03/04

June03/04

Percent Change in IHSS Population by Ethnicity from 1995 to 2001

120%

80%

100%

60%

80%% Changein IHSSPopulation

40% % ChangeinCalifornia

20%CaliforniaPopulation

0%

Asian Black Hispanic AmericanIndian

White

2. Provider Wage Increases/Addition of ProviderIncreases/Addition of Provider

BenefitsGovernor Davis increased the number of counties utilizing Public Authorities by signing AB 1632AB 1632

The primary focus of this bill was for California counties to establish an “Employer of Record” system for IHSS providers to have collective bargaining.

To satisfy the “Employer of Record” mandateTo satisfy the Employer of Record mandate, most counties (74%) have established Public Authorities

Employer of Record Delivery Modes

Public Authority

2

72

Non-ProfitConsortium

3

2Joint PowersAgreement

3 County asEmployer

Contract Mode

48HomemakerMode

2. Provider Wage Increases/Addition of ProviderIncreases/Addition of Provider

Benefits, ContinuedPublic Authorities have the following responsibilities:

maintaining a egi e egist iesmaintaining caregiver registriesgiving IHSS consumers provider referralsproviding trainings for both the caregiver and the recipient.

AB 1682 mandates that counties establish an advisory committee to assist with the implementation of public authoritiesimplementation of public authorities.

Advisory Committee members include IHSS providers, advocates from nonprofit community-based organizations for home care employees, and one county employeeo a p oy , a d o ou y p oyMany Public Authorities and Advisory Committees are overseen by the County Board of Supervisors

3 Lack of a Uniform3. Lack of a Uniform Assessment Process

Currently, there is large variability between counties on the number of authorized IHSS provider hours per case.

Average Monthly Paid Hours Per Case, by Countya , by ou y

120

140

100

FY

80

FY96/97

FY

40

60 98/99

20

0Fresno Kern Kings Madera Mariposa Merced San

JoaquinSan LuisObispo

SantaBarbara

Stanislaus Tulare

3 Lack of a Uniform3. Lack of a Uniform Assessment Process

A research project by the University of California, Berkeley determined that IHSS outcomes were similar across counties despite the number ofsimilar across counties despite the number of authorized hours per case.To facilitate a uniform assessment process, Barnes p ,et. al. (1996) tested the CDSS IHSS Functional Index and determined that this instrument was highly reliable and could prevent the unnecessary over-reliable and could prevent the unnecessary overauthorization of IHSS hours.

Cost-Containment Strategies/ProgramStrategies/Program

Alternatives1. Cash and Counseling2 Governor’s recent budget proposal2. Governor s recent budget proposal3. Medicaid waiver

1. Cash and CounselingCash and Counseling is a consumer-directed approach to supportive services that enables consumers to purchase individualized careconsumers to purchase individualized care rather than receiving it through an agency. It provides consumers with the following:It provides consumers with the following:

Cash: A cash allowance is provided to consumers. The consumers are given the flexibility to spend the cash allowance to hire their own providers or pay for p p ygoods/materials that will improve quality of life (i.e. hands-free phones)Counseling: Consumers are also given counseling and fiscal

i t t h l th th i h ll dassistance to help them manage their cash allowance and their responsibilities as employers.

1 Cash and Counseling1. Cash and Counseling, Continued

Cash and Counseling was implemented in three states: Arkansas, Florida and ,New Jersey. Mathematica Policy Research IncMathematica Policy Research, Inc. conducted a study to examine the effectiveness of the Cash andeffectiveness of the Cash and Counseling programs in these three statesstates.

1 Cash and Counseling1. Cash and Counseling, Continued

Mathematica Policy Research, Inc. made the following observations:

Cash and Co nseling did not in ease o e all ostsCash and Counseling did not increase overall costsAcross all three states, consumers were highly satisfied (96% in Arkansas would recommend the program; 97% in New Jersey)New Jersey)Most consumers hired family members or friends as personal caregiversMany consumers found the fiscal counseling helpful.Many consumers found the fiscal counseling helpful.There have been no major instances of fraud/abuse.All three states have already decided that they want to make the program permanently available to consumers.p g p y

2 Governor’s Recent Budget2. Governor s Recent Budget Proposal

Governor Schwarzenegger’s preliminary 2004-05 Budget Bill proposed to g p peliminate the Residual Program of IHSS.IHSS is currently composed of twoIHSS is currently composed of two independent programs: Personal Care Services Program (PCSP) and theServices Program (PCSP) and the Residual Program

2 Governor’s Recent Budget2. Governor s Recent Budget Proposal, Continued

Personal Care Services Program

Residual ProgramFunded by State Funds and County Funds

Funded by Federal funds (Medicaid), State Funds County

and County FundsServices include

Any service by a responsible relativeState Funds, County

FundsServices include:

responsible relativedomestic and related services onlyprotective supervision

Paramedical Non-medical personal assistance

protective supervisionAdvance Pay Restaurant/Meal Allowance

Residual and Split Recipients by Service SubgroupService Subgroup

14%1%

1%

14%

22%

16%

Parent ProvidersSpouse ProvidersDomestic Care OnlyProtective Supervision

46%

Advance PayMeal Allowance

2 Governor’s Recent Budget2. Governor s Recent Budget Proposal, Continued

The proposed elimination of the Residual program was estimated to provide the state budget a net savings of $366 million dollars.However, through legislative analysis, it was determined that the net savings would be much lower:

A large number of Residual Program recipients would qualify for g g p q ythe IHSS PCSP. Therefore, these consumers would simply switch programs. Additionally, other Residual program recipients would turn to 24-h f ilitihour care facilities.Finally, the elimination of the Residual program could spark a number of expensive Olmstead-related litigation cases for the state to fundto fund.

3. Medicaid WaiversFinally, the state administration withdrew the proposed reductions to p pthe IHSS program and opted to pursue waivers from existing Medicaid gregulations.

3 Medicaid Waivers3. Medicaid Waivers, Continued

The Medicaid waiver would enroll all existing Residual Program recipientsTh i i d i d ff lf di dThe waiver is designed to offer self-directed service components. These services include:

Person-Centered Planning: recipients are allowedPerson Centered Planning: recipients are allowed to utilize their personal long-term resources (I.e. they can hire their relatives)Individual Budgeting: recipients are either givenIndividual Budgeting: recipients are either given an allocation of service hours or and advance cash payment