Revisiting The Name Game: A Taxonomy of Home and Community-Based Services National Home and Community Based Services Conference September 14, 2011 Jean Accius Ralph Lollar Centers for Medicare & Medicaid Services Steve Eiken, Thomson Reuters Carol Irvin, Mathematica Policy Research
HCBS Taxonomy Description Steve Eiken Thomson Reuters Community Living Systems 2
Purpose of the HCBS Taxonomy The purpose of the taxonomy is to better understand what services are being provided The taxonomy organizes a broad range of HCBS services into an orderly classification of services The taxonomy describes existing services and may need to change in future years to accommodate new services 3
Potential Uses of the Taxonomy Identify states that provide a certain service in a 1915(c) waiver, even if they use a different name Compare waiver service utilization and expenditures across states Provide national data regarding service availability, utilization, and expenditures 4
Taxonomy Methodology: Directed Content Analysis The University of Minnesota Institute for Community Integration provided expertise regarding qualitative analysis and recommended a three-step approach: 1. Use existing knowledge from theory and research to identify key concepts 2. Analyze text starting with the key concepts to determine if new or different concepts apply 3. Test the analysis results to identify additional concepts or other changes necessary 5
Taxonomy Methodology: Initial Analysis 1. Use existing knowledge: Thomson Reuters developed an initial taxonomy based on a review of previous categorization efforts and interviews with CMS staff and other experts 2. Analysis of text: Thomson Reuters reviewed all service definitions in the Waiver Management System for approved programs as of July 2009 (159 1915(c) waivers and 9 PRTF demonstrations) using NVivo qualitative analysis software. Services were added and changed based on this analysis. 6
Taxonomy Methodology: Testing and Refinement 3. Test the analysis results: Several testing methods were used for this final step in the Directed Content Analysis: A working group identified by state associations (NASDDDS, NASHIA, NASMHPD, NASMD, NASUAD) reviewed the taxonomy for clarity and consistency. Staff from 10 states and one Area Agency on Aging, identified by the state associations, applied the taxonomy to existing waivers. Thomson Reuters verified the taxonomy included services described in 2008 MSIS procedure code data for 1915(c) waivers provided by Mathematica Policy Research. 7
Version 1 of the HCBS Taxonomy Thomson Reuters submitted Version 1 of the HCBS Taxonomy in September 2010, which included 82 services. Feedback received during and after fall 2010 conference presentations indicated the number of services was too large to concisely summarize HCBS, so a clear categorization structure was necessary. 8
Development of Version 2 of the HCBS Taxonomy Thomson Reuters and Mathematica each developed recommendations to revise Version 1: Thomson Reuters grouped services into categories based on common instances where two or more taxonomy services were in a single Waiver Management System service entry Mathematica attempted to apply Version 1 to 2008 MSIS claims data for 1915(c) waivers and recommended fewer services and a slightly different categorization scheme Thomson Reuters and Mathematica reached consensus regarding recommendations and jointly submitted Version 2 in April 2011. 9
Version 2 of the HCBS Taxonomy: Overview Version 2 contains 66 services within 17 categories. In some instances, a middle sub-category level identifies similar services within a category. For example, the category Caregiver Support includes the sub-category respite and the services respite, inhome and respite, out-of-home. The categories, sub-categories, and services are arranged in order of consideration when mapping a state service to the taxonomy. 10
Category 01: Case Management Service 01.01: case management 11
Category 02: Round-the-Clock Services Service 02.01: residential mental health services Service 02.02: residential substance abuse services Sub-category 02.03: group living Service 02.03.1: group living, residential habilitation Service 02.03.2: group living, other Sub-category 02.04: family living Service 02.04.1: family living, residential habilitation Service 02.04.2: family living, other Sub-category 02.05: in-home round-the-clock services Service 02.05.1: in-home residential habilitation Service 02.05.2: in-home round-the-clock services, other 12
Category 03: Supported Employment Service 03.01: job development Sub-category 03.02: ongoing supported employment Service 03.02.1: ongoing supported employment, competitive Service 03.02.2: ongoing supported employment, individual Service 03.02.3: ongoing supported employment, group 13
Category 04: Day Services Service 04.01: prevocational services Service 04.02: day habilitation Service 04.03: education services Service 04.04: day treatment/partial hospitalization Service 04.05: adult day health/adult day care Service 04.06: community integration Service 04.07: medical day care for children 14
Category 05: Nursing Service 05.01: private duty nursing Service 05.02: skilled nursing 15
Category 06: Home Delivered Meals Service 06.01: home delivered meals 16
Category 07: Rent and Food Expenses for Live-In Caregiver Service 07.01: rent and food expenses for live-in caregiver 17
Category 08: Home-Based Services Service 08.01: home-based habilitation Service 08.02: home health aide Service 08.03: personal care Service 08.04: companion Service 08.05: homemaker/chore 18
Category 09: Caregiver Support Sub-category 09.01: respite Service 09.01.1: respite, out-of-home Service 09.02.1: respite, in-home Service 09.02: caregiver counseling and/or training 19
Category 10: Other Mental Health and Behavioral Services Service 10.01: mental health assessment Service 10.02: assertive community treatment Service 10.03: crisis intervention Service 10.04: behavior support Service 10.05: peer specialist Service 10.06: counseling Service 10.07: psychosocial rehabilitation Service 10.08: clinic service Service 10.09: substance abuse treatment 20
Category 11: Other Health and Therapeutic Services Service 11.01: health monitoring Service 11.02: health assessment Service 11.03: medication assessment Service 11.04: nutritional consultation Service 11.05: physician services Service 11.06: prescription drugs Service 11.07: dental services Service 11.08: occupational therapy Service 11.09: physical therapy Service 11.10: speech, hearing, and language therapy Service 11.11: respiratory therapy Service 11.12: cognitive rehabilitative therapy Service 11.13: other therapies 21
Category 12: Services Supporting Participant Direction Service 12.01: financial management services Service 12.02: information and assistance in support of participant direction 22
Category 13: Participant Training Service 13.01: participant training 23
Category 14: Equipment, Technology, and Modifications Service 14.01: personal emergency response systems (PERS) Service 14.02: home and vehicle accessibility adaptations Sub-category 14.03: equipment, technology, and supplies Service 14.03.1: equipment and technology Service 14.03.2: supplies 24
Category 15: Non-Medical Transportation Service 15.01: non-medical transportation 25
Category 16: Community Transition Services Service 16.01: community transition services 26
Category 17: Other Services Service 17.01: goods and services Service 17.02: interpreter Service 17.03: housing consultation Service 17.99: other 27
For More Information, contact: Steve Eiken Community Living Systems Thomson Reuters steve.eiken@thomsonreuters.com (651) 687-1136 28
Applying the HCBS Taxonomy to Person-Level Medicaid Data Carol Irvin on Behalf of: Audra Wenzlow, Victoria Peebles, and Stephen Kuncaitis Mathematica Policy Research 29
Background Person-level HCBS data help identify: Which HCBS beneficiaries use What care plans/services are effective Who benefits most How HCBS can be improved Medicaid administrative data could be useful for HCBS studies: Evaluation of the Money Follows the Person demonstration Comparative effectiveness research 30
Medicaid Administrative Files MSIS = Medicaid Statistical Information System Person-level eligibility, claims, and some encounter data submitted by all states quarterly since 1999 MAX = Medicaid Analytic extract Enhanced research files derived from MSIS containing characteristics of the approximately 60 million persons enrolled in Medicaid annually and the services they use during a calendar year 31
HCBS Information in MAX Claims-level HCBS information Whether service was covered under a 1915(c) waiver Procedure codes Place of service (home, nursing facility, etc.) Type of service (personal care, home health, etc.) Person-summary level information Monthly and annual 1915(c) enrollment (since 2005) Summary person-level expenditures by type of service and waiver coverage (since 2005) 32
Limitations of HCBS Data in MAX Type of service coding is incomplete Over 50% of waiver claims are reported as Other Service type definitions and thus reporting varies across states Procedure code use is inconsistent Same procedure codes are used for different services Although HIPAA requires use of national procedure codes, some state-specific codes are still used Some HCBS types have no national procedure codes 33
Potential Solutions Develop HCBS taxonomy Ask states to report to MSIS using taxonomy Implement new taxonomy in MAX using procedure codes, place of service, etc. Implementable with existing data Time intensive 34
Project: Apply Taxonomy in MAX 2008 Map procedure codes into new taxonomy Consult with states on appropriate reporting Assess the quality of reporting 35
Methods in Detail Used HCBS claims from 44 states and the District of Columbia Excluded 2 states that did not operate HCBS waivers in 2008 4 states whose HCBS waiver claims could not be reliably identified 36
Methods in Detail (continued) Mapped all procedure codes into 66 distinct taxonomy services for each state Assigned each HCBS waiver claim to a taxonomy category and service based on the mapping Calculated the share of total national HCBS waiver expenditures contributed by each taxonomy category and service 37
Key Findings 38
Three Services Dominate Waiver Expenditures 13.2% 15.6% In 2008, 45 states provided $25.8 million in HCBS waiver services 7.0% 41.2% Round the clock services Home based services Day services Other taxonomy services Unspecified services 23.0% Source: Mathematicaanalysis of 2008 MSIS Claims Data from 44 states and the District of Columbia 39
Several Taxonomy Services are Small in Expenditure Terms Service Category Case management Other mental and behavioral health services Caregiver support Non-medical transportation Nursing services Supported employment Participant training All other service categories Share of Total Waiver Expenditures 3.3 percent 2.8 percent 2.0 percent 1.3 percent 1.2 percent 1.1 percent 1.0 percent < 1.0 percent each 40
A Few States Dominate National Expenditures 7 states accounted for 52 percent of total waiver expenditures California, Florida, Illinois, Minnesota, New York, Ohio, and Texas 41
One Service Category Frequently Dominates at the State Level One taxonomy service category dominates expenditures in half the states Either round-the-clock services or home-based services Service Category Proportion Of Total Waiver Expenditures in the State Number of States Round-the-clock Over 50 percent 15 states Home-based Over 50 percent 8 states Caregiver Over 10 percent 3 states 42
States Offer Broad Range of Services 41 of 45 states provided 10 or more unique HCBS taxonomy service categories 43 of 45 states provided home-based, day services, caregiver support, and equipment 43
Data Quality Issues 44
MSIS Reporting Often Consistent with Waiver Applications Category Number of States Reporting in MSIS Percentage of States Reporting Coverage in MSIS or WMS Case management 37 out of 40 92.5% Round-the-clock 39 out of 42 92.9% Day services 43 out of 44 97.7% Home-based 43 out of 45 95.6% Caregiver support 43 out of 44 97.7% Services supporting participant direction Rent and food for live-in caregiver 13 out of 25 52.0% 1 out of 6 16.7% 45
Some State-Specific Data Anomalies Remain 2 states, incomplete reporting of procedure codes 1 state, local codes that could not be interpreted 7 states, unspecified services accounted for over 20 percent of waiver expenditures 46
Summary 47
Overall, The Taxonomy Works Well Provides researchers and policymakers more detailed information on HCBS 48
Precautions for Use Service definitions vary within and across states Taxonomy works best at the category level (17 categories) When the 66 service types are required, focus on states with the most complete data 49
How States Can Improve their Data Improve identification of waiver enrollment and claims 13 states appear to have misreported either waiver claims or waiver enrollment in MSIS in either 2007 or 2008 Improve place of service reporting Helps to differentiate assisted living from other types of residential services in-home habilitation from fixed-site day services in-home respite from out-of-home respite 50
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 51
Additional Work Needed Something similar for state-plan HCBS More work on understanding the continuum of care 52
For More Information Please contact: Carol Irvin, Mathematica Policy Research cirvin@mathematica-mpr.com Jean Accius, Centers for Medicaid & Medicare Services Jean.Accius@cms.hhs.gov 53