June 2015 Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients Erik Krisle, MPP I Nathan Smith, MS I David Muhlestein, PhD Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients Erik Krisle, MPP I Nathan Smith, MS I David Muhlestein, PhD ABSTRACT INTRODUCTION Home health services provide a critical role in the care continuum. Shortages in skilled nursing labor, an aging population, and the expanding role of government in health insurance markets suggest that an increased demand for home health services should be materializing. This analysis uses recent poll results and utilization data for home health agencies (HHAs) and investigates the growth of total services provided to home health patients. Specifically, we investigate access to home health care for Medi-Cal patients in California. We find that while total capacity of the home health care market is growing, services available for Medi-Cal patients have remained stagnant since 2002. Significant growth in new Medi-Cal enrollees and lack of growth in agencies willing to provide services to enrollees suggests a substantial access-to-care gap materializing between Medi-Cal patients and nonMedi-Cal patients for home health services. More than 12 million Californians depend on Department of Health Care Services (DHCS) funded programs for access to medical care.1 In FY2014, California spent an estimated $24 billion on Medi-Cal services,2 accounting for more than 26% of general funds expended in the state.3 Recent economic woes coupled with growing demand for health care services and expanding government participation in the health care economy have greatly increased the burden on the state health care system. DHCS’s express mission to “provide Californians with access to affordable, high-quality health care”4 seems more elusive than ever. Nationally, the top 5% of health care spenders account for nearly half of all health care spending.5 High spenders, often with a chronic condition, are substantially more likely to utilize home health services.6 These patients are particularly affected by fluctuations in access to home health care services. Our analysis focuses on how HHAs specifically have trended in providing services to Medi-Cal patients versus commercially insured patients. The Health Agencies and Hospice Facility Annual Utilization survey conducted by California’s Office of Statewide Health Planning & Development (OSHPD) provided the data for this analysis. We conclude that over the last several years HHAs have shifted their resources away from providing care to Medi-Cal patients in favor of providing more services to commercially insured patients. Poll results indicate that the shift is, at least in part, due to deliberate decisions agencies have made relative to deploying their resources. Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients 1 Figure 1: California Home Health Agencies Over Time Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients Figure 1: California Home Health Agencies Over Time 1800 KEY FINDINGS • The California Medi-Cal population has grown by 39% in 7 years (1.8 million more people), while the number of home health visits provided to Medi-Cal patients has stayed relatively stable during the same time period. • An increasing percentage of HHAs are not treating Medi-Cal patients (22% in 2002 to 56% in 2013). 1600 18001: California Home Health Agencies Over Time Figure 1600 1400 Figure 1: California HHAs Over TIme 1200 18001400 1000 16001200 1000 800 1400 800 600 1200 600 400 1000 400 200 800 200 0 600 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 400 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 • HHAs are significantly more likely to immediately accept new patients if they are privately insured than if they are on Medi-Cal. • 60% of all the agencies treating Medi-Cal patients are only able to provide 0 to 25% of the approved hours to Medi-Cal patients. • 17% of all agencies have a cap on the number of MediCal patients they will accept. • By 2018, only 4 in 10 Medi-Cal certified agencies will actually accept Medi-Cal patients in a given year. 200 All Home Health Agencies All Home Health Agencies Medi-Cal Medi-CalCertified CertifiedAgencies Agencies 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 All Home Health Agencies Medi-Cal Certified Agencies Figure 2: Total California HomeHealth HealthVisits Visits Over Over Time Figure 2: Total California Home Time Figure 2: Total California Home Health Visits Over Time 16,000,000 16,000,000 14,000,000 14,000,000 Figure 2: Total 12,000,000 California Home Health Visits Over Time 12,000,000 10,000,000 16,000,000 10,000,000 8,000,000 14,000,000 8,000,000 6,000,000 12,000,000 6,000,000 4,000,000 OSHPD housed and tracked utilization data from HHAs since 2001. We aggregated data and analyzed the change in health care utilization of Medi-Cal patients in HHAs between the years 2002 and 2013. We collected enrollment and population data from the Kaiser Foundation and the California Department of Finance (DOF) respectively. The combined data set offered the ability to assess HHAs’ propensity and capacity to provide services to patients with Medi-Cal insurance as well as those with commercial insurance. Additionally, we conducted a poll of currently active HHAs in which we asked about willingness and capacity to accept new home health patients covered by Medi-Cal or commercial insurance. A N A L Y S I S : Home Health Services for Medi-Cal Patients HHAs are required to become certified to provide care to patients with Medi-Cal insurance. In practice, many become certified concurrently when they become certified for MediCal patients. As such, certification alone is not a guarantee that any particular agency is in fact providing care to MediCal patients. In 2002, OSHPD recorded a total of 600 Medi-Cal certified HHAs across the state out of 870 total HHAs. In 2013, that number climbed to more than 1200 agencies (see Figure 1). 2 Leavitt Partners 0 6,000,000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 4,000,000 Total Visits 2,000,000 0 Total Visits Total Medi-Cal Visits Total Medi-Cal Visits Figure 3: CA Medicaid Enrollment 2002Medi-Cal 2003 2004Enrollment 2005 2006 2007 2008 2009 Figure 3: CA (2006-13) and2010 2011 Figure 3: CA Medicaid Enrollment Projections (2014-19) Total Visits Total Medi-Cal Visits 30% 30% Population Percentage D ATA 10,000,000 4,000,000 2,000,000 8,000,000 2,000,000 28% 26% 28% 2012 2013 Figure 3: CA Medicaid Enrollment 26% 24% 22% 24% 30% 20% 22% 28% 18% 20% 26% 16% 18% 24% 14% 16% 22% 12% 14% 20% 10% 12% 18% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 10% Note: Data were taken from the Kaiser Foundation, Projetions were done using the 16% 2006 2007 done 2008by2009 2011 2012Dietz, 2013 2014(2013) 2015 2016 2017 2018 2019 estimation Lucia,2010 Jacobs, Watson, & Roby 14% 12% Likewise the total number of visits for home health services 10% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 has increased from 8.3 million to 13.7 million over the same time period (see Figure 2). Total capacity for home health care has in fact been increasing in recent years. From 2006 to 2013 there was a dramatic increase in the percentage and number of California’s population that were Leavitt Partners Figure 4: Figure 4: Percentage Percentage of of Agencies Agencies with with Medi-Cal Medi-Cal Visits Visits Figure 4: Percentage of Agencies with Medi-Cal Visits Figure 6: Percentage of Agencies -Cal Visits with Medi Figure 6: Change in Agency Acceptance of Medi-Cal Patients 100% 100% 100% 90% 90% 90% 80% 80% 80% 70% 70% 70% 60% 60% 60% 50% 50% 50% 40% 40% 40% 30% 30% 30% 20% 20% 20% 10% 10% 10% 0% 0% ‘02 ‘02 ‘03 ‘03 ‘04 ‘04 ‘05 ‘05 ‘06 ‘06 ‘07 ‘07 ‘08 ‘08 ‘09 ‘09 ‘10 ‘10 ‘11 ‘11 ‘12 ‘12 ‘13 ‘13 ‘14 ‘14 ‘15 ‘15 ‘16 ‘16 ‘17 ‘17 ‘18 ‘18 More than than 100 100 Patients Patients More 1 to to 100 100 Patients Patients 1 0% No Medi-Cal Medi-Cal No Note: Forecased figures calculated using linear regression with a time series adjustment, based on historical OSHPD data ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 ‘17 ‘18 Took Medi-Cal During Year Took Medi-Cal Previously Never Took Medi-Cal Note: Forecased figures calculated using linear regression with a time series adjustment, based on historical OSHPD data Figure 5: Percentage Agencies of Agencies withMedi-Cal Medi-Cal Figure Figure 5: 5: Percentage Percentage of of Agencies with with Medi-Cal Visits Visits (Weighted) (Weighted) Visits (weighted) Medi-Cal-certified HHAs that are regularly treating MediCalYears patients reveals a diminishing supply of home health Figure 7: Until Agency Stops Accepting Medi-Cal Patients* services to these patients relative to all services provided. The percentage of agencies that are certified to accept Medi-Cal patients but are not actually treating any Medi-Cal patients has grown from 22% in 2002 to 56% in 2013 (see Figure 4). This percent is expected to increase to at least 60% in 2018. The proportion of agencies that are treating Medi-Cal patients in high volume (more than 100 patients per year) has decreased by more than half, and is expected to continue to decrease (see 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 4). The proportion of low volume agencies (fewer than Percent 100 patients) decreased slightly to around 20%. 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% ‘02 ‘02 ‘03 ‘03 ‘04 ‘04 ‘05 ‘05 ‘06 ‘06 ‘07 ‘07 ‘08 ‘08 ‘09 ‘09 ‘10 ‘10 ‘11 ‘11 ‘12 ‘12 ‘13 ‘13 ‘14 ‘14 ‘15 ‘15 ‘16 ‘16 ‘17 ‘17 ‘18 ‘18 More More than than 100 100 Patients Patients 1 1 to to 100 100 Patients Patients No No Medi-Cal Medi-Cal Note: Forecased figures calculated using linear regression with a time series adjustment, based on historical OSHPD data enrolled in Medi-Cal (see Figure 3). Beginning in 2014, with the expansion of Medicaid due to the Affordable Care Act, the proportion of the California population eligible for and enrolled in Medi-Cal is expected to increase rapidly.7 This increase should be associated with a similar increase in the number and percentage of home health visits billed to Medi-Cal during the same years. However, that has not been the case. Overall growth in the total capacity of HHAs has not benefited all patient populations equally. A look at the percentage of all The trend indicates a reduction in Medi-Cal patient volume across all agencies. Smaller volume agencies provide fewer services to Medi-Cal patients reaching the point at which they provide no Medi-Cal services at all. Agencies that traditionally provided large volumes of services have moved toward providing fewer services in a given year. A weighted analysis of the same agencies shows a similar result. We applied a frequency weight, corresponding to the total number of visits each agency had on record. The frequency weights provide an assessment for how agencies of different sizes and with different capacities are changing their business model. In other words, movement among agencies with higher numbers of annual visits will move the trends faster than agencies with less initial service volume. The weighted analysis confirms that in general, firms are Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients 3 Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients Figure 10: Number of Agencies that Offer Pediatric Services Figure 7: Years Until Agencies Stopped Accepting Medi-Cal Patients* 1 Year 42% 0% 2-4 Years 37% Figure 10: Number of Medi-Cal Certified Agencies 5+ Years 20% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent *Includes only those agencies who began treating Medi-Cal patients and later ceased to accept Medi-Cal patients during the analysis period, 2002-2013. 1400 1200 1000 800 600 400 200 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Figure 8: 8: Percentage Percentage of of HHAs HHAs that that Offer Offer Pediatric Pediatric Services Services Figure Figure 8: Percentage of HHAsby thatTotal OfferVisits) Pediatric Services (Weighted (Weighted by Total Visits) (Weighted by Total Visits) 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% Total Total Medi-Cal Certified Agencies Offered Pediatric Services Agencies that Offer Pediatric Services Offered Pediatric Services and Took Medi-Cal Patients Agencies that Offer Pediatric Services and Took Medi-Cal decreasing the number of services they provide to MediCal patients and are expected to continue to decrease those services in the future (see Figure 5). An increasing number of Medi-Cal certified agencies are rejecting Medi-Cal patients altogether. Year over year, the percentage of agencies in the market that accepted Medi-Cal patients in previous years, but provide no visits in the current year is increasing (see Figure 6). These agencies are staying in the home health care market, but leaving the market with to Medi-Cal patients. Likewise, the percentage Figure 11:regard Are you currently accepting any new patients? of agencies that never provided any Medi-Cal visits nearly ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 ‘17 ‘18 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 ‘17 ‘18 tripled, from 11% of all Medi-Cal-certified agencies in 2002 Pediatric Services No Pediatric Services to 29% in 2013 (see Figure 6). By 2018, more than onePediatric Services No Pediatric Services Note: Forecased figures calculated using linear regression with a time series adjustment, third of agencies will have never served a Medi-Cal patient. based on historical OSHPD data Figure 9: 9: Percentage Percentage of of HHAs HHAs that that Offer Offer Pediatric Pediatric Services Services The data also suggest that agencies make the decision to reject Figure (Weighted by Medi Visits) Cal -CalPediatric Medi-Cal patients early in their experience. 42% of agencies Figure 9: Percentage of HHAs Offer (Weighted by that Medi Visits) Services 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% (Weighted by Medi-Cal Visits) 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 ‘17 ‘18 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 ‘17 ‘18 Pediatric Services Pediatric Services No Pediatric Services No Pediatric Services Note: Forecased figures calculated using linear regression with a time series adjustment, based on historical OSHPD data 4 Leavitt Partners that eventually cease to provide Medi-Cal services do so within one year of first providing services. An additional 1/3, totaling 79%, leave the Medi-Cal market within four years (see Figure 7). The picture becomes particularly concerning in light of pediatric services.0%The percentage Medi-Cal-certified 10% 20% 30% of 40% 50% 60% 70% 80%agencies 90% 100% that offer pediatric services has declined from 45% in 2002 to 27% in 2013 (see Figure 8). When corrected for Medi-Cal patient volume, the trend continues (see Figure 9). By 2018, that figure will dip below one-quarter of Medi-Cal certified agencies. The trend indicates a decrease in access to home health care for pediatric Medi-Cal patients relative to other Medi-Cal patients and relative to non-Medi-Cal patients. Unlike other services, not only has the percentage of agencies offering pediatric services declined, but the absolute number of agencies offering pediatric services has declined as well. Just 191 agencies statewide (15.7%) offered both specialized Leavitt Partners pediatric care services and accepted Medi-Cal patients in 2013—down from 212 agencies (42.5%) in 2002. Of all agencies that provide pediatric services, nearly 1/5 did not accept any Medi-Cal patients in 2013 (see Figure 10). A N A L Y S I S : 2015 Poll of HHAs To further investigate the willingness and capacity of HHAs to provide services to Medi-Cal patients relative to other populations, we conducted a poll of HHAs throughout the state. The poll was fielded via telephone from May 05, 2015, to May 12, 2015. 922 responses were collected from intake staff at HHAs listed in the OSHPD facilities listings,8 representing 61% of all active agencies. The poll results are correct within 2 percentage points. The poll results confirm trends observed in the OSHPD data. Most agencies show a willingness to accept new patients. For agencies that reported being Medi-Cal certified we asked if they were currently accepting new Medi-Cal patients. 21% said they were not accepting Medi-Cal patients (see Figure 11). For non-Medi-Cal certified agencies we asked if they were accepting any new patients. Just 7% said they were not able to accept new patients. Medi-Cal patients appear to have many fewer options than patients with alternative payment sources searching for HHAs. We asked agencies how quickly they could accept a hypothetical pediatric patient with a ventilator and tracheostomy needing 16 hours a day of skilled nursing services. Those who reported being Medi-Cal certified were asked if they would take a Medi-Cal patient with the hypothetical needs. Those who reported not being certified were asked if they would take a privately insured patient with the same needs. When presented with the case for a privately insured patient, 50% of agencies reported being able to immediately accept the patient. When Medi-Cal was presented as the insurance source just 28% were able to accept the patient immediately (see Figure 12). A full one-third of agencies accepting MediCal required more than a week to accept the hypothetical case patient. The hypothetical situation suggests that Medi-Cal servicing agencies are more strained for resources than agencies that do not service Medi-Cal patients. As such, Medi-Cal patients would have a harder time finding a suitable agency than those with other insurance sources, particularly in the short-term. Figure 11: Are you currently accepting any new patients? Medi-Cal Certified Yes 79% 0% No 21% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Not Medi-Cal Certified Yes 93% 0% No 7% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 12: How soon could you accept a 16 hours per day pediatric vent-trac patient? (By Insurance Type) Medi-Cal Patients Imediately 28% 0% Less than a week 39% More than a week 33% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Privately Insured Patients Imediately 50% 0% Less than a week 25% More than a week 25% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 13: What percent of authorized hours are you actually providing on a weekly basis? 76-100% of approved hours 28% 0–25% of approved hours 59% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 26–75% of approved hours 12% Figure 14: Are there and areas your agency used to serve but no longer accepts patients in? Yes 19% 0% No 81% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Figure 15: Do you have a cap on the number of Medi-Cal patients you will accept? Yes 17% 0% No 83% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% * Margin of error for a simple random sample of 922 out of a population of 1506 is equal to ±2.01%. The sample is not a true random sample. We made an attempt to contact all of the 1506 active agencies. Responses represent the agencies that could be contacted and polled during the time allotted for the poll. Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients 5 Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients Almost all Medi-Cal certified agencies report being unable to staff all the hours approved for their Medi-Cal patients. About 60% of responding agencies say they can only deliver between 0 and 25% of the approved hours for their MediCal patients. Just 28% say they can provide greater than 75% of approved hours (see Figure 13) Nearly 20% of Medi-Cal certified agencies report having ceased to provide services to an area they previously served (see Figure 14), and about as many report having placed a cap on the number of Medi-Cal patients they will accept (see Figure 15). Both results indicate that nearly one-fifth of agencies are actively contracting their service areas, and limiting the services they choose to make available to MediCal patients specifically. DISCUSSION All evidence suggests that HHAs are shifting resources away from providing care to Medi-Cal patients. Increasingly, entrants into the home health market are choosing to focus resources on non-Medi-Cal patients. Agencies that continue to accept Medi-Cal patients do so in lower volumes than previously. Additionally, wait times for Medi-Cal patients seem to exceed those of privately insured patients. Several possibilities could contribute to the access-to-care gap between Medi-Cal and privately insured patients for home health services. California is experiencing a substantial shortfall in the skilled nursing labor force. Steep population growth, especially in older demographics, has created significant demands for nurses throughout the country. Meanwhile the average age for nurses has been increasing steadily for more than a decade,9 and increasing numbers of nurses are leaving the workforce. Researchers have estimated California will be deficient more than 193,000 nurses by 2030.10 Increasing demand for nurses in all clinical care settings will put upward pressure on wages for skilled nurses. Evidence suggests wages for nurses must increase substantially for labor markets to adjust enough to close the shortage.11 Given the current economic conditions, nurses have extraordinary flexibility in choosing employment. Lower paying HHA’s will find it is increasingly difficulty to staff nurses as the labor force moves towards healthcare settings with the highest compensation potential. 6 Leavitt Partners CO N C LU S I O N S A N D I M P L I C AT I O N S The movement of HHAs away from providing services to Medi-Cal suggests three important conclusions. 1) Growth in the home health care market has not increased access to care for Medi-Cal patients as might have been expected. 2) When entering the home health market, new agencies are less likely to provide services to Medi-Cal patients. 3) Access-to-care problems are exacerbated for certain sub-populations, such as high-needs pediatric patients. Without correction it is likely that the access gap between Medi-Cal patients and other patients will widen for home health services. Medi-Cal patients will experience increasing wait times for higher acuity conditions, potentially leading patients to seek care in other settings such as acute care hospitals. This final conclusion should be the subject of further research. It is plausible that reimbursement rate stagnation in the presence of care access gaps could actually increase total expenditures as services needed are diverted to higher acuity, inpatient settings that come with much higher costs. This study is limited to the data provided by OSHPD up until 2013. Recent health care reforms enacted may have an impact on some of our results. However, the compelling evidence on an access gap is not likely to have changed substantially since 2013. It is more likely that the recent influx of new Medi-Cal enrollees through Medicaid expansion has only exacerbated the situation. Further research using claims data might investigate more narrow populations and geographic variations in which access to home health is particularly troublesome. Such information may point the way toward closing the gap, improving care, and decreasing costs for home health in California. ACKNOWLEDGEMENTS This research was funded by Maxim Health Care Services. The authors retain sole responsibility for the content of the report. Leavitt Partners References 1. Kaiser Family Foundation. Total Monthly Medicaid and CHIP Enrollment [Internet]. 2015 Feb [cited 2015 May 13]. Available from: http://kff.org/health-reform/state-indicator/total-monthlymedicaid-and-chip-enrollment/ 2. State of California. Enacted Budget - Health and Human Services [Internet]. 2013 Jun [cited 2015 May 13]. Available from: http:// www.ebudget.ca.gov/2013-14/Enacted/StateAgencyBudgets/4000/ agency.html 3. State of California. Enacted Budget - Enacted Budget Detail [Internet]. 2013 Jun [cited 2015 May 13]. Available from: http:// www.ebudget.ca.gov/2013-14/Enacted/agencies.html 4. California Department of Health Care Services. Strategic Plan 20132017 [Internet]. 2013 [cited 2015 May 13]. Available from: http:// www.dhcs.ca.gov/Documents/DHCSStrategicPlan.pdf 5. National Institute for Health Care Management Foundation. The Concentration of Health Care Spending [Internet]. 2012 Jul [cited 2015 May 13]. Available from: http://www.nihcm.org/images/ stories/DataBrief3_Final.pdf 6. Alecxih L, Shen S, Chan I, Taylor D, Drabek J. Individuals Living in the Community with Chronic Conditions and Functional Limitations: A Closer Look [Internet]. Office of the Assistant Secretary for Planning and Evaluation; 2010 Jan [cited 2015 May 13]. Available from: http://aspe.hhs.gov/daltcp/reports/2010/ closerlook.htm 7. Lucia L, Jacobs K, Watson G, Dietz M, Roby DH. Medi-Cal Expansion under the Affordable Care Act: Significant Increase in Coverage with Minimal Cost to the State [Internet]. UCLA Center for Health Policy Research & UC Berkeley Labor Center; 2013 Jan [cited 2015 Jun 11]. Available from: https://escholarship.org/uc/ item/1pt6t9h3.pdf 8. California Office of Statewide Health Planning & Development. OSHPD Facility Listings [Internet]. 2014 [cited 2015 May 13]. Available from: http://www.oshpd.ca.gov/HID/Products/Listings. html#HHA 9. Buerhaus PI, Staiger DO, Auerbach DI. Implications of an Aging Registered Nurse Workforce. JAMA. 2000 Jun 14;283(22):2948–54. 10. Juraschek SP, Zhang X, Ranganathan V, Lin VW. United States Registered Nurse Workforce Report Card and Shortage Forecast. Am J Med Qual. 2012 May 1;27(3):241–9. 11. Spetz J, Given R. The Future Of The Nurse Shortage: Will Wage Increases Close The Gap? Health Aff (Millwood). 2003 Nov 1;22(6):199–206. Analysis of California Home Health Care: Decreasing Access for Medi-Cal Patients 7 © Copyright 2015 L E AV I T T PA R T N E R S I Le a v i t t P a r t n e r s . c o m I O f f i c e s i n S a l t L a k e C i t y, C h i c a g o , a n d Wa s h i n g t o n D. C . I 801-538-5082