MA Reform Analysis: Preliminary FindingsBRIEFING FOR HCBS PARTNERS PANEL

SARA GALANTOWICZ

MARCH 9, 2012

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Review Analysis Areas• Demographics

• Diagnosis

• Assessment

• Community-based LTSS– Utilization and cost– Common service combinations

• Non-LTSS utilization (FFS, non-duals, <65)

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Analysis Populations• Community Alternatives for Disabled Individuals (CADI)

• Community Alternative Care (CAC)

• Brain Injury waiver (BI)

• Developmental Disabilities waiver (DD)

• Alternative Care (AC)

• Elderly Waiver (EW)

• Personal Care Attendant (PCA)

• Private Duty Nursing (PDN)

• Consumer Support Grant (CSG)

• Intensive Rehabilitative Treatment Services (IRTS)

• Adult Rehabilitative Mental Health Services (ARMHS)

• Children’s Therapeutic Services and Supports (CTSS)

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Stratification and Profiling• By age-group (where appropriate)

– <21– 21 – 64– 65+

• By level of need– Case mix (AC and EW)– Profile (DD)– Home care rating (PCA and PDN recipients with this data)

• For specific diagnosis groups– DD, MH, Autism Spectrum Disorders, BI

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Data Sources• MMIS extract, January 2012

– Claims– Demographics, including diagnosis– Medicare– Eligibility

• MAXIS extract, January 2012– Selected income variables– Person Master Index (PMI)

• Assessment extracts, January 2012– Long Term Care Consultation– DD– Home care

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MAIN THEMES

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Take Aways• Programs and service groups have distinct profiles

but populations overlap

• MH diagnoses are prevalent and pervasive

• Meaningful differences in utilization, diagnosis and need by age– Children are more likely to have ASD and DD diagnoses,

and – in some programs – greater assessed need and higher use and costs

• Elderly Waiver versus Alternative Care– EW population appears to be more impaired than AC

• Utilization generally tracks level of need

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DEMOGRAPHICS

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Mean Age• CAC and PDN recipients under age 21 have the

youngest average age.

• Children on the BI and DD waivers are more likely to be adolescents.

• The average age of elders is highest for the AC and EW programs.

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Other Demographics• Gender

– EW and AC disproportionately female – BI disproportionately male– Boys predominate among children receiving services– ARMHS slightly more female

• Race and ethnicity– Populations are primarily white and non-Hispanic

• Marital status– Percent of adults who are married and living with their spouse is

low, no more than a fifth of any group

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Current Living Arrangement• Only available for those with LTCC screening data

• The majority of AC participants live alone

• Approximately one-third of EW participants live in congregate settings

• CADI adults most often live alone or in a congregate setting

• CAC participants disproportionately live with others (spouse, parents, other family, friends)

• Congregate settings predominate for adults on the BI waiver

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Wages Among Working- Age Adults

Most working-aged adults in the DD waiver had wages in 2010, as did many working adults on the BI waiver.

Wages were less common in other population groups, including those receiving mental health rehabilitation services.

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Other Income• Countable income varies

– Highest among ARMHS 65+– Lowest among CAC<21

• Minnesota Supplemental Aid– Nearly half of older PCA recipients– Rare among children

• Group Residential Housing– Most prevalent among DD and BI participants, and those

receiving rehabilitative mental health (IRTS)

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Medicare Eligibility• Approximately half or more of non-elderly adults in

LTSS or rehabilitative programs were eligible for Medicare at some point in 2010

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DIAGNOSIS

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Across Populations• Examined Dx categories provided by DHS and the

CMS Chronic Condition Warehouse (CCW) groups– Combined 5 types of cancer into one indicator

• Mental health diagnoses are prevalent– Could reflect episodic or on-going needs

• Depression is the most common CCW chronic condition

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Variations by Age• Children look different than adults in waiver

programs and the PCA and PDN populations– Autism, developmental disabilities, epilepsy, cerebral

palsy more prevalent

• Children in mental health programs have disproportionate rates of autism relative to adults

• Older adults have higher rates of acquired cognitive disabilities

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Elderly Waiver vs. Alternative Care• Some diagnoses appear to be more prevalent

among EW participants, relative to AC participants– Acquired Cognitive Disability– Mental Health– Alzheimer's/Related or Senile Dementia– Chronic Obstructive Pulmonary Disease– Depression

• EW participants are more likely to have two or more chronic conditions

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Other Dx Findings• Similarities between children in the CADI, BI, PCA

and DD populations

• Higher/similar rates of autism, epilepsy, cerebral palsy and mental health diagnosis

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ASSESSMENT

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Assessment Data Sources• Long Term Care Consultation

– EW, AC, BI, CADI, CAC– About half of PCA and PDN recipients– ADLs, IADLs, behavior and cognition

• Developmental Disabilities Screening– DD waiver only– Behavior and functional variables

• Home Care Assessment– Data for approximately half of PDN and PCA recipients in

2010

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Assessment Analysis• Examined prevalence of need by assessment

areas

• Recoded to dichotomous variables– Needs any assistance with bathing, dressing,

housekeeping, etc.– Any level of impairment in vision, mobility, expressive

communication– Any challenging behavior

• Future analysis may want to look at the weighted averages of the ratings to compare level of need between programs

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LTCC Results• EW participants show higher level of impairment relative to

AC participants for several (but not all) assessment areas– Mental Health– Cognition– Dressing– Grooming– Medication management– Money management– Telephone calls

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LTCC Results: Continued• CAC

– High (near universal) levels of ADL, IADL and medical need

– Lower levels of mental health and behavioral health needs

• CADI– Mental health and behavioral health needs are more

common– Much lower levels of unstable health and need for

complex care or special treatment– ADL needs are less prevalent; IADLs more common, but

still not as high as CAC

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LTSS Results: Continued• Universal need for behavioral supports, in all age

groups

• Half or more of each age group assessed with a mental health diagnosis

• Increased need with age for select ADLs– Transferring, walking, toileting

• Little need for complex care or specialized treatment– Prevalence of unstable health is also low

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DD Screening Results• Children on the waiver show higher levels of need

relative to adults, especially for behavioral issues– Eating non-nutritive substances– Injurious to self– Physically aggressive– Runs away– Fine motor skills– Expressive communication– Program to address excessive behavior– Temper outburst

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Home Care Screening Results• Missing for many PCA and PDN recipients

• PCA screening results– Children show higher rates of cognitive impairment and

behavioral needs than adults– All show higher rates of ADL impairment

• PDN screening results– Cognitive impairment and behavioral needs less prevalent

than PCA population– Universal high needs for some level of ADL assistance

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UTILIZATION

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Utilization of Community LTSS• Looked at number of individuals in each population

with at least one claim during December 2010By service area and service unit

• Percent of users– Divided number of unique users by all those eligible in the

month

• Average units of services per user in December 2010– Summed total units across all claims for the month– Very small number of claims span months

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LTSS Utilization: AC and EW• Commonly used services in December 2010

– Homemaker– Home-delivered meals– Monthly PERS– Specialized supplies and equipment– PCA

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LTSS Utilization: AC and EW• Customized living (EW only)

– About one-third of all participants

• Home health skilled nursing– About one-third of AC participants

• Very limited use of PDN

• Limited use of ARMHS by EW recipients

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LTSS Utilization: CADI• Children: common services

– CDCS– PCA– CTSS skill development and training

• Non-elderly adults: common services– Homemaker– Customized living/Adult foster care– ARMHS psycho-social rehabilitation– Independent living skills consultation

• Older adults: common services– Customized living– PCA

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LTSS Utilization: CAC• Frequent use of PDN and PCA services by non-

elderly adults

• Children on CAC also frequently used PDN (LPN and RN), December 2010 – PCA less common– Many received CDCS

• Too few older adults to analyze

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LTSS: Brain Injury Waiver• Common services for children

– CDCS and PCA– Behavioral programming, Independent living skills– Respite

• Working age adults– Adult foster care and transportation– Independent living skills maintenance, 19 hours average– Prevocational services/structured day program

• Older adults– Small numbers, many in corporate adult foster care

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LTSS Utilization: Developmental Disabilities• Children

– CDCS is common– In-home family supports, respite– Limited PCA and CTSS

• Working-age adults– Most received day training and habilitation (full day), and

transportation– Supported living is common

• Older adults have similar utilization patterns to working age adults– Somewhat lower rate of DT&H– Higher rate of supported living

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LTSS Utilization: PCA services• Children

– Averaged more than 100 hours PCA services in December 2010

– About one in 10 received CTSS skill training

• Working-age adults– Higher monthly average hours– A smaller percent also received ARMHS: psycho-social

rehabilitation

• Older Adults– Similar utilization to children– Very limited use of MH services

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LTSS Utilization: PDN services• Children

– Approximately three-quarters received PD LPN– About one in five also received PCA services

• Working-age adults– PD RN services very common– More than half also received PCA services– A very small number also received ARMHS: psycho-social

rehabilitation

• Older Adults– PD RN also very common– PCA use less common than younger adults

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LTSS Utilization: MH Services• ARMHS

– Psychosocial rehabilitation1 is most common service– A small percentage of individuals received community

intervention

• IRTS– Non-elderly adults and children averaged similar units of

service in December 2010

• CTSS– Skill training and development most prevalent service – About one in ten of children received individual

psychotherapy (45-50 minute sessions)

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LTSS Service Correlations• Grouped like services in each program or service

population and ran correlation matrices

• The resulting data contained no surprises but were not very informative

• Need to explore different methodological approaches in the secondary analysis

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Utilization of non-LTSS• Preliminary analysis limited to:

– Fee-for-service– Under 65– Non Medicare (can’t identify other third-party payers)

• Categories of services– Inpatient (non-psychiatric and psychiatric)– Physician visits– Emergency department– Outpatient, non-ER

• Percent using service during the month– Units of service not meaningful

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COST

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LTSS FFS Costs: DSD waivers• CAC recipients had very high monthly costs overall

in December 2010

• Average monthly costs by age for common services were similar across age groups in CAC– Independent living skill and supply/equipment costs were

higher for children

• Brain injury waiver participants had high monthly foster care costs

• Children on the DD waiver averaged higher monthly supported living costs, relative to adults

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LTSS FFS Costs: PCA and PDN• No real differences by age group for all PCA users

in December 2010

• Private duty nursing costs are slightly lower for older adults

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VARIATIONS BY LEVEL OF NEED

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Analysis By Level of Need• Case mix

– Alternative Care and Elderly Waiver– 12 categories (A through L)

• Profile– Developmental Disabilities waiver– Four levels (1 through 4, 1 is highest)

• Home Care Rating– PCA and PDN recipients– Limited to those with a home care assessment– Looked only at those ratings still active in December 2010

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Case Mix: AC and EW • Lower case mix levels predominate for both EW and AC

participants

• About half are A or L

• Low-need AC participants are slightly more likely to be case mix A, relative to EW participants

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Case Mix Regroupings• For stratification, case mix categories were

grouped as follows– L: Very low (or no) ADLs– A: Low ADLs only– B and C: Low ADLs with behavior or special nursing– D: Medium ADLs– E and F: Medium ADLs with behavior or special nursing– G: High ADLs– H and I: High ADLs with behavior or high eating need– J and K: High ADLs with additional needs

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Living Arrangement by Case Mix: AC• Likelihood of living with others or in a congregate

setting increases with case mix.

• Relationship between congregate living and living with others less linear in EW relative to AC.– Individuals who also have behavioral needs are more

likely to live congregate settings than their peers with comparable ADL impairments.

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Utilization by Case Mix: AC• Use of PCA services increases appreciably with

case mix

• PCA RN supervision also increases

• Homemaker units per user increase with need

• Percent using PERS, home-delivered meals decrease with need

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Utilization by Case Mix: EW• Use of home-based services declines with

increasing need

• Homemaker services also less common

• Average number of homemaker hours higher

• Use of home delivered meals also decreases

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DD Service Utilization by Profile• Children under 21 are disproportionately Profiles 1

and 2– Increased use of CDCS at higher needs– Decreased use of in-home family support at high need

• Older adults, 65+– Fewer service types used overall– Use of supported living increases with need– Profile 1 less likely to receive DT&H

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DD Service Utilization by Profile: 21 - 64• Decreasing intensity of respite use with profile

• In-home family support more common at lower levels of need, but average units lower

• Supported living use related to need

• Little difference in use of Day Training & Habilitation by profile

• Costs for all age groups trend with need– Profile 1 has the highest average monthly cost for

supported living

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Home Care Rating• Only available for PCA and PDN recipients with a

home care assessment (approximately half)

• 12 codes were discontinued in 2010– Had lots of observations associated with them

• 20 codes were still active in December 2010

• Distribution across codes varies by age and program

• Distribution is too skewed to support sub-analysis

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DIAGNOSTIC GROUPS

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Diagnosis Groups• Individuals with a developmental disability

– Includes Down’s Syndrome and intellectual disability

• Individuals with autism spectrum disorders

• Individuals with a mental health diagnosis

• Individuals with a brain injury

• Defined using logic provided by DHS– Screening and claims Dx codes

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Individuals with Developmental Disabilities• Children with DD are less likely to be served on the

DD waiver than to be receiving services elsewhere

• Not all adults with DD are in the waiver– About one-quarter are being served somewhere

else

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Individuals with Autism Spectrum Disorders • Children with ASD served by multiple programs

– PCA– CTSS– DD waiver– CADI

• More than half of adults in DD waiver

• Very few elders

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Individuals with Mental Health Diagnoses• Children with MH diagnoses served primarily in

CTSS, PCA and DD waiver

• Many adults 21 to 64 are in the CADI waiver– About one-quarter in PCA and ARMHS

• Most elders are in EW

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Individuals with a Brain Injury• Most children in PCA or CTSS

– Only a small percentage are on the waiver

• More adults are on CADI than the BI waiver

• Most elders in EW

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NEXT STEPS• Validate Findings with DHS

• Make detailed data available

• Priorities for secondary analysis