Table 9 shows the number of HCC’s, counted after aggregation into body systems.26 The prevalence distribution is relatively consistent within IHSS recipient age groups comparing new and continuing IHSS recipients. Those age 18-64 tend to have more conditions than the other age groups. Because of the relative prevalence consistency within age group we have combined the IHSS recipient entry cohorts in the HCC prevalence descriptive tables presented later.
The IHSS recipients included in the analyses of health conditions are limited to those enrolled in fee for service Medicaid for all their Medicaid participation months in 2005. This decision, resulting in the exclusion of those enrolled in Medicaid managed care for any portion of 2005 (n=56,152), was necessitated by the under reporting of Medicaid encounters by managed care members.27 Managed care enrollees represented about 13.9% of the IHSS recipients in 2005. The managed care members excluded varied by recipient age: minor children 28.8%, non-aged adults 17.8%, aged 10.4%.28
IHSS Recipients Age 3-17. Parents predominate as IHSS providers for minor children recipients. As shown in Table 10a, there is also a tendency for parents to be providers of recipients with more health problems. Recipients with paid parents as providers have an average of 3.62 chronic conditions. This compares to an average of 2.98 among “Other Relative” providers, and 2.58 among “Non-Relative” providers. Prevalence differences are present across most of the specific HCC categories. Ear, nose, throat, and mouth disorders were the most pervasive, affecting about 45% of all recipients. Central nervous system disorders (including seizures and convulsions, and spinal cord injuries) were the next most prevalent, affecting about 30% of the recipients. Musculoskeletal and connective tissues; lung problems (including asthma and other conditions); gastrointestinal system; cerebrovascular disease (particularly cerebral palsy and other paralytic syndromes), and Mental retardation/developmental disabilities each affected between 15%-25% of this age group. Neoplasms; cardio-vascular; kidney/other genitourinary system; mental health disorders; and endocrine, nutritional and metabolic disorders each affect close to 10% of recipients. Infections and parasitic disease; fractures, other injuries and poisoning, and dermatological disorders (e.g., decubitus ulcers, other local skin infections) affected about 10%-15% of the recipients. The general pattern was that the prevalence of conditions tended to be higher among Parent providers and lowest among Non-Relative providers.
IHSS Recipients Age 18-64. Non-relatives predominate as the IHSS providers for non-aged adults with disabilities, followed in descending order by Other Relatives, Parents. Spouses, eligible to be paid under the IHSS Plus Waiver, are the smallest provider group. As shown in Table 10b, the prevalence of HCC conditions tends to be lowest among recipients with Parent providers (average 2.75 conditions), and relatively similar among those with the other types of providers (averages of 4.49, 4.55, and 4.39 among those with Spouse, Other Relative, and Non-Relative providers respectively).
Musculoskeletal and connective tissue disorders are the most prevalent of the HCC’s among both Non-Relatives, Other Relative providers, and Spouses. Various cardiovascular; endocrine, nutritional and metabolic; gastrointestinal; and pulmonary disorders affect 25%-40% recipients with Non-Parent providers. Recipients with Parent providers have about half the prevalence of these conditions. Genitourinary systems disorders; ear, nose, and throat; and cerebral and other vascular problems each affected about 15%-20% of the recipients with Non-Parent providers. Most conditions follow similar patterns, with Parent providers having notably lower problem prevalence. Only among recipients with mental retardation/developmental disability, and central nervous system injuries/disorders (e.g., quadriplegia, paraplegia, other extensive paralysis or spinal cord disorders, and seizure disorders) do parents care for a higher problem prevalence than the other provider groups. Spouse providers tend to have prevalence rates a few percentage points below those of other relatives and non-relatives. These latter provider groups have relatively similar condition prevalence among most conditions. Acute conditions such as infections, fractures and injuries tend to be relatively similar among recipients. Treatment complications affect about 50%-60% of the recipients in each provider group.
IHSS Recipients Age 65 or More. Relatives (excluding spouses and parents) are IHSS providers for just over half of the aged recipients, closely followed by non-relatives. Spouses account for just over 2%. Recipients with paid Spouse providers have an average of 3.18 chronic conditions as measured from Medicaid claims. This compares to an average of 2.82 conditions among those with Other Relative providers and 3.03 among those with Non-Relative providers. Cardiovascular system disorders (e.g., coronary atherosclerosis and congestive heart failure) are the most prevalent group of conditions across all provider types in this recipient age group see Table 10c. Proportionate differences in disease prevalence between provider groups are generally low (<2%). When differences exist, prevalence tends to be slightly higher among those with Spouse providers than the others. Musculoskeletal and connective tissue disorders, are the one exception: non-relatives care for proportionately more recipients (35%) with this disease burden. Prevalence among those with Other Relatives (32%) and Spouse providers (30%) was marginally lower. Recipients with Spouse providers have condition prevalence rates 3%-5% higher than those among other provider groups in the other high prevalence condition groups: endocrine, nutritional and metabolic disorders; pulmonary; cerebral and other vascular system; renal and other genitourinary system disorders; and treatment complications. Infectious disease, and injuries, all have similar prevalence among the three provider groups.
A full listing of HCCs by age and IHSS provider is included in Appendix D.
This difference is illustrated in Table B-3, Appendix B. These show claims records among recipients in and not in managed care in 2005. For inpatient care, physician, durable medical equipment, medical transportation, and most ancillary services, those in managed care have one-third or fewer the number of vendor service claims compared to those not in managed care. While some of this difference may be related to case mix, similar differentials are not present in services (including IHSS and HCBS waivers) billed directly to Medicaid and not included in managed care capitation agreements.
Appendix C provides an analysis of IHSS recipient and county factors associated with provider use, and whether managed care participation is associated with provider selection, after adjusting for recipient attributes. Managed care membership was used in the estimated models to assess whether enrollment in these Medicaid plans might be biased relative to the various provider types. Among minor children there was generally no significant difference in membership among those with each type of provider. The exception was a marginally significant difference with those having Non-Relative providers being less likely to be in managed care. For recipients age 18-64, managed care members were more likely among those with Parent and Spouse providers, and less likely among those with Other Relatives and Non-Relative providers. For recipients age 65+, managed care members were more likely among Spouse and Other Relative providers, and less likely among Non-Relatives. Recipients with greater propensity toward managed care participation may have a bias toward fewer chronic health conditions and lower Medicaid expenditures. Analyses within age group, adjusting for other risk factors may help minimize this differential effect, but it cannot fully eliminate any systematic bias if healthier (or sicker) persons enroll in managed care.