California County Profiles of Medi-Cal Beneficiaries Who ... · California’s Medicaid program, Medi-Cal, is administered by the California Department of Health Care Services (DHCS)

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.

http://thescanfoundation.org/california-medicaid-research-institute-studying-recipients-long-term-care-services-and-supports-case

http://thescanfoundation.org/california-medicaid-research-institute-studying-recipients-long-term-care-services-and-supports-case

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.


“Medicaid and Medicare Spending on Acute, Post-Acute and Long-Term Services and Supports

http://www.calduals.org/

http://camri.universityofcalifornia.edu/documents/hcbs-report-dhcs.pdf

http://www.thescanfoundation.org/california-medicaid-research-institute-recipients-home-and-community-based-services-california


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

http://thescanfoundation.org/california-medicaid-research-institute-medicaid-and-medicare-spending-acute-post-acute-and-long-term


http://camri.universityofcalifornia.edu/publications.html

http://www.thescanfoundation.org/california-medicaid-research-institute-extended-nursing-facility-stays-among-californias-dual


http://camri.universityofcalifornia.edu/documents/camri_extended_nf_stays_among_california_dual_eligibles_medi-cal-only_beneficiaries-9-25-13.pdf

http://camri.universityofcalifornia.edu/documents/camri_extended_nf_stays_among_california_dual_eligibles_medi-cal-only_beneficiaries-9-25-13.pdf

http://thescanfoundation.org/updated-california-medicaid-research-institute-medi-cal-beneficiaries-who-use-long-term-services-and

http://thescanfoundation.org/updated-california-medicaid-research-institute-medi-cal-beneficiaries-who-use-long-term-services-and

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.



http://camri.universityofcalifornia.edu/HCBS-County-Tables.pdf


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.


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






services-california. 15


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.






http://camri.universityofcalifornia.edu/publications.html



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


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)


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)


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)


YUBA (N=690)

VENTURA (N=4,640)


PLUMAS (N=307)


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)



YOLO* (N=43)

MARIN (N=1,340)


COLUSA (N=211)

SIERRA (N=66)

LAKE (N=1,403)

EL DORADO (N=849)

KERN (N=5,089)


KINGS (N=1,523)


TUOLUMNE (N=573)


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)



MODOC (N=66)


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)





ALAMEDA (N=2,878)


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)



ORANGE (N=21,578)

MARIN (N=2,117)

GLENN (N=513)


ALAMEDA (N=19,244)

IMPERIAL (N=5,429)

YUBA (N=1,319)



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)



SAN MATEO (N=3,922)

SAN LUIS OBISPO (N=2,278)


NAPA (N=915)

NEVADA (N=559)

TEHAMA (N=1,098)


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)


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


Documents

California County Profiles of Medi-Cal Beneficiaries Who ... · California’s Medicaid program, Medi-Cal, is administered by the California Department of Health Care Services (DHCS)