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Assistive Technology in Medicaid Home- and Community-Based Waiver Programs

Correspondence: Address correspondence to Charlene Harrington, PhD, Department of Social and Behavioral Sciences, University of California, San Francisco, 3333 California Street, Suite 455, San Francisco, CA 94118. E-mail: Charlene.Harrington{at}ucsf.edu

	Abstract

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Purpose: As consensus emerges concerning the need to extend publicly funded home- and community-based services that support the independence of seniors, studies have reported the efficacy and cost effectiveness of assistive technology (AT). This article presents the latest available national AT expenditure and participation trends (1999–2002) for Medicaid 1915(c) waivers, the largest Medicaid home- and community-based service program. Design and Methods: We collected annually reported Centers for Medicare and Medicaid Form 372 data from state officials for each waiver providing AT for the period from 1999 to 2002. Descriptive statistics examined trends in national participation and expenditures, interstate variations in participation and expenditures, and differences in provision between elderly persons and persons with developmental disabilities.  Results: Although we report a rise in the number of waivers providing AT, there has been much slower participant growth compared with the broader waiver program, and there is wide interstate variation in waiver AT provision. Not only do most waivers with AT serve persons with developmental disabilities, AT spending for that target group is almost twice that for aged or disabled waiver participants. Implications: This study highlights three policy concerns: first, the large interstate variations in AT provision in Medicaid waivers may signal access problems in some states; second, policy choices in some states may favor Medicaid spending on AT for the developmental disability population over that for the elderly population; and third, data limitations prevent a comparable state-by-state analysis of Medicare AT provision.

Key Words: Assistive technology • Home- and community-based care • Medicaid waivers

Although previous analyses of publicly funded AT have concentrated on the federal Medicare program, data limitations have restricted the capacity to examine interstate variations (Agree & Freedman, 2000; Cornman, Freedman, & Agree, 2005). For low-income elders and disabled persons, less is known about AT provision within the Medicaid program, which is the largest single payer of long-term care (Smith, Cowan, Sensenig, & Catlin, 2005; Harrington, LeBlanc, Wood & Satten, 2000). Although AT is a service option in the Medicaid 1915(c) HCBS waiver program (the largest Medicaid HCBS program), no study of waivers has concentrated on the provision of AT (Carlson & Ehrlich, 2006). In this article we draw from the most recent and comprehensive available dataset to report trends in Medicaid AT waiver participants and expenditures (1999–2002), interstate variations in Medicaid AT waiver participants and expenditures, and differences in Medicaid AT waiver provision between elderly persons and persons with developmental disabilities (DDs).

Assistive Technology
Studies of AT have employed multiple definitions that range from a narrower focus on specific devices (e.g., power wheelchairs) or limitations (mobility) to broader considerations of a wider range of supports (Freedman et al., 2005; Wolff et al., 2005). In this study we use the definition from the Assistive Technology Act of 1998: "any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities." This relatively broad definition of AT is estimated to comprise more than 18,000 devices, items of durable medical equipment (DME), and environmental modifications that are supplied by an industry of more than 2,000 companies (Abledata, 2001). Under this broad definition, AT ranges from relatively low-tech items such as canes, crutches, grab bars, and walkers to more high-tech equipment such as speech synthesizers and power wheelchairs.

Previous research on AT has focused on the Medicare program, which covers individuals who are elderly, certain disabled persons, and certain persons with kidney disease under Title XVIII of the Social Security Act (Hoffman, Klees, & Curtis, 2005). Four main themes were identified from this research. First, studies have documented the growing use of AT generally (Freedman et al., 2005; Manton et al., 1993) and have examined the efficacy of specific devices (e.g., Batavia 1999; Kwon et al., 2002; Scherer 2000; Verbrugge, Rennert, & Madans, 1997). Second, studies of AT adoption in the community and in the workplace report the importance of factors including the provision of appropriate training and the reduction of stigma associated with device use (e.g., Agree, Freedman, & Sengupta, 2004; Gitlin, 1995; Roelands, Van Oost, Depoorter, & Buysse, 2002; Scherer, Sax, Vanbiervliet, Cushman, & Scherer, 2005; Stoddard & Kraus, 2006). A third line of AT research reports outcomes including improved functioning, reduced isolation, and improved quality of life (Agree & Freedman, 2003; Taylor & Hoenig, 2004; Verbrugge et al.); lower costs for paid home care (Hoenig, Taylor & Sloan, 2003; Mann, Ottenbacher, Raas, Tomita, & Granger, 1999); and reduced caregiver burden (Gitlin, Corcoran, Winter, Boyce, & Hauck, 2001). Finally, a recent line of inquiry has considered the extent to which AT substitutes or supplements for personal care (Allen, Foster, & Berg, 2001; Taylor & Hoenig). Findings suggest that although simple AT may substitute for informal care, more complex AT may supplement formal care (Agree & Freedman, 2000; Agree, Freedman, Cornman, Wolf, & Marcotte, 2005).

Paying for AT
Although the majority of AT is paid for by personal funding (LaPlante, Hendershot & Moss, 1992; Yeager, Kaye, & Reed, 2006), there are three other main ways of paying for AT in the United States (Carlson & Ehrlich, 2006): (a) private insurance, (b) Medicare, and (c) Medicaid. Although most private health insurance plans cover some forms of AT, policies are typically not generous and coverage disputes are common (Singer et al., 1999). Despite mounting evidence of the efficacy of AT, its predominate use in daily functioning rather than for therapeutic purposes has contributed to ambiguity in both commercial health insurance coverage and public programs such as the Medicare and Medicaid benefits considered in the following paragraphs (Wolff et al., 2005).

AT under Medicare is limited to DME, which is defined as covered medical supplies and items such as hospital beds, wheelchairs, assistive devices, and oxygen used in a patient's home (U.S. Department of Health and Human Services, 2002–2004). In 2002, it was estimated that the combination of Medicare fee-for-service and managed-care DME served nearly 10 million participants with expenditures of over $11 billion (Table 1<--CO?2-->). However, Medicare limits DME provision to equipment that is reusable, medically necessary, and ordered by a physician for use in the client's home. This definition excludes AT that is obtained without medical authorization, designed for use outside of the home (e.g., portable wheelchairs), and environmental modifications used mainly to enhance functioning or safety. In 2001, from within this restrictive Medicare DME program, 6.2% of beneficiaries received mobility AT costing approximately $1.5 billion, or just over 2% of total program spending (Wolff et al., 2005).

In this study we examined AT expenditures paid by the Medicaid program, which is designed for low-income individuals who are aged, blind, or disabled and certain individuals and families with low incomes and resources under Title XIX of the Social Security Act (Hoffman et al., 2005). The three major approaches used by states to purchase AT by using federally matched Medicaid dollars are under the 1915(c) HCBS waivers, the optional state plan personal care services benefit, and 1915(b) managed-care initiatives (Kitchener, Ng, Miller, & Harrington, 2005). Although little is known about the services provided, it is estimated that, in 2003, 25.6% of mobility AT users (2.5 million out of 9.8 million) were covered under Medicaid (Kaye, 2006). This study did not examine AT provided under the Medicaid personal care services benefit, managed-care initiatives, or demonstration waivers (e.g., Arizona's Long-Term Care System), because states do not report AT participants or expenditures for these programs.

The Medicaid 1915(c) waivers considered in this study allow states to offer a wide range of services and supports, including AT devices, DME, and environmental modifications. The waiver program requires that states operate three forms of costs controls on all waivers: (a) capping the number of individuals served; (b) using more restrictive functional eligibility criteria than the personal care services benefit (Smith et al., 2000); and (c) certifying that participants require a level of care provided by a hospital, nursing facility, or an intermediate care facility for people with DDs (GAO 2003). States must also direct HCBS waivers to specific target populations, such as those who are aged, have a physical disability, have traumatic brain injuries, or have DDs (Kitchener et al., 2005).

	Methods

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Data Source
In this study we conducted a descriptive analyses of a dataset compiled from the Centers for Medicare and Medicaid Services (CMS) Form 372 waiver reports for the period from 1999 to 2002. Since 1994, we have collected annually, from state officials, the CMS Form 372 reports that report unduplicated participant and expenditure data for each waiver program (total waivers were 252 in 2002). In 2005, as in previous years, we made between three and five requests to every state Medicaid program in order to collect the 2002 reports, plus any missing from previous years. We included waivers in this analysis only if they provided AT.

To operate our broad definition of AT, we examined "total AT in waivers" and three reported components: AT devices, home modifications, and DME. It should be noted that states are given wide latitude to use different definitions for AT devices, home modifications, and DME by the CMS. We identified waivers providing AT by triangulating multiple sources of information: CMS Form 372 reports, state Medicaid-provider manuals, waiver-program information, and 1915(c) waiver applications available on state Web sites. This process left us confident that we identified all waivers that offered AT services (154 out of the 252 total waivers in 2002). All states except the following four offered at least one waiver with AT in 2002: Arizona, which does not offer 1915(c) waivers; Washington, DC; Mississippi; and North Dakota.

Analysis
We coded our data by using a standardized protocol and then used an Excel database that allowed us to conduct four descriptive analyses. First, we produced three sets of state and national program data concerning waivers with AT for the period from 1999 to 2002: (a) participants and expenditures by program for total waiver AT plus its three components (AT, DME, home modifications); (b) participants per 1,000 population; and (c) inflation-adjusted expenditures per participant. Second, we identified participant and expenditure data by three client target groups: DD, aged or disabled, and other (e.g., traumatic brain injury, children, and mental health).

	Results

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Medicaid Waiver Participants Receiving AT, 1999–2002
Whereas the total number of HCBS waiver programs increased by 16% between 1999 and 2002 (Kitchener et al., 2005), those waivers offering any AT increased by 29% from 119 to 154. As a result, the proportion of waivers offering AT increased from 55% in 1999 to 63% percent in 2002 (no table shown).

Figure 1<--CO?1--> shows that the number of waiver participants receiving AT increased 42% over the study period (1999–2002). In 2002, 40% of AT participants received DME, 35% received AT devices, and 25% received home modifications. Although the total number of waiver AT participants increased by 3% from 2001 to 2002, participants receiving DME fell by more than 18% that year. This decline was largely accounted for by reductions in DME services provided in an Ohio aged or disabled waiver and a Michigan DD waiver.

View larger version (21K): [in this window] [in a new window]   Figure 1. Waiver participants receiving assistive technology (AT) by service category, 1999–2002 [source: Centers for Medicare & Medicaid Services Form 372 for 1915(c) waivers]

View larger version (23K): [in this window] [in a new window]   Figure 2. Waivers expenditures for assistive technology (AT) services by category, 1999–2002 (consumer price index or CPI-adjusted expenditures per participant are reported in constant 2002 dollars)

View larger version (25K): [in this window] [in a new window]   Figure 3. Total Medicaid assistive technology (AT) waiver participant and expenditure program trends, 1999–2002. [Consumer price index or CPI-adjusted expenditures per participant are reported in constant 2002 dollars. Source: Centers for Medicare & Medicaid Services Form 372 for 1915(c) waivers. Population figures based on the U.S. population, excluding AZ)

State Waivers with AT Participants and Expenditures With Need Estimates, 2002
Table 3<--CO?5--> shows the state AT waiver participants and expenditures per 1,000 population that were classified by states as meeting either (a) the nursing facility level-of-care eligibility criteria or (b) a higher level-of-care eligibility criteria (than nursing facilities) set at either the hospital or the intermediate facility care for the DD level of care. Over the 1999–2002 study period, AT waiver participants increased at a faster rate for waiver programs that used higher levels of care criteria than nursing facilities (31%) compared with those using a nursing facility level of care (28%; no table shown). In 2002, however, AT waivers with eligibility criteria established at a nursing facility level of care made up 51% (78 waivers) of all waivers providing AT (Table 3<--CO?6-->).

Among states providing AT under a nursing facility level-of-care waiver, there was an average of 0.36 per 1,000 persons, with average expenditures of $798 per participant. Among states proving AT under the higher level-of-care waivers, the average number of participants was 0.14 per 1,000 persons, with average per participant expenditures of $1,577 (Table 3).

State participants and expenditures per population varied widely across states (Table 3). Among AT waivers at the nursing facility level of care, the highest ranked state for expenditures per participant was New Mexico ($4,952) and the lowest ranked state was Massachusetts ($135). For AT waiver-program participants per 1,000 population, Oklahoma (2.97) was highest, and Missouri was lowest (0.004). Among AT waiver programs using a higher level of care than nursing facilities, New York ($5,354) had the highest AT waiver expenditures per participant, whereas Nebraska ($330) had the lowest. For the higher level-of-care AT waivers, South Dakota (2.65) had the highest number of waiver participants per 1,000 population whereas Nebraska had the lowest (0.001).

To take into account an estimated level of need for Medicaid AT within each state, the final column in Table 3 displays a ratio of AT waiver participants to Medicaid-eligible disabled persons in each state. Among the states providing Medicaid AT waivers, the average ratio of participants to disabled was 15.76, where Oklahoma ranked highest (150.56) and Nebraska ranked lowest (0.06).

	Discussion and Conclusions

TOP Abstract Methods Results Discussion and Conclusions References

 
To the best of our knowledge, this article presents the first analysis of AT participation and expenditure trends in Medicaid 1915(c) HCBS waiver programs. In addition to reporting the growing number of states that provide AT to Medicaid waiver participants, the study showed an increasing number of AT participant and expenditures. This study presents three sets of findings of interest to policymakers. First, the vast majority of states (47 of 51) operate waivers that provide some form of AT; the waivers with AT represented 63% of all waivers operating in 2002. That said, annual growth in AT participant per 1,000 population from 2001 to 2002 was only 2% and AT expenditures per participant growth was only $120 in the same period. In contrast, national Medicaid HCBS waivers recorded average annual population-adjusted participant growth of 8% and reported growth of more than $18,350 in per participant spending between 1999 and 2002 (Kitchener, Ng, & Harrington, 2006). Explanations for the relatively slow growth in AT waiver participation include state financial constraints, increased numbers of dual-eligible clients receiving services under the Medicare DME benefit, and the possibility that current Medicaid AT provision matches the actual demand.

Second, this study reveals considerable interstate variation in the Medicaid HCBS waiver provision of AT. In terms of assessing potential met need for Medicaid AT, Table 3 presented, for each state, a ratio between waiver participants receiving AT and the number of Medicaid-eligible disabled persons. The national range on this scale (from 150.56 in Oklahoma to 0.06 in Nebraska) suggests a notable variation in access to AT provision in Medicaid waivers. Although it is reported that many states operated waiver waiting lists in 2002, it is not known how many of those persons required AT (Kitchener, Ng, & Harrington, 2004). Thus, to better understand interstate variation in Medicaid waiver AT service participants and expenditures trends, future studies must examine the roles played by both (a) Medicaid waiver-program policies such as cost caps and waiting lists, and (b) other modes of AT provision, including Medicare and Medicaid personal care services, managed-care programs, and demonstration waivers.

In a related line of work, studies of total waiver expenditures have identified several supply and demand, state policy, and political factors associated with interstate variation in general waiver provision (Kitchener, Carrillo, & Harrington, 2002; Miller, Harrington, & Goldstein, 2002; Miller, Harrington, Ramsland, & Goldstein, 2002). Future studies could examine factors related to state variations in Medicaid AT service participants and expenditures.

Third, this study indicated that some state policy choices appear to favor AT spending for the DD population over the elderly population. Of the 47 states that provide AT services in Medicaid waiver programs, 64 waivers in 40 of these states were for the DD population, whereas only 58 waivers in 37 states provided such coverage for the aged or disabled population. Although total waiver with AT participation and expenditures were higher for the aged or disabled population, expenditures per participant were more than double for DD waivers than for aged or disabled waivers. This may result from a combination of factors, including the following: possible higher level of need for AT devices among the DD population, the higher institutional rate that is used to measure the cost effectiveness of DD waivers, and the political strength or political effectiveness of the DD lobby compared with the elder advocates.

There are three main limitations to this study of AT provision in Medicaid waiver programs. First, currently reported Medicaid data do not include information on AT provision through the personal care services program, demonstration projects, and managed-care initiatives. As a result, the extent of Medicaid AT provision is understated here and there is no way of assessing how states differentially use these three Medicaid programs to provide AT. Second, from our waiver data, it was impossible to identify the exact nature of the services and supports provided within the three categories of AT reported here (AT devices, DME, and home modifications). Finally, the lack of state-by-state Medicare DME data prevented us from investigating Medicaid AT provision in relation to Medicare provision for dual-eligible persons.

As a consensus builds concerning the efficacy of extending publicly funded AT to support the independence of seniors, this article suggests that elderly advocates may have something to learn from DD colleagues in terms of leveraging AT funds from the Medicaid waiver programs. With federal initiatives such as Money Follows the Persons grants indicating government support for independence, a relatively receptive context may exist for senior advocates to lobby at the state level for increased access to AT through the Medicaid waiver program.

	Footnotes

 
This study was supported by grants from the Kaiser Commission on Medicaid and the Uninsured (grant no. 07-1011-400), and the National Institute on Disability and Rehabilitation Research (grant no. H133B031102). The views expressed in this article do not necessarily reflect those of either sponsor.

¹ Department of Social and Behavioral Sciences, University of California, San Francisco.

Decision Editor: William J. McAuley, PhD

Received for publication April 4, 2007. Accepted for publication July 31, 2007.

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