Sunday, April 17, 2011


Eight years ago, Indiana legislators passed a law that could save taxpayers millions of dollars that the state spends to support elderly and disabled Hoosiers who live in nursing homes. The law also would make it possible for thousands of Hoosiers to remain in their homes or with loved ones. The law had bipartisan support and was championed by fiscal conservatives and advocates for the elderly. But in what one lawmaker describes as a "penny-wise and pound-foolish" decision, the state has never taken advantage of a key program in the law. Not under then-Gov. Joe Kernan, a Democrat. And not under Republican Gov. Mitch Daniels. Instead, eight years later, Indiana taxpayers continue to be on the hook for about $300 million a year in nursing home costs. Under the program, the state would pump money into home health-care services each year, knowing that Hoosiers would use the services -- nursing, financial planning, bathing and personal care -- and stay at home instead of going into nursing homes. As more people chose home health care, the number of people in nursing homes would diminish. That matters because nursing homes cost state taxpayers about $14,129 per patient, while home health care costs taxpayers an estimated $9,265 to $12,411 per patient, according to an Indianapolis Star analysis of Family and Social Services Administration cost reports. The state then would reinvest those savings to create even more home health care for Hoosiers, driving even more savings. But that program has never been used. Year after year, the state has been unwilling to put up the money for that investment. And as such, it has missed out on the long-term savings. "It's penny-wise and pound foolish," said Sen. Vaneta Becker, R-Evansville, a sponsor of the 2003 law. Sen. John Broden, D-South Bend, who worked with Becker on the law, is dismayed and a bit befuddled. "We just have not been able to make this commitment," Broden said. "Our constituents want it; it's what they prefer. And then when you couple that with the fact that it is cheaper, it is a constant struggle for me to ascertain why we don't embrace it. "We pat ourselves on the back that we managed to save this much money by not spending it on home health care, but what we have to remember is you're expending dollars to keep someone out of a nursing home, (and) that's what really busts the budget. "If we would have been transitioning (to home- and community-based services)," Broden said, "by now, we'd be saving a lot of money." How much? The state pays nursing home costs for more than 28,000 elderly and disabled Hoosiers. If 10 percent of those patients had been shifted to home health care, the state would be saving from $4.8 million to $13.6 million this year. And 2,800 more Hoosiers would be living at home instead of in nursing homes. Whether Hoosiers would choose home health care if it were provided to more people is not up for debate. The two major home-care programs both have nearly 6,000-person waiting lists. In contrast, 18 percent of the state's nursing home beds sit empty. Nursing home industry officials say that shifting patients to home health care would further hurt their business. Critics, who say the state has too many nursing homes, are wary of the industry's powerful lobby, which has fought hard to ensure that patients -- and the taxpayer money that comes with them -- continue to flow in their direction. The result is that Indiana ranked 45th among the states in the percentage of its Medicaid long-term care budget devoted to home- and community-based care, according to a 2009 study by the AARP Public Policy Institute. The data for the study were collected in 2007, but the percentage of Indiana's long-term care budget spent on nursing homes hasn't changed since. Ellen Miller, director of the University of Indianapolis Center for Aging & Community, said Indiana needs to improve. "There's not much of an excuse," Miller said. "When you look at the rankings and the numbers, we're always in the bottom 20 percent in terms of how much money we're spending" on in-home care. An estimated 75 percent of Indiana's long-term care budget is devoted to nursing home care. Meanwhile, other states are saving money Other states have made much more progress. Wisconsin reduced its nursing home rate to 41 percent after a decadelong campaign to expand home- and community-based care. Washington state pushed its rate down to 33 percent after it began shifting funds to home and community-based care 16 years ago. The 1995 legislation was similar to Indiana's 2003 law in that it directed money saved back into home care. The difference? Washington's law wasn't optional. The legislation saved Washington $109 million in the first two years -- with $52 million going to the state and $57 million to home- care programs, said Kathy Leitch, who served as assistant secretary of the state's Aging and Disability Services Administration from 2000 to 2010. Nursing home care, unlike home care, is a federal entitlement -- states are required to pay for it when someone is eligible and cannot afford it. So states that do not take action to improve home care are destined to pay ever-increasing nursing home costs. In the tough 2011 budget climate, some states, such as Pennsylvania, are expanding home care services to save money. That's not happening in Indiana. Here, legislators have viewed the programs not as a way to invest money and create savings down the road but as an expense to hold steady, or even cut. Indiana has put the same amount of dollars -- from $60 million to $70 million a year -- into the state's two major home-care programs since 2003. One of those is the Medicaid Aged & Disabled waiver program, which is paid for primarily by the federal government. The program matches Indiana dollars at 2-1 or better, but waivers go only to the poorest and sickest Americans under rules set by the federal government. The other is the state-run Community and Home Options to Institutional Care for the Elderly and Disabled program, or CHOICE. CHOICE is withering. This year, CHOICE received $28.6 million, a $7 million cut from the year before. The two-year House budget now under consideration would reserve about $20 million a year for the CHOICE program, and the governor's budget would allow the state to shift all money for CHOICE into the Medicaid program. The Senate will work out its version of the budget when its Appropriations Committee meets Monday. The cuts could mean the end of CHOICE, the state's 23-year-old locally developed home-care program, something Broden called "a huge setback" in the state's push to expand home care. Advocates say both services are badly needed. CHOICE, however, has a particularly important role in keeping costs down. It allows people who are not yet poor enough or sick enough to receive Medicaid to remain at home. Without that option, those people end up in more costly nursing homes before they necessarily need them. Taxpayers end up footing that bill because the higher cost of nursing home care quickly eats up personal assets -- making people eligible for Medicaid and, thus, forcing the state to step in. Eighty percent of all nursing home patients either start out or end up being Medicaid patients. Family has waited a year for home help The Dennis family of Indianapolis is a good example of what can happen. Delbert Dennis, 55, suffers from Huntington's disease, a condition where one's abilities to walk, eat and speak deteriorate slowly -- often resulting in the need for 24-hour care. He has been receiving 15 to 20 hours a week of CHOICE services for about three years. A year ago, when it became risky for Delbert to be alone for even a short time, his wife, Susie, put his name on a waiting list for 40 hours of care a week through the Medicaid waiver program. After the wait stretched to a year -- a year Susie and 14-year-old daughter Marisol Dennis spent caring for Delbert around the clock -- Susie, 51, is looking at nursing homes. "It just takes a lot out of you," Susie Dennis said. "Had we had the care over the last year . . . who knows how long he could have stayed at home." Susie Dennis' wait is not uncommon, as cuts and freezes have hobbled the two home-care programs. Many who wait for services eventually get them. But often, said John Cardwell, chairman of the Indiana Home Care Task Force, the person dies or goes into a nursing home before his or her name comes up. Stimulus money helped, but it's gone The state, however, would argue that while it has not put any extra money into home health care -- at least any of its own -- or reduced the number of nursing home patients paid for by taxpayers, it still has made some progress. In one important way, it has. Relying heavily on federal stimulus money, the state increased the number of people in home health care by about 6,000 from 2004 to 2010. "We have really grown home- and community-based services," FSSA spokesman Marcus Barlow said. "We just haven't used Senate Enrolled Act 493" -- the law passed in 2003. However, almost all of that growth is in the federal program. During that time, $15.3 million has been cut from the CHOICE program -- in part to pull funds for the waiver program. Those cuts also have reduced the amount of hours and services available to CHOICE clients, Cardwell said, and made that program less effective at keeping people in their homes. FSSA says that the waiver program is more cost-effective, though some advocates dispute that, and the debate is heated -- in part because there is so little home-care money to go around. When senators work out their two-year budget proposal Monday, CHOICE and the waiver program will be pitted against each other, competing over less than $70 million in home-care funds per year, while nursing homes reap about $300 million. Director Faith Laird of FSSA's Division of Aging acknowledged that the push toward home and community-based care has been an uphill one. "We are moving in that direction," Laird said. "It isn't as fast as we want, but we are moving in that direction." It's about to become tougher. The source that drove those new home health-care patients -- the federal stimulus -- has ended. And that, experts and advocates for the elderly say, makes it especially crucial for the state to finally take advantage of the 2003 law. Call Star reporter Heather Gillers at (317) 444-6405. Source

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