MA Reform Analysis: Preliminary Findings

1. MA Reform Analysis: Preliminary Findings BRIEFING FOR HCBS PARTNERS PANEL SARA GALANTOWICZ MARCH 9, 2012

2. Review Analysis Areas • Demographics • Diagnosis • Assessment • Community-based LTSS • Utilization and cost • Common service combinations • Non-LTSS utilization (FFS, non-duals, <65)

3. 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)

4. 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

5. 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

6. MAIN THEMES

7. 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

8. DEMOGRAPHICS

9. 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.

10. 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

11. 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

12. Wages Among Working- Age Adults Wages were less common in other population groups, including those receiving mental health rehabilitation services. Most working-aged adults in the DD waiver had wages in 2010, as did many working adults on the BI waiver.

13. 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)

14. Medicare Eligibility • Approximately half or more of non-elderly adults in LTSS or rehabilitative programs were eligible for Medicare at some point in 2010

15. DIAGNOSIS

16. 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

17. 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

18. 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

19. 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

20. ASSESSMENT

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. UTILIZATION

29. Utilization of Community LTSS • Looked at number of individuals in each population with at least one claim during December 2010 By 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

30. LTSS Utilization: AC and EW • Commonly used services in December 2010 • Homemaker • Home-delivered meals • Monthly PERS • Specialized supplies and equipment • PCA

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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)

39. 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

40. 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

41. COST

42. 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

43. 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

44. VARIATIONS BY LEVEL OF NEED

45. 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

46. 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

47. 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

48. 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.

49. 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

50. 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