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CA Home Care and Hospice: Where We Stand in 2009

CA Home Care and Hospice: Where We Stand in 2009. California Association for Health Services at Home (CAHSAH) March 23, 2009. What is Home Care?. Provision of services and products in the home Broad definition Encompasses many different sectors. Home Care Spectrum. Services and Programs.

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CA Home Care and Hospice: Where We Stand in 2009

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  1. CA Home Care and Hospice: Where We Stand in 2009 California Association for Health Services at Home (CAHSAH) March 23, 2009 California Association for Health Services at Home (CAHSAH)

  2. What is Home Care? • Provision of services and products in the home • Broad definition • Encompasses many different sectors California Association for Health Services at Home (CAHSAH)

  3. Home Care Spectrum California Association for Health Services at Home (CAHSAH)

  4. Services and Programs • Home health – Medicare and Medicaid • Hospice – Medicare and Medicaid • Shift Nursing and personal care – Medicaid • Private Duty California Association for Health Services at Home (CAHSAH)

  5. Why Promote Home Care? • Cost-effectiveness vs. other settings • MedPAC, June 2005 Report to Congress reported that “in terms of Part A costs, episodes in an inpatient rehab facility or SNF are much more costly for Medicare than episodes of care among patients going home.” • Medicaid waivers • Preferred by patients and families • Olmstead Decision (least restrictive environment) California Association for Health Services at Home (CAHSAH)

  6. Sources of Payment forHome Care, 2007(billions) California Association for Health Services at Home (CAHSAH) Source: CMS, National Health Expenditures, 2009

  7. Congressional Budget OfficeProjected versus Actual Expenditures California Association for Health Services at Home (CAHSAH)

  8. Reality of the Medicare Home Health Benefit/Access to Care • Medicare home health benefit has taken the largest cut versus any other provider the past 10 years, starting with the Balanced Budget Act of 1997 • Home Health share of Medicare spending has dropped from 8.7 percent in 1997 to 3.1 percent today • Projected to decline to 2.6 percent of Medicare by 2015 California Association for Health Services at Home (CAHSAH)

  9. Personal Health Care Expenditures, 2007 California Association for Health Services at Home (CAHSAH) Source: CMS, National Health Expenditures, 2009

  10. Sector Growth, 1995-2005 • Nursing homes 263% • Physicians 214% • Medicare 84% • Hospitals 66% • Home Health 45% California Association for Health Services at Home (CAHSAH)

  11. Medicare: Prospective Payment System (PPS) • 60 day episodes • Payment adjusted by 153 HHRGs • Episode exceptions (LUPAs, PEPs, outliers, etc) California Association for Health Services at Home (CAHSAH)

  12. Medicare Home Health Payment Elements • Base Rate – National 60-day Episode Payment Rate • Market Basket Update • Case Mix Creep Adjustment • Rural Add-on – five percent increase expired 12/31/06 • Wage Index California Association for Health Services at Home (CAHSAH)

  13. Outlook for Home Care? Concerns: • Years of Cuts Taken in Home Health • Impact of President’s Budget • Casemix Creep Adjustment • Loss of Rural Add On California Association for Health Services at Home (CAHSAH)

  14. Medicare Home Health Spending in California • US Spending on Home Health = $13.9 Billion • California Spending on Home Health = $1.1 Billion • California comprises 7.8% of the Nation’s Current Spending Source: NAHC Estimates California Association for Health Services at Home (CAHSAH)

  15. Impact of the President’s Proposal on Home Health? • Reduces Home Health spending by $13.1 billion over the next five years • By freezing the market basket over the next five years (2009-2013) • Casemix Creep Adjustment California Association for Health Services at Home (CAHSAH)

  16. Budget Proposal Impact on CaliforniaHome Health Medicare Payments • FY 2010 Projected Losses for California: $42.6 million • FY 2010-2014: $1.1 billion Source: NAHC Estimates California Association for Health Services at Home (CAHSAH)

  17. Why Home Health Needs Annual Increases • President Obama: “Now is the time to help families care for their aging parents by enacting a real long-term care plan to lower costs and guarantee all Americans receive quality care in their later years.” • Rising nursing salaries to compete with hospitals and nursing homes • Cost of regulatory requirements • Rising cost of gasoline and insurance California Association for Health Services at Home (CAHSAH)

  18. Special Needs of Rural Agencies Why Rural Add on is critical: • 24 of CAs 58 counties are rural • 9 of these counties served by 2 or less HHAs • Shortage of personnel • Longer driving distances California Association for Health Services at Home (CAHSAH)

  19. History of Rural Add On • Rural add on was historically 10% • In FY 2003, the rural add on expired • From April 1, 2004-March 31, 2004, it was re-instituted as 5% • No Add On: April 1, 2005 – December 31, 2005 • Effective January 1, 2006- December 31, 2006 – 5% restored temporarily • Currently, there is no add-on California Association for Health Services at Home (CAHSAH)

  20. Add-On Counteracts Higher Costs, Negative Margins • Rural agency costs 12-15% higher • Rural margins= -4.2% vs. urban 6.6% • Differential is 10.8% California Association for Health Services at Home (CAHSAH)

  21. What is Hospice? • Individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course • Care is focused on providing “comfort,” and not cure • Provided in Patients’ Home or Primary Place of Residence California Association for Health Services at Home (CAHSAH)

  22. Medicare Hospice Spending in California • US Spending on Hospice = $9.2 Billion • California Spending on Hospice = $811 million • California comprises 8.9% of the Nation’s Current Spending Source: NAHC Estimates California Association for Health Services at Home (CAHSAH)

  23. Impact of the President’s Proposal on Hospice? • Budget Neutrality Adjustment Factor set to be reduced by 75% in 2010 and 100% in 2011 • Loss of BNAF FY 2010-2014 = $3.4 billion California Association for Health Services at Home (CAHSAH)

  24. Impact on CaliforniaHospice Payments • FY 2010 = $38 million • FY 2011 = $50 million • Total cuts FY 2010-2014 = $298 million California Association for Health Services at Home (CAHSAH)

  25. Hospice Needs Stable Increases • Subject to same cost factors as home health • New CoPs and quality measures will add to costs • Overwhelmingly cost-effective vs. heroic treatment California Association for Health Services at Home (CAHSAH)

  26. Medicaid: Visit and Hourly Payment Structure • Medicaid Has Set “Rates” • “Rates” Set by State Legislature – • Hourly Nursing Rate: $29.41 • Nursing Visit: $74.86 – One hour visit • Last Rate Increase August 1, 2000 • California’s Match: 50/50 with Feds California Association for Health Services at Home (CAHSAH)

  27. Lack of Access to Medi-Cal Home Health Services in California • 1994 State Plan Amendment (SPA) to Require Annual Review of Medi-Cal Rates • CAHSAH vs. Department of Health Services • Filed – April 2004 • Trial Court Decision – September 14, 2005 • Court of Appeal Decision – March 15, 2007 • 2006 SPA to Remove HHA Annual Review California Association for Health Services at Home (CAHSAH)

  28. Lack of Access to Medi-Cal Home Health Services in California CAHSAH conducted an Analysis of 2005 OSHPD Data -- Office of State Health Planning and Development Data (latest data available) • Only 5 percent of all visits and 7.5 percent of all payments are Medi-Cal • 82 percent of all home health agencies are eligible to provide Medi-Cal services; However: • 40 percent provide NO Medi-Cal home health services • 52 percent provide 75 visits or less for an entire year • 3.9 percent or 31 agencies providing most Medi-Cal home health services (5,000 or more visits per year) California Association for Health Services at Home (CAHSAH)

  29. Lack of Access to Medi-Cal Home Health Services in California • 19 California Counties have no or only one Medi-Cal home health provider • Especially Acute for Northern and Rural Counties • Remaining 39 Counties have a concentration of two to four providers per county providing 80 percent of all services • Includes Larger Counties, such as Alameda, Contra Costa, Fresno, Kern, Marin, Merced, Monterey, Orange County, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Cruz, Santa Clara, Sonoma, Stanislaus, Tulare and Ventura • Los Angeles County has 8 agencies with two providing most of the services • Conclusion: Leaves very few safety net home and community based providers in the California Counties California Association for Health Services at Home (CAHSAH)

  30. HR 3582 (Woolsey) • Would eliminate federal companion and CA personal attendant exemptions • Would increase cost of a live-in from $192 to $304 per day (58%) • Home care would no longer be affordable California Association for Health Services at Home (CAHSAH)

  31. Employee Free Choice Act • Eliminates right to secret ballot • Eliminates federal supervision of union elections • Forces binding arbitration on both the employer and the collective bargaining unit California Association for Health Services at Home (CAHSAH)

  32. What We Need • Regular full annual updates for home health and hospice • Permanent extension of rural add-on • Elimination of Casemix Creep Adjustment and Hospice Budget Neutrality Adjustment • Oppose HR 3582 (Woolsey) and EFCA California Association for Health Services at Home (CAHSAH)

  33. More Information? • Contact California Association for Health Services at Home (CAHSAH) • http://www.cahsah.org • 3780 Rosin Court, Suite 190 • Sacramento, CA 95834 • 916-641-5795 • jlindsey@cahsah.org • jhafkenschiel@cahsah.org California Association for Health Services at Home (CAHSAH)

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