I H
In-Home
S
Supportive
ti S
Services
i
Descriptive
D
i ti Data,
D t C
Costs
t and
dC
Costt
Containment
St t i /Alt
Strategies/Alternative
ti P
Programs
Presentation by:
Kathy Harwell and Egon Stammler
San Joaquin County Human Services
12/2004
Age of Recipients
0-17 yea
0
years
s
4%
18-64 years
37%
65+ years
59%
Ethnicity of Recipients
Hispanic
22%
White
44%
American Indian
1%
Black
17%
Asian
16%
Primary Language by Ethnicity
1%
100%
6%
90%
36%
80%
63%
70%
60%
85%
99%
50%
94%
Non-English
g
English
40%
64%
30%
37%
20%
10%
15%
0%
Asian
Black
Hispanic
American
Indian
White
Primary Language of Recipients
Other
43%
English
57%
Other Languages Spoken by
Recipients
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
Spanish
Armenian
Russian
Farsi
Cantonese Vietnamese Tagalog
Mandarin Cambodian
Korean
Hmong
Consumer Type of Recipients
Aged
47%
Disabled
50%
Blind
3%
Change in Consumer Type
from 1996 to 1998
60.0%
50 0%
50.0%
51.3%
5
3%
48.8%
47.5%
44.9%
40.0%
1996
1998
30.0%
20.0%
10.0%
3.7%
3.7%
0 0%
0.0%
Aged
Blind
Disabled
Distribution of County IHSS Cases by Program
100%
90%
80%
70%
60%
50%
%
Residual
/Split
40%
% PCSP
30%
20%
10%
0%
Fresno
Kern
Kings
Madera
Mariposa
Merced
San
Joaquin
San Luis
Obispo
Santa Stanislaus
Barbara
Tulare
Total IHSS Caseload byy Countyy
800000
700000
600000
500000
400000
300000
200000
100000
0
Fresno
Kern
Kings
Madera
Merced
San
Joaquin
San Luis
Obispo
Santa
Barbara
Tulare
Stanislaus Mariposa
IHSS Cost Drivers
From FY 1998-99 to 2002-03, IHSS program
costs nearly doubled (from $1.4 billion in
1998 99 to $2.3
1998-99
$2 3 billion in 2002-03).
2002 03)
Due to Realignment pressures, counties are
being forced to transfer revenue (up to 10%)
from the Mental Health Account and the
Health Account to subsidize the Social Service
A
Account.
t
The overall cost per authorized case has
increased 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
$1,400,000,000
$1,200,000,000
$1,224,354,859
$1,000,000,000
$800,000,000
$879,469,434
$600,000,000
$400 000 000
$400,000,000
$200,000,000
$0
FY 96/97
FY 98/99
Percent Change in Average Monthly Cost Per
Authorized Case from FY 96/97 to FY 98/99
40%
35%
37%
35%
33%
30%
Statewide, 27%
28%
25%
26%
28%
28%
27%
22%
20%
17%
15%
15%
10%
5%
0%
Fresno
Kern
Kings
Madera
Mariposa
Merced
San Joaquin
San Luis
Obispo
Santa
Barbara
Stanislaus
Tulare
Cost-Related Concerns
1. Caseload growth/Overall population
g
growth
2. Provider wage increases/Addition of
provider benefits
3. Lack of uniform assessment process
1
1. Caseload Growth/General
Population Growth
In 1995-96, IHSS consumed 2.7% of
the Realignment
g
funds. In 2001-02,,
IHSS consumed 52% of the
Realignment
g
funds.
Overall population growth has increased
IHSS caseloads
caseloads.
IHSS paid cases have increased 58% from
July 98
98-99
99 to June 03
03-04.
04.
IHSS Paid Cases, July 1998 - January 2004
350000
300000
250000
200000
1 0000
150000
100000
50000
0
July
98/99
June
98/99
July
99/00
June
99/00
July
00/01
June
00/01
July
01/02
June
01/02
July
02/03
June
02/03
July
03/04
June
03/04
120%
Percent Change in IHSS Population
by Ethnicity from 1995 to 2001
100%
80%
% Change
in IHSS
Population
60%
40%
% Change
in
California
Population
20%
0%
Asian
Black
Hispanic
American
Indian
White
2. Provider Wage
Increases/Addition of Provider
Benefits
Governor Davis increased the number of
counties utilizing Public Authorities by signing
AB 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
Employer of Record”
Record mandate,
mandate
most counties (74%) have established Public
Authorities
Employer of Record Delivery Modes
Public Authority
2
7
Non-Profit
Consortium
2
Joint Powers
Agreement
3
County as
Employer
3
Contract Mode
48
Homemaker
Mode
2. Provider Wage
Increases/Addition of Provider
Benefits, Continued
Public Authorities have the following
responsibilities:
maintaining caregiver
a egi e registries
egist ies
giving IHSS consumers provider referrals
providing trainings for both the caregiver and the recipient.
AB 1682 mandates that counties establish an
advisory committee to assist with the
implementation of public authorities.
authorities
Advisory Committee members include IHSS providers,
advocates from nonprofit community-based organizations for
o
care
a employees,
p oy , and
a d one
o county
ou y employee
p oy
home
Many Public Authorities and Advisory Committees are
overseen by the County Board of Supervisors
3
3. 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
a , by County
ou y
Case,
140
120
100
FY
96/97
80
FY
98/99
60
40
20
0
Fresno
Kern
Kings
Madera
Mariposa
Merced
San
Joaquin
San Luis
Obispo
Santa Stanislaus
Barbara
Tulare
3
3. 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 of
authorized hours per case.
To facilitate a uniform assessment p
process,, Barnes
et. al. (1996) tested the CDSS IHSS Functional Index
and determined that this instrument was highly
reliable and could prevent the unnecessary overover
authorization of IHSS hours.
Cost-Containment
Strategies/Program
Alternatives
1. Cash and Counseling
2 Governor
2.
Governor’ss recent budget proposal
3. Medicaid waiver
1. Cash and Counseling
Cash and Counseling is a consumer-directed
approach to supportive services that enables
consumers to purchase individualized care
rather than receiving it through an agency.
It provides consumers with the following:
Cash: A cash allowance is provided to consumers. The
consumers are given the flexibility to spend the cash
providers or pay
p y for
allowance to hire their own p
goods/materials that will improve quality of life (i.e. handsfree phones)
Counseling: Consumers are also given counseling and fiscal
assistance
i t
to
t h
help
l them
th
manage their
th i cash
h allowance
ll
and
d
their responsibilities as employers.
1
1. Cash and Counseling
Counseling,
Continued
Cash and Counseling was implemented
in three states: Arkansas,, Florida and
New Jersey.
Mathematica Policy Research,
Research Inc
Inc.
conducted a study to examine the
effectiveness of the Cash and
Counseling programs in these three
states.
states
1
1. Cash and Counseling
Counseling,
Continued
Mathematica Policy Research, Inc. made the
following observations:
Cash and Co
Counseling
nseling did not increase
in ease overall
o e all costs
osts
Across all three states, consumers were highly satisfied
(96% in Arkansas would recommend the program; 97% in
New Jersey)
Most consumers hired family members or friends as personal
caregivers
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
program
g
permanently
p
y available to consumers.
the p
2
2. Governor’s
Governor s Recent Budget
Proposal
Governor Schwarzenegger’s preliminary
2004-05 Budget
g Bill proposed
p p
to
eliminate the Residual Program of IHSS.
IHSS is currently composed of two
independent programs: Personal Care
Services Program (PCSP) and the
Residual Program
2
2. Governor’s
Governor s Recent Budget
Proposal, Continued
Personal Care
Services Program
Funded by Federal
funds (Medicaid),
State Funds
Funds, County
Funds
Services include:
Paramedical
Non-medical personal
assistance
Residual Program
Funded by State Funds
and County Funds
Services include
Any service by a
responsible relative
domestic and related
services only
protective supervision
Advance Pay
Restaurant/Meal
Allowance
Residual and Split Recipients by
Service Subgroup
1%
1%
14%
22%
16%
Parent Providers
Spouse Providers
Domestic Care Only
Protective Supervision
Advance Pay
Meal Allowance
46%
2
2. Governor’s
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
g number of Residual Program
g
recipients
p
would qualify
q
y for
the IHSS PCSP. Therefore, these consumers would simply switch
programs.
Additionally, other Residual program recipients would turn to 24h
hour
care facilities.
f iliti
Finally, the elimination of the Residual program could spark a
number of expensive Olmstead-related litigation cases for the state
to fund.
fund
3. Medicaid Waivers
Finally, the state administration
withdrew the p
proposed
p
reductions to
the IHSS program and opted to pursue
waivers from existing
g Medicaid
regulations.
3
3. Medicaid Waivers
Waivers,
Continued
The Medicaid waiver would enroll all existing
Residual Program recipients
Th waiver
The
i
is
i designed
d i
d to offer
ff self-directed
lf di
d
service components. These services include:
Person Centered Planning: recipients are allowed
Person-Centered
to utilize their personal long-term resources (I.e.
they can hire their relatives)
Individual Budgeting: recipients are either given
an allocation of service hours or and advance cash
payment