center for health policy & research page 1 lobat hashemi, ms (1) raymond e. glazier, ph.d. (2)...

Center for Health Policy & Research

Lobat Hashemi, MS (1) Raymond E. Glazier, Ph.D. (2)

Frederick H. Hooven, MMHS (1)Jay Himmelstein MD, MPH (1)

(1) Center for Health Policy & Research, University of Massachusetts Medical School

(2) Abt Associates Inc.

Contact for further info: [email protected] 508-856-8525

Medicaid Expenditures for Working and Non-Working Consumers Who Use Personal

Assistance Services (PAS):The Massachusetts Experience

Center for Health Policy & Research (chpr)


• Personal Assistance Services (PAS) are felt to be a critical component in the continuum of community based long-term care services that allow people with disabilities to live and work in the community.

• Little information is available on the cost, utilization and impact of PAS services offered through Medicaid programs. Key questions include:

- How much do PAS programs cost?- Does this cost differ for working disabled vis-à-vis non-

working disabled individuals?- Does providing PAS services have an effect on the

overall expenditures of the Medicaid program for these consumers?

Background


• Massachusetts has one of the first Medicaid programs in the country to pay for PAS services for working persons with disabilities. The program began in 1988.

• MassHealth (Medicaid) is the only health insurance plan in MA that covers PAS services.

• PAS services are Consumer-Directed: Consumers recruit, interview, hire, train and manage their Personal Care Attendants (PCA).

Personal Assistance Services Program in Massachusetts


Who can receive PAS services?

Eligibility criteria:• MassHealth member.• Chronic or permanent disability.• Approved by Primary Care Physician.• Need for physical assistance in two or more of the following

activities of daily living:– Mobility, assistance with medication, bathing, dressing,

range of motion, eating, toileting.Note:

– No age restriction for receiving PAS services. – No limit on the number of PAS hours authorized.– Number of hours approved are based on functional status

and household composition.


Previous studies

• In fiscal year 2002, almost 3% of the working disabled MassHealth members used PAS services, with an average cost of approximately $24,000 per year per member.

• During the same fiscal year, approximately 4% of the non-working disabled MassHealth members used PAS services, with an average cost of approximately $18,000 per year per member*.

*“Utilization of Personal Assistance Services (PAS) by Medicaid Consumers with Disabilities: The Massachusetts Experience.” Hashemi, et al., Academy Health Conference, June 2003.


Research Question

• Do working PAS users have lower overall Medicaid expenditures than non-working PAS users? – When controlling for

• Functional status

• Other insurance coverage

• Demographic characteristics


• Data source: Fiscal Year 2003 MassHealth claims and eligibility

data.• Study population:

1. MassHealth Disabled members between 18 and 64 in two MassHealth Plans: Standard Disabled (Non-working) or CommonHealth Working/Buy-in (Working).

2. Must have used at least one hour of PAS service during the fiscal year. Procedure codes were used to identify PAS claims.

Methods


Standard Disabled (Non-working): Meets SSA disability criteria:Lower income only (based on income and family size)No work requirementNo premium payments

CommonHealth Working/Buy-In (Working): Meets SSA disability criteria:No income or asset limit40 hour per month work requirementMay pay a monthly premium based on income and

family size

Methods – Study Groups:


Methods - Analysis

• Univariate analysis was used to compare the overall Medicaid expenditures between the two populations.

• Multivariate analysis was used to control for functional status, other insurance coverage (Medicare or private), age and gender.

- Functional status measure: Approved hours of PAS services.


Results: Demographics

Working

N=202 (2.3%)

Non-working

N=5,016 (3.8%)

P-value

Age - mean (+/-STD)

49 (+/-10) 44 (+/-13) <.0001

Males 54% 42% .0003

Race, white 89% 86% .5127

FPL, > 200% 87% <1% <.0001

Other insurance:

Medicare

Private

Medicaid only

36%

55%

9%

52%

10%

38%

<.0001


Results

Working Non-working

Mean approved hrs/week 51 42

Mean used hrs/week 39 30

Ratio used/approved hrs .76 .71

PAS hours approved vs. hours used*:

Working PAS users are approved for more hours (suggesting lower functional status or greater need due to living arrangements) and use more of their approved hours compared to the Non-working PAS users.

•There was not a significant difference between the two population on the ratio of used/approved hours.


$2,162$1,410

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

Working Non-Working

PAS PharmacyInpatient OutpatientMental Health Services Other

Results: Overall Medicaid Per Member Per Month Expenditures (PMPM)

$3,332$2,694

There was a significant difference between the PMPM in each category shown above at P<.0001

PMPM

Non-PAS

PAS

Non-PAS

PAS

$532$1,922


Results

Variable Coefficient % change P-value

Working -1.3895 -74% <.0001

Other insurance -0.6234 -46% <.0001

Gender (1 male) -0.1297 -12% 0.0006

Age 0.0017 <.01% 0.2604

Hours approved* -0.0095 -<.01% 0.7554

Dependent variable: Non-PAS expenditures Per Member Month*

Non-PAS expenditures are 74% less in the working population compared to non-working, after controlling for presence of other insurance, functional status and demographic characteristics.

*Natural log of non-PAS pmpm and hours approved were used.


Results

Variable Coefficient % change P-value

Working -.2838 -25% <.0001

Other insurance -.2189 -20% <.0001

Gender (1 male) -.0266 -0.03% 0.1620

Age -.0017 -<0.01% 0.0226

Hours approved* -.5802 44% <.0001

Dependent variable: Overall expenditures Per Member Month*

*Natural log of non-PAS pmpm and hours approved were used.

Overall expenditures are 25% less in the working population compared to non-working, after controlling for presence of other insurance, functional status and demographic characteristics.


• The overall and non-PAS Medicaid expenditures were significantly lower among working PAS users than among non-working PAS users.

• This cost difference holds true even among those without other insurance, suggesting that lower Medicaid expenditures among the working disabled is not due to third party insurance alone.

Conclusions


Study Limitations

• We can not rule out that unmeasured difference in severity of disability between the two groups had an effect on costs.

• We lacked a variable for household composition, which could have been different in the two populations, resulting in different numbers of hours approved in each group for household chores.


Policy Implications

• States who are planning to add a PAS benefit to their Medicaid programs should recognize that utilization and total costs may vary for working as compared to non-working populations.

• Further study of the impact of PAS services on health care utilization and system-wide economic impact are warranted.


• Funding for this research provided by the Centers for Medicare and Medicaid Services (CMS) P-91234 - http://www.cms.hhs.gov

• Further information on the Massachusetts Medicaid Infrastructure grant and PAS/PCA services:– Massachusetts Medicaid Infrastructure Grant -

http://www.massmig.org– Massachusetts Division of Medical Assistance -

http://www.state.ma.us/dma/– Independent Living Research Utilization - http://www.ilru.org/– World Institute on Disability - http://www.wid.org/– Center for Living and Working - http://www.centerlw.org/

Funding Source, Acknowledgments& Further Information

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