HHS Logo: bird/facesU.S. Department of Health and Human Services

Analysis of the California In-Home Supportive Services (IHSS) Plus Waiver Demonstration Program

Robert Newcomer, Ph.D. and Taewoon Kang, Ph.D.

University of California, Center for Personal Assistance Services

July 2008

PDF Version: http://aspe.hhs.gov/daltcp/reports/2008/IHSSPlus.pdf (147 PDF pages)

This report was prepared under contract contract #HHS-100-03-0025 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Research Triangle Institute. Additional funds were provided by the National Institute for Disability and Rehabilitation Research under grant #H133B031102. For additional information, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact Pamela Doty, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Pamela.Doty@hhs.gov.

This report was prepared under subcontract 5-312-0208826 between RTI International and the University of California (Edith G. Walsh, Ph.D., project director). The opinions and findings expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.


TABLE OF CONTENTS

EXECUTIVE SUMMARY
BACKGROUND AND PURPOSE
RESEARCH QUESTIONS
METHODS
Data Sources
Sample
Recipient Characteristics Measures
Outcome Measures
County Characteristics
Analysis Plan
FINDINGS
Waiver and Non-Waiver Program Participation
Consistency in Provider Relationships
Who are the IHSS Recipients?
Health Care Expenditures and Use
CONCLUSIONS
IHSS Plus vs. the Residual Program Participation
Preferences in the Selection of Paid IHSS Providers and Outcomes
Implications for Medicaid and IHSS Expenditures
REFERENCES
NOTES
APPENDICES
APPENDIX A: Sample Selection Procedures
APPENDIX B: Recipient and Other Predictor Variables, Detailed Tables
APPENDIX C: Testing Factors Associated with Provider Selection
APPENDIX D: Hierarchical Condition Classification and Distribution for IHSS Recipients by Age and Provider Relationship
APPENDIX E: Physician, Outpatient Department, and Emergency Room Use and Expenditures
APPENDIX F: Home Care and Nursing Home Expenditures and Use
LIST OF TABLES
TABLE 1: Share of Cost, Advance Pay, Meals Allowance Participation by IHSS Recipient Age, Provider Relationship, and Program Entry Status
TABLE 2: Consistency of Provider Relationships
TABLE 3: Race/Ethnicity of New and Continuing IHSS Recipients, 2005
TABLE 4: IHSS Recipient Race/Ethnicity Distribution Among Provider Groups, 2005
TABLE 5a: Selected Household Characteristics of IHSS Recipients, Age 3-17
TABLE 5b: Selected Household Characteristics of IHSS Recipients, Age 18-64
TABLE 5c: Selected Household Characteristics of IHSS Recipients, Age 65+
TABLE 6: Physical and Cognitive Limitations Among New and Continuing IHSS Recipients, 2005
TABLE 7: Physical and Cognitive Limitations Among Meals Allowance and Advance Pay IHSS Waiver Recipients, 2005
TABLE 8: Average Hourly IHSS Wage Rate, by County, 2005
TABLE 9: Number of Chronic Health Conditions by Medicaid Recipient Age, Comparing New and Continuing IHSS Recipients, 2005
TABLE 10a: Summary of Health Conditions Among IHSS Recipients Age 3-17 by Provider Group, 2005
TABLE 10b: Summary of Health Conditions Among IHSS Recipients Age 18-64 by Provider Group, 2005
TABLE 10c: Summary of Health Conditions Among IHSS Recipients Age 65+ by Provider Group, 2005
TABLE 11: Mean Medicaid Expenditures for IHSS Recipients by Observation Months and Age, 2005
TABLE 12: Mean Medicaid Expenditures for IHSS Recipients by Age and Provider Type, 2005
TABLE 13: Adjusted Mean Monthly Medicaid Expenditures by IHSS Recipient Age, 2005
TABLE 14: Mean Monthly Medicaid Inpatient Expenditures by IHSS Recipient Age and Provider Type, 2005
TABLE 15: Unadjusted Probability of Medicaid-Paid “Any Cause” Hospital Days, 2005
TABLE 16: Adjusted “Any Cause” Medicaid-Paid Hospital Use by IHSS Recipient Age, 2005
TABLE 17: Unadjusted Probability of Medicaid-Paid Ambulatory Care Sensitive Condition-Related Hospital Stays, 2005
TABLE 18: Adjusted Ambulatory Care Sensitive Condition-Related Hospital Use by IHSS Recipient Age, 2005
TABLE 19: Unadjusted Probability of Medicaid-Paid Medical Care Use, 2005
TABLE 20: Unadjusted Probability of Medicaid-Paid Medical Care Use, Including Emergency Rooms, by IHSS Recipients, 2005
TABLE 21: Adjusted Probability of Medicaid-Paid Medical Care Use, Including Emergency Rooms, by IHSS Recipients, 2005
TABLE 22: Unadjusted Probability of Medicaid-Paid Emergency Room Visits by IHSS Recipients, 2005
TABLE 23: Adjusted Medicaid-Paid Emergency Room Visits by IHSS Recipients, 2005
TABLE 24: Mean Combined Medicaid-Paid Physician and Outpatient Department Expenditures by IHSS Recipients, 2005
TABLE 25: Adjusted Mean Monthly Medicaid-Paid Medical Care Expenditures by IHSS Recipients, 2005
TABLE 26: Mean Monthly Medicaid-Paid Home and Community-Based Care Expenditures by IHSS Recipients, 2005
TABLE 27: Adjusted Mean Monthly Medicaid-Paid Home and Community-Based Care Expenditures by IHSS Recipients, 2005
TABLE 28: Mean Monthly Medicaid-Paid Home Health Care Expenditures by IHSS Recipients, 2005
TABLE 29: Unadjusted Medicaid-Paid Nursing Home Use by IHSS Recipients, 2005
TABLE 30: Adjusted Medicaid-Paid Nursing Home Use by Adult IHSS Recipients, 2005
TABLE 31: Mean Monthly Medicaid-Paid Nursing Home Expenditures by IHSS Recipients, 2005

TABLE B-1: Race/Ethnicity of IHSS Recipients, 2005
TABLE B-2: Functional Limitations of IHSS Recipients, 2005
TABLE B-3: Vendor Claims Counts Fee for Service and Managed Care Recipients, 2005
TABLE B-4: County Per Capita Income, 2005

TABLE C-1: Predicting Provider Relationships, IHSS Recipients Age 3-17, 2005
TABLE C-2: Predicting Provider Relationships, IHSS Recipients Age 18-64, 2005
TABLE C-3: Predicting Provider Relationships, IHSS Recipients Age 65+, 2005

TABLE D-1: Hierarchical Condition Classification Distribution for IHSS Recipients Age 3-17 by Provider Relationship, 2005
TABLE D-2: Hierarchical Condition Classification Distribution for IHSS Recipients Age 18-64 by Provider Relationship, 2005
TABLE D-3: Hierarchical Condition Classification Distribution for IHSS Recipients Age 65+ by Provider Relationship, 2005
TABLE D-4: Ambulatory Care Sensitive Conditions by Provider Relationship, Recipients Age 3-17, 2005
TABLE D-5: Ambulatory Care Sensitive Conditions by Provider Relationship, Recipients Age 18+, 2005

TABLE E-1: Adjusted Medicaid-Paid Medical Care Use, Excluding Emergency Room Use, by IHSS Recipients, 2005
TABLE E-2: Mean Medicaid-Paid Physician Expenditures by IHSS Recipients, 2005
TABLE E-3: Mean Medicaid-Paid Outpatient Department Expenditures by IHSS Recipients, 2005

TABLE F-1: Unadjusted Probability of Medicaid-Paid Nursing Home Stays by IHSS Recipients, 2005
TABLE F-2: Adjusted Medicaid-Paid Nursing Home Use by Adult IHSS Recipients, 2005
TABLE F-3: Adjusted Mean Medicaid-Paid Monthly HCBS Waiver Expenditures by IHSS Recipients, 2005
TABLE F-4: Logarithm Transformed Mean Monthly Medicaid-Paid IHSS Expenditures by IHSS Recipients, 2005
TABLE F-5: Logarithm Transformed Mean Monthly Medicaid-Paid Nursing Home Expenditures by IHSS Recipients, 2005
Main Report: http://aspe.hhs.gov/daltcp/reports/2008/IHSSPlus.htm

Appendices: http://aspe.hhs.gov/daltcp/reports/2008/IHSSPlus2.htm


EXECUTIVE SUMMARY

In 2004, the Centers for Medicare and Medicaid Services (CMS) approved California’s In-Home Supportive Services (IHSS) Plus program under the Section 1115 demonstration authority of the Social Security Act. California refers to this program as the IHSS Plus Waiver. Full Medicaid (referred to as Medi-Cal in California) benefits and IHSS Plus benefits are available to all eligible IHSS Plus recipients. The IHSS program began in the early 1970s and was originally funded primarily with state and county funds and some federal Title XX (later renamed Social Services Block Grant) funds. Beginning in 1993, most IHSS services were financed through the Personal Care Services Program (PCSP) optional benefit and California benefited from 50% federal financial participation to cover these costs. However, prior to the granting of the IHSS Plus waiver, some services provided to a minority of IHSS recipients were not eligible for Medicaid federal matching payments. The cost of these “Residual Program” services had to be borne entirely by the state, with county cost sharing.

The effect of the IHSS Plus Waiver is to reduce the state and county share of costs for eligible Residual Program services to the same rates as in the state’s PCSP. About 26,000 persons were receiving all or a portion of their IHSS personal assistance in 2004 through elements of the Residual Program that were to be incorporated into the IHSS Plus Waiver. The components of the IHSS Plus Waiver (i.e., the services not previously eligible for federal matching payments) include:

As a condition of granting the IHSS Plus Waiver, CMS required an evaluation. All “1115” research and demonstration waivers are subject to a “budget neutrality” requirement; that is, Medicaid costs under the waiver cannot exceed estimated costs in the absence of the waiver. Thus, the primary purpose of the evaluation was to determine the impact of the waiver on Medicaid service use patterns and associated costs. However, the Office of the Assistant Secretary for Planning and Evaluation also wished to know about availability of and preferences for Spouse and Parent providers and whether IHSS recipients with Spouse or Parent providers (especially minor children with Parent providers) and differences in characteristics, such as medical diagnoses and severity of disability, among those receiving services from different provider types (e.g., Spouse or Parent, Other Relatives, and Non-Relatives).

Changes made to Medicaid law and policy through the Deficit Reduction Act of 2005 now make it possible California and other states to offer Medicaid coverage for personal care services provided by “legally responsible relatives” (i.e., spouses or parents/guardians of minor children) without an “1115” waiver. The results of the IHSS Plus evaluation indicate that allowing personal care services to be provided by such previously prohibited provider types is unlikely to increase -- and may even slightly decrease -- Medicaid costs.

The IHSS Plus Waiver was initiated in August 2004. This report documents IHSS Plus Waiver implementation and recipient Medicaid service use in calendar year 2005. Analyses compare recipients having a waiver-eligible provider (i.e., parents of children, spouses of adults) for any portion of 2005 with recipients in the regular IHSS program who received personal assistant services through Other Relatives and Non-Relative providers during the same period. Recipients are classified by these provider types on an “intention to treat” basis. Recipients changing between Spouse/Parent providers and non-waiver-eligible providers are considered throughout the analysis as being in the spouse/parent group. This is analogous to an experiment where an individual enrolls into the innovative care group and later changes into “usual” care, but for purposes of analysis, the recipient is included within the group to which they were originally assigned.

The following questions are examined:

Taken together, these descriptive questions assess four fundamental policy issues: whether there was a change in the number and attributes of spouses and parents of minors that are paid providers under the IHSS program; whether hiring legally responsible relatives as personal assistance providers seems to be a recipient/family preference; whether Spouse and/or Parent providers performed, as well as the use of other providers in enabling IHSS recipients to remain at home, safely; and whether the employment of family providers has been budget neutral for Medicaid in terms of health care use/expenditures. These policy issues are addressed in the conclusions section of this summary.

Approximately 407,000 persons received IHSS services in 2005. Of these approximately 25,700 recipients had as paid providers either parents of minor children, or spouses of adults. These recipients were classified as being in the IHSS Plus Waiver. Restaurant Meals voucher and Advance Pay recipients combined to include 1,600 additional Waiver recipients. About 60% of all IHSS recipients in 2005 were age 65 or more. Minor children (age 3-17) accounted for about 4% of recipients. The remaining one-third was recipients age 18-64. The distribution of recipients by IHSS Plus Waiver and PCSP providers varied by recipient age group. Parents predominate (70%) as providers among recipients age 3-17. Other Relatives and Non-Relatives are the predominant source (75%-95%) of providers for adult IHSS recipients. About 5% of non-aged adults and 2.5% of the aged IHSS recipients had IHSS-paid Spouse providers. There were only minor differences in these distributions comparing IHSS recipients continuing in the program from 2004 and those entering the program in 2005.

Females are the absolute majority of IHSS recipients, as well as the majority of those cared for by Other Relatives and Non-Relatives. Males predominate as IHSS recipients age 3-17, and they account for the majority of those cared for by an IHSS-paid Spouse. The IHSS program has a broad mix of racial/ethnic groups, with non-White groups accounting for the majority of recipients across all age groups. Hispanic and Asian recipients are more likely to use relatives (parents, spouses, or other relatives) as paid IHSS providers than are White or Black recipients.

The disability/chronic illness profile of each age group is different, as is the distribution of recipients among the types of paid providers used. Because of this most of the discussion is presented by recipient age group.

Summary of Findings

Racial/Ethnic and Household Characteristics of IHSS Recipients

Functional Limitations and Chronic Health Conditions

Continuity of Provider Relationships and Share of Cost

Authorized Hours of Service

Average Monthly Total Medicaid Expenditures

Medicaid-Reimbursed Hospital Expenditures and Use

Medicaid-Reimbursed Physician, Outpatient and Emergency Room Use

Home and Community-Based Services

Nursing Home Use

Conclusions

This section addresses four fundamental policy issues implicit in the IHSS Plus Waiver and its efforts to extend the use of spouses and parents as paid providers for personal care services.

IHSS Plus vs. the IHSS Residual Program Participation

The number of recipients cared for by Spouses and Parents of minors paid as IHSS providers remained relatively constant between 2004 (under the IHSS Residual Program) and 2005 (under the IHSS Plus Waiver); as did the total number of persons (about 1,600 recipients in 2005) participating in the Restaurant Meals voucher and Advance Pay waiver-eligible services. The new recipients, as a group, tended to be somewhat less impaired, to have lower health care expenditures, and to receive fewer IHSS authorized hours than the group of recipients who were in IHSS during the prior year, or longer. These attributes likely could be common to all cohorts of new recipients, and may not be unique to IHSS Plus Waiver program entrants. The race/ethnic and provider mix was somewhat different comparing the new and continuing program cohorts, showing a proportionate increase in Hispanic and Asian recipients.

Preferences in the Selection of Paid IHSS Providers and Outcomes

The selection of a Parent or Spouse as a paid provider, across all age groups, is partly a function of available family members, but differences in the proportion among race/ethnic groups “selecting” each of the various provider types suggests that cultural preferences may be an important selection factor. Wage and other possible influences on provider availability were not an in-depth focus of these analyses, but IHSS wage rates (which vary by county) did not have a consistent association with the selection of paid Parent or Spouse providers. To the contrary, higher wages were marginally associated with an increased use of Non-Relative providers, and Parents and Spouse providers were more likely when wages were low (and presumably low wages may make it more difficult to attract Non-Relative providers).

Recipients Age 3-17

Minor children in IHSS generally have at least one parent in the home. Consequently, for most of these children, the choice of Parent/Non-Parent provider was possible and the choice made by families was for a Parent provider (70% overall and 80% when a parent was present in the home). Hispanics had the highest proportion selecting Parent providers (81%) and the least selecting Non-Relative providers (9%). Blacks (60%) were the least likely to have paid Parent provider, and comparable to Whites in the proportion selecting Non-Relative providers (20%). The decision of families to seek IHSS versus other service options was outside the scope of this study.

There were few differences by provider type in the number of ADL/IADL and cognitive limitations among minor children IHSS recipients. However, proportionately more minor children with paid Parent providers were dependent on human assistance with breathing (this includes assistance with self-administration of oxygen, and the cleaning of this equipment), and had more chronic health conditions (including mental retardation, seizure disorders, and paralysis). These conditions have been shown to be associated with nursing home use in minor children (Fries, Wodchis, Blaum, et al., 2005), and may be indicative of the Parent provider’s willingness and/or greater ability to assume the demanding care responsibilities associated with these conditions. Contributing to this ability may be that parents are legally permitted to perform “skilled nursing” tasks that other providers, especially Non-Relatives, would not be permitted to perform. Investigation of the “cause” of this pattern is outside the scope of the current study.

Recipients Age 18-64

Spouse providers were rarely available as a choice to the non-aged adults participating in IHSS. Most IHSS recipients in this age group were either not married or their spouses were also IHSS recipients or otherwise not able physically/mentally to be paid caregivers. However, when spouses were available and able, the “preference” for them appears to be strong (90% among those with an available/able spouse). Parents were more readily available than spouses to non-elderly adults, and more recipients of this age group selected Parent paid providers. The availability of parents beyond those selected as paid providers is unknown in the IHSS data. There were discernable ethnic differences in the propensity to select Parent or Spouse providers. Hispanics were most likely to select Parent providers (26%), and the second most likely to select Spouse providers (9%). Asians were the most likely to select Spouse providers (11%), and second most likely to select Parent providers (18%). Blacks were the least likely to select either Spouse (2%) or Parent (10%) providers. More than half of the Blacks and Whites relied on Non-Relative providers. This contrasted with about a third among Hispanics and Asians.

In general, recipients with paid Parent or Spouse providers had more limitations in ADL and cognitive functioning, and a comparable number of chronic health conditions than recipients with other providers. However, those with paid Parent providers had higher rates of mental retardation/developmental disability, central nervous system injuries/disorders such as quadriplegia, paraplegia, other extensive paralysis or spinal cord disorders, and seizure disorder) -- all of which are conditions shown by Fries and associates (2005) to be associated with higher risk of nursing home placement.

Recipients Age 65 or More

Spouses were present among about 25% of this age group of IHSS recipients, but except for those paid as Spouse providers, the number able/available reduced to about 3%. When a recipient-provider was an Other Relative or a Non-Relative, almost half of the spouses present were also IHSS recipients. This pattern of both partners being on IHSS may be the consequence of the income and asset eligibility criteria used for Medicaid among IHSS recipients. Unlike the criteria used for nursing home recipients, IHSS recipients are not allowed to separate their couple assets when determining program Medicaid eligibility for one individual. Recipients with IHSS-paid Spouse providers tended to have more ADL, cognitive, and breathing assistance limitations, but there were no substantial differences in the number of health conditions. Race/ethnicity had a minor association with the presence of a paid Spouse provider (the percentages range from 1%-4%), but the more striking differences involved recipients with Other Relative and Non-Relative providers. More than half of the Asian (64%) and Hispanic (54%) recipients had an Other Relative as their paid provider, whereas more than half of the Whites (53%) and Blacks (56%) had Non-Relative providers.

Implications for Medicaid and IHSS Expenditures

For all recipient age groups, IHSS expenditures, adjusting impairment severity and service needs, are expected to be lower relative to those with Non-Relative providers when Parents, Spouses, and Other Relatives living in the household are paid IHSS providers. This cost difference arises because an IHSS algorithm adjusts the authorized time for housekeeping/meal preparation when there are relatives living in the household who might be expected to perform these tasks for themselves as well as for the recipient. This adjusted cost difference was observed for Parent providers to minor children, and for Spouse providers of adults. The cost differences for Parent provider (non-aged adults) and Other Relative providers were minor or non-significant. This could be because these providers were not living with the recipient or they may reflect limitations in the risk adjustment model.

Minor children with Parent providers, after adjusting for recipient functional and health conditions, have lower average monthly Medicaid expenditures than those with Non-Relative providers. These recipients also have lower adjusted use of IHSS and other home care service expenditures.

Adjusting for recipient characteristics, recipients age 18-64 with Spouse providers had lower average Medicaid monthly expenditures than those with Non-Relative providers. There were no statistically significant differences comparing recipients with Parent and Non-Relative providers. Among these adult IHSS recipients each of the paid relative provider groups had a significantly reduced likelihood of nursing home placement compared to those with Non-Relative providers. The Parent provider effect for those age18-64 appears greatest. Those with Spouse providers tended to have higher risk of “any cause” hospital stays (but not those associated with ambulatory sensitive conditions), higher risk of ER use, but lower IHSS and home care expenditures than recipients with Non-Relative providers. Recipients with Parent providers compared to those with Non-Relative providers had lower adjusted use of hospitals, ERs, and home care.

Average monthly Medicaid expenditures among recipients age 65 or more, adjusting for recipient characteristics, were lower for those with Spouse providers and Other Relative compared to Non-Relative providers. This tendency for lower risk among those with family providers was also present with respect to ambulatory sensitive hospital stays; and those with Other Relative providers compared to those with Non-Relative providers had reduced risk of ER use, lower monthly expenditures for IHSS and other home care. The protective effect of relatives as paid providers was also present, but this association was with the Other Relative provider category as compared to Non-Relative providers.

In short, these analyses found no financial disadvantage and some advantages to Medicaid from allowing spouses, parents (and other relatives) to be paid IHSS providers. This argues in favor of honoring the recipient’s and family’s preference for such providers. Whether the availability of spouse, parent, and other relatives can be expanded beyond its current proportion among all race/ethnic groups in IHSS is unknown, but changes in the race/ethnic mix of recipients evident in the new cohort of enrollees may affect this. The proportion of recipients who are Hispanic or Asian seems to be growing. These groups presently have the highest proportionate use of Spouse, Parent, and Other Relative providers.

These effects of selecting Parent, Spouse, and Other Relatives as paid providers are present within a program where the rate of Medicaid nursing home stays among IHSS recipients with Non-Relative providers seems to be low. This suggests that IHSS in general is doing a good job of enabling recipients to remain in the community regardless of the provider type selected. Not examined in this analysis were the factors (such as hospital stays, avoidable changes is health or functional status) associated with entry into and exit from IHSS; or the duration of participation in IHSS and the cost/use comparisons over time.


BACKGROUND AND PURPOSE

California’s In-Home Supportive Services (IHSS) program provides personal assistance services (PAS) for low-income people with physical, sensory, memory, or cognitive disabilities. Services available include assistance with activities of daily living (ADLs) (e.g., bathing, dressing, eating, bladder/bowel requirements) and instrumental activities of daily living (IADLs) (e.g., shopping, meal preparation, house cleaning). In calendar year 2005, IHSS served about 385,000 aged, blind, and disabled adults or children per month, or about 408,000 persons annually. IHSS is financed through a combination of federal, state, and county funds. To qualify for IHSS, an individual must be either over age 65, or disabled; and either eligible for (including current recipients) of Supplemental Security Income/State Supplementary Payment (SSI/SSP)1 or meeting all the eligibility criteria for SSI/SSP except for income limits (DSS, 2000).2 All components of IHSS operate as an entitlement program, meaning that IHSS is available to all persons who meet the income and benefit eligibility criteria. In principle there is no waiting list for admittance into the program and no cap on the overall growth of the program. The types and amount of services provided are determined by county social workers who conduct eligibility assessments and authorize services according to state and federal policies.

From 1973 to 1992, IHSS was supported entirely by state and county funds. Starting in 1993 the state converted its program to Medicaid (aka Medi-Cal)3 State Plan personal care services and began receiving Medicaid funds for the services meeting federal reimbursement criteria. State (33%) and county (17%) funds finance the 50% federal match of the program expenditures. Services in the former program not qualifying for Medicaid were retained within IHSS in what came to be known as the “Residual” Program. These services continued to be paid solely using state and county funds. Included in the Residual Program were those IHSS recipients receiving paid care from legally responsible relatives (i.e., parents of minor children or spouses), persons authorized to receive “Advance Pay,” and recipients who received Restaurant Meals vouchers in lieu of hours of attendant care for in-home meal preparation. Advance Pay enabled recipients to pay their consumer-hired PAS workers in full and on time, rather than having to submit timesheets through the county and on to the state for payment.

In 2004, California submitted a Social Security Act section 1115 waiver request to the Centers for Medicare and Medicaid Services (CMS). This is known as the IHSS Plus Waiver. It was approved and began implementation in August 2004. The Waiver enables federal financing participation for services brought into IHSS Plus from California’s IHSS Residual Program. The effect of this is to reduce the state and county share of costs in the State Plan program. About 26,000 persons were receiving all or a portion of their IHSS personal care assistance through those elements of the Residual Program in 2004 that were to be incorporated into the IHSS Plus Waiver. Not all Residual Program services are included in the Waiver. The following are the components of the IHSS Plus Waiver:

This report documents IHSS Plus Waiver implementation and recipient Medicaid service use in calendar year 2005. Analyses compare recipients in the IHSS Plus Waiver program with recipients in the IHSS State Plan (aka PCSP). Waiver recipients are minor children whose parent is a paid IHSS provider, or those whose spouse is a paid IHSS provider. Recipients are classified by these provider types on an “intention to treat” basis. Namely, recipients having either an IHSS Parent or Spouse provider for any portion of 2005 are considered to be in the Waiver for the calendar, even if they had another relative or a non-relative as a paid provider for a portion of the year. Likewise, those not having a paid Parent/Spouse provider during the calendar year are considered to by in the regular IHSS program or PCSP. This is analogous to an experiment where an individual enrolls into the innovative care group and later changes into “usual” care, but for purposes of analysis, the recipient is included within the group to which they were originally assigned.

Study outcomes include recipient state Medicaid expenditures and service use, such as hospital and emergency room (ER) use, and nursing home placement.4 This work supports the California’s evaluation of the IHSS Plus Waiver and complements other consumer-directed services research conducted under the aegis of the federal Office of Disability, Aging and Long-Term Care Policy (DALTCP). DALTCP is a unit of the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Human and Health Services. The analyses consider the consequences of allowing “legally responsible” family members (i.e., parents/legal guardians of minor children and spouses) of Medicaid beneficiaries to be paid as personal care attendants. Such payments are permitted when the financing mechanism is a 1915(c) home and community-based services (HCBS) waiver, and section 1915(j) provisions applicable to the State Plan.


RESEARCH QUESTIONS

Many state Medicaid program administrators are interested in having the flexibility within their Medicaid State Plan personal care programs to authorize paying family members to provide care to recipients. A number of factors contribute to this. For example, traditional providers, such as licensed home care agencies, are experiencing direct care worker shortages (Stone, 2000; GAO, 2001). Within both agency and independent provider situations, there are also concerns about absenteeism, frequent schedule changes, and high turnover of attendants (Harmuth & Dyson, 2002; Salsberg, Wing, Langelier, et al., 2002; Stone, 2001). Perhaps most germane is the recognition that for many severely disabled individuals, home care is not a cost-effective substitute for facility care unless paid home care is provided as a supplement to unpaid family care. The evidence on which program administrators and recipient advocates base their arguments in favor of permitting legally responsible family members to become paid workers is, other than in the Cash and Counseling Demonstration, largely anecdotal.5 Thus, further examination of these issues may be helpful for policy makers.

This analysis is interested in understanding who the IHSS Plus Waiver provisions serve, and in evaluating program and recipient outcomes. Outcomes are represented by IHSS, Medicaid service use and expenditures by IHSS recipients. The following questions are examined:6


METHODS

Because IHSS (including the IHSS Plus Waiver and Residual Program) is an ongoing statewide program, an experimental design in the implementation and evaluation of the waiver was not feasible. Instead, a quasi-experimental design was used. This design relies on statistical controls to adjust for measured differences between the waiver and non-waiver recipients. This work identifies the circumstances and characteristics associated with the types of providers (e.g., Parent, Spouse, Relative, Non-Relative) used by IHSS recipients, and compares service use/expenditures and other outcomes among provider types adjusting for recipient attributes.

Comparisons of waiver and non-waiver IHSS recipients are organized within age categories, controlling for other characteristics, such as disability severity. Children under age 18 who have Parents as paid caregivers are compared with children whose paid caregivers are Other Relatives or Non-Relatives. Similarly, adults aged 18-64 who have spouses as paid caregivers and elders aged 65 or older whose paid attendants are their spouses are compared with married and unmarried adults in the same age cohort with Non-Spouse providers. Advance Pay and Restaurant Meals vouchers have small recipient enrollments. Analyses of these options are descriptive.

Data Sources7

The project uses administrative data from three California departments: Health Care Services, Social Services, and Developmental Services. These were linked using a combination of each data set’s assigned identification number, a Medicaid eligibility number, and a unique project assigned identifier. To assure the confidentiality of the individual recipients the records available to the project included only the project’s unique identification number. Recipient and provider name, phone number, address, and Social Security number were all removed from these records:8

Sample

The study sample was selected from IHSS recipient listings in 2005. It included anyone in the program as of January 1 of that year, or who entered the IHSS program sometime during the calendar year. The inclusion rules assured that we obtained all waiver recipients in each of the target age categories as well as recipients in Advance Pay and Restaurant Meals vouchers. Analyses involving Medicaid claims-records (such as to include medical diagnoses or to compare health outcomes) reduced the sample to persons participating in Medicaid through fee for services. Those enrolled in Medicaid managed care programs were excluded as Medicaid claims are not submitted for managed care covered services. Appendix A provides an elaboration of the steps used to select, screen, and qualify IHSS recipients into the study sample.

Recipient Characteristics Measures

Recipient Characteristics measures were obtained largely from CMIPS. These files are compiled monthly and include recipient eligibility and assessment files, provider eligibility, and payment files. Recipient assessment data in CMIPS are generally updated every two years or after a substantial change in status. IHSS Plus Waiver recipients receive annual assessments. To obtain reasonable comparability between waiver and non-waiver recipients we averaged each recipient’s assessment measures drawn from each IHSS participation month in 2005. These items can vary from month to month with changes in status or periodic reassessments. If the individual was not a recipient in January, then the first assessment in 2005 was used as the starting assessment. Following is a description of the measures drawn from CMIPS for this analysis.10

Health Conditions and Diagnoses were compiled from Medicaid claims to supplement the CMIPS recipient characteristics.15 These records include up to two diagnoses, coded using the International Classification of Disease or ICD-9-CM (CDC, 2007), for each individual service claim. Analyses using claims and other administrative data have adopted a variety of approaches for identifying and adjusting for patient diagnoses. Important areas of conceptual consensus are that the diagnostic categories be: (a) clinically meaningful and related to well-specified disease or medical conditions; (b) the categories predict medical expenditures or other specified outcomes of interest (e.g., mortality); and (c) have sufficient prevalence to permit stable estimates. Two of the most prominent approaches are used in this analysis, one for recipient characteristics (described below), the other as a health care outcome indicator (described in the Outcome Measures section).

The CMS hierarchical condition categories (HCC) are used as health condition predictor variables in our analysis.16 HCC classification uses both inpatient and outpatient data. The HCC provides a standardized protocol for combining over 15,000 ICD-9 categories into 189 condition categories or CCs (Pope, Ellis, Ash, et al., 2000). Most CCs describe a broad set of similar diseases, generally organized into 23 body systems, but CCs 185-189 are assigned by beneficiary utilization of selected types of durable medical equipment. The CCs can be organized into hierarchies, designed so that a person is coded only for the most severe manifestation among the related diseases defining the CC. Within the same HCC a person is classified once. This avoids the problem of duplicative counting of related conditions. For unrelated diseases (i.e., diseases in other CCs), the number of HCC’s accumulate.

HCCs are assigned using any mention of the eligible diagnosis from any of five sources.17 Information or the frequency of mentions are not differentially weighted among these sources (Pope, et al., 2004):

Additional information required for the identification of a qualifying diagnosis is a date on the eligible record establishing that the diagnosis was made (or was present) during the relevant reporting period.18

Outcome Measures

Medicaid claims-records are also used to identify the occurrence of selected events (e.g., ER, hospital stay, nursing home placement) and to compile expenditures. These are used as the program evaluation’s primary outcome measures. As shown below, a number of specific services were identified in the claims data. A further refinement involves the convention of identifying hospital stays where an ambulatory care sensitive condition (ACSC) is a primary or secondary diagnosis. Hospitalizations with one of these diagnoses are said to be indicative of a potentially “avoidable” hospital stay, and indicative of the quality or performance of primary health care (Billings, Zeitel, Lukomnik, et al., 1993). While there is some overlap in ACSC classifications for children and adults, there are separate standardized algorithms for each of these age groups (AHRQ, 2007a, 2007b).19

Following is a brief description of the claims-based items compiled for 2005. Both expenditures and service use rates are adjusted by the number of IHSS eligibility days in the study year.20

County Characteristics

County characteristics are included in the analyses, primarily because of a concern about some variation in IHSS practice among the counties. The IHSS program is administered by county governments and IHSS program social workers in the counties are responsible for conducting program recipient assessments. Assessments are conducted at the time of program application and at least every two years for the regular IHSS recipients (annually for those in the IHSS Plus Waiver). They are also supposed to be conduct when there is a major change in status, there may be practice variation in this. Additionally, variation can occur in how social workers evaluate (or score) the level of the recipient’s limitations. A computer-based algorithm is applied against the assessments to determine the number of IHSS authorized hours. The algorithm adjusts hours based on household size and the availability of household members to provide domestic services. Other potential sources of program variation among counties include the mix of long-term care services available to those with personal care assistance needs, and the county’s discretion (within a cap set by the state) in setting the hourly rate paid to IHSS workers, and whether (and to whom) they offer health care benefits to IHSS workers. Counties share 17% of the cost of the IHSS program (34% of the pre-waiver Residual Program expenditures), and vary substantially with each other on wage rates. Within a county, the hourly rate paid for IHSS services by independent providers is relatively uniform. The combination of alternative service supply, IHSS wage rates, and per capital income (a proxy for cost of living), may influence the relative supply of IHSS workers. These factors may contribute to differences in whom recipients “select” as their IHSS provider.21

The following describes the measures compiled and used for county-level adjustments:

Analysis Plan

The analytic interest is in understanding who the IHSS Plus Waiver provisions serve, and in evaluating program and recipient outcomes. Analyses are stratified by three age subgroups of IHSS recipients. Within these age groups comparisons are among those with Parent, Spouse, Other Relatives, and Non-Relative as paid caregivers. Comparisons also include recipients in IHSS during 2004 who continued in the program in 2005 and those recipients newly enrolling in the IHSS in 2005. Outcomes are represented by IHSS and Medicaid health, nursing home, and community service use and expenditures. Utilization and expenditures are standardized by average monthly expenditures (based on the recipient’s exposure months in the calendar year). The Behavioral model (Aday & Anderson, 1974) was used to conceptually organize the selection of predictor and control measures.

Y = f(Predisposing: recipient age, gender, race/ethnicity; Enabling: household size, provider relationship, authorized IHSS hours; Need: cognitive status, ADL limitations; breathing limitations; chronic conditions; Service Supply: Per capita income.)

Where Y is separately

Total Medicaid Expenditures, hospital days/stays, nursing home days/stays, ER visits; IHSS expenditures; other Medi-Cal paid home care/personal care long-term care; “avoidable” hospital stays.


FINDINGS

The analysis seeks to both understand who the IHSS Plus Waiver provisions serve, and to compare program and recipient outcomes among recipient age groups and provider types. Outcomes are represented by Medicaid service use and expenditures by IHSS recipients. This section is organized by the research questions outlined in the Introduction.

Waiver and Non-Waiver Program Recipients

IHSS Plus Waiver recipients include individuals age 3-17 who have a parent as a paid IHSS provider, those age 18 and over who have a spouse as a paid provider, and recipients in either the Advance Pay or Restaurant Meals voucher programs. Table 1 shows the number of IHSS recipients by age, provider type (including Advance Pay and or Restaurant Meals voucher payments, and those having a Share of Cost requirement. Separate tabulations are shown for IHSS recipients who continued into 2005, and those recipients entering IHSS in 2005. Those age 65 and over account for almost 60% of IHSS recipients in 2005. Those age 3-17 in contrast account for just over 4%. The remaining one-third are non-aged adults. The type of provider varies substantially across IHSS recipient age groups. Parents, who are allowed to be paid providers for minor children under the IHSS Plus Waiver, account for more than 70% of the providers for those age 3-17. Parents, who can be paid providers under the regular IHSS program for adult-aged IHSS recipients, are much less prominent caregiver resources: for recipients age 18-64 (15%), and essentially non-existent among recipients age 65+.

Reliance on Other Relatives (i.e., adult children, siblings, and relatives other than spouses) increases exponentially (as measured across age cohorts) with the age of the recipient. The proportion grows from 13% among minor children to more than half of all paid providers for those age 65+. The proportion of Non-Relative providers is relatively similar to that of Other Relatives among minor children recipients, and about 45% of the providers among adult age IHSS recipients. Spouses are the third major group of providers. Spouses can be paid as providers under the IHSS Plus Waiver, but their proportion is relatively small among recipients age 18-64 and 65+, and too few for analysis among those under age 18.

These patterns are generally stable comparing the adult recipients continuing from 2004 with those joining the program in 2005. Among minor children, there was a modest decrease in Parent and a modest increase in Non-Relative providers among the new recipients in 2005.

Share of Cost is included in the table as an indicator of the extent to which the program may have widen or narrowed its income screening between 2004 and 2005, a period in which county and state costs for program entry were reduced by 50% for the “waiver” programs. Share of Cost means that the recipient is required to make cash payments to financially qualify for IHSS participation. Relatively few recipients, usually less than 3% were required to make such payments in 2005. The rate is lowest among minor children, and somewhat higher among those 65+; and for those with a spouse paid as an IHSS provider. Within this low range, slightly more of the adult recipients entering the program had a Share of Cost than was true of continuing recipients. Whether this is typical in comparisons of new versus continuing recipients, a reflection of fewer restrictions on entry, or tighter eligibility processes in 2005 is not known.

The remaining IHSS Plus Waiver programs are those of Advance Pay and Restaurant Meals voucher. Participation rates are low. Fewer than 1,700 recipients statewide (about 0.5%) used one or the other of these programs during 2005. Adults age 18-64 were the main users (with fewer than 500 recipients) of the Advance Pay program. Those age 65+ (about 600 recipients) accounted for 60% of Restaurant Meals voucher users. Participation was higher among continuing versus new recipients. Participation in these programs can vary from month to month, but among those participating, most recipients received these benefits for three-quarters of the year or more.

Consistency in Provider Relationships

Classification into Provider Type as used throughout the report was done using the principle of “intention to treat.” For example, ever having a spouse paid as an IHSS provider in 2005 defined one in this group. Similarly, ever having a Parent provider (but no Spouse provider), or an Other Relative (i.e., but no Spouse or Parent) for at least one month defined one in these respective groups. Non-relatives had no family members as providers during the year. In other words, a recipient was defined as being in the highest order of provider type they experienced in the year, with legally responsible providers ranking highest, descending in order through Other Relatives and Non-Relatives. Those consistently without a defined provider relationship were classified as having Non-Relative providers. The intention to treat approach is supported by the cumulative monthly consistency in provider relationships shown in Table 2. Fewer than 6% of the recipients changed provider types during the year. Children were the most consistent, non-aged adults the least consistent. Among specific provider types, Spouses as paid providers were the most likely to vary during the year. Non-relatives were somewhat comparable to Other Relative in the rate of inconsistency or change between provider types.

Who are the IHSS Recipients?

This section summarizes the racial/ethnicity, living arrangements, task abilities, and health conditions of IHSS recipients in 2005. This information descriptively addresses two questions:

Race/Ethnicity

As seen in Table 3, Whites are the most prevalent recipients overall. This prevalence is lower among those age 65 or more -- especially among those entering the program. Hispanics are the next most prevalent group of adults and the largest group of children recipients. The proportion of Hispanics increases almost 10% between continuing versus entering IHSS recipients in 2005. Blacks (about 17% overall, 11% among those age 65+) are the third most prevalent group. There are proportionately fewer Blacks among new recipients than among continuing recipients. The most striking changes are evident among Asians.22 These groups collectively account for about 10% of recipients. However, among those age 65+ Chinese (10%), Filipino (5%), and Vietnamese (4%) combine for almost 20% of all recipients; and as a group, Asian and Pacific Islanders are second to Whites in prevalence of participation. They are basically equal in number to Whites among new recipients in 2005. Within column comparisons show that race/ethnicity group distributions vary by age of recipient and the use of a family member versus a Non-Relative as their paid providers. These patterns are relatively stable when comparing continuing to new IHSS recipients.

Within row comparisons, Table 4, show the propensity of race/ethnicity groups to use one type of provider over another. For example among continuing recipients age 3-17 more than 80% of the Hispanic IHSS recipients have Parent provider. This contrasts with just over two-thirds of Whites and Asian recipients, and 60% of Black recipients having Parent providers. For the new IHSS recipients, the percentage having Parent providers drops about 10% among all race/ethnic groups. The differences narrow somewhat among other recipient age groups, but two patterns are evident. Hispanic and Asian recipients are more likely to have Spouse and/or Parent providers than the other groups. Asians are the most likely of all the groups to use Other Relative providers. In contrast, more than half of the White and Black recipients have Non-Relative providers. These patterns are consistent among recipients age 18-64 as well as those 65+. Comparing continuing with new recipients, there is a reduction across all age and race/ethnic groups in the percentage having Parent providers and an increase in the percentage with Other Relative providers.

The Advance Pay and Restaurant Meals voucher programs have a much different race/ethnic distribution than IHSS generally: Meals program, Whites (64.3%), Hispanic (13.7%), Black (10.2%), Asian/Other (11.8%); Advance Pay, Whites (68.5%), Hispanics (13.7%), Black (14.3%), Asian/Other (3.5%).

Household Size and Living Arrangements

Table 5a, Table 5b and Table 5c show the distribution by age and provider type for selected living arrangements. Gender of the recipient is also shown here because of its association with provider type. Except among children, females are the most common recipients: 59% among non-aged adults, and 69% among the aged. However, when considered by provider type, females are less likely to have Spouse or Parent providers than males, and much more likely to have Other Relatives and Non-Relatives as their provider. This pattern is present for both new and continuing IHSS recipients.

Gender differences widen by age group, however women age 18-64 are more likely to have Other Relatives than Non-Relative providers. This pattern persists but narrows among those over the age of 65. These shifts may be associated with changing racial/ethnic mix in the population evident among the age cohorts.

Household size also ranges widely, but somewhat in association with recipient age. More than two-thirds of the children live in households of four or more persons. This pattern holds across all family-related provider types and among both new and continuing recipients. Among recipients age 18-64, two and three person households predominate (about 50%) with those living with a spouse or parent, but substantial proportions of the remaining recipients live in households of more than three persons. Those having Other Relative and Non-Relative providers tend to be in smaller households, with almost 40% of those having Non-Relative providers living alone. Recipients age 65+ generally live in smaller households, with two person household predominating for those with a Spouse or Other Relative. Almost half of the recipients having Non-Relative providers live alone. For both adult age groups, the preceding patterns are consistent comparing new and continuing recipients.

Houses and apartments predominate as the type of residence, but as with household size, the distribution varies by age of recipient. Apartments gain prominence as recipients get older (and household sizes tend to be smaller). There are minor differences within age group and provider type between new and continuing recipients. One interesting pattern is that mobile homes and other forms of housing (e.g., residential hotels and boarding homes) combine for 5%-8% of all units seem to be increasing among new recipients in all age groups, but they continue to be used more frequently by those age 18-64. Whether this is a function of geography is not known.

Another living arrangement characteristic of interest is the status of spouses and parents as potential personal assistance providers. Among the adult recipients, the prevailing pattern (70%-80%) is for there to be no spouse present. However, even when there is a spouse present they are not always considered by the IHSS social worker as “available and/or able” to be PAS providers. Particularly notable is the proportion of spouses who are themselves IHSS recipients. Among those age 65+, 21%-23% of IHSS recipients have a spouse who is also a recipient. This is almost 80% (70% among new recipients) of the aged households with a spouse present. Among recipients age 18-64, the percentage of households with a spouse present (about 10% for those without spouse as paid providers) is lower than among the aged, but the number and proportion who are also IHSS recipients account for about one-third of the households with a spouse. These patterns may be influenced by Medicaid eligibility. Medicaid rules do not readily allow separation of a couple’s assets when they live together in community settings. The proportion of spouses who are IHSS recipients is somewhat lower among new recipients than those continuing. Except in situations where spouses are the paid providers, IHSS social workers have determined that fewer than 5% (much fewer among those age 65+) are able and available as PAS providers.

Within the CMIPS assessment, the role of parents is more completely enumerated and differentiated for minor children than for adult recipient groups. Among children, more than 80% of the parents available are said to be providing some or all IHSS-related services. Seventy percent are paid as IHSS providers. This pattern holds for both new and continuing groups. The information available for parents of adult IHSS recipients is much more limited. Except for those paid as IHSS providers (e.g., non-aged adults 16.6% are paid providers among continuing recipients, 9% among new recipients), the number of parents available is not well documented. The factors contributing to the decline in the proportion of parents as paid providers between continuing and new recipients are not readily apparent in the CMIPS data. However, some of this difference may be associated with an increase in the proportion of recipients with Other Relative providers. These provider choices are not affected by the incentives in the IHSS Plus Waiver to pay legally responsible relatives.

Functional and Other Limitations of IHSS Recipients

The IHSS program authorizes PAS based on consideration of four broad areas of assistance need. These include cognitive limitations (i.e., memory, orientation, judgment), assistance in ADLs (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual care; eating), IADLs (i.e., housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside), and problems in breathing. Each of these areas is evaluated and scored on a 1-5 (some on six) point scale.23

  1. Independent -- able to perform functions without human assistance though recipient may have difficulty; and completion of the task with or without a device poses no risk to safety of the recipient.

  2. Able to perform, but needs verbal assistance such as reminding, guidance, or encouragement.

  3. Can perform but needs some human help (e.g., direct physical assistance from the provider).

  4. Can perform with a lot of human assistance.

  5. Cannot perform function at all without human assistance.

  6. Paramedical services needed.

The number of limitations were compiled for each recipient during every month of their IHSS participation in 2005 and averaged over these participation months. An average of score of 3.0 or more indicates a task in which individuals were determined to have task assistance needs requiring at least direct physical assistance from a provider in 2005. Table 6, shows the group mean of the number of tasks that received an assessment score of three or more. The results are organized by age group and provider type; and by new and continuing IHSS recipients. ADL assistance dependence in three or more areas predominates for all recipient age groups, with at least one-third of recipients having task assistance needs in four or more areas. Children as a group, have somewhat more recipients with higher numbers of task assistance needs, averaging 3.6 such limitations compared to averages of two+ among the other age groups. IADL limitations are even more pervasive, with more than 95% of the aged and non-aged IHSS recipients needing direct physical assistance in four or more tasks. The proportion among children is somewhat lower, with two-thirds having this level of assistance needs. Cognitive limitations as represented in this compilation are also indicative of the level of impairment requiring human assistance. Levels of assistance that require only “reminding, guidance, and supervision-level” are not included in this scoring. Rates of cognitive limitations at this level of need are higher within the adult recipients than among children. Children on the other hand are more commonly characterized (about 15%) with severe breathing limitations (i.e., require human assistance to use self-administered oxygen or the cleaning of this equipment. This rate is about double those of the other age groups).24

The main interest in these analyses is whether there are differences among provider subgroups in each recipient age cohort. Among children, there are essentially no differences in the mean number of cognitive, ADL, or IADL limitations. This is generally true, as well, comparing new versus continuing recipients. The most notable difference is in the percentage of recipients with severe breathing limitations. This rate is lower among the entering recipients than among those continuing, but it is relatively consistent among the provider subgroups. Parents continue to be the predominant providers for this condition, but the percentage of recipients needing this level of care is more uniformly distributed among the other providers. Non-Relative providers proportionately serve more such recipients among the new recipients than either of the other provider groups. A striking difference is in the number of authorized IHSS service hours. On average the continuing recipients are receiving about 40 more hours per month than new recipients. This difference is constant among provider types. Some of this seeming disparity may be an artifact of the CMIPS data system, where authorized hours are adjusted with changes in functional conditions and living arrangements, but where revisions in the recorded assessment data may lag by a number of months. In other words, continuing recipients may be somewhat more functional limitations than new recipients, with this difference being reflected in authorized hours rather than in the number of functional limitations recorded in the data set.

Recipients age 18-64 and those 65+ have several patterns in common. First, Spouse providers tend to have proportionately more impaired recipients than the other provider types, and to be comparable to each other going across the age groups. These patterns are reflected in the mean number of cognitive and ADL limitations, and in the percentage of recipients with severe breathing limitations. Other Relatives and non-relatives, tend to have proportionately similar levels of impairment in their recipients across these aged and non-aged adult groups, and comparing new with continuing recipients. Parents (represented only among non-aged adults) tend to have recipients with cognitive and ADL impairment levels somewhat in between those of recipients with Spouse and the other providers. Paradoxically, Parent providers receive the highest average number of authorized IHSS service hours. Perhaps this occurs because of higher acuity needs of recipients known to the social workers that are not well represented in the CMIPS measures. Spouses receive hours comparable to those of non-relatives. Other Relatives have fewer authorized hours, with some of this difference possibly reflective of the household size and the downward adjustments made with IHSS hours when there are parents, spouses, or other non-disabled individuals residing in the household who are able to do routine household chores. Finally, the pattern of systematic differences in authorized hours comparing continuing with new recipients is also present among adult recipients. This difference tends to be in the range of 20-30 hours, rather than 40 hours observed with minor children recipients.

Table 7 shows the distribution of physical and cognitive limitations by age for recipients in the Restaurant Meals voucher and Advance Pay programs. Those receiving Restaurant Meals vouchers generally have at least three limitations in IADL. At the same time fewer than one-third have three or more ADL limitations for which human assistance is necessary. About half have one or fewer such limitations. Very few recipients have cognitive or breathing problems. Similar patterns hold for IADL, cognition, and breathing limitations among recipients in Advance Pay. This group, however, is predominated by high levels of ADL limitations. More than 90% of recipients in each group have at least four ADLs for which human assistance is necessary. The difference in frailty mix between these two programs is consistent with their target recipients.

County Characteristics

Two measures are used to represent county differences in the analysis. One of these is the modal hourly wage rate paid for IHSS services. For purposes of the analysis we have grouped these into categories into wage categories that also happen to be broadly indicative of geographic regions. The groupings are less than $7.50/hour (17.8% of IHSS recipients statewide), $7.50 (44.5%), $8-$8.50 (15.6%), $9.50-$9.75 (14.4%), $10-$10.50 (7.7%). The distribution of the wage rates is shown in Table 8. Los Angeles and Fresno Counties, which have the same modal wage rate, are combined as the reference category, allowing the vector of dummy coded price ranges to be interpreted as both a comparison to these counties and the statewide median wage rate (the average is about $8.06). The second county measure is personal income per 1,000 county population. This has been represented in the analysis in units per $1,000.25

Health Conditions Among IHSS Recipients

Table 9 shows the number of HCC’s, counted after aggregation into body systems.26 The prevalence distribution is relatively consistent within IHSS recipient age groups comparing new and continuing IHSS recipients. Those age 18-64 tend to have more conditions than the other age groups. Because of the relative prevalence consistency within age group we have combined the IHSS recipient entry cohorts in the HCC prevalence descriptive tables presented later.

The IHSS recipients included in the analyses of health conditions are limited to those enrolled in fee for service Medicaid for all their Medicaid participation months in 2005. This decision, resulting in the exclusion of those enrolled in Medicaid managed care for any portion of 2005 (n=56,152), was necessitated by the under reporting of Medicaid encounters by managed care members.27 Managed care enrollees represented about 13.9% of the IHSS recipients in 2005. The managed care members excluded varied by recipient age: minor children 28.8%, non-aged adults 17.8%, aged 10.4%.28

IHSS Recipients Age 3-17. Parents predominate as IHSS providers for minor children recipients. As shown in Table 10a, there is also a tendency for parents to be providers of recipients with more health problems. Recipients with paid parents as providers have an average of 3.62 chronic conditions. This compares to an average of 2.98 among “Other Relative” providers, and 2.58 among “Non-Relative” providers. Prevalence differences are present across most of the specific HCC categories. Ear, nose, throat, and mouth disorders were the most pervasive, affecting about 45% of all recipients. Central nervous system disorders (including seizures and convulsions, and spinal cord injuries) were the next most prevalent, affecting about 30% of the recipients. Musculoskeletal and connective tissues; lung problems (including asthma and other conditions); gastrointestinal system; cerebrovascular disease (particularly cerebral palsy and other paralytic syndromes), and Mental retardation/developmental disabilities each affected between 15%-25% of this age group. Neoplasms; cardio-vascular; kidney/other genitourinary system; mental health disorders; and endocrine, nutritional and metabolic disorders each affect close to 10% of recipients. Infections and parasitic disease; fractures, other injuries and poisoning, and dermatological disorders (e.g., decubitus ulcers, other local skin infections) affected about 10%-15% of the recipients. The general pattern was that the prevalence of conditions tended to be higher among Parent providers and lowest among Non-Relative providers.

IHSS Recipients Age 18-64. Non-relatives predominate as the IHSS providers for non-aged adults with disabilities, followed in descending order by Other Relatives, Parents. Spouses, eligible to be paid under the IHSS Plus Waiver, are the smallest provider group. As shown in Table 10b, the prevalence of HCC conditions tends to be lowest among recipients with Parent providers (average 2.75 conditions), and relatively similar among those with the other types of providers (averages of 4.49, 4.55, and 4.39 among those with Spouse, Other Relative, and Non-Relative providers respectively).

Musculoskeletal and connective tissue disorders are the most prevalent of the HCC’s among both Non-Relatives, Other Relative providers, and Spouses. Various cardiovascular; endocrine, nutritional and metabolic; gastrointestinal; and pulmonary disorders affect 25%-40% recipients with Non-Parent providers. Recipients with Parent providers have about half the prevalence of these conditions. Genitourinary systems disorders; ear, nose, and throat; and cerebral and other vascular problems each affected about 15%-20% of the recipients with Non-Parent providers. Most conditions follow similar patterns, with Parent providers having notably lower problem prevalence. Only among recipients with mental retardation/developmental disability, and central nervous system injuries/disorders (e.g., quadriplegia, paraplegia, other extensive paralysis or spinal cord disorders, and seizure disorders) do parents care for a higher problem prevalence than the other provider groups. Spouse providers tend to have prevalence rates a few percentage points below those of other relatives and non-relatives. These latter provider groups have relatively similar condition prevalence among most conditions. Acute conditions such as infections, fractures and injuries tend to be relatively similar among recipients. Treatment complications affect about 50%-60% of the recipients in each provider group.

IHSS Recipients Age 65 or More. Relatives (excluding spouses and parents) are IHSS providers for just over half of the aged recipients, closely followed by non-relatives. Spouses account for just over 2%. Recipients with paid Spouse providers have an average of 3.18 chronic conditions as measured from Medicaid claims. This compares to an average of 2.82 conditions among those with Other Relative providers and 3.03 among those with Non-Relative providers. Cardiovascular system disorders (e.g., coronary atherosclerosis and congestive heart failure) are the most prevalent group of conditions across all provider types in this recipient age group see Table 10c. Proportionate differences in disease prevalence between provider groups are generally low (<2%). When differences exist, prevalence tends to be slightly higher among those with Spouse providers than the others. Musculoskeletal and connective tissue disorders, are the one exception: non-relatives care for proportionately more recipients (35%) with this disease burden. Prevalence among those with Other Relatives (32%) and Spouse providers (30%) was marginally lower. Recipients with Spouse providers have condition prevalence rates 3%-5% higher than those among other provider groups in the other high prevalence condition groups: endocrine, nutritional and metabolic disorders; pulmonary; cerebral and other vascular system; renal and other genitourinary system disorders; and treatment complications. Infectious disease, and injuries, all have similar prevalence among the three provider groups.

Implications for Modeling Recipient Outcomes

The preceding sections presented information about the living arrangements, functional limitations, and chronic health conditions of IHSS recipients and how these were distributed by age and provider type. Comparisons were also made between those entering the IHSS program in 2005 versus those continuing from 2004. Several conclusions can be drawn from these analyses relative to the recipient and other attributes that need to be adjusted in comparing recipient outcomes by provider type.29 First, it is apparent that the factors associated with Parent, Spouse, and others providers are, in part, a function of the family and other resources available. For example, among those without parents, spouses or other relatives, the options reduce to using non-relatives. This influence is most apparent among minor children, where the vast majority of those with available parents have paid Parent providers; and among the few adults with spouses. Additionally, there are preferences and other influences that are not measured by CMIPS assessments. Typically, a two-stage model would be used to estimate the “predicted” provider type in the first stage, and estimate the predicted outcomes associated with the provider type in the second stage. Ideally such a process adjusts for “selection” effects on provider choice, with the outcome of these models compared against the observed outcomes of waiver vs. non-waiver recipients. However, the absence of complete information in CMIPS about the availability of relatives (including legally responsible relatives) and recipient-provider preferences severely limits the applicability of such two-stage models here. Given the data limitations constraining the estimation of such models, the outcomes analysis reported in the subsequent sections uses observed provider type as one of the predictors of service use and expenditure outcomes. Provider type will be based on the notion of “intention to treat” described in the Methods section. If a legally responsible relative is ever used in the study year, this provider type is the presumed preference regardless of changes in provider type made during the year. Similar assumptions are made contrasting other relatives with non-relatives.

A third conclusion is suggested by the differences among race/ethnicity groups in their association with provider type. These differences are present across all age groups after adjustments for physical and cognitive limitations, household size, and IHSS wage effects. This suggests the appropriateness of using race/ethnicity as a proxy for cultural preferences or predispositions to assume caregiving roles.

Per capita income, one of several county-level measures tested, represents the cost of living in the counties, and has a significant, if modest association with provider type. This measure is retained in the outcome models.

Finally, the differences among some of the provider types in the association with managed care membership may have an effect on comparisons in analyses of Medicaid expenditures and health care events. Medicaid claims-records are generally not available for those in managed care because monthly payments are made to the health plan based on member characteristics, not on reimbursement for the use of specific services. Groups with a greater propensity toward managed care participation may have fewer chronic health conditions and lower Medicaid expenditures, but this cannot be determined with the data available. Analyses within age group, adjusting for other risk factors will help minimize this differential reporting, but it cannot fully eliminate any systematic difference if healthier (or sicker) persons enroll in managed care compared to those in fee for service. For this reason, the analyses when using health conditions as a control variable exclude recipients who are in Medicaid managed care. Payment for community care services, including IHSS, is not included in the managed care capitation payments. Consequently, analysis of this outcome is done both including adjustments for medical conditions (obtained from claims data and limited to those in fee for service), and all IHSS recipients without adjustment for medical conditions.

Health Care Expenditures and Use

This section shifts the analysis from a description of IHSS program recipients to the consideration of the quality of care and other outcomes given the “choice” of provider types. The data sources used for this comparison are the IHSS assessments and Medicaid claims data. In combination these data sources enable us to investigate the following question:

Adjusting for disability and other attributes, what are the Medicaid program expenditures and health care events incurred by IHSS Plus Waiver program and non-waiver recipients? Are there differences by age group?

Included in these comparisons are all IHSS services, as well as personal care from Medicaid HCBS waiver programs. These services are available to eligible Medicaid recipients, and are unaffected by whether the recipient is enrolled in Medicaid managed care. Additionally, we examine Medicaid-reimbursed hospital, ER, nursing home, home health, and medical provider claims. These services generally do not generate a claims-record for persons in Medicaid managed care, so the sample size for analyses involving these services reduce to beneficiaries receiving health care reimbursed through fee for service claims. For hospital, nursing home, and ER use, the compilation of claims starts with encounters occurring within or subsequent to the first month of IHSS eligibility in 2005. Expenditures and utilization for all remaining months in 2005 are compiled as the basis for calculating mean monthly expenditures for these services. The compilation of chronic health conditions from Medicaid claims, includes all claims in 2005, regardless of months of IHSS participation. This was done under the assumption that chronic conditions are pre-existing in 2005, and with recognition that the inclusion of all claims reduced some of the under reporting of conditions that occurs if only prior year claims are used in identifying diagnoses.

Both unadjusted descriptive and multivariate analyses of expenditures and health care events are reported. The measures of primary interest in the multivariate models are the coefficients for IHSS provider types. All models adjust for recipient gender, race/ethnicity; household size; cognitive, ADL, and breathing limitations; the number of chronic health conditions. Household size and recipient limitations are the basis of IHSS benefit eligibility. Total Authorized IHSS Hours are also included as potentially reflecting changes in functional limitations or living arrangement that may not be reflected on the baseline IHSS assessments. Authorized hours are reduced as the availability of informal care increases, so that higher hours (up to the cap of 283 hours) corresponds to an increasing reliance on paid IHSS assistance. Complementing the recipient characteristics is one county indicator: per capita income, an adjustment for prevailing cost of living. The models also include a dummy variable representing whether the individual was a new IHSS recipient in 2005 or continuing from 2004. This tests whether new recipients had different expenses and utilization than continuing recipients, after adjusting for recipient characteristics.30

Monthly Medicaid Expenditures

Across all age groups participating in IHSS, mean unadjusted Medicaid expenditures (excluding pharmacy payments) range from $1,400 to $1,700 per IHSS participation month. This is a cost inclusive of Medicaid-reimbursed personal assistance-related expenses, which averaged about $825 in 2005. The highest average total expenditures are among those ages 18-64, the lowest among those ages 65 or more. Lower expenditures among this latter group are explained, in part, by more of these recipients having access to Medicare -- their primary payer for hospital, physician, and other health care use.

As shown in Table 11, mean unadjusted monthly expenditures for all age groups vary substantially by the number of an IHSS recipient’s exposure months in 2005. Expenditures shown in this table are accumulated for every month after IHSS eligibility in 2005. For recipients continuing from 2004, all would be eligible in January 2005. The new recipients could have entered in any month starting with January. Approximately 4,000 recipients entered the program each month, with an approximately equal number leaving. Persons with fewer than three months in the year tend to have average monthly expenditures that are about three times higher than the average monthly expenditures for those in the IHSS program for a full year. The causes for the difference across exposure months are beyond the scope of this analysis, but they likely are associated with changes in health status immediately preceding program entry or that contribute to leaving the program.

Provider Type and Medicaid Expenditures. Table 12 arrays the mean expenditures data by age and IHSS provider groups. These unadjusted results show a tendency for recipients of Spouse providers to have lower mean monthly expenditures than those receiving care from other providers. There are relatively few unadjusted differences in mean expenditures comparing recipients of Other Relatives and Non-Relatives providers. Expenditures among new recipients tend to be lower than for those of continuing IHSS recipients.

A set of ordinary least squares regression models, Table 13, were used to provide a comparison of adjusted provider effects on expenditures. Each column presents a model for a particular IHSS recipient age group. The comparisons of interest in the analysis are those of provider type. The reference category for the provider types is Non-Relatives. The coefficients, multiplied by 1,000, convert the effect into the metric of dollar units and facilitate interpretation of the differences among the recipient-provider groups in terms of average monthly dollar expenditures.31 While the models do not fit the data particularly well, the purpose is to test the adjusted predicted expenditure differences between providers. The individual covariates for these comparisons tend to have high levels of statistical significance, even for small difference in the predicted mean monthly expenditures. This is due, in part, to the large sample size.32

Among these age 3-17, Parent providers tend to have about $920 lower adjusted Medicaid expenditures than Non-Relatives. Other Relatives seem to have slightly lower adjusted expenditures than non-relatives, but this difference is not statistically or practically significant. Recipients age 18-64 with Spouse IHSS providers have predicted mean monthly Medicaid expenditures (holding everything else constant) about $1,000 lower than do those with Non-Relative providers. This estimate is somewhat larger than the difference in the unadjusted comparisons. Recipients with Other Relative providers have mean expenditures about $170 lower than Non-Relatives. There was no statistically significant difference between those with Parent providers and Non-Relatives. Among recipients age 65 or more, those with Non-Relative providers have predicted average monthly month expenditures that are higher than those for either recipients with Spouse providers ($780), or Other Relatives ($110).

Expenditures comparing new with continuing IHSS recipients showed only minor differences in adjusted mean monthly expenditures: non-significant among children recipients, slightly higher among those 18-64, slightly lower among the aged.

Medicaid Hospital Expenditures and Use

This section begins an examination of some of the component services that contribute to the total Medicaid expenditures. We begin with hospital use, often a contributor to high expenditures. Hospital use may also serve as an indicator for problems in medical care and quality of home care. Table 14 shows unadjusted mean expenditures for hospital care (among those having a hospital stay) organized by age and provider group; and by continuing and recipients enrolling in IHSS during 2005. The highest mean monthly hospital expenditures (incurred after IHSS enrollment) are among those ages 3-17. For all age groups, but especially for those age 65 or more, it is important to recognize that these figures may be biased downward relative to total “all-payer” expenditures as the Medicaid results do not include reimbursements from other payers (e.g., private insurance, Medicare, Veterans Administration (VA), out of pocket).33 Among all recipients age groups the unadjusted average monthly Medicaid hospital expenditures generally show the IHSS Plus Waiver recipients (i.e., spouses of adults, parents of minor children) to have either the lowest mean expenditures or to have expenditures approaching the lowest group. IHSS recipients entering the program in 2005 tend to have higher mean monthly expenditures than recipients continuing from 2004. This may be, in part, a function of the fewer IHSS participation days among new recipient. As seen later, new recipients have lower incidences of hospital stays. Further as shown in the “Mean Total $” rows in Table 14, there is little difference within age group in the average of hospital expenditures incurred over the observed months by hospital users in each recipient-provider group. In general, these expenses are indicative of short stays, but as evident from the standard deviations, some recipients accumulated ten’s of thousands of dollars in hospital costs.

Any Cause Hospital Stays. The next several tables refine the hospital expenditure analyses to assess whether there are differences between provider groups in the likelihood of having hospital stays. Hospital use may be indicative of differences in recipient case mix and/or of the quality of IHSS and the condition management assistance received. Table 15 shows the unadjusted probability of an “any cause” hospital stay in 2005. These incidents occurred after IHSS enrollment (or in the same month as IHSS enrollment). The unadjusted likelihood of a hospital stay is relatively comparable among the adult recipients, with rates about double those for minor children. IHSS recipients across the provider types generally have similar rates, although recipients of Spouse providers are more likely to have stays.

Table 16 extends the analysis of hospital use by adjusting for recipient case mix differences. These logistic regression models compare the difference in odds (expressed as an odds ratio) of an “any cause” hospital stay during 2005 between each of the provider groups. These comparisons are based on consideration of the main effect of provider type. (Interactions between provider type and the number of health conditions, as a group, did not statistically improve the model and were not retained in the analysis.) With the modeled adjustments the differences between recipients having IHSS Plus Waiver-permitted providers (i.e., parent and spouse respectively) and those with Non-Relative providers generally become statistically non-significant. This finding holds among all but the non-aged adults who have Spouse providers. These recipients are about 15% more likely to have hospital stays than those with non-relatives. Recipient outcome comparisons between those with Non-Relative providers and Parents (of those 18-64), as with the unadjusted results, show substantially lower odds of a hospital stay for those with Parent providers. This difference is reduced to about 25%, rather than 50% in the unadjusted results. Non-aged adults with Other Relatives as providers show about a 10% lower risk of hospital stays than those with Non-Relatives -- an advantage not evident in the unadjusted results. Such comparisons are non-significant or very minor among the aged and children recipients.

Another finding of interest in this table is that adults in non-White race/ethnic groups tend to have higher odds of hospital stays than Whites. This effect is examined further in subsequent analyses of access to physician services. Also of note is the lower likelihood of hospital use among new IHSS recipients than continuing recipients. This is consistent with the likelihood that a hospital stay in a year increases over time for IHSS recipients if the become more disabled.

Ambulatory Care Sensitive Hospital Admissions. Hospital stays for which the primary admission diagnosis is an ACSC are thought to be indicative of the quality or performance of primary health care (AHRQ, 2007a, 2007b). Better care would be suggested by low rates of these potentially “avoidable” hospital stays. The unadjusted prevalence of ACSC hospital admissions in 2005 is shown in Table 17. Comparing unadjusted “any cause” hospital stays (i.e., Table 15) with the unadjusted ACSC stays shows almost an eight-fold decrease among children and more than 3x decrease among adults using the more restricted ACSC criteria. Differences between provider groups narrow substantially when only ACSC outcomes are considered. Recipients with Spouse IHSS providers continue to have the highest unadjusted hospitalization rate.

Table 18 shows the predicted odds of ACSC hospitalization adjusting for recipient characteristics. Holding other factors constant, there were no statistically significant differences comparing the recipient outcomes of provider groups among children. This finding is consistent with the “any cause” hospital stay comparisons. Among recipients age 18-64, a similar finding also occurs when comparing Spouse and Other Relative providers to Non-Relatives. On the other hand, recipients in this age group with Parent providers have lower adjusted odds for an ACSC hospital stay than Non-Relatives. Finally, among recipients age 65 or more, there is significant difference in the spouse/non-relative comparison. Recipients of Spouse providers have reduced risk of an ACSC hospital stay. There are no statistically significant differences comparing those with Other Relatives to those with Non-Relative providers. (Interaction tests involving provider type with the number of health conditions were non-significant and are not included in the final models.)

Consistent with the “any cause” hospital stays, non-White adult age recipients tend to have increased risk for ACSC admissions. Whether this is a function of differences in access to care, or problems in culturally appropriate care is not known. Among minors, new IHSS recipients have no differences from continuing recipient in ACSC admission. For adults, new recipients have about half the risk of ACSC admission than recipients continuing from 2004.

Medicaid Physician and Outpatient Department Use

Differences in hospital use described in the preceding section are more evident comparing White to non-White IHSS recipients than in comparisons among recipient-provider groups. In this section, we examine the use of physician and outpatient departments as a potential influence on hospital use. Access to medical care is necessary to assure appropriate health care and condition management, but measurement of the levels of use are confounded by the inter-relationship between health status and need for care. For example, individuals with declining health status or with acute problems are more likely to seek care than those not experiencing such problems. Unraveling the cause-effect pattern is beyond the scope of this analysis, but statistics have been compiled to first descriptively compare any use between recipients by age and provider group and among race/ethnic groups, and then to compare use adjusting for health status and other characteristics.

Table 19 shows an important contrast among IHSS recipients. About 20% do not have any claims with vendor codes for either physician services (including MDs, nurse practitioners, medical groups, surgi-centers, and rural clinics), or outpatient department (including hospital-based and other organized outpatient departments) use in 2005. These rates differ somewhat among IHSS recipient age groups, and between provider types. Table 20 recalculates access to medical care, to add any Medicaid claims for ER use. These combined rates reflect about a 2%-3% increase in the percentage of recipients having access to Medicaid medical care. None of these estimates include medical care encounters that are billed solely to non-Medicaid sources without requiring a Medicaid co-payment or other Medicaid claims-based record of the encounter. Minor children recipients as a group have lower unadjusted rates of access to medical care than either of the other recipient age groups.

Table 21 extends the analysis of Medicaid-reimbursed medical care by using logistic regression to adjust for health status and other recipient attributes. As shown in this table, Parent providers of minor children, and Spouse providers of adult IHSS recipients have a higher likelihood of any medical care use compared to those with Non-Relative providers after adjusting for health and functional status. Comparisons between IHSS recipients with other relatives and non-relatives are not statistically different. Adults with Parent providers have a lower likelihood of medical care use than do those with non-relatives as paid IHSS providers.34

The differences in hospital use comparing non-White race/ethnic groups to Whites (Table 16) are not broadly “explained” by differences in medical care use. After adjusting for health conditions and functional limitations, there are no statistically significant differences in the likelihood of medical care use comparing non-White to White race/ethnic groups among IHSS recipients age 3-17 and comparing Hispanic and Asians to White among recipients age 65+. Adult African-American IHSS recipients, on the other hand, were less likely to use medical services than Whites. Non-aged adult Hispanic and Asian recipients tended to have a higher likelihood of medical care use than Whites of the same age.

Emergency Room Use

The preceding results, show relatively comparable access to medical care across race/ethnic groups, and between recipients in the IHSS provider groups. However, claims data are not sufficient for determining the quality, timeliness, or appropriateness of this care. Here we separately examine the use of ERs. ERs can serve as alternatives for those without access to physicians or clinics, and/or as an indicator of crisis that may be suggestive of difficulty managing the needs of the personal assistant care recipient.

As seen in Table 22, ER use is a relatively common experience among IHSS recipients of all ages: experienced by more than half of the recipients in each age group. There is some variability among the provider types, with minor children of Parent providers, and adults with Spouse providers having the highest unadjusted rates. Extending this analysis, using the logistic regressions shown in Table 23, the risk adjusted differences among provider groups for recipients age 3-17 become non-significant. Among recipients age 18-64 and those 65 or more, the differences observed in the unadjusted results persist. Spouse providers in both age groups tend to have about 20% higher odds of ER use compared to Non-Relatives. Recipients with Parent providers (non-aged recipients only), in contrast have reduce odds of ER use. Other Relatives in both recipient age groups similarly have lower risk of use. New IHSS recipients, in all age groups similarly have reduced likelihood of ER use.

Looking at race/ethnicity, patterns similar to ACSC hospital use persist with non-Whites (other than Asians) ages 18 and over tending to have higher rates of ER use than Whites. Whether this is in response to problems accessing medical care, or responses to emergent conditions cannot be determined with the available data. As one might expect, this rate increases with more chronic health conditions, and the presence of severe breathing problems.

Medical Care Expenditures

The final analysis of medical care use examines expenditures made for physician services, outpatient departments, and the aggregation of these services into combined medical care services. Unadjusted monthly Medical care service expenditures averaged over the recipients’ IHSS eligibility months in 2005 are shown in Table 24. This table has three panels, one with data for all recipients, one for recipients continuing from 2004, and those newly entering IHSS in 2005. The table combines both physician services and those of outpatient departments.35

Within recipient age groups there is little difference in the average monthly expenditures for physician and outpatient department services among the provider groups. Average monthly Medicaid expenditures tend to be highest for children, lowest for those 65 or older. Combining the sources of medical care, the mean monthly expenses for IHSS from recipients age 3-17 continuing from 2004, range from a $140-$180 across all provider groups; the ranges are respectively $105-$170 among those age 18-64, and $40-$50 among those age 65 or more. The lower expenditures among adults, and the aged in particular, are likely due to Medicare or another source being a primary payer on these services. Expenditures for those who enter the IHSS program are marginally higher than for continuing recipients. This may be associated with instability in service needs that predated enrollment in IHSS. However, the underlying causes cannot be determined from the study’s single year of data.

Table 25 uses ordinary least squares regression to adjust for recipient characteristics in evaluating recipient mean expenditure differences among provider and race/ethnicity groups. Expenditures are inclusive of all physician and outpatient department claims during the calendar year for those continuing as an IHSS recipient from 2004, and after the date of IHSS eligibility in 2005 for new recipients. Expenditures are in dollar units divided by 1,000.36 The predicted difference in recipient expenditure levels associated with the provider group measures is generally modest. For minor children there are no statistically significant differences between the estimated expenditures for Parent or Other Relative providers and Non-Relatives. Among non-aged adult recipients, those with either Spouse or Other Relative providers have about $14 lower average monthly expenditures than Non-Relatives. Expenditures for those with Parent providers are not statistically different from those of Non-Relatives. Among recipients aged 65+, there are no adjusted differences between recipients with IHSS-paid Spouse or Other Relative providers and Non-Relative providers.

Returning to the issue of equality of medical care access by race/ethnic groups, the coefficients for the race/ethnicity groups regressed on medical care expenditures are generally not statistically different from those of Whites. The most important differences are that Black Adults have lower average monthly expenditures than Whites. This difference, as in the earlier analysis, may be explained by lower use medical care use by Black. New enrollees into IHSS in 2005 tend to have higher average adjusted monthly expenses than continuing recipients. Whether this is a function of ongoing problems or only those associated with the reasons for entering the program have not been determined.

Home and Community-Based Service Use and Expenditures

IHSS recipients may have access to Medicaid funded home care services in addition to IHSS. These can include several Medicaid HCBS waiver (e.g., AIDS waiver, Multi-Purpose Senior Services Program (MSSP), and developmental disabilities).37 The first panel of Table 26, shows the use of these waiver services (i.e., excluding IHSS). It is proportionately low: fewer than 0.04% among IHSS recipients age 3-17, 4.2% age 18-64, 17% age 65+. Among the users of the waivers, mean monthly expenditures tend to be somewhat higher than the comparable IHSS expenditures. Average monthly waiver expenditures tend to be highest among recipients age 18-64, particularly those with Parent providers. There is little unadjusted difference among the provider subgroups for waiver beneficiaries age 65+, and too few minor children recipients to appropriately draw conclusions.

The second panel shows Medicaid expenditures associated with IHSS use. This service is used by most of the study recipients in 2005. Average monthly expenditures are relatively comparable among adult recipient groups, and generally higher among recipients age 3-17. Parents among children, and spouses among the adults have the lowest unadjusted average monthly expenditures. This likely reflects the effects of the IHSS needs assessment protocol and service authorization algorithm that assigns no or few housekeeping and meals preparation task assistance hours when non-disabled family members also reside in the household. This algorithm applies whether or not non-disabled household members are paid IHSS providers. However, spouses of adult IHSS recipients and parents of minor children who are paid IHSS providers are usually considered “non-disabled.” When spouses and parents of minor children reside in the home of an IHSS recipient but do not become paid providers, this is often because they have health/disabilities that impair their caregiving ability. Indeed, especially in the case of the elderly, spouses are often also IHSS recipients. There are minor differences comparing Other Relative versus Non-Relative providers within each recipient age group. The third panel combines IHSS and spending for other community-based waiver reimbursed care. Average monthly expenditures are essentially unaffected by this, suggesting that the funding sources largely complement each other, rather that substantially augmenting the hours of care. The pattern of provider differences within age groups remains the same.

Ordinary least squares regression were used to adjust the within age group comparisons for recipient characteristics in assessing whether recipient expenditures differ among provider types.38 Table 27 shows models that combine all the home care expenditures for all recipients and all exposure months in 2005.39 The coefficients need to be multiplied by 1,000 to convert them to the original dollar metric. For all age groups, the IHSS Plus Waiver-permitted providers (i.e., parents for children, spouses for adults) have coefficients with negative signs, indicative of lower average monthly home care expenditures than recipients with Non-Relative providers -- a finding expected given the above described algorithm used to allocate total authorized IHSS hours.

Recipients ages 3-17 with Parent providers have average monthly home care expenditures about $500 less than those having Non-Relative providers. There is no difference between Other Relative and Non-Relative groups. Among adults IHSS recipients, those with Spouse providers have lower average estimated expenses ($430 less for the non-aged, $340 less for the aged) than those with Non-Relative providers. This is a difference of about 6-10 provider hours per week -- a level comparable to the unadjusted results. The high unadjusted expenses evident for Parent providers (non-aged recipients only) reduce markedly after adjusting for recipient characteristics. The OLS estimates show these expenses to be about $30 less per month than those of non-relatives holding everything else constant. The last contrast is between Relatives and Non-Relative providers. Here too there is a shift once adjustments are made for case mix. For both adult age groups of recipients these expenditure comparisons are either not statistically significant or so low as to be trivial between. Children and non-aged adults entering the IHSS program in 2005, have on average, lower monthly home care expenditures, holding other things constant, than those continuing from 2004. Among the aged, average monthly expenditures among new recipients tend to be about $50 higher than for continuing recipients.

Home Health Care Expenditures

In addition to unskilled home care, IHSS recipients may receive home health care (a home-based service either provided by a nurse or other licensed professional and/or under their supervision). Generally, this service is for a limited duration, such as following a hospital stay, or as an adjunct to outpatient physical therapy. Among the adult IHSS recipients, home health care utilization follows this expected pattern. There were relatively few such recipients in 2005 (0.3% of the aged, 3.6% non-aged adults). Home health care services are used by somewhat more minor children (8%), and with substantially higher average monthly expenditures (more than $5,000 across all provider groups) than adult recipients. Some of the difference in expenditures between adults and children may be that Medicaid is the primary payer for services to children, while large percentages of these costs may be covered by Medicare or other payers among adults. As shown in Table 28, within both children and aged recipient groups, there was little difference in average monthly Medicaid expenditures between provider groups. Among non-aged adults this pattern changed. Parent providers had substantially higher (about $700 higher) average monthly Medicaid unadjusted expenditures than recipients having non-Parent IHSS providers. Analyses incorporating Medicare expenditures, may alter these findings, but such data were not available to this project.

Differences among provider types in home health care expenditures, adjusting for recipient characteristics, were evaluated using ordinary least squares regression. Each model (not shown) used the same measures as in the earlier OLS regression. Among children and aged IHSS recipients none of the coefficients for provider type or its interaction with the number of health conditions were statistically significant in comparison to non-relatives. Among recipients age 18-64, only Other Relatives differed ($240 lower) from non-relatives. Adult recipients entering IHSS in 2005, tended to have marginally higher average monthly Medicaid-reimbursed home health expenditures among users than continuing recipients (about $940 for non-aged adults, $780 for those age 65+).

Medicaid-Paid Nursing Home Use and Expenditures

The occurrence of nursing home use is derived from Medicaid-reimbursement claims. We have limited the use of claims to those occurring during or following the period in which the individual was a recipient in the IHSS program. Only nursing home stays occurring in 2005 are counted.40 The claims (both payments and stays) available do not include skilled care placements or days covered entirely by payers such as Medicare, the VA, or private funds. A consequence of these limitations is that these data may under report short-term, skilled care days/stays; and under count total expenditures if service use was paid by these sources. Medicaid-paid co-payments are included in tabulations of Medicaid-paid nursing home stays and days. Within these biases the preponderance of nursing home claims are those involving IHSS recipients age 65 or more. The incidence of Medicaid-paid nursing home placement among IHSS recipients is low: about 0.26% among children, 2.25% among non-aged adult recipients, and 5.9% among those age 65+. As shown in Table 29 there are some differences in the unadjusted probabilities of nursing home use by IHSS recipient age and provider group. As a group, those with Other Relative providers tend to have among the lowest likelihood of placements. Adults with Spouse providers tend to be among those with a higher likelihood of placement.

These patterns are somewhat effected after adjusting for recipient characteristics, as shown in logistic regression equations in Table 30.41 Among recipients age 18-64, there is a persistent adjusted effect: IHSS recipients related to their providers have a lower adjusted odds of nursing home use than persons with Non-Relative providers. Further, recipients with paid Parent providers tend to have a lower adjusted risk than recipients with either Spouse or Other Relative providers. Among recipients age 65 or more, the protective effect of relatives as providers is present only comparing Other Relatives to Non-Relatives. Spouses have a modest tendency toward a lower placement rate, but this does not reach statistical significance. In short, the IHSS program, including its waiver-permitted providers, is at least as successful in aiding families and individuals remain in the community as are recipients with Non-Relative providers. New IHSS recipients age 65+ are also less likely than continuing recipients to have a nursing home placement.

Nursing home use has a direct effect on Medicaid costs. One consequence of this is seen in the nursing home expenditures for 2005 shown in Table 31. These expenditures reflect the accumulated costs for any nursing home stay in 2005, restricted to stays occurring after entry into (and, if applicable, exit from) IHSS. Most of these expenses seem to be for non-skilled care as the average monthly rate among nursing home users approximates the 2005 Medicaid daily nursing reimbursement rate of $115. Comparisons between continuing and new recipients show generally similar average daily expenses. In both age groups, IHSS recipients tend to have relatively similar average monthly expenditures across provider types. Recipients (non-aged adult only) with Parent providers, the one exception, have the highest average daily expenditures, but this may be an artifact of sample size. Parents are the smallest subgroup and their mean values are perhaps affected upward by the wide standard deviation in these data.

Analysis of expenses associated with the transition from IHSS to nursing home care, the transitions from nursing homes into IHSS, and the total Medicaid expenditures incurred by nursing home recipients are beyond the scope of this analysis; as is an analysis of the duration of nursing home placements.


CONCLUSIONS

California has paid legally responsible relatives as IHSS providers for years under a state and county financed component of IHSS known as the Residual Program. Many of the Residual Program elements were assumed into the IHSS Plus Waiver, implemented in 2005. This waiver allows Medicaid participation in jointly financing the PAS provided by parents of minor children and spouses of adults. It also allows for Advance Pay and Restaurant Meal voucher payments to qualified IHSS applicants.

The analyses presented in this report were organized around five broad questions pertaining to implementation of the IHSS Plus Waiver:

Taken together, these descriptive questions assess four fundamental policy issues: whether there was a change in the number and attributes of spouses and parents of minors that are paid providers under the IHSS program; whether hiring legally responsible relatives as personal assistance providers seems to be a recipient/family preference; whether Spouse and/or Parent providers performed as well as the use of other providers in enabling IHSS recipients to remain at home, safely; and whether the employment of family providers has been budget neutral for Medicaid in terms of health care use/expenditures.

IHSS recipients fall into three distinct age groups: minor children, non-elderly adults, and elderly adults. Elderly adults are the majority (60%). Minor children represent a small minority (about 4%), but still a sizable number of recipients. As the disability/chronic illness profile of each age group is different, as is the distribution of recipients among the types of paid providers used, most of the discussion is organized by recipient age group.

IHSS Plus vs. the Residual Program Participation

The number of recipients cared for by spouses and parents of minors paid as IHSS providers remained relatively constant between 2004 (under the IHSS Residual Program) and 2005 (under the IHSS Plus Waiver); as did the number of persons (about 1,600 recipients combined in 2005) participating in the Restaurant Meal voucher and Advance Pay waiver-eligible services. The new recipients, as a group, tended to be somewhat less impaired, to have lower health care expenditures, and to receive fewer IHSS authorized hours than the group of recipients who were in IHSS for the prior year or longer. These attributes likely could be common to all cohorts of new recipients, and may not be unique to IHSS Plus Waiver program entrants. The race/ethnic and provider mix is somewhat different comparing the new and continuing program cohorts, showing a proportionate increase in Hispanic and Asian recipients. A single year comparison is not sufficient to document a trend in these characteristics.

Preferences in the Selection of Paid IHSS Providers and Outcomes

The selection of a parent or spouse as a paid provider, across all age groups, is partly a function of available family members, but differences in the proportion among race/ethnic groups “selecting” each of the various provider types suggests that cultural preferences may be an important selection factor. Wage and other possible influences on provider availability were not a focus of these analyses, but IHSS wage rates (which vary by county) did not have a consistent association with the selection of paid Parent or Spouse providers. To the contrary, higher wages were marginally associated with an increased use of Non-Relative providers, and Parents and Spouses were more likely to be paid providers when wages were low (and presumably it may be more difficult to attract Non-Relative providers). These patterns could be regional effects, rather than associated with wages.

Recipients Age 3-17

Minor children in IHSS generally have at least one parent in the home. Consequently, for most of these children, the choice of Parent/Non-Parent provider was possible and the choice made by families was for a Parent provider (70% overall and 80% when a parent was present in the home). Hispanics had the highest proportion selecting Parent providers (81%) and the least selecting Non-Relatives (9%). Blacks were the least likely to have paid Parent providers (60%), and comparable with Whites in the proportion selecting Non-Relatives (20%). The decision of families to seek IHSS versus other service options was outside the scope of this study.

There were few differences by provider type in the number of ADL/IADL and cognitive limitations among minor children IHSS recipients. However, proportionately more minor children with paid Parent providers were dependent on human assistance with breathing (this includes assistance with self-administration of oxygen, and the cleaning of this equipment), and had more chronic health conditions (including mental retardation, seizure disorders, and paralysis). These conditions have been shown to be associated with nursing home use in minor children (Fries, Wodchis, Blaum, et al., 2005), and may be indicative of the Parent provider’s willingness and or greater ability to assume the demanding care responsibility associated with these conditions. Contributing to this ability may be that parents are legally permitted to perform “skilled nursing” tasks that would not be permitted by other providers. Investigation of the “cause” of this pattern is outside the scope of the current study.

Recipients Age 18-64

Spouse providers were rarely available as a choice to the non-aged adults participating in IHSS. Most IHSS recipients in this age group were either not married or their spouses were also IHSS recipients or otherwise not able physically/mentally to be paid caregivers. However, when spouses were available and able, the “preference” for them appears to be strong (90% among those with an available/able spouse). Parents were more readily available than spouses to non-elderly adults, and more recipients of this age group selected parents as paid providers. The availability of parents beyond those selected as paid providers is unknown in the IHSS data. There were discernable ethnic differences in the propensity to select Parent or Spouse providers. Hispanics were most likely to select Parent providers (26%) and the second most likely to select Spouse providers (9%). Asian were the most likely to select Spouse providers (11%) and second most likely to select Parent providers (18%). Blacks were the least likely to have either a spouse (2%) or parent (10%) as a paid provider. More than half of the Blacks and Whites relied on Non-Relative providers. This contrasted with about a third among Hispanics and Asians.

In general, recipients with paid Parent or Spouse providers had more limitations in ADL and cognitive functioning, and a comparable number of chronic health conditions, than recipients with other providers. However, those with paid Parent providers had higher rates of mental retardation/developmental disability, central nervous system injuries/disorders (such as quadriplegia, paraplegia, other extensive paralysis or spinal cord disorders), and seizure disorder) -- conditions shown by Fries and associates (2005) to have higher risk of nursing home placement.

Recipients Age 65 or More

Spouses were present among about 25% of this age group of IHSS recipients, but except for those paid as Spouse providers, the number able/available reduced to about 3%. When a recipient’s provider was an Other Relative or a Non-Relative, almost half of the spouses present were also IHSS recipients. Recipients with IHSS-paid Spouse providers tended to have more ADL, cognitive, and breathing assistance limitations, but there were no substantial differences in the number of health conditions. Race/ethnicity had a minor association with the presence of a paid Spouse provider (the percentages range from 1%-4%), but the more striking differences involved recipients with Other Relative and Non-Relative providers. More than half of the Asian (64%) and Hispanic (54%) recipients had an Other Relative as their paid provider, whereas more than half of the Whites (53%) and Blacks (56%) had Non-Relative providers.

Implications for Medicaid and IHSS Expenditures

For all recipient age groups, IHSS expenditures, adjusting impairment severity and service needs, are expected to be lower relative to those with Non-Relative providers when Parents, Spouses, and Other Relatives living in the household are paid IHSS providers. This cost difference arises because an IHSS algorithm adjusts the authorized time for housekeeping/meal preparation when there are relatives living in the household who might be expected to perform these tasks for themselves as well as for the recipient. This adjusted cost difference was observed for Parent providers to minor children, and for Spouse providers of adults. The cost differences for Parent provider (non-aged adults) and Other Relative providers were minor or non-significant. This could be because these providers were not living with the recipient or they may reflect limitations in the risk adjustment model.

Minor children with Parent IHSS-paid providers, adjusting for recipient functional and health conditions, have lower average monthly Medicaid expenditures, and lower IHSS and other home care expenditures than recipients with Non-Relative providers.

Adjusting for recipient characteristics, recipients age 18-64 with Spouse providers had lower average Medicaid monthly expenditures than those with Non-Relative providers. There were no statistically significant differences comparing recipients with Parent and Non-Relative providers. Among these adult IHSS recipients each of the paid relative provider groups had a significantly reduced likelihood of nursing home placement compared to those with Non-Relative providers. The Parent provider effect for those age18-64 appears greatest. Those with Spouse providers tended to have higher risk of “any cause” hospital stays (but not those associated with ambulatory sensitive conditions), higher risk of ER use, but lower IHSS and home care expenditures than recipients with Non-Relative providers. Recipients with Parent providers compared to those with Non-Relative providers had lower adjusted use of hospitals, ERs, and home care.

Average monthly Medicaid expenditures among recipients age 65 or more, adjusting for recipient characteristics, were lower for those with paid Spouse providers and Other Relative providers compared to those with Non-Relative providers. This tendency for lower risk among those with family providers (both legally responsible and otherwise) was also present with respect to ambulatory sensitive hospital stays; and those with Other Relative providers compared to those with Non-Relative providers had reduced risk of ER use, lower monthly expenditures for IHSS and other home care.

In short, these analyses found no financial disadvantage and some advantages to Medicaid from allowing spouses, parents (and other relatives) to be paid IHSS providers. This argues in favor of honoring the recipient’s and family’s preference for such providers. Whether the availability of spouse, parent, and other relatives can be expanded beyond its current proportion among all race/ethnic groups in IHSS is unknown, but changes in the race/ethnic mix of recipients evident in the new cohort of enrollees may affect this. The proportion of recipients who are Hispanic or Asian seems to be growing. These groups presently have the highest proportionate use of Spouse, Parent, and Other Relative providers.

These effects of selecting Parent, Spouse, and Other Relatives as paid providers are present within a program where the rate of Medicaid nursing home stays among IHSS recipients with Non-Relative providers seems to be low. This suggests that IHSS in general is doing a good job of enabling recipients to remain in the community regardless of the provider type selected. Not examined in this analysis were the factors (such as hospital stays, avoidable changes is health or functional status) associated with entry into and exit from IHSS; or the duration of participation in IHSS and the cost/use comparisons over time.


REFERENCES

Aday LA, R Anderson. (1974). A framework for the study of access to medical care. Health Services Research, 9(3):208-220.

Agency for Healthcare Research and Quality (AHRQ). (2007a). Pediatric Quality Indicators, Revision 3.1. Internet address: http://www.qualityindicators.ahrq.gov/software.htm.

Agency for Healthcare Research and Quality (AHRQ). (2007b). Prevention Quality Indicators, Revision 3.1. Internet address: http://qualityindicators.ahrq.gov/pqi_download.htm.

Ash AS, F Porell, L Gruenberg, E Sawitz, A Belser. (1989). Adjusting Medicare capitation payments using prior hospitalization. Health Care Financing Review, 10(4):17-29.

Billings J, L Zeitel, J Lukomink, TS Carey, AE Blank, L Newman. (1993). Impact of socioeconomic status on hospital use in New York City. Health Affairs, 12(1):162-173.

Centers for Disease Control and Prevention (CDC). (Accessed 2007). International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Internet address: http://www.cdc.gov/nchs/icd9.htm.

Charlson ME, P Pompei, KL Ales, CR MacKenzie. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Disease, 40(5):373-383.

Deyo R, D Cherkin, M Ciol. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of Clinical Epidemiology, 45(6):613-619.

Dudley RA, CA Medlin, LB Hammann, MG Cisternas, R Brand, DJ Renne, HS Luft. (2003). The best of both worlds? Potential of hybrid prospective/concurrent risk adjustment. Medical Care, 41(1):56-69.

Ellis RP, GC Pope, LI Iezzoni, JZ Ayanian, DW Bates, H Burstin, AS Ash. (1996). Diagnosis-based risk adjustment for Medicare capitation payments. Health Care Financing Review, 17(3):101-128.

Elixhauser A, C Steiner, DR Harris, RM Coffey. (1998). Comorbidity measures for use with administrative data. Medical Care, 36(1):8-27.

Fries B, W Wodchis, C Blaum, A Buttar, J Drabek, J Morris. (2005). A national study showed that diagnoses varied by age group in nursing home residents under age 65. Journal of Clinical Epidemiology, 58(2):198-205. Internet address: http://aspe.hhs.gov/daltcp/reports/nhunder65.htm.

Harmuth S, S Dyson. (2002). Results of the 2002 National Survey of State Initiatives on the Long Term Care Direct Care Workforce. New York, NY: Paraprofessional Healthcare Institute and the North Carolina Department of Health and Human Services.

Newcomer R, T Clay, J Luxenberg, R Miller. (1999). Misclassification and selection bias when identifying Alzheimer’s Disease solely from Medicare claims records. Journal of the American Geriatrics Society, 47(2):215-219.

Newcomer R, T Scherzer. (2006). Exploring experiences and factors influencing participation in the In Home Supportive Service Plus Waiver Program. San Francisco, CA: University of California. Prepared for the Research Triangle Institute and the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.

Pope GC, RP Ellis, AS Ash, JZ Ayanian, DW Bates, H Burstin, LI Iezzoni, E Marcantonio, B Wu. (2000). Diagnostic Cost Group Hierarchical Condition Category Models for Medicare Risk Adjustment. Waltham, MA: Health Economics Research, Inc. Final Report to the Centers to Medicare and Medicaid Services under contract 500-95-048.

Pope GC, J Kautter, RP Ellis, AS Ash, JZ Ayanian, LI Iezzoni, MJ Ingber, JM Levy, J Robst. (2004). Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financing Review, 25(4):119-140

Romano P, LL Roos, JG Jollis. (1993). Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: Differing perspectives. Journal of Clinical Epidemiology, 46(10):1075-1079.

Roos LL, SM Sharp, MM Cohen. (1991). Comparing clinical information with claims data: Some similarities and differences. Journal of Clinical Epidemiology, 44(9):881-888.

Salsberg E, P Wing, M Langelier, et al. (2002). The Direct Care Professional Workforce Providing Long Term Care Services in the United States: Data Sources and Data Issues. Washington, DC: Bureau of Health Professions, Health Resources and Services Administration.

Stone RI. (2000). Long-Term Care for the Elderly with Disabilities: Current Policy, Emerging Trends, and Implications for the 21st Century. New York, NY: Milbank Memorial Fund.

Stone RI. (2001). Frontline Workers in Long-Term Care: A Background Paper. Washington, DC: American Association of Homes and Services for the Aging.

US Department of Commerce, (2007). Per Capita Personal Income by County, California, 1991-2001. Table D-9. Washington, DC: Bureau of Economic Analysis. Internet address: http://www.bea.doc.gov.

US General Accounting Office (GAO). (2001). Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides is a Growing Concern. Washington, DC: US Senate. Testimony before the Committee on Health, Education, Labor, and Pensions.


TABLE 1: Share of Cost, Advance Pay, Meals Allowance Participation by IHSS Recipient Age, Provider Relationship, & Program Entry Statusa
Eligible IHSS Recipients Spouse Parent Other Relative Non-Relative Total
n % n % n % n % n %
Age 3-17 from 2004 na na 9,798 72.6 1,701 12.6 2,006 14.9 13,505 100.0
Share of Cost na na 143 1.5 8 0.5 4 0.2 155 1.1
   Mean Months if Yes na na 8.1   9.0   7.5   8.1  
Advance Pay na na 34 0.3 12 0.7 7 0.3 53 0.4
   Mean Months if Yes na na 9.5   8.3   12.0   9.5  
Meals Allowance na na 2 0.02 1 0.06 - - 3 0.02
   Mean Months if Yes na na 10.5   12.0   - - 11.0  
Age 3-17, new in 2005 na na 1,780 64.7 389 14.1 583 21.2 2,752 100.0
Share of Cost na na 10 0.6 1 0.3 3 0.5 14 0.5
   Mean Months if Yes na na 6.1   1.0   3.3   5.1  
Advance Pay na na 1 0.06 1 0.3 - - 2 0.07
   Mean Months if Yes na na 9.0   3.0   - - 6.0  
Meals Allowance na na - - - - - - - -
   Mean Months if Yes na na - - - - - - - -
Age 18-64 from 2004   7,121   5.6   21,008     16.7     39,932     31.7     58,057     46.0     126,118     100.0  
Share of Cost 741   10.4   392 1.9 879 2.2 1,567 2.7 3,579 2.8
   Mean Months if Yes 8.9   9.7   8.9   8.9   9.0  
Advance Pay 27 0.4 138 0.7 37 0.1 272 0.5 474 0.4
   Mean Months if Yes 10.6   10.7   9.9   10.4   10.4  
Meals Allowance 6 0.08 13 0.06 47 0.1 278 0.5 344 0.3
   Mean Months if Yes 7.8   10.2   9.7   9.9   9.8  
Age 18-64 new 2005 1,597 6.0 2,484 9.4 9,475 35.8 12,917 48.8 26,473 100.0
Share of Cost 148 9.3 45 1.8 281 3.0 439 3.4 913 3.4
   Mean Months if Yes 4.8   5.9   5.3   4.6   4.9  
Advance Pay 1 0.06 3 0.1 1 0.01 7 0.05 12 0.05
   Mean Months if Yes 12.0   3.7   4.0   5.7   5.6  
Meals Allowance 1 0.06 1 0.04 3 0.03 33 0.3 38 0.14
   Mean Months if Yes 2.0   7.0   9.0   4.7   5.1  
Age 65+ from 2004 4,373 2.2 na na 103,990 52.4 90,160 45.4 198,523 100.0
Share of Cost 507 11.6 na na 3,061 2.9 2,970 3.3 6,538 3.3
   Mean Months if Yes 8.7   na na 9.0   8.6   8.8  
Advance Pay 7 0.16 na na 25 0.02 66 0.07 98 0.05
   Mean Months if Yes 8.6   na na 10.8   8.7   9.2  
Meals Allowance 3 0.07 na na 113 0.11 434 0.5 550 0.3
   Mean Months if Yes 6.7   na na 9.5   9.9   9.8  
Age 65+ new 2005 1,016 2.9 na na 19,506 55.2 14,811 41.9 35,333 100.0
Share of Cost 94 9.3 na na 974 5.0 923 6.2 1,991 5.6
   Mean Months if Yes 5.4   na na 5.5   4.4   5.0  
Advance Pay - - na na 2 0.01 4 0.03 6 0.02
   Mean Months if Yes - - na na 1.0   3.3   2.5  
Meals Allowance - - na na 23 0.12 36 0.24 59 0.17
   Mean Months if Yes - - na na 4.8   4.6   4.7  
Total 14,107   35,070   174,993   178,543   402,704  
SOURCE: California Department of Social Services, unpublished CMIPS data for 2004 and 2005. “na” is not applicable.
  1. Classification into Provider Type was done using the principle of “intention to treat.” Ever having a Spouse provider for one month or in 2005 defined one in this group. Similarly, ever having a Parent provider (but no Spouse provider), or an Other Relative (i.e., but no Spouse or Parent) for at least one month defined one in these respective groups. Non-Relatives had no family members as providers during the year.


TABLE 2: Consistency of Provider Relationships
Provider Relationship Age 3-17 Age 18-64 Age 65+
All   Inconsistent   All   Inconsistent   All   Inconsistent  
2005 n n % n n % n n %
Spouse na na na 8,718 821 9.4 5,389 501 9.3
Parent   11,578     481     4.2   23,492 1,763 7.5 na na na
Other Relative 2,090 98 4.7 49,407 3,601 7.3 123,496 4,671 3.8
Non-Relativea 2,589 124 4.8 70,974 4,135 5.8 104,971 6,776 6.5
Total Inconsistent Relationships   703 4.3     10,320     6.8       11,948     5.1  
Total All (Consistent, & Inconsistent) Relationships   16,257       152,591         233,856      
SOURCE: California Department of Social Services, unpublished CMIPS data for 2004 and 2005.


TABLE 3: Race/Ethnicity of New & Continuing IHSS Recipients, 2005
  Spouse Parent Other Relative Non-Relative Total
n % n % n % n % n %
Continuing Recipients Age 3-17     9,798   1,701   2,006   13,505  
1 White na na 2,546 26.0 468 27.5 769 38.3 3,783 28.0
2 Hispanic na na 4,951 50.5 568 33.4 568 28.3 6,087 45.1
3 Black na na 1,422 14.5 455 26.7 489 24.4 2,366 17.5
4 Asian & Others na na 879 9.0 210 12.3 180 9.0 1,269 9.4
New Recipients Age 3-17     1,780   389   583   2,752  
1 White na na 489 27.5 83 21.3 225 38.6 797 29.0
2 Hispanic na na 824 46.3 127 32.6 182 31.2 1,133 41.2
3 Black na na 273 15.3 125 32.1 111 19.0 509 18.5
4 Asian & Others na na 194 10.9 54 13.9 65 11.1 313 11.4
Continuing Recipients Age 18-64     7,121       21,008     39,932   58,057     126,118    
1 White 2,434   34.2   8,612   41.0     14,803     37.1     28,183     48.5   54,032   42.8  
2 Hispanic 2,616 36.7 6,967 33.2 8,759 21.9 8,899 15.3 27,241 21.6
3 Black 687 9.6 3,183 15.2 10,771 27.0 17,701 30.5 32,342 25.6
4 Asian & Others 1,384 19.4 2,246 10.7 5,599 14.0 3,274 5.6 12,503 9.9
New Recipients Age 18-64 1,597   2,484   9,475   12,917   26,473  
1 White 500 31.3 941 37.9 3,371 35.6 6,556 50.8 11,368 42.9
2 Hispanic 636 39.8 785 31.6 2,259 23.8 1,966 15.2 5,646 21.3
3 Black 166 10.4 501 20.2 2,637 27.8 3,614 28.0 6,918 26.1
4 Asian & Others 295 18.5 257 10.3 1,208 12.7 781 6.0 2,541 9.6
Continuing Recipients Age 65+   4,373       103,990   90,160   198,523  
1 White 911 20.8 na na 36,448 35.0 41,568 46.1 78,927 39.8
2 Hispanic 1813 41.5 na na 24,800 23.8 19,275 21.4 45,888 23.1
3 Black 201 4.6 na na 9,472 9.1 12,288 13.6 21,961 11.1
4 Asian & Others 1448 33.1 na na 33,270 32.0 17,029 18.9 51,747 26.1
New Recipients Age 65+ 1,016       19,506   14,811   35,333  
1 White 194 19.1 na na 5,182 26.6 6,259 42.3 11,635 32.9
2 Hispanic 435 42.8 na na 5,538 28.4 3,466 23.4 9,439 26.7
3 Black 63 6.2 na na 1,652 8.5 1,480 10.0 3,195 9.0
4 Asian & Others 324 31.9 na na 7,134 36.6 3,606 24.3 11,064 31.3
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005. “na” means that these provider types were not included in the analysis.


TABLE 4: Race/Ethnicity Distribution Among IHSS Provider Groups, 2005
  Spouse Parent Other Relative Non-Relative Total
n % n % n % n % n
Continuing Recipients Age 3-17     9,798   1,701   2,006   13,505
1 White na na 2,546 67.3 468 12.4 769 20.3 3,783
2 Hispanic na na 4,951 81.3 568 9.3 568 9.3 6,087
3 Black na na 1,422 60.1 455 19.2 489 20.7 2,366
4 Asian & Others na na 879 69.3 210 16.5 180 14.2 1,269
New Recipients Age 3-17     1,780   389   583   2,752
1 White na na 489 61.4 83 10.4 225 28.2 797
2 Hispanic na na 824 72.7 127 11.2 182 16.1 1,133
3 Black na na 273 53.6 125 24.6 111 21.8 509
4 Asian & Others na na 194 62.0 54 17.3 65 20.8 313
Continuing Recipients Age 18-64     7,121       21,008     39,932     58,057       126,118  
1 White 2,434 4.5 8,612   15.9   14,803   27.4   28,183   52.2   54,032
2 Hispanic 2,616 9.6 6,967 25.6 8,759 32.2 8,899 32.7 27,241
3 Black 687 2.1 3,183 9.8 10,771 33.3 17,701 54.7 32,342
4 Asian & Others 1,384   11.1   2,246 18.0 5,599 44.8 3,274 26.2 12,503
New Recipients Age 18-64 1,597   2,484   9,475   12,917   26,473
1 White 500 4.4 941 8.3 3,371 29.7 6,556 57.7 11,368
2 Hispanic 636 11.3 785 13.9 2,259 40.0 1,966 34.8 5,646
3 Black 166 2.4 501 7.2 2,637 38.1 3,614 52.2 6,918
4 Asian & Others 295 11.6 257 10.1 1,208 47.5 781 30.7 2,541
Continuing Recipients Age 65+ 4,373         103,990     90,160   198,523
1 White 911 1.2 na na 36,448 46.2 41,568 52.7 78,927
2 Hispanic 1813 4.0 na na 24,800 54.0 19,275 42.0 45,888
3 Black 201 0.9 na na 9,472 43.1 12,288 56.0 21,961
4 Asian & Others 1448 2.8 na na 33,270 64.3 17,029 32.9 51,747
New Recipients Age 65+ 1,016       19,506   14,811   35,333
1 White 194 1.7 na na 5,182 44.5 6,259 53.8 11,635
2 Hispanic 435 4.6 na na 5,538 58.7 3,466 36.7 9,439
3 Black 63 2.0 na na 1,652 51.7 1,480 46.3 3,195
4 Asian & Others 324 2.9 na na 7,134 64.5 3,606 32.6 11,064
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005. “na” means that these provider types were not included in the analysis.


TABLE 5a: Selected Household Characteristics of IHSS Recipients, Age 3-17
IHSS Recipients Parent Other Relative Non-Relative Total
n % n % n % n %
Continuing from 2004   9798       1701       2006       13505    
  Female 3808   38.9   647   38.0   784   39.1   5239   38.8  
Household size
  1 15 0.2 8 0.5 16 0.8 39 0.3
  2 1051 10.7 192 11.3 274 13.7 1517 11.2
  3 2157 22.0 364 21.4 470 23.4 2991 22.2
  4 2502 25.5 428 25.2 544 27.1 3474 25.7
  5+ 4073 41.6 709 41.7 702 35.0 5484 40.6
Parent Presenta
  No Parent Present 396 4.0 520 30.6 377 18.8 1293 9.6
  Provides All Services 8138 83.1 251 14.8 578 28.8 8967 66.4
  Provides Some Services   1129 11.5 481 28.3 517 25.8 2127 15.7
  Provides No Services 113 1.2 313 18.4 304 15.2 730 5.4
  Parent IHSS Recipient 22 0.2 136 8.0 230 11.5 388 2.9
Housing
  House 5493 56.1 1144 67.3 1339 66.7 7976 59.1
  Apartment 3861 39.4 492 28.9 594 29.6 4947 36.6
  Mobile Home 316 3.2 47 2.8 53 2.6 416 3.1
  Hotel/Other 128 1.3 18 1.1 20 1.0 166 1.2
Entering IHSS in 2005 1,780   389   583   2752  
  Female 705 39.6 150 38.6 212 36.4 1067 38.8
Household Size
  1 2 0.1 0 0.0 3 0.5 5 0.2
  2 179 10.1 35 9.0 71 12.2 285 10.4
  3 330 18.5 82 21.1 158 27.1 570 20.7
  4 499 28.0 93 23.9 158 27.1 750 27.3
  5+ 770 43.3 179 46.0 193 33.1 1142 41.5
Parent Presenta
  No Parent Present 0 0.0 108 27.8 107 18.4 341 12.4
  Provides All Services 1426 80.1 49 12.6 190 32.6 1665 60.5
  Provides Some Services 203 11.4 121 31.1 150 25.7 474 17.2
  Provides No Services 145 8.1 70 18.0 92 15.8 181 6.6
  Parent IHSS Recipient 6 0.3 41 10.5 44 7.5 91 3.3
Housing
  House 966 54.3 229 58.9 376 64.5 1571 57.1
  Apartment 715 40.2 144 37.0 179 30.7 1038 37.7
  Mobile Home 64 3.6 9 2.3 18 3.1 91 3.3
  Hotel/Other 35 2.0 7 1.8 10 1.7 52 1.9
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005.
  1. May not total to 100% due to missing values, “na” not applicable, “unk” unknown.


TABLE 5b: Selected Household Characteristics of IHSS Recipients, Age 18-64
IHSS Recipients Spouse Parent   Other Relative   Non-Relative Total
n % n % n % n % n %
Continuing from 2004 7121     21008     39932   58057     126118    
  Female   2407     33.8   9494   45.2     27676     69.3     34944     60.2   74521   59.1  
Household size
  1 120 1.7 1336 6.4 7548 18.9 22800 39.3 31804 25.2
  2 2596 36.5 5418 25.8 13093 32.8 20877 36.0 41984 33.3
  3 1598 22.4 6457 30.7 7916 19.8 7347 12.7 23318 18.5
  4 1253 17.6 3792 18.1 4817 12.1 3548 6.1 13410 10.6
  5+ 1554 21.8 4005 19.1 6558 16.4 3485 6.0 15602 12.4
Spouse Presenta
  No Spouse na   19298 91.9 31009 77.7 52607 90.6 102914 81.6
  Spouse Able/Available 6145 86.3 73 0.3 1431 3.6 1221 2.1 8870 7.0
  Spouse Availability Limited 400 5.6 75 0.4 786 2.0 558 1.0 1819 1.4
  Spouse Not Able 537 7.5 17 0.1 1179 3.0 703 1.2 2436 1.9
  Spouse is IHSS Recipient 22 0.3 54 0.3 5291 13.3 2633 4.5 8000 6.3
Parent Presenta
  No Parent Present unk   na   unk   unk   unk  
  Provides Some Services 16 0.2 1448 6.9 94 0.2 193 0.3 1751 1.4
  Provides No Services     32 0.2 27 0.1 48 0.1 107 0.1
  Parent is IHSS Recipient 1 0.0 11 0.1 115 0.3 94 0.2 221 0.2
Housing
  House 3810 53.5 14401 68.6 19095 47.8 22210 38.3 59516 47.2
  Apartment 2687 37.7 5565 26.5 18896 47.3 31070 53.5 58218 46.2
  Mobile Home 484 6.8 830 4.0 1427 3.6 3498 6.0 6239 4.9
  Hotel/Other 140 2.0 212 1.0 514 1.3 1279 2.2 2145 1.7
Entering IHSS in 2005 1597   2484   9475   12917   26473  
  Female 506 31.7 1022 41.1 6386 67.4 7273 56.3 15187 57.4
Household size
  1 31 1.9 172 6.9 1653 17.4 4989 38.6 6845 25.9
  2 557 34.9 534 21.5 2748 29.0 4118 31.9 7957 30.1
  3 342 21.4 704 28.3 1950 20.6 1851 14.3 4847 18.3
  4 259 16.2 492 19.8 1293 13.6 933 7.2 2977 11.2
  5+ 408 25.5 582 23.4 1831 19.3 1026 7.9 3847 14.5
Spouse Presenta
  No Spouse na na 2303 92.7 7273 76.8 11723 90.8 21299 80.5
  Spouse Able/Available 1441 90.2 19 0.8 465 4.9 417 3.2 2342 8.8
  Spouse Availability Limited 52 3.3 7 0.3 229 2.4 112 0.9 400 1.5
  Spouse Not Able 88 5.5 4 0.2 335 3.5 197 1.5 624 2.1
  Spouse is IHSS Recipient 7 0.4 5 0.2 1143 12.1 430 3.3 1585 6.0
Parent Presenta
  No Parent Present unk   na   unk   unk   unk  
  Provides Some Services 8 0.5 145 5.8 13 0.1 22 0.2 188 0.7
  Parent is IHSS Recipient 1 0.1 1 0.0 12 0.1 8 0.1 22 0.1
Housing
  House 845 52.9 1613 64.9 4356 46.0 4776 37.0 11590 43.8
  Apartment 596 37.3 713 28.7 4589 48.4 6679 51.7 12577 47.5
  Mobile Home 119 7.5 116 4.7 367 3.9 936 7.2 1538 5.8
  Hotel/Other 37 2.3 42 1.7 163 1.7 526 4.1 768 2.9
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005
  1. May not total to 100% due to missing items, “na” not applicable, “unk” unknown.


TABLE 5c: Selected Household Characteristics of IHSS Recipients, Age 65+
IHSS Recipients Parent Other Relative Non-Relative Total
n % n % n % n %
Continuing from 2004   4373       103990       90160       198523    
  Female 836   19.1   74883   72.0   64223   71.2   139942   70.5  
Household Size
  1 85 1.9 20271 19.5 41840 46.4 62196 31.3
  2 2343 53.6 34892 33.6 31463 34.9 68698 34.6
  3 722 16.5 17182 16.5 7387 8.2 25291 12.7
  4 465 10.6 11006 10.6 3840 4.3 15311 7.7
  5+ 758 17.3 20639 19.8 5630 6.2 27027 13.6
Spouse Presenta
  No Spouse Present na   70564 67.9 69419 77.0 139983 70.5
  Spouse Able/Available 3881 88.7 1801 1.7 1053 1.2 6735 3.4
  Spouse Availability Limited 156 3.6 300 0.3 225 0.2 681 0.3
  Spouse Not Able 286 6.5 2962 2.8 1831 2.0 5079 2.6
  Spouse is IHSS Recipient 45 1.0 28317 27.2 17602 19.5 45964 23.2
Parent Presenta
  Parent Present unk   unk   unk   unk  
  Provides Some Services     2 <0.00 3 <0.00 5 <0.00
  Parent is IHSS Recipient     35 0.03 22 0.02 57 0.05
Housing
  House 2288 52.3 53719 51.7 30116 33.4 86123 43.4
  Apartment 1731 39.6 45445 43.7 54323 60.3 101499 51.1
  Mobile Home 283 6.5 3123 3.0 4343 4.8 7749 3.9
  Hotel/Other 71 1.6 1703 1.6 1378 1.5 3152 1.6
# Entering in 2005 1016   19506   14811   35333  
  Female 174 17.1 13605 69.7 9855 66.5 23634 66.9
Household Size
  1 14 1.4 3161 16.2 6596 44.5 9771 27.7
  2 533 52.5 5658 29.0 4735 32.0 10926 30.9
  3 171 16.8 3534 18.1 1447 9.8 5152 14.6
  4 94 9.2 2440 12.5 794 5.4 3328 9.4
  5+ 204 20.1 4713 24.2 1239 8.4 6156 17.4
Spouse Presenta
  No Spouse Present na   13073 67.0 11398 77.0 24471 69.3
  Spouse Able/Available 933 91.8 561 2.9 430 2.9 1924 5.4
  Spouse Availability Limited 19 1.9 86 0.4 73 0.5 178 0.5
  Spouse Not Able 8 0.8 698 3.6 457 3.1 1163 3.0
  Spouse is IHSS Recipient 10 1.0 5067 26.0 2441 16.5 7518 21.3
Parent Present a
  Parent Present unk   unk   unk   unk  
  Provides Some Services 2 0.2 7 0.04 9 0.06 18 0.05
  Parent is IHSS Recipient 1 0.1 12 0.06 3 0.02 16 0.05
Housing
  House 510 50.2 11013 56.5 5541 37.4 17064 48.3
  Apartment 422 41.5 7348 37.7 7871 53.1 15641 44.3
  Mobile Home 61 6.0 757 3.9 1051 7.1 1869 5.3
  Hotel/Other 23 2.3 388 2.0 348 2.3 759 2.1
SOURCE:: California Department of Social Services, unpublished CMIPS data for 2005.
  1. May not total to 100% due to missing values, “na” not applicable, “unk” unknown.


TABLE 6: Physical & Cognitive Limitations Among New & Continuing IHSS Recipients, 2005
  Spouse Parent Other Relative Non-Relative Total
n n n n n
Continuing Recipients Age 3-17   9,798 1,701 2,006 13,505
  Average Total Authorized IHSS Hours   112.3 102.3 107.8 110.4
  Mean Number Cognitive Limitationsa   0.6 0.5 0.6 0.6
  Mean Number ADL Limitationsb   3.6 3.5 3.6 3.6
  Mean Number IADL Limitationsc   3.1 3.4 3.3 3.2
  % with Breathing Limitationd   16.2 14.8 12.3 15.4
New Recipients Age 3-17   1,780 389 583 2,752
  Average Total Authorized IHSS Hours   70.1 61.4 69.2 68.7
  Mean Number Cognitive Limitationsa   0.4 0.4 0.4 0.4
  Mean Number ADL Limitationsb   3.3 3.0 3.2 3.2
  Mean Number IADL Limitationsc   2.9 3.3 3.0 3.0
  % with Breathing Limitationd   9.3 9.3 11.5 9.8
Continuing Recipients Age 18-64   7,121     21,008     39,932     58,057     126,118  
  Average Total Authorized IHSS Hours 86.3 134.6 79.6 89.2 93.6
  Mean Number Cognitive Limitationsa 0.1 0.7 0.1 0.1 0.2
  Mean Number ADL Limitationsb 3.7 3.1 2.5 2.3 2.6
  Mean Number IADL Limitationsc 4.6 4.3 4.3 4.3 4.3
  % with Breathing Limitationd 11.1 7.2 6.6 7.5 7.4
New Recipients Age 18-64 1,597 2,484 9,475 12,917 26,473
  Average Total Authorized IHSS Hours 61.4 79.3 57.4 57.2 59.6
  Mean Number Cognitive Limitationsa 0.04 0.3 0.05 0.04 0.1
  Mean Number ADL Limitationsb 3.5 2.4 2.1 1.8 2.1
  Mean Number IADL Limitationsc 4.4 4.2 4.3 4.1 4.2
  % with Breathing Limitationd 8.1 4.0 4.5 5.1 5.0
Continuing Recipients Age 65+ 4,373     103,990   90,160 198,523
  Average Total Authorized IHSS Hours 83.4   82.5 85.8 84.0
  Mean Number Cognitive Limitationsa 0.1   0.1 0.1 0.1
  Mean Number ADL Limitationsb 3.9   2.8 2.5 2.7
  Mean Number IADL Limitationsc 4.6   4.5 4.4 4.5
  % with Breathing Limitationd 11.0   6.2 6.2 6.3
New Recipients Age 65+ 1,016   19,506 14,811 35,333
  Average Total Authorized IHSS Hours 58.6   61.2 58.9 60.2
  Mean Number Cognitive Limitationsa 0.1   0.1 0.05 0.1
  Mean Number ADL Limitationsb 3.6   2.4 1.9 2.2
  Mean Number IADL Limitationsc 4.4   4.4 4.2 4.3
  % with Breathing Limitationd 10.0   4.5 4.5 4.6
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005
  1. Number of tasks cannot perform memory, orientation, or judgment tasks without human assistance.
  2. Number of tasks cannot perform ADLs (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual care; eating) without human assistance.
  3. Number of tasks cannot perform IADLs (i.e., housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside) without human assistance.
  4. Cannot breathe without human assistance.


TABLE 7: Limitations Among Meals Allowance & Advance Pay IHSS Waiver Recipients, 2005
Age Group Meals Allowance Advance Pay
3-17 18-64 65+ 3-17 18-64 65+
IHSS Plus Recipients N=3   N=382     N=609     N=55     N=486     N=104  
ADL Limitationsa
  % 3 or more 66.7 27.2 31.4 96.4 97.9 100.0
IADL Limitationsb
  % 3 or more 100.0 95.5 98.7 72.7 100.0 100.0
Cognitive Limitationsc
  % 0 66.7 98.4 98.9 54.5 83.7 83.7
  % 2 or more 33.3 1.3 0.8 36.4 14.0 13.5
Breathing Problemsd
  % 0   100.0   94.8 94.3   69.1   78.0 75.0
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005
  1. Number of tasks cannot perform assistance in ADLs (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual care; eating) without human assistance.
  2. Number of tasks cannot perform IADLs (i.e., housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside) without at least direct physical human assistance.
  3. Number of tasks cannot perform memory, orientation, or judgment tasks without human assistance.
  4. Cannot breathe without human assistance.


TABLE 8: Modal Hourly IHSS Wage Rate, by County, 2003
County   Hourly Wage Rate   County   Hourly Wage Rate  
ALAMEDA 9.50 ORANGE 8.00
ALPINE 7.11 PLACER 6.75
AMADOR 6.95 PLUMAS 7.11
BUTTE 7.11 RIVERSIDE 7.11
CALAVERAS 6.75 SACRAMENTO 9.50
COLUSA 6.75 SAN BENITO 6.75
CONTRA COSTA   9.50 SAN BERNARDINO   8.50
DEL NORTE 6.75 SAN DIEGO 8.50
EL DORADO 6.75 SAN FRANCISCO 10.10
FRESNO 7.50 SAN JOAQUIN 8.50
GLENN 7.11 SAN LUIS OBISPO 6.95
HUMBOLDT 6.75 SAN MATEO 9.50
IMPERIAL 6.75 SANTA BARBARA 7.11
INYO 6.75 SANTA CLARA 10.50
KERN 6.75 SANTA CRUZ 9.50
KINGS 6.75 SHASTA 6.75
LAKE 6.75 SIERRA 7.11
LASSEN 6.75 SISKIYOU 6.75
LOS ANGELES 7.50 SOLANO 9.50
MADERA 6.75 SONOMA 9.50
MARIN 9.75 STANISLAUS 6.95
MARIPOSA 6.75 SUTTER 6.75
MENDOCINO 7.11 TEHAMA 6.75
MERCED 6.95 TRINITY 6.75
MODOC 6.75 TULARE 6.75
MONO 7.11 TUOLUMNE 6.75
MONTEREY 9.50 VENTURA 7.11
NAPA 8.50 YOLO 9.60
NEVADA 7.11 YUBA 6.75
SOURCE: Derived from unpublished CMIPS recorded payments to IHSS recipients in 2003


TABLE 9: Number of Chronic Health Conditions by Medicaid Recipient Age Comparing New and Continuing IHSS Recipient, 2005
IHSS Recipient Age Group   # IHSS Recipients, 2005     Mean # HCC’s     Standard Deviation  
Total Recipients, 2005 346,552 3.41 2.82
  3-17 11,583 3.37 2.97
  18-64 125,502 4.21 3.25
  65 or more 209,467 2.93 2.40
Recipients Continuing from 2004   293,459 3.35 2.77
  3-17 9,914 3.43 2.96
  18-64 104,786 4.09 3.20
  65 or more 178,759 2.91 2.36
New IHSS Recipients 2005 53,093 3.71 3.09
  3-17 1,669 3.01 3.05
  18-64 20,716 4.78 3.44
  65 or more 30,708 3.03 2.60
SOURCE: California Department of Health Care Services, Medicaid claims for 2005. HCC refers to Hierarchical Condition Classifications (Pope, Ellis, Ash, et al., 2000). Recipient counts are limited to IHSS recipients not enrolled in Medicaid managed care at anytime in 2005, but includes any claims in 2005 regardless of the IHSS eligibility period.


TABLE 10a: Summary of Health Conditions Among IHSS Recipients Age 3-17 by Provider Group, 2005
  Parent Other Relative Non-Relative
  Number   %   Number   %   Number   %
Total Recipients 8,293   100.0   1,455   100.0   1,835   100.0  
Recipients w/ Any HCCa 6,740 81.3 1,055 72.5 1,261 68.7
Collapsed HCC Groupings
  Infectious and Parasitic Disease 1,055 12.7 156 10.7 171 9.3
  Neoplasms 334 4.0 38 2.6 43 2.3
  Endocrine, Nutritional & Metabolic Disorders 706 8.5 105 7.2 101 5.5
  Liver & Gallbladder Disease 80 1.0 10 0.7 7 0.4
  Gastro-Intestinal Disease 1,583 19.1 218 15.0 216 11.8
  Musculoskeletal/Connective Tissue 1,937 23.4 246 16.9 295 16.1
  Disease of the Blood & Blood Forming Organs 273 3.3 42 2.9 50 2.7
  Mental Disorders 859 10.4 140 9.6 131 7.1
  Mental Retardation/Developmental Disability 1,464 17.7 216 14.8 250 13.6
  Central Nervous System Injuries/Disorders 2,575 31.1 384 26.4 411 22.4
  Respiratory System Disease/Disorders 360 4.3 41 2.8 57 3.1
  Cardiovascular System 664 8.0 79 5.4 77 4.2
  Cerebral & Other Vascular System 1,302 15.7 200 13.7 203 11.1
  Pulmonary System 2,143 25.8 319 21.9 361 19.7
  Eyes & Vision Disorders 1,360 16.4 168 11.5 195 10.6
  Ear, Nose, & Throat Disorders 3,856 46.5 565 38.8 621 33.8
  Renal System 85 1.0 11 0.8 10 0.5
  Other Genitourinary System 924 11.1 142 9.8 136 7.4
  Pregnancy/Child Birth Complications 143 1.7 19 1.3 14 0.8
  Dermatological Disorders 1,218 14.7 186 12.8 190 10.4
  Fractures, Other Injuries, & Poisoning 1,146 13.8 169 11.6 238 13.0
  Treatment Complications, Ill-Defined Conditions   3,621 43.7 534 36.7 584 31.8
  Miscellaneous 2,318 28.0 345 23.7 367 20.0
SOURCE: California Department of Health Care Services, Medicaid claims, 2005. Counts apply to IHSS recipients not in Medicaid Managed for any month in calendar year 2005.
  1. HCC refers to Hierarchical Condition Classifications (Pope, Ellis, Ash, et al., 2000).


TABLE 10b: Summary of Health Conditions Among IHSS Recipients Age 18-64 by Provider Group, 2005
  Spouse Parent Other Relative Non-Relative
  Number   %   Number   %   Number   %   Number   %
Total Recipients 6,721   100.0   18,749   100.0   40,603   100.0   59,429   100.0  
Recipients w/ Any HCCa 6,003 89.3 13,789 73.5 36,362 89.6 52,197 87.8
Collapsed HCC Groupings
  Infectious and Parasitic Disease 791 11.8 1,655 8.8 4,511 11.1 8,006 13.5
  Neoplasms 865 12.9 981 5.2 5,604 13.8 7,643 12.9
  Endocrine, Nutritional & Metabolic Disorders 2,284 34.0 2,559 13.6 13,697 33.7 16,587 27.9
  Liver & Gallbladder Disease 494 7.4 539 2.9 2,594 6.4 4,133 7.0
  Gastro-Intestinal Disease 1,633 24.3 2,479 13.2 9,740 24.0 13,378 22.5
  Musculoskeletal/Connective Tissue 2,814 41.9 3,888 20.7 19,406 47.8 27,639 46.5
  Disease of the Blood & Blood Forming Organs 533 7.9 759 4.0 3,060 7.5 4,071 6.9
  Mental Disorders 741 11.0 1,967 10.5 5,112 12.6 9,425 15.9
  Mental Retardation/ Developmental Disability 19 0.3 1,143 6.1 385 0.9 650 1.1
  Central Nervous System Injuries/Disorders 1,080 16.1 4,025 21.5 5,386 13.3 9,627 16.2
  Respiratory System Disease/Disorders 279 4.2 489 2.6 1,419 3.5 2,093 3.5
  Cardiovascular System 2,548 37.9 2,321 12.4 16,984 41.8 19,959 33.6
  Cerebral & Other Vascular System 1,258 18.7 1,762 9.4 6,200 15.3 8,212 13.8
  Pulmonary System 1,739 25.9 2,804 15.0 10,869 26.8 15,659 26.3
  Eyes & Vision Disorders 1,123 16.7 1,468 7.8 7,991 19.7 8,825 14.8
  Ear, Nose, & Throat Disorders 1,355 20.2 3,899 20.8 8,664 21.3 12,019 20.2
  Renal System 809 12.0 576 3.1 2,813 6.9 2,980 5.0
  Other Genitourinary System 1,363 20.3 2,507 13.4 8,490 20.9 11,768 19.8
  Pregnancy/Child Birth Complications 45 0.7 147 0.8 194 0.5 449 0.8
  Dermatological Disorders 1,159 17.2 2,682 14.3 7,330 18.1 12,025 20.2
  Fractures, Other Injuries, & Poisoning 1,356 20.2 2,549 13.6 7,599 18.7 13,695 23.0
  Treatment Complications, Ill-Defined Conditions   3,778 56.2 6,277 33.5 22,972 56.6 32,156 54.1
  Miscellaneous 2,129 31.7 4,120 22.0 13,819 34.0 20,151 33.9
SOURCE:: California Department of Health Care Services, Medicaid claims, 2005. Counts apply to IHSS recipients not in Medicaid Managed for any month in calendar year 2005.
  1. HCC refers to Hierarchical Condition Classifications (Pope, Ellis, Ash, et al., 2000).


TABLE 10c: Summary of Health Conditions Among IHSS Recipients Age 65+ by Provider Group, 2005
  Spouse Other Relative Non-Relative
  Number   %   Number   %   Number   %
Total Recipients 4,656   100.0   109,260   100.0   95,551   100.0  
Recipients w/ Any HCCa 3,847 82.6 91,221 83.5 80,167 83.9
Collapsed HCC Groupings
  Infectious and Parasitic Disease 330 7.1 6,263 5.7 6,593 6.9
  Neoplasms 611 13.1 11,898 10.9 12,085 12.6
  Endocrine, Nutritional & Metabolic Disorders 1,047 22.5 18,517 16.9 15,975 16.7
  Liver & Gallbladder Disease 167 3.6 2,848 2.6 2,347 2.5
  Gastro-Intestinal Disease 812 17.4 16,924 15.5 16,041 16.8
  Musculoskeletal/Connective Tissue 1,246 26.8 34,101 31.2 32,979 34.5
  Disease of the Blood & Blood Forming Organs 270 5.8 5,311 4.9 4,893 5.1
  Mental Disorders 286 6.1 6,369 5.8 6,359 6.7
  Mental Retardation/Developmental Disability 1 0.0 32 0.0 32 0.0
  Central Nervous System Injuries/Disorders 251 5.4 3,604 3.3 3,566 3.7
  Respiratory System Disease/Disorders 149 3.2 1,821 1.7 1,658 1.7
  Cardiovascular System 1,842 39.6 41,481 38.0 36,234 37.9
  Cerebral & Other Vascular System 927 19.9 14,141 12.9 13,436 14.1
  Pulmonary System 936 20.1 18,348 16.8 16,283 17.0
  Eyes & Vision Disorders 662 14.2 18,109 16.6 16,198 17.0
  Ear, Nose, & Throat Disorders 354 7.6 8,407 7.7 7,630 8.0
  Renal System 414 8.9 4,064 3.7 3,045 3.2
  Other Genitourinary System 630 13.5 10,967 10.0 10,573 11.1
  Pregnancy/Child Birth Complications 4 0.1 66 0.1 58 0.1
  Dermatological Disorders 435 9.3 10,408 9.5 12,443 13.0
  Fractures, Other Injuries, & Poisoning 532 11.4 12,159 11.1 12,411 13.0
  Treatment Complications, Ill-Defined Conditions   2,115 45.4 45,290 41.5 41,474 43.4
  Miscellaneous 769 16.5 17,424 15.9 17,536 18.4
SOURCE: California Department of Health Care Services, Medicaid claims, 2005. Counts apply to IHSS recipients not in Medicaid Managed for any month in calendar year 2005.
  1. HCC refers to Hierarchical Condition Classifications (Pope, Ellis, Ash, et al., 2000).


TABLE 11: Mean Medicaid Expendituresa for IHSS Recipients by Observation Months and Age, 2005
  # Months     Variable   All Ages Age 3-17 Age 18-64 Age 65 or More
N Mean Std Dev N Mean Std Dev N Mean Std Dev N Mean Std Dev
1 Mean Total $ 7470 6429 21286 161 4952 22513 2737 6130 23623 4572 6660 19708
Average $/month     6429 21286   4952 22513   6130 23623   6660 19708
2 Mean Total $ 8143 7450 30155 156 5837 19420 2898 7912 24204 5089 7237 33315
Average $/month     3725 15078   2918 9710   3956 12102   3618 16657
3 Mean Total $ 8200 8519 33349 177 10462 40166 2943 9847 47735 5080 7682 20437
Average $/month     2840 11116   3487 13389   3283 15912   2561 6812
4 Mean Total $ 7924 9002 24208 187 9838 68754 2923 10424 28450 4864 8115 17077
Average $/month     2251 6052   2459 17189   2606 7112   2029 4269
5 Mean Total $ 8306 9799 26326 202 7215 19105 3088 11552 35135 5016 8824 19237
Average $/month     1960 5265   1443 3821   2310 7027   1765 3847
6 Mean Total $ 7792 10660 26714 215 7862 17845 2901 12913 36594 4676 9391 18409
Average $/month     1777 4452   1310 2974   2152 6099   1565 3068
7 Mean Total $ 8132 11137 25274 213 13057 51298 2958 13326 32396 4961 9749 17438
Average $/month     1591 3611   1865 7328   1904 4628   1393 2491
8 Mean Total $ 7964 11876 27485 211 11094 29938 2982 14251 39098 4771 10426 16145
Average $/month     1485 3436   1387 3742   1781 4887   1303 2018
9 Mean Total $ 8354 12747 30990 249 15776 41906 3139 15247 45601 4966 11016 14363
Average $/month     1416 3443   1753 4656   1694 5067   1224 1596
10 Mean Total $ 10274 13081 23861 322 13644 32412 4046 14329 24634 5906 12196 22713
Average $/month     1308 2386   1364 3241   1433 2463   1220 2271
11 Mean Total $ 12809 14854 28848 450 14279 30923 4905 17383 37615 7454 13224 20849
Average $/month     1350 2623   1298 2811   1580 3420   1202 1895
12 Mean Total $ 245976 12808 16164 8459 14592 32210 88293 14366 21113 149224 11785 10269
Average $/month     1067 1347   1216 2684   1197 1759   982 856
Grand Average Total   341394     12248     20017     11002     13802     33328     123813     13841     25951     206579     11211     14024  
$/month   1405 4872   1394 5030   1570 5522   1306 4425
SOURCE: California Department of Health Care Services, Medicaid claims, 2005
  1. Services included in the compilation of expenditures include personal assistance/home care, home health, inpatient hospital and nursing home care, physicians, clinics, outpatient departments, ancillary providers, physical/occupational/speech therapy, durable medical equipment, vision and hearing services, and mental health services. Excluded are payments for pharmacy products, and expenditure by Medicare, VA, out of pocket, or other payers.


TABLE 12: Mean Medicaid Expendituresa by IHSS Recipient Age and Provider Type, 2005
Variable All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean Std Dev n Mean Std Dev n Mean Std Dev n Mean Std Dev
Total 2005   341,394         11,002         123,813         206,579      
Grand Totalb     12248     20017       13802     33328       13841     25951       11211     14024  
  Mean $/month     1405 4872   1394 5030   1570 5522   1306 4425
Spouse 10,438     na     6282     4156    
  Mean Total $   7206 20109   na     8249 20883   5628 18771
  Mean $/month     954 3789   na     1075 4113   770 3232
Parent 26,410     7,785     18,625     na    
  Mean Total $   15089 28332   12313 33843   16250 25592   na  
  Mean $/month     1491 5010   1260 5400   1588 4835   na  
Other Relative 150,124     1,449     40,304     108,371    
  Mean Total $   11757 18246   18875 31935   13282 24991   11095 14605
  Mean $/month     1321 5031   1759 3196   1482 5534   1256 4850
Non-Relative 154,422     1768     58,602     94,052    
  Mean Total $   12581 19853   16198 31579   14060 27074   11591 13003
  Mean $/month     1502 4752   1686 4519   1679 5837   1388 3927
Continuing 290,000     9,529     103,608     176,863    
Grand Totalb   13275 20282   14878 34672   14883 26079   12247 14443
  Mean $/month     1433 4904   1444 5250   1548 5361   1366 4593
Spouse 8,749     na     5,301     3,448    
  Mean Total $   7482 20921   na na   8448 21493   5996 19922
  Mean $/month     919 3879   na na   1017 4173   769 3372
Parent 23,660     6,883     16,777     na    
  Mean Total $   15894 29049   13201 35325   16998 25961   na na
  Mean $/month     1515 5183   1311 5652   1598 4975   na na
Other Relative 125,782     1,223     32,973     91,586    
  Mean Total $   12785 18178   20224 30634   14318 24154   12134 15140
  Mean $/month     1363 5308   1798 2748   1480 5709   1315 5182
Non-Relative 131,809     1,423     48,557     81,829    
  Mean Total $   13657 20134   18392 34044   15238 27665   12637 13258
  Mean $/month     1520 4490   1781 4823   1635 5357   1447 3877
New Recipients 51,394     1,473     20,205     29,716    
Grand Totalb   6456 17349   6839 21529   8503 24603   5045 9011
  Mean $/month     1243 4687   1071 3253   1684 6280   952 3231
Spouse 1,689     na     981     708    
  Mean Total $   5775 15149   na na   7174 17190   3835 11482
  Mean $/month     1134 3284   na na   1392 3757   777 2441
Parent 2,750     902     1,848     na    
  Mean Total $   8170 19877   5535 17660   9457 20757   na na
  Mean $/month     1288 3152   868 2785   1493 3298   na na
Other Relative 24,342     226     7,331     16,785    
  Mean Total $   6448 17669   11576 37456   8625 27985   5428 9407
  Mean $/month     1105 3230   1547 4968   1489 4664   932 2282
Non-Relative 22,613     345     10,045     12,223    
  Mean Total $   6307 16806   7147 15150   8368 23188   4590 8234
  Mean $/month     1395 6053   1292 2920   1890 7746   991 4228
SOURCE: California Department of Health Care Services, Medicaid claims, 2005
  1. Services included in the compilation of expenditures include personal assistance/home care, home health, inpatient hospital and nursing home care, physicians, clinics, outpatient departments, ancillary providers, physical/occupational/speech therapy, durable medical equipment, vision and hearing services, and mental health services. Excluded are payments for pharmacy products, and expenditure by Medicare, VA, out of pocket, or other payers.


TABLE 13: Adjusted Mean Monthly Medicaid Expenditures by IHSS Recipient Age, 2005a
Predictors Age 3-17g
n=11,002 		Age 18-64
n=123,813		 Age 65+
n=206,579
B   Pr >|t|   B   Pr >|t|   B   Pr >|t|  
  Intercept   -1.056   **   -1.219   ****   -0.346   ****
Recipient Characteristicsb
  Female Recipient 0.114   -0.325 **** -0.073 ***
  Hispanic -0.080   -0.022   -0.098 ****
  Blacka -0.015   0.094 * -0.046  
  Asian/Other -0.056   -0.058   -0.012  
  3+ Cognitive Limitationsc -0.617 **** -0.745 **** -0.155 *
  3+ ADL Limitationsd 0.023   0.243 **** 0.189 ****
  Breathing Limitationse 1.681 **** 0.840 **** 0.151 ***
  Household size (1-5+)f 0.087   0.095 *** 0.049 ****
  Number Health Conditionsg 0.360 **** 0.345 **** 0.171 ****
IHSS Providersh
  Spouse Provider na   -0.979 **** -0.773 ****
  Parent Provider -0.920 **** -0.012   na  
  Relative Provider -0.049   -0.172 **** -0.103 ****
  Total Authorized Hours 0.008 **** 0.011 **** 0.011 ****
County Characteristics
  Per Capita Income 0.018 ** 0.008 **** 0.007 ****
New IHSS Recipient -0.019   0.270 **** -0.152 ****
Model Goodness of Fit
  Adjusted R2 .087 **** .057 **** .0268 ****
* p<0.05, ** p<0.01, *** p<0.001, **** p<0.0001
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The Medicaid Expenditures used as the basis for this analysis include reimbursement for personal assistance/home care, home health, inpatient hospital and nursing home care, physicians, clinics, outpatient departments, ancillary providers, physical/occupational/speech therapy, durable medical equipment, vision and hearing services, and mental health services. Not included are pharmacy-related reimbursements, and expenditures by Medicare, the VA, out of pocket, or other payers.
  2. Reference is White. Race/ethnicity Asian/Other by descending number, Chinese, Filipino, Vietnamese, Korean, Laotian, Cambodian, Asian Indian, American Indian or Alaskan Native, Japanese, Samoan, and all others.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Number of persons in household, including other IHSS recipients, excludes non-IHSS children <age 14.
  7. Refers to HCC, summing the number of each of 23 subgroups of this classification schema.
  8. Reference is Non-Relative provider, “na” means the provider type was not included in the model.


TABLE 14: Mean Monthly Medicaid Inpatient Expenditures by IHSS Recipient Age and Provider Type, 2005
Recipients All Ages Age 3-17 Age 18-64 Age 65 or More
n   Mean     Std Dev   n   Mean     Std Dev   n   Mean     Std Dev   n   Mean     Std Dev  
All Recipients   87508         1439         28881         57188      
Grand Total   7,182 29717   22543 47847   12708 41465   4005 19850
  Mean $/months     1,101 7728   2466 7540   1928 9611   649 6536
Spouse 3403     na     1923     1480    
  Mean Total $   8065 28046   na na   10717 28631   4619 26889
  Mean $/month     1184 5008   na na   1618 5711   620 3842
Parent 3745     1118     2627     na    
  Mean Total $   16375 45401   22454 46229   13787 44803   na na
  Mean $/month     2049 10189   2408 7557   1896 11120   na na
Other Relative 38236     166     9468     28602    
  Mean Total $   6766 28507   20237 48727   12553 40746   4771 22517
  Mean $/month     1023 8588   2125 5783   1798 9812   761 8140
Non-Relative 42124     155     14863     27106    
  Mean Total $   6671 29021   25652 57590   12873 42685   3162 15985
  Mean $/month     1081 6766   3249 8946   2056 9594   533 4400
Continuing 77671     1314     24625     51732    
Total   6986 29267   22577 47924   12369 40732   4028 20232
  Mean $/months     991 7547   2368 7571   1681 9213   627 6576
Spouse 2908     na     1657     1251    
  Mean Total $   8102 29014   na na   10640 29334   4740 28247
  Mean $/month     1097 5037   na na   1480 5699   591 3941
Parent 3401     1034     2367     na    
  Mean Total $   16215 46229   22705 47164   13379 45535   na na
  Mean $/month     1959 10522   2361 7727   1784 11530   na na
Other Relative 33737     146     7945     25646    
  Mean Total $   6639 27429   18534 39280   12289 37449   4821 23077
  Mean $/month     970 8884   1833 3848   1653 10017   753 8512
Non-Relative 37625     134     12656     24835    
  Mean Total $   6377 28761   25989 60698   12456 42978   3174 16159
  Mean $/month     914 5895   3002 9237   1705 8548   499 3800
New in 2005 9837     125     4256     5456    
Total   8724 33015   22190 47229   14669 45427   3779 15776
  Mean $/months     1972 8985   3502 7149   3355 11545   859 6136
Spouse 495     na     266     229    
  Mean Total $   7848 21516   na na   11199 23824   3956 17748
  Mean $/month     1692 4809   na na   2477 5717   779 3251
Parent 344     84     260     na    
  Mean Total $   17957 36226   19367 32655   17501 37355   na na
  Mean $/month     2932 5908   2994 5010   2911 6179   na na
Other Relative 4499     20     1523     2956    
  Mean Total $   7713 35553   32665 93057   13929 54816   4341 16888
  Mean $/month     1425 5907   4255 13113   2550 8630   826 3546
Non-Relative 4499     21     2207     2271    
  Mean Total $   9127 30998   23507 32131   15264 40891   3030 13936
  Mean $/month     2477 11654   4819 6772   4068 14008   910 8547
SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of either 50 (county hospital -- acute inpatient) or 60 (community hospital -- acute inpatient) indicating hospital inpatient claims. Expenditures shown under count expenditures in the IHSS recipient population as the figures shown exclude persons in managed care for portions of 2005. “na” means that expenditures were not compiled for this provider type.


TABLE 15: Unadjusted Probability of Medicaid-Paid “Any Cause” Hospital Days, 2005
Provider Type Any Inpatient Days
No Yes Total % Yes
Recipients Age 3-17
  Parent 6,667 1,118 7,785 14.3%
  Other Relative 1,283 166 1,449 11.5%
  Non-Relative   1,613 155 1,768 8.8%
  Total 9,563 1,439 11,002 13.1%
Recipients Age 18-64
  Spouse 4,359 1,923 6,282 30.6%
  Parent 15,998 2,627 18,625 14.1%
  Other Relative 30,836 9,468 40,304 23.5%
  Non-Relative 43,739 14,863 58,602 25.4%
  Total 94,932 28,881 123,813 23.3%
Recipients Age 65+
  Spouse 2,676 1,480 4,156 35.6%
  Other Relative 79,769 28,602 108,371 26.4%
  Non-Relative 66,946 27,106 94,052 28.8%
  Total   149,391     57,188     206,579     27.7%  
SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of either 50 or 60 indicating hospital inpatient claims. Events shown under count actual use as they exclude persons in managed care for portions of the period, and stays paid fully by non-Medicaid sources.


TABLE 16: Adjusted “Any Cause” Hospital Use by IHSS Recipient Age & Provider Type, 2005a
Predictors Age 3-17
n=11,002 		Age 18-64
n=123,813		 Age 65 or More
n=206,579
  Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
Recipient Characteristics
  Female Recipient 0.92 0.80-1.05 0.79 0.77-0.82 0.84 0.82-0.86
  Hispanicb 0.83 0.70-0.98 1.29 1.24-1.34 1.22 1.19-1.26
  Blackb 1.32 1.07-1.64 1.37 1.32-1.42 1.32 1.27-1.37
  Asian/Otherb 0.89 0.67-1.16 0.76 0.72-0.81 1.16 1.25-1.20
  Household size (1-5+) 1.03 0.97-1.10 0.99 0.98-1.00 1.03 1.02-1.04
  3+ Cognitive Limitationsc   0.60 0.50-0.73 0.42 0.38-0.46 0.67 0.62-0.72
  3+ ADL Limitationsd 0.92 0.76-1.11 1.15 1.11-1.20 1.17 1.13-1.20
  Breathing Limitationse 1.43 1.22-1.68 1.78 1.69-1.88 1.82 1.74-1.91
  Number Health Conditionsf 1.62 1.58-1.66 1.40 1.40-1.41 1.69 1.68-1.70
IHSS Providersg
  Spouse na   1.15 1.08-1.23 1.01 0.93-1.09
  Parent 1.09 0.88-1.34 0.73 0.69-0.77 na  
  Other Relative 1.12 0.85-1.46 0.91 0.88-0.94 0.97 0.95-0.99
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.01 1.00-1.01
County Characteristics
  Per Capita Income 1.00 0.99-1.01 1.00 1.00-1.01 0.99 0.99-0.99
New IHSS Recipient 0.56   0.44-0.70   0.67   0.64-0.70   0.43   0.42-0.45  
Model Goodness of Fit
  -2Log Likelihood 6132     108700       186851    
  Maximum Rescaled R2   0.364     0.284   0.348  
SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of either 50 or 60 indicating hospital inpatient claims. Events shown under count actual use as they exclude stays paid fully by non-Medicaid sources.
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCC.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.


TABLE 17: Unadjusted Probability of Medicaid-Paid Ambulatory Care Sensitive Condition-Related Hospital Days, 2005
Provider Type Any ACSC Inpatient Days
No Yes Total % Yes
Recipients Age 3-17
  Parent 7,657 128 7,785 1.6%
  Other Relative   1,430 19 1,449 1.3%
  Non-Relative 1,744 24 1,768 1.4%
  Total 10,831 171 11,002 1.6%
Recipients Age 18-64
  Spouse 5,752 530 6,282 8.4%
  Parent 18,016 609 18,625 3.3%
  Other Relative 37,500 2,804 40,304 7.0%
  Non-Relative 54,499 4,103 58,602 7.0%
  Total   115,767   8,046   123,813   6.5%
Recipients Age 65+
  Spouse 3,705 451 4,156   10.9%  
  Other Relative 99,487 8,884 108,371 8.2%
  Non-Relative 85,880 8,172 94,052 8.7%
  Total 189,072   17,507   206,579 8.5%
SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of either 50 or 60 indicating hospital inpatient claims. Events shown under count actual use as they exclude persons in managed care for portions of the period, and stays paid fully by non-Medicaid sources. ACSC refers to a set of conditions indicative of a potentially “avoidable” hospital stay. Separate standardized algorithms are used for children and adult age groups (AHRQ, 2007a, 2007b).


TABLE 18: Adjusted Ambulatory Care Sensitive Condition Hospital Use by IHSS Recipient Age and Provider Type, 2005a
Predictors Age 3-17
n=11,002		 Age 18-64
n=123,813		 Age 65 or More
n=206,579
OR 95% CI OR 95% CI OR 95% CI
Recipient Characteristics
  Female Recipient 1.10 0.80-1.51 0.79 0.75-0.83 0.86 0.83-0.90
  Hispanicb 0.98 0.65-1.47 1.35 1.27-1.44 1.31 1.26-1.37
  Blackb 1.56 0.94-2.56 1.68 1.59-1.78 1.38 1.30-1.45
  Asian/Otherb 1.43 0.75-2.72 0.92 0.83-1.02 1.23 1.17-1.29
  Household size (1-5+) 0.85 0.73-0.98 1.02 1.00-1.04 1.06 1.05-1.08
  3+ Cognitive Limitationsc   0.48 0.30-0.79 0.48 0.41-0.56 0.75 0.67-0.84
  3+ ADL Limitationsd 0.68 0.44-1.04 1.10 1.03-1.16 1.20 1.15-1.25
  Breathing Limitationse 1.31 0.92-1.88 2.62 2.44-2.80 2.60 2.48-2.74
  Number Health Conditionsf 1.48 1.41-1.55 1.32 1.31-1.33 1.36 1.36-1.37
IHSS Providersg
  Spouse na na 1.02 0.92 -1.14 0.86 0.78-0.97
  Parent 0.77 0.48-1.23 0.65 0.59-0.71 na na
  Other Relative 0.78 0.42-1.47 1.01 0.95-1.06 0.96 0.93-1.00
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.00 1.00-1.00
County Characteristics
  Per Capita Income 0.99 0.96-1.02 1.00 0.99-1.00 0.99 0.99-0.99
New IHSS Recipient 0.61   0.34-1.08   0.62   0.58-0.66   0.47   0.44-0.50  
Model Goodness of Fit
  -2Log Likelihood 1413     50844       104751    
  Maximum Rescaled R2   0.212     0.178   0.161  
SOURCE: Derived from California Department of Health Care Services, Medicaid claims (vendor codes 50 or 60) indicating hospital inpatient claims. Events exclude stays paid fully by non-Medicaid sources. OR refers to odds ratio, CI refers to confidence interval.
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCC.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.


TABLE 19: Unadjusted Probability of Medicaid-Paid Medical Care Use, 2005
Provider Type Any Use
No Yes Total % Yes
Recipients Age 3-17
  Parent 1,201 6,584 7,785 84.6
  Other Relative 434 1,015 1,449 70.0
  Non-Relative 597 1,171 1,768 66.2
  Total 2,232 8,770 11,002 79.7
Recipients Age 18-64
Spouse 351 5,931 6,282 94.4
  Parent 5,013 13,612 18,625 73.1
  Other Relative 4,549 35,755 40,304 88.7
  Non-Relative 7,579 51,023 58,602 87.1
  Total 17,492 106,321 123,813 85.9
Recipients Age 65+
Spouse 458 3,698 4,156 89.0
  Other Relative 20,755 87,616 108,371 80.8
  Non-Relative 16,919 77,133 94,052 82.0
  Total   38,132     168,447     206,579     81.5  
SOURCE: Derived from the California Department of Health Care Services, Medicaid claims. “Yes” means that a vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics) or a vendor group 6 (hospital outpatient departments, organized outpatient clinics) claim was present. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.


TABLE 20: Unadjusted Probability of Medicaid-Paid Medical Care Use, Including Emergency Rooms, by IHSS Recipients, 2005
Provider Type Any Use
No Yes Total % Yes
Recipients Age 3-17
  Parent 1,045 6,740 7,785 86.6
  Other Relative 395 1,054 1,449 72.7
  Non-Relative 534 1,234 1,768 69.8
  Total 1,974 9,028 11,002 82.1
Recipients Age 18-64
  Spouse 294 5,988 6,282 95.3
  Parent 4,756 13,869 18,625 74.5
  Other Relative 4,328 35,976 40,304 89.3
  Non-Relative 7,081 51,521 58,602 87.9
  Total 16,459 107,354 123,813 86.7
Recipients Age 65+
  Spouse 364 3,792 4,156 91.2
  Other Relative 18,906 89,465 108,371 82.6
  Non-Relative 15,256 78,796 94,052 83.8
  Total 34,526 172,053 206,579 83.3
SOURCE: Derived from the California Department of Health Care Services, Medicaid claims. “Yes” means that a vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics) or a vendor group 6 (hospital outpatient departments, organized outpatient clinics) claim, or an ER claim was present. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.


TABLE 21: Adjusted Medicaid-Paid Medical Care Use, Including Emergency Rooms, by IHSS Recipients,a 2005
Predictors Age 3-17
n=11,002		 Age 18-64
n=123,813		 Age 65 or More
n=206,579
  Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
Recipient Characteristics
  Female Recipient 0.98   0.82-1.18   0.93   0.88-0.98   0.94   0.90-0.97  
  Hispanicb 1.12 0.90-1.40 1.13 1.05-1.22 0.96 0.92-1.01
  Black 1.00 0.77-1.29 0.93 0.87-0.99 0.76 0.72-0.80
  Asian/Other 1.20 0.88-1.64 1.22 1.10-1.35 1.00 0.96-1.05
  Household size (1-5) 1.03 0.94-1.12 0.98 0.95-1.00 1.04 1.02-1.05
  3+ Cognitive Limitationsc 0.72 0.57-0.92 0.76 0.69-0.85 0.84 0.76-0.94
  3+ ADL Limitationsd 1.05 0.82-1.35 0.95 0.89-1.02 0.99 0.95-1.03
  Breathing Limitationse 0.95 0.72-1.26 1.03 0.92-1.16 0.99 0.92-1.07
  Number Health Conditionsf   19.9 17.0-23.4 10.6 10.2-11.0 7.44 7.27-7.61
IHSS Providersg
  Spouse na na 2.19 1.86-2.59 1.69 1.46-1.96
  Parent 1.54 1.23-1.92 0.83 0.78-0.90 na na
  Other Relative 0.94 072-1.26 1.05 0.98-1.12 1.03 1.00-1.07
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.00 1.00-1.00
County Characteristics
  Per Capita Income 0.99 0.98-1.00 0.99 0.99-0.99 1.00 1.00-1.00
New IHSS Recipient 0.18 0.14-0.23 0.07 0.06-0.08 0.05 0.05-0.05
Model Goodness of Fit
  -2Log Likelihood 3302   35258   87211  
  Maximum Rescaled R2 0.776   0.723   0.642  
SOURCE: Unpublished tables derived from California Department of Health Care Services, Medicaid claims. Events shown under count actual use as they exclude stays paid for fully by non-Medicaid sources. “na” not applicable
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. Any ER user counts were as follows: age 3-17, age 18-64, age 65+.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of 5 or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCC.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.


TABLE 22: Unadjusted Probability of Medicaid-Paid Emergency Room Visits by IHSS Recipients, 2005
Provider Type Any ER Use
No Yes Total % Yes
Recipients Age 3-17
  Parent 3,073 4,712 7,785 60.5%
  Other Relative   737 712 1,449 49.1%
  Non-Relative 965 803 1,768 45.4%
  Total 4,775 6,227 11,002 56.6%
Recipients Age 18-64
  Spouse 1,968 4,314 6,282 68.7%
  Parent 10,308 8,317 18,625 44.7%
  Other Relative 16,762 23,542 40,304 58.4%
  Non-Relative 22,389 36,213 58,602 61.8%
  Total 51,427 72,386 123,813 58.5%
Recipients Age 65+
  Spouse 1,474 2,682 4,156 64.5%
  Other Relative 53,957 54,414 108,371 50.2%
  Non-Relative 43,282 50,770 94,052 54.0%
  Total   98,713     107,866     206,579     52.2%  
SOURCE: Derived from California Department of Health Care Services, Medicaid claims, 2005


TABLE 23: Adjusted Medicaid-Paid Emergency Room Visits by IHSS Recipients,a 2005
Predictors Age 3-17
n=11,002		 Age 18-64
n=123,813		 Age 65 or More
n=206,579
  Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
Recipient Characteristics
  Female Recipient 0.96   0.87-1.06   0.84   0.82-0.87   0.89   0.87-0.91  
  Hispanicb 0.98 0.87-1.11 1.22 1.17-1.26 1.16 1.13-1.20
  Black 1.26 1.08-1.47 1.41 1.36-1.46 1.20 1.16-1.25
  Asian/Other 0.87 0.72-1.05 0.72 0.69-0.76 0.96 0.93-0.98
  Household size (1-5) 0.98 0.94-1.03 0.99 0.98-1.00 1.04 1.03-1.05
  3+ Cognitive Limitationsc 0.74 0.64-0.86 0.56 0.52-0.60 0.66 0.62-0.72
  3+ ADL Limitationsd 1.07 0.93-1.22 1.10 1.06-1.14 1.11 1.08-1.14
  Breathing Limitationse 1.70 1.46-1.97 1.86 1.75-1.98 2.00 1.91-2.10
  Number Health Conditionsf   1.88 1.84-1.93 1.72 1.71-1.73 2.01 1.99-2.02
IHSS Providersg
  Spouse na na 1.20 1.12-1.29 1.27 1.17-1.38
  Parent 1.10 0.96-1.25 0.83 0.80-0.87 na na
  Other Relative 0.99 0.83-1.18 0.80 0.77-0.83 0.95 0.93-0.97
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.01 1.01-1.01
County Characteristics
  Per Capita Income 0.99 0.99-1.00 0.99 0.99-1.00 0.99 0.99-1.00
New IHSS Recipient 0.45 0.38-0.52 0.45 0.43-0.46 0.35 0.34-0.36
Model Goodness of Fit
  -2Log Likelihood 10220   120103   205914  
  Maximum Rescaled R2 0.477   0.432   0.429  
SOURCE: Unpublished tables derived from California Department of Health Care Services, Medicaid claims. Events shown under count actual use as they exclude stays paid for fully by non-Medicaid sources. “na” not applicable
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCC.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.


TABLE 24: Mean Combined Medicaid-Paid Physician and Outpatient Department Expenditures by IHSS Recipients,a 2005
Variable All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev  
All Recipients   8,770         106,321         168,447         8,770      
Grand Total     1741   8061     1483   3975     408   1519     1741   8061
  Mean $/months     177 780   178 573   45 203   177 780
Spouse na     5,931     3,698     na    
  Period Mean Total $   na na   1641 4095   540 1916   na na
  Mean $/month     na na   192 533   62 270   na na
Parent 6,584     13,612     na     6,584    
  Period Mean Total $   1860 9123   1089 5400   na na   1860 9123
  Mean $/month     184 864   117 550   na na   184 864
Other Relative 1,015     35,755     87,616     1,015    
  Period Mean Total $   1454 2978   1591 3898   398 1466   1454 2978
  Mean $/month     145 342   183 555   44 207   145 342
Non-Relative 1,171     51,023     77,133     1,171    
  Period Mean Total $   1316 3272   1493 3534   414 1555   1316 3272
  Mean $/month     166 503   189 594   46 195   166 503
Continuing Recipients 7,765     90,277     150,437     7,765    
Grand Total   1799 8480   1477 3963   409 1537   1799 8480
  Mean $/months     172 798   158 524   42 187   172 798
Spouse na     5,028     3,114     na    
  Period Mean Total $   na na   1581 3931   531 1962   na na
  Mean $/month     na na   166 483   52 183   na na
Parent 5,905     12,474     na     5,905    
  Period Mean Total $   1920 9569   1062 5521   na na   1920 9569
  Mean $/month     181 895   106 527   na na   181 895
Other Relative 885     29,769     77,540     885    
  Period Mean Total $   1459 2733   1589 3805   394 1459   1459 2733
  Mean $/month     138 273   165 513   40 183   138 273
Non-Relative 975     43,006     69,783     975    
  Period Mean Total $   1380 3326   1508 3500   420 1599   1380 3326
  Mean $/month     147 387   167 533   43 192   147 387
New Recipients 1,005     16,044     18,010     1,005    
Grand Total   1287 3334   1515 4037   405 1353   1287 3334
  Mean $/months     218 619   292 786   75 303   218 619
Spouse na     903     584     na    
  Period Mean Total $   na na   1976 4898   586 1649   na na
  Mean $/month     na na   342 735   116 530   na na
Parent 679     1,138     na     679    
  Period Mean Total $   1345 3220   1385 3812   na na   1345 3220
  Mean $/month     211 523   244 747   na na   211 523
Other Relative 130     5,986     10,076     130    
  Period Mean Total $   1422 4302   1602 4333   426 1524   1422 4302
  Mean $/month     196 636   276 722   75 335   196 636
Non-Relative 196     8,017     7,350     196    
  Period Mean Total $   998 2974   1416 3714   361 1042   998 2974
  Mean $/month     260 869   304 840   72 220   260 869
SOURCE: Derived from the California Department of Health Care Services, Medicaid claims. Vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics), and 6 (hospital outpatient departments, organized outpatient clinics) are combined.
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The number of care recipients does not equal the number of eligible recipients due to the absence of vendor group 5 and 6 claims. “na” not applicable.


TABLE 25: Adjusted Mean Medicaid-Paid Medical Care Expenditures by IHSS Recipients, 2005a
Predictors Age 3-17g
n=8,770		 Age 18-64
n=106,318		 Age 65+
n=168,442
B   Pr >|t|   B   Pr >|t|   B   Pr >|t|  
  Intercept   -0.115   *   -0.193   ****   -0.026   ****
Recipient Characteristics
  Female Recipient -0.007   -0.027 **** -0.011 ****
  Hispanicb -0.039   0.006   -0.002  
  Blackb -0.009   0.020 **** 0.008 ****
  Asian/Otherb -0.028   0.004   -0.002  
  3+ Cognitive Limitationsc -0.022   -0.014   -0.000  
  3+ ADL Limitationsd -0.045 * 0.013 *** 0.004 **
  Breathing Limitationse 0.225   0.013 * -0.007 **
  Household size (1-5+)f 0.001   0.009 **** 0.002 ****
  Number Health Conditionsg   0.075 **** 0.062 **** 0.019 ****
IHSS Providersh
  Spouse Provider     -0.014   0.003  
  Parent Provider -0.015   0.002      
  Relative Provider -0.040   -0.014 *** 0.001  
  Total Authorized Hours 0.000   0.000   0.000  
County Characteristics
  Per Capita Income 0.001   0.001 **** 0.000 *
New IHSS Recipient 0.034   0.070 **** 0.017 ****
Model Goodness of Fit
  Adjusted R2 .067 **** .112 **** .048 ****
* p<0.05, ** p<0.01, *** p<0.001, **** p<0.0001
SOURCE: Derived from the California Department of Health Care Services, Medicaid claims. Vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics), and 6 (hospital outpatient departments, organized outpatient clinics) are combined. Expenditures are divided by 1,000.
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The number of care recipients may not equal the number of eligible recipients due to missing expenditure values or negative claims amounts.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Number of persons in household, including other IHSS recipients, excludes non-IHSS children <age 14.
  7. Refers to HCC, collapsed into 23 subgroups, count is unduplicated number of these groupings.
  8. Reference is Non-Relative provider, “na” means the provider type was not included in the model.


TABLE 26: Mean Monthly Medicaid-Paid Home and Community-Based Care Expenditures by IHSS Recipients, 2005a
Variable All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev  
Community-Based Care
Grand Total 49   5786   8807 5192   12108   28274 34954   6605   5407 49   5786   8807
  Average $/month   556 900   1149 2677   620 565   556 900
Spouse                        
  Period Mean Total $   na na na 200 12065 22573 601 6766 11390 na na na
  Average $/month   na na   1133 2025   639 983   na na
Parent                        
  Period Mean Total $ 29 3940 4238 719 26201 43946 na na na 29 3940 4238
  Average $/month   373 408   2292 3710   na na   373 408
Other Relative                        
  Period Mean Total $ 10 9450 11803 1708 8366 17624 15899 6766 4607 10 9450 11803
  Average $/month   981 1486   793 1619   634 515   981 1486
Non-Relative                        
  Period Mean Total $ 10 7478 13761 2565 10653 27644 18454 6452 5730 10 7478 13761
  Average $/month   661 1130   1068 2851   608 586   661 1130
IHSS
Grand Total   3964   8509 7202   114743   8127 6774   198656   7639 5329   3964   8509 7202
  Average $/month   776 624   747 570   715 456   776 624
Spouse                        
  Period Mean Total $ na na na 1128 4410 5766 756 3734 4509 na na na
  Average $/month   na na   402 509   356 422   na na
Parent                        
  Period Mean Total $ 1109 5780 5500 18352 11132 8400 na na na 1109 5780 5500
  Average $/month   519 520   980 701   na na   519 520
Other Relative                        
  Period Mean Total $ 1415 9628 7428 39710 7105 5509 107004 7470 5087 1415 9628 7428
  Average $/month   869 621   663 462   702 436   869 621
Non-Relative                        
  Period Mean Total $ 1440 9510 7575 55553 7939 6713 90896 7871 5587 1440 9510 7575
  Average $/month   881 643   738 570   733 476   881 643
Any Unskilled Home Care
Grand Total 3983 8539 7327 115070 8650 9759 199622 8759 6580 3983 8539 7327
  Average $/month   779 639   797 865   820 575   779 639
Spouse                        
  Period Mean Total $ na na na 1279 5776 11452 1208 5703 9330 na na na
  Average $/month   na na   532 1024   541 818   na na
Parent                        
  Period Mean Total $ 1127 5789 5553 18381 12140 13726 na na na 1127 5789 5553
  Average $/month   521 522   1068 1157   na na   521 522
Other Relative                        
  Period Mean Total $ 1415 9695 7579 39731 7461 7056 107109 8468 6086 1415 9695 7579
  Average $/month   876 647   697 610   795 534   876 647
Non-Relative                        
  Period Mean Total $ 1441 9556 7742 55679 8412 9529 91305 9140 7050 1441 9556 7742
  Average $/month   885 656   786 885   852 614   885 656
SOURCE: Derived from California Department of Health Care Services, Medicaid claims, 2005, vendor codes 71 (HCBS), 73 (AIDS waiver), 81 (MSSP), and 89 (IHSS).
  1. Number of home care recipients does not equal the number of eligible recipients, as those in hospitals, nursing homes, or community facilities, or who may have no paid providers in a month do not receive IHSS payments.


TABLE 27: Adjusted Mean Monthly Medicaid-Paid Home and Community-Based Care Expenditures by IHSS Recipients, 2005a
Predictors Age 3-17g
n=3,983		 Age 18-64
n=115,070		 Age 65+
n=199,622
  B Pr >|t| B Pr >|t| B Pr >|t|
  Intercept -0.075   -0.246 **** -0.104 ****
Recipient Characteristicsb
  Female Recipient 0.019   -0.030 **** 0.001  
  Hispanic 0.021   -0.000   -0.087 ****
  Blacka 0.016   -0.009   -0.072 ****
  Asian/Other 0.032   0.003 ** -0.032 ****
  3+ Cognitive Limitationsc -0.209 **** -0.472 **** -0.288 ****
  3+ ADL Limitationsd 0.089 **** 0.058 **** 0.062 ****
  Breathing Limitationse 0.061 ** 0.272 **** -0.028 ****
  Household size (1-5+)f -0.012   0.003 * -0.007 ****
  Number Health Conditionsg 0.005 * -0.001 * 0.001 ***
IHSS Providersh
  Spouse Provider na   -0.430 **** -0.341 ****
  Parent Provider -0.520 **** -0.030 **** na  
  Relative Provider 0.027   0.003   -0.007 ****
  Total Authorized Hours 0.006 **** 0.009 **** 0.009 ****
County Characteristics
  Per Capita Income 0.009 **** 0.009 **** 0.009 ****
New IHSS Recipient -0.022   -0.022 **** 0.048 ****
Model Goodness of Fit
  Adjusted R2 .570 **** .412 **** .547 ****
* p<0.05, ** p<0.01, *** p<0.001, **** p<0.0001
SOURCE: Medicaid claims-records maintained by the California Department of Health Care Services. Expenditures were compiled using vendor codes 71 (HCBS waiver), 73 (AIDS waiver services), 81 (MSSP waiver services), and 89 (IHSS). The number of home care recipients may not equal the number of eligible recipients, as those in hospitals, nursing homes, or community facilities do not receive IHSS payments.
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. Number of home care recipients does not equal the number of eligible recipients, as those in hospitals, nursing homes, or community facilities, or who may have no paid providers in a month do not receive IHSS payments.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 Paramedical Services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Number of persons in household, including other IHSS recipients, excludes non-IHSS children <age 14.
  7. Refers to HCC, collapsed into 23 subgroups, count is unduplicated number of these groupings.
  8. Reference is Non-Relative provider, “na” means the provider type was not included in the model.


TABLE 28: Mean Monthly Medicaid-Paid Home Health Care Expenditures by IHSS Recipients, 2005a
  Age 3-17 Age 18-64 Age 65 or More
n Mean Std Dev n Mean Std Dev n Mean Std Dev
Home Health Care
Grand Total   882     52075     49281     4492     2613     11376     526     1200     3398  
  Average $/month   4970 6161   283 1017   151 387
Spouse na na na            
  Period Mean Total $   na na na 280 1244 1590 30 1222 1349
  Average $/month na na na   160 273   176 185
Parent             na na na
  Period Mean Total $ 642 52571 49723 552 9359 25834 na na na
  Average $/month   5069 6682   890 2275 na na na
Other Relative                  
  Period Mean Total $ 109 55393 49214 1392 1527 7112 302 1159 3661
  Average $/month   4925 4283   163 616   141 362
Non-Relative                  
  Period Mean Total $ 131 46887 47101 2268 1807 7081 194 1259 3199
  Average $/month   4523 4644   224 668   163 443
SOURCE: Unpublished tables derived from California Department of Health Care Services, Medicaid claims using vendor code 44 (home health agency), 2005. “na” not applicable.
  1. Number of home health care recipients may not equal the number of eligible recipients, as those in hospitals, nursing homes, or community facilities do not receive IHSS payments.


TABLE 29: Unadjusted Probability of Medicaid-Paid Nursing Home Stays by IHSS Recipients, 2005
Provider Type Any Nursing Home Stays
No Yes Total % Yes
Recipients Age 3-17
  Parent 10,458 31 10,489 0.30%
  Other Relative   2,077 3 2,080 0.14%
  Non-Relative 2,473 5 2,478 0.20%
  Total 15,008 39 15,047 0.26%
Recipients Age 18-64
  Spouse 7,097 179 7,276 2.46%
  Parent 23,043 271 23,314 1.16%
  Other Relative 48,041 991 49,032 2.02%
  Non-Relative 67,757 1,911 69,668 2.74%
  Total 145,938 3,352 149,290 2.25%
Recipients Age 65+
  Spouse 4,253 318 4,571 6.96%
  Other Relative 116,693 5,771 122,464 4.71%
  Non-Relative 95,745 7,375 103,120 7.15%
  Total   216,691     13,464     230,155     5.85%  
SOURCE: Derived from Medicaid claims maintained by the California Department of Health Care Services. Nursing home use identified by vendor codes 47 ICF-DD), and 80 (nursing facility).


TABLE 30: Adjusted Medicaid-Paid Nursing Home Use by Adult IHSS Recipients, 2005a
Predictors Age 18-64
n=149,290		 Age 65 or More
n=230,155
  Odds Ratio   95% CI   Odds Ratio   95% CI
Recipient Characteristics
  Female Recipient 0.89   0.83-0.95   0.98   0.94-1.02  
  Hispanicb 0.95 0.86-1.04 0.96 0.92-1.01
  Blackb 0.94 0.86-1.02 1.17 1.11-1.23
  Asian/Otherb 0.78 0.67-0.89 0.80 0.76-0.84
  Householdsize (1-5) 0.96 0.93-0.98 0.95 0.93-0.96
  3+ Cognitive Limitationsc   0.34 0.28-0.42 0.95 0.86-1.05
  3+ ADL Limitationsd 1.52 1.40-1.66 1.35 1.29-1.41
  Breathing Limitationse 1.16 1.03-1.30 1.16 1.08-1.23
IHSS Providersf
  Spouse 0.82 0.70-0.97 0.98 0.86-1.10
  Parent 0.44 0.38-0.50 na  
  Other Relative 0.83 0.77-0.90 0.70 0.68-0.73
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00
County Characteristics
  Per Capita Income 1.02 1.01-1.02 1.00 1.00-1.00
New IHSS Recipients 1.09 0.99-1.20 0.87 0.82-0.92
Managed Care=yes 0.29 0.25-0.34 0.34 0.31-0.37
Model Goodness of Fit
  -2Log Likelihood 30885   98977  
  Maximum Rescaled R2 0.041   0.043  
SOURCE: Derived from Medicaid claims maintained by the California Department of Health Care Services. Nursing home use was identified using vendor codes 47 ICF-DD), and 80 (nursing facility). The number of nursing home users age 3-17 (n=34) not included as the group was too small for reliable logistic models. Nursing home users age 18-64 or age 65+ may not equal the number of actual users, if the use was paid solely from non-Medicaid sources.
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Reference is Non-Relative provider, “na” means the provider type was not included in the model.


TABLE 31: Mean Monthly Medicaid-Paid Nursing Home Expenditures by IHSS Recipients, 2005
Recipients All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev  
All Recipients   16855         39         3352         13464      
Grand Total     12287   15963     46041   66074     12313   17314     12183   15124
  Mean $/months   3661 8777   19649 50432   3268 7496   3713 8631
Spouse 497     na     179     318    
  Period Mean Total $     10372 15958   na na   10877 16319   10088 15770
  Mean $/month   2924 7724   na na   3049 9282   2853 6705
Parent 302     31     271     na    
  Period Mean Total $   19504 33318   45108 69752   16575 24759   na na
  Mean $/month   5628 19777   20782 54946   3895 8438   na na
Other Relative 6765     3     991     5771    
  Period Mean Total $   11945 15184   26480 12769   11890 15827   11947 15070
  Mean $/month   3255 7870   4195 2505   2778 6151   3337 8129
Non-Relative 9291     5     1911     7375    
  Period Mean Total $   12405 15585   63558 65007   12063 16784   12458 15130
  Mean $/month   3932 8857   21897 36348   3453 7788   4044 9062
Continuing 14861     36     2811     12014    
Grand Total   12786 16438   49071 67906   12962 18068   12637 15507
  Mean $/months   3755 9005   21178 52250   3288 7694   3812 8805
Spouse 425     na     156     269    
  Period Mean Total $   10884 16790   na na   11239 17027   10679 16680
  Mean $/month   3057 8201   na na   3219 9888   2964 7059
Parent 267     29     238     na    
  Period Mean Total $   20865 34634   47927 71304   17568 25399   na na
  Mean $/month   5962 20889   22182 56597   3986 8671   na na
Other Relative 6004     3     837     5164    
  Period Mean Total $   12374 15538   26480 12769   12478 16365   12349 15400
  Mean $/month   3367 7995   4195 2505   2852 6345   3450 8231
Non-Relative 8165     4     1580     6581    
  Period Mean Total $   12924 16065   74305 69747   12695 17612   12942 15533
  Mean $/month   4005 9084   26636 40147   3421 7935   4131 9280
New in 2005 1994     3     541     1450    
Grand Total   8568 11163   9684 10268   8943 12166   8426 10771
  Mean $/months   2962 6807   1302 1484   3162 6374   2891 6968
Spouse 72     na     23     49    
  Period Mean Total $   7349 9203   na na   8420 10237   6846 8743
  Mean $/month   2133 3803   na na   1895 2593   2245 4274
Parent 35     2     33     na    
  Period Mean Total $   9117 17813   4240 5750   9412 18291   na na
  Mean $/month   3079 6429   483 622   3236 6592   na na
Other Relative 761     0     154     607    
  Period Mean Total $   8560 11491         8696 12052   8526 11354
  Mean $/month   2377 6745         2377 4964   2377 7130
Non-Relative 1126     1     331     794    
  Period Mean Total $   8635 10794   20572 --   9048 11634   8447 10425
  Mean $/month   3406 6979   2939 --   3607 7057   3323 6953
SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of 47 (ICF-DD) or 80 (nursing facility) indicating nursing home inpatient claims.


NOTES

  1. The SSI is a federally funded income support program (Social Security Act, Title XVI) for the aged, blind, and disabled. The SSP is a state program that supplements the SSI income level. SSI/SSP benefits in California (as in most states) are administered by the Social Security Administration (SSA). Eligibility for both programs is determined by SSA using federal criteria for income and assets. Benefits are in the form of cash assistance (CDSS, 2003, SSI Eligibility).

  2. About 2.2% of IHSS recipients did not meet income limits for at least one month in 2005, and paid a “share of cost” for services in those months where their income exceed Medicaid eligibility levels.

  3. Medicaid is a federal program (Social Security Act, Title XIX) that provides health and long-term care coverage for low-income families and aged, blind, or disabled individuals. Medi-Cal is the term California uses for Medicaid.

  4. Community care facility placement, and mortality risk were initially considered as potential programs as well. However, the indicator of placements in the IHSS recipient termination status field was found to be unreliable. Mortality similarly is not fully documented on IHSS records as death often occurs after a hospital admission and may not be recorded in the IHSS record. An attempt was made to obtain Medicaid eligibility records that have this information, but these were not made available to project.

  5. The federally funded Cash and Counseling Demonstration has reported positive experience from the Florida program which allows payments to parents of minors in the consumer-directed program for children with developmental disabilities. Reports from the demonstration are available at http://www.cashandcounseling.org.

  6. Qualitative interviews explored a number of issues with both waiver and non-waiver recipients and their families (Newcomer & Scherzer, 2006). Among these were the other caregiving arrangements that had been tried; why they elected (or did not elect) to participate as a paid Parent/Spouse provider; or to accept or not accept the benefits of Advance Pay or Restaurant Meal vouchers; and whether being a paid Parent or Spouse provider affected Medicaid, SSI, or other program eligibility.

  7. The initial planning for this project had hoped to include information from community care licensing (CCL). CCL is a division within DSS responsible for licensing supportive housing. Such data would have allowed us to identify any months (either before or subsequent to IHSS receipt) in which the study’s IHSS recipients lived in licensed residential care facilities and/or adult care facilities. This phase of the project was precluded by the recipient confidentiality terms of the Data Sharing Agreements negotiated between the University of California and the study’s three collaborating state departments.

  8. These procedures assure autonomy of recipients and comply with the protection of human subjects protections procedures approved by the Committee on Human Research, University of California, San Francisco (approval #H945-28245), and the California State Committee on the Protection of Human Subjects (approval #06-02-03).

  9. CDER provides developmental, mental health, and medical diagnostic information; and information on hearing, vision, behavioral medication, health care equipment, behavior risk assessment, legal information, motor domain assessment, independent living domain assessment, social skills domain assessment, emotional needs assessment, cognitive domain assessment, and communication domain assessment. POS data identifies provider fiscal information for both state general funds and Medicaid DDS waiver funded service use and expenditure. These later data are also available in Medi-Cal claims files. To assure consistency in the source of Medicaid expenditures, we limited our attention to the claims files.

  10. Provider attributes such as race/ethnicity, age, and gender are available in CMIPS, but other than relationship to the recipient, these data were not used in the analysis.

  11. Appendix B, Table B-1 shows the distribution of the study samples’ race/ethnicity groups, by recipient age group and provider type by new recipients in 2005 and those continuing from 2004.

  12. Measures of living arrangement, such as housing type, having a live-in provider, and various shared housing arrangements were incompletely coded in assessments and correlated with household size. Consequently, only household size was used.

  13. Within CMIPS there is a calculated unmet need, defined to be the difference in total need hours and authorized hours. This measure was not used because it is confounded by ceilings on the maximum number of authorized hours (283 hours/month) used by IHSS, and non-transparent adjustments made for household composition or unmeasured changes in status. An alternative unmet need measure derived from the difference between authorized hours and paid hours was considered. This measure proved to be problematic as the distribution of hours per week is not determinable from the monthly payment data. Consequently, there may be unmet hours in particular days or weeks that are masked by accumulated monthly billings.

  14. IADLs included in CMIPS are housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside one’s home. Each task is scored on a five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance fro the provider, 4 Can perform with a lot of human assistance, 5 Cannot perform without human assistance. This measure is not included in the analysis because of the absence of variance. Across all provider groups, 85% or more of the recipients have four or more limitations with a score of three or higher.

  15. The project considered using the CDER and the POS file -- both from DDS. Together, these provide recipient assessment information and service use data. However, given the proportionately small number of IHSS recipients in these data sets, and the incomparability of the assessment measures with those in CMIPS, the redundancy with salient POS items with those in Medicaid claims, the decision was made to limit age and provider analysis to the uniform common data available from CMIPS and Medicaid claims.

  16. The CMS-HCC model was developed for Medicare using claims data to provide risk adjustment for Medicare capitation payment rates (Pope, Kautter, Ellis, et al., 2004). This method has been extensively tested for predictive validity among aged and disabled persons; and with both community and institution-based populations.

  17. Diagnoses from other claims records (including home health providers, durable medical equipment providers, skilled nursing homes, ambulatory surgery centers, hospice, clinical laboratories, radiology/imaging) are excluded. The basis for these exclusions are practical. This is due to poor predictive power found in the development of the HCC model, and concern about the reliability of the diagnoses from non-physicians, or confusion arising from the coding of “rule-out” diagnoses that sometimes appears on laboratory or imaging records.

  18. Applications of HCCs for prospective payment protocols require that the diagnoses be obtained from the baseline (i.e., prior) year. These classifications are used as the basis for reimbursement in the subsequent year. This model evolved from multiple studies over two decades (e.g., Ash, Porell, Gruenberg, et al., 1989; Ellis, Pope, Iezzoni, et al., 1996). Clinical applications of HCC or other condition groups, such as for assignment of members/patients into special clinics or care management panels, have found improved prediction of service use and expenditures if concurrent diagnoses are incorporated into the classification (Dudley, Medlin, Hammann, et al., 2003). Because of this and evidence that using a single year to identify diagnoses for an individual may lead to an under counting of conditions and a bias toward classifying beneficiaries who have higher cost (e.g., those with hospital stays or frequent or specialty physician visits) (Newcomer, Clay, Luxenberg, Miller, 1999), we have elected to use concurrent year claims in HCC assignment. Even with this adjustment there is still a concern that chronic condition prevalence and service use are under reported in the IHSS recipient population. This occurs for several reasons. First, Medicaid reimbursed service use is reliably reported only for those in fee for service. Services covered under managed care capitation agreements (such as hospitals, skilled nursing facilities, physicians, and other health care providers) do not usually generate a billing or reimbursement claim. Managed care enrollees are omitted from any analysis involving diagnostic classifications or counts of conditions. Secondly, recipients dually eligible for Medicare or other payers such as the Veterans Administration may have services exclusively or substantially paid for by these sources. In such circumstances, there will be no or fewer Medicaid claims and diagnoses reported. A third factor is that Medicaid claims have fields for recording only two diagnoses. When a patient has (or their service claim involves) more than two conditions, then the number of diagnoses will be under reported on the claim. This may result in some conditions not being recorded on the claims records. These factors are not thought to be differentially distributed within recipient age groups or their provider types.

  19. Table D-4 and Table D-5 in Appendix D show the conditions used to identify ACSC outcomes.

  20. The original work plan also included the generation of Medicaid claims data for 2004. This information was compiled, but as the analyses reported are largely focused on comparisons of IHSS continuing from 2004 and new IHSS recipients in 2005, we have limited the presentation of data to 2005, differentiating new recipients. Payments via other state programs, and non-state sources are not represented. For example, expenses reimbursed by Medicare will under report total use and expenditures as some claims are reimbursed solely by this non-Medicaid source or for which Medicaid payment is limited to co-payments and deductibles. These limitations primary concern the expenditures for recipients who are dually eligible for Medicare and Medicaid. Service events, such as a hospital stay, usually have at least a Medicaid co-payment, and can be identified. Data on Medi-Cal eligible months in the period was not available to the project, but we do have months of IHSS eligibility.

  21. Residential care facilities for the elderly (RCFEs), adult residential facilities (ARFs), community care facilities (CCFs) beds are licensed by the DSS to provide room, board, and some levels of IADL and ADL support (ARFs service non-aged adults, CCFs serve the developmentally disabled, both those under and over age 18); nursing home beds, and state developmental centers (hospital-like settings for the developmentally disabled) and intermediate care facilities-DD and ICF-DD-H beds (freestanding nursing homes that specialize in custodial care for persons with developmental disabilities) are licensed by the Department of Health Care Services. These facilities in a county were initially considered as competing alternatives to IHSS use, but these services were found to be more associated with selection into IHSS, than IHSS use once in the program. Consequently, these measures were dropped from the analyses predicting provider type or health outcomes.

  22. Most prevalent are Chinese, Filipinos, and Vietnamese. Table B-1 in Appendix B, shows the distribution of expanded race/ethnicity categories for continuing and entering recipients in 2005.

  23. Laundry is scored as 1, 4 or 5; shopping and errands as 1, 3 or 5; eating as 1, 5 or 6; breathing as 1, 5 or 6; memory, orientation and judgment as 1, 2 or 5. Meal preparation and eating both include a six point score.

  24. Table B-2 in Appendix B provides the frequency distribution of the functional task limitations of IHSS recipients in 2005.

  25. See Appendix B, Table B-4 for a listing of personal income per capita by county.

  26. A full listing of HCCs by age and IHSS provider is included in Appendix D.

  27. This difference is illustrated in Table B-3, Appendix B. These show claims records among recipients in and not in managed care in 2005. For inpatient care, physician, durable medical equipment, medical transportation, and most ancillary services, those in managed care have one-third or fewer the number of vendor service claims compared to those not in managed care. While some of this difference may be related to case mix, similar differentials are not present in services (including IHSS and HCBS waivers) billed directly to Medicaid and not included in managed care capitation agreements.

  28. Appendix C provides an analysis of IHSS recipient and county factors associated with provider use, and whether managed care participation is associated with provider selection, after adjusting for recipient attributes. Managed care membership was used in the estimated models to assess whether enrollment in these Medicaid plans might be biased relative to the various provider types. Among minor children there was generally no significant difference in membership among those with each type of provider. The exception was a marginally significant difference with those having Non-Relative providers being less likely to be in managed care. For recipients age 18-64, managed care members were more likely among those with Parent and Spouse providers, and less likely among those with Other Relatives and Non-Relative providers. For recipients age 65+, managed care members were more likely among Spouse and Other Relative providers, and less likely among Non-Relatives. Recipients with greater propensity toward managed care participation may have a bias toward fewer chronic health conditions and lower Medicaid expenditures. Analyses within age group, adjusting for other risk factors may help minimize this differential effect, but it cannot fully eliminate any systematic bias if healthier (or sicker) persons enroll in managed care.

  29. Appendix C extends the descriptive findings using logistic regression to adjust for recipient differences within a provider group. Separate analyses were conducted by recipient age group to assess the adjusted association of recipients and the “selection” of provider type. These analyses also evaluated the relative value of using IHSS wage rate as a proxy for county IHSS policy. Conclusions coming from these analyses were that the comparison of provider effects on recipient outcomes could be accommodated by using models which compare effects associated with provider type rather than using separate models by provider type of those using predicted provider types as covariates. IHSS modal wage rates were used with all comparisons being made to Los Angeles and Fresno Counties which reflect 45% of all IHSS recipients statewide and the statewide median IHSS wage rate. Among minor children, the comparison of recipients in counties across all modal IHSS wage levels found few statistically significant provider choice differences from the reference counties. The exception was that in counties with modal hourly wages of $10 or more, the likelihood of a parent being a paid provider reduced relative to the likelihood of recipients in the reference counties. No differences were found for the other provider groups. Recipients age 18-64 offer a somewhat similar pattern. Parents in counties with modal IHSS wages above $9 per hour were less likely to be paid providers, and there was a modest tendency for Non-Relatives to assume the provider role. The choice of Spouse provider was positive across wage rate levels, suggesting that choice of spouses was not related to IHSS wage rates. Among aged recipients, the prior pattern for Spouse providers holds, accept in the highest wage rate counties, which do not differ from the reference counties. Across all but the highest wage rates, counties show a tendency toward more Other Relative providers and somewhat less likelihood of Non-Relative providers than in the reference counties.

  30. A series of equations that included interactions between provider type and the number of chronic conditions were evaluated. These items did not sufficiently improve the fit of the model to be retained in the analyses presented. Additionally, the ordinary least squares analyses were replicated using logarithm transformations of the expenditures measures instead of raw expenditures data. These models generally had higher R2 values, but as the results testing whether the coefficients on the Parent and Spouse provider measures were significantly different from Non-Relative providers were consistent (in terms of the direction of the sign) with those in the non-transformed models we have elected to report only models with the non-transformed data. These models have the advantage of being in dollar units, and more readily understandable than the percentage comparisons possible using the logarithm transformations.

  31. The association of provider type with expenditures was evaluated as both a main effect, and as the interaction of provider type and the number of the recipient’s health conditions. The interaction models did not improve the model and were not retained.

  32. Additional models were estimated to test the stability of the provider findings. These included models limited to those with 12-month participation, and those with fewer than 12 months. The former had higher R2 values, the latter, lower R2 values. This is consistent with the higher variability in this latter group. In spite of these differences in model fit, the effect of provider type remained relatively constant. There were no changes in statistical significance or direction of effect, nor in substantively meaningful magnitude. Analyses were also conducted using the logarithm of expenditures. These models produce findings consistent with the non-transformed models. They are available on request.

  33. For example, it is likely that Medicare will be the primary payer for health care expenditures by the aged and those non-aged disabled adults eligible for Medicare due to their disability. Similarly, the VA is the primary payer for medical care among qualified veterans if they elect to use VA facilities.

  34. Similar analyses were conducted using logistic regression models comparing medical care use, excluding the use of ERs. The results relative to IHSS provider groups and in comparisons of non-White race/ethnic groups were similar to the results in Table 21. They are available in Appendix D, Table D-1.

  35. Separate tables showing unadjusted results for physician service use and outpatient department use can be found in Appendix D.

  36. Separate models were also run using interaction main effects, but these did not significantly change the model goodness of fit and have not been used.

  37. State, county and federal programs not represented in the Medicaid claims system are not included here.

  38. Variations on these analyses include separate sets of models for IHSS expenditures, non-IHSS expenditures, and combined expenditures. Each set of models was estimated using only recipients having 12 months of participation in 2005, only those having fewer than 12 months, and then all recipients regardless of the number of participation months in the year. Models limited to persons with 12 months of participation had the largest proportion of explained variance, those with fewer than 12 months the least, but all models yielded similar findings with respect to provider affects, and the comparison between new and continuing and IHSS recipients. Non-IHSS recipient models for minor children were estimated due to the small recipient counts.

  39. These results are similar to models estimating only IHSS and only other home care waiver service expenditures, see Appendix F.

  40. Persons in managed care have been included in these analyses, as Medicaid claims for non-skilled nursing home care are available. Custodial nursing home care is not included under managed care capitation payments. Tables showing the likelihood of nursing home place among IHSS recipients, excluding those in managed care are in Appendix F, Table F-1. The exclusion of the managed care recipients, results in minor changes in the percentages, approximately 0.05% among minor children, and 0.2% among adult recipients.

  41. Provider by health condition interaction terms were tested in earlier models, but were not statistically significant. Estimates involving recipients age 3-17 are omitted from Table 30, as there were too few cases to estimate reliable models. Appendix F, Table F-2 shows the logistic regression results for models excluding managed care recipients. These results are very similar to those shown in Table 30.

Main Report: http://aspe.hhs.gov/daltcp/reports/2008/IHSSPlus.htm

Appendices: http://aspe.hhs.gov/daltcp/reports/2008/IHSSPlus2.htm