Analysis of the California In-Home Supportive Services (IHSS) Plus Waiver Demonstration Program. Summary of Findings


Racial/Ethnic and Household Characteristics of IHSS Recipients

  • Hispanics are the largest group (45%) of continuing recipients age 3-17. Whites are about 40% of continuing adult recipients, Hispanics about 22%. Blacks account for about 20% of the non-aged adult recipients, Asians about 10%. These latter proportions reverse among recipients age 65 or over.

  • The race/ethnic characteristics of persons entering IHSS in 2005 among minor children and non-aged adults are generally similar to those of the continuing recipients. Among recipients age 65 or more the proportion of Whites and Blacks is about 20% lower, and the proportion of Hispanic and Asian is 10%-20% higher among recipients entering the program in 2005.

  • Hispanic IHSS recipients are more likely than any of the other race/ethnic groups to have paid Parent providers, whereas Black IHSS recipients are the least likely. (80% of Hispanic recipients age 3-17 and 20% of Hispanic recipients age 18-64 have paid Parent providers, compared to 60% of Black IHSS recipients age 3-17 and 9% of Black non-aged adult recipients.

  • Black non-aged adult IHSS recipients are the least likely of the four race/ethnic groups to have Spouse (2%) providers.

  • More than half the White and Black adult age IHSS recipients use Non-Relative IHSS providers. This contrasts with about one-third among Hispanic and Asian groups.

  • The Advance Pay and Restaurant Meals voucher programs have a much different race/ethnicity distribution than the IHSS personal assistance program. Whites account for about two-thirds of each program, Hispanics and Blacks, each about 13%. Chinese account for about half of the Asian/Other recipients.

  • Regardless of age or race/ethnicity, larger households are more likely to have an Other Relative provider and less likely to have Non-Relative providers. Among those 18-64 household size is positively related to having a paid Parent or Other Relative provider, and negatively related to having Non-Relative providers. Recipients age 65 or more in larger households are less likely to have Spouse and Non-Relative providers, and more likely to have Other Relatives as providers.

  • The presence of a parent or spouse in the household reduces the odds of having non-relatives as paid IHSS providers. Among those age 18-64 a present spouse has a modest association with having Other Relatives as providers.

Functional Limitations and Chronic Health Conditions

  • Children average 3.6 activities of daily living (ADLs: bathing and grooming, dressing, toileting, transferring, and eating) where human assistance is required. These rates of impairment are similar for both new and continuing IHSS recipients in 2005 and among all provider types.

  • Adult IHSS recipients average about 2.5 ADL limitations requiring human assistance. These rates increase to an average of about 3.5 ADLs for recipients having a paid Spouse provider. There is little difference in average impairment levels among those with Other Relative and Non-Relative providers. Recipients entering IHSS in 2005 average about 0.5 fewer ADL limitations.

  • Limitations in instrumental activities of daily living (IADLs: housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside) requiring human assistance are pervasive, averaging more than four IADL limitations among adults, and three IADLs among children. These levels of impairment are similar across all provider types and between new and continuing IHSS recipients.

  • More than 10% of children and 5% of adults require human assistance with breathing.

  • Based on Medicaid claims, minor children in IHSS have an average of 3.5 chronic health conditions. This rate is 4.2 among those age 18-64, and 3.0 among those age 65+. The prevalence rates are slightly lower among recipients entering IHSS in 2005. Prevalence rates derived from claims data may under report the actual prevalence.

  • Minor children recipients with paid Parent providers tend to have a slightly higher prevalence of chronic conditions than those with Other Relatives or Non-Relative providers. (e.g., 81% with at least one condition vs. 72% and 69% respectively).

  • Among IHSS recipients age 18-64, there is a comparable prevalence of chronic conditions (e.g., 89% with at least one condition) among those with paid Spouse, Other Relative, and Non-Relative providers. Recipients in this age group with Parent providers tend to have somewhat fewer conditions (74% with at least one condition), but they are five times as likely to have mental retardation/developmental disabilities (6.1%) and one-third more likely to have central nervous system injuries/disorders (22%).

  • IHSS recipients age 65 or older have similar prevalence of chronic conditions (e.g., 83% with at least one condition) regardless of paid provider type. Those with paid Spouse providers tend to have slightly higher prevalence of Endocrine and Metabolic disorders, Cerebral and Other Vascular system disorders, and Pulmonary System disorders; and slightly lower prevalence of other conditions.

Continuity of Provider Relationships and Share of Cost

  • The factors associated with selection of a Parent, Spouse, or Other Relative or Non-Relative providers are, in part, a function of the family and other resources available. For those without parents, spouses or other relatives, the only paid provider option becomes a non-relative. This influence is most apparent among minor children, where the vast majority of those with available parents have paid Parent providers; and among the few adults with parents or spouses.

  • Cultural preferences may also contribute to provider selection. This is most evident in the greater propensity of Hispanics and Asians to have other relatives as paid IHSS providers.

  • Fewer than 6% of IHSS recipients changed the type of provider they were using during 2005. Children were the most consistent (95% consistent), non-aged adults the least consistent (93% consistent).

  • Change from having a spouse as a paid provider to another provider type was the most common change (9%). Changes between other relatives and non-relatives affected about 7% of non-aged recipients and 4% of the aged.

  • Share of Cost requirements affected relatively few IHSS recipients in 2005: about 1% of recipients age 3-17 and 3% of those age 18 or older. Among adult recipients more of those entering the program in 2005 had a Share of Cost compared to the continuing recipients: 3.4% vs. 2.8% non-aged, 5.6% vs. 3.3% aged.

  • Among minor children Share of Cost was more common when the provider was a Parent (1.5%). Among adults, Share of Cost was most common when the provider was a Spouse (10% non-aged, 11% aged).

Authorized Hours of Service

  • A maximum of 283 hours of IHSS services can be authorized in a month. This is based on the number and degree of the recipient’s limitations, with adjustments made for the living arrangement. Time that would otherwise be allocated for performance of household tasks is deducted when the recipient is living with others who can be expected to routinely perform (for their own benefit as well as for the IHSS recipient) tasks such as house cleaning, meal preparation, and shopping.

  • Regardless of the IHSS recipients’ age, those continuing in IHSS from 2004 have a higher number of authorized hours than those entering the program: this difference averages about 40 hours per month among minor children, 30 hours among non-aged adults, and 25 hours among the aged.

  • Among recipients age 3-17, there is little difference in authorized hours comparing continuing recipients having Parent providers (an average of 112 hours/month) and those with Non-Relative providers (an average of 108 hours/month). Those with other relatives had the fewest average authorized hours (102 per month). These minor differences persist among those entering IHSS in 2005.

  • Recipients age 18-64 continuing from 2004 with Parent providers have substantially more authorized hours (average of 135 hours/month) than those with any other provider type. Those with Non-Relatives (average of 89 hours/month) and those with Spouse (average of 86 hours/month) have a similar amount of hours authorized. These differences reduce among recipients entering IHSS in 2005, but those with Parent providers average about 20 hours more per month than those with other provider types.

  • Aged recipients have a similar amount of authorized hours (about 84 hours per month) across all provider types. Average authorized hours reduce to about 60 hours per month among recipients entering IHSS in 2005, with little difference among provider types.

Average Monthly Total Medicaid Expenditures

  • Across all age groups participating in IHSS, mean unadjusted Medicaid expenditures (excluding pharmacy payments) range from $1,400 to $1,700 per IHSS participation month. This is a cost inclusive of Medicaid-reimbursed personal assistance-related expenses, which averages about $825 in 2005. The highest average total expenditures are among that age 18-64, the lowest among those age 65 or more. Lower expenditures among this latter group are explained, in part, by more of these recipients having access to Medicare -- their primary payer for hospital, physician, and other health care use.

  • Among IHSS recipients age 3-17, those with Parent providers tend to have about $900 lower adjusted monthly Medicaid expenditures (i.e., holding health status, functional ability and other factors constant) than those with Non-Relative providers. Comparisons between those with Other Relatives and Non-Relative providers were not statistically significant.

  • Recipients age 18-64 with paid Spouse providers have adjusted mean monthly Medicaid expenditures about $1,000 lower than do those with Non-Relative providers. There was no statistically significant difference between those with Parent providers and those with Non-Relative providers.

  • Among IHSS recipients age 65 or more, those with Non-Relative providers have higher adjusted average monthly expenditures than those for either recipients with Spouse providers ($780) or Other Relative providers ($110).

  • Expenditures of new as compared to continuing IHSS recipients showed minor differences in adjusted mean monthly expenditures: non-significant among children, slightly higher among those age 18-64, slightly lower among the aged.

Medicaid-Reimbursed Hospital Expenditures and Use

  • Among all IHSS recipients’ age groups the unadjusted average monthly hospital expenditures generally show the Waiver recipients (i.e., those adults with paid Spouse providers, minor children with paid Parent providers) to have within their age group either the lowest mean expenditures or expenditures approaching the lowest group.

  • About 13% of the minor children and 25% of the IHSS adult recipients had at least one “any cause” hospital stay in 2005. Among minor children and the aged, comparisons (adjusting for recipient characteristics) of the likelihood of a hospital stay between those having waiver providers (i.e., Parent and Spouse providers respectively) and those with Non-Relative providers found no statistically significant differences.

  • Among IHSS recipients age 18-64, those with Spouse providers were about 15% more likely to have hospital stays than those with Non-Relative providers (adjusting for recipient characteristics). Comparisons between those with Non-Relative and Parent providers found 25% lower adjusted odds of a hospital stay for those with Parent providers. Non-aged adults with Other Relative providers show about a 10% lower risk of hospital stays than those with Non-Relative providers.

  • These findings of favorable or neutral outcomes comparing recipients with Waiver-related providers vs. those with Other Relative and Non-Relative providers were sustained using a more targeted comparison of hospital stays. These involved admissions having an Ambulatory Care Sensitive Condition (ACSC) -- conditions thought to be manageable with appropriate primary care. For IHSS recipients age 3-17 (adjusting for recipient characteristics), there were no statistically significant differences in the likelihood of an ACSC hospital stay comparing across all provider groups. For recipients age 18-64, a similar finding occurs comparing those with Spouse and Other Relative providers to those with Non-Relative providers. Those with Parent providers had lower adjusted odds for an ACSC hospital stay than those with Non-Relative providers. Among recipients age 65 or more, those with Spouse providers have reduced risk of an ACSC hospital stay. There were no statistically significant differences comparing those with Other Relative providers to those with Non-Relative providers.

  • Consistently, whether testing “any cause” or ACSC hospital admissions, non-White adult age IHSS recipients tended to have an increased risk for admissions. Among minor children, the pattern was less consistent, and non-significant in the ACSC comparisons. New IHSS recipients, across all age groups and provider types, tended to have about half the odds of a hospital stay compared to recipients continuing from 2004.

Medicaid-Reimbursed Physician, Outpatient and Emergency Room Use

  • About 17% of IHSS recipients, regardless of age group did not have any Medicaid claims for either physician services (including MDs, nurse practitioners, medical groups, surgi-centers, and rural clinics), or outpatient department (including hospital-based and other organized outpatient departments) use in 2005. Minor children recipients (85%) with Parent providers and adults with Spouse providers (94% non-aged adults 85% aged) have the highest rate of any use. (Service use estimates do not include uncompensated care or medical care encounters billed solely to non-Medicaid payment sources.)

  • ER use is experienced by more than half of the IHSS recipients in each age group. Adjusting for recipient characteristics differences among provider groups for recipients age 3-17 become non-significant. Among adult age recipients (ages 18 and over), those with Spouse providers tend to have about 20% higher odds of ER use compared to those with Non-Relative providers. Recipients age 18-64 with Parent providers have reduced odds of ER use. Adult age recipients with Other Relative providers have lower risk of ER use. New IHSS recipients, in all age groups have about 50% lower odds of ER use. The cause of the difference is unknown, but the main point is that recipients entering IHSS after initiation of the waiver are seemingly healthier than the recipients who continued in the program from 2004.

  • Inclusion of Medicaid ER use claims results in a 2%-3% increase, across all IHSS recipient subgroups, in the percentage of recipients having any medical care use.

  • Adjusting for recipient characteristics: minor children with Parent providers and adult recipients with Spouse providers have a higher likelihood of any medical care use (including ER use) compared to those with Non-Relative providers. Comparisons between IHSS recipients with Other Relative and Non-Relative providers are not statistically different. Adults with Parent providers have a 20% lower odds of medical care use than do those with Non-Relatives as paid IHSS providers.

  • The race/ethnicity of IHSS recipients, adjusting for health conditions and functional limitations, showed no statistically significant differences in the odds of medical care use (both including and excluding ER use) comparing Non-White to White race/ethnic groups among IHSS recipients age 3-17, and comparing Hispanics and Asians to Whites among recipients age 65+. Adult Black IHSS recipients, on the other hand, were less likely to use medical services than Whites. Non-aged adult Hispanic and Asian recipients tended to have a higher likelihood of medical care use than Whites of the same age.

  • Medical care expenditures follow patterns consistent with service use. Within recipient age groups there is little difference in the average monthly expenditures for physician and outpatient department services among recipients, regardless their provider type. Average monthly Medicaid expenditures tend to be highest for children, lowest for those 65 or older. Combining the sources of medical care (excluding ER use), the mean monthly expenditures for IHSS recipients age 3-17 continuing from 2004, range from a $140-$180 across all provider types; the ranges are respectively $105-$170 among those age 18-64, and $40-$50 among those age 65 or more. The lower expenditures among adults (the aged in particular), are likely due to Medicare or another source being a primary payer on these services. Expenditures for those who entered the IHSS program in 2005 are marginally higher than for continuing recipients.

Home and Community-Based Services

  • The use of Medicaid HCBS waiver or State Plan services (excluding IHSS) is proportionately low among IHSS recipients: fewer than 0.04% among IHSS recipients age 3-17, 4.2% among those age 18-64, and 17% among those age 65+. Average monthly expenditures for the users of these services tend to be highest among IHSS recipients age 18-64, particularly those with Parent providers (mean $2300/month). This rate is about double that for recipients with Spouse and Other providers. There is little unadjusted difference among recipients with different provider types for those age 65+ (mean $620), and too few minor children recipients to appropriately draw conclusions.

  • IHSS average monthly expenditures are comparable among adult recipients regardless of whether they are older or younger than age 65, but are higher among recipients age 3-17. Children with Parent providers ($520), and Adults with Spouse providers ($350 non-aged-$400 aged recipients) have the lowest unadjusted average monthly expenditures. The non-aged adult recipients with Parent providers had the highest average monthly expenditures ($980). There are minor differences comparing monthly expenditures for recipients with Other Relative versus Non-Relative providers within each of the recipient age groups: age 3-17 $870 vs. $880, age 18-64 $660 vs. $740, age 65+ $700 vs. $730.

  • Analyses combining IHSS and the other home care expenditures, and adjusting for recipient characteristics, found that IHSS Plus Waiver recipients (i.e., minor children whose parents are paid IHSS providers, and adults whose spouses are paid IHSS providers) had lower average monthly home care expenditures than recipients with Non-Relative providers. Differences averaged $520 for minor children, $340 for aged, and $430 for non-aged adults.

Nursing Home Use

  • The incidence of nursing home placement among IHSS recipients in 2005 was low: 0.26% among children, 2.25% among non-aged adult recipients, and 5.9% among those age 65+.

  • Among recipients age 18-64, there is a persistent adjusted effect: IHSS recipients related to their providers have lower adjusted odds of nursing home use than persons with Non-Relative providers. Recipients with paid Parent providers tend to have a lower adjusted risk than recipients with either Spouse or Other Relative providers. There were no differences between new and continuing IHSS recipients in placement rates.

  • Among recipients age 65 or older, the protective effect of relatives as providers is present only comparing recipients with Other Relatives to those with Non-Relative providers. Recipients with paid Spouse providers have a modest tendency toward a lower placement rate, but this did not reach statistical significance. Recipients joining IHSS in 2005 were less likely than continuing recipients to have a nursing home placement.

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