Analysis of the California In-Home Supportive Services (IHSS) Plus Waiver Demonstration Program. Home and Community-Based Service Use and Expenditures


IHSS recipients may have access to Medicaid funded home care services in addition to IHSS. These can include several Medicaid HCBS waiver (e.g., AIDS waiver, Multi-Purpose Senior Services Program (MSSP), and developmental disabilities).37 The first panel of Table 26, shows the use of these waiver services (i.e., excluding IHSS). It is proportionately low: fewer than 0.04% among IHSS recipients age 3-17, 4.2% age 18-64, 17% age 65+. Among the users of the waivers, mean monthly expenditures tend to be somewhat higher than the comparable IHSS expenditures. Average monthly waiver expenditures tend to be highest among recipients age 18-64, particularly those with Parent providers. There is little unadjusted difference among the provider subgroups for waiver beneficiaries age 65+, and too few minor children recipients to appropriately draw conclusions.

The second panel shows Medicaid expenditures associated with IHSS use. This service is used by most of the study recipients in 2005. Average monthly expenditures are relatively comparable among adult recipient groups, and generally higher among recipients age 3-17. Parents among children, and spouses among the adults have the lowest unadjusted average monthly expenditures. This likely reflects the effects of the IHSS needs assessment protocol and service authorization algorithm that assigns no or few housekeeping and meals preparation task assistance hours when non-disabled family members also reside in the household. This algorithm applies whether or not non-disabled household members are paid IHSS providers. However, spouses of adult IHSS recipients and parents of minor children who are paid IHSS providers are usually considered “non-disabled.” When spouses and parents of minor children reside in the home of an IHSS recipient but do not become paid providers, this is often because they have health/disabilities that impair their caregiving ability. Indeed, especially in the case of the elderly, spouses are often also IHSS recipients. There are minor differences comparing Other Relative versus Non-Relative providers within each recipient age group. The third panel combines IHSS and spending for other community-based waiver reimbursed care. Average monthly expenditures are essentially unaffected by this, suggesting that the funding sources largely complement each other, rather that substantially augmenting the hours of care. The pattern of provider differences within age groups remains the same.

Ordinary least squares regression were used to adjust the within age group comparisons for recipient characteristics in assessing whether recipient expenditures differ among provider types.38 Table 27 shows models that combine all the home care expenditures for all recipients and all exposure months in 2005.39 The coefficients need to be multiplied by 1,000 to convert them to the original dollar metric. For all age groups, the IHSS Plus Waiver-permitted providers (i.e., parents for children, spouses for adults) have coefficients with negative signs, indicative of lower average monthly home care expenditures than recipients with Non-Relative providers -- a finding expected given the above described algorithm used to allocate total authorized IHSS hours.

Recipients ages 3-17 with Parent providers have average monthly home care expenditures about $500 less than those having Non-Relative providers. There is no difference between Other Relative and Non-Relative groups. Among adults IHSS recipients, those with Spouse providers have lower average estimated expenses ($430 less for the non-aged, $340 less for the aged) than those with Non-Relative providers. This is a difference of about 6-10 provider hours per week -- a level comparable to the unadjusted results. The high unadjusted expenses evident for Parent providers (non-aged recipients only) reduce markedly after adjusting for recipient characteristics. The OLS estimates show these expenses to be about $30 less per month than those of non-relatives holding everything else constant. The last contrast is between Relatives and Non-Relative providers. Here too there is a shift once adjustments are made for case mix. For both adult age groups of recipients these expenditure comparisons are either not statistically significant or so low as to be trivial between. Children and non-aged adults entering the IHSS program in 2005, have on average, lower monthly home care expenditures, holding other things constant, than those continuing from 2004. Among the aged, average monthly expenditures among new recipients tend to be about $50 higher than for continuing recipients.

  1. State, county and federal programs not represented in the Medicaid claims system are not included here.

  2. Variations on these analyses include separate sets of models for IHSS expenditures, non-IHSS expenditures, and combined expenditures. Each set of models was estimated using only recipients having 12 months of participation in 2005, only those having fewer than 12 months, and then all recipients regardless of the number of participation months in the year. Models limited to persons with 12 months of participation had the largest proportion of explained variance, those with fewer than 12 months the least, but all models yielded similar findings with respect to provider affects, and the comparison between new and continuing and IHSS recipients. Non-IHSS recipient models for minor children were estimated due to the small recipient counts.

  3. These results are similar to models estimating only IHSS and only other home care waiver service expenditures, see Appendix F.

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