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An Improved Method for Classifying HCBS Service Use and Expenditures: The HCBS Taxonomy September 10, 2013 Ralph Lollar, Victoria Peebles, Dan Timmel National Home- and Community-Based Services Conference
Transcript of An Improved Method for Classifying HCBS Service Use and ... · An Improved Method for Classifying...
An Improved Method for Classifying HCBS Service Use and Expenditures:
The HCBS Taxonomy September 10, 2013
Ralph Lollar, Victoria Peebles, Dan Timmel
National Home- and Community-Based Services Conference
Introduction
Importance of the taxonomy
History and development of the taxonomy
Results from the Medicaid Analytic eXtract (MAX) 2010
Next steps and questions
Today’s Presentation
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Introduction
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Importance of the Taxonomy
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State flexibility in waivers and state plan amendments creates variation in services and supports in claims data
– Variation in terminology and procedure codes make it difficult to know what is happening with HCBS at a national level
Measuring what occurs is necessary to demonstrate the effectiveness of HCBS
The HCBS taxonomy creates an orderly classification of services so the Centers for Medicare & Medicaid Services (CMS) and researchers can aggregate data – The taxonomy classifies, but does not limit, state
service definitions
Purpose of HCBS Taxonomy
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The taxonomy can be used in a variety of analyses, such as – Which states provide a particular service? – How many people use a service or group
of services? – How much does a state spend on a particular
service and how does this compare to other states? – What services are provided under state waivers?
Ruttner & Irvin used the taxonomy to analyze personal care services provided under waivers and state plans (2013)
Uses of the HCBS Taxonomy
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HCBS Taxonomy Development
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Developed in 2009 by Thomson Reuters (now Truven Health Analytics) using previous research and an analysis of service definition text from 159 waiver programs
Tested and reviewed by stakeholders
Feedback indicated Version 1 lacked a clear categorization structure
History—Version 1
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History—Version 1 (cont.)
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Developed jointly by Truven Health Analytics and Mathematica and submitted in April 2011 – Truven Health proposed a categorization scheme
based on common instances where two or more taxonomy services were in a single service entry in the Waiver Management System
– Mathematica applied Version 2 to 2008 Medicaid Statistical Information System (MSIS) claims data for 1915(c) waivers and recommended fewer services and a categorization scheme
Subsequent revisions reflected additional feedback from CMS, state associations, and a 2012 pilot with state and CMS staff
History—Version 2
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Version 2 was applied to 2008 MSIS waiver claims data – To document processes and procedures for allocating claims – To characterize Medicaid HCBS expenditures under waivers
and state plans
Results – Most waiver expenditures allocated to round-the-clock
services, followed by home care and day services – Unable to classify only 7 percent of waiver expenditures
• An improvement over the 80 percent in MSIS and the 37 percent in MAX classified as "other" type of service (TOS)
– Claims reporting varies by state and affected our ability to classify services, but taxonomy facilitates understanding of state-specific codes
History—Version 2 in 2008 MSIS Data
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Taxonomy Categories
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1. Case management 2. Round-the-clock services 3. Supported employment 4. Day services 5. Nursing 6. Home-delivered meals 7. Rent and food expenses
for live-in caregiver 8. Home-based services 9. Caregiver support 10. Other mental health and
behavioral services
11. Other health and therapeutic services
12. Services supporting participant direction
13. Participant training 14. Equipment, technology,
and modifications 15. Non-medical transportation 16. Community transition 17. Other services 18. Unknown
Results from MAX 2010
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Research-friendly Medicaid administrative files with information on eligibility, service use, and payments
Advantages of the HCBS taxonomy in MAX – Stakeholder-approved categories – Consistent definition across all 51 states, even
if they use a different name for the service – Accounts for national and state-specific
service codes – More specific than MSIS TOS – More nuanced and more meaningful to researchers
MAX 2010
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Examine service code, service code flag, service code modifier, MSIS TOS, MAX TOS, place of service
Assign HCBS taxonomy
When in doubt, consult state documentation, websites, and staff; Truven Health; and other stakeholders
HCBS—Conception to Implementation
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National HCPCS – E0100–E0159 (cane, crutches, walkers)
equipment and technology
National CPT code – 99509 (home visit for assistance with activities
of daily living and personal care) personal care
HCBS Implemented in MAX 2010 (1)
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National codes with state’s differentiation – MN-T2017 (Habilitation, residential, waiver;
15 minutes), modifier U9 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
HCBS Implemented in MAX 2010 (2)
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Reviewed claims data for each of the 28 approved states in MAX
Analyzed the proportion of claims mapped to the “unknown” taxonomy category compared to claims originally mapped to the “unknown” or “other” TOS in MAX
Analyzed expenditures and the number of users for 1915(c) waiver recipients across each HCBS taxonomy service and category
Approach
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In 2010, 28 states spent almost $23.6 billion on HCBS
We mapped 97 percent of expenditures to an HCBS taxonomy category – The MSIS TOS field categorized only 20 percent
of claims – The MAX TOS field categorized 71 percent of claims
Results in MAX 2010
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Use of HCBS
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Of more than 850,000 Medicaid waiver participants across 28 states, no one type of HCBS was used by the majority or participants
Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010
HCBS Taxonomy Category
0 5 10 15 20 25 30 35 40 45 50
Live-in caregiverCommunity transition
Other servicesParticipant direction
Supported employmentParticipant training
NursingOther health
UnknownMental health
Home-delivered mealsNonmedical transportation
Caregiver supportRound-the-clock
Day servicesEquipment, technology, and modifications
Home-basedCase management
Waiver use (percentage)
HCBS Expenditures
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Three of the 18 HCBS categories—round-the-clock, home-based, and day services—accounted for nearly 80 percent of all waiver expenditures
Round the clock (46%)
Home based (18%)
Day services (15%)
Case management
(4%)
Mental health (3%)
Unknown (3%)
All others (11%)
Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010
Round-the-Clock Services: Total 1915(c) Waiver Amount Paid
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Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010
0
50,000,000
100,000,000
150,000,000
200,000,000
250,000,000
300,000,000
350,000,000
400,000,000
450,000,000
Alabama Alaska Delaware Indiana Iowa
Expenditures ($)
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Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010
Round-the-Clock-Services: Average Amount Paid
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
Alabama Alaska Delaware Indiana Iowa
Average Amount Paid per User ($)
Round-the-Clock vs. Home-Based Services by State
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0
10
20
30
40
50
60
70
80
90
100
Percentage of State Expenditures
State
Round-the-Clock Home-Based Services
Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010
Round-the-clock Home-based services
Number of States Reporting Waiver Claims
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0 5 10 15 20 25 30
Live-In CaregiverParticipant Direction
Community TransitionOther Services
Participant TrainingHome-Delivered Meals
NursingSupported Employment
Nonmedical TransportationOther Health
UnknownMental Health
Case ManagementRound-the-Clock
Day ServicesCaregiver Support
Home-BasedEquipment, Technology, and Modifications
Number of States Reporting Waiver Claims
HC
BS
Taxo
nom
y C
ateg
ory
Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010
Average Paid per User
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0 10,000 20,000 30,000 40,000 50,000 60,000
Equipment, Technology, and ModificationsHome-Delivered Meals
Community Transition ServicesOther Health and Therapeutic Services
Nonmedical TransportationCase ManagementCaregiver Support
OtherServices Supporting Participant Direction
NursingUnknown
Supported EmploymentOther Mental HealthParticipant Training
Home-Based ServicesDay Services
TotalRound-the-Clock Services
Average Paid per User ($)
HC
BS
Taxo
nom
y C
ateg
ory
Source: Mathematica analysis of MAX data for 28 states approved as of June 1, 2013, for services provided in calendar year 2010
Next Steps
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MAX 2010 production began in April 2012
Data available for 36 states
Data for the 15 remaining states is contingent on the states’ submission of their MSIS files
MAX 2010 Timeline
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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 services – In-home respite from out-of-home respite
Quality of State’s Data Is Important
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Use specific national HCPCS codes
How States Can Improve Their Data
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Choose Instead of Assisted living, adult foster care, supported living, and group living
Residential habilitation or general residential
24-hour private-duty nursing and short-term skilled nursing
Unspecified nursing care
In-home respite and out-of- home respite
Respite in unspecified location
Specific assistive technologies, supplies, and home adaptations
Unspecified personal items, miscellaneous therapeutic items and supplies, or supplies not otherwise specified
Implementation in the new expanded version of MSIS, the Transformed Medicaid Statistical Information System (T-MSIS)
– States will begin reporting the taxonomy in T-MSIS
Integration into the CMS electronic system for 1915(c) waiver applications in the future
Next Steps for the Taxonomy
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Truven Health Analytics – Steve Eiken
Mathematica Policy Research – Alex Bohl – Carol Irvin – Julie Sykes
Centers for Medicare & Medicaid Services – Cara Petroski, Project Officer
Acknowledgements
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Victoria Peebles, Mathematica Policy Research – [email protected]
Ralph Lollar, CMS – [email protected]
Dan Timmel, CMS – [email protected]
MAX website – www.cms.gov/Research-Statistics-Data-and-Systems/
Computer-Data-and-Systems/ MedicaidDataSourcesGenInfo/MAXGeneralInformation.html
Research data assistance center – www.resdac.org
For More Information
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