HCBS Taxonomy Development. Steve Eiken Truven Health Analytics

Transcription

1 HCBS Taxonomy Development Steve Eiken Truven Health Analytics 1

2 Purpose of HCBS Taxonomy An important characteristic of 1915(c) Waivers and 1915(i) State Plan Amendments is state flexibility to identify new services and supports One consequence is that it is difficult to know what is happening in HCBS at a national level Measuring what occurs is a necessary step to demonstrating the effectiveness of HCBS The HCBS taxonomy creates an orderly classification of services so CMS can aggregate data 2

3 Uses of the HCBS Taxonomy The taxonomy can be used in a variety of analyses, such as: What are the outcomes resulting from a particular service? What states provide a particular service? How many people use a service or group of services? 3

4 History of Taxonomy Development Version 1 was developed in 2009 using Directed Content Analysis 1. Used existing knowledge from previous research to identify an initial draft 2. Revised the draft based on an analysis of service definition text from 159 HCBS waivers in the on-line Waiver Management System as of July 2009, using NVivo qualitative analysis software 3. Tested the draft taxonomy using a working group of state associations; a pilot using staff from 10 states and one Area Agency on Aging; and a review of procedure codes submitted in MSIS

5 History of Taxonomy Development, pg. 2 Feedback indicated Version 1 had too many services and did not have a clear categorization structure Version 2 was developed in jointly by Truven Health and Mathematica Policy Research Truven Health proposed a categorization scheme based on common instances where two or more taxonomy services were in a single Waiver Management System service entry Mathematica applied Version 1 to 2008 MSIS claims data for 1915(c) waivers and recommended fewer services and a categorization scheme 5

6 History of Taxonomy Development, pg. 3 Version 2 was jointly submitted April 2011 Subsequent revisions reflected additional feedback from CMS, state associations, and a 2012 pilot with state and CMS staff 6

7 HCBS Taxonomy Pilot Occurred April July 2012 Twelve states applied the taxonomy to 15 waivers and one draft 1915(i) benefit. Five of the waivers were being renewed, and CMS Central and Regional staff reviewed the states use of the taxonomy for these five waivers Truven Health reviewed all 15 waivers and the draft 1915(i) benefit Truven Health compared the use of the taxonomy between States and CMS and States and Truven Health 7

8 HCBS Taxonomy Pilot Findings Both CMS and Truven Health agreed with state use of the taxonomy 85% of the time In most instances of disagreement, the state used multiple taxonomy services when Truven Health or CMS believed only one service was necessary For example, a personal care service was listed as both personal care and homemaker, because the provider sometimes does housekeeping tasks 8

9 HCBS Taxonomy Revisions The pilot revealed that some service definitions in the taxonomy were not clear Truven Health submitted a revised taxonomy that changed service definitions to clarify when a state does not need to use multiple services CMS approved the revised taxonomy 9

10 Next Steps CMS plans to implement the taxonomy in State Plan Amendments and Waiver applications for 1915(c) Waivers and the 1915(i) State Plan HCBS benefit CMS is considering implementation for Medicaid authorities that are not explicitly for HCBS (e.g., 1115 and 1915(b) waivers) Mathematica Policy Research is applying a draft taxonomy to 1915(c) waiver claims in the Medicaid Analytic extract (MAX) file for

11 Applying the HCBS Taxonomy to Person-Level Medicaid Data Julie Sykes Mathematica Policy Research 11

12 Medicaid Administrative Files EL PS IP IP MMIS (MSIS) LT MAX LT RX RX OT OT 12

13 Medicaid Administrative Files MSIS Files (Medicaid Statistical Information System) Produced by the state s Medicaid Mgmt Info System Quarterly since 1999 Person-level enrollment Claims and encounter data adjudicated in the quarter MAX Files (Medicaid Analytic extract) Researcher-friendly version Calendar year Enrollment in the CY Services provided in the CY 13

14 HCBS in MAX - Historical MSIS TOS MAX TOS CLTC FLAG HCBS TAXONOMY * Personal Care * Private Duty Nursing * Home Health * Rehabilitation * Targeted Case Mgmt * Transportation * Hospice * DME * Residential Care * Psych Svcs * Adult Day Svcs * Community Based LTC * 21 categories by: (c) Waiver Services - Non-Waiver Services * Pgm Type and MAX TOS * Too many with TOS = Other * Version 2 * 17 categories * 66 services 14

15 HCBS Conceptual to Implementation Examine service code, service code flag, service code modifier, MSIS TOS, place of service Assign HCBS Taxonomy When in doubt, consult state documentation, websites, and staff; Truven Health; and other stakeholders 15

16 HCBS Implementation Examples National HCPCS E0100-E0159 (cane, crutches, walkers) eq t and technology National CPT code (Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes) nutrition consultation National Codes with State s Differentiation MN T2017 (Habilitation, residential, waiver; 15 minutes), modifier U shared living, residential habilitation MT T2016 (Habilitation, residential, waiver; per diem ), place of service = group home group living, residential habilitation State Codes LA - Z0060 (Environmental modifications lift) home accessibility and/or vehicle accessibility 16

17 HCBS in MAX 2010 HCBS Taxonomy field added to each OT claim 18 HCBS waiver expenditure fields added to the PS records (17 plus unknown category) Total waiver expenditures Number of people with waiver services Average waiver expenditures per user 17

18 Importance of HCBS Taxonomy Stakeholder-approved categories Consistent definition across all 51 states, even if they use a different name for the service Takes into account the national and statespecific service codes More specific than MSIS Type of Service More nuanced and more meaningful to researchers 18

19 State-Specific Analysis Distribution of HCBS Waiver Expenditures Case Management Round-the-Clock Services Supported Employment Day Services Home-Based Services Caregiver Support Other Mental Health and BHS Other Health and Therapeutic Services Equipment, Technology, and Modifications Other Services Unknown 19

20 Cross-State Analysis Round-the-Clock Total Waiver Expenditures $450,000,000 $400,000,000 $350,000,000 $300,000,000 $250,000,000 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $0 ALABAMA ALASKA DELAWARE INDIANA IOWA 20

21 Cross-State Analysis Round-the-Clock Average Waiver Expenditures $80,000 $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 ALABAMA ALASKA DELAWARE INDIANA IOWA 21

22 MAX 2010 Timeline MAX 2010 Production began in April 2012 Data will be available July states may not be ready due to delays in MSIS file submissions by the states 22

23 How States Can Improve their Data Use specific national HCPCS codes Choose Assisted living, adult foster care, supported living, and group living 24-hour private-duty nursing and short-term skilled nursing In-home respite and out-of-home respite Specific assistive technologies, supplies, and home adaptations Instead of Residential habilitation or general residential Unspecified nursing care Respite in unspecified location Unspecified personal items, miscellaneous therapeutic items and supplies, or supplies not otherwise specified 23

24 Quality of State s Data is Important Use national service codes when possible Use state-specific service codes as needed (please be specific in your service definitions) Waiver enrollment and waiver services should align Be thoughtful about MSIS TOS Place of service helps to differentiate Assisted living from other types of residential svcs In-home respite from out-of-home respite 24

25 For More Information Steve Eiken, Truven Health, Julie Sykes, Mathematica Policy Research MAX website Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/ MAXGeneralInformation.html Research data assistance center: 25