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Medicare and Medicaid Home Health and Medicaid Waiver Services for Dually Eligible Older Adults: Risk Factors for Use and Correlates of Expenditures

Correspondence: Address correspondence to Richard H. Fortinsky, PhD, Center on Aging, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030-5215. E-mail: fortinsky{at}nso1.uchc.edu

	Abstract

TOP Abstract Background Design and Methods Results Discussion References

 
Purpose: The purpose of this work was to, among frail dually eligible older adults, determine risk factors for the likelihood of using Medicare home health and Medicaid home health services and to, among service users, determine correlates of Medicare home health, Medicaid home health, and Medicaid waiver service expenditures. Design and Methods: Dually eligible individuals enrolled in Connecticut's Medicaid home- and community-based services (HCBS) waiver program for the aged (N = 5,232) were identified from a statewide database containing person-level linked data from Medicare claims, Medicaid claims, and uniform clinical assessment forms. Expenditures, based on claims data, were observed from the month following clinical assessment over the period August 1995 to December 1997. Results: In multivariate models controlling for medical conditions and sociodemographic variables, similar functional disability measures were strongly associated with the probability of the use of, and expenditures for, Medicare home health and Medicaid home health services; severe cognitive impairment was strongly associated with greater Medicaid waiver service expenditures. Implications: Given the similarity of factors associated with Medicare and Medicaid home health service use and expenditures, greater integration of Medicare and Medicaid financing, reimbursement, and delivery strategies for home health services may be feasible and warranted for dually eligible older adults enrolled in state Medicaid HCBS waiver programs.

Key Words: Medicare and Medicaid integration • Dual eligibles • Linked data • Functional disability • Home- and community-based care

Because of their vulnerabilities, dually eligible beneficiaries often require a comprehensive set of acute and long-term care services. They may, however, be confronted with a lack of clinical care continuity as well as administrative and funding fragmentation between Medicare and Medicaid programs. Although innovative programs such as On Lok and Program of All-Inclusive Care for the Elderly (PACE) replication sites have been established to address these problems, they currently operate only in selected locales and serve limited numbers of clients (Bodenheimer, 1999; Eng, Pedulla, Eleazer, McCann, & Fox, 1997). Meanwhile, several states are considering or developing integrated care systems for dually eligible beneficiaries because of the growing magnitude of their impact on state Medicaid budgets (U.S. Government Accounting Office [GAO], 2000). Better information about dually eligible beneficiaries is essential in planning these initiatives, in obtaining necessary federal approvals, and in developing creative reimbursement strategies to integrate Medicare and Medicaid funding streams and service-delivery mechanisms (Clark & Hulbert, 1998; Miller & Weissert, 2003). Such information would be especially beneficial to help integrate Medicare and Medicaid services for frail community-dwelling dually eligible older adults who are eligible for nursing facility admission, similar to the target populations in On Lok and PACE replication sites.

To address these knowledge gaps, we studied a sample of dually eligible older adults enrolled in a Medicaid home- and community-based services (HCBS) waiver program in the State of Connecticut. By federal law, Medicaid HCBS waiver program clients in all states must be classified as eligible for nursing home admission; therefore, medically and functionally, they closely resemble On Lok and PACE program clients, for whom integrated Medicare and Medicaid financing strategies have already been developed. We sought to determine whether similar risk factors were associated with the use of and expenditures for both Medicare-reimbursed and Medicaid-reimbursed services to stimulate more widespread discussions among public policy makers and service providers about evidence required to develop more integrated Medicare and Medicaid initiatives for frail dually eligible older adults residing in a given geographic area.

Specifically, this article addresses two major questions: In a sample of Medicaid HCBS waiver program for the aged clients, (a) What risk factors are associated with the likelihood of using Medicare home health and Medicaid home health services? (b) Among those who use services, what are the most important correlates of Medicare home health care expenditures, Medicaid home health expenditures, and Medicaid waiver service expenditures?

	Background

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Connecticut and the Medicaid HCBS Waiver Program
The Medicaid HCBS waiver program was established in 1981 as part of the Omnibus Budget Reconciliation Act and is limited to individuals living at home who would otherwise require the level of care provided in nursing facilities (Harrington, Carrillo, Wellin, Miller, & LeBlanc, 2000; O'Keeffe, 1996). States may target Medicaid HCBS programs to specific groups of individuals such as older adults (aged), younger adults with physical disabilities (disabled), and individuals with mental retardation or developmental disabilities. States also have flexibility to establish need criteria for Medicaid HCBS waiver program eligibility (Harrington et al., 2000). Connecticut, like most states, gives greatest weight to medical and nursing needs and functional needs when determining waiver program eligibility (O'Keeffe, 1996). Eligibility criteria for the Medicaid HCBS waiver program for the aged did not change in Connecticut during the study period. The range of Medicaid waiver services provided in Connecticut is similar to that of services provided in most states' Medicaid HCBS waiver programs for the aged (O'Keeffe, 1996). However, the Connecticut Medicaid program does not offer a personal care services benefit in addition to the Medicaid home health benefit, and no Medicaid-managed care program is available for older adults in Connecticut.

To place the Medicaid HCBS waiver program for the aged in the context of Connecticut's older dually eligible population during the study period, in 1995–1996, there were an estimated 27,000 Medicare beneficiaries aged 65 and older in Connecticut also covered by Medicaid (Lamphere, Brangan, Bee, & Semansky, 1998). In 1996, an estimated 18,000 of these dually eligible older adults resided in nursing facilities (Bectel & Graves, 1998); therefore, an estimated 9,000 dually eligible older adults lived at home. The average monthly caseload in the Medicaid HCBS waiver program for the aged during state fiscal year (SFY) 1996 was 4,442 (Connecticut Department of Social Services, 1997). Therefore, approximately 50% of Connecticut's dually eligible older population living at home during the study period was enrolled in the Medicaid HCBS waiver program.

Focus on Functional Disability and Cognitive Impairment as Risk Factors and Correlates
Numerous studies have shown that functional disability, measured most often as dependence in personal activities of daily living (ADL) and instrumental ADL (IADL), is a major predictor of home care use (Branch et al., 1988; Coughlin, McBride, Perozek, & Liu, 1992; Fortinsky, Granger, & Seltzer, 1981; Fried, Bradley, Williams, & Tinetti, 2001; Kemper, 1992; Madigan, Tullai-McGuinness, & Neff, 2002; Solomon, Wagner, Maremberg, Acampora, Cooney, & Inouye, 1993). However, none of these studies examined Medicare and Medicaid home health care use in the same cohort of dually eligible older adults.

Cognitive impairment is characterized by memory loss, compromised judgment, and impaired decision-making skills. Alzheimer's disease, the most common cause of cognitive impairment, affects an estimated 4 million older Americans today; prevalence is expected to reach 14 million by the year 2040 (Costa et al., 1996; Evans et al., 1992; Small et al., 1997). Several studies based on Medicare claims data found that Medicare expenditures are considerably higher for beneficiaries with Alzheimer's disease and other types of cognitive impairment compared with those without such a diagnosis (Newcomer, Clay, Luxenberg, & Miller, 1999; Taylor & Sloan, 2000; Weiner, Powe, Weller, Shaffer, & Anderson, 1998). From the perspective of the Medicaid program, cognitive impairment has been implicated as a risk factor for greater use of long-term care services among community-dwelling older adults, but little evidence exists to support this contention. Moreover, uniform clinical measures of cognitive impairment are not routinely incorporated into eligibility criteria for Medicaid home- and community-based care programs (Fogel, Brock, Goldscheider, & Royall, 1994; O'Keeffe, 1999).

	Design and Methods

TOP Abstract Background Design and Methods Results Discussion References

 
Sources of Data
Results in this article are based on data from the Connecticut Long Term Care Health (CLTC) database constructed for the Connecticut Department of Social Services by JEN Associates, Inc. (Cambridge, MA). The CLTC database contains data extracted from Medicare and Medicaid claims and linked at the person level and aggregated into monthly Medicare and Medicaid expenditures for a wide variety of covered health services. In this work, we focused on monthly expenditures for Medicare home health services, Medicaid home health services, and services covered by Connecticut's Medicaid HCBS waiver program (hereafter referred to as Medicaid waiver services). Claims data from the CLTC database relevant to this study cover the time period August 1995 to December 1997.

The CLTC database also contains clinical assessment data linked at the person level to claims data for dually eligible individuals served by Medicaid waiver services for the aged. Clinical assessments were done using the uniform assessment tool known as the Modified Community Care Assessment tool (O'Keeffe, 1996), which was developed for use in Connecticut by adapting measures of medical, functional, and behavioral problems from a variety of sources. This tool is used to finalize waiver-program eligibility determination, determine service needs for eligible clients, and calculate whether a plan of care can be developed that will safely and cost-effectively meet the client's needs in the community (O'Keeffe, 1996). The lag between clinical assessment and medical eligibility determination is usually 30 days. Clinical assessments are conducted annually after eligibility is established.

Study Cohort
Individuals from the CLTC database were considered eligible for the study cohort if they had a clinical assessment completed between July 1995 and June 1997, followed by at least 1 month of Medicaid waiver program for the aged eligibility. We chose this time period because claims data in the CLTC database were truncated at December 1997, and we chose to allow each eligible individual the opportunity to accumulate Medicare and Medicaid expenditures for at least 6 months following the clinical assessment. For clients with more than one assessment form in the database between July 1995 and June 1997, the first assessment form was used in this study; for some clients, this assessment was the initial assessment that determined waiver program eligibility, and for others, this assessment was an annual assessment conducted for continuing waiver program clients. These selection criteria yielded a sample size of 5,232 unduplicated individuals in the study cohort.

Variable Measurement: Dependent Variables
Our two goals in constructing dependent variables were to (a) classify each cohort member as either using or not using Medicare and Medicaid home health and Medicaid waiver services and (b) calculate, among service users, expenditure measures with policy relevance. We constructed an observation period for each cohort member over which these Medicare and Medicaid expenditures were identified and accumulated. The start month for the observation period was defined as the first month following the clinical assessment month that the client was eligible for the Medicaid waiver program (nearly always the immediately following month, except when new clients delayed seeking financial eligibility for Medicaid), and the end month was either December 1997 or the last month before December 1997 that the client was eligible for the Medicaid waiver program.

Three separate types of services were measured: (a) Medicare home health services, (b) Medicaid home health services, and (c) Medicaid waiver services.

Medicare home health services include skilled nursing, home health aide, physical therapy, occupational therapy, speech therapy, and medical social work. Expenditures for these six services cannot be disaggregated in the CLTC database; therefore, we report expenditures for all Medicare home health services combined.

Medicaid home health services include skilled nursing and home health aide, but because they cannot be disaggregated in the CLTC database, we report expenditures for these two services combined.

Medicaid waiver services include supportive in-home and community-based services covered under Connecticut's Medicaid HCBS waiver program for the aged. Three services accounted for >80% of Medicaid waiver expenditures in SFY 1996: homemaker (44%), case management (21%), and adult day health (16%); home-delivered meals and personal emergency response systems accounted for most of the remainder of expenditures (Connecticut Department of Social Services, 1997). These services cannot be disaggregated in the CLTC database; therefore, we report expenditures for all Medicaid waiver services combined.

The first set of dependent variables was dichotomous: Cohort members with any identified expenditures of each service type were distinguished from cohort members with no identified expenditures.

Among service users, expenditure measures were constructed by dividing total expenditures accumulated by the total number of months in the observation period, thereby adjusting total expenditures for the specific number of months eligible for the Medicaid waiver program. Expenditures are therefore expressed as "per client per month." This measurement approach was chosen to maximize policy relevance; monthly capitated Medicare rates per client are often negotiated between the Centers for Medicare and Medicaid Services and service providers caring for dually eligible older adults enrolled in the On Lok and PACE programs (GAO, 2000).

Variable Measurement: Independent Variables
Functional Disability
Four measures of functional disability were created based on data from the clinical assessment tool. First, we measured ability to conduct personal care ADL using five ADL from the clinical assessment tool: bathing, dressing, eating, toileting, and transferring. These five items are widely used in published studies to measure personal care disability (e.g., Fortinsky, Covinsky, Palmer, & Landefeld, 1999). We combined the two dependent categories for each item (partially and fully dependent) and then classified each individual according to the number of dependent ADL (zero to five).

Second, we measured ability to conduct eight IADLs. Specific IADL items available in the clinical assessment tool were very similar to items used by Lawton and Brody (1969) to measure IADL disability: prepare meals, do housework, do laundry, use telephone, shop for food, travel outside the home, and take oral medications. As with ADL, we combined the two dependent categories for each item and then classified each individual according to the number of dependent IADL (zero to eight).

Third, bladder and bowel incontinence items were combined into a separate measure. Cohort members designated as partially or totally incontinent in either function were considered incontinent in that function. We then classified individuals into three categories: continent in both bladder and bowel, incontinent in bowel or bladder function, or incontinent in both.

Finally, because lower-body functional disability has been shown to predict a variety of adverse health outcomes in older adults (Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995), we created separate single-item measures of dependence in ambulation and in climbing stairs. For both measures, individuals were categorized as either independent or dependent.

Cognitive Impairment
The clinical assessment form includes the 10-item Short Portable Mental Status Questionnaire (MSQ) (Pfeiffer, 1975). Following recommendations by Pfeiffer, five or more errors in response to the MSQ items was considered severely cognitively impaired. Clients with zero to one errors were considered to be cognitively intact. The remainder of the cohort was equally divided between those making two errors and those making three to four errors; we considered the former group mildly cognitively impaired and the latter group moderately cognitively impaired.

Additional independent variables were chosen as factors potentially associated with Medicare or Medicaid home care expenditures, as suggested in previous home care studies cited above. Sociodemographic characteristics were gender, age group, and ethnicity. Following the health services utilization model developed by Andersen (1995), these are viewed as predisposing characteristics. Clients were grouped into the following age groups, consistent with many published studies: 65–74, 75–84, and 85 years. Ethnic group categories were based on clinical assessment form data; clients self-identified their ethnic group identification. Categories included White, African American or Black, Hispanic, and other (mostly Asian American).

Clients' living arrangements at the time of the clinical assessment were the best available approximation of their social support system, often viewed as an enabling characteristic in health services research (Andersen, 1995). Clients were classified as living alone, living with spouse only, living with children only, living with spouse and children, or other living arrangements.

Finally, we created independent variables for several medical conditions based on Medicare claims data. Medical conditions, defined by conventional and uniform International Classification of Diseases (9th ed.) codes or code groups, were summarized as customized variables in the CLTC database during each calendar year. For this report, medical condition variables were selected if they appeared in the CLTC database during any calendar year(s) corresponding to an individual's observation period. Physical conditions include stroke or other cerebrovascular accident (CVA), congestive heart failure (CHF), diabetes, pneumonia, pulmonary conditions (chronic obstructive pulmonary disease, bronchitis, or asthma), osteoporosis, and urinary tract infection (UTI). Mental conditions selected because of their clinical importance in the dually eligible population included depression, schizophrenia or other psychosis, and alcohol or drug abuse.

Analysis Procedures
The first research question was addressed by employing multivariate logistic regression techniques to estimate the probability of using each service, yielding odds ratios for each independent variable, or risk factor, in each equation. Each odds ratio was adjusted for the effects of all other risk factors; adjusted odds ratios with 95% confidence intervals that did not cross 1.0 (in either direction) were considered statistically significant.

To address the second research question, we included only service users and determined the extent to which each of the home- and community-based care expenditure variables was associated with each risk factor. Multivariate ordinary least squares regression modeling techniques were employed; separate regression models were created for each dependent variable. Due to skewed distributions of expenditures, transformations (i.e., log, square root) were calculated and tested in separate regression models. Results based on transformations were comparable with those obtained with untransformed expenditure values; accordingly, we present untransformed values. Parameter estimates are unstandardized regression coefficients, indicating the net excess (or decreased) expenditures per client per month associated with each independent variable. Statistical significance levels were based on two-tailed tests; p values of .05 were considered statistically significant.

In all regression models, independent variables representing measures of physical disability and cognitive impairment were constructed using dummy variables and a reference group that was omitted from the model. The reference group was consistently the least functionally disabled and cognitively impaired categories of these variables. Dummy variables were constructed for one to five ADL dependencies; coefficients associated with each dummy represent the difference in expenditures between that number of ADL dependencies and no ADL dependency. For IADL, zero to three dependencies was the reference group; additional dummy variables were constructed for bladder and bowel incontinence, dependence in ambulation, and dependence in climbing stairs. For cognitive impairment, dummy variables were constructed for mild (two errors), moderate (three to four errors), and severe (five or more errors) cognitive impairment. Dummy variables were constructed for each medical condition and entered as independent variables in all regression models.

	Results

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Sociodemographic, functional disability, and cognitive impairment characteristics of sample members (N = 5,232) are summarized in Table 1. Nearly 80% were female, 14% were African American, and more than one-third were 85 years or older (mean ± SD age = 82 ± 8 years). Functional disability was widespread; nearly 30% were dependent in three or more ADL, 56% were dependent in seven or eight IADL, and 77% were dependent in climbing stairs. Cognitive impairment was evident in nearly 40% of the sample, including 17% with severe cognitive impairment.

	Discussion

TOP Abstract Background Design and Methods Results Discussion References

Several findings are emphasized. First, personal care ADL dependencies were the most consistent factors associated with the probability of using, and with the amount of expenditures per month for, both Medicare and Medicaid home health services. The greater the number of ADL dependencies, the greater the probability of using service, and the greater the expenditures per month among service users. Second, cognitive impairment severity was positively associated with Medicaid waiver service expenditures but was unrelated to home health service use funded by either Medicare or Medicaid. Third, most medical conditions increased the probability of using Medicare home health care; only a few (UTI, CHF, diabetes) were associated with greater Medicare home health expenditures per month, and only stroke was associated with a greater probability of using Medicaid home health services and with greater Medicaid waiver service expenditures. Finally, clients who lived alone showed a fairly consistent pattern of generating greater expenditures for all types of services studied compared with clients living with family members.

Several important limitations of this study are acknowledged. First, it was not possible to disaggregate specific types of service expenditures within the Medicare home health, Medicaid home health, or Medicaid waiver service groupings. This restriction in the study database prevented a more penetrating analysis into whether, for example, Medicare home health expenditures were more likely to be for skilled nursing services or whether Medicaid home health expenditures were more likely to be for home health aide services. Second, it was not possible to assign temporal interpretation to results involving medical conditions because these conditions were based on claims data extracted on an annual basis only. Consequently, results related to medical conditions should be interpreted as associations, not as cause and effect, in relation to service use and expenditures. Third, the reliability of clinical assessment data used in this study could not be formally evaluated. Fourth, study data are from only one state and from a time period when Medicare home health service reimbursement was cost based (until October 1997) and then subject to a more restrictive interim payment system under the Balanced Budget Act of 1997. Today, Medicare home health services are reimbursed under a prospective payment system; therefore, a more current linked database constructed to study similar questions might yield different results. Finally, study results cannot be generalized to other community-dwelling dually eligible individuals such as individuals younger than age 65 and adults aged 65 and older not enrolled in Medicaid HCBS waiver programs.

Despite these limitations, study results yield several implications that could inform recent discussions about how to design more integrated Medicare and Medicaid initiatives for frail dually eligible older adults (Capitman, 2003; Miller & Weissert, 2003). First, efforts by policy makers to design Medicare and Medicaid service-integration initiatives might begin with dually eligible individuals enrolled in Medicaid HCBS waiver programs for the aged, because this study found that >70% of these clients used Medicare home health and Medicaid home health services in addition to Medicaid waiver services. Results from other states could help refine insights about how to improve efficiencies between Medicare- and Medicaid-reimbursed providers serving the older dually eligible population enrolled in Medicaid waiver programs. This would be a first step toward considering how to improve Medicare and Medicaid home health care integration for all dually eligible older adults living in the community.

Second, state reimbursement strategies for Medicaid-funded services for older Medicaid HCBS waiver clients could be informed by study findings. For example, measures of personal ADL dependence might be factored into a case mix payment system for Medicaid home health services in a state Medicaid HCBS waiver program for the aged. It is worth noting that ADL dependence is incorporated into the Medicare prospective payment system for home health care, implemented in October 2000.

Third, based on the low amount of variance explained in the Medicaid waiver model (5%), few risk factors are associated with expenditures for the bundle of services covered in Connecticut's Medicaid waiver package. A likely explanation for the low amount of variance explained is that all waiver services are bundled into a single dependent variable; each specific service might indeed have a different set of risk factors. Nevertheless, moderate to severe cognitive impairment and extensive dependence in IADL are risk factors for greater total waiver service expenditures. Thus, these types of services may be used more often to supplement the daily care of cognitively impaired clients already provided by family members or to sustain at home cognitively impaired clients with little or no family support system. Further evidence in other states might also show that expenditures for supportive services offered in their Medicaid waiver packages are greatest for clients with more progressive cognitive impairment and extensive IADL dependence.

Finally, study sample members living alone are at greatest risk for high expenditures of all types of home- and community-based services examined in this study, even after controlling for many other important covariates. Medicare and Medicaid service integration would be especially useful for dually eligible individuals living alone because they are less likely to have personal advocates to help navigate both public programs.

In conclusion, this study provides evidence-based insights into the important policy issue of Medicare and Medicaid integration. Similar empirical research from other states will help policy makers design strategies for integrating Medicare and Medicaid services for the growing numbers of dually eligible older adults who are projected to use both Medicare and Medicaid home- and community-based services in the next several decades (Clark & Hulbert, 1998; Kemper, 2003; Knickman & Snell, 2002; Miller & Weissert, 2003).

	Footnotes

 
This work was supported by the Robert Wood Johnson Foundation and the Connecticut Department of Social Services under a grant to the New England Consortium, Medicare and Medicaid Integration Project. This publication does not express the views of the Connecticut Department of Social Services or the State of Connecticut. The views and opinions expressed are those of the authors. We also gratefully acknowledge data analysis assistance provided by Ramon I. Garcia, MS, and guidance and insights regarding the study database provided by Daniel Gilden of JEN Associates, Inc., Cambridge, MA.

¹ Center on Aging, University of Connecticut Health Center, Farmington.

² Connecticut VNA, Wallingford.

Decision Editor: Linda S. Noelker, PhD

Received for publication February 12, 2003. Accepted for publication January 27, 2004.

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