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

Publication Date

Robert Newcomer, Ph.D. and Taewoon Kang, Ph.D.

University of California, Center for Personal Assistance Services


This report was prepared under contract contract #HHS-100-03-0025 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Research Triangle Institute. Additional funds were provided by the National Institute for Disability and Rehabilitation Research under grant #H133B031102. For additional information, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact Pamela Doty, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Pamela.Doty@hhs.gov.

This report was prepared under subcontract 5-312-0208826 between RTI International and the University of California (Edith G. Walsh, Ph.D., project director). The opinions and findings expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

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Executive Summary

In 2004, the Centers for Medicare and Medicaid Services (CMS) approved California’s In-Home Supportive Services (IHSS) Plus program under the Section 1115 demonstration authority of the Social Security Act. California refers to this program as the IHSS Plus Waiver. Full Medicaid (referred to as Medi-Cal in California) benefits and IHSS Plus benefits are available to all eligible IHSS Plus recipients. The IHSS program began in the early 1970s and was originally funded primarily with state and county funds and some federal Title XX (later renamed Social Services Block Grant) funds. Beginning in 1993, most IHSS services were financed through the Personal Care Services Program (PCSP) optional benefit and California benefited from 50% federal financial participation to cover these costs. However, prior to the granting of the IHSS Plus waiver, some services provided to a minority of IHSS recipients were not eligible for Medicaid federal matching payments. The cost of these “Residual Program” services had to be borne entirely by the state, with county cost sharing.

The effect of the IHSS Plus Waiver is to reduce the state and county share of costs for eligible Residual Program services to the same rates as in the state’s PCSP. About 26,000 persons were receiving all or a portion of their IHSS personal assistance in 2004 through elements of the Residual Program that were to be incorporated into the IHSS Plus Waiver. The components of the IHSS Plus Waiver (i.e., the services not previously eligible for federal matching payments) include:

  • Advance Pay: IHSS recipients meeting severely impaired criteria have the option to receive Advance Pay (i.e., Medicaid funds are paid to recipients in advance of personal assistance service delivery). This allows recipients to assure timely payments to care providers (including any emergency back-up providers).

  • Parent and Spouse Providers: IHSS Plus Waiver permits spouses of adults, and parents of minor children to be paid as IHSS providers for personal care, protective supervision, domestic and related services. Other family members as well as Non-Relative providers can provide similar services under California’s regular IHSS (i.e., PCSP) program.

  • Restaurant Meal Vouchers: IHSS Plus Waiver recipients have the option, under appropriate circumstances, to receive a Restaurant Meal voucher in lieu of in-home assistance for meal preparation and related tasks.

As a condition of granting the IHSS Plus Waiver, CMS required an evaluation. All “1115” research and demonstration waivers are subject to a “budget neutrality” requirement; that is, Medicaid costs under the waiver cannot exceed estimated costs in the absence of the waiver. Thus, the primary purpose of the evaluation was to determine the impact of the waiver on Medicaid service use patterns and associated costs. However, the Office of the Assistant Secretary for Planning and Evaluation also wished to know about availability of and preferences for Spouse and Parent providers and whether IHSS recipients with Spouse or Parent providers (especially minor children with Parent providers) and differences in characteristics, such as medical diagnoses and severity of disability, among those receiving services from different provider types (e.g., Spouse or Parent, Other Relatives, and Non-Relatives).

Changes made to Medicaid law and policy through the Deficit Reduction Act of 2005 now make it possible California and other states to offer Medicaid coverage for personal care services provided by “legally responsible relatives” (i.e., spouses or parents/guardians of minor children) without an “1115” waiver. The results of the IHSS Plus evaluation indicate that allowing personal care services to be provided by such previously prohibited provider types is unlikely to increase -- and may even slightly decrease -- Medicaid costs.

The IHSS Plus Waiver was initiated in August 2004. This report documents IHSS Plus Waiver implementation and recipient Medicaid service use in calendar year 2005. Analyses compare recipients having a waiver-eligible provider (i.e., parents of children, spouses of adults) for any portion of 2005 with recipients in the regular IHSS program who received personal assistant services through Other Relatives and Non-Relative providers during the same period. Recipients are classified by these provider types on an “intention to treat” basis. Recipients changing between Spouse/Parent providers and non-waiver-eligible providers are considered throughout the analysis as being in the spouse/parent group. This is analogous to an experiment where an individual enrolls into the innovative care group and later changes into “usual” care, but for purposes of analysis, the recipient is included within the group to which they were originally assigned.

The following questions are examined:

  • Do Waiver recipients differ from regular IHSS program recipients in race/ethnicity, living arrangement (e.g., household size, and availability of legally responsible relatives)?

  • What are the functional limitations, task assistance needs, and chronic health conditions of individuals participating in each waiver component (e.g., Parent providers, Spouse providers, Advance Pay, Restaurant Meals voucher)? Do these differ from recipients in the regular program?

  • Do Waiver and regular IHSS recipients differ in terms of continuity with their provider relationship, and Share of Cost?

  • Are there differences between waiver and regular program recipients in the number of IHSS hours authorized?

  • What are the Medicaid (aka Medi-Cal) expenditures incurred by waiver and regular program recipients? This includes all IHSS services; personal care from Medicaid home and community-based services (HCBS) waiver programs; Medicaid hospital, emergency room (ER), nursing home, home health, and medical provider claims.

Taken together, these descriptive questions assess four fundamental policy issues: whether there was a change in the number and attributes of spouses and parents of minors that are paid providers under the IHSS program; whether hiring legally responsible relatives as personal assistance providers seems to be a recipient/family preference; whether Spouse and/or Parent providers performed, as well as the use of other providers in enabling IHSS recipients to remain at home, safely; and whether the employment of family providers has been budget neutral for Medicaid in terms of health care use/expenditures. These policy issues are addressed in the conclusions section of this summary.

Approximately 407,000 persons received IHSS services in 2005. Of these approximately 25,700 recipients had as paid providers either parents of minor children, or spouses of adults. These recipients were classified as being in the IHSS Plus Waiver. Restaurant Meals voucher and Advance Pay recipients combined to include 1,600 additional Waiver recipients. About 60% of all IHSS recipients in 2005 were age 65 or more. Minor children (age 3-17) accounted for about 4% of recipients. The remaining one-third was recipients age 18-64. The distribution of recipients by IHSS Plus Waiver and PCSP providers varied by recipient age group. Parents predominate (70%) as providers among recipients age 3-17. Other Relatives and Non-Relatives are the predominant source (75%-95%) of providers for adult IHSS recipients. About 5% of non-aged adults and 2.5% of the aged IHSS recipients had IHSS-paid Spouse providers. There were only minor differences in these distributions comparing IHSS recipients continuing in the program from 2004 and those entering the program in 2005.

Females are the absolute majority of IHSS recipients, as well as the majority of those cared for by Other Relatives and Non-Relatives. Males predominate as IHSS recipients age 3-17, and they account for the majority of those cared for by an IHSS-paid Spouse. The IHSS program has a broad mix of racial/ethnic groups, with non-White groups accounting for the majority of recipients across all age groups. Hispanic and Asian recipients are more likely to use relatives (parents, spouses, or other relatives) as paid IHSS providers than are White or Black recipients.

The disability/chronic illness profile of each age group is different, as is the distribution of recipients among the types of paid providers used. Because of this most of the discussion is presented by recipient age group.

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.

Conclusions

This section addresses four fundamental policy issues implicit in the IHSS Plus Waiver and its efforts to extend the use of spouses and parents as paid providers for personal care services.

IHSS Plus vs. the IHSS Residual Program Participation

The number of recipients cared for by Spouses and Parents of minors paid as IHSS providers remained relatively constant between 2004 (under the IHSS Residual Program) and 2005 (under the IHSS Plus Waiver); as did the total number of persons (about 1,600 recipients in 2005) participating in the Restaurant Meals voucher and Advance Pay waiver-eligible services. The new recipients, as a group, tended to be somewhat less impaired, to have lower health care expenditures, and to receive fewer IHSS authorized hours than the group of recipients who were in IHSS during the prior year, or longer. These attributes likely could be common to all cohorts of new recipients, and may not be unique to IHSS Plus Waiver program entrants. The race/ethnic and provider mix was somewhat different comparing the new and continuing program cohorts, showing a proportionate increase in Hispanic and Asian recipients.

Preferences in the Selection of Paid IHSS Providers and Outcomes

The selection of a Parent or Spouse as a paid provider, across all age groups, is partly a function of available family members, but differences in the proportion among race/ethnic groups “selecting” each of the various provider types suggests that cultural preferences may be an important selection factor. Wage and other possible influences on provider availability were not an in-depth focus of these analyses, but IHSS wage rates (which vary by county) did not have a consistent association with the selection of paid Parent or Spouse providers. To the contrary, higher wages were marginally associated with an increased use of Non-Relative providers, and Parents and Spouse providers were more likely when wages were low (and presumably low wages may make it more difficult to attract Non-Relative providers).

Recipients Age 3-17

Minor children in IHSS generally have at least one parent in the home. Consequently, for most of these children, the choice of Parent/Non-Parent provider was possible and the choice made by families was for a Parent provider (70% overall and 80% when a parent was present in the home). Hispanics had the highest proportion selecting Parent providers (81%) and the least selecting Non-Relative providers (9%). Blacks (60%) were the least likely to have paid Parent provider, and comparable to Whites in the proportion selecting Non-Relative providers (20%). The decision of families to seek IHSS versus other service options was outside the scope of this study.

There were few differences by provider type in the number of ADL/IADL and cognitive limitations among minor children IHSS recipients. However, proportionately more minor children with paid Parent providers were dependent on human assistance with breathing (this includes assistance with self-administration of oxygen, and the cleaning of this equipment), and had more chronic health conditions (including mental retardation, seizure disorders, and paralysis). These conditions have been shown to be associated with nursing home use in minor children (Fries, Wodchis, Blaum, et al., 2005), and may be indicative of the Parent provider’s willingness and/or greater ability to assume the demanding care responsibilities associated with these conditions. Contributing to this ability may be that parents are legally permitted to perform “skilled nursing” tasks that other providers, especially Non-Relatives, would not be permitted to perform. Investigation of the “cause” of this pattern is outside the scope of the current study.

Recipients Age 18-64

Spouse providers were rarely available as a choice to the non-aged adults participating in IHSS. Most IHSS recipients in this age group were either not married or their spouses were also IHSS recipients or otherwise not able physically/mentally to be paid caregivers. However, when spouses were available and able, the “preference” for them appears to be strong (90% among those with an available/able spouse). Parents were more readily available than spouses to non-elderly adults, and more recipients of this age group selected Parent paid providers. The availability of parents beyond those selected as paid providers is unknown in the IHSS data. There were discernable ethnic differences in the propensity to select Parent or Spouse providers. Hispanics were most likely to select Parent providers (26%), and the second most likely to select Spouse providers (9%). Asians were the most likely to select Spouse providers (11%), and second most likely to select Parent providers (18%). Blacks were the least likely to select either Spouse (2%) or Parent (10%) providers. More than half of the Blacks and Whites relied on Non-Relative providers. This contrasted with about a third among Hispanics and Asians.

In general, recipients with paid Parent or Spouse providers had more limitations in ADL and cognitive functioning, and a comparable number of chronic health conditions than recipients with other providers. However, those with paid Parent providers had higher rates of mental retardation/developmental disability, central nervous system injuries/disorders such as quadriplegia, paraplegia, other extensive paralysis or spinal cord disorders, and seizure disorder) -- all of which are conditions shown by Fries and associates (2005) to be associated with higher risk of nursing home placement.

Recipients Age 65 or More

Spouses were present among about 25% of this age group of IHSS recipients, but except for those paid as Spouse providers, the number able/available reduced to about 3%. When a recipient-provider was an Other Relative or a Non-Relative, almost half of the spouses present were also IHSS recipients. This pattern of both partners being on IHSS may be the consequence of the income and asset eligibility criteria used for Medicaid among IHSS recipients. Unlike the criteria used for nursing home recipients, IHSS recipients are not allowed to separate their couple assets when determining program Medicaid eligibility for one individual. Recipients with IHSS-paid Spouse providers tended to have more ADL, cognitive, and breathing assistance limitations, but there were no substantial differences in the number of health conditions. Race/ethnicity had a minor association with the presence of a paid Spouse provider (the percentages range from 1%-4%), but the more striking differences involved recipients with Other Relative and Non-Relative providers. More than half of the Asian (64%) and Hispanic (54%) recipients had an Other Relative as their paid provider, whereas more than half of the Whites (53%) and Blacks (56%) had Non-Relative providers.

Implications for Medicaid and IHSS Expenditures

For all recipient age groups, IHSS expenditures, adjusting impairment severity and service needs, are expected to be lower relative to those with Non-Relative providers when Parents, Spouses, and Other Relatives living in the household are paid IHSS providers. This cost difference arises because an IHSS algorithm adjusts the authorized time for housekeeping/meal preparation when there are relatives living in the household who might be expected to perform these tasks for themselves as well as for the recipient. This adjusted cost difference was observed for Parent providers to minor children, and for Spouse providers of adults. The cost differences for Parent provider (non-aged adults) and Other Relative providers were minor or non-significant. This could be because these providers were not living with the recipient or they may reflect limitations in the risk adjustment model.

Minor children with Parent providers, after adjusting for recipient functional and health conditions, have lower average monthly Medicaid expenditures than those with Non-Relative providers. These recipients also have lower adjusted use of IHSS and other home care service expenditures.

Adjusting for recipient characteristics, recipients age 18-64 with Spouse providers had lower average Medicaid monthly expenditures than those with Non-Relative providers. There were no statistically significant differences comparing recipients with Parent and Non-Relative providers. Among these adult IHSS recipients each of the paid relative provider groups had a significantly reduced likelihood of nursing home placement compared to those with Non-Relative providers. The Parent provider effect for those age18-64 appears greatest. Those with Spouse providers tended to have higher risk of “any cause” hospital stays (but not those associated with ambulatory sensitive conditions), higher risk of ER use, but lower IHSS and home care expenditures than recipients with Non-Relative providers. Recipients with Parent providers compared to those with Non-Relative providers had lower adjusted use of hospitals, ERs, and home care.

Average monthly Medicaid expenditures among recipients age 65 or more, adjusting for recipient characteristics, were lower for those with Spouse providers and Other Relative compared to Non-Relative providers. This tendency for lower risk among those with family providers was also present with respect to ambulatory sensitive hospital stays; and those with Other Relative providers compared to those with Non-Relative providers had reduced risk of ER use, lower monthly expenditures for IHSS and other home care. The protective effect of relatives as paid providers was also present, but this association was with the Other Relative provider category as compared to Non-Relative providers.

In short, these analyses found no financial disadvantage and some advantages to Medicaid from allowing spouses, parents (and other relatives) to be paid IHSS providers. This argues in favor of honoring the recipient’s and family’s preference for such providers. Whether the availability of spouse, parent, and other relatives can be expanded beyond its current proportion among all race/ethnic groups in IHSS is unknown, but changes in the race/ethnic mix of recipients evident in the new cohort of enrollees may affect this. The proportion of recipients who are Hispanic or Asian seems to be growing. These groups presently have the highest proportionate use of Spouse, Parent, and Other Relative providers.

These effects of selecting Parent, Spouse, and Other Relatives as paid providers are present within a program where the rate of Medicaid nursing home stays among IHSS recipients with Non-Relative providers seems to be low. This suggests that IHSS in general is doing a good job of enabling recipients to remain in the community regardless of the provider type selected. Not examined in this analysis were the factors (such as hospital stays, avoidable changes is health or functional status) associated with entry into and exit from IHSS; or the duration of participation in IHSS and the cost/use comparisons over time.

Background and Purpose

California’s In-Home Supportive Services (IHSS) program provides personal assistance services (PAS) for low-income people with physical, sensory, memory, or cognitive disabilities. Services available include assistance with activities of daily living (ADLs) (e.g., bathing, dressing, eating, bladder/bowel requirements) and instrumental activities of daily living (IADLs) (e.g., shopping, meal preparation, house cleaning). In calendar year 2005, IHSS served about 385,000 aged, blind, and disabled adults or children per month, or about 408,000 persons annually. IHSS is financed through a combination of federal, state, and county funds. To qualify for IHSS, an individual must be either over age 65, or disabled; and either eligible for (including current recipients) of Supplemental Security Income/State Supplementary Payment (SSI/SSP)1 or meeting all the eligibility criteria for SSI/SSP except for income limits (DSS, 2000).2 All components of IHSS operate as an entitlement program, meaning that IHSS is available to all persons who meet the income and benefit eligibility criteria. In principle there is no waiting list for admittance into the program and no cap on the overall growth of the program. The types and amount of services provided are determined by county social workers who conduct eligibility assessments and authorize services according to state and federal policies.

From 1973 to 1992, IHSS was supported entirely by state and county funds. Starting in 1993 the state converted its program to Medicaid (aka Medi-Cal)3 State Plan personal care services and began receiving Medicaid funds for the services meeting federal reimbursement criteria. State (33%) and county (17%) funds finance the 50% federal match of the program expenditures. Services in the former program not qualifying for Medicaid were retained within IHSS in what came to be known as the “Residual” Program. These services continued to be paid solely using state and county funds. Included in the Residual Program were those IHSS recipients receiving paid care from legally responsible relatives (i.e., parents of minor children or spouses), persons authorized to receive “Advance Pay,” and recipients who received Restaurant Meals vouchers in lieu of hours of attendant care for in-home meal preparation. Advance Pay enabled recipients to pay their consumer-hired PAS workers in full and on time, rather than having to submit timesheets through the county and on to the state for payment.

In 2004, California submitted a Social Security Act section 1115 waiver request to the Centers for Medicare and Medicaid Services (CMS). This is known as the IHSS Plus Waiver. It was approved and began implementation in August 2004. The Waiver enables federal financing participation for services brought into IHSS Plus from California’s IHSS Residual Program. The effect of this is to reduce the state and county share of costs in the State Plan program. About 26,000 persons were receiving all or a portion of their IHSS personal care assistance through those elements of the Residual Program in 2004 that were to be incorporated into the IHSS Plus Waiver. Not all Residual Program services are included in the Waiver. The following are the components of the IHSS Plus Waiver:

  • Advance Pay: IHSS recipients meeting severely impaired criteria have the option to receive Advance Pay (i.e., Medicaid funds are paid to recipients in advance of PAS delivery). This allows recipients to assure timely payments to care providers (including any emergency back-up providers).

  • Parent and Spouse Providers: IHSS Plus Waiver permits spouses of adults, and parents of minor children to be paid as IHSS providers for personal care, protective supervision, domestic and related services. Other family members as well as Non-Relative providers can provide similar services under California’s regular IHSS (i.e., Personal Care Services Program (PCSP)) program.

  • Restaurant Meal Vouchers: IHSS Plus Waiver recipients have the option, under appropriate circumstances, to receive a Restaurant Meal voucher in lieu of in-home assistance for meal preparation and related tasks.

This report documents IHSS Plus Waiver implementation and recipient Medicaid service use in calendar year 2005. Analyses compare recipients in the IHSS Plus Waiver program with recipients in the IHSS State Plan (aka PCSP). Waiver recipients are minor children whose parent is a paid IHSS provider, or those whose spouse is a paid IHSS provider. Recipients are classified by these provider types on an “intention to treat” basis. Namely, recipients having either an IHSS Parent or Spouse provider for any portion of 2005 are considered to be in the Waiver for the calendar, even if they had another relative or a non-relative as a paid provider for a portion of the year. Likewise, those not having a paid Parent/Spouse provider during the calendar year are considered to by in the regular IHSS program or PCSP. This is analogous to an experiment where an individual enrolls into the innovative care group and later changes into “usual” care, but for purposes of analysis, the recipient is included within the group to which they were originally assigned.

Study outcomes include recipient state Medicaid expenditures and service use, such as hospital and emergency room (ER) use, and nursing home placement.4 This work supports the California’s evaluation of the IHSS Plus Waiver and complements other consumer-directed services research conducted under the aegis of the federal Office of Disability, Aging and Long-Term Care Policy (DALTCP)DALTCP is a unit of the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Human and Health Services. The analyses consider the consequences of allowing “legally responsible” family members (i.e., parents/legal guardians of minor children and spouses) of Medicaid beneficiaries to be paid as personal care attendants. Such payments are permitted when the financing mechanism is a 1915(c) home and community-based services (HCBS) waiver, and section 1915(j) provisions applicable to the State Plan.


  1. The SSI is a federally funded income support program (Social Security Act, Title XVI) for the aged, blind, and disabled. The SSP is a state program that supplements the SSI income level. SSI/SSP benefits in California (as in most states) are administered by the Social Security Administration (SSA). Eligibility for both programs is determined by SSA using federal criteria for income and assets. Benefits are in the form of cash assistance (CDSS, 2003, SSI Eligibility).

  2. About 2.2% of IHSS recipients did not meet income limits for at least one month in 2005, and paid a “share of cost” for services in those months where their income exceed Medicaid eligibility levels.

  3. Medicaid is a federal program (Social Security Act, Title XIX) that provides health and long-term care coverage for low-income families and aged, blind, or disabled individuals. Medi-Cal is the term California uses for Medicaid.

  4. Community care facility placement, and mortality risk were initially considered as potential programs as well. However, the indicator of placements in the IHSS recipient termination status field was found to be unreliable. Mortality similarly is not fully documented on IHSS records as death often occurs after a hospital admission and may not be recorded in the IHSS record. An attempt was made to obtain Medicaid eligibility records that have this information, but these were not made available to project.

Research Questions

Many state Medicaid program administrators are interested in having the flexibility within their Medicaid State Plan personal care programs to authorize paying family members to provide care to recipients. A number of factors contribute to this. For example, traditional providers, such as licensed home care agencies, are experiencing direct care worker shortages (Stone, 2000; GAO, 2001). Within both agency and independent provider situations, there are also concerns about absenteeism, frequent schedule changes, and high turnover of attendants (Harmuth & Dyson, 2002; Salsberg, Wing, Langelier, et al., 2002; Stone, 2001). Perhaps most germane is the recognition that for many severely disabled individuals, home care is not a cost-effective substitute for facility care unless paid home care is provided as a supplement to unpaid family care. The evidence on which program administrators and recipient advocates base their arguments in favor of permitting legally responsible family members to become paid workers is, other than in the Cash and Counseling Demonstration, largely anecdotal.5 Thus, further examination of these issues may be helpful for policy makers.

This analysis is interested in understanding who the IHSS Plus Waiver provisions serve, and in evaluating program and recipient outcomes. Outcomes are represented by IHSS, Medicaid service use and expenditures by IHSS recipients. The following questions are examined:6

  • Do IHSS Plus Waiver recipients (e.g., Parent, Spouse providers, Advance Pay, Restaurant Meals voucher) differ from regular IHSS program recipients in race/ethnicity, living arrangement (e.g., household size, and availability of legally responsible relatives)?

  • What are the functional limitations, task assistance needs, and chronic health conditions of recipients in each IHSS Plus Waiver component? Do these differ from recipients in the regular program?

  • Do IHSS Plus Waiver and regular IHSS recipients differ in terms of continuity with their provider relationship, and Share of Cost?

  • Adjusting for disability levels, are there differences within age group between IHSS Plus Waiver and non-Waiver recipients in the number of authorized hours?

  • Adjusting for disability and other attributes, what are the Medicaid (aka Medi-Cal) program use and expenditures incurred by waiver program and non-waiver recipients? This includes all IHSS services; HCBS waiver programs; Medicaid hospital, ER, nursing home, home health, and medical provider claims.


  1. The federally funded Cash and Counseling Demonstration has reported positive experience from the Florida program which allows payments to parents of minors in the consumer-directed program for children with developmental disabilities. Reports from the demonstration are available at http://www.cashandcounseling.org.

  2. Qualitative interviews explored a number of issues with both waiver and non-waiver recipients and their families (Newcomer & Scherzer, 2006). Among these were the other caregiving arrangements that had been tried; why they elected (or did not elect) to participate as a paid Parent/Spouse provider; or to accept or not accept the benefits of Advance Pay or Restaurant Meal vouchers; and whether being a paid Parent or Spouse provider affected Medicaid, SSI, or other program eligibility.

Methods

Because IHSS (including the IHSS Plus Waiver and Residual Program) is an ongoing statewide program, an experimental design in the implementation and evaluation of the waiver was not feasible. Instead, a quasi-experimental design was used. This design relies on statistical controls to adjust for measured differences between the waiver and non-waiver recipients. This work identifies the circumstances and characteristics associated with the types of providers (e.g., Parent, Spouse, Relative, Non-Relative) used by IHSS recipients, and compares service use/expenditures and other outcomes among provider types adjusting for recipient attributes.

Comparisons of waiver and non-waiver IHSS recipients are organized within age categories, controlling for other characteristics, such as disability severity. Children under age 18 who have Parents as paid caregivers are compared with children whose paid caregivers are Other Relatives or Non-Relatives. Similarly, adults aged 18-64 who have spouses as paid caregivers and elders aged 65 or older whose paid attendants are their spouses are compared with married and unmarried adults in the same age cohort with Non-Spouse providers. Advance Pay and Restaurant Meals vouchers have small recipient enrollments. Analyses of these options are descriptive.

Data Sources (7)

The project uses administrative data from three California departments: Health Care Services, Social Services, and Developmental Services. These were linked using a combination of each data set’s assigned identification number, a Medicaid eligibility number, and a unique project assigned identifier. To assure the confidentiality of the individual recipients the records available to the project included only the project’s unique identification number. Recipient and provider name, phone number, address, and Social Security number were all removed from these records:8

  • Case Management Information and Payrolling System (CMIPS). This data set is compiled and maintained by the Department of Social Services (DSS). It contains information on all IHSS recipients (including age, gender, race/ethnicity, living arrangement, physical and cognitive status, and hours of authorized IHSS services), provider characteristics (age, gender, race/ethnicity, relationship to recipient, and hours of paid personal care service), and for 2004 the IHSS payments for Residual Program services. IHSS 2005 expenditures are obtained from Medicaid claims.

  • Medi-Cal Claims Data. These data are compiled and maintained by the California Department of Health Care Services as part of the Medi-Cal service payment system. Claims provide diagnoses, Medicaid-reimbursed health care use (i.e., physician, ER, hospital, home health, personal care, nursing home), and HCBS use (including both State Plan PCSP and waivers).

  • Department of Developmental Services (DDS) Data. Three data sets are available for the persons served by programs in DDS: the Client Master File (CMF), the Client Development Evaluation Report, and the Purchase of Services System (POS). The CMF contains demographic and address information on all persons served by DDS. This file was used to link DDS data with the CMIPS core data set. The other data files were not used in the present analysis.9


  1. The initial planning for this project had hoped to include information from community care licensing (CCL). CCL is a division within DSS responsible for licensing supportive housing. Such data would have allowed us to identify any months (either before or subsequent to IHSS receipt) in which the study’s IHSS recipients lived in licensed residential care facilities and/or adult care facilities. This phase of the project was precluded by the recipient confidentiality terms of the Data Sharing Agreements negotiated between the University of California and the study’s three collaborating state departments.

  2. These procedures assure autonomy of recipients and comply with the protection of human subjects protections procedures approved by the Committee on Human Research, University of California, San Francisco (approval #H945-28245), and the California State Committee on the Protection of Human Subjects (approval #06-02-03).

  3. CDER provides developmental, mental health, and medical diagnostic information; and information on hearing, vision, behavioral medication, health care equipment, behavior risk assessment, legal information, motor domain assessment, independent living domain assessment, social skills domain assessment, emotional needs assessment, cognitive domain assessment, and communication domain assessment. POS data identifies provider fiscal information for both state general funds and Medicaid DDS waiver funded service use and expenditure. These later data are also available in Medi-Cal claims files. To assure consistency in the source of Medicaid expenditures, we limited our attention to the claims files.

Sample

The study sample was selected from IHSS recipient listings in 2005. It included anyone in the program as of January 1 of that year, or who entered the IHSS program sometime during the calendar year. The inclusion rules assured that we obtained all waiver recipients in each of the target age categories as well as recipients in Advance Pay and Restaurant Meals vouchers. Analyses involving Medicaid claims-records (such as to include medical diagnoses or to compare health outcomes) reduced the sample to persons participating in Medicaid through fee for services. Those enrolled in Medicaid managed care programs were excluded as Medicaid claims are not submitted for managed care covered services. Appendix A provides an elaboration of the steps used to select, screen, and qualify IHSS recipients into the study sample.

Recipient Characteristics Measures

Recipient Characteristics measures were obtained largely from CMIPS. These files are compiled monthly and include recipient eligibility and assessment files, provider eligibility, and payment files. Recipient assessment data in CMIPS are generally updated every two years or after a substantial change in status. IHSS Plus Waiver recipients receive annual assessments. To obtain reasonable comparability between waiver and non-waiver recipients we averaged each recipient’s assessment measures drawn from each IHSS participation month in 2005. These items can vary from month to month with changes in status or periodic reassessments. If the individual was not a recipient in January, then the first assessment in 2005 was used as the starting assessment. Following is a description of the measures drawn from CMIPS for this analysis.10

  • Recipient Age. Used to classify recipients into the target age cohorts.

  • Recipient Gender.

  • Recipient Race/Ethnicity. There are 16 race/ethnicity categories used in CMIPS, we consolidated these into four groups: White, Hispanic, African-American, Asian/and all Others for the analysis.11

  • Recipient Household Size and Living Arrangement. There are several measures potentially available for these items. One is a count of persons in the household, excluding non-IHSS recipients <age 14. A second is a measure indicating for those under 18, if a parent is present and whether the parent is able and available to be a care provider. There is a similar measure relative to spouses, but this measure was found to be unreliable and was not used.12

  • Provider Relationship. This information is obtained from the provider eligibility files. Three types of provider relationships are used to classify the IHSS recipient into a waiver and non-waiver status: Parent/Spouse, Other Relative, Non-Relatives. (See the sampling discussion for the decision rules used when there were changes in providers, and multiple providers in a month or year.)

  • Recipient Income and Share of Cost. Recipient income was not used in the analysis as all study subjects were Medicaid eligible. Fewer than 4% among all provider groups had any IHSS “Share of Cost” payment requirements.

  • Eligible Months. Number of months eligible for IHSS in 2005 is used as the denominator to standardize IHSS authorized hours, and total IHSS and Medicaid expenditures into averages per IHSS participation months in 2005.

  • Authorized IHSS Hours. This measure is represented in the analysis by the monthly authorized hours in a calendar year, averaged over the number of active IHSS participation months in the year. More precise time varying measurement was not used because of data limitations. Authorized hours can change with a change in recipient status or living arrangement, but the items in the assessment files are commonly not updated until the next assessment -- which may be more than a year away.13

  • Recipient Cognitive Limitations. For consistency in classifying recipients across all age groups and payer sources, recipient cognitive limitations are limited to three items available in CMIPS: Cognition is defined by: Memory, Orientation, and Judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance.

  • Recipient Limitations in ADLs. ADLs include bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating. Each task is scored on a five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance.14

  • Recipient Breathing problems (which includes assistance with self-administration of oxygen and the cleaning of this equipment) are scored in CMIPS as 1 independent, 5 cannot perform without human assistance, 6 Paramedical Services needed. The measure used in the analysis is the presence/absence of a Breathing item with a score of five or more.

Health Conditions and Diagnoses were compiled from Medicaid claims to supplement the CMIPS recipient characteristics.15 These records include up to two diagnoses, coded using the International Classification of Disease or ICD-9-CM (CDC, 2007), for each individual service claim. Analyses using claims and other administrative data have adopted a variety of approaches for identifying and adjusting for patient diagnoses. Important areas of conceptual consensus are that the diagnostic categories be: (a) clinically meaningful and related to well-specified disease or medical conditions; (b) the categories predict medical expenditures or other specified outcomes of interest (e.g., mortality); and (c) have sufficient prevalence to permit stable estimates. Two of the most prominent approaches are used in this analysis, one for recipient characteristics (described below), the other as a health care outcome indicator (described in the Outcome Measures section).

The CMS hierarchical condition categories (HCC) are used as health condition predictor variables in our analysis.16 HCC classification uses both inpatient and outpatient data. The HCC provides a standardized protocol for combining over 15,000 ICD-9 categories into 189 condition categories or CCs (Pope, Ellis, Ash, et al., 2000). Most CCs describe a broad set of similar diseases, generally organized into 23 body systems, but CCs 185-189 are assigned by beneficiary utilization of selected types of durable medical equipment. The CCs can be organized into hierarchies, designed so that a person is coded only for the most severe manifestation among the related diseases defining the CC. Within the same HCC a person is classified once. This avoids the problem of duplicative counting of related conditions. For unrelated diseases (i.e., diseases in other CCs), the number of HCC’s accumulate.

HCCs are assigned using any mention of the eligible diagnosis from any of five sources.17 Information or the frequency of mentions are not differentially weighted among these sources (Pope, et al., 2004):

  • Principal hospital inpatient;
  • Secondary hospital inpatient;
  • Hospital outpatient;
  • Physician claims-record; and
  • Clinically-trained non-physicians (e.g., psychologist, podiatrist, nurse practitioner).

Additional information required for the identification of a qualifying diagnosis is a date on the eligible record establishing that the diagnosis was made (or was present) during the relevant reporting period.18


  1. Provider attributes such as race/ethnicity, age, and gender are available in CMIPS, but other than relationship to the recipient, these data were not used in the analysis.

  2. Appendix BTable B-1 shows the distribution of the study samples’ race/ethnicity groups, by recipient age group and provider type by new recipients in 2005 and those continuing from 2004.

  3. Measures of living arrangement, such as housing type, having a live-in provider, and various shared housing arrangements were incompletely coded in assessments and correlated with household size. Consequently, only household size was used.

  4. Within CMIPS there is a calculated unmet need, defined to be the difference in total need hours and authorized hours. This measure was not used because it is confounded by ceilings on the maximum number of authorized hours (283 hours/month) used by IHSS, and non-transparent adjustments made for household composition or unmeasured changes in status. An alternative unmet need measure derived from the difference between authorized hours and paid hours was considered. This measure proved to be problematic as the distribution of hours per week is not determinable from the monthly payment data. Consequently, there may be unmet hours in particular days or weeks that are masked by accumulated monthly billings.

  5. IADLs included in CMIPS are housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside one’s home. Each task is scored on a five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance fro the provider, 4 Can perform with a lot of human assistance, 5 Cannot perform without human assistance. This measure is not included in the analysis because of the absence of variance. Across all provider groups, 85% or more of the recipients have four or more limitations with a score of three or higher.

  6. The project considered using the CDER and the POS file -- both from DDS. Together, these provide recipient assessment information and service use data. However, given the proportionately small number of IHSS recipients in these data sets, and the incomparability of the assessment measures with those in CMIPS, the redundancy with salient POS items with those in Medicaid claims, the decision was made to limit age and provider analysis to the uniform common data available from CMIPS and Medicaid claims.

  7. The CMS-HCC model was developed for Medicare using claims data to provide risk adjustment for Medicare capitation payment rates (Pope, Kautter, Ellis, et al., 2004). This method has been extensively tested for predictive validity among aged and disabled persons; and with both community and institution-based populations.

  8. Diagnoses from other claims records (including home health providers, durable medical equipment providers, skilled nursing homes, ambulatory surgery centers, hospice, clinical laboratories, radiology/imaging) are excluded. The basis for these exclusions are practical. This is due to poor predictive power found in the development of the HCC model, and concern about the reliability of the diagnoses from non-physicians, or confusion arising from the coding of “rule-out” diagnoses that sometimes appears on laboratory or imaging records.

  9. Applications of HCCs for prospective payment protocols require that the diagnoses be obtained from the baseline (i.e., prior) year. These classifications are used as the basis for reimbursement in the subsequent year. This model evolved from multiple studies over two decades (e.g., Ash, Porell, Gruenberg, et al., 1989; Ellis, Pope, Iezzoni, et al., 1996). Clinical applications of HCC or other condition groups, such as for assignment of members/patients into special clinics or care management panels, have found improved prediction of service use and expenditures if concurrent diagnoses are incorporated into the classification (Dudley, Medlin, Hammann, et al., 2003). Because of this and evidence that using a single year to identify diagnoses for an individual may lead to an under counting of conditions and a bias toward classifying beneficiaries who have higher cost (e.g., those with hospital stays or frequent or specialty physician visits) (Newcomer, Clay, Luxenberg, Miller, 1999), we have elected to use concurrent year claims in HCC assignment. Even with this adjustment there is still a concern that chronic condition prevalence and service use are under reported in the IHSS recipient population. This occurs for several reasons. First, Medicaid reimbursed service use is reliably reported only for those in fee for service. Services covered under managed care capitation agreements (such as hospitals, skilled nursing facilities, physicians, and other health care providers) do not usually generate a billing or reimbursement claim. Managed care enrollees are omitted from any analysis involving diagnostic classifications or counts of conditions. Secondly, recipients dually eligible for Medicare or other payers such as the Veterans Administration may have services exclusively or substantially paid for by these sources. In such circumstances, there will be no or fewer Medicaid claims and diagnoses reported. A third factor is that Medicaid claims have fields for recording only two diagnoses. When a patient has (or their service claim involves) more than two conditions, then the number of diagnoses will be under reported on the claim. This may result in some conditions not being recorded on the claims records. These factors are not thought to be differentially distributed within recipient age groups or their provider types.

Outcome Measures

Medicaid claims-records are also used to identify the occurrence of selected events (e.g., ER, hospital stay, nursing home placement) and to compile expenditures. These are used as the program evaluation’s primary outcome measures. As shown below, a number of specific services were identified in the claims data. A further refinement involves the convention of identifying hospital stays where an ambulatory care sensitive condition (ACSC) is a primary or secondary diagnosis. Hospitalizations with one of these diagnoses are said to be indicative of a potentially “avoidable” hospital stay, and indicative of the quality or performance of primary health care (Billings, Zeitel, Lukomnik, et al., 1993). While there is some overlap in ACSC classifications for children and adults, there are separate standardized algorithms for each of these age groups (AHRQ, 2007a, 2007b).19

Following is a brief description of the claims-based items compiled for 2005. Both expenditures and service use rates are adjusted by the number of IHSS eligibility days in the study year.20

  • Member of managed care Medi-Cal in 2005. This measured is used to omit cases from analyses involving claims-based items.

  • Total Medi-Cal Expenditures 2005, adjusted for IHSS eligible months in period. We limited these data to non-pharmacy-related expenditures.

  • Medicaid expenditures use HCBS waivers in combination with State Plan optional personal care benefit in 2005.

  • IHSS expenditures (separate from the above) in 2005.

  • Hospital use in 2005; total hospital Medicaid expenditures; repeated for ACSC admissions.

  • Nursing home use in 2005; total Medicaid expenditures, and use.

  • Home health use in 2005; total Medicaid expenditures.

  • Medical provider and other outpatient services in 2005; total Medicaid expenditures.

  • ER use in 2005.


  1. Table D-4 and Table D-5 in Appendix D show the conditions used to identify ACSC outcomes.

  2. The original work plan also included the generation of Medicaid claims data for 2004. This information was compiled, but as the analyses reported are largely focused on comparisons of IHSS continuing from 2004 and new IHSS recipients in 2005, we have limited the presentation of data to 2005, differentiating new recipients. Payments via other state programs, and non-state sources are not represented. For example, expenses reimbursed by Medicare will under report total use and expenditures as some claims are reimbursed solely by this non-Medicaid source or for which Medicaid payment is limited to co-payments and deductibles. These limitations primary concern the expenditures for recipients who are dually eligible for Medicare and Medicaid. Service events, such as a hospital stay, usually have at least a Medicaid co-payment, and can be identified. Data on Medi-Cal eligible months in the period was not available to the project, but we do have months of IHSS eligibility.

County Characteristics

County characteristics are included in the analyses, primarily because of a concern about some variation in IHSS practice among the counties. The IHSS program is administered by county governments and IHSS program social workers in the counties are responsible for conducting program recipient assessments. Assessments are conducted at the time of program application and at least every two years for the regular IHSS recipients (annually for those in the IHSS Plus Waiver). They are also supposed to be conduct when there is a major change in status, there may be practice variation in this. Additionally, variation can occur in how social workers evaluate (or score) the level of the recipient’s limitations. A computer-based algorithm is applied against the assessments to determine the number of IHSS authorized hours. The algorithm adjusts hours based on household size and the availability of household members to provide domestic services. Other potential sources of program variation among counties include the mix of long-term care services available to those with personal care assistance needs, and the county’s discretion (within a cap set by the state) in setting the hourly rate paid to IHSS workers, and whether (and to whom) they offer health care benefits to IHSS workers. Counties share 17% of the cost of the IHSS program (34% of the pre-waiver Residual Program expenditures), and vary substantially with each other on wage rates. Within a county, the hourly rate paid for IHSS services by independent providers is relatively uniform. The combination of alternative service supply, IHSS wage rates, and per capital income (a proxy for cost of living), may influence the relative supply of IHSS workers. These factors may contribute to differences in whom recipients “select” as their IHSS provider.21

The following describes the measures compiled and used for county-level adjustments:

  • IHSS provider wage rates. These data are available on individual IHSS provider payment records. These were used to compile modal wage rates by county, information used in analyses of provider “choice.”

  • Per capita income was used to adjust for the cost of living in the county.


21. Residential care facilities for the elderly (RCFEs), adult residential facilities (ARFs), community care facilities (CCFs) beds are licensed by the DSS to provide room, board, and some levels of IADL and ADL support (ARFs service non-aged adults, CCFs serve the developmentally disabled, both those under and over age 18); nursing home beds, and state developmental centers (hospital-like settings for the developmentally disabled) and intermediate care facilities-DD and ICF-DD-H beds (freestanding nursing homes that specialize in custodial care for persons with developmental disabilities) are licensed by the Department of Health Care Services. These facilities in a county were initially considered as competing alternatives to IHSS use, but these services were found to be more associated with selection into IHSS, than IHSS use once in the program. Consequently, these measures were dropped from the analyses predicting provider type or health outcomes.

Analysis Plan

The analytic interest is in understanding who the IHSS Plus Waiver provisions serve, and in evaluating program and recipient outcomes. Analyses are stratified by three age subgroups of IHSS recipients. Within these age groups comparisons are among those with Parent, Spouse, Other Relatives, and Non-Relative as paid caregivers. Comparisons also include recipients in IHSS during 2004 who continued in the program in 2005 and those recipients newly enrolling in the IHSS in 2005. Outcomes are represented by IHSS and Medicaid health, nursing home, and community service use and expenditures. Utilization and expenditures are standardized by average monthly expenditures (based on the recipient’s exposure months in the calendar year). The Behavioral model (Aday & Anderson, 1974) was used to conceptually organize the selection of predictor and control measures.

Y = f(Predisposing: recipient age, gender, race/ethnicity; Enabling: household size, provider relationship, authorized IHSS hours; Need: cognitive status, ADL limitations; breathing limitations; chronic conditions; Service Supply: Per capita income.)

Where Y is separately

Total Medicaid Expenditures, hospital days/stays, nursing home days/stays, ER visits; IHSS expenditures; other Medi-Cal paid home care/personal care long-term care; “avoidable” hospital stays.

Findings

The analysis seeks to both understand who the IHSS Plus Waiver provisions serve, and to compare program and recipient outcomes among recipient age groups and provider types. Outcomes are represented by Medicaid service use and expenditures by IHSS recipients. This section is organized by the research questions outlined in the Introduction.

Waiver and Non-Waiver Program Recipients

IHSS Plus Waiver recipients include individuals age 3-17 who have a parent as a paid IHSS provider, those age 18 and over who have a spouse as a paid provider, and recipients in either the Advance Pay or Restaurant Meals voucher programs. Table 1 shows the number of IHSS recipients by age, provider type (including Advance Pay and or Restaurant Meals voucher payments, and those having a Share of Cost requirement. Separate tabulations are shown for IHSS recipients who continued into 2005, and those recipients entering IHSS in 2005. Those age 65 and over account for almost 60% of IHSS recipients in 2005. Those age 3-17 in contrast account for just over 4%. The remaining one-third are non-aged adults. The type of provider varies substantially across IHSS recipient age groups. Parents, who are allowed to be paid providers for minor children under the IHSS Plus Waiver, account for more than 70% of the providers for those age 3-17. Parents, who can be paid providers under the regular IHSS program for adult-aged IHSS recipients, are much less prominent caregiver resources: for recipients age 18-64 (15%), and essentially non-existent among recipients age 65+.

Reliance on Other Relatives (i.e., adult children, siblings, and relatives other than spouses) increases exponentially (as measured across age cohorts) with the age of the recipient. The proportion grows from 13% among minor children to more than half of all paid providers for those age 65+. The proportion of Non-Relative providers is relatively similar to that of Other Relatives among minor children recipients, and about 45% of the providers among adult age IHSS recipients. Spouses are the third major group of providers. Spouses can be paid as providers under the IHSS Plus Waiver, but their proportion is relatively small among recipients age 18-64 and 65+, and too few for analysis among those under age 18.

These patterns are generally stable comparing the adult recipients continuing from 2004 with those joining the program in 2005. Among minor children, there was a modest decrease in Parent and a modest increase in Non-Relative providers among the new recipients in 2005.

Share of Cost is included in the table as an indicator of the extent to which the program may have widen or narrowed its income screening between 2004 and 2005, a period in which county and state costs for program entry were reduced by 50% for the “waiver” programs. Share of Cost means that the recipient is required to make cash payments to financially qualify for IHSS participation. Relatively few recipients, usually less than 3% were required to make such payments in 2005. The rate is lowest among minor children, and somewhat higher among those 65+; and for those with a spouse paid as an IHSS provider. Within this low range, slightly more of the adult recipients entering the program had a Share of Cost than was true of continuing recipients. Whether this is typical in comparisons of new versus continuing recipients, a reflection of fewer restrictions on entry, or tighter eligibility processes in 2005 is not known.

The remaining IHSS Plus Waiver programs are those of Advance Pay and Restaurant Meals voucher. Participation rates are low. Fewer than 1,700 recipients statewide (about 0.5%) used one or the other of these programs during 2005. Adults age 18-64 were the main users (with fewer than 500 recipients) of the Advance Pay program. Those age 65+ (about 600 recipients) accounted for 60% of Restaurant Meals voucher users. Participation was higher among continuing versus new recipients. Participation in these programs can vary from month to month, but among those participating, most recipients received these benefits for three-quarters of the year or more.

Consistency in Provider Relationships

Classification into Provider Type as used throughout the report was done using the principle of “intention to treat.” For example, ever having a spouse paid as an IHSS provider in 2005 defined one in this group. Similarly, ever having a Parent provider (but no Spouse provider), or an Other Relative (i.e., but no Spouse or Parent) for at least one month defined one in these respective groups. Non-relatives had no family members as providers during the year. In other words, a recipient was defined as being in the highest order of provider type they experienced in the year, with legally responsible providers ranking highest, descending in order through Other Relatives and Non-Relatives. Those consistently without a defined provider relationship were classified as having Non-Relative providers. The intention to treat approach is supported by the cumulative monthly consistency in provider relationships shown in Table 2. Fewer than 6% of the recipients changed provider types during the year. Children were the most consistent, non-aged adults the least consistent. Among specific provider types, Spouses as paid providers were the most likely to vary during the year. Non-relatives were somewhat comparable to Other Relative in the rate of inconsistency or change between provider types.

Who are the IHSS Recipients?

This section summarizes the racial/ethnicity, living arrangements, task abilities, and health conditions of IHSS recipients in 2005. This information descriptively addresses two questions:

  • Do non-waiver recipients differ from IHSS Plus Waiver recipients in terms of race/ethnicity living, arrangement (e.g., household size, type of housing unit), and availability of legally responsible relatives?

  • What are the functional limitations, and chronic health conditions of individuals participating in each IHSS Plus Waiver component? Do these differ from those of non-waiver recipients?

Race/Ethnicity

As seen in Table 3, Whites are the most prevalent recipients overall. This prevalence is lower among those age 65 or more -- especially among those entering the program. Hispanics are the next most prevalent group of adults and the largest group of children recipients. The proportion of Hispanics increases almost 10% between continuing versus entering IHSS recipients in 2005. Blacks (about 17% overall, 11% among those age 65+) are the third most prevalent group. There are proportionately fewer Blacks among new recipients than among continuing recipients. The most striking changes are evident among Asians.22 These groups collectively account for about 10% of recipients. However, among those age 65+ Chinese (10%), Filipino (5%), and Vietnamese (4%) combine for almost 20% of all recipients; and as a group, Asian and Pacific Islanders are second to Whites in prevalence of participation. They are basically equal in number to Whites among new recipients in 2005. Within column comparisons show that race/ethnicity group distributions vary by age of recipient and the use of a family member versus a Non-Relative as their paid providers. These patterns are relatively stable when comparing continuing to new IHSS recipients.

Within row comparisons, Table 4, show the propensity of race/ethnicity groups to use one type of provider over another. For example among continuing recipients age 3-17 more than 80% of the Hispanic IHSS recipients have Parent provider. This contrasts with just over two-thirds of Whites and Asian recipients, and 60% of Black recipients having Parent providers. For the new IHSS recipients, the percentage having Parent providers drops about 10% among all race/ethnic groups. The differences narrow somewhat among other recipient age groups, but two patterns are evident. Hispanic and Asian recipients are more likely to have Spouse and/or Parent providers than the other groups. Asians are the most likely of all the groups to use Other Relative providers. In contrast, more than half of the White and Black recipients have Non-Relative providers. These patterns are consistent among recipients age 18-64 as well as those 65+. Comparing continuing with new recipients, there is a reduction across all age and race/ethnic groups in the percentage having Parent providers and an increase in the percentage with Other Relative providers.

The Advance Pay and Restaurant Meals voucher programs have a much different race/ethnic distribution than IHSS generally: Meals program, Whites (64.3%), Hispanic (13.7%), Black (10.2%), Asian/Other (11.8%); Advance Pay, Whites (68.5%), Hispanics (13.7%), Black (14.3%), Asian/Other (3.5%).


22. Most prevalent are Chinese, Filipinos, and Vietnamese. Table B-1 in Appendix B, shows the distribution of expanded race/ethnicity categories for continuing and entering recipients in 2005.

Household Size and Living Arrangements

Table 5a, Table 5b and Table 5c show the distribution by age and provider type for selected living arrangements. Gender of the recipient is also shown here because of its association with provider type. Except among children, females are the most common recipients: 59% among non-aged adults, and 69% among the aged. However, when considered by provider type, females are less likely to have Spouse or Parent providers than males, and much more likely to have Other Relatives and Non-Relatives as their provider. This pattern is present for both new and continuing IHSS recipients.

Gender differences widen by age group, however women age 18-64 are more likely to have Other Relatives than Non-Relative providers. This pattern persists but narrows among those over the age of 65. These shifts may be associated with changing racial/ethnic mix in the population evident among the age cohorts.

Household size also ranges widely, but somewhat in association with recipient age. More than two-thirds of the children live in households of four or more persons. This pattern holds across all family-related provider types and among both new and continuing recipients. Among recipients age 18-64, two and three person households predominate (about 50%) with those living with a spouse or parent, but substantial proportions of the remaining recipients live in households of more than three persons. Those having Other Relative and Non-Relative providers tend to be in smaller households, with almost 40% of those having Non-Relative providers living alone. Recipients age 65+ generally live in smaller households, with two person household predominating for those with a Spouse or Other Relative. Almost half of the recipients having Non-Relative providers live alone. For both adult age groups, the preceding patterns are consistent comparing new and continuing recipients.

Houses and apartments predominate as the type of residence, but as with household size, the distribution varies by age of recipient. Apartments gain prominence as recipients get older (and household sizes tend to be smaller). There are minor differences within age group and provider type between new and continuing recipients. One interesting pattern is that mobile homes and other forms of housing (e.g., residential hotels and boarding homes) combine for 5%-8% of all units seem to be increasing among new recipients in all age groups, but they continue to be used more frequently by those age 18-64. Whether this is a function of geography is not known.

Another living arrangement characteristic of interest is the status of spouses and parents as potential personal assistance providers. Among the adult recipients, the prevailing pattern (70%-80%) is for there to be no spouse present. However, even when there is a spouse present they are not always considered by the IHSS social worker as “available and/or able” to be PAS providers. Particularly notable is the proportion of spouses who are themselves IHSS recipients. Among those age 65+, 21%-23% of IHSS recipients have a spouse who is also a recipient. This is almost 80% (70% among new recipients) of the aged households with a spouse present. Among recipients age 18-64, the percentage of households with a spouse present (about 10% for those without spouse as paid providers) is lower than among the aged, but the number and proportion who are also IHSS recipients account for about one-third of the households with a spouse. These patterns may be influenced by Medicaid eligibility. Medicaid rules do not readily allow separation of a couple’s assets when they live together in community settings. The proportion of spouses who are IHSS recipients is somewhat lower among new recipients than those continuing. Except in situations where spouses are the paid providers, IHSS social workers have determined that fewer than 5% (much fewer among those age 65+) are able and available as PAS providers.

Within the CMIPS assessment, the role of parents is more completely enumerated and differentiated for minor children than for adult recipient groups. Among children, more than 80% of the parents available are said to be providing some or all IHSS-related services. Seventy percent are paid as IHSS providers. This pattern holds for both new and continuing groups. The information available for parents of adult IHSS recipients is much more limited. Except for those paid as IHSS providers (e.g., non-aged adults 16.6% are paid providers among continuing recipients, 9% among new recipients), the number of parents available is not well documented. The factors contributing to the decline in the proportion of parents as paid providers between continuing and new recipients are not readily apparent in the CMIPS data. However, some of this difference may be associated with an increase in the proportion of recipients with Other Relative providers. These provider choices are not affected by the incentives in the IHSS Plus Waiver to pay legally responsible relatives.

Functional and Other Limitations of IHSS Recipients

The IHSS program authorizes PAS based on consideration of four broad areas of assistance need. These include cognitive limitations (i.e., memory, orientation, judgment), assistance in ADLs (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual care; eating), IADLs (i.e., housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside), and problems in breathing. Each of these areas is evaluated and scored on a 1-5 (some on six) point scale.23

  1. Independent -- able to perform functions without human assistance though recipient may have difficulty; and completion of the task with or without a device poses no risk to safety of the recipient.

  2. Able to perform, but needs verbal assistance such as reminding, guidance, or encouragement.

  3. Can perform but needs some human help (e.g., direct physical assistance from the provider).

  4. Can perform with a lot of human assistance.

  5. Cannot perform function at all without human assistance.

  6. Paramedical services needed.

The number of limitations were compiled for each recipient during every month of their IHSS participation in 2005 and averaged over these participation months. An average of score of 3.0 or more indicates a task in which individuals were determined to have task assistance needs requiring at least direct physical assistance from a provider in 2005. Table 6, shows the group mean of the number of tasks that received an assessment score of three or more. The results are organized by age group and provider type; and by new and continuing IHSS recipients. ADL assistance dependence in three or more areas predominates for all recipient age groups, with at least one-third of recipients having task assistance needs in four or more areas. Children as a group, have somewhat more recipients with higher numbers of task assistance needs, averaging 3.6 such limitations compared to averages of two+ among the other age groups. IADL limitations are even more pervasive, with more than 95% of the aged and non-aged IHSS recipients needing direct physical assistance in four or more tasks. The proportion among children is somewhat lower, with two-thirds having this level of assistance needs. Cognitive limitations as represented in this compilation are also indicative of the level of impairment requiring human assistance. Levels of assistance that require only “reminding, guidance, and supervision-level” are not included in this scoring. Rates of cognitive limitations at this level of need are higher within the adult recipients than among children. Children on the other hand are more commonly characterized (about 15%) with severe breathing limitations (i.e., require human assistance to use self-administered oxygen or the cleaning of this equipment. This rate is about double those of the other age groups).24

The main interest in these analyses is whether there are differences among provider subgroups in each recipient age cohort. Among children, there are essentially no differences in the mean number of cognitive, ADL, or IADL limitations. This is generally true, as well, comparing new versus continuing recipients. The most notable difference is in the percentage of recipients with severe breathing limitations. This rate is lower among the entering recipients than among those continuing, but it is relatively consistent among the provider subgroups. Parents continue to be the predominant providers for this condition, but the percentage of recipients needing this level of care is more uniformly distributed among the other providers. Non-Relative providers proportionately serve more such recipients among the new recipients than either of the other provider groups. A striking difference is in the number of authorized IHSS service hours. On average the continuing recipients are receiving about 40 more hours per month than new recipients. This difference is constant among provider types. Some of this seeming disparity may be an artifact of the CMIPS data system, where authorized hours are adjusted with changes in functional conditions and living arrangements, but where revisions in the recorded assessment data may lag by a number of months. In other words, continuing recipients may be somewhat more functional limitations than new recipients, with this difference being reflected in authorized hours rather than in the number of functional limitations recorded in the data set.

Recipients age 18-64 and those 65+ have several patterns in common. First, Spouse providers tend to have proportionately more impaired recipients than the other provider types, and to be comparable to each other going across the age groups. These patterns are reflected in the mean number of cognitive and ADL limitations, and in the percentage of recipients with severe breathing limitations. Other Relatives and non-relatives, tend to have proportionately similar levels of impairment in their recipients across these aged and non-aged adult groups, and comparing new with continuing recipients. Parents (represented only among non-aged adults) tend to have recipients with cognitive and ADL impairment levels somewhat in between those of recipients with Spouse and the other providers. Paradoxically, Parent providers receive the highest average number of authorized IHSS service hours. Perhaps this occurs because of higher acuity needs of recipients known to the social workers that are not well represented in the CMIPS measures. Spouses receive hours comparable to those of non-relatives. Other Relatives have fewer authorized hours, with some of this difference possibly reflective of the household size and the downward adjustments made with IHSS hours when there are parents, spouses, or other non-disabled individuals residing in the household who are able to do routine household chores. Finally, the pattern of systematic differences in authorized hours comparing continuing with new recipients is also present among adult recipients. This difference tends to be in the range of 20-30 hours, rather than 40 hours observed with minor children recipients.

Table 7 shows the distribution of physical and cognitive limitations by age for recipients in the Restaurant Meals voucher and Advance Pay programs. Those receiving Restaurant Meals vouchers generally have at least three limitations in IADL. At the same time fewer than one-third have three or more ADL limitations for which human assistance is necessary. About half have one or fewer such limitations. Very few recipients have cognitive or breathing problems. Similar patterns hold for IADL, cognition, and breathing limitations among recipients in Advance Pay. This group, however, is predominated by high levels of ADL limitations. More than 90% of recipients in each group have at least four ADLs for which human assistance is necessary. The difference in frailty mix between these two programs is consistent with their target recipients.


  1. Laundry is scored as 1, 4 or 5; shopping and errands as 1, 3 or 5; eating as 1, 5 or 6; breathing as 1, 5 or 6; memory, orientation and judgment as 1, 2 or 5. Meal preparation and eating both include a six point score.

  2. Table B-2 in Appendix B provides the frequency distribution of the functional task limitations of IHSS recipients in 2005.

County Characteristics

Two measures are used to represent county differences in the analysis. One of these is the modal hourly wage rate paid for IHSS services. For purposes of the analysis we have grouped these into categories into wage categories that also happen to be broadly indicative of geographic regions. The groupings are less than $7.50/hour (17.8% of IHSS recipients statewide), $7.50 (44.5%), $8-$8.50 (15.6%), $9.50-$9.75 (14.4%), $10-$10.50 (7.7%). The distribution of the wage rates is shown in Table 8. Los Angeles and Fresno Counties, which have the same modal wage rate, are combined as the reference category, allowing the vector of dummy coded price ranges to be interpreted as both a comparison to these counties and the statewide median wage rate (the average is about $8.06). The second county measure is personal income per 1,000 county population. This has been represented in the analysis in units per $1,000.25


25. See Appendix B, Table B-4 for a listing of personal income per capita by county.

Health Conditions Among IHSS Recipients

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.


  1. A full listing of HCCs by age and IHSS provider is included in Appendix D.

  2. 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.

  3. 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.


Implications for Modeling Recipient Outcomes

The preceding sections presented information about the living arrangements, functional limitations, and chronic health conditions of IHSS recipients and how these were distributed by age and provider type. Comparisons were also made between those entering the IHSS program in 2005 versus those continuing from 2004. Several conclusions can be drawn from these analyses relative to the recipient and other attributes that need to be adjusted in comparing recipient outcomes by provider type.29 First, it is apparent that the factors associated with Parent, Spouse, and others providers are, in part, a function of the family and other resources available. For example, among those without parents, spouses or other relatives, the options reduce to using non-relatives. 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 spouses. Additionally, there are preferences and other influences that are not measured by CMIPS assessments. Typically, a two-stage model would be used to estimate the “predicted” provider type in the first stage, and estimate the predicted outcomes associated with the provider type in the second stage. Ideally such a process adjusts for “selection” effects on provider choice, with the outcome of these models compared against the observed outcomes of waiver vs. non-waiver recipients. However, the absence of complete information in CMIPS about the availability of relatives (including legally responsible relatives) and recipient-provider preferences severely limits the applicability of such two-stage models here. Given the data limitations constraining the estimation of such models, the outcomes analysis reported in the subsequent sections uses observed provider type as one of the predictors of service use and expenditure outcomes. Provider type will be based on the notion of “intention to treat” described in the Methods section. If a legally responsible relative is ever used in the study year, this provider type is the presumed preference regardless of changes in provider type made during the year. Similar assumptions are made contrasting other relatives with non-relatives.

A third conclusion is suggested by the differences among race/ethnicity groups in their association with provider type. These differences are present across all age groups after adjustments for physical and cognitive limitations, household size, and IHSS wage effects. This suggests the appropriateness of using race/ethnicity as a proxy for cultural preferences or predispositions to assume caregiving roles.

Per capita income, one of several county-level measures tested, represents the cost of living in the counties, and has a significant, if modest association with provider type. This measure is retained in the outcome models.

Finally, the differences among some of the provider types in the association with managed care membership may have an effect on comparisons in analyses of Medicaid expenditures and health care events. Medicaid claims-records are generally not available for those in managed care because monthly payments are made to the health plan based on member characteristics, not on reimbursement for the use of specific services. Groups with a greater propensity toward managed care participation may have fewer chronic health conditions and lower Medicaid expenditures, but this cannot be determined with the data available. Analyses within age group, adjusting for other risk factors will help minimize this differential reporting, but it cannot fully eliminate any systematic difference if healthier (or sicker) persons enroll in managed care compared to those in fee for service. For this reason, the analyses when using health conditions as a control variable exclude recipients who are in Medicaid managed care. Payment for community care services, including IHSS, is not included in the managed care capitation payments. Consequently, analysis of this outcome is done both including adjustments for medical conditions (obtained from claims data and limited to those in fee for service), and all IHSS recipients without adjustment for medical conditions.


29. Appendix C extends the descriptive findings using logistic regression to adjust for recipient differences within a provider group. Separate analyses were conducted by recipient age group to assess the adjusted association of recipients and the “selection” of provider type. These analyses also evaluated the relative value of using IHSS wage rate as a proxy for county IHSS policy. Conclusions coming from these analyses were that the comparison of provider effects on recipient outcomes could be accommodated by using models which compare effects associated with provider type rather than using separate models by provider type of those using predicted provider types as covariates. IHSS modal wage rates were used with all comparisons being made to Los Angeles and Fresno Counties which reflect 45% of all IHSS recipients statewide and the statewide median IHSS wage rate. Among minor children, the comparison of recipients in counties across all modal IHSS wage levels found few statistically significant provider choice differences from the reference counties. The exception was that in counties with modal hourly wages of $10 or more, the likelihood of a parent being a paid provider reduced relative to the likelihood of recipients in the reference counties. No differences were found for the other provider groups. Recipients age 18-64 offer a somewhat similar pattern. Parents in counties with modal IHSS wages above $9 per hour were less likely to be paid providers, and there was a modest tendency for Non-Relatives to assume the provider role. The choice of Spouse provider was positive across wage rate levels, suggesting that choice of spouses was not related to IHSS wage rates. Among aged recipients, the prior pattern for Spouse providers holds, accept in the highest wage rate counties, which do not differ from the reference counties. Across all but the highest wage rates, counties show a tendency toward more Other Relative providers and somewhat less likelihood of Non-Relative providers than in the reference counties.

Health Care Expenditures and Use

This section shifts the analysis from a description of IHSS program recipients to the consideration of the quality of care and other outcomes given the “choice” of provider types. The data sources used for this comparison are the IHSS assessments and Medicaid claims data. In combination these data sources enable us to investigate the following question:

Adjusting for disability and other attributes, what are the Medicaid program expenditures and health care events incurred by IHSS Plus Waiver program and non-waiver recipients? Are there differences by age group?

Included in these comparisons are all IHSS services, as well as personal care from Medicaid HCBS waiver programs. These services are available to eligible Medicaid recipients, and are unaffected by whether the recipient is enrolled in Medicaid managed care. Additionally, we examine Medicaid-reimbursed hospital, ER, nursing home, home health, and medical provider claims. These services generally do not generate a claims-record for persons in Medicaid managed care, so the sample size for analyses involving these services reduce to beneficiaries receiving health care reimbursed through fee for service claims. For hospital, nursing home, and ER use, the compilation of claims starts with encounters occurring within or subsequent to the first month of IHSS eligibility in 2005. Expenditures and utilization for all remaining months in 2005 are compiled as the basis for calculating mean monthly expenditures for these services. The compilation of chronic health conditions from Medicaid claims, includes all claims in 2005, regardless of months of IHSS participation. This was done under the assumption that chronic conditions are pre-existing in 2005, and with recognition that the inclusion of all claims reduced some of the under reporting of conditions that occurs if only prior year claims are used in identifying diagnoses.

Both unadjusted descriptive and multivariate analyses of expenditures and health care events are reported. The measures of primary interest in the multivariate models are the coefficients for IHSS provider types. All models adjust for recipient gender, race/ethnicity; household size; cognitive, ADL, and breathing limitations; the number of chronic health conditions. Household size and recipient limitations are the basis of IHSS benefit eligibility. Total Authorized IHSS Hours are also included as potentially reflecting changes in functional limitations or living arrangement that may not be reflected on the baseline IHSS assessments. Authorized hours are reduced as the availability of informal care increases, so that higher hours (up to the cap of 283 hours) corresponds to an increasing reliance on paid IHSS assistance. Complementing the recipient characteristics is one county indicator: per capita income, an adjustment for prevailing cost of living. The models also include a dummy variable representing whether the individual was a new IHSS recipient in 2005 or continuing from 2004. This tests whether new recipients had different expenses and utilization than continuing recipients, after adjusting for recipient characteristics.30


30. A series of equations that included interactions between provider type and the number of chronic conditions were evaluated. These items did not sufficiently improve the fit of the model to be retained in the analyses presented. Additionally, the ordinary least squares analyses were replicated using logarithm transformations of the expenditures measures instead of raw expenditures data. These models generally had higher R2 values, but as the results testing whether the coefficients on the Parent and Spouse provider measures were significantly different from Non-Relative providers were consistent (in terms of the direction of the sign) with those in the non-transformed models we have elected to report only models with the non-transformed data. These models have the advantage of being in dollar units, and more readily understandable than the percentage comparisons possible using the logarithm transformations.

Monthly 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 averaged about $825 in 2005. The highest average total expenditures are among those ages 18-64, the lowest among those ages 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.

As shown in Table 11, mean unadjusted monthly expenditures for all age groups vary substantially by the number of an IHSS recipient’s exposure months in 2005. Expenditures shown in this table are accumulated for every month after IHSS eligibility in 2005. For recipients continuing from 2004, all would be eligible in January 2005. The new recipients could have entered in any month starting with January. Approximately 4,000 recipients entered the program each month, with an approximately equal number leaving. Persons with fewer than three months in the year tend to have average monthly expenditures that are about three times higher than the average monthly expenditures for those in the IHSS program for a full year. The causes for the difference across exposure months are beyond the scope of this analysis, but they likely are associated with changes in health status immediately preceding program entry or that contribute to leaving the program.

Provider Type and Medicaid Expenditures. Table 12 arrays the mean expenditures data by age and IHSS provider groups. These unadjusted results show a tendency for recipients of Spouse providers to have lower mean monthly expenditures than those receiving care from other providers. There are relatively few unadjusted differences in mean expenditures comparing recipients of Other Relatives and Non-Relatives providers. Expenditures among new recipients tend to be lower than for those of continuing IHSS recipients.

A set of ordinary least squares regression models, Table 13, were used to provide a comparison of adjusted provider effects on expenditures. Each column presents a model for a particular IHSS recipient age group. The comparisons of interest in the analysis are those of provider type. The reference category for the provider types is Non-Relatives. The coefficients, multiplied by 1,000, convert the effect into the metric of dollar units and facilitate interpretation of the differences among the recipient-provider groups in terms of average monthly dollar expenditures.31 While the models do not fit the data particularly well, the purpose is to test the adjusted predicted expenditure differences between providers. The individual covariates for these comparisons tend to have high levels of statistical significance, even for small difference in the predicted mean monthly expenditures. This is due, in part, to the large sample size.32

Among these age 3-17, Parent providers tend to have about $920 lower adjusted Medicaid expenditures than Non-Relatives. Other Relatives seem to have slightly lower adjusted expenditures than non-relatives, but this difference is not statistically or practically significant. Recipients age 18-64 with Spouse IHSS providers have predicted mean monthly Medicaid expenditures (holding everything else constant) about $1,000 lower than do those with Non-Relative providers. This estimate is somewhat larger than the difference in the unadjusted comparisons. Recipients with Other Relative providers have mean expenditures about $170 lower than Non-Relatives. There was no statistically significant difference between those with Parent providers and Non-Relatives. Among recipients age 65 or more, those with Non-Relative providers have predicted average monthly month expenditures that are higher than those for either recipients with Spouse providers ($780), or Other Relatives ($110).

Expenditures comparing new with continuing IHSS recipients showed only minor differences in adjusted mean monthly expenditures: non-significant among children recipients, slightly higher among those 18-64, slightly lower among the aged.


  1. The association of provider type with expenditures was evaluated as both a main effect, and as the interaction of provider type and the number of the recipient’s health conditions. The interaction models did not improve the model and were not retained.

  2. Additional models were estimated to test the stability of the provider findings. These included models limited to those with 12-month participation, and those with fewer than 12 months. The former had higher R2 values, the latter, lower R2 values. This is consistent with the higher variability in this latter group. In spite of these differences in model fit, the effect of provider type remained relatively constant. There were no changes in statistical significance or direction of effect, nor in substantively meaningful magnitude. Analyses were also conducted using the logarithm of expenditures. These models produce findings consistent with the non-transformed models. They are available on request.

Medicaid Hospital Expenditures and Use

This section begins an examination of some of the component services that contribute to the total Medicaid expenditures. We begin with hospital use, often a contributor to high expenditures. Hospital use may also serve as an indicator for problems in medical care and quality of home care. Table 14 shows unadjusted mean expenditures for hospital care (among those having a hospital stay) organized by age and provider group; and by continuing and recipients enrolling in IHSS during 2005. The highest mean monthly hospital expenditures (incurred after IHSS enrollment) are among those ages 3-17. For all age groups, but especially for those age 65 or more, it is important to recognize that these figures may be biased downward relative to total “all-payer” expenditures as the Medicaid results do not include reimbursements from other payers (e.g., private insurance, Medicare, Veterans Administration (VA), out of pocket).33 Among all recipients age groups the unadjusted average monthly Medicaid hospital expenditures generally show the IHSS Plus Waiver recipients (i.e., spouses of adults, parents of minor children) to have either the lowest mean expenditures or to have expenditures approaching the lowest group. IHSS recipients entering the program in 2005 tend to have higher mean monthly expenditures than recipients continuing from 2004. This may be, in part, a function of the fewer IHSS participation days among new recipient. As seen later, new recipients have lower incidences of hospital stays. Further as shown in the “Mean Total $” rows in Table 14, there is little difference within age group in the average of hospital expenditures incurred over the observed months by hospital users in each recipient-provider group. In general, these expenses are indicative of short stays, but as evident from the standard deviations, some recipients accumulated ten’s of thousands of dollars in hospital costs.

Any Cause Hospital Stays. The next several tables refine the hospital expenditure analyses to assess whether there are differences between provider groups in the likelihood of having hospital stays. Hospital use may be indicative of differences in recipient case mix and/or of the quality of IHSS and the condition management assistance received. Table 15 shows the unadjusted probability of an “any cause” hospital stay in 2005. These incidents occurred after IHSS enrollment (or in the same month as IHSS enrollment). The unadjusted likelihood of a hospital stay is relatively comparable among the adult recipients, with rates about double those for minor children. IHSS recipients across the provider types generally have similar rates, although recipients of Spouse providers are more likely to have stays.

Table 16 extends the analysis of hospital use by adjusting for recipient case mix differences. These logistic regression models compare the difference in odds (expressed as an odds ratio) of an “any cause” hospital stay during 2005 between each of the provider groups. These comparisons are based on consideration of the main effect of provider type. (Interactions between provider type and the number of health conditions, as a group, did not statistically improve the model and were not retained in the analysis.) With the modeled adjustments the differences between recipients having IHSS Plus Waiver-permitted providers (i.e., parent and spouse respectively) and those with Non-Relative providers generally become statistically non-significant. This finding holds among all but the non-aged adults who have Spouse providers. These recipients are about 15% more likely to have hospital stays than those with non-relatives. Recipient outcome comparisons between those with Non-Relative providers and Parents (of those 18-64), as with the unadjusted results, show substantially lower odds of a hospital stay for those with Parent providers. This difference is reduced to about 25%, rather than 50% in the unadjusted results. Non-aged adults with Other Relatives as providers show about a 10% lower risk of hospital stays than those with Non-Relatives -- an advantage not evident in the unadjusted results. Such comparisons are non-significant or very minor among the aged and children recipients.

Another finding of interest in this table is that adults in non-White race/ethnic groups tend to have higher odds of hospital stays than Whites. This effect is examined further in subsequent analyses of access to physician services. Also of note is the lower likelihood of hospital use among new IHSS recipients than continuing recipients. This is consistent with the likelihood that a hospital stay in a year increases over time for IHSS recipients if the become more disabled.

Ambulatory Care Sensitive Hospital Admissions. Hospital stays for which the primary admission diagnosis is an ACSC are thought to be indicative of the quality or performance of primary health care (AHRQ, 2007a, 2007b). Better care would be suggested by low rates of these potentially “avoidable” hospital stays. The unadjusted prevalence of ACSC hospital admissions in 2005 is shown in Table 17. Comparing unadjusted “any cause” hospital stays (i.e., Table 15) with the unadjusted ACSC stays shows almost an eight-fold decrease among children and more than 3x decrease among adults using the more restricted ACSC criteria. Differences between provider groups narrow substantially when only ACSC outcomes are considered. Recipients with Spouse IHSS providers continue to have the highest unadjusted hospitalization rate.

Table 18 shows the predicted odds of ACSC hospitalization adjusting for recipient characteristics. Holding other factors constant, there were no statistically significant differences comparing the recipient outcomes of provider groups among children. This finding is consistent with the “any cause” hospital stay comparisons. Among recipients age 18-64, a similar finding also occurs when comparing Spouse and Other Relative providers to Non-Relatives. On the other hand, recipients in this age group with Parent providers have lower adjusted odds for an ACSC hospital stay than Non-Relatives. Finally, among recipients age 65 or more, there is significant difference in the spouse/non-relative comparison. Recipients of Spouse providers have reduced risk of an ACSC hospital stay. There are no statistically significant differences comparing those with Other Relatives to those with Non-Relative providers. (Interaction tests involving provider type with the number of health conditions were non-significant and are not included in the final models.)

Consistent with the “any cause” hospital stays, non-White adult age recipients tend to have increased risk for ACSC admissions. Whether this is a function of differences in access to care, or problems in culturally appropriate care is not known. Among minors, new IHSS recipients have no differences from continuing recipient in ACSC admission. For adults, new recipients have about half the risk of ACSC admission than recipients continuing from 2004.


33. For example, it is likely that Medicare will be the primary payer for health care expenditures by the aged and those non-aged disabled adults eligible for Medicare due to their disability. Similarly, the VA is the primary payer for medical care among qualified veterans if they elect to use VA facilities.

Medicaid Physician and Outpatient Department Use

Differences in hospital use described in the preceding section are more evident comparing White to non-White IHSS recipients than in comparisons among recipient-provider groups. In this section, we examine the use of physician and outpatient departments as a potential influence on hospital use. Access to medical care is necessary to assure appropriate health care and condition management, but measurement of the levels of use are confounded by the inter-relationship between health status and need for care. For example, individuals with declining health status or with acute problems are more likely to seek care than those not experiencing such problems. Unraveling the cause-effect pattern is beyond the scope of this analysis, but statistics have been compiled to first descriptively compare any use between recipients by age and provider group and among race/ethnic groups, and then to compare use adjusting for health status and other characteristics.

Table 19 shows an important contrast among IHSS recipients. About 20% do not have any claims with vendor codes 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. These rates differ somewhat among IHSS recipient age groups, and between provider types. Table 20 recalculates access to medical care, to add any Medicaid claims for ER use. These combined rates reflect about a 2%-3% increase in the percentage of recipients having access to Medicaid medical care. None of these estimates include medical care encounters that are billed solely to non-Medicaid sources without requiring a Medicaid co-payment or other Medicaid claims-based record of the encounter. Minor children recipients as a group have lower unadjusted rates of access to medical care than either of the other recipient age groups.

Table 21 extends the analysis of Medicaid-reimbursed medical care by using logistic regression to adjust for health status and other recipient attributes. As shown in this table, Parent providers of minor children, and Spouse providers of adult IHSS recipients have a higher likelihood of any medical care use compared to those with Non-Relative providers after adjusting for health and functional status. Comparisons between IHSS recipients with other relatives and non-relatives are not statistically different. Adults with Parent providers have a lower likelihood of medical care use than do those with non-relatives as paid IHSS providers.34

The differences in hospital use comparing non-White race/ethnic groups to Whites (Table 16) are not broadly “explained” by differences in medical care use. After adjusting for health conditions and functional limitations, there are no statistically significant differences in the likelihood of medical care use comparing non-White to White race/ethnic groups among IHSS recipients age 3-17 and comparing Hispanic and Asians to White among recipients age 65+. Adult African-American 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.


34. Similar analyses were conducted using logistic regression models comparing medical care use, excluding the use of ERs. The results relative to IHSS provider groups and in comparisons of non-White race/ethnic groups were similar to the results in Table 21. They are available in Appendix D, Table D-1.

Emergency Room Use

The preceding results, show relatively comparable access to medical care across race/ethnic groups, and between recipients in the IHSS provider groups. However, claims data are not sufficient for determining the quality, timeliness, or appropriateness of this care. Here we separately examine the use of ERs. ERs can serve as alternatives for those without access to physicians or clinics, and/or as an indicator of crisis that may be suggestive of difficulty managing the needs of the personal assistant care recipient.

As seen in Table 22, ER use is a relatively common experience among IHSS recipients of all ages: experienced by more than half of the recipients in each age group. There is some variability among the provider types, with minor children of Parent providers, and adults with Spouse providers having the highest unadjusted rates. Extending this analysis, using the logistic regressions shown in Table 23, the risk adjusted differences among provider groups for recipients age 3-17 become non-significant. Among recipients age 18-64 and those 65 or more, the differences observed in the unadjusted results persist. Spouse providers in both age groups tend to have about 20% higher odds of ER use compared to Non-Relatives. Recipients with Parent providers (non-aged recipients only), in contrast have reduce odds of ER use. Other Relatives in both recipient age groups similarly have lower risk of use. New IHSS recipients, in all age groups similarly have reduced likelihood of ER use.

Looking at race/ethnicity, patterns similar to ACSC hospital use persist with non-Whites (other than Asians) ages 18 and over tending to have higher rates of ER use than Whites. Whether this is in response to problems accessing medical care, or responses to emergent conditions cannot be determined with the available data. As one might expect, this rate increases with more chronic health conditions, and the presence of severe breathing problems.

Medical Care Expenditures

The final analysis of medical care use examines expenditures made for physician services, outpatient departments, and the aggregation of these services into combined medical care services. Unadjusted monthly Medical care service expenditures averaged over the recipients’ IHSS eligibility months in 2005 are shown in Table 24. This table has three panels, one with data for all recipients, one for recipients continuing from 2004, and those newly entering IHSS in 2005. The table combines both physician services and those of outpatient departments.35

Within recipient age groups there is little difference in the average monthly expenditures for physician and outpatient department services among the provider groups. Average monthly Medicaid expenditures tend to be highest for children, lowest for those 65 or older. Combining the sources of medical care, the mean monthly expenses for IHSS from recipients age 3-17 continuing from 2004, range from a $140-$180 across all provider groups; 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, and the aged in particular, are likely due to Medicare or another source being a primary payer on these services. Expenditures for those who enter the IHSS program are marginally higher than for continuing recipients. This may be associated with instability in service needs that predated enrollment in IHSS. However, the underlying causes cannot be determined from the study’s single year of data.

Table 25 uses ordinary least squares regression to adjust for recipient characteristics in evaluating recipient mean expenditure differences among provider and race/ethnicity groups. Expenditures are inclusive of all physician and outpatient department claims during the calendar year for those continuing as an IHSS recipient from 2004, and after the date of IHSS eligibility in 2005 for new recipients. Expenditures are in dollar units divided by 1,000.36 The predicted difference in recipient expenditure levels associated with the provider group measures is generally modest. For minor children there are no statistically significant differences between the estimated expenditures for Parent or Other Relative providers and Non-Relatives. Among non-aged adult recipients, those with either Spouse or Other Relative providers have about $14 lower average monthly expenditures than Non-Relatives. Expenditures for those with Parent providers are not statistically different from those of Non-Relatives. Among recipients aged 65+, there are no adjusted differences between recipients with IHSS-paid Spouse or Other Relative providers and Non-Relative providers.

Returning to the issue of equality of medical care access by race/ethnic groups, the coefficients for the race/ethnicity groups regressed on medical care expenditures are generally not statistically different from those of Whites. The most important differences are that Black Adults have lower average monthly expenditures than Whites. This difference, as in the earlier analysis, may be explained by lower use medical care use by Black. New enrollees into IHSS in 2005 tend to have higher average adjusted monthly expenses than continuing recipients. Whether this is a function of ongoing problems or only those associated with the reasons for entering the program have not been determined.


  1. Separate tables showing unadjusted results for physician service use and outpatient department use can be found in Appendix D.

  2. Separate models were also run using interaction main effects, but these did not significantly change the model goodness of fit and have not been used.

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.

Home Health Care Expenditures

In addition to unskilled home care, IHSS recipients may receive home health care (a home-based service either provided by a nurse or other licensed professional and/or under their supervision). Generally, this service is for a limited duration, such as following a hospital stay, or as an adjunct to outpatient physical therapy. Among the adult IHSS recipients, home health care utilization follows this expected pattern. There were relatively few such recipients in 2005 (0.3% of the aged, 3.6% non-aged adults). Home health care services are used by somewhat more minor children (8%), and with substantially higher average monthly expenditures (more than $5,000 across all provider groups) than adult recipients. Some of the difference in expenditures between adults and children may be that Medicaid is the primary payer for services to children, while large percentages of these costs may be covered by Medicare or other payers among adults. As shown in Table 28, within both children and aged recipient groups, there was little difference in average monthly Medicaid expenditures between provider groups. Among non-aged adults this pattern changed. Parent providers had substantially higher (about $700 higher) average monthly Medicaid unadjusted expenditures than recipients having non-Parent IHSS providers. Analyses incorporating Medicare expenditures, may alter these findings, but such data were not available to this project.

Differences among provider types in home health care expenditures, adjusting for recipient characteristics, were evaluated using ordinary least squares regression. Each model (not shown) used the same measures as in the earlier OLS regression. Among children and aged IHSS recipients none of the coefficients for provider type or its interaction with the number of health conditions were statistically significant in comparison to non-relatives. Among recipients age 18-64, only Other Relatives differed ($240 lower) from non-relatives. Adult recipients entering IHSS in 2005, tended to have marginally higher average monthly Medicaid-reimbursed home health expenditures among users than continuing recipients (about $940 for non-aged adults, $780 for those age 65+).

Medicaid-Paid Nursing Home Use and Expenditures

The occurrence of nursing home use is derived from Medicaid-reimbursement claims. We have limited the use of claims to those occurring during or following the period in which the individual was a recipient in the IHSS program. Only nursing home stays occurring in 2005 are counted.40 The claims (both payments and stays) available do not include skilled care placements or days covered entirely by payers such as Medicare, the VA, or private funds. A consequence of these limitations is that these data may under report short-term, skilled care days/stays; and under count total expenditures if service use was paid by these sources. Medicaid-paid co-payments are included in tabulations of Medicaid-paid nursing home stays and days. Within these biases the preponderance of nursing home claims are those involving IHSS recipients age 65 or more. The incidence of Medicaid-paid nursing home placement among IHSS recipients is low: about 0.26% among children, 2.25% among non-aged adult recipients, and 5.9% among those age 65+. As shown in Table 29 there are some differences in the unadjusted probabilities of nursing home use by IHSS recipient age and provider group. As a group, those with Other Relative providers tend to have among the lowest likelihood of placements. Adults with Spouse providers tend to be among those with a higher likelihood of placement.

These patterns are somewhat effected after adjusting for recipient characteristics, as shown in logistic regression equations in Table 30.41Among recipients age 18-64, there is a persistent adjusted effect: IHSS recipients related to their providers have a lower adjusted odds of nursing home use than persons with Non-Relative providers. Further, recipients with paid Parent providers tend to have a lower adjusted risk than recipients with either Spouse or Other Relative providers. Among recipients age 65 or more, the protective effect of relatives as providers is present only comparing Other Relatives to Non-Relatives. Spouses have a modest tendency toward a lower placement rate, but this does not reach statistical significance. In short, the IHSS program, including its waiver-permitted providers, is at least as successful in aiding families and individuals remain in the community as are recipients with Non-Relative providers. New IHSS recipients age 65+ are also less likely than continuing recipients to have a nursing home placement.

Nursing home use has a direct effect on Medicaid costs. One consequence of this is seen in the nursing home expenditures for 2005 shown inTable 31. These expenditures reflect the accumulated costs for any nursing home stay in 2005, restricted to stays occurring after entry into (and, if applicable, exit from) IHSS. Most of these expenses seem to be for non-skilled care as the average monthly rate among nursing home users approximates the 2005 Medicaid daily nursing reimbursement rate of $115. Comparisons between continuing and new recipients show generally similar average daily expenses. In both age groups, IHSS recipients tend to have relatively similar average monthly expenditures across provider types. Recipients (non-aged adult only) with Parent providers, the one exception, have the highest average daily expenditures, but this may be an artifact of sample size. Parents are the smallest subgroup and their mean values are perhaps affected upward by the wide standard deviation in these data.

Analysis of expenses associated with the transition from IHSS to nursing home care, the transitions from nursing homes into IHSS, and the total Medicaid expenditures incurred by nursing home recipients are beyond the scope of this analysis; as is an analysis of the duration of nursing home placements.


  1. Persons in managed care have been included in these analyses, as Medicaid claims for non-skilled nursing home care are available. Custodial nursing home care is not included under managed care capitation payments. Tables showing the likelihood of nursing home place among IHSS recipients, excluding those in managed care are in Appendix F, Table F-1. The exclusion of the managed care recipients, results in minor changes in the percentages, approximately 0.05% among minor children, and 0.2% among adult recipients.

  2. Provider by health condition interaction terms were tested in earlier models, but were not statistically significant. Estimates involving recipients age 3-17 are omitted from Table 30, as there were too few cases to estimate reliable models. Appendix F, Table F-2 shows the logistic regression results for models excluding managed care recipients. These results are very similar to those shown in Table 30.

Conclusions

California has paid legally responsible relatives as IHSS providers for years under a state and county financed component of IHSS known as the Residual Program. Many of the Residual Program elements were assumed into the IHSS Plus Waiver, implemented in 2005. This waiver allows Medicaid participation in jointly financing the PAS provided by parents of minor children and spouses of adults. It also allows for Advance Pay and Restaurant Meal voucher payments to qualified IHSS applicants.

The analyses presented in this report were organized around five broad questions pertaining to implementation of the IHSS Plus Waiver:

  • Do IHSS Plus Waiver recipients (e.g., Parent providers, Spouse providers, Advance Pay, Restaurant Meals voucher) differ from regular IHSS program recipients in race/ethnicity, living arrangement (e.g., household size, and availability of legally responsible relatives)?

  • What are the functional limitations, task assistance needs, and chronic health conditions of recipients in each IHSS Plus Waiver component? Do these differ from recipients in the regular program?

  • Do IHSS Plus Waiver and regular IHSS recipients differ in terms of continuity with their provider relationship, and Share of Cost?

  • Adjusting for disability levels, are there differences within age group between IHSS Plus Waiver and non-Waiver recipients in the number of authorized hours?

  • Adjusting for disability and other attributes, what are the Medicaid (aka Medi-Cal) program use and expenditures incurred by waiver program and non-waiver recipients? This includes all IHSS services; HCBS waiver programs; Medicaid hospital, ER, nursing home, home health, and medical provider claims.

Taken together, these descriptive questions assess four fundamental policy issues: whether there was a change in the number and attributes of spouses and parents of minors that are paid providers under the IHSS program; whether hiring legally responsible relatives as personal assistance providers seems to be a recipient/family preference; whether Spouse and/or Parent providers performed as well as the use of other providers in enabling IHSS recipients to remain at home, safely; and whether the employment of family providers has been budget neutral for Medicaid in terms of health care use/expenditures.

IHSS recipients fall into three distinct age groups: minor children, non-elderly adults, and elderly adults. Elderly adults are the majority (60%). Minor children represent a small minority (about 4%), but still a sizable number of recipients. As the disability/chronic illness profile of each age group is different, as is the distribution of recipients among the types of paid providers used, most of the discussion is organized by recipient age group.

IHSS Plus vs. the Residual Program Participation

The number of recipients cared for by spouses and parents of minors paid as IHSS providers remained relatively constant between 2004 (under the IHSS Residual Program) and 2005 (under the IHSS Plus Waiver); as did the number of persons (about 1,600 recipients combined in 2005) participating in the Restaurant Meal voucher and Advance Pay waiver-eligible services. The new recipients, as a group, tended to be somewhat less impaired, to have lower health care expenditures, and to receive fewer IHSS authorized hours than the group of recipients who were in IHSS for the prior year or longer. These attributes likely could be common to all cohorts of new recipients, and may not be unique to IHSS Plus Waiver program entrants. The race/ethnic and provider mix is somewhat different comparing the new and continuing program cohorts, showing a proportionate increase in Hispanic and Asian recipients. A single year comparison is not sufficient to document a trend in these characteristics.

Preferences in the Selection of Paid IHSS Providers and Outcomes

The selection of a parent or spouse as a paid provider, across all age groups, is partly a function of available family members, but differences in the proportion among race/ethnic groups “selecting” each of the various provider types suggests that cultural preferences may be an important selection factor. Wage and other possible influences on provider availability were not a focus of these analyses, but IHSS wage rates (which vary by county) did not have a consistent association with the selection of paid Parent or Spouse providers. To the contrary, higher wages were marginally associated with an increased use of Non-Relative providers, and Parents and Spouses were more likely to be paid providers when wages were low (and presumably it may be more difficult to attract Non-Relative providers). These patterns could be regional effects, rather than associated with wages.

Recipients Age 3-17

Minor children in IHSS generally have at least one parent in the home. Consequently, for most of these children, the choice of Parent/Non-Parent provider was possible and the choice made by families was for a Parent provider (70% overall and 80% when a parent was present in the home). Hispanics had the highest proportion selecting Parent providers (81%) and the least selecting Non-Relatives (9%). Blacks were the least likely to have paid Parent providers (60%), and comparable with Whites in the proportion selecting Non-Relatives (20%). The decision of families to seek IHSS versus other service options was outside the scope of this study.

There were few differences by provider type in the number of ADL/IADL and cognitive limitations among minor children IHSS recipients. However, proportionately more minor children with paid Parent providers were dependent on human assistance with breathing (this includes assistance with self-administration of oxygen, and the cleaning of this equipment), and had more chronic health conditions (including mental retardation, seizure disorders, and paralysis). These conditions have been shown to be associated with nursing home use in minor children (Fries, Wodchis, Blaum, et al., 2005), and may be indicative of the Parent provider’s willingness and or greater ability to assume the demanding care responsibility associated with these conditions. Contributing to this ability may be that parents are legally permitted to perform “skilled nursing” tasks that would not be permitted by other providers. Investigation of the “cause” of this pattern is outside the scope of the current study.

Recipients Age 18-64

Spouse providers were rarely available as a choice to the non-aged adults participating in IHSS. Most IHSS recipients in this age group were either not married or their spouses were also IHSS recipients or otherwise not able physically/mentally to be paid caregivers. However, when spouses were available and able, the “preference” for them appears to be strong (90% among those with an available/able spouse). Parents were more readily available than spouses to non-elderly adults, and more recipients of this age group selected parents as paid providers. The availability of parents beyond those selected as paid providers is unknown in the IHSS data. There were discernable ethnic differences in the propensity to select Parent or Spouse providers. Hispanics were most likely to select Parent providers (26%) and the second most likely to select Spouse providers (9%). Asian were the most likely to select Spouse providers (11%) and second most likely to select Parent providers (18%). Blacks were the least likely to have either a spouse (2%) or parent (10%) as a paid provider. More than half of the Blacks and Whites relied on Non-Relative providers. This contrasted with about a third among Hispanics and Asians.

In general, recipients with paid Parent or Spouse providers had more limitations in ADL and cognitive functioning, and a comparable number of chronic health conditions, than recipients with other providers. However, those with paid Parent providers had higher rates of mental retardation/developmental disability, central nervous system injuries/disorders (such as quadriplegia, paraplegia, other extensive paralysis or spinal cord disorders), and seizure disorder) -- conditions shown by Fries and associates (2005) to have higher risk of nursing home placement.

Recipients Age 65 or More

Spouses were present among about 25% of this age group of IHSS recipients, but except for those paid as Spouse providers, the number able/available reduced to about 3%. When a recipient’s provider was an Other Relative or a Non-Relative, almost half of the spouses present were also IHSS recipients. Recipients with IHSS-paid Spouse providers tended to have more ADL, cognitive, and breathing assistance limitations, but there were no substantial differences in the number of health conditions. Race/ethnicity had a minor association with the presence of a paid Spouse provider (the percentages range from 1%-4%), but the more striking differences involved recipients with Other Relative and Non-Relative providers. More than half of the Asian (64%) and Hispanic (54%) recipients had an Other Relative as their paid provider, whereas more than half of the Whites (53%) and Blacks (56%) had Non-Relative providers.

Implications for Medicaid and IHSS Expenditures

For all recipient age groups, IHSS expenditures, adjusting impairment severity and service needs, are expected to be lower relative to those with Non-Relative providers when Parents, Spouses, and Other Relatives living in the household are paid IHSS providers. This cost difference arises because an IHSS algorithm adjusts the authorized time for housekeeping/meal preparation when there are relatives living in the household who might be expected to perform these tasks for themselves as well as for the recipient. This adjusted cost difference was observed for Parent providers to minor children, and for Spouse providers of adults. The cost differences for Parent provider (non-aged adults) and Other Relative providers were minor or non-significant. This could be because these providers were not living with the recipient or they may reflect limitations in the risk adjustment model.

Minor children with Parent IHSS-paid providers, adjusting for recipient functional and health conditions, have lower average monthly Medicaid expenditures, and lower IHSS and other home care expenditures than recipients with Non-Relative providers.

Adjusting for recipient characteristics, recipients age 18-64 with Spouse providers had lower average Medicaid monthly expenditures than those with Non-Relative providers. There were no statistically significant differences comparing recipients with Parent and Non-Relative providers. Among these adult IHSS recipients each of the paid relative provider groups had a significantly reduced likelihood of nursing home placement compared to those with Non-Relative providers. The Parent provider effect for those age18-64 appears greatest. Those with Spouse providers tended to have higher risk of “any cause” hospital stays (but not those associated with ambulatory sensitive conditions), higher risk of ER use, but lower IHSS and home care expenditures than recipients with Non-Relative providers. Recipients with Parent providers compared to those with Non-Relative providers had lower adjusted use of hospitals, ERs, and home care.

Average monthly Medicaid expenditures among recipients age 65 or more, adjusting for recipient characteristics, were lower for those with paid Spouse providers and Other Relative providers compared to those with Non-Relative providers. This tendency for lower risk among those with family providers (both legally responsible and otherwise) was also present with respect to ambulatory sensitive hospital stays; and those with Other Relative providers compared to those with Non-Relative providers had reduced risk of ER use, lower monthly expenditures for IHSS and other home care.

In short, these analyses found no financial disadvantage and some advantages to Medicaid from allowing spouses, parents (and other relatives) to be paid IHSS providers. This argues in favor of honoring the recipient’s and family’s preference for such providers. Whether the availability of spouse, parent, and other relatives can be expanded beyond its current proportion among all race/ethnic groups in IHSS is unknown, but changes in the race/ethnic mix of recipients evident in the new cohort of enrollees may affect this. The proportion of recipients who are Hispanic or Asian seems to be growing. These groups presently have the highest proportionate use of Spouse, Parent, and Other Relative providers.

These effects of selecting Parent, Spouse, and Other Relatives as paid providers are present within a program where the rate of Medicaid nursing home stays among IHSS recipients with Non-Relative providers seems to be low. This suggests that IHSS in general is doing a good job of enabling recipients to remain in the community regardless of the provider type selected. Not examined in this analysis were the factors (such as hospital stays, avoidable changes is health or functional status) associated with entry into and exit from IHSS; or the duration of participation in IHSS and the cost/use comparisons over time.

References

Aday LA, R Anderson. (1974). A framework for the study of access to medical care. Health Services Research, 9(3):208-220.

Agency for Healthcare Research and Quality (AHRQ). (2007a). Pediatric Quality Indicators, Revision 3.1. Internet address:http://www.qualityindicators.ahrq.gov/software.htm.

Agency for Healthcare Research and Quality (AHRQ). (2007b). Prevention Quality Indicators, Revision 3.1. Internet address:http://qualityindicators.ahrq.gov/pqi_download.htm.

Ash AS, F Porell, L Gruenberg, E Sawitz, A Belser. (1989). Adjusting Medicare capitation payments using prior hospitalization. Health Care Financing Review, 10(4):17-29.

Billings J, L Zeitel, J Lukomink, TS Carey, AE Blank, L Newman. (1993). Impact of socioeconomic status on hospital use in New York City.Health Affairs, 12(1):162-173.

Centers for Disease Control and Prevention (CDC). (Accessed 2007). International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Internet address: http://www.cdc.gov/nchs/icd9.htm.

Charlson ME, P Pompei, KL Ales, CR MacKenzie. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Disease, 40(5):373-383.

Deyo R, D Cherkin, M Ciol. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of Clinical Epidemiology, 45(6):613-619.

Dudley RA, CA Medlin, LB Hammann, MG Cisternas, R Brand, DJ Renne, HS Luft. (2003). The best of both worlds? Potential of hybrid prospective/concurrent risk adjustment. Medical Care, 41(1):56-69.

Ellis RP, GC Pope, LI Iezzoni, JZ Ayanian, DW Bates, H Burstin, AS Ash. (1996). Diagnosis-based risk adjustment for Medicare capitation payments. Health Care Financing Review, 17(3):101-128.

Elixhauser A, C Steiner, DR Harris, RM Coffey. (1998). Comorbidity measures for use with administrative data. Medical Care, 36(1):8-27.

Fries B, W Wodchis, C Blaum, A Buttar, J Drabek, J Morris. (2005). A national study showed that diagnoses varied by age group in nursing home residents under age 65. Journal of Clinical Epidemiology, 58(2):198-205. Internet address:http://aspe.hhs.gov/daltcp/reports/nhunder65.htm.

Harmuth S, S Dyson. (2002). Results of the 2002 National Survey of State Initiatives on the Long Term Care Direct Care Workforce. New York, NY: Paraprofessional Healthcare Institute and the North Carolina Department of Health and Human Services.

Newcomer R, T Clay, J Luxenberg, R Miller. (1999). Misclassification and selection bias when identifying Alzheimer’s Disease solely from Medicare claims records. Journal of the American Geriatrics Society, 47(2):215-219.

Newcomer R, T Scherzer. (2006). Exploring experiences and factors influencing participation in the In Home Supportive Service Plus Waiver Program. San Francisco, CA: University of California. Prepared for the Research Triangle Institute and the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.

Pope GC, RP Ellis, AS Ash, JZ Ayanian, DW Bates, H Burstin, LI Iezzoni, E Marcantonio, B Wu. (2000). Diagnostic Cost Group Hierarchical Condition Category Models for Medicare Risk Adjustment. Waltham, MA: Health Economics Research, Inc. Final Report to the Centers to Medicare and Medicaid Services under contract 500-95-048.

Pope GC, J Kautter, RP Ellis, AS Ash, JZ Ayanian, LI Iezzoni, MJ Ingber, JM Levy, J Robst. (2004). Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financing Review, 25(4):119-140

Romano P, LL Roos, JG Jollis. (1993). Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: Differing perspectives. Journal of Clinical Epidemiology, 46(10):1075-1079.

Roos LL, SM Sharp, MM Cohen. (1991). Comparing clinical information with claims data: Some similarities and differences. Journal of Clinical Epidemiology, 44(9):881-888.

Salsberg E, P Wing, M Langelier, et al. (2002). The Direct Care Professional Workforce Providing Long Term Care Services in the United States: Data Sources and Data Issues. Washington, DC: Bureau of Health Professions, Health Resources and Services Administration.

Stone RI. (2000). Long-Term Care for the Elderly with Disabilities: Current Policy, Emerging Trends, and Implications for the 21st Century. New York, NY: Milbank Memorial Fund.

Stone RI. (2001). Frontline Workers in Long-Term Care: A Background Paper. Washington, DC: American Association of Homes and Services for the Aging.

US Department of Commerce, (2007). Per Capita Personal Income by County, California, 1991-2001. Table D-9. Washington, DC: Bureau of Economic Analysis. Internet address: http://www.bea.doc.gov.

US General Accounting Office (GAO). (2001). Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides is a Growing Concern. Washington, DC: US Senate. Testimony before the Committee on Health, Education, Labor, and Pensions.

TABLE 1: Share of Cost, Advance Pay, Meals Allowance Participation by IHSS Recipient Age, Provider Relationship, & Program Entry Statusa

Eligible IHSS Recipients Spouse Parent Other Relative Non-Relative Total
n % n % n % n % n %
Age 3-17 from 2004 na na 9,798 72.6 1,701 12.6 2,006 14.9 13,505 100.0
Share of Cost na na 143 1.5 8 0.5 4 0.2 155 1.1
   Mean Months if Yes na na 8.1   9.0   7.5   8.1  
Advance Pay na na 34 0.3 12 0.7 7 0.3 53 0.4
   Mean Months if Yes na na 9.5   8.3   12.0   9.5  
Meals Allowance na na 2 0.02 1 0.06 - - 3 0.02
   Mean Months if Yes na na 10.5   12.0   - - 11.0  
Age 3-17, new in 2005 na na 1,780 64.7 389 14.1 583 21.2 2,752 100.0
Share of Cost na na 10 0.6 1 0.3 3 0.5 14 0.5
   Mean Months if Yes na na 6.1   1.0   3.3   5.1  
Advance Pay na na 1 0.06 1 0.3 - - 2 0.07
   Mean Months if Yes na na 9.0   3.0   - - 6.0  
Meals Allowance na na - - - - - - - -
   Mean Months if Yes na na - - - - - - - -
Age 18-64 from 2004   7,121   5.6   21,008     16.7     39,932     31.7     58,057     46.0     126,118     100.0  
Share of Cost 741   10.4   392 1.9 879 2.2 1,567 2.7 3,579 2.8
   Mean Months if Yes 8.9   9.7   8.9   8.9   9.0  
Advance Pay 27 0.4 138 0.7 37 0.1 272 0.5 474 0.4
   Mean Months if Yes 10.6   10.7   9.9   10.4   10.4  
Meals Allowance 6 0.08 13 0.06 47 0.1 278 0.5 344 0.3
   Mean Months if Yes 7.8   10.2   9.7   9.9   9.8  
Age 18-64 new 2005 1,597 6.0 2,484 9.4 9,475 35.8 12,917 48.8 26,473 100.0
Share of Cost 148 9.3 45 1.8 281 3.0 439 3.4 913 3.4
   Mean Months if Yes 4.8   5.9   5.3   4.6   4.9  
Advance Pay 1 0.06 3 0.1 1 0.01 7 0.05 12 0.05
   Mean Months if Yes 12.0   3.7   4.0   5.7   5.6  
Meals Allowance 1 0.06 1 0.04 3 0.03 33 0.3 38 0.14
   Mean Months if Yes 2.0   7.0   9.0   4.7   5.1  
Age 65+ from 2004 4,373 2.2 na na 103,990 52.4 90,160 45.4 198,523 100.0
Share of Cost 507 11.6 na na 3,061 2.9 2,970 3.3 6,538 3.3
   Mean Months if Yes 8.7   na na 9.0   8.6   8.8  
Advance Pay 7 0.16 na na 25 0.02 66 0.07 98 0.05
   Mean Months if Yes 8.6   na na 10.8   8.7   9.2  
Meals Allowance 3 0.07 na na 113 0.11 434 0.5 550 0.3
   Mean Months if Yes 6.7   na na 9.5   9.9   9.8  
Age 65+ new 2005 1,016 2.9 na na 19,506 55.2 14,811 41.9 35,333 100.0
Share of Cost 94 9.3 na na 974 5.0 923 6.2 1,991 5.6
   Mean Months if Yes 5.4   na na 5.5   4.4   5.0  
Advance Pay - - na na 2 0.01 4 0.03 6 0.02
   Mean Months if Yes - - na na 1.0   3.3   2.5  
Meals Allowance - - na na 23 0.12 36 0.24 59 0.17
   Mean Months if Yes - - na na 4.8   4.6   4.7  
Total 14,107   35,070   174,993   178,543   402,704  

SOURCE: California Department of Social Services, unpublished CMIPS data for 2004 and 2005. “na” is not applicable.

  1. Classification into Provider Type was done using the principle of “intention to treat.” Ever having a Spouse provider for one month or in 2005 defined one in this group. Similarly, ever having a Parent provider (but no Spouse provider), or an Other Relative (i.e., but no Spouse or Parent) for at least one month defined one in these respective groups. Non-Relatives had no family members as providers during the year.

TABLE 2: Consistency of Provider Relationships

Provider Relationship Age 3-17 Age 18-64 Age 65+
All   Inconsistent   All   Inconsistent   All   Inconsistent  
2005 n n % n n % n n %
Spouse na na na 8,718 821 9.4 5,389 501 9.3
Parent   11,578     481     4.2   23,492 1,763 7.5 na na na
Other Relative 2,090 98 4.7 49,407 3,601 7.3 123,496 4,671 3.8
Non-Relativea 2,589 124 4.8 70,974 4,135 5.8 104,971 6,776 6.5
Total Inconsistent Relationships   703 4.3     10,320     6.8       11,948     5.1  
Total All (Consistent, & Inconsistent) Relationships   16,257       152,591         233,856      

SOURCE: California Department of Social Services, unpublished CMIPS data for 2004 and 2005.


TABLE 3: Race/Ethnicity of New & Continuing IHSS Recipients, 2005

  Spouse Parent Other Relative Non-Relative Total
n % n % n % n % n %
Continuing Recipients Age 3-17     9,798   1,701   2,006   13,505  
1 White na na 2,546 26.0 468 27.5 769 38.3 3,783 28.0
2 Hispanic na na 4,951 50.5 568 33.4 568 28.3 6,087 45.1
3 Black na na 1,422 14.5 455 26.7 489 24.4 2,366 17.5
4 Asian & Others na na 879 9.0 210 12.3 180 9.0 1,269 9.4
New Recipients Age 3-17     1,780   389   583   2,752  
1 White na na 489 27.5 83 21.3 225 38.6 797 29.0
2 Hispanic na na 824 46.3 127 32.6 182 31.2 1,133 41.2
3 Black na na 273 15.3 125 32.1 111 19.0 509 18.5
4 Asian & Others na na 194 10.9 54 13.9 65 11.1 313 11.4
Continuing Recipients Age 18-64     7,121       21,008     39,932   58,057     126,118    
1 White 2,434   34.2   8,612   41.0     14,803     37.1     28,183     48.5   54,032   42.8  
2 Hispanic 2,616 36.7 6,967 33.2 8,759 21.9 8,899 15.3 27,241 21.6
3 Black 687 9.6 3,183 15.2 10,771 27.0 17,701 30.5 32,342 25.6
4 Asian & Others 1,384 19.4 2,246 10.7 5,599 14.0 3,274 5.6 12,503 9.9
New Recipients Age 18-64 1,597   2,484   9,475   12,917   26,473  
1 White 500 31.3 941 37.9 3,371 35.6 6,556 50.8 11,368 42.9
2 Hispanic 636 39.8 785 31.6 2,259 23.8 1,966 15.2 5,646 21.3
3 Black 166 10.4 501 20.2 2,637 27.8 3,614 28.0 6,918 26.1
4 Asian & Others 295 18.5 257 10.3 1,208 12.7 781 6.0 2,541 9.6
Continuing Recipients Age 65+   4,373       103,990   90,160   198,523  
1 White 911 20.8 na na 36,448 35.0 41,568 46.1 78,927 39.8
2 Hispanic 1813 41.5 na na 24,800 23.8 19,275 21.4 45,888 23.1
3 Black 201 4.6 na na 9,472 9.1 12,288 13.6 21,961 11.1
4 Asian & Others 1448 33.1 na na 33,270 32.0 17,029 18.9 51,747 26.1
New Recipients Age 65+ 1,016       19,506   14,811   35,333  
1 White 194 19.1 na na 5,182 26.6 6,259 42.3 11,635 32.9
2 Hispanic 435 42.8 na na 5,538 28.4 3,466 23.4 9,439 26.7
3 Black 63 6.2 na na 1,652 8.5 1,480 10.0 3,195 9.0
4 Asian & Others 324 31.9 na na 7,134 36.6 3,606 24.3 11,064 31.3

SOURCE: California Department of Social Services, unpublished CMIPS data for 2005. “na” means that these provider types were not included in the analysis.


TABLE 4: Race/Ethnicity Distribution Among IHSS Provider Groups, 2005

  Spouse Parent Other Relative Non-Relative Total
n % n % n % n % n
Continuing Recipients Age 3-17     9,798   1,701   2,006   13,505
1 White na na 2,546 67.3 468 12.4 769 20.3 3,783
2 Hispanic na na 4,951 81.3 568 9.3 568 9.3 6,087
3 Black na na 1,422 60.1 455 19.2 489 20.7 2,366
4 Asian & Others na na 879 69.3 210 16.5 180 14.2 1,269
New Recipients Age 3-17     1,780   389   583   2,752
1 White na na 489 61.4 83 10.4 225 28.2 797
2 Hispanic na na 824 72.7 127 11.2 182 16.1 1,133
3 Black na na 273 53.6 125 24.6 111 21.8 509
4 Asian & Others na na 194 62.0 54 17.3 65 20.8 313
Continuing Recipients Age 18-64     7,121       21,008     39,932     58,057       126,118  
1 White 2,434 4.5 8,612   15.9   14,803   27.4   28,183   52.2   54,032
2 Hispanic 2,616 9.6 6,967 25.6 8,759 32.2 8,899 32.7 27,241
3 Black 687 2.1 3,183 9.8 10,771 33.3 17,701 54.7 32,342
4 Asian & Others 1,384   11.1   2,246 18.0 5,599 44.8 3,274 26.2 12,503
New Recipients Age 18-64 1,597   2,484   9,475   12,917   26,473
1 White 500 4.4 941 8.3 3,371 29.7 6,556 57.7 11,368
2 Hispanic 636 11.3 785 13.9 2,259 40.0 1,966 34.8 5,646
3 Black 166 2.4 501 7.2 2,637 38.1 3,614 52.2 6,918
4 Asian & Others 295 11.6 257 10.1 1,208 47.5 781 30.7 2,541
Continuing Recipients Age 65+ 4,373         103,990     90,160   198,523
1 White 911 1.2 na na 36,448 46.2 41,568 52.7 78,927
2 Hispanic 1813 4.0 na na 24,800 54.0 19,275 42.0 45,888
3 Black 201 0.9 na na 9,472 43.1 12,288 56.0 21,961
4 Asian & Others 1448 2.8 na na 33,270 64.3 17,029 32.9 51,747
New Recipients Age 65+ 1,016       19,506   14,811   35,333
1 White 194 1.7 na na 5,182 44.5 6,259 53.8 11,635
2 Hispanic 435 4.6 na na 5,538 58.7 3,466 36.7 9,439
3 Black 63 2.0 na na 1,652 51.7 1,480 46.3 3,195
4 Asian & Others 324 2.9 na na 7,134 64.5 3,606 32.6 11,064

SOURCE: California Department of Social Services, unpublished CMIPS data for 2005. “na” means that these provider types were not included in the analysis.


TABLE 5a: Selected Household Characteristics of IHSS Recipients, Age 3-17

IHSS Recipients Parent Other Relative Non-Relative Total
n % n % n % n %
Continuing from 2004   9798       1701       2006       13505    
  Female 3808   38.9   647   38.0   784   39.1   5239   38.8  
Household size
  1 15 0.2 8 0.5 16 0.8 39 0.3
  2 1051 10.7 192 11.3 274 13.7 1517 11.2
  3 2157 22.0 364 21.4 470 23.4 2991 22.2
  4 2502 25.5 428 25.2 544 27.1 3474 25.7
  5+ 4073 41.6 709 41.7 702 35.0 5484 40.6
Parent Presenta
  No Parent Present 396 4.0 520 30.6 377 18.8 1293 9.6
  Provides All Services 8138 83.1 251 14.8 578 28.8 8967 66.4
  Provides Some Services   1129 11.5 481 28.3 517 25.8 2127 15.7
  Provides No Services 113 1.2 313 18.4 304 15.2 730 5.4
  Parent IHSS Recipient 22 0.2 136 8.0 230 11.5 388 2.9
Housing
  House 5493 56.1 1144 67.3 1339 66.7 7976 59.1
  Apartment 3861 39.4 492 28.9 594 29.6 4947 36.6
  Mobile Home 316 3.2 47 2.8 53 2.6 416 3.1
  Hotel/Other 128 1.3 18 1.1 20 1.0 166 1.2
Entering IHSS in 2005 1,780   389   583   2752  
  Female 705 39.6 150 38.6 212 36.4 1067 38.8
Household Size
  1 2 0.1 0 0.0 3 0.5 5 0.2
  2 179 10.1 35 9.0 71 12.2 285 10.4
  3 330 18.5 82 21.1 158 27.1 570 20.7
  4 499 28.0 93 23.9 158 27.1 750 27.3
  5+ 770 43.3 179 46.0 193 33.1 1142 41.5
Parent Presenta
  No Parent Present 0 0.0 108 27.8 107 18.4 341 12.4
  Provides All Services 1426 80.1 49 12.6 190 32.6 1665 60.5
  Provides Some Services 203 11.4 121 31.1 150 25.7 474 17.2
  Provides No Services 145 8.1 70 18.0 92 15.8 181 6.6
  Parent IHSS Recipient 6 0.3 41 10.5 44 7.5 91 3.3
Housing
  House 966 54.3 229 58.9 376 64.5 1571 57.1
  Apartment 715 40.2 144 37.0 179 30.7 1038 37.7
  Mobile Home 64 3.6 9 2.3 18 3.1 91 3.3
  Hotel/Other 35 2.0 7 1.8 10 1.7 52 1.9

SOURCE: California Department of Social Services, unpublished CMIPS data for 2005.

  1. May not total to 100% due to missing values, “na” not applicable, “unk” unknown.]

TABLE 5b: Selected Household Characteristics of IHSS Recipients, Age 18-64

IHSS Recipients Spouse Parent   Other Relative   Non-Relative Total
n % n % n % n % n %
Continuing from 2004 7121     21008     39932   58057     126118    
  Female   2407     33.8   9494   45.2     27676     69.3     34944     60.2   74521   59.1  
Household size
  1 120 1.7 1336 6.4 7548 18.9 22800 39.3 31804 25.2
  2 2596 36.5 5418 25.8 13093 32.8 20877 36.0 41984 33.3
  3 1598 22.4 6457 30.7 7916 19.8 7347 12.7 23318 18.5
  4 1253 17.6 3792 18.1 4817 12.1 3548 6.1 13410 10.6
  5+ 1554 21.8 4005 19.1 6558 16.4 3485 6.0 15602 12.4
Spouse Presenta
  No Spouse na   19298 91.9 31009 77.7 52607 90.6 102914 81.6
  Spouse Able/Available 6145 86.3 73 0.3 1431 3.6 1221 2.1 8870 7.0
  Spouse Availability Limited 400 5.6 75 0.4 786 2.0 558 1.0 1819 1.4
  Spouse Not Able 537 7.5 17 0.1 1179 3.0 703 1.2 2436 1.9
  Spouse is IHSS Recipient 22 0.3 54 0.3 5291 13.3 2633 4.5 8000 6.3
Parent Presenta
  No Parent Present unk   na   unk   unk   unk  
  Provides Some Services 16 0.2 1448 6.9 94 0.2 193 0.3 1751 1.4
  Provides No Services     32 0.2 27 0.1 48 0.1 107 0.1
  Parent is IHSS Recipient 1 0.0 11 0.1 115 0.3 94 0.2 221 0.2
Housing
  House 3810 53.5 14401 68.6 19095 47.8 22210 38.3 59516 47.2
  Apartment 2687 37.7 5565 26.5 18896 47.3 31070 53.5 58218 46.2
  Mobile Home 484 6.8 830 4.0 1427 3.6 3498 6.0 6239 4.9
  Hotel/Other 140 2.0 212 1.0 514 1.3 1279 2.2 2145 1.7
Entering IHSS in 2005 1597   2484   9475   12917   26473  
  Female 506 31.7 1022 41.1 6386 67.4 7273 56.3 15187 57.4
Household size
  1 31 1.9 172 6.9 1653 17.4 4989 38.6 6845 25.9
  2 557 34.9 534 21.5 2748 29.0 4118 31.9 7957 30.1
  3 342 21.4 704 28.3 1950 20.6 1851 14.3 4847 18.3
  4 259 16.2 492 19.8 1293 13.6 933 7.2 2977 11.2
  5+ 408 25.5 582 23.4 1831 19.3 1026 7.9 3847 14.5
Spouse Presenta
  No Spouse na na 2303 92.7 7273 76.8 11723 90.8 21299 80.5
  Spouse Able/Available 1441 90.2 19 0.8 465 4.9 417 3.2 2342 8.8
  Spouse Availability Limited 52 3.3 7 0.3 229 2.4 112 0.9 400 1.5
  Spouse Not Able 88 5.5 4 0.2 335 3.5 197 1.5 624 2.1
  Spouse is IHSS Recipient 7 0.4 5 0.2 1143 12.1 430 3.3 1585 6.0
Parent Presenta
  No Parent Present unk   na   unk   unk   unk  
  Provides Some Services 8 0.5 145 5.8 13 0.1 22 0.2 188 0.7
  Parent is IHSS Recipient 1 0.1 1 0.0 12 0.1 8 0.1 22 0.1
Housing
  House 845 52.9 1613 64.9 4356 46.0 4776 37.0 11590 43.8
  Apartment 596 37.3 713 28.7 4589 48.4 6679 51.7 12577 47.5
  Mobile Home 119 7.5 116 4.7 367 3.9 936 7.2 1538 5.8
  Hotel/Other 37 2.3 42 1.7 163 1.7 526 4.1 768 2.9

SOURCE: California Department of Social Services, unpublished CMIPS data for 2005

  1. May not total to 100% due to missing items, “na” not applicable, “unk” unknown.

TABLE 5c: Selected Household Characteristics of IHSS Recipients, Age 65+

IHSS Recipients Parent Other Relative Non-Relative Total
n % n % n % n %
Continuing from 2004   4373       103990       90160       198523    
  Female 836   19.1   74883   72.0   64223   71.2   139942   70.5  
Household Size
  1 85 1.9 20271 19.5 41840 46.4 62196 31.3
  2 2343 53.6 34892 33.6 31463 34.9 68698 34.6
  3 722 16.5 17182 16.5 7387 8.2 25291 12.7
  4 465 10.6 11006 10.6 3840 4.3 15311 7.7
  5+ 758 17.3 20639 19.8 5630 6.2 27027 13.6
Spouse Presenta
  No Spouse Present na   70564 67.9 69419 77.0 139983 70.5
  Spouse Able/Available 3881 88.7 1801 1.7 1053 1.2 6735 3.4
  Spouse Availability Limited 156 3.6 300 0.3 225 0.2 681 0.3
  Spouse Not Able 286 6.5 2962 2.8 1831 2.0 5079 2.6
  Spouse is IHSS Recipient 45 1.0 28317 27.2 17602 19.5 45964 23.2
Parent Presenta
  Parent Present unk   unk   unk   unk  
  Provides Some Services     2 <0.00 3 <0.00 5 <0.00
  Parent is IHSS Recipient     35 0.03 22 0.02 57 0.05
Housing
  House 2288 52.3 53719 51.7 30116 33.4 86123 43.4
  Apartment 1731 39.6 45445 43.7 54323 60.3 101499 51.1
  Mobile Home 283 6.5 3123 3.0 4343 4.8 7749 3.9
  Hotel/Other 71 1.6 1703 1.6 1378 1.5 3152 1.6
# Entering in 2005 1016   19506   14811   35333  
  Female 174 17.1 13605 69.7 9855 66.5 23634 66.9
Household Size
  1 14 1.4 3161 16.2 6596 44.5 9771 27.7
  2 533 52.5 5658 29.0 4735 32.0 10926 30.9
  3 171 16.8 3534 18.1 1447 9.8 5152 14.6
  4 94 9.2 2440 12.5 794 5.4 3328 9.4
  5+ 204 20.1 4713 24.2 1239 8.4 6156 17.4
Spouse Presenta
  No Spouse Present na   13073 67.0 11398 77.0 24471 69.3
  Spouse Able/Available 933 91.8 561 2.9 430 2.9 1924 5.4
  Spouse Availability Limited 19 1.9 86 0.4 73 0.5 178 0.5
  Spouse Not Able 8 0.8 698 3.6 457 3.1 1163 3.0
  Spouse is IHSS Recipient 10 1.0 5067 26.0 2441 16.5 7518 21.3
Parent Present a
  Parent Present unk   unk   unk   unk  
  Provides Some Services 2 0.2 7 0.04 9 0.06 18 0.05
  Parent is IHSS Recipient 1 0.1 12 0.06 3 0.02 16 0.05
Housing
  House 510 50.2 11013 56.5 5541 37.4 17064 48.3
  Apartment 422 41.5 7348 37.7 7871 53.1 15641 44.3
  Mobile Home 61 6.0 757 3.9 1051 7.1 1869 5.3
  Hotel/Other 23 2.3 388 2.0 348 2.3 759 2.1

SOURCE:: California Department of Social Services, unpublished CMIPS data for 2005.

  1. May not total to 100% due to missing values, “na” not applicable, “unk” unknown.

TABLE 6: Physical & Cognitive Limitations Among New & Continuing IHSS Recipients, 2005

  Spouse Parent Other Relative Non-Relative Total
n n n n n
Continuing Recipients Age 3-17   9,798 1,701 2,006 13,505
  Average Total Authorized IHSS Hours   112.3 102.3 107.8 110.4
  Mean Number Cognitive Limitationsa   0.6 0.5 0.6 0.6
  Mean Number ADL Limitationsb   3.6 3.5 3.6 3.6
  Mean Number IADL Limitationsc   3.1 3.4 3.3 3.2
  % with Breathing Limitationd   16.2 14.8 12.3 15.4
New Recipients Age 3-17   1,780 389 583 2,752
  Average Total Authorized IHSS Hours   70.1 61.4 69.2 68.7
  Mean Number Cognitive Limitationsa   0.4 0.4 0.4 0.4
  Mean Number ADL Limitationsb   3.3 3.0 3.2 3.2
  Mean Number IADL Limitationsc   2.9 3.3 3.0 3.0
  % with Breathing Limitationd   9.3 9.3 11.5 9.8
Continuing Recipients Age 18-64   7,121     21,008     39,932     58,057     126,118  
  Average Total Authorized IHSS Hours 86.3 134.6 79.6 89.2 93.6
  Mean Number Cognitive Limitationsa 0.1 0.7 0.1 0.1 0.2
  Mean Number ADL Limitationsb 3.7 3.1 2.5 2.3 2.6
  Mean Number IADL Limitationsc 4.6 4.3 4.3 4.3 4.3
  % with Breathing Limitationd 11.1 7.2 6.6 7.5 7.4
New Recipients Age 18-64 1,597 2,484 9,475 12,917 26,473
  Average Total Authorized IHSS Hours 61.4 79.3 57.4 57.2 59.6
  Mean Number Cognitive Limitationsa 0.04 0.3 0.05 0.04 0.1
  Mean Number ADL Limitationsb 3.5 2.4 2.1 1.8 2.1
  Mean Number IADL Limitationsc 4.4 4.2 4.3 4.1 4.2
  % with Breathing Limitationd 8.1 4.0 4.5 5.1 5.0
Continuing Recipients Age 65+ 4,373     103,990   90,160 198,523
  Average Total Authorized IHSS Hours 83.4   82.5 85.8 84.0
  Mean Number Cognitive Limitationsa 0.1   0.1 0.1 0.1
  Mean Number ADL Limitationsb 3.9   2.8 2.5 2.7
  Mean Number IADL Limitationsc 4.6   4.5 4.4 4.5
  % with Breathing Limitationd 11.0   6.2 6.2 6.3
New Recipients Age 65+ 1,016   19,506 14,811 35,333
  Average Total Authorized IHSS Hours 58.6   61.2 58.9 60.2
  Mean Number Cognitive Limitationsa 0.1   0.1 0.05 0.1
  Mean Number ADL Limitationsb 3.6   2.4 1.9 2.2
  Mean Number IADL Limitationsc 4.4   4.4 4.2 4.3
  % with Breathing Limitationd 10.0   4.5 4.5 4.6

SOURCE: California Department of Social Services, unpublished CMIPS data for 2005

  1. Number of tasks cannot perform memory, orientation, or judgment tasks without human assistance.
  2. Number of tasks cannot perform ADLs (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual care; eating) without human assistance.
  3. Number of tasks cannot perform IADLs (i.e., housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside) without human assistance.
  4. Cannot breathe without human assistance.

TABLE 7: Limitations Among Meals Allowance & Advance Pay IHSS Waiver Recipients, 2005

Age Group Meals Allowance Advance Pay
3-17 18-64 65+ 3-17 18-64 65+
IHSS Plus Recipients N=3   N=382     N=609     N=55     N=486     N=104  
ADL Limitationsa
  % 3 or more 66.7 27.2 31.4 96.4 97.9 100.0
IADL Limitationsb
  % 3 or more 100.0 95.5 98.7 72.7 100.0 100.0
Cognitive Limitationsc
  % 0 66.7 98.4 98.9 54.5 83.7 83.7
  % 2 or more 33.3 1.3 0.8 36.4 14.0 13.5
Breathing Problemsd
  % 0   100.0   94.8 94.3   69.1   78.0 75.0

SOURCE: California Department of Social Services, unpublished CMIPS data for 2005

  1. Number of tasks cannot perform assistance in ADLs (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual care; eating) without human assistance.
  2. Number of tasks cannot perform IADLs (i.e., housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside) without at least direct physical human assistance.
  3. Number of tasks cannot perform memory, orientation, or judgment tasks without human assistance.
  4. Cannot breathe without human assistance.

TABLE 8: Modal Hourly IHSS Wage Rate, by County, 2003

County   Hourly Wage Rate   County   Hourly Wage Rate  
ALAMEDA 9.50 ORANGE 8.00
ALPINE 7.11 PLACER 6.75
AMADOR 6.95 PLUMAS 7.11
BUTTE 7.11 RIVERSIDE 7.11
CALAVERAS 6.75 SACRAMENTO 9.50
COLUSA 6.75 SAN BENITO 6.75
CONTRA COSTA   9.50 SAN BERNARDINO   8.50
DEL NORTE 6.75 SAN DIEGO 8.50
EL DORADO 6.75 SAN FRANCISCO 10.10
FRESNO 7.50 SAN JOAQUIN 8.50
GLENN 7.11 SAN LUIS OBISPO 6.95
HUMBOLDT 6.75 SAN MATEO 9.50
IMPERIAL 6.75 SANTA BARBARA 7.11
INYO 6.75 SANTA CLARA 10.50
KERN 6.75 SANTA CRUZ 9.50
KINGS 6.75 SHASTA 6.75
LAKE 6.75 SIERRA 7.11
LASSEN 6.75 SISKIYOU 6.75
LOS ANGELES 7.50 SOLANO 9.50
MADERA 6.75 SONOMA 9.50
MARIN 9.75 STANISLAUS 6.95
MARIPOSA 6.75 SUTTER 6.75
MENDOCINO 7.11 TEHAMA 6.75
MERCED 6.95 TRINITY 6.75
MODOC 6.75 TULARE 6.75
MONO 7.11 TUOLUMNE 6.75
MONTEREY 9.50 VENTURA 7.11
NAPA 8.50 YOLO 9.60
NEVADA 7.11 YUBA 6.75

SOURCE: Derived from unpublished CMIPS recorded payments to IHSS recipients in 2003


TABLE 9: Number of Chronic Health Conditions by Medicaid Recipient Age Comparing New and Continuing IHSS Recipient, 2005

IHSS Recipient Age Group   # IHSS Recipients, 2005     Mean # HCC’s     Standard Deviation  
Total Recipients, 2005 346,552 3.41 2.82
  3-17 11,583 3.37 2.97
  18-64 125,502 4.21 3.25
  65 or more 209,467 2.93 2.40
Recipients Continuing from 2004   293,459 3.35 2.77
  3-17 9,914 3.43 2.96
  18-64 104,786 4.09 3.20
  65 or more 178,759 2.91 2.36
New IHSS Recipients 2005 53,093 3.71 3.09
  3-17 1,669 3.01 3.05
  18-64 20,716 4.78 3.44
  65 or more 30,708 3.03 2.60

SOURCE: California Department of Health Care Services, Medicaid claims for 2005. HCC refers to Hierarchical Condition Classifications (Pope, Ellis, Ash, et al., 2000). Recipient counts are limited to IHSS recipients not enrolled in Medicaid managed care at anytime in 2005, but includes any claims in 2005 regardless of the IHSS eligibility period.


TABLE 10a: Summary of Health Conditions Among IHSS Recipients Age 3-17 by Provider Group, 2005

  Parent Other Relative Non-Relative
  Number   %   Number   %   Number   %
Total Recipients 8,293   100.0   1,455   100.0   1,835   100.0  
Recipients w/ Any HCCa 6,740 81.3 1,055 72.5 1,261 68.7
Collapsed HCC Groupings
  Infectious and Parasitic Disease 1,055 12.7 156 10.7 171 9.3
  Neoplasms 334 4.0 38 2.6 43 2.3
  Endocrine, Nutritional & Metabolic Disorders 706 8.5 105 7.2 101 5.5
  Liver & Gallbladder Disease 80 1.0 10 0.7 7 0.4
  Gastro-Intestinal Disease 1,583 19.1 218 15.0 216 11.8
  Musculoskeletal/Connective Tissue 1,937 23.4 246 16.9 295 16.1
  Disease of the Blood & Blood Forming Organs 273 3.3 42 2.9 50 2.7
  Mental Disorders 859 10.4 140 9.6 131 7.1
  Mental Retardation/Developmental Disability 1,464 17.7 216 14.8 250 13.6
  Central Nervous System Injuries/Disorders 2,575 31.1 384 26.4 411 22.4
  Respiratory System Disease/Disorders 360 4.3 41 2.8 57 3.1
  Cardiovascular System 664 8.0 79 5.4 77 4.2
  Cerebral & Other Vascular System 1,302 15.7 200 13.7 203 11.1
  Pulmonary System 2,143 25.8 319 21.9 361 19.7
  Eyes & Vision Disorders 1,360 16.4 168 11.5 195 10.6
  Ear, Nose, & Throat Disorders 3,856 46.5 565 38.8 621 33.8
  Renal System 85 1.0 11 0.8 10 0.5
  Other Genitourinary System 924 11.1 142 9.8 136 7.4
  Pregnancy/Child Birth Complications 143 1.7 19 1.3 14 0.8
  Dermatological Disorders 1,218 14.7 186 12.8 190 10.4
  Fractures, Other Injuries, & Poisoning 1,146 13.8 169 11.6 238 13.0
  Treatment Complications, Ill-Defined Conditions   3,621 43.7 534 36.7 584 31.8
  Miscellaneous 2,318 28.0 345 23.7 367 20.0

SOURCE: California Department of Health Care Services, Medicaid claims, 2005. Counts apply to IHSS recipients not in Medicaid Managed for any month in calendar year 2005.

  1. HCC refers to Hierarchical Condition Classifications (Pope, Ellis, Ash, et al., 2000).

TABLE 10b: Summary of Health Conditions Among IHSS Recipients Age 18-64 by Provider Group, 2005

  Spouse Parent Other Relative Non-Relative
  Number   %   Number   %   Number   %   Number   %
Total Recipients 6,721   100.0   18,749   100.0   40,603   100.0   59,429   100.0  
Recipients w/ Any HCCa 6,003 89.3 13,789 73.5 36,362 89.6 52,197 87.8
Collapsed HCC Groupings
  Infectious and Parasitic Disease 791 11.8 1,655 8.8 4,511 11.1 8,006 13.5
  Neoplasms 865 12.9 981 5.2 5,604 13.8 7,643 12.9
  Endocrine, Nutritional & Metabolic Disorders 2,284 34.0 2,559 13.6 13,697 33.7 16,587 27.9
  Liver & Gallbladder Disease 494 7.4 539 2.9 2,594 6.4 4,133 7.0
  Gastro-Intestinal Disease 1,633 24.3 2,479 13.2 9,740 24.0 13,378 22.5
  Musculoskeletal/Connective Tissue 2,814 41.9 3,888 20.7 19,406 47.8 27,639 46.5
  Disease of the Blood & Blood Forming Organs 533 7.9 759 4.0 3,060 7.5 4,071 6.9
  Mental Disorders 741 11.0 1,967 10.5 5,112 12.6 9,425 15.9
  Mental Retardation/ Developmental Disability 19 0.3 1,143 6.1 385 0.9 650 1.1
  Central Nervous System Injuries/Disorders 1,080 16.1 4,025 21.5 5,386 13.3 9,627 16.2
  Respiratory System Disease/Disorders 279 4.2 489 2.6 1,419 3.5 2,093 3.5
  Cardiovascular System 2,548 37.9 2,321 12.4 16,984 41.8 19,959 33.6
  Cerebral & Other Vascular System 1,258 18.7 1,762 9.4 6,200 15.3 8,212 13.8
  Pulmonary System 1,739 25.9 2,804 15.0 10,869 26.8 15,659 26.3
  Eyes & Vision Disorders 1,123 16.7 1,468 7.8 7,991 19.7 8,825 14.8
  Ear, Nose, & Throat Disorders 1,355 20.2 3,899 20.8 8,664 21.3 12,019 20.2
  Renal System 809 12.0 576 3.1 2,813 6.9 2,980 5.0
  Other Genitourinary System 1,363 20.3 2,507 13.4 8,490 20.9 11,768 19.8
  Pregnancy/Child Birth Complications 45 0.7 147 0.8 194 0.5 449 0.8
  Dermatological Disorders 1,159 17.2 2,682 14.3 7,330 18.1 12,025 20.2
  Fractures, Other Injuries, & Poisoning 1,356 20.2 2,549 13.6 7,599 18.7 13,695 23.0
  Treatment Complications, Ill-Defined Conditions   3,778 56.2 6,277 33.5 22,972 56.6 32,156 54.1
  Miscellaneous 2,129 31.7 4,120 22.0 13,819 34.0 20,151 33.9

SOURCE:: California Department of Health Care Services, Medicaid claims, 2005. Counts apply to IHSS recipients not in Medicaid Managed for any month in calendar year 2005.

  1. HCC refers to Hierarchical Condition Classifications (Pope, Ellis, Ash, et al., 2000).

TABLE 10c: Summary of Health Conditions Among IHSS Recipients Age 65+ by Provider Group, 2005

  Spouse Other Relative Non-Relative
  Number   %   Number   %   Number   %
Total Recipients 4,656   100.0   109,260   100.0   95,551   100.0  
Recipients w/ Any HCCa 3,847 82.6 91,221 83.5 80,167 83.9
Collapsed HCC Groupings
  Infectious and Parasitic Disease 330 7.1 6,263 5.7 6,593 6.9
  Neoplasms 611 13.1 11,898 10.9 12,085 12.6
  Endocrine, Nutritional & Metabolic Disorders 1,047 22.5 18,517 16.9 15,975 16.7
  Liver & Gallbladder Disease 167 3.6 2,848 2.6 2,347 2.5
  Gastro-Intestinal Disease 812 17.4 16,924 15.5 16,041 16.8
  Musculoskeletal/Connective Tissue 1,246 26.8 34,101 31.2 32,979 34.5
  Disease of the Blood & Blood Forming Organs 270 5.8 5,311 4.9 4,893 5.1
  Mental Disorders 286 6.1 6,369 5.8 6,359 6.7
  Mental Retardation/Developmental Disability 1 0.0 32 0.0 32 0.0
  Central Nervous System Injuries/Disorders 251 5.4 3,604 3.3 3,566 3.7
  Respiratory System Disease/Disorders 149 3.2 1,821 1.7 1,658 1.7
  Cardiovascular System 1,842 39.6 41,481 38.0 36,234 37.9
  Cerebral & Other Vascular System 927 19.9 14,141 12.9 13,436 14.1
  Pulmonary System 936 20.1 18,348 16.8 16,283 17.0
  Eyes & Vision Disorders 662 14.2 18,109 16.6 16,198 17.0
  Ear, Nose, & Throat Disorders 354 7.6 8,407 7.7 7,630 8.0
  Renal System 414 8.9 4,064 3.7 3,045 3.2
  Other Genitourinary System 630 13.5 10,967 10.0 10,573 11.1
  Pregnancy/Child Birth Complications 4 0.1 66 0.1 58 0.1
  Dermatological Disorders 435 9.3 10,408 9.5 12,443 13.0
  Fractures, Other Injuries, & Poisoning 532 11.4 12,159 11.1 12,411 13.0
  Treatment Complications, Ill-Defined Conditions   2,115 45.4 45,290 41.5 41,474 43.4
  Miscellaneous 769 16.5 17,424 15.9 17,536 18.4

SOURCE: California Department of Health Care Services, Medicaid claims, 2005. Counts apply to IHSS recipients not in Medicaid Managed for any month in calendar year 2005.

  1. HCC refers to Hierarchical Condition Classifications (Pope, Ellis, Ash, et al., 2000).

TABLE 11: Mean Medicaid Expendituresa for IHSS Recipients by Observation Months and Age, 2005

  # Months     Variable   All Ages Age 3-17 Age 18-64 Age 65 or More
N Mean Std Dev N Mean Std Dev N Mean Std Dev N Mean Std Dev
1 Mean Total $ 7470 6429 21286 161 4952 22513 2737 6130 23623 4572 6660 19708
Average $/month     6429 21286   4952 22513   6130 23623   6660 19708
2 Mean Total $ 8143 7450 30155 156 5837 19420 2898 7912 24204 5089 7237 33315
Average $/month     3725 15078   2918 9710   3956 12102   3618 16657
3 Mean Total $ 8200 8519 33349 177 10462 40166 2943 9847 47735 5080 7682 20437
Average $/month     2840 11116   3487 13389   3283 15912   2561 6812
4 Mean Total $ 7924 9002 24208 187 9838 68754 2923 10424 28450 4864 8115 17077
Average $/month     2251 6052   2459 17189   2606 7112   2029 4269
5 Mean Total $ 8306 9799 26326 202 7215 19105 3088 11552 35135 5016 8824 19237
Average $/month     1960 5265   1443 3821   2310 7027   1765 3847
6 Mean Total $ 7792 10660 26714 215 7862 17845 2901 12913 36594 4676 9391 18409
Average $/month     1777 4452   1310 2974   2152 6099   1565 3068
7 Mean Total $ 8132 11137 25274 213 13057 51298 2958 13326 32396 4961 9749 17438
Average $/month     1591 3611   1865 7328   1904 4628   1393 2491
8 Mean Total $ 7964 11876 27485 211 11094 29938 2982 14251 39098 4771 10426 16145
Average $/month     1485 3436   1387 3742   1781 4887   1303 2018
9 Mean Total $ 8354 12747 30990 249 15776 41906 3139 15247 45601 4966 11016 14363
Average $/month     1416 3443   1753 4656   1694 5067   1224 1596
10 Mean Total $ 10274 13081 23861 322 13644 32412 4046 14329 24634 5906 12196 22713
Average $/month     1308 2386   1364 3241   1433 2463   1220 2271
11 Mean Total $ 12809 14854 28848 450 14279 30923 4905 17383 37615 7454 13224 20849
Average $/month     1350 2623   1298 2811   1580 3420   1202 1895
12 Mean Total $ 245976 12808 16164 8459 14592 32210 88293 14366 21113 149224 11785 10269
Average $/month     1067 1347   1216 2684   1197 1759   982 856
Grand Average Total   341394     12248     20017     11002     13802     33328     123813     13841     25951     206579     11211     14024  
$/month   1405 4872   1394 5030   1570 5522   1306 4425

SOURCE: California Department of Health Care Services, Medicaid claims, 2005

  1. Services included in the compilation of expenditures include personal assistance/home care, home health, inpatient hospital and nursing home care, physicians, clinics, outpatient departments, ancillary providers, physical/occupational/speech therapy, durable medical equipment, vision and hearing services, and mental health services. Excluded are payments for pharmacy products, and expenditure by Medicare, VA, out of pocket, or other payers.

TABLE 12: Mean Medicaid Expendituresa by IHSS Recipient Age and Provider Type, 2005

Variable All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean Std Dev n Mean Std Dev n Mean Std Dev n Mean Std Dev
Total 2005   341,394         11,002         123,813         206,579      
Grand Totalb     12248     20017       13802     33328       13841     25951       11211     14024  
  Mean $/month     1405 4872   1394 5030   1570 5522   1306 4425
Spouse 10,438     na     6282     4156    
  Mean Total $   7206 20109   na     8249 20883   5628 18771
  Mean $/month     954 3789   na     1075 4113   770 3232
Parent 26,410     7,785     18,625     na    
  Mean Total $   15089 28332   12313 33843   16250 25592   na  
  Mean $/month     1491 5010   1260 5400   1588 4835   na  
Other Relative 150,124     1,449     40,304     108,371    
  Mean Total $   11757 18246   18875 31935   13282 24991   11095 14605
  Mean $/month     1321 5031   1759 3196   1482 5534   1256 4850
Non-Relative 154,422     1768     58,602     94,052    
  Mean Total $   12581 19853   16198 31579   14060 27074   11591 13003
  Mean $/month     1502 4752   1686 4519   1679 5837   1388 3927
Continuing 290,000     9,529     103,608     176,863    
Grand Totalb   13275 20282   14878 34672   14883 26079   12247 14443
  Mean $/month     1433 4904   1444 5250   1548 5361   1366 4593
Spouse 8,749     na     5,301     3,448    
  Mean Total $   7482 20921   na na   8448 21493   5996 19922
  Mean $/month     919 3879   na na   1017 4173   769 3372
Parent 23,660     6,883     16,777     na    
  Mean Total $   15894 29049   13201 35325   16998 25961   na na
  Mean $/month     1515 5183   1311 5652   1598 4975   na na
Other Relative 125,782     1,223     32,973     91,586    
  Mean Total $   12785 18178   20224 30634   14318 24154   12134 15140
  Mean $/month     1363 5308   1798 2748   1480 5709   1315 5182
Non-Relative 131,809     1,423     48,557     81,829    
  Mean Total $   13657 20134   18392 34044   15238 27665   12637 13258
  Mean $/month     1520 4490   1781 4823   1635 5357   1447 3877
New Recipients 51,394     1,473     20,205     29,716    
Grand Totalb   6456 17349   6839 21529   8503 24603   5045 9011
  Mean $/month     1243 4687   1071 3253   1684 6280   952 3231
Spouse 1,689     na     981     708    
  Mean Total $   5775 15149   na na   7174 17190   3835 11482
  Mean $/month     1134 3284   na na   1392 3757   777 2441
Parent 2,750     902     1,848     na    
  Mean Total $   8170 19877   5535 17660   9457 20757   na na
  Mean $/month     1288 3152   868 2785   1493 3298   na na
Other Relative 24,342     226     7,331     16,785    
  Mean Total $   6448 17669   11576 37456   8625 27985   5428 9407
  Mean $/month     1105 3230   1547 4968   1489 4664   932 2282
Non-Relative 22,613     345     10,045     12,223    
  Mean Total $   6307 16806   7147 15150   8368 23188   4590 8234
  Mean $/month     1395 6053   1292 2920   1890 7746   991 4228

SOURCE: California Department of Health Care Services, Medicaid claims, 2005

  1. Services included in the compilation of expenditures include personal assistance/home care, home health, inpatient hospital and nursing home care, physicians, clinics, outpatient departments, ancillary providers, physical/occupational/speech therapy, durable medical equipment, vision and hearing services, and mental health services. Excluded are payments for pharmacy products, and expenditure by Medicare, VA, out of pocket, or other payers.

TABLE 13: Adjusted Mean Monthly Medicaid Expenditures by IHSS Recipient Age, 2005a

Predictors Age 3-17g
n=11,002
Age 18-64
n=123,813
Age 65+
n=206,579
B   Pr >|t|   B   Pr >|t|   B   Pr >|t|  
  Intercept   -1.056   **   -1.219   ****   -0.346   ****
Recipient Characteristicsb
  Female Recipient 0.114   -0.325 **** -0.073 ***
  Hispanic -0.080   -0.022   -0.098 ****
  Blacka -0.015   0.094 * -0.046  
  Asian/Other -0.056   -0.058   -0.012  
  3+ Cognitive Limitationsc -0.617 **** -0.745 **** -0.155 *
  3+ ADL Limitationsd 0.023   0.243 **** 0.189 ****
  Breathing Limitationse 1.681 **** 0.840 **** 0.151 ***
  Household size (1-5+)f 0.087   0.095 *** 0.049 ****
  Number Health Conditionsg 0.360 **** 0.345 **** 0.171 ****
IHSS Providersh
  Spouse Provider na   -0.979 **** -0.773 ****
  Parent Provider -0.920 **** -0.012   na  
  Relative Provider -0.049   -0.172 **** -0.103 ****
  Total Authorized Hours 0.008 **** 0.011 **** 0.011 ****
County Characteristics
  Per Capita Income 0.018 ** 0.008 **** 0.007 ****
New IHSS Recipient -0.019   0.270 **** -0.152 ****
Model Goodness of Fit
  Adjusted R2 .087 **** .057 **** .0268 ****

* p<0.05, ** p<0.01, *** p<0.001, **** p<0.0001

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The Medicaid Expenditures used as the basis for this analysis include reimbursement for personal assistance/home care, home health, inpatient hospital and nursing home care, physicians, clinics, outpatient departments, ancillary providers, physical/occupational/speech therapy, durable medical equipment, vision and hearing services, and mental health services. Not included are pharmacy-related reimbursements, and expenditures by Medicare, the VA, out of pocket, or other payers.
  2. Reference is White. Race/ethnicity Asian/Other by descending number, Chinese, Filipino, Vietnamese, Korean, Laotian, Cambodian, Asian Indian, American Indian or Alaskan Native, Japanese, Samoan, and all others.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Number of persons in household, including other IHSS recipients, excludes non-IHSS children <age 14.
  7. Refers to HCC, summing the number of each of 23 subgroups of this classification schema.
  8. Reference is Non-Relative provider, “na” means the provider type was not included in the model.

TABLE 14: Mean Monthly Medicaid Inpatient Expenditures by IHSS Recipient Age and Provider Type, 2005

Recipients All Ages Age 3-17 Age 18-64 Age 65 or More
n   Mean     Std Dev   n   Mean     Std Dev   n   Mean     Std Dev   n   Mean     Std Dev  
All Recipients   87508         1439         28881         57188      
Grand Total   7,182 29717   22543 47847   12708 41465   4005 19850
  Mean $/months     1,101 7728   2466 7540   1928 9611   649 6536
Spouse 3403     na     1923     1480    
  Mean Total $   8065 28046   na na   10717 28631   4619 26889
  Mean $/month     1184 5008   na na   1618 5711   620 3842
Parent 3745     1118     2627     na    
  Mean Total $   16375 45401   22454 46229   13787 44803   na na
  Mean $/month     2049 10189   2408 7557   1896 11120   na na
Other Relative 38236     166     9468     28602    
  Mean Total $   6766 28507   20237 48727   12553 40746   4771 22517
  Mean $/month     1023 8588   2125 5783   1798 9812   761 8140
Non-Relative 42124     155     14863     27106    
  Mean Total $   6671 29021   25652 57590   12873 42685   3162 15985
  Mean $/month     1081 6766   3249 8946   2056 9594   533 4400
Continuing 77671     1314     24625     51732    
Total   6986 29267   22577 47924   12369 40732   4028 20232
  Mean $/months     991 7547   2368 7571   1681 9213   627 6576
Spouse 2908     na     1657     1251    
  Mean Total $   8102 29014   na na   10640 29334   4740 28247
  Mean $/month     1097 5037   na na   1480 5699   591 3941
Parent 3401     1034     2367     na    
  Mean Total $   16215 46229   22705 47164   13379 45535   na na
  Mean $/month     1959 10522   2361 7727   1784 11530   na na
Other Relative 33737     146     7945     25646    
  Mean Total $   6639 27429   18534 39280   12289 37449   4821 23077
  Mean $/month     970 8884   1833 3848   1653 10017   753 8512
Non-Relative 37625     134     12656     24835    
  Mean Total $   6377 28761   25989 60698   12456 42978   3174 16159
  Mean $/month     914 5895   3002 9237   1705 8548   499 3800
New in 2005 9837     125     4256     5456    
Total   8724 33015   22190 47229   14669 45427   3779 15776
  Mean $/months     1972 8985   3502 7149   3355 11545   859 6136
Spouse 495     na     266     229    
  Mean Total $   7848 21516   na na   11199 23824   3956 17748
  Mean $/month     1692 4809   na na   2477 5717   779 3251
Parent 344     84     260     na    
  Mean Total $   17957 36226   19367 32655   17501 37355   na na
  Mean $/month     2932 5908   2994 5010   2911 6179   na na
Other Relative 4499     20     1523     2956    
  Mean Total $   7713 35553   32665 93057   13929 54816   4341 16888
  Mean $/month     1425 5907   4255 13113   2550 8630   826 3546
Non-Relative 4499     21     2207     2271    
  Mean Total $   9127 30998   23507 32131   15264 40891   3030 13936
  Mean $/month     2477 11654   4819 6772   4068 14008   910 8547

SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of either 50 (county hospital -- acute inpatient) or 60 (community hospital -- acute inpatient) indicating hospital inpatient claims. Expenditures shown under count expenditures in the IHSS recipient population as the figures shown exclude persons in managed care for portions of 2005. “na” means that expenditures were not compiled for this provider type.


TABLE 15: Unadjusted Probability of Medicaid-Paid “Any Cause” Hospital Days, 2005

Provider Type Any Inpatient Days
No Yes Total % Yes
Recipients Age 3-17
  Parent 6,667 1,118 7,785 14.3%
  Other Relative 1,283 166 1,449 11.5%
  Non-Relative   1,613 155 1,768 8.8%
  Total 9,563 1,439 11,002 13.1%
Recipients Age 18-64
  Spouse 4,359 1,923 6,282 30.6%
  Parent 15,998 2,627 18,625 14.1%
  Other Relative 30,836 9,468 40,304 23.5%
  Non-Relative 43,739 14,863 58,602 25.4%
  Total 94,932 28,881 123,813 23.3%
Recipients Age 65+
  Spouse 2,676 1,480 4,156 35.6%
  Other Relative 79,769 28,602 108,371 26.4%
  Non-Relative 66,946 27,106 94,052 28.8%
  Total   149,391     57,188     206,579     27.7%  

SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of either 50 or 60 indicating hospital inpatient claims. Events shown under count actual use as they exclude persons in managed care for portions of the period, and stays paid fully by non-Medicaid sources.


TABLE 16: Adjusted “Any Cause” Hospital Use by IHSS Recipient Age & Provider Type, 2005a

Predictors Age 3-17
n=11,002
Age 18-64
n=123,813
Age 65 or More
n=206,579
  Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
Recipient Characteristics
  Female Recipient 0.92 0.80-1.05 0.79 0.77-0.82 0.84 0.82-0.86
  Hispanicb 0.83 0.70-0.98 1.29 1.24-1.34 1.22 1.19-1.26
  Blackb 1.32 1.07-1.64 1.37 1.32-1.42 1.32 1.27-1.37
  Asian/Otherb 0.89 0.67-1.16 0.76 0.72-0.81 1.16 1.25-1.20
  Household size (1-5+) 1.03 0.97-1.10 0.99 0.98-1.00 1.03 1.02-1.04
  3+ Cognitive Limitationsc   0.60 0.50-0.73 0.42 0.38-0.46 0.67 0.62-0.72
  3+ ADL Limitationsd 0.92 0.76-1.11 1.15 1.11-1.20 1.17 1.13-1.20
  Breathing Limitationse 1.43 1.22-1.68 1.78 1.69-1.88 1.82 1.74-1.91
  Number Health Conditionsf 1.62 1.58-1.66 1.40 1.40-1.41 1.69 1.68-1.70
IHSS Providersg
  Spouse na   1.15 1.08-1.23 1.01 0.93-1.09
  Parent 1.09 0.88-1.34 0.73 0.69-0.77 na  
  Other Relative 1.12 0.85-1.46 0.91 0.88-0.94 0.97 0.95-0.99
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.01 1.00-1.01
County Characteristics
  Per Capita Income 1.00 0.99-1.01 1.00 1.00-1.01 0.99 0.99-0.99
New IHSS Recipient 0.56   0.44-0.70   0.67   0.64-0.70   0.43   0.42-0.45  
Model Goodness of Fit
  -2Log Likelihood 6132     108700       186851    
  Maximum Rescaled R2   0.364     0.284   0.348  

SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of either 50 or 60 indicating hospital inpatient claims. Events shown under count actual use as they exclude stays paid fully by non-Medicaid sources.

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCC.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.

TABLE 17: Unadjusted Probability of Medicaid-Paid Ambulatory Care Sensitive Condition-Related Hospital Days, 2005

Provider Type Any ACSC Inpatient Days
No Yes Total % Yes
Recipients Age 3-17
  Parent 7,657 128 7,785 1.6%
  Other Relative   1,430 19 1,449 1.3%
  Non-Relative 1,744 24 1,768 1.4%
  Total 10,831 171 11,002 1.6%
Recipients Age 18-64
  Spouse 5,752 530 6,282 8.4%
  Parent 18,016 609 18,625 3.3%
  Other Relative 37,500 2,804 40,304 7.0%
  Non-Relative 54,499 4,103 58,602 7.0%
  Total   115,767   8,046   123,813   6.5%
Recipients Age 65+
  Spouse 3,705 451 4,156   10.9%  
  Other Relative 99,487 8,884 108,371 8.2%
  Non-Relative 85,880 8,172 94,052 8.7%
  Total 189,072   17,507   206,579 8.5%

SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of either 50 or 60 indicating hospital inpatient claims. Events shown under count actual use as they exclude persons in managed care for portions of the period, and stays paid fully by non-Medicaid sources. ACSC refers to a set of conditions indicative of a potentially “avoidable” hospital stay. Separate standardized algorithms are used for children and adult age groups (AHRQ, 2007a, 2007b).


TABLE 18: Adjusted Ambulatory Care Sensitive Condition Hospital Use by IHSS Recipient Age and Provider Type, 2005a

Predictors Age 3-17
n=11,002
Age 18-64
n=123,813
Age 65 or More
n=206,579
OR 95% CI OR 95% CI OR 95% CI
Recipient Characteristics
  Female Recipient 1.10 0.80-1.51 0.79 0.75-0.83 0.86 0.83-0.90
  Hispanicb 0.98 0.65-1.47 1.35 1.27-1.44 1.31 1.26-1.37
  Blackb 1.56 0.94-2.56 1.68 1.59-1.78 1.38 1.30-1.45
  Asian/Otherb 1.43 0.75-2.72 0.92 0.83-1.02 1.23 1.17-1.29
  Household size (1-5+) 0.85 0.73-0.98 1.02 1.00-1.04 1.06 1.05-1.08
  3+ Cognitive Limitationsc   0.48 0.30-0.79 0.48 0.41-0.56 0.75 0.67-0.84
  3+ ADL Limitationsd 0.68 0.44-1.04 1.10 1.03-1.16 1.20 1.15-1.25
  Breathing Limitationse 1.31 0.92-1.88 2.62 2.44-2.80 2.60 2.48-2.74
  Number Health Conditionsf 1.48 1.41-1.55 1.32 1.31-1.33 1.36 1.36-1.37
IHSS Providersg
  Spouse na na 1.02 0.92 -1.14 0.86 0.78-0.97
  Parent 0.77 0.48-1.23 0.65 0.59-0.71 na na
  Other Relative 0.78 0.42-1.47 1.01 0.95-1.06 0.96 0.93-1.00
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.00 1.00-1.00
County Characteristics
  Per Capita Income 0.99 0.96-1.02 1.00 0.99-1.00 0.99 0.99-0.99
New IHSS Recipient 0.61   0.34-1.08   0.62   0.58-0.66   0.47   0.44-0.50  
Model Goodness of Fit
  -2Log Likelihood 1413     50844       104751    
  Maximum Rescaled R2   0.212     0.178   0.161  

SOURCE: Derived from California Department of Health Care Services, Medicaid claims (vendor codes 50 or 60) indicating hospital inpatient claims. Events exclude stays paid fully by non-Medicaid sources. OR refers to odds ratio, CI refers to confidence interval.

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCC.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.

TABLE 19: Unadjusted Probability of Medicaid-Paid Medical Care Use, 2005

Provider Type Any Use
No Yes Total % Yes
Recipients Age 3-17
  Parent 1,201 6,584 7,785 84.6
  Other Relative 434 1,015 1,449 70.0
  Non-Relative 597 1,171 1,768 66.2
  Total 2,232 8,770 11,002 79.7
Recipients Age 18-64
Spouse 351 5,931 6,282 94.4
  Parent 5,013 13,612 18,625 73.1
  Other Relative 4,549 35,755 40,304 88.7
  Non-Relative 7,579 51,023 58,602 87.1
  Total 17,492 106,321 123,813 85.9
Recipients Age 65+
Spouse 458 3,698 4,156 89.0
  Other Relative 20,755 87,616 108,371 80.8
  Non-Relative 16,919 77,133 94,052 82.0
  Total   38,132     168,447     206,579     81.5  

SOURCE: Derived from the California Department of Health Care Services, Medicaid claims. “Yes” means that a vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics) or a vendor group 6 (hospital outpatient departments, organized outpatient clinics) claim was present. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.


TABLE 20: Unadjusted Probability of Medicaid-Paid Medical Care Use, Including Emergency Rooms, by IHSS Recipients, 2005

Provider Type Any Use
No Yes Total % Yes
Recipients Age 3-17
  Parent 1,045 6,740 7,785 86.6
  Other Relative 395 1,054 1,449 72.7
  Non-Relative 534 1,234 1,768 69.8
  Total 1,974 9,028 11,002 82.1
Recipients Age 18-64
  Spouse 294 5,988 6,282 95.3
  Parent 4,756 13,869 18,625 74.5
  Other Relative 4,328 35,976 40,304 89.3
  Non-Relative 7,081 51,521 58,602 87.9
  Total 16,459 107,354 123,813 86.7
Recipients Age 65+
  Spouse 364 3,792 4,156 91.2
  Other Relative 18,906 89,465 108,371 82.6
  Non-Relative 15,256 78,796 94,052 83.8
  Total 34,526 172,053 206,579 83.3

SOURCE: Derived from the California Department of Health Care Services, Medicaid claims. “Yes” means that a vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics) or a vendor group 6 (hospital outpatient departments, organized outpatient clinics) claim, or an ER claim was present. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.


TABLE 21: Adjusted Medicaid-Paid Medical Care Use, Including Emergency Rooms, by IHSS Recipients,a 2005

Predictors Age 3-17
n=11,002
Age 18-64
n=123,813
Age 65 or More
n=206,579
  Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
Recipient Characteristics
  Female Recipient 0.98   0.82-1.18   0.93   0.88-0.98   0.94   0.90-0.97  
  Hispanicb 1.12 0.90-1.40 1.13 1.05-1.22 0.96 0.92-1.01
  Black 1.00 0.77-1.29 0.93 0.87-0.99 0.76 0.72-0.80
  Asian/Other 1.20 0.88-1.64 1.22 1.10-1.35 1.00 0.96-1.05
  Household size (1-5) 1.03 0.94-1.12 0.98 0.95-1.00 1.04 1.02-1.05
  3+ Cognitive Limitationsc 0.72 0.57-0.92 0.76 0.69-0.85 0.84 0.76-0.94
  3+ ADL Limitationsd 1.05 0.82-1.35 0.95 0.89-1.02 0.99 0.95-1.03
  Breathing Limitationse 0.95 0.72-1.26 1.03 0.92-1.16 0.99 0.92-1.07
  Number Health Conditionsf   19.9 17.0-23.4 10.6 10.2-11.0 7.44 7.27-7.61
IHSS Providersg
  Spouse na na 2.19 1.86-2.59 1.69 1.46-1.96
  Parent 1.54 1.23-1.92 0.83 0.78-0.90 na na
  Other Relative 0.94 072-1.26 1.05 0.98-1.12 1.03 1.00-1.07
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.00 1.00-1.00
County Characteristics
  Per Capita Income 0.99 0.98-1.00 0.99 0.99-0.99 1.00 1.00-1.00
New IHSS Recipient 0.18 0.14-0.23 0.07 0.06-0.08 0.05 0.05-0.05
Model Goodness of Fit
  -2Log Likelihood 3302   35258   87211  
  Maximum Rescaled R2 0.776   0.723   0.642  

SOURCE: Unpublished tables derived from California Department of Health Care Services, Medicaid claims. Events shown under count actual use as they exclude stays paid for fully by non-Medicaid sources. “na” not applicable

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. Any ER user counts were as follows: age 3-17, age 18-64, age 65+.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of 5 or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCC.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.

TABLE 22: Unadjusted Probability of Medicaid-Paid Emergency Room Visits by IHSS Recipients, 2005

Provider Type Any ER Use
No Yes Total % Yes
Recipients Age 3-17
  Parent 3,073 4,712 7,785 60.5%
  Other Relative   737 712 1,449 49.1%
  Non-Relative 965 803 1,768 45.4%
  Total 4,775 6,227 11,002 56.6%
Recipients Age 18-64
  Spouse 1,968 4,314 6,282 68.7%
  Parent 10,308 8,317 18,625 44.7%
  Other Relative 16,762 23,542 40,304 58.4%
  Non-Relative 22,389 36,213 58,602 61.8%
  Total 51,427 72,386 123,813 58.5%
Recipients Age 65+
  Spouse 1,474 2,682 4,156 64.5%
  Other Relative 53,957 54,414 108,371 50.2%
  Non-Relative 43,282 50,770 94,052 54.0%
  Total   98,713     107,866     206,579     52.2%  

SOURCE: Derived from California Department of Health Care Services, Medicaid claims, 2005


TABLE 23: Adjusted Medicaid-Paid Emergency Room Visits by IHSS Recipients,a 2005

Predictors Age 3-17
n=11,002
Age 18-64
n=123,813
Age 65 or More
n=206,579
  Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
Recipient Characteristics
  Female Recipient 0.96   0.87-1.06   0.84   0.82-0.87   0.89   0.87-0.91  
  Hispanicb 0.98 0.87-1.11 1.22 1.17-1.26 1.16 1.13-1.20
  Black 1.26 1.08-1.47 1.41 1.36-1.46 1.20 1.16-1.25
  Asian/Other 0.87 0.72-1.05 0.72 0.69-0.76 0.96 0.93-0.98
  Household size (1-5) 0.98 0.94-1.03 0.99 0.98-1.00 1.04 1.03-1.05
  3+ Cognitive Limitationsc 0.74 0.64-0.86 0.56 0.52-0.60 0.66 0.62-0.72
  3+ ADL Limitationsd 1.07 0.93-1.22 1.10 1.06-1.14 1.11 1.08-1.14
  Breathing Limitationse 1.70 1.46-1.97 1.86 1.75-1.98 2.00 1.91-2.10
  Number Health Conditionsf   1.88 1.84-1.93 1.72 1.71-1.73 2.01 1.99-2.02
IHSS Providersg
  Spouse na na 1.20 1.12-1.29 1.27 1.17-1.38
  Parent 1.10 0.96-1.25 0.83 0.80-0.87 na na
  Other Relative 0.99 0.83-1.18 0.80 0.77-0.83 0.95 0.93-0.97
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.01 1.01-1.01
County Characteristics
  Per Capita Income 0.99 0.99-1.00 0.99 0.99-1.00 0.99 0.99-1.00
New IHSS Recipient 0.45 0.38-0.52 0.45 0.43-0.46 0.35 0.34-0.36
Model Goodness of Fit
  -2Log Likelihood 10220   120103   205914  
  Maximum Rescaled R2 0.477   0.432   0.429  

SOURCE: Unpublished tables derived from California Department of Health Care Services, Medicaid claims. Events shown under count actual use as they exclude stays paid for fully by non-Medicaid sources. “na” not applicable

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCC.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.

TABLE 24: Mean Combined Medicaid-Paid Physician and Outpatient Department Expenditures by IHSS Recipients,a 2005

Variable All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev  
All Recipients   8,770         106,321         168,447         8,770      
Grand Total     1741   8061     1483   3975     408   1519     1741   8061
  Mean $/months     177 780   178 573   45 203   177 780
Spouse na     5,931     3,698     na    
  Period Mean Total $   na na   1641 4095   540 1916   na na
  Mean $/month     na na   192 533   62 270   na na
Parent 6,584     13,612     na     6,584    
  Period Mean Total $   1860 9123   1089 5400   na na   1860 9123
  Mean $/month     184 864   117 550   na na   184 864
Other Relative 1,015     35,755     87,616     1,015    
  Period Mean Total $   1454 2978   1591 3898   398 1466   1454 2978
  Mean $/month     145 342   183 555   44 207   145 342
Non-Relative 1,171     51,023     77,133     1,171    
  Period Mean Total $   1316 3272   1493 3534   414 1555   1316 3272
  Mean $/month     166 503   189 594   46 195   166 503
Continuing Recipients 7,765     90,277     150,437     7,765    
Grand Total   1799 8480   1477 3963   409 1537   1799 8480
  Mean $/months     172 798   158 524   42 187   172 798
Spouse na     5,028     3,114     na    
  Period Mean Total $   na na   1581 3931   531 1962   na na
  Mean $/month     na na   166 483   52 183   na na
Parent 5,905     12,474     na     5,905    
  Period Mean Total $   1920 9569   1062 5521   na na   1920 9569
  Mean $/month     181 895   106 527   na na   181 895
Other Relative 885     29,769     77,540     885    
  Period Mean Total $   1459 2733   1589 3805   394 1459   1459 2733
  Mean $/month     138 273   165 513   40 183   138 273
Non-Relative 975     43,006     69,783     975    
  Period Mean Total $   1380 3326   1508 3500   420 1599   1380 3326
  Mean $/month     147 387   167 533   43 192   147 387
New Recipients 1,005     16,044     18,010     1,005    
Grand Total   1287 3334   1515 4037   405 1353   1287 3334
  Mean $/months     218 619   292 786   75 303   218 619
Spouse na     903     584     na    
  Period Mean Total $   na na   1976 4898   586 1649   na na
  Mean $/month     na na   342 735   116 530   na na
Parent 679     1,138     na     679    
  Period Mean Total $   1345 3220   1385 3812   na na   1345 3220
  Mean $/month     211 523   244 747   na na   211 523
Other Relative 130     5,986     10,076     130    
  Period Mean Total $   1422 4302   1602 4333   426 1524   1422 4302
  Mean $/month     196 636   276 722   75 335   196 636
Non-Relative 196     8,017     7,350     196    
  Period Mean Total $   998 2974   1416 3714   361 1042   998 2974
  Mean $/month     260 869   304 840   72 220   260 869

SOURCE: Derived from the California Department of Health Care Services, Medicaid claims. Vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics), and 6 (hospital outpatient departments, organized outpatient clinics) are combined.

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The number of care recipients does not equal the number of eligible recipients due to the absence of vendor group 5 and 6 claims. “na” not applicable.

TABLE 25: Adjusted Mean Medicaid-Paid Medical Care Expenditures by IHSS Recipients, 2005a

Predictors Age 3-17g
n=8,770
Age 18-64
n=106,318
Age 65+
n=168,442
B   Pr >|t|   B   Pr >|t|   B   Pr >|t|  
  Intercept   -0.115   *   -0.193   ****   -0.026   ****
Recipient Characteristics
  Female Recipient -0.007   -0.027 **** -0.011 ****
  Hispanicb -0.039   0.006   -0.002  
  Blackb -0.009   0.020 **** 0.008 ****
  Asian/Otherb -0.028   0.004   -0.002  
  3+ Cognitive Limitationsc -0.022   -0.014   -0.000  
  3+ ADL Limitationsd -0.045 * 0.013 *** 0.004 **
  Breathing Limitationse 0.225   0.013 * -0.007 **
  Household size (1-5+)f 0.001   0.009 **** 0.002 ****
  Number Health Conditionsg   0.075 **** 0.062 **** 0.019 ****
IHSS Providersh
  Spouse Provider     -0.014   0.003  
  Parent Provider -0.015   0.002      
  Relative Provider -0.040   -0.014 *** 0.001  
  Total Authorized Hours 0.000   0.000   0.000  
County Characteristics
  Per Capita Income 0.001   0.001 **** 0.000 *
New IHSS Recipient 0.034   0.070 **** 0.017 ****
Model Goodness of Fit
  Adjusted R2 .067 **** .112 **** .048 ****

* p<0.05, ** p<0.01, *** p<0.001, **** p<0.0001 
SOURCE: Derived from the California Department of Health Care Services, Medicaid claims. Vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics), and 6 (hospital outpatient departments, organized outpatient clinics) are combined. Expenditures are divided by 1,000.

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The number of care recipients may not equal the number of eligible recipients due to missing expenditure values or negative claims amounts.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Number of persons in household, including other IHSS recipients, excludes non-IHSS children <age 14.
  7. Refers to HCC, collapsed into 23 subgroups, count is unduplicated number of these groupings.
  8. Reference is Non-Relative provider, “na” means the provider type was not included in the model.

TABLE 26: Mean Monthly Medicaid-Paid Home and Community-Based Care Expenditures by IHSS Recipients, 2005a

Variable All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev  
Community-Based Care
Grand Total 49   5786   8807 5192   12108   28274 34954   6605   5407 49   5786   8807
  Average $/month   556 900   1149 2677   620 565   556 900
Spouse                        
  Period Mean Total $   na na na 200 12065 22573 601 6766 11390 na na na
  Average $/month   na na   1133 2025   639 983   na na
Parent                        
  Period Mean Total $ 29 3940 4238 719 26201 43946 na na na 29 3940 4238
  Average $/month   373 408   2292 3710   na na   373 408
Other Relative                        
  Period Mean Total $ 10 9450 11803 1708 8366 17624 15899 6766 4607 10 9450 11803
  Average $/month   981 1486   793 1619   634 515   981 1486
Non-Relative                        
  Period Mean Total $ 10 7478 13761 2565 10653 27644 18454 6452 5730 10 7478 13761
  Average $/month   661 1130   1068 2851   608 586   661 1130
IHSS
Grand Total   3964   8509 7202   114743   8127 6774   198656   7639 5329   3964   8509 7202
  Average $/month   776 624   747 570   715 456   776 624
Spouse                        
  Period Mean Total $ na na na 1128 4410 5766 756 3734 4509 na na na
  Average $/month   na na   402 509   356 422   na na
Parent                        
  Period Mean Total $ 1109 5780 5500 18352 11132 8400 na na na 1109 5780 5500
  Average $/month   519 520   980 701   na na   519 520
Other Relative                        
  Period Mean Total $ 1415 9628 7428 39710 7105 5509 107004 7470 5087 1415 9628 7428
  Average $/month   869 621   663 462   702 436   869 621
Non-Relative                        
  Period Mean Total $ 1440 9510 7575 55553 7939 6713 90896 7871 5587 1440 9510 7575
  Average $/month   881 643   738 570   733 476   881 643
Any Unskilled Home Care
Grand Total 3983 8539 7327 115070 8650 9759 199622 8759 6580 3983 8539 7327
  Average $/month   779 639   797 865   820 575   779 639
Spouse                        
  Period Mean Total $ na na na 1279 5776 11452 1208 5703 9330 na na na
  Average $/month   na na   532 1024   541 818   na na
Parent                        
  Period Mean Total $ 1127 5789 5553 18381 12140 13726 na na na 1127 5789 5553
  Average $/month   521 522   1068 1157   na na   521 522
Other Relative                        
  Period Mean Total $ 1415 9695 7579 39731 7461 7056 107109 8468 6086 1415 9695 7579
  Average $/month   876 647   697 610   795 534   876 647
Non-Relative                        
  Period Mean Total $ 1441 9556 7742 55679 8412 9529 91305 9140 7050 1441 9556 7742
  Average $/month   885 656   786 885   852 614   885 656

SOURCE: Derived from California Department of Health Care Services, Medicaid claims, 2005, vendor codes 71 (HCBS), 73 (AIDS waiver), 81 (MSSP), and 89 (IHSS).

  1. Number of home care recipients does not equal the number of eligible recipients, as those in hospitals, nursing homes, or community facilities, or who may have no paid providers in a month do not receive IHSS payments.

TABLE 27: Adjusted Mean Monthly Medicaid-Paid Home and Community-Based Care Expenditures by IHSS Recipients, 2005a

Predictors Age 3-17g
n=3,983
Age 18-64
n=115,070
Age 65+
n=199,622
  B Pr >|t| B Pr >|t| B Pr >|t|
  Intercept -0.075   -0.246 **** -0.104 ****
Recipient Characteristicsb
  Female Recipient 0.019   -0.030 **** 0.001  
  Hispanic 0.021   -0.000   -0.087 ****
  Blacka 0.016   -0.009   -0.072 ****
  Asian/Other 0.032   0.003 ** -0.032 ****
  3+ Cognitive Limitationsc -0.209 **** -0.472 **** -0.288 ****
  3+ ADL Limitationsd 0.089 **** 0.058 **** 0.062 ****
  Breathing Limitationse 0.061 ** 0.272 **** -0.028 ****
  Household size (1-5+)f -0.012   0.003 * -0.007 ****
  Number Health Conditionsg 0.005 * -0.001 * 0.001 ***
IHSS Providersh
  Spouse Provider na   -0.430 **** -0.341 ****
  Parent Provider -0.520 **** -0.030 **** na  
  Relative Provider 0.027   0.003   -0.007 ****
  Total Authorized Hours 0.006 **** 0.009 **** 0.009 ****
County Characteristics
  Per Capita Income 0.009 **** 0.009 **** 0.009 ****
New IHSS Recipient -0.022   -0.022 **** 0.048 ****
Model Goodness of Fit
  Adjusted R2 .570 **** .412 **** .547 ****

* p<0.05, ** p<0.01, *** p<0.001, **** p<0.0001 
SOURCE: Medicaid claims-records maintained by the California Department of Health Care Services. Expenditures were compiled using vendor codes 71 (HCBS waiver), 73 (AIDS waiver services), 81 (MSSP waiver services), and 89 (IHSS). The number of home care recipients may not equal the number of eligible recipients, as those in hospitals, nursing homes, or community facilities do not receive IHSS payments.

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. Number of home care recipients does not equal the number of eligible recipients, as those in hospitals, nursing homes, or community facilities, or who may have no paid providers in a month do not receive IHSS payments.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 Paramedical Services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Number of persons in household, including other IHSS recipients, excludes non-IHSS children <age 14.
  7. Refers to HCC, collapsed into 23 subgroups, count is unduplicated number of these groupings.
  8. Reference is Non-Relative provider, “na” means the provider type was not included in the model.

TABLE 28: Mean Monthly Medicaid-Paid Home Health Care Expenditures by IHSS Recipients, 2005a

  Age 3-17 Age 18-64 Age 65 or More
n Mean Std Dev n Mean Std Dev n Mean Std Dev
Home Health Care
Grand Total   882     52075     49281     4492     2613     11376     526     1200     3398  
  Average $/month   4970 6161   283 1017   151 387
Spouse na na na            
  Period Mean Total $   na na na 280 1244 1590 30 1222 1349
  Average $/month na na na   160 273   176 185
Parent             na na na
  Period Mean Total $ 642 52571 49723 552 9359 25834 na na na
  Average $/month   5069 6682   890 2275 na na na
Other Relative                  
  Period Mean Total $ 109 55393 49214 1392 1527 7112 302 1159 3661
  Average $/month   4925 4283   163 616   141 362
Non-Relative                  
  Period Mean Total $ 131 46887 47101 2268 1807 7081 194 1259 3199
  Average $/month   4523 4644   224 668   163 443

SOURCE: Unpublished tables derived from California Department of Health Care Services, Medicaid claims using vendor code 44 (home health agency), 2005. “na” not applicable.

  1. Number of home health care recipients may not equal the number of eligible recipients, as those in hospitals, nursing homes, or community facilities do not receive IHSS payments.

TABLE 29: Unadjusted Probability of Medicaid-Paid Nursing Home Stays by IHSS Recipients, 2005

Provider Type Any Nursing Home Stays
No Yes Total % Yes
Recipients Age 3-17
  Parent 10,458 31 10,489 0.30%
  Other Relative   2,077 3 2,080 0.14%
  Non-Relative 2,473 5 2,478 0.20%
  Total 15,008 39 15,047 0.26%
Recipients Age 18-64
  Spouse 7,097 179 7,276 2.46%
  Parent 23,043 271 23,314 1.16%
  Other Relative 48,041 991 49,032 2.02%
  Non-Relative 67,757 1,911 69,668 2.74%
  Total 145,938 3,352 149,290 2.25%
Recipients Age 65+
  Spouse 4,253 318 4,571 6.96%
  Other Relative 116,693 5,771 122,464 4.71%
  Non-Relative 95,745 7,375 103,120 7.15%
  Total   216,691     13,464     230,155     5.85%  

SOURCE: Derived from Medicaid claims maintained by the California Department of Health Care Services. Nursing home use identified by vendor codes 47 ICF-DD), and 80 (nursing facility).


TABLE 30: Adjusted Medicaid-Paid Nursing Home Use by Adult IHSS Recipients, 2005a

Predictors Age 18-64
n=149,290
Age 65 or More
n=230,155
  Odds Ratio   95% CI   Odds Ratio   95% CI
Recipient Characteristics
  Female Recipient 0.89   0.83-0.95   0.98   0.94-1.02  
  Hispanicb 0.95 0.86-1.04 0.96 0.92-1.01
  Blackb 0.94 0.86-1.02 1.17 1.11-1.23
  Asian/Otherb 0.78 0.67-0.89 0.80 0.76-0.84
  Householdsize (1-5) 0.96 0.93-0.98 0.95 0.93-0.96
  3+ Cognitive Limitationsc   0.34 0.28-0.42 0.95 0.86-1.05
  3+ ADL Limitationsd 1.52 1.40-1.66 1.35 1.29-1.41
  Breathing Limitationse 1.16 1.03-1.30 1.16 1.08-1.23
IHSS Providersf
  Spouse 0.82 0.70-0.97 0.98 0.86-1.10
  Parent 0.44 0.38-0.50 na  
  Other Relative 0.83 0.77-0.90 0.70 0.68-0.73
  Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00
County Characteristics
  Per Capita Income 1.02 1.01-1.02 1.00 1.00-1.00
New IHSS Recipients 1.09 0.99-1.20 0.87 0.82-0.92
Managed Care=yes 0.29 0.25-0.34 0.34 0.31-0.37
Model Goodness of Fit
  -2Log Likelihood 30885   98977  
  Maximum Rescaled R2 0.041   0.043  

SOURCE: Derived from Medicaid claims maintained by the California Department of Health Care Services. Nursing home use was identified using vendor codes 47 ICF-DD), and 80 (nursing facility). The number of nursing home users age 3-17 (n=34) not included as the group was too small for reliable logistic models. Nursing home users age 18-64 or age 65+ may not equal the number of actual users, if the use was paid solely from non-Medicaid sources.

  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with an score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Reference is Non-Relative provider, “na” means the provider type was not included in the model.

TABLE 31: Mean Monthly Medicaid-Paid Nursing Home Expenditures by IHSS Recipients, 2005

Recipients All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev  
All Recipients   16855         39         3352         13464      
Grand Total     12287   15963     46041   66074     12313   17314     12183   15124
  Mean $/months   3661 8777   19649 50432   3268 7496   3713 8631
Spouse 497     na     179     318    
  Period Mean Total $     10372 15958   na na   10877 16319   10088 15770
  Mean $/month   2924 7724   na na   3049 9282   2853 6705
Parent 302     31     271     na    
  Period Mean Total $   19504 33318   45108 69752   16575 24759   na na
  Mean $/month   5628 19777   20782 54946   3895 8438   na na
Other Relative 6765     3     991     5771    
  Period Mean Total $   11945 15184   26480 12769   11890 15827   11947 15070
  Mean $/month   3255 7870   4195 2505   2778 6151   3337 8129
Non-Relative 9291     5     1911     7375    
  Period Mean Total $   12405 15585   63558 65007   12063 16784   12458 15130
  Mean $/month   3932 8857   21897 36348   3453 7788   4044 9062
Continuing 14861     36     2811     12014    
Grand Total   12786 16438   49071 67906   12962 18068   12637 15507
  Mean $/months   3755 9005   21178 52250   3288 7694   3812 8805
Spouse 425     na     156     269    
  Period Mean Total $   10884 16790   na na   11239 17027   10679 16680
  Mean $/month   3057 8201   na na   3219 9888   2964 7059
Parent 267     29     238     na    
  Period Mean Total $   20865 34634   47927 71304   17568 25399   na na
  Mean $/month   5962 20889   22182 56597   3986 8671   na na
Other Relative 6004     3     837     5164    
  Period Mean Total $   12374 15538   26480 12769   12478 16365   12349 15400
  Mean $/month   3367 7995   4195 2505   2852 6345   3450 8231
Non-Relative 8165     4     1580     6581    
  Period Mean Total $   12924 16065   74305 69747   12695 17612   12942 15533
  Mean $/month   4005 9084   26636 40147   3421 7935   4131 9280
New in 2005 1994     3     541     1450    
Grand Total   8568 11163   9684 10268   8943 12166   8426 10771
  Mean $/months   2962 6807   1302 1484   3162 6374   2891 6968
Spouse 72     na     23     49    
  Period Mean Total $   7349 9203   na na   8420 10237   6846 8743
  Mean $/month   2133 3803   na na   1895 2593   2245 4274
Parent 35     2     33     na    
  Period Mean Total $   9117 17813   4240 5750   9412 18291   na na
  Mean $/month   3079 6429   483 622   3236 6592   na na
Other Relative 761     0     154     607    
  Period Mean Total $   8560 11491         8696 12052   8526 11354
  Mean $/month   2377 6745         2377 4964   2377 7130
Non-Relative 1126     1     331     794    
  Period Mean Total $   8635 10794   20572 --   9048 11634   8447 10425
  Mean $/month   3406 6979   2939 --   3607 7057   3323 6953

SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of 47 (ICF-DD) or 80 (nursing facility) indicating nursing home inpatient claims.

Appendixes

Appendix A. Sample Selection Procedures

The study sample was selected from In-Home Supportive Services (IHSS) recipient listings in 2005. It included anyone in the program as of January 1 of that year, or who entered the IHSS program sometime during 2005. This full sample of recipients is used in analyses describing program recipient characteristics and in analysis of the factors associated with provider selection. Analysis that consider health care use, Medicaid expenditures, or that include health conditions were limited to a subset of IHSS recipients: persons receiving Medicaid through fee for service reimbursement. The exclusion of Medicaid managed care program recipients was necessary because Medicaid claims are not submitted for managed care covered services. The following outlines the steps used to select, screen, and qualify IHSS recipients into the study sample. In combination these assure that we obtained all waiver recipients in each of the target age categories as well as recipients in Advance Pay, and Restaurant Meals vouchers:

  1. All recipients identified as being an active IHSS recipient during any month in calendar year 2005 were tentatively selected into the study (n=408,276).1 Data for both 2004 and 2005 was compiled for these individuals.

  2. The tentatively eligible IHSS recipients included 4,350 pairs of recipients with the same Social Security number, but different IHSS identification numbers. This can occur as recipients are given a new IHSS number if they move from one county to another, even while being an IHSS recipient. There is also the possibility of typographical errors in the identification numbers recorded in the data files. To determine if cases with the same Social Security number were the same individuals, we compared the records on date of birth and whether they had no more than one overlapping month of claims data. Cases meeting these criteria were retained, consolidating the pair under a single common IHSS number. Of the pairs with consistent birthdates, 3,486 had no overlapping claims months, 346 had one overlapping claim month, 301 had more than one overlapping claims month. The remaining 217 pairs had different birth dates. These latter 518 cases were dropped from the study sample.

  3. An additional 42 IHSS recipients had duplicate Department of Developmental Services (DDS) identification numbers that could not be resolved. These cases were also dropped from the IHSS sample.

  4. Within the age group 3-17 any recipient with a Spouse provider (one person in 2005) was excluded because there were too few cases for subgroup analysis. Among those 65 or older, those with “Parent” providers (n=2) were similarly excluded.

  5. The final eligible IHSS sample was sorted into three subgroups: those age 3-17, those age 18-64, those age 65 or more. Individuals changing age group during the calendar year were retained in the original age group.

  6. Advance Pay and Restaurant Meals voucher program recipients were identified using the IHSS Services Assessment. This indicates recipients requesting who are eligible for the program. Such recipients were selected, and the number of participation months was compiled.

  7. IHSS recipients are eligible for Medicaid, but the number of Medicaid claims-records can be under reported for individuals enrolled in a managed care plan. Being in managed care affects the availability and reliability of Medicaid claims data. Managed care organizations are reimbursed on a capitated basis for members, rather than on the basis of utilization. As a consequence services such as hospital, physician, and outpatient services (services included under the capitation payment) may not generate a Medicaid claim. Services (e.g., community-based care, IHSS, and extended nursing home stays) not included under the capitation are not affected. In 2005, 56,1522 (13.9%) study recipients were managed care members for all or part of the year, another. All such cases were list-wise excluded from analyses using Medicaid claims for diagnoses and health care use/expenditures.

  8. IHSS recipients participating in DDS programs were identified by linking the IHSS study sample records with DDS assessment files. This match was limited to persons having Medicaid eligibility.

  9. Classification of waiver and non-waiver recipients was based on the provider relationship information available in the IHSS provider eligibility files. Among those age less that 18, waiver/Residual Program participants are those with a Parent provider. For those 18-64 and 65 or more waiver/Residual Program participants are those with a paid Spouse provider. (Parents of those age 65 or more would also be eligible, but these cases were excluded from the analysis.)2

Appendix B. Recipient and Other Predictor Variables, Detailed Tables

TABLE B-1: Race/Ethnicity of IHSS Recipients, 2005
  Age of IHSS Recipients
3-17 18-64 65+ Total
n % n % n % n %
All Recipients 2005   16,257     100.0     152,591     100.0     233,856     100.0     402,704     100.0  
White 4,580 28.2 65,400 42.9 90,562 38.7 160,542 39.9
Hispanic 7,220 44.4 32,887 21.6 55,327 23.7 95,434 23.7
Black 2,875 17.7 39,260 25.7 25,156 10.8 67,291 16.7
Otder Asian or Pacific Islander   182 1.1 1,691 1.1 3,180 1.4 5,053 1.3
Am Indian or Alaskan Native 91 0.6 1,337 0.9 870 0.4 2,298 0.6
Filipino 245 1.5 1,803 1.2 12,734 5.4 14,782 3.7
Chinese 241 1.5 1,995 1.3 23,331 10.0 25,567 6.3
Cambodian 142 0.9 1,456 1.0 2,459 1.1 4,057 1.0
Japanese 12 0.1 141 0.1 329 0.1 482 0.1
Korean 62 0.4 590 0.4 4,334 1.9 4,986 1.2
Samoan 25 0.2 291 0.2 319 0.1 635 0.2
Asian Indian 84 0.5 471 0.3 1,766 0.8 2,321 0.6
Hawaiian 13 0.1 44 0.0 42 0.0 99 0.0
Guamanian 5 0.0 53 0.0 44 0.0 102 0.0
Laotian 132 0.8 2,120 1.4 3,146 1.3 5,398 1.3
Vietnamese 348 2.1 3,052 2.0 10,257 4.4 13,657 3.4
Recipients Continuing from 2004   13505   126118   198523   338146  
White 3783 28.0 54032 42.8 78927 39.8 136742 40.4
Hispanic 6087 45.1 27241 21.6 45888 23.1 79216 23.4
Black 2366 17.5 32342 25.6 21961 11.1 56669 16.8
Otder Asian or Pacific Islander 143 1.1 1372 1.1 2578 1.3 4093 1.2
Am Indian or Alaskan Native 74 0.5 1075 0.8 721 0.4 1870 0.6
Filipino 196 1.4 1450 1.1 10002 5.0 11648 3.4
Chinese 180 1.3 1652 0.3 19380 9.8 21212 6.3
Cambodian 130 1.0 1219 1.0 2190 1.1 3539 1.0
Japanese 11 0.1 118 0.1 250 0.1 379 0.1
Korean 47 0.03 470 0.4 3474 1.7 3991 1.2
Samoan 20 0.01 218 0.2 258 0.1 496 0.1
Asian Indian 65 0.05 368 0.3 1431 0.7 1864 0.6
Hawaiian 10 0.1 38 0.03 31 0.02 79 0.02
Guamanian 4 0.03 41 0.03 38 0.02 83 0.02
Laotian 112 0.8 1831 0.5 2820 1.4 4763 1.4
Vietnamese 277 2.1 2651 2.1 8574 4.3 11502 3.4
Recipients Entering in 2005 2752   26473   35333   64558  
White 797 29.0 11368 42.9 11635 32.9 23800 36.9
Hispanic 1133 41.2 5646 21.3 9439 26.7 16218 25.1
Black 509 18.5 6918 26.1 3195 9.0 10622 16.5
Otder Asian or Pacific Islander 39 1.4 319 1.2 602 1.7 960 1.5
Am Indian or Alaskan Native 17 0.6 262 1.0 149 0.4 428 1.7
Filipino 49 1.8 353 1.3 2732 7.7 3134 4.9
Chinese 61 2.2 343 1.3 3951 11.2 4355 6.7
Cambodian 12 0.4 237 0.9 269 0.8 518 0.8
Japanese 1 0.04 23 0.09 79 0.2 103 0.2
Korean 15 0.5 120 0.5 860 2.4 995 1.5
Samoan 5 0.2 73 0.3 61 0.2 139 0.2
Asian Indian 19 0.7 103 0.4 335 0.9 457 0.7
Hawaiian 3 0.1 6 0.02 11 0.03 20 0.03
Guamanian 1 0.04 12 0.04 6 0.02 19 0.03
Laotian 20 0.7 289 1.1 326 0.9 635 1.0
Vietnamese 71 2.6 401 1.5 1683 4.8 2155 3.3
TABLE B-2: Functional Limitations of IHSS Recipients, 2005
  Age of IHSS Recipients
3-17 18-64 65+ Total
n % n % n % n %
  1. Number of tasks cannot perform memory, orientation, or judgment tasks without human assistance.
  2. Number of tasks cannot perform assistance in activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual care; eating) without human assistance.
  3. Number of tasks cannot perform instrumental activities of daily living (i.e., housework, laundry, shopping and errands, meal preparation and clean-up, mobility inside) without human assistance.
  4. Cannot breathe without human assistance.
Functional Areas     16,257     100.0     152,591     100.0     233,856     100.0     402,704     100.0  
Cognitive Limitationsa
  0 12,346 75.9 141,114 92.5 227,051 97.1 380,511 94.5
  1 914 5.6 2,580 1.7 1,682 0.7 5,176 1.3
  2 501 3.1 1,685 1.1 1,022 0.4 3,208 0.8
  3 2,496 15.4 7,212 4.7 4,101 1.8 13,809 3.4
ADL Limitationsb
  0 545 3.4 23,539 15.4 26,619 11.4 50,703 12.6
  1 805 5.0 21,862 14.3 35,331 15.1 57,998 14.4
  2 1,732 10.7 29,866 19.6 44,513 19.0 76,111 18.9
  3 3,962 24.4 27,676 18.1 41,947 17.9 73,585 18.3
  4 4,567 28.1 31,760 20.8 57,932 24.8 94,259 23.4
  5 4,646 28.6 17,888 11.7 27,514 11.8 50,048 12.4
IADL Limitationsc
  0 2,571 15.8 215 0.1 83 0.0 2,869 0.7
  1 1,826 11.2 581 0.4 508 0.2 2,915 0.7
  2 678 4.2 1,338 0.9 1,209 0.5 3,225 0.8
  3 730 4.5 5,072 3.3 5,676 2.4 11,478 2.9
  4 6,716 41.3 89,577 58.7 115,673 49.5 211,966 52.6
  5 3,736 23.0 55,808 36.6 110,707 47.3 170,251 42.3
Breathingd 2,352 14.5 10,623 7.0 14,219 6.1 27,194 6.8
TABLE B-3: Vendor Claims Counts Fee for Service and Managed Care Recipients, 2005
Vendor Group Descriptions Total
  # Recipients   % # MC %
  1. Includes AIDS waiver, MSSP, and Home Care waivers.
  2. Includes nurse midwife (n=32 FFS and 2 MC clients), and genetic testing (n=153 FFS and 47 MC clients).
  3. Includes nurse practitioners, physicians, physician groups, rural clinics, surgi-centers.
  4. Includes county and community hospital outpatient departments, and other organized outpatient clinics.
  5. Includes psychologist/social worker outpatient services, and inpatient mental health.
  6. Includes acupuncturist, chiropractor, podiatrist, prosthetist, breast cancer detection center, EPSDT supplemental services, hemodialysis/renal centers, respirator care practitioner, hospice services, nurse anesthetist.
  7. Also includes hospital and freestanding rehabilitation facilities.
  8. Includes optical labs, optometric groups, optometrists, optician, audiologist, hearing aid dispenser.
  9. Includes clinical labs, portable x-ray lab, blood bank, local health education.
Community-Based Care
Adult Day Health Care 31,418 7.9% 2,018 3.8%
IHSS (State Plan Personal Care) 366,625   92.5%     48,982     91.3%  
Medicaid Home Care Waiversa 13,638 3.4% 2,100 3.9%
Home Health Agency 7,088 1.8% 398 0.7%
Inpatient Services
Hospital (County & Community hospitals)   100,127 25.3% 4,496 8.4%
Nursing Homes (and ICF-DDs) 18,585 4.7% 776 1.4%
Medical Care/Physician Services
Birthing Servicesb 183 0.0% 49 0.1%
Physician Offices/Clinicsc 300,203 75.8% 17,182 32.0%
Outpatient Departments/Clinicsd 193,697 48.9% 6,946 12.9%
Mental Health Servicese 951 0.2% 62 0.1%
Other Providers
Ancillary Providersf 65,436 16.5% 1,847 3.4%
Physical/Occupational/Speech Therapyg   10,627 2.7% 1,463 2.7%
Vision/Hearing Servicesh 114,187 28.8% 10,201 19.0%
Other Servicesi 79,108 20.0% 5,081 9.5%
Durable Medical Equipment 112,749 28.5% 4,151 7.7%
Medical Transportation 56,244 14.2% 1,685 3.1%
Total 394,987   53,571  
TABLE B-4: County Per Capita Income, 2003
County Per Capita
  Income/1000  
Population
  IHSS Recipients  
by County
County Per Capita
  Income/1000  
Population
  IHSS Recipients  
by County
SOURCE: Table D-9, US Department of Commerce, Bureau of Economic Analysis, http://www.bea.doc.gov
ALAMEDA 38.618 14,508 ORANGE 36.647 13,702
ALPINE 24.946 15 PLACER 35.847 1,498
AMADOR 23.570 214 PLUMAS 26.597 371
BUTTE 22.818 3,389 RIVERSIDE 25.691 14,629
CALAVERAS 23.537 313 SACRAMENTO 29.548 18,342
COLUSA 21.668 226 SAN BENITO 23.484 352
CONTRA COSTA   41.992 7,208 SAN BERNARDINO   22.141 18,801
DEL NORTE 17.676 367 SAN DIEGO 33.883 22,977
EL DORADO 33.477 679 SAN FRANCISCO 55.819 18,468
FRESNO 21.938 12,640 SAN JOAQUIN 23.155 6,784
GLENN 18.031 453 SAN LUIS OBISPO 27.917 1,695
HUMBOLDT 23.909 2,116 SAN MATEO 57.906 2,667
IMPERIAL 18.171 5,117 SANTA BARBARA 33.739 2.824
INYO 26.084 137 SANTA CLARA 51.579 12,395
KERN 21.021 5,647 SANTA CRUZ 36.865 2,005
KINGS 16.717 1,619 SHASTA 25.175 2,932
LAKE 23.538 1,974 SIERRA 24.681 34
LASSEN 18.122 287 SISKIYOU 22.640 553
LOS ANGELES 30.611 167,927 SOLANO 26.830 2,886
MADERA 18.392 1,615 SONOMA 34.671 4,319
MARIN 63.083 1,484 STANISLAUS 22.677 5,701
MARIPOSA 22.903 270 SUTTER 24.075 712
MENDOCINO 25.947 1,549 TEHAMA 19.868 1,263
MERCED 18.461 3,112 TRINITY 21.223 192
MODOC 21.275 163 TULARE 20.166 2,787
MONO 24.241 44 TUOLUMNE 23.515 341
MONTEREY 29.901 3,199 VENTURA 32.232 3,408
NAPA 37.086 690 YOLO 27.332 1,506
NEVADA 31.241 799 YUBA 19.236 829

Appendix C. Testing Factors Associated with Provider Selection

The analyses presented in this Appendix extend the descriptive findings using logistic regression to adjust for recipient differences within a provider group. Separate analyses are conducted by recipient age group to address the following questions:

  • Do the functional limitations, task assistance needs, and chronic health conditions of individuals differ between waiver and non-waiver recipients?

  • Do waiver and non-waiver recipients differ in terms of living arrangement household size, race/ethnicity, and availability of legally responsible relatives?

  • Adjusting for recipient characteristics and living arrangements, are there differences between new and continuing IHSS recipients in provider selection?

The “outcome” of these models is provider type. The recipient data are from the first available IHSS assessment instrument available prior to the start of the observation period. Most of the models, Table C-1, Table C-2 and Table C-3, include all IHSS recipients in the modeled age group, but there are three exceptions. The models predicting Parent providers among those age 3-17 are limited to minor children with a parent in the household. Similarly, the models predicting Spouse providers among adults are limited to persons with a spouse in the household. The Authorized IHSS Service Hours, while it may reflect unmeasured functional status is not included in these models as this measure is determined in part by living arrangement and provider type.

The coefficient of primary interest in these models is the dummy variable representing recipients entering IHSS in 2005 versus those who were continuing from 2004. Among minor children, those with Parent providers are less likely to be newly entering IHSS recipients in 2005, and those with Non-Relative providers are more likely to be new recipients. Non-aged adults reflect a somewhat similar pattern with those having Parent or Spouse providers being less likely to be new recipients. Correspondingly, new recipients had higher odds of having either Other Relatives and Non-Relative providers. This pattern changes somewhat among those 65+. New IHSS recipients have higher odds than continuing recipients of having a Spouse provider, and slightly lower odds of having a Non-Relative provider. There is no difference between recipient participation status in the odds of having Other Relative providers. These findings suggest that between 2004 and 2005 (the starting year for the IHSS Plus Waiver program) there was no consistent pattern in the enrollment of new recipients shifting them toward waiver covered providers (i.e., parents for minor children recipients, spouses for adult recipients). Among children the opposite occurred, with new recipients being less likely than continuing recipients to be among those with Parent providers. Among non-aged adults there was no difference in the odds of new recipients using Spouse providers. Only among those age 65+ did new recipients have greater odds than continuing recipients of having a Spouse provider.

Turning now to the other policy questions, the coefficients in the models provide indicators of the statistically significant differences within provider type relative to race/ethnicity, functional ability, and living arrangement.

The findings from the tables are briefly summarized here:

  • Females show no difference from males in predicting providers among children. However among adults, they are less likely to have Parent or Spouse providers. They are also more likely to have Other Relative providers and less likely to have Non-Relatives.

  • Hispanic recipients across all age strata are substantially more likely than Whites to have Parent or Spouse providers, and less likely to have Non-Relative providers; and among adults to be more likely to have Other Relative providers.

  • Black recipients across children and non-aged adults are less likely than Whites to have Parent providers, more likely to have Other Relative providers, and less likely to have Non-Relative providers. Among the aged they are more likely to have a Spouse provider and somewhat less likely to have Other Relative providers.

  • Asian and the other minority children recipients are more likely than Whites to use Parent and Other Relative providers, and less likely to use Non-Relatives. Among adults they are more likely than Whites to use Spouse and Other Relative providers and less likely to use Parents and Non-Relatives.

  • The odds of having a paid Parent provider increase substantially among minor children who require task assistance from another individual in three or more ADLs, or in three cognitive tasks, or with breathing problems. These same factors reduce the odds of having other providers (with no difference between Relative and Non-Relative providers). Among adult recipients these higher levels of limitations are generally associated with increased odds of Parent and Spouse providers (when they are available). Correspondingly these frailty measures are generally associated with reduced odds of having either Other Relative or Non-Relative providers.

  • Managed care membership is in the models to assess the extent to which 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 Relative 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. Managed care differences may contribute to an under count of chronic health conditions and health service use among those provider types having higher likelihood of enrollment in such plans.

  • Household size, adjusting for race, has no association with the odds of Parent providers for children, but larger households are more likely to have Other Relative and less likely to have Non-Relative providers. Among those 18-64 size is positively related to having a 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.

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

  • Among minor children the comparison of recipients in counties with IHSS wage levels relative to the average rate in the state (i.e., Los Angeles and Fresno Counties) showed few statistically significant relationships. In counties with hourly wages of $10 or more, the likelihood of a Parent being a paid provider reduced relative to recipients in Los Angeles. No differences were found for the other provider groups. Recipients age 18-64 offer a somewhat similar pattern. Parents in counties with IHSS wages above $9 per hour were less likely to be paid providers, and there was a modest tendency for non-relatives to assume the provider role. The choice of Spouse provider was positive across all wage rate levels, suggesting differences between Los Angeles and Fresno and the other counties in the state that may not necessarily be related to wage rates. Among aged recipients, the prior pattern for Spouse providers holds, accept in the highest wage rate counties, which do not differ from Los Angeles and Fresno. Across all but the highest wage rates, counties show a tendency toward more Other Relative providers and somewhat less likelihood of Non-Relative providers than Los Angeles and Fresno.3

  • County per capita, in the models as an adjustment for cost of living, has an association with provider type, but with a weight near 1.0 across all recipient ages and provider types. These effects reflect the change in likelihood of a provider with each $1,000 increment in county per capita income. There is a modest positive association with Non-Relative providers among all age groups, and no statistically significant association with Spouse providers among adult recipients. Among minor children recipients, higher per capita income is associated with a reduced likelihood of a Parent provider. Among those age 18-64, there is a positive association with per capita income and Parent providers, and for all adult recipients a lower likelihood of Other Relative providers.

TABLE C-1: Predicting Provider Relationships, IHSS Recipients Age 3-17, 2005
Total Recipients
n=16257
Provider Relationship
Parentg
n=11056
Other Relative
n=2090
Non-Relative
n=2589
Predictors   Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005.
  1. Reference is White. Race/ethnicity Asian/Other includes in descending order by number in this age group, Vietnamese, Filipino, Chinese, Cambodian, Laotian, American Indian or Alaskan Native, Asian Indian, Korean, Samoan, Hawaiian, Japanese, and all others.
  2. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  3. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with a score of three or more indicating the need for human assistance.
  4. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  5. Number of persons in household, including other IHSS recipients, excludes recipients non-IHSS children <age 14.
  6. The omitted category for IHSS wages is $7.50/hr (reflective of Los Angeles and Fresno Counties residence for about 44% of IHSS recipients.
  7. The model includes only recipients who have a parent present, n shown in the column heading is the number of Parent providers, n shown in the Parent Present row is the number of parents available in the sample. “na” is not applicable.
Intercept            
Recipient Characteristicsa
Female Recipient 1.04   0.96-1.12   0.95   0.86-1.05   0.99   0.91-1.08  
Hispanic 1.94 1.75-2.14 0.79 0.70-0.90 0.44 0.40-0.50
Black 0.80 0.71-0.90 1.63 1.42-1.88 0.87 0.77-0.98
Asian/Other 1.28 1.10-1.48 1.21 1.01-1.43 0.57 0.49-0.67
3+ Cognitive Limitationsb 1.22 1.11-1.35 0.83 0.73-0.93 0.86 0.77-0.95
3+ ADL Limitationsc 1.17 1.06-1.30 0.88 0.78-0.99 0.85 0.77-0.95
Respiratory Limitationsd 1.15 1.03-1.29 0.99 0.86-1.14 0.80 0.70-0.91
Managed Care Member 1.08 0.98-1.18 0.93 0.83-1.04 0.90 0.81-0.99
Living Arrangement
Parent Present (n=14623)   na na 0.19 0.17-0.21 0.47 0.42-0.53
Household size (1-5)e 0.98 0.94-1.02 1.10 1.05-1.15 0.93 0.89-0.97
County Measures
IHSS Wage Ratef            
  <$7.50 per hour 1.08 0.96-1.23 0.74 0.63-0.87 1.02 0.89-1.16
  $8 per hour 1.30 1.17-1.45 0.92 0.81-1.05 0.69 0.61-0.79
  $9.50-$9.75 per hour 0.88 0.78-1.01 1.00 0.85-1.18 1.07 0.92-1.23
  >$10 per hour 0.64 0.49-0.83 1.11 0.81-1.52 0.93 0.71-1.23
Per Capita Income (000’s) 0.97 0.97-0.98 1.01 1.00-1.02 1.03 1.02-1.04
New IHSS Recipient 0.69 0.63-0.76 1.03 0.91-1.07 1.43 1.28-1.59
Model Goodness of Fit
-2Log Likelihood   15536.5       11471.0       13493.0    
Maximum Rescaled R2 0.071   0.112   0.078  
TABLE C-2: Predicting Provider Relationships, IHSS Recipients Age 18-64, 2005
Total Recipients
n=152,591
Provider Relationship
Parent
n=23,492
Spouseg
n=8,132
Other Relative
n=49,407
Non-Relative
n=70,974
Predictors   Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005.
  1. Reference is White. Race/ethnicity Asian/Other includes in descending order by number in this age group, Vietnamese, Laotian, Chinese, Filipino, Cambodian, American Indian or Alaskan Native, Korean, Asian Indian, Samoan, Japanese, and others.
  2. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  3. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with a score of three or more indicating the need for human assistance.
  4. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  5. Number of persons in household, including other IHSS recipients, excludes recipients non-IHSS children <age 14.
  6. The omitted category for IHSS wages is $7.50/hr (reflective of Los Angeles and Fresno Counties residence for about 44% of IHSS recipients.
  7. The model includes only recipients who have a spouse present, n shown in the column heading is the number of Spouse providers, n shown in the Spouse Present row is the number of spouses available in the IHSS recipient sample. “na” is not applicable.
Intercept                
Recipient Characteristicsa
Female Recipient 0.50   0.48-0.51   0.31   0.29-0.33   2.04   1.99-2.09   0.90   0.88-0.92  
Hispanic 1.42 1.37-1.48 2.51 2.33-2.71 1.16 1.12-1.19 0.56 0.55-0.58
Black 0.56 0.53-0.58 1.54 1.38-1.72 1.32 1.28-1.36 0.90 0.88-0.93
Asian/Other 0.86 0.81-0.91 1.57 1.44-1.72 1.79 1.72-1.86 0.51 0.49-0.53
3+ Cognitive Limitationsb 4.10 3.92-4.28 2.21 1.84-2.67 0.54 0.51-0.57 0.45 0.43-0.48
3+ ADL Limitationsc   1.53 1.48-1.58 5.27 4.90-5.68 0.75 0.74-0.77 0.85 0.83-0.87
Respiratory Limitationsd 0.97 0.91-1.03 1.29 1.16-1.44 0.91 0.87-0.95 1.05 1.01-1.10
Managed Care Member 1.22 1.17-1.27 1.41 1.31-1.53 0.89 0.87-0.92 0.94 0.91-0.97
Living Arrangement
Spouse Present (n=25,516) 0.03 0.02-0.03 na na 1.55 1.51-1.60 0.40 0.39-0.41
Household size (1-5)e 1.53 1.51-1.54 0.99 0.97-1.02 1.24 1.23-1.25 0.65 0.64-0.65
County Measures
IHSS Wage Ratef                
  <$7.50 per hour 1.10 1.04-1.15 2.07 1.90-2.26 0.61 0.59-0.63 1.27 1.23-1.31
  $8 per hour 1.39 1.33-1.45 2.06 1.89-2.26 0.80 0.77-0.82 0.89 0.86-0.92
  $9.50-$9.75 per hour 0.93 0.88-0.98 1.29 1.17-1.43 0.94 0.91-0.97 1.04 1.00-1.07
  >$10 per hour 0.78 0.70-0.87 1.59 1.28-1.98 0.90 0.83-0.97 1.19 1.10-1.28
Per Capita Income (000’s) 1.01 1.01-1.01 1.00 0.99-1.01 0.98 0.98-0.98 1.01 1.01-1.02
New IHSS Recipient 0.57 0.55-0.60 0.95 0.88-1.03 1.14 1.11-1.18 1.11 1.08-1.14
Model Goodness of Fit
-2Log Likelihood   103,330.5       25,616.7       181,058.3       185,067.1    
Maximum Rescaled R2 0.288   0.307   0.098   0.207  
TABLE C-3: Predicting Provider Relationships, IHSS Recipients 65+ or More, 2005
Total Recipients
n=233,856
Provider Relationship
Spouseg
n=5,130
Other Relative
n=123,496
Non-Relative
n=104,971
Predictors   Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
SOURCE: California Department of Social Services, unpublished CMIPS data for 2005.
  1. Reference is White. Race/ethnicity Asian/Other includes in descending order by number in this age group, Chinese, Filipino, Vietnamese, Korean, Laotian, Cambodian, Asian Indian, American Indian or Alaskan Native, Japanese, Samoan, and all others.
  2. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  3. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with a score of three or more indicating the need for human assistance.
  4. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  5. Number of persons in household, including other IHSS recipients, excludes recipient’s non-IHSS children <age 14.
  6. The omitted category for IHSS wages is $7.50/hr (reflective of Los Angeles and Fresno Counties residence for about 44% of IHSS recipients.
  7. The model includes only recipients who have a spouse present, n shown in the column heading is the number of Spouse providers, n shown in the Spouse Present row is the number of spouses available in the IHSS recipient sample. “na” is not applicable.
Intercept            
Recipient Characteristics
Female Recipient 0.23   0.21-0.24   1.38   1.35-1.41   0.85   0.84-0.87  
Hispanica 4.75 4.37-5.17 1.13 1.10-1.16 0.76 0.75-0.78
Blacka 3.64 3.10-4.27 0.94 0.92-0.97 0.98 0.95-1.01
Asian/Othera 2.31 2.12-2.52 1.46 1.42-1.49 0.63 0.62-0.65
3+ Cognitive Limitationsb 1.58 1.34-1.86 0.98 0.93-1.03 0.98 0.93-1.03
3+ ADL Limitationsc 7.79 7.12-8.51 1.03 1.01-1.05 0.84 0.82-0.85
Respiratory Limitationsd 1.48 1.34-1.64 0.93 0.90-0.96 1.02 0.98-1.05
Managed Care Member 1.16 1.05-1.29 1.08 1.05-1.11 0.90 0.87-0.93
Living Arrangement
Spouse Present (n=69,034)   na na 1.10 1.08-1.12 0.68 0.66-0.69
Household size (1-5+)e 0.88 0.86-0.91 1.60 1.59-1.61 0.63 0.62-0.63
County Measures
IHSS Wage Ratef            
  <$7.50 per hour 1.99 1.80-2.20 0.79 0.77-0.81 1.16 1.12-1.19
  $8 per hour 1.86 1.70-2.04 1.23 1.19-1.26 0.75 0.73-0.77
  $9.50-$9.75 per hour 1.32 1.19-1.48 1.17 1.13-1.20 0.82 0.79-0.84
  >$10 per hour 0.88 0.72-1.09 1.06 1.00-1.12 0.94 0.89-1.00
Per Capita Income (000’s) 1.00 1.00-1.01 0.99 0.98-0.99 1.02 1.01-1.02
New IHSS Recipients 1.32 1.22-1.44 1.02 0.99-1.04 0.95 0.93-0.97
Model Goodness of Fit
-2Log Likelihood   29,318.4       296,098.0       289,899.0    
Maximum Rescaled R2 0.242   0.147   0.170  

Appendix D. Hierarchical Condition Classification and Distribution for Ihss Recipients by Age and Provider Relationship

TABLE D-1: Hierarchical Condition Classification Distribution for IHSS Recipients Age 3-17 by Provider Relationship, 2005
HCC Parents Other Relative Non-Relative
# % # % # %
Parent is paid as an IHSS worker for their minor child, Other Relatives (other than spouse or parent) paid as an IHSS worker for recipient, Non-Relatives refers to all other paid IHSS workers for recipient.

HCC refers to the CMS hierarchical condition categories or CMS-HCC model (Pope, Kautter, Ellis, et al., 2004). The HCC provide an established standardized protocol for combining International Classification of Disease (CDC, 2007) or ICD-9 diagnostic codes. HCC’s aggregate the over 15,000 ICD-9 categories into 189 condition categories (CCs), five of which are based on beneficiary utilization of selected types of durable medical equipment (Pope, Ellis, Ash, et al., 2000). The CCs describe a broad set of similar diseases, generally organized into body systems. Another advantage is that the CCs hierarchies are designed so that a person is coded only for the most severe manifestation among the related diseases defining the CC. Within the same HCC a person is classified once. This avoids duplicative counting of related conditions. For unrelated diseases (i.e., diseases in other CCs), the number of HCC’s accumulate.
  1. The computer code used for creating the HCC groupings from ICD-9 coding was downloaded from the CMS website as a SAS program in 2007. The program code did not include HCC 20 in the HCC ICD-9 code file.
  2. The inconsistent number sequence within "Pregnancy/Child Birth Complications" is a result of how the contractor grouped HCCs into the body systems structure used in this table.
  3. The computer code used for creating the HCC groupings from ICD-9 coding was downloaded from the CMS website as a SAS program in 2007. The program code did not include HCC 173 in the HCC ICD-9 code file.
  Total Recipients   8,293     100.0     1,455     100.0     1,835     100.0  
  Recipients w/any HCC 6,740 81.3 1,055 72.5 1,261 68.7
 
  Infectious and Parasitic Disease            
1 HIV/AIDS 12 0.1 7 0.5 12 0.7
2 Septicemia/Shock 64 0.8 4 0.3 7 0.4
3 Central Nervous System Infection 31 0.4 3 0.2 6 0.3
4 Tuberculosis 13 0.2 8 0.5 0 -
5 Opportunistic Infections 12 0.1 1 0.1 2 0.1
6 Other Infectious Diseases 967 11.7 141 9.7 152 8.3
  NEOPLASMS            
7 Metastatic Cancer & Acute Leukemia 54 0.7 8 0.5 5 0.3
8 Lung, Upper Digestive Tract, & Other Severe Cancers 11 0.1 1 0.1 0 -
9 Lymphatic, Head & Neck, Brain, and Other Major Cancers 117 1.4 10 0.7 15 0.8
10 Breast, Prostate, Colorectal & Other Cancers & Tumors 114 1.4 11 0.8 14 0.8
11 Other Respiratory & Heart Neoplasms 15 0.2 1 0.1 1 0.1
12 Other Digestive & Urinary Neoplasms 24 0.3 1 0.1 5 0.3
13 Other Neoplasms 82 1.0 7 0.5 9 0.5
14 Benign Neoplasms of Skin, Breast, Eye 49 0.6 12 0.8 9 0.5
a Endocrine, Nutritional and Metabolic Disorders            
15 Diabetes with Renal or Peripheral Circulatory Manifestation 4 0.0 1 0.1 0 -
16 Diabetes with Neurologic or Other Specified Manifestation 7 0.1 1 0.1 2 0.1
17 Diabetes with Acute Complications 6 0.1 4 0.3 4 0.2
18 Diabetes with Ophthalmologic or Unspecified Manifestation 10 0.1 1 0.1 4 0.2
19 Diabetes without Complication 101 1.2 15 1.0 13 0.7
21 Protein-Calorie Malnutrition 29 0.3 4 0.3 4 0.2
22 Other Significant Endocrine and Metabolic Disorders 193 2.3 25 1.7 26 1.4
23 Disorders of Fluid/Electrolyte/Acid-Base Balance 87 1.0 14 1.0 13 0.7
24 Other Endocrine, Metabolic, or Nutritional Disorders 417 5.0 66 4.5 61 3.3
  Liver and Gallbladder Disease            
25 End-Stage Liver Disease 9 0.1 3 0.2 1 0.1
26 Cirrhosis of Liver 4 0.0 2 0.1 0 -
27 Chronic Hepatitis 7 0.1 1 0.1 0 -
28 Acute Liver Failure/Disease 3 0.0 0 - 1 0.1
29 Other Hepatitis & Liver Disease 48 0.6 6 0.4 3 0.2
30 Gallbladder & Biliary Tract Disorders 26 0.3 2 0.1 4 0.2
  Gastrointestinal Disease/Disorders            
31 Intestinal Obstruction/Perforation 97 1.2 20 1.4 9 0.5
32 Pancreatic Disease 82 1.0 4 0.3 10 0.5
33 Inflammatory Bowel Disease 12 0.1 1 0.1 4 0.2
34 Peptic Ulcer, Hemorrhage, Other Specified Gastrointestinal Disorders 125 1.5 17 1.2 12 0.7
35 Appendicitis 16 0.2 5 0.3 1 0.1
36 Other Gastrointestinal Disorders 1,492 18.0 202 13.9 203 11.1
  Musculoskeletal/Connective Tissue Disease Disorders            
37 Bone/Joint/Muscle Infections/Necrosis 34 0.4 9 0.6 2 0.1
38 Rheumatoid Arthritis & Inflammatory Connective Tissue Disease 56 0.7 5 0.3 13 0.7
39 Disorders of the Vertebrae & Spinal Discs 654 7.9 76 5.2 96 5.2
40 Osteoarthritis of Hip or Knee 10 0.1 1 0.1 3 0.2
41 Osteoporosis & Other Bone/Cartilage Disorders 157 1.9 20 1.4 12 0.7
42 Congenital/Developmental Skeletal and Connective Tissue Disorders 214 2.6 37 2.5 26 1.4
43 Other Musculoskeletal & Connective Tissue Disorders 1,384 16.7 175 12.0 214 11.7
  Blood and Blood Forming Organ Disease/Disorders            
44 Severe Hematological Disorders 66 0.8 5 0.3 8 0.4
45 Disorders of Immunity 37 0.4 8 0.5 14 0.8
46 Coagulation Defects & Other Specified Hematological Disorders 67 0.8 9 0.6 8 0.4
47 Iron Deficiency & Other Unspecified Anemias & Blood Disease 163 2.0 27 1.9 27 1.5
  Mental Disorders            
48 Delirium & Encephalopathy 147 1.8 37 2.5 15 0.8
49 Dementia/Cerebral Degeneration 319 3.8 29 2.0 43 2.3
50 Nonpsychotic Organic Brain Syndromes/Conditions 132 1.6 14 1.0 16 0.9
51 Drug/Alcohol Psychosis 1 0.0 1 0.1 0 -
52 Drug/Alcohol Dependence 3 0.0 0 - 1 0.1
53 Drug/Alcohol Abuse, Without Dependence 1 0.0 1 0.1 3 0.2
54 Schizophrenia 14 0.2 3 0.2 3 0.2
55 Major Depressive, Bipolar, and Paranoid Disorders 51 0.6 12 0.8 11 0.6
56 Reactive and Unspecified Psychosis 17 0.2 4 0.3 6 0.3
57 Personality Disorders 10 0.1 0 - 1 0.1
58 Depression 38 0.5 9 0.6 7 0.4
59 Anxiety Disorders 71 0.9 14 1.0 10 0.5
60 Other Psychiatric Disorders 214 2.6 32 2.2 40 2.2
  Mental Retardation/Developmental Disability            
61 Profound Mental Retardation, Developmental Disability 87 1.0 7 0.5 10 0.5
62 Severe Mental Retardation, Developmental Disability 41 0.5 8 0.5 9 0.5
63 Moderate Mental Retardation, Developmental Disability 20 0.2 7 0.5 5 0.3
64 Mild Mental Retardation, Autism, Down's Syndrome 860 10.4 111 7.6 136 7.4
65 Other Developmental Disability 438 5.3 69 4.7 62 3.4
66 Attention Deficit Disorder 190 2.3 37 2.5 55 3.0
  Central Nervous System Injuries/Disorders            
67 Quadriplegia/Other Extensive Paralysis 667 8.0 102 7.0 103 5.6
68 Paraplegia 162 2.0 36 2.5 29 1.6
69 Spinal Cord Disorders/Injuries 488 5.9 66 4.5 68 3.7
70 Muscular Dystrophy 134 1.6 14 1.0 22 1.2
71 Polyneuropathy 81 1.0 14 1.0 12 0.7
72 Multiple Sclerosis 6 0.1 0 - 1 0.1
73 Parkinson's & Huntington's Diseases 4 0.0 1 0.1 0 -
74 Seizure Disorders & Convulsions 1,583 19.1 243 16.7 267 14.6
75 Coma, Brain Compression/Anoxic Damage 45 0.5 6 0.4 6 0.3
76 Mononeuropathy, Other Neurological Conditions/Injuries 144 1.7 16 1.1 20 1.1
  Respiratory System Disorders            
77 Respirator Dependence, Tracheostomy Status 148 1.8 11 0.8 19 1.0
78 Respiratory Arrest 11 0.1 1 0.1 3 0.2
79 Cardio-Respiratory Failure & Shock 284 3.4 35 2.4 45 2.5
  Cardiovascular System Disease/Disorders            
80 Congestive Heart Failure 130 1.6 16 1.1 10 0.5
81 Acute Myocardial Infarction 1 0.0 0 - 1 0.1
82 Unstable Angina & Other Acute Ischemic Heart Disease 3 0.0 1 0.1 0 -
83 Angina Pectoris/Old Myocardial Infarction 4 0.0 0 - 0 -
84 Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease 11 0.1 1 0.1 2 0.1
85 Heart Infection/Inflammation, Except Rheumatic 29 0.3 2 0.1 3 0.2
86 Valvular & Rheumatic Heart Disease 130 1.6 8 0.5 18 1.0
87 Major Congenital Cardiac, Circulatory Defect 97 1.2 10 0.7 8 0.4
88 Other Congenital Heart/Circulatory Disease 220 2.7 23 1.6 21 1.1
89 Hypertensive Heart & Renal Disease or Encephalopathy 12 0.1 0 - 3 0.2
90 Hypertensive Heart Disease 5 0.1 1 0.1 0 -
91 Hypertension 97 1.2 11 0.8 14 0.8
92 Specified Heart Arrhythmias 46 0.6 6 0.4 7 0.4
93 Other Heart Rhythm & Conduction Disorders 114 1.4 20 1.4 13 0.7
94 Other & Unspecified Heart Disease 84 1.0 12 0.8 5 0.3
  Cerebral and Other Vascular System Disease/Disorders            
95 Cerebral Hemorrhage 24 0.3 1 0.1 6 0.3
96 Ischemic or Unspecified Stroke 21 0.3 2 0.1 4 0.2
97 Precerebral Arterial Occlusion & Transient Cerebral Ischemia 14 0.2 0 - 5 0.3
98 Cerebral Atherosclerosis & Aneurysm 11 0.1 1 0.1 2 0.1
99 Cerebrovascular Disease, Unspecified 8 0.1 1 0.1 1 0.1
100 Hemiplegia/Hemiparesis 129 1.6 21 1.4 16 0.9
101 Cerebral Palsy & Other Paralytic Syndromes 1,122 13.5 177 12.2 170 9.3
102 Speech, Language, Cognitive, Perceptual Deficits 5 0.1 1 0.1 2 0.1
103 Cerebrovascular Disease Late Effects, Unspecified 3 0.0 0 - 1 0.1
104 Vascular Disease with Complications 17 0.2 3 0.2 1 0.1
105 Vascular Disease 32 0.4 2 0.1 4 0.2
106 Other Circulatory Disease 53 0.6 5 0.3 10 0.5
  Pulmonary System Disease/Disorders            
107 Cystic Fibrosis 48 0.6 10 0.7 10 0.5
108 Chronic Obstructive Pulmonary Disease 182 2.2 24 1.6 28 1.5
109 Fibrosis of Lung & Other Chronic Lung Disorders 91 1.1 12 0.8 22 1.2
110 Asthma 846 10.2 137 9.4 141 7.7
111 Aspiration & Specified Bacterial Pneumonias 146 1.8 20 1.4 28 1.5
112 Pneumococcal Pneumonia, Empyema, Lung Abscess 44 0.5 4 0.3 6 0.3
113 Viral & Unspecified Pneumonia, Pleurisy 633 7.6 86 5.9 96 5.2
114 Pleural Effusion/Pneumothorax 64 0.8 5 0.3 11 0.6
115 Other Lung Disorders 1,266 15.3 184 12.6 195 10.6
  Eyes and Vision Disorders            
116 Legally Blind 24 0.3 3 0.2 5 0.3
117 Major Eye Infections, Inflammations 7 0.1 0 - 5 0.3
118 Retinal Detachment 22 0.3 1 0.1 4 0.2
119 Proliferative Diabetic Retinopathy & Vitreous Hemorrhage 0 - 0 - 1 0.1
120 Diabetic & Other Vascular Retinopathies 34 0.4 5 0.3 7 0.4
121 Retinal Disorders, Except Detachment & Vascular Retinopathies 25 0.3 3 0.2 1 0.1
122 Glaucoma 54 0.7 6 0.4 4 0.2
123 Cataract 26 0.3 6 0.4 5 0.3
124 Other Eye Disorders 1,290 15.6 160 11.0 184 10.0
  Ear, Nose, and Throat Disorders            
125 Significant Ear, Nose, & Throat Disorders 46 0.6 5 0.3 7 0.4
126 Hearing Loss 218 2.6 28 1.9 24 1.3
127 Other Ear, Nose, Throat, & Mouth Disorders 3,802 45.8 556 38.2 613 33.4
  Renal System Disorders            
128 Kidney Transplant Status 23 0.3 6 0.4 5 0.3
130 Dialysis Status 11 0.1 1 0.1 3 0.2
131 Renal Failure 63 0.8 6 0.4 7 0.4
132 Nephritis 16 0.2 1 0.1 0 -
  Other Genitourinary System Disorders            
133 Urinary Obstruction & Retention 311 3.8 38 2.6 24 1.3
134 Incontinence 99 1.2 21 1.4 17 0.9
135 Urinary Tract Infection 384 4.6 49 3.4 56 3.1
136 Other Urinary Tract Disorders 170 2.0 22 1.5 17 0.9
137 Female Infertility 0 - 0 - 0 -
138 Pelvic Inflammatory Disease & Other Specified Female Genital Disorders 21 0.3 3 0.2 2 0.1
139 Other Female Genital Disorders 146 1.8 32 2.2 35 1.9
140 Male Genital Disorders 115 1.4 21 1.4 15 0.8
b Pregnancy/Child Birth Complications            
141 Ectopic Pregnancy 0 - 0 - 0 -
142 Miscarriage/Abortion 3 0.0 1 0.1 0 -
143 Completed Pregnancy With Major Complications 0 - 1 0.1 0 -
144 Completed Pregnancy With Complications 6 0.1 0 - 0 -
145 Completed Pregnancy Without Complications (Normal Delivery) 3 0.0 1 0.1 0 -
146 Uncompleted Pregnancy With Complications 4 0.0 1 0.1 0 -
147 Uncompleted Pregnancy With No or Minor Complications 7 0.1 1 0.1 0 -
168 Extremely Low Birthweight Neonates 0 - 0 - 0 -
169 Very Low Birthweight Neonates 0 - 0 - 0 -
170 Serious Perinatal Problem Affecting Newborn 111 1.3 15 1.0 11 0.6
171 Other Perinatal Problems Affecting Newborn 21 0.3 2 0.1 2 0.1
172 Normal, Single Birth 4 0.0 1 0.1 1 0.1
  Dermatological Disorders            
148 Decubitus Ulcer of Skin 54 0.7 11 0.8 3 0.2
149 Chronic Ulcer of Skin, Except Decubitus 21 0.3 5 0.3 4 0.2
150 Extensive Third-Degree Burns 0 - 0 - 0 -
151 Other Third-Degree & Extensive Burns 3 0.0 0 - 0 -
152 Cellulitis, Local Skin Infection 313 3.8 53 3.6 53 2.9
153 Other Dermatological Disorders 969 11.7 144 9.9 150 8.2
  Fractures, Other Injuries, and Poisoning            
154 Severe Head Injury 4 0.0 0 - 0 -
155 Major Head Injury 54 0.7 6 0.4 15 0.8
156 Concussion or Unspecified Head Injury 81 1.0 12 0.8 20 1.1
157 Vertebral Fractures without Spinal Cord Injury 1 0.0 1 0.1 3 0.2
158 Hip Fracture/Dislocation 105 1.3 10 0.7 25 1.4
159 Major Fracture, Except of Skull, Vertebrae, or Hip 90 1.1 13 0.9 21 1.1
160 Internal Injuries 7 0.1 1 0.1 3 0.2
161 Traumatic Amputation 9 0.1 2 0.1 0 -
162 Other Injuries 872 10.5 138 9.5 177 9.6
163 Poisonings & Allergic Reactions 135 1.6 15 1.0 23 1.3
b,c Treatment Complications and Status            
164 Major Complications of Medical Care & Trauma 280 3.4 40 2.7 36 2.0
165 Other Complications of Medical Care 83 1.0 18 1.2 9 0.5
166 Major Symptoms, Abnormalities 2,489 30.0 385 26.5 392 21.4
167 Minor Symptoms, Signs, Findings 1,686 20.3 243 16.7 277 15.1
174 Major Organ Transplant Status 41 0.5 2 0.1 3 0.2
175 Other Organ Transplant, Replacement 46 0.6 5 0.3 3 0.2
176 Artificial Openings for Feeding or Elimination 377 4.5 52 3.6 49 2.7
177 Amputation Status, Lower Limb/Amputation Complications 4 0.0 0 - 1 0.1
178 Amputation Status, Upper Limb 0 - 0 - 0 -
179 Post-Surgical States/Aftercare/Elective 1,034 12.5 121 8.3 140 7.6
  Miscellaneous            
180 Radiation Therapy 9 0.1 1 0.1 0 -
181 Chemotherapy 21 0.3 1 0.1 1 0.1
182 Rehabilitation 81 1.0 14 1.0 20 1.1
183 Screening/Observation/Special Exams 2,240 27.0 334 23.0 356 19.4
184 History of Disease 52 0.6 3 0.2 7 0.4
TABLE D-2: Hierarchical Condition Classification Distribution for IHSS Recipients, Age 18-64 by Provider Relationship, 2005
HCC Spouse Parent Other Relatives Non-Relative
# % # % # % # %
Parent is paid as an IHSS worker for their adult child, Spouse is paid as an IHSS worker for recipient, Other Relatives (other than spouse or parent) paid as an IHSS worker for recipient, Non-Relatives refers to all other paid IHSS workers for recipient.

HCC refers to the CMS hierarchical condition category or CMS-HCC model (Pope, Kautter, Ellis, et al., 2004). The HCC provide an established standardized protocol for combining International Classification of Disease (CDC, 2007) or ICD-9 diagnostic codes. HCCs aggregate the over 15,000 ICD-9 categories into 189 condition categories (CCs), five of which are based on beneficiary utilization of selected types of durable medical equipment (Pope, Ellis, Ash, et al., 2000). The CCs describe a broad set of similar diseases, generally organized into body systems. Another advantage is that the CC hierarchies are designed so that a person is coded only for the most severe manifestation among the related diseases defining the CC. Within the same HCC a person is classified once. This avoids duplicative counting of related conditions. For unrelated diseases (i.e., diseases in other CCs), the number of HCCs accumulate.
  1. The computer code used for creating the HCC groupings from ICD-9 coding was downloaded from the CMS website as a SAS program in 2007. The program code did not include HCC 20 in the HCC ICD-9 code file.
  2. The inconsistent number sequence within "Pregnancy/Child Birth Complications" is a result of how the contractor grouped HCCs into the body systems structure used in this table.
  3. The computer code used for creating the HCC groupings from ICD-9 coding was downloaded from the CMS website as a SAS program in 2007. The program code did not include HCC 173 in the HCC ICD-9 code file.
  Total Recipients   6,721     100.0     18,749     100.0     40,603     100.0     59,429     100.0  
  Recipients w/ any HCC 6,003 89.3 13,789 73.5 36,362 89.6 52,197 87.8
 
  Infections and Parasitic Disease                
1 HIV/AIDS 55 0.8 222 1.2 523 1.3 1,987 3.3
2 Septicemia/Shock 198 2.9 280 1.5 861 2.1 1,283 2.2
3 Central Nervous System Infection 48 0.7 75 0.4 148 0.4 288 0.5
4 Tuberculosis 18 0.3 46 0.2 127 0.3 148 0.2
5 Opportunistic Infections 30 0.4 42 0.2 96 0.2 161 0.3
6 Other Infectious Diseases 508 7.6 1,139 6.1 3,119 7.7 4,927 8.3
  Neoplasms                
7 Metastatic Cancer and Acute Leukemia 117 1.7 78 0.4 556 1.4 573 1.0
8 Lung, Upper Digestive Tract, and Other Severe Cancers 114 1.7 54 0.3 569 1.4 726 1.2
9 Lymphatic, Head and Neck, Brain, and Other Major Cancers 154 2.3 165 0.9 658 1.6 914 1.5
10 Breast, Prostate, Colorectal and Other Cancers and Tumors 265 3.9 253 1.3 1,589 3.9 1,931 3.2
11 Other Respiratory and Heart Neoplasms 36 0.5 25 0.1 149 0.4 183 0.3
12 Other Digestive and Urinary Neoplasms 216 3.2 137 0.7 1,115 2.7 1,568 2.6
13 Other Neoplasms 172 2.6 207 1.1 1,188 2.9 1,838 3.1
14 Benign Neoplasms of Skin, Breast, Eye 174 2.6 315 1.7 1,991 4.9 2,589 4.4
a Endocrine, Nutritional and Metabolic Disorders                
15 Diabetes with Renal or Peripheral Circulatory Manifestation 231 3.4 108 0.6 897 2.2 881 1.5
16 Diabetes with Neurologic or Other Specified Manifestation 322 4.8 213 1.1 1,608 4.0 1,984 3.3
17 Diabetes with Acute Complications 39 0.6 61 0.3 221 0.5 331 0.6
18 Diabetes with Ophthalmologic or Unspecified Manifestation 206 3.1 117 0.6 1,078 2.7 1,214 2.0
19 Diabetes without Complication 1,383 20.6 958 5.1 7,830 19.3 8,880 14.9
21 Protein-Calorie Malnutrition 32 0.5 47 0.3 92 0.2 162 0.3
22 Other Significant Endocrine and Metabolic Disorders 89 1.3 216 1.2 469 1.2 623 1.0
23 Disorders of Fluid/Electrolyte/Acid-Base Balance 182 2.7 272 1.5 999 2.5 1,408 2.4
24 Other Endocrine/Metabolic/ Nutritional Disorders 837 12.5 1,350 7.2 5,987 14.7 7,459 12.6
  Liver and Gallbladder Disease                
25 End-Stage Liver Disease 77 1.1 50 0.3 318 0.8 453 0.8
26 Cirrhosis of Liver 136 2.0 97 0.5 619 1.5 897 1.5
27 Chronic Hepatitis 153 2.3 154 0.8 628 1.5 1,321 2.2
28 Acute Liver Failure/Disease 12 0.2 24 0.1 93 0.2 160 0.3
29 Other Hepatitis and Liver Disease 271 4.0 278 1.5 1,357 3.3 2,235 3.8
30 Gallbladder and Biliary Tract Disorders 106 1.0 158 0.8 771 1.9 897 1.5
  Gastrointestinal Disease                
31 Intestinal Obstruction/Perforation 108 1.6 211 1.1 576 1.4 817 1.4
32 Pancreatic Disease 74 1.1 111 0.6 443 1.1 689 1.2
33 Inflammatory Bowel Disease 22 0.3 55 0.3 142 0.3 260 0.4
34 Peptic Ulcer, Hemorrhage, Other Specified Gastrointestinal Disorders 348 5.2 383 2.0 2,015 5.0 2,485 4.2
35 Appendicitis 11 0.2 27 0.1 50 0.1 61 0.1
36 Other Gastrointestinal Disorders 1,438 21.4 2,207 11.8 8,714 21.5 11,943 20.1
  Musculoskeletal/Connective Tissue                
37 Bone/Joint/Muscle Infections/Necrosis 111 1.7 176 0.9 457 1.1 905 1.5
38 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease 181 2.7 276 1.5 1,397 3.4 1,857 3.1
39 Disorders of the Vertebrae and Spinal Discs 561 8.3 564 3.0 3,535 8.7 5,652 9.5
40 Osteoarthritis of Hip or Knee 181 2.7 150 0.8 1,671 4.1 2,266 3.8
41 Osteoporosis and Other Bone/Cartilage Disorders 235 3.5 338 1.8 2,025 5.0 2,385 4.0
42 Congenital/Developmental Skeletal and Connective Tissue Disorders 7 0.1 49 0.3 32 0.1 92 0.2
43 Other Musculoskeletal and Connective Tissue Disorders 2,533 37.7 3,363 17.9 17,451 43.0 25,016 42.1
  Diseases of the Blood and Blood Forming Organs                
44 Severe Hematological Disorders 47 0.7 114 0.6 298 0.7 459 0.8
45 Disorders of Immunity 7 0.1 37 0.2 32 0.1 113 0.2
46 Coagulation Defects and Other Specified Hematological Disorders 71 1.1 125 0.7 381 0.9 569 1.0
47 Iron Deficiency and Other/Unspecified Anemias and Blood Disease 466 6.9 568 3.0 2,649 6.5 3,344 5.6
  Mental Disorders                
48 Delirium and Encephalopathy 56 0.8 187 1.0 319 0.8 522 0.9
49 Dementia/Cerebral Degeneration 128 1.9 241 1.3 553 1.4 767 1.3
50 Nonpsychotic Organic Brain Syndromes/Conditions 66 1.0 127 0.7 346 0.9 502 0.8
51 Drug/Alcohol Psychosis 13 0.2 46 0.2 130 0.3 397 0.7
52 Drug/Alcohol Dependence 33 0.5 56 0.3 209 0.5 602 1.0
53 Drug/Alcohol Abuse, Without Dependence 38 0.6 106 0.6 330 0.8 887 1.5
54 Schizophrenia 45 0.7 464 2.5 654 1.6 1,367 2.3
55 Major Depressive, Bipolar, and Paranoid Disorders 119 1.8 344 1.8 1,048 2.6 2,375 4.0
56 Reactive and Unspecified Psychosis 44 0.7 192 1.0 320 0.8 627 1.1
57 Personality Disorders 3 0.0 17 0.1 32 0.1 104 0.2
58 Depression 130 1.9 256 1.4 1,072 2.6 1,921 3.2
59 Anxiety Disorders 56 0.8 152 0.8 389 1.0 787 1.3
60 Other Psychiatric Disorders 199 3.0 452 2.4 1,313 3.2 2,492 4.2
  Mental Retardation/ Developmental Disability                
61 Profound Mental Retardation/Developmental Disability 1 0.0 92 0.5 16 0.0 46 0.1
62 Severe Mental Retardation/Developmental Disability - - 43 0.2 11 0.0 21 0.0
63 Moderate Mental Retardation/Developmental Disability - - 44 0.2 26 0.1 19 0.0
64 Mild Mental Retardation, Autism, Down's Syndrome 12 0.2 826 4.4 277 0.7 422 0.7
65 Other Developmental Disability 2 0.0 164 0.9 41 0.1 106 0.2
66 Attention Deficit Disorder 4 0.1 42 0.2 23 0.1 73 0.1
  Central Nervous System Injuries/Disorders                
67 Quadriplegia, Other Extensive Paralysis 65 1.0 443 2.4 145 0.4 487 0.8
68 Paraplegia 67 1.0 281 1.5 217 0.5 497 0.8
69 Spinal Cord Disorders/Injuries 84 1.2 427 2.3 318 0.8 650 1.1
70 Muscular Dystrophy 20 0.3 145 0.8 45 0.1 110 0.2
71 Polyneuropathy 13 2.1 15 0.8 574 1.4 1,031 1.7
72 Multiple Sclerosis 88 1.3 158 0.8 265 0.7 690 1.2
73 Parkinson's and Huntington's Diseases 62 0.9 49 0.3 175 0.4 236 0.4
74 Seizure Disorders and Convulsions 379 5.6 2,359 12.6 2,002 4.9 3,741 6.3
75 Coma, Brain Compression/Anoxic Damage 22 0.3 68 0.4 104 0.3 166 0.3
76 Mononeuropathy, Other Neurological Conditions/Injuries 341 5.1 573 3.1 2,211 5.4 3,469 5.8
  Respiratory System Disorders                
77 Respirator Dependence/Tracheostomy Status 19 0.3 105 0.6 86 0.2 158 0.3
78 Respiratory Arrest 12 0.2 18 0.1 52 0.1 75 0.1
79 Cardio-Respiratory Failure and Shock 268 4.0 425 2.3 1,364 3.4 2,008 3.4
  Cardiovascular System                
80 Congestive Heart Failure 586 8.7 481 2.6 3,331 8.2 4,258 7.2
81 Acute Myocardial Infarction 74 1.1 38 0.2 369 0.9 406 0.7
82 Unstable Angina and Other Acute Ischemic Heart Disease 179 2.7 71 0.4 1,099 2.7 1,269 2.1
83 Angina Pectoris/Old Myocardial Infarction 170 2.5 77 0.4 1,342 3.3 1,207 2.0
84 Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease 635 9.4 200 1.1 3,414 8.4 3,718 6.3
85 Heart Infection/Inflammation, Except Rheumatic 46 0.7 44 0.2 237 0.6 301 0.5
86 Valvular and Rheumatic Heart Disease 367 5.5 359 1.9 2,326 5.7 2,623 4.4
87 Major Congenital Cardiac/Circulatory Defect 1 0.0 30 0.2 20 0.0 23 0.0
88 Other Congenital Heart/Circulatory Disease 26 0.4 109 0.6 181 0.4 220 0.4
89 Hypertensive Heart and Renal Disease or Encephalopathy 33 0.5 20 0.1 168 0.4 162 0.3
90 Hypertensive Heart Disease 140 2.1 89 0.5 1,290 3.2 1,229 2.1
91 Hypertension 1,366 20.3 1,089 5.8 10,511 25.9 11,700 19.7
92 Specified Heart Arrhythmias 221 3.3 182 1.0 1,279 3.2 1,700 2.9
93 Other Heart Rhythm and Conduction Disorders 313 4.7 312 1.7 1,784 4.4 2,333 3.9
94 Other and Unspecified Heart Disease 308 4.6 283 1.5 1,763 4.3 2,295 3.9
  Cerebral and Other Vascular Systems                
95 Cerebral Hemorrhage 49 0.7 63 0.3 219 0.5 269 0.5
96 Ischemic or Unspecified Stroke 367 5.5 195 1.0 1,324 3.3 1,635 2.8
97 Precerebral Arterial Occlusion and Transient Cerebral Ischemia 239 3.6 139 0.7 1,252 3.1 1,436 2.4
98 Cerebral Atherosclerosis and Aneurysm 37 0.6 33 0.2 199 0.5 264 0.4
99 Cerebrovascular Disease, Unspecified 19 0.3 26 0.1 94 0.2 139 0.2
100 Hemiplegia/Hemiparesis 114 1.7 154 0.8 279 0.7 522 0.9
101 Cerebral Palsy and Other Paralytic Syndromes 39 0.6 755 4.0 263 0.6 667 1.1
102 Speech, Language, Cognitive, Perceptual Deficits 29 0.4 35 0.2 110 0.3 189 0.3
103 Cerebrovascular Disease Late Effects, Unspecified 48 0.7 24 0.1 168 0.4 226 0.4
104 Vascular Disease with Complications 134 2.0 111 0.6 622 1.5 806 1.4
105 Vascular Disease 386 5.7 256 1.4 2,181 5.4 2,650 4.5
106 Other Circulatory Disease 362 5.4 332 1.8 1,838 4.5 2,467 4.2
  Pulmonary System                
107 Cystic Fibrosis 3 0.0 15 0.1 20 0.0 25 0.0
108 Chronic Obstructive Pulmonary Disease 470 7.0 427 2.3 3,516 8.7 5,731 9.6
109 Fibrosis of Lung and Other Chronic Lung Disorders 141 2.1 207 1.1 803 2.0 1,179 2.0
110 Asthma 325 4.8 557 3.0 2,507 6.2 3,806 6.4
111 Aspiration and Specified Bacterial Pneumonias 72 1.1 183 1.0 299 0.7 479 0.8
112 Pneumococcal Pneumonia, Empyema, Lung Abscess 49 0.7 80 0.4 212 0.5 345 0.6
113 Viral and Unspecified Pneumonia, Pleurisy 488 7.3 807 4.3 2,536 6.2 3,684 6.2
114 Pleural Effusion/Pneumothorax 156 2.3 181 1.0 787 1.9 1,033 1.7
115 Other Lung Disorders 923 13.7 1,630 8.7 5,748 14.2 7,757 13.1
  Eyes and Vision Disorders                
116 Legally Blind 11 0.2 27 0.1 50 0.1 104 0.2
117 Major Eye Infections/Inflammations 9 0.1 23 0.1 49 0.1 88 0.1
118 Retinal Detachment 24 0.4 38 0.2 123 0.3 145 0.2
119 Proliferative Diabetic Retinopathy and Vitreous Hemorrhage 144 2.1 43 0.2 523 1.3 440 0.7
120 Diabetic and Other Vascular Retinopathies 137 2.0 53 0.3 744 1.8 703 1.2
121 Retinal Disorders, Except Detachment and Vascular Retinopathies 79 1.2 44 0.2 399 1.0 447 0.8
122 Glaucoma 240 3.6 184 1.0 1,458 3.6 1,675 2.8
123 Cataract 282 4.2 152 0.8 2,063 5.1 2,072 3.5
124 Other Eye Disorders 672 10.0 1,145 6.1 5,236 12.9 5,736 9.7
  Ears, Nose, and Throat Disorders                
125 Significant Ear, Nose, and Throat Disorders 32 0.5 39 0.2 192 0.5 258 0.4
126 Hearing Loss 57 0.8 141 0.8 373 0.9 628 1.1
127 Other Ear, Nose, Throat, and Mouth Disorders 1,315 19.6 3,826 20.4 8,381 20.6 11,597 19.5
  Renal System                
128 Kidney Transplant Status 65 1.0 86 0.5 207 0.5 225 0.4
130 Dialysis Status 257 3.8 181 1.0 849 2.1 824 1.4
131 Renal Failure 742 11.0 485 2.6 2,549 6.3 2,686 4.5
132 Nephritis 37 0.6 46 0.2 177 0.4 180 0.3
  Other Genitourinary System                
133 Urinary Obstruction and Retention 328 4.9 706 3.8 1,307 3.2 2,063 3.5
134 Incontinence 70 1.0 162 0.9 545 1.3 783 1.3
135 Urinary Tract Infection 543 8.1 1,064 5.7 3,114 7.7 4,629 7.8
136 Other Urinary Tract Disorders 394 5.9 454 2.4 1,842 4.5 2,347 3.9
137 Female Infertility - - 1 0.0 3 0.0 8 0.0
138 Pelvic Inflammatory Disease and Other Specified Female Genital Disorders 78 1.2 159 0.8 662 1.6 821 1.4
139 Other Female Genital Disorders 279 4.2 718 3.8 3,302 8.1 4,013 6.8
140 Male Genital Disorders 232 3.5 201 1.1 719 1.8 1,206 2.0
b Pregnancy/Child Birth Complications                
141 Ectopic Pregnancy 4 0.1 2 0.0 6 0.0 6 0.0
142 Miscarriage/Abortion 10 0.1 34 0.2 47 0.1 110 0.2
143 Completed Pregnancy With Major Complications 5 0.1 17 0.1 14 0.0 35 0.1
144 Completed Pregnancy With Complications 11 0.2 38 0.2 38 0.1 115 0.2
145 Completed Pregnancy Without Complications (Normal Delivery) 13 0.2 41 0.2 35 0.1 105 0.2
146 Uncompleted Pregnancy w/complications 13 0.2 35 0.2 39 0.1 116 0.2
147 Uncompleted Pregnancy With No or Minor Complications 31 0.5 98 0.5 103 0.3 268 0.5
168 Extremely Low Birthweight Neonates 2 0.0 - - 1 0.0 1 0.0
169 Very Low Birthweight Neonates - - 1 0.0 1 0.0 2 0.0
170 Serious Perinatal Problem Affecting Newborn 4 0.1 18 0.1 30 0.1 57 0.1
171 Other Perinatal Problems Affecting Newborn 3 0.0 18 0.1 29 0.1 48 0.1
172 Normal, Single Birth 13 0.2 41 0.2 35 0.1 108 0.2
  Dermatological Disorders                
148 Decubitus Ulcer of Skin 93 1.4 266 1.4 351 0.9 819 1.4
149 Chronic Ulcer of Skin, Except Decubitus 199 3.0 248 1.3 826 2.0 1,366 2.3
150 Extensive Third-Degree Burns - - - - - - 7 0.0
151 Other Third-Degree and Extensive Burns 6 0.1 6 0.0 16 0.0 55 0.1
152 Cellulitis, Local Skin Infection 496 7.4 934 5.0 2,720 6.7 5,032 8.5
153 Other Dermatological Disorders 647 9.6 1,716 9.2 4,779 11.8 7,398 12.4
  Fractures, Other Injuries and Poisoning                
154 Severe Head Injury 2 0.0 9 0.0 10 0.0 24 0.0
155 Major Head Injury 46 0.7 169 0.9 215 0.5 440 0.7
156 Concussion or Unspecified Head Injury 82 1.2 177 0.9 445 1.1 858 1.4
157 Vertebral Fractures without Spinal Cord Injury 30 0.4 41 0.2 181 0.4 351 0.6
158 Hip Fracture/Dislocation 47 0.7 101 0.5 268 0.7 595 1.0
159 Major Fracture, Except of Skull, Vertebrae, or Hip 92 1.4 172 0.9 515 1.3 1,037 1.7
160 Internal Injuries 14 0.2 38 0.2 81 0.2 141 0.2
161 Traumatic Amputation 60 0.9 62 0.3 175 0.4 296 0.5
162 Other Injuries 1,033 15.4 1,932 10.3 6,048 14.9 11,126 18.7
163 Poisonings and Allergic Reactions 186 2.8 340 1.8 948 2.3 1,795 3.0
b,c Treatment Complications and Status                
164 Major Complications of Medical Care and Trauma 298 4.4 444 2.4 1,217 3.0 1,805 3.0
165 Other Complications of Medical Care 113 1.7 183 1.0 572 1.4 911 1.5
166 Major Symptoms, Abnormalities 2,756 41.0 3,993 21.3 16,897 41.6 23,250 39.1
167 Minor Symptoms, Signs, Findings 2,318 34.5 3,609 19.2 14,745 36.3 20,037 33.7
174 Major Organ Transplant Status 52 0.8 55 0.3 140 0.3 165 0.3
175 Other Organ Transplant/Replacement 29 0.4 39 0.2 103 0.3 109 0.2
176 Artificial Openings for Feeding or Elimination 81 1.2 245 1.3 280 0.7 422 0.7
177 Amputation Status, Lower Limb/Amputation Complications 44 0.7 35 0.2 137 0.3 229 0.4
178 Amputation Status, Upper Limb - - - - 2 0.0 4 0.0
179 Post-Surgical States/Aftercare/Elective 563 8.4 994 5.3 2,715 6.7 4,531 7.6
  Miscellaneous                
180 Radiation Therapy 25 0.4 17 0.1 154 0.4 190 0.3
181 Chemotherapy 5 0.1 14 0.1 70 0.2 74 0.1
182 Rehabilitation 205 3.1 273 1.5 772 1.9 1,488 2.5
183 Screening/Observation/Special Exams 1,969 29.3 3,924 20.9 13,199 32.5 18,994 32.0
184 History of Disease 100 1.5 95 0.5 495 1.2 753 1.3
TABLE D-3: Hierarchical Condition Classification Distribution for IHSS Recipients Age 65+ by Provider Relationship, 2005
HCC Parents Other Relative Non-Relative
# % # % # %
Spouse is paid as an IHSS worker for recipient, Other Relatives (other than spouse or parent) paid as an IHSS worker for recipient, Non-Relatives refers to all other paid IHSS workers for recipient.

HCC refers to the CMS hierarchical condition category or CMS-HCC model (Pope, Kautter, Ellis, et al., 2004). The HCC provide an established standardized protocol for combining International Classification of Disease (CDC, 2007) or ICD-9 diagnostic codes. HCCs aggregate the over 15,000 ICD-9 categories into 189 condition categories (CCs), five of which are based on beneficiary utilization of selected types of durable medical equipment (Pope, Ellis, Ash, et al., 2000). The CCs describe a broad set of similar diseases, generally organized into body systems. Another advantage is that the CCs hierarchies are designed so that a person is coded only for the most severe manifestation among the related diseases defining the CC. Within the same HCC a person is classified once. For unrelated diseases (i.e., diseases in other CCs), the number of HCCs accumulate.
  1. The computer code used for creating the HCC groupings from ICD-9 coding was downloaded from the CMS website as a SAS program in 2007. The program code did not include HCC 20 in the HCC ICD-9 code file.
  2. The inconsistent number sequence within "Pregnancy/Child Birth Complications" is a result of how the contractor grouped HCCs into the body systems structure used in this table.
  3. The computer code used for creating the HCC groupings from ICD-9 coding was downloaded from the CMS website as a SAS program in 2007. The program code did not include HCC 173 in the HCC ICD-9 code file.
  Total Recipients   4,656     100.0     109,260     100.0     95,551     100.0  
  Recipients w/any HCC 3,847 82.6 91,221 83.5 80,167 83.9
 
  Infections and Parasitic Disease            
1 HIV/AIDS 3 0.1 27 0.0 75 01
2 Septicemia/Shock 119 2.6 1,781 1.6 1,389 1.5
3 Central Nervous System Infection 9 0.2 96 0.1 107 0.1
4 Tuberculosis 14 0.3 192 0.2 106 0.1
5 Opportunistic Infections 14 0.3 94 0.1 75 0.1
6 Other Infectious Diseases 192 4.1 4,263 3.9 5,017 5.3
  Neoplasms            
7 Metastatic Cancer and Acute Leukemia 65 1.4 971 0.9 868 0.9
8 Lung, Upper Digestive Tract, and Other Severe Cancers 97 2.1 1,572 1.4 1,436 1.5
9 Lymphatic, Head and Neck, Brain, and Other Major Cancers 82 1.8 1,182 1.1 1,078 1.1
10 Breast, Prostate, Colorectal and Other Cancers and Tumors 259 5.6 4,206 3.8 4,107 4.3
11 Other Respiratory and Heart Neoplasms 24 0.5 237 0.2 234 0.2
12 Other Digestive and Urinary Neoplasms 167 3.6 3,271 3.0 3,170 3.3
13 Other Neoplasms 56 1.2 1,435 1.3 1,665 1.7
14 Benign Neoplasms of Skin, Breast, Eye 45 1.0 2,181 2.0 2,589 2.7
a Endocrine, Nutritional and Metabolic Disorders            
15 Diabetes with Renal or Peripheral Circulatory Manifestation 109 2.3 1,171 1.1 1,010 1.1
16 Diabetes with Neurologic or Other Specified Manifestation 178 3.8 2,181 2.0 1,919 2.0
17 Diabetes with Acute Complications 8 0.2 161 0.1 153 0.2
18 Diabetes with Ophthalmologic or Unspecified Manifestation 78 1.7 915 0.8 762 0.8
19 Diabetes without Complication 580 12.5 9,905 9.1 8,322 8.7
21 Protein-Calorie Malnutrition 14 0.3 186 0.2 140 0.1
22 Other Significant Endocrine and Metabolic Disorders 25 0.5 341 0.3 318 0.3
23 Disorders of Fluid/Electrolyte/Acid-Base Balance 103 2.2 1,529 1.4 1,406 1.5
24 Other Endocrine/Metabolic/Nutritional Disorders 217 4.7 5,687 5.2 5,007 5.2
  Liver and Gallbladder Disease            
25 End-Stage Liver Disease 18 0.4 186 0.2 142 0.1
26 Cirrhosis of Liver 39 0.8 384 0.4 321 0.3
27 Chronic Hepatitis 14 0.3 198 0.2 174 0.2
28 Acute Liver Failure/Disease 5 0.1 61 0.1 49 0.1
29 Other Hepatitis and Liver Disease 60 1.3 1,050 1.0 844 0.9
30 Gallbladder and Biliary Tract Disorders 73 1.6 1,383 1.3 1,128 1.2
  Gastrointestinal Disease/Disorders            
31 Intestinal Obstruction/Perforation 77 1.7 1,096 1.0 1,083 1.1
32 Pancreatic Disease 41 0.9 651 0.6 590 0.6
33 Inflammatory Bowel Disease 12 0.3 147 0.1 160 0.2
34 Peptic Ulcer, Hemorrhage, Other Specified Gastrointestinal Disorders 194 4.2 3,758 3.4 3,435 3.6
35 Appendicitis 5 0.1 79 0.1 65 0.1
36 Other Gastrointestinal Disorders 669 14.4 14,064 12.9 13,445 14.1
  Musculoskeletal/Connective Tissue Disease/Disorders            
37 Bone/Joint/Muscle Infections/Necrosis 50 1.1 473 0.4 434 0.5
38 Rheumatoid Arthritis & Inflammatory Connective Tissue Disease 57 1.2 1,032 0.9 1,171 1.2
39 Disorders of the Vertebrae and Spinal Discs 238 5.1 5,441 5.0 5,940 6.2
40 Osteoarthritis of Hip or Knee 102 2.2 3,567 3.3 3,467 3.6
41 Osteoporosis and Other Bone/Cartilage Disorders 89 1.9 3,471 3.2 3,321 3.5
42 Congenital/Developmental Skeletal and Connective Tissue Disorders 1 0.0 19 0.0 20 0.0
43 Other Musculoskeletal and Connective Tissue Disorders 1,037 22.3 28,437 26.0 27,887 29.2
  Blood and Blood Forming Organ Disease/Disorders            
44 Severe Hematological Disorders 32 0.7 5 0.6 470 0.5
45 Disorders of Immunity 1 0.0 16 0.0 19 0.0
46 Coagulation Defects and Other Specified Hematological Disorders 22 0.5 390 0.4 393 0.4
47 Iron Deficiency and Other/Unspecified Anemias and Blood Disease 239 5.1 4,647 4.3 4,316 4.5
  Mental Disorders            
48 Delirium and Encephalopathy 18 0.4 293 0.3 298 0.3
49 Dementia/Cerebral Degeneration 167 3.6 3,510 3.2 3,091 3.2
50 Nonpsychotic Organic Brain Syndromes/Conditions 30 0.6 570 0.5 517 0.5
51 Drug/Alcohol Psychosis 5 0.1 42 0.0 89 0.1
52 Drug/Alcohol Dependence 4 0.1 28 0.0 83 0.1
53 Drug/Alcohol Abuse, Without Dependence 7 0.2 82 0.1 151 0.2
54 Schizophrenia 5 0.1 133 0.1 186 0.2
55 Major Depressive, Bipolar, and Paranoid Disorders 23 0.5 711 0.7 936 1.0
56 Reactive and Unspecified Psychosis 18 0.4 319 0.3 301 0.3
57 Personality Disorders - - 8 0.0 12 0.0
58 Depression 19 0.4 488 0.4 546 0.6
59 Anxiety Disorders 5 0.1 144 0.1 186 0.2
60 Other Psychiatric Disorders 25 0.5 678 0.6 867 0.9
  Mental Retardation/Developmental Disability            
61 Profound Mental Retardation/Developmental Disability - - 2 0.0 2 0.0
62 Severe Mental Retardation/Developmental Disability - - 3 0.0 - -
63 Moderate Mental Retardation/Developmental Disability - - - - - -
64 Mild Mental Retardation, Autism, Down's Syndrome - - 16 0.0 9 0.0
65 Other Developmental Disability 1 0.0 8 0.0 13 0.0
66 Attention Deficit Disorder - - 5 0.0 9 0.0
  Central Nervous System Injuries/Disorders            
67 Quadriplegia, Other Extensive Paralysis 5 0.1 42 0.0 36 0.0
68 Paraplegia 7 0.2 37 0.0 43 0.0
69 Spinal Cord Disorders/Injuries 17 0.4 299 0.3 266 0.3
70 Muscular Dystrophy - - 4 0.0 9 0.0
71 Polyneuropathy 33 0.7 430 0.4 446 0.5
72 Multiple Sclerosis 6 0.1 30 0.0 60 0.1
73 Parkinson's and Huntington's Diseases 60 1.3 569 0.5 493 0.5
74 Seizure Disorders and Convulsions 56 1.2 897 0.8 784 0.8
75 Coma, Brain Compression/Anoxic Damage 2 0.0 86 0.1 79 0.1
76 Mononeuropathy, Other Neurological Conditions/Injuries 82 1.8 1,413 1.3 1,560 1.6
  Respiratory System Disorders            
77 Respirator Dependence/Tracheostomy Status 4 0.1 59 0.1 52 0.1
78 Respiratory Arrest 3 0.1 32 0.0 23 0.0
79 Cardio-Respiratory Failure and Shock 145 3.1 1,770 1.6 1,608 1.7
  Cardiovascular System Disease/Disorders            
80 Congestive Heart Failure 483 10.4 8,575 7.8 7,813 8.2
81 Acute Myocardial Infarction 72 1.5 1,322 1.2 1,074 1.1
82 Unstable Angina and Other Acute Ischemic Heart Disease 127 2.7 2,272 2.1 2,017 2.1
83 Angina Pectoris/Old Myocardial Infarction 111 2.4 2,233 2.0 1,959 2.1
84 Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease 520 11.2 9,711 8.9 8,643 9.0
85 Heart Infection/Inflammation, Except Rheumatic 17 0.4 287 0.3 233 0.2
86 Valvular and Rheumatic Heart Disease 234 5.0 5,371 4.9 4,530 4.7
87 Major Congenital Cardiac/Circulatory Defect - - 11 0.0 5 0.0
88 Other Congenital Heart/Circulatory Disease 20 0.4 438 0.4 310 0.3
89 Hypertensive Heart and Renal Disease or Encephalopathy 17 0.4 221 0.2 160 0.2
90 Hypertensive Heart Disease 79 1.7 2,208 2.0 1,721 1.8
91 Hypertension 697 15.0 17,995 16.5 14,887 15.6
92 Specified Heart Arrhythmias 298 6.4 5,575 5.1 5,359 5.6
93 Other Heart Rhythm and Conduction Disorders 239 5.1 4,467 4.1 4,523 4.7
94 Other and Unspecified Heart Disease 172 3.7 3,303 3.0 2,864 3.0
  Cerebral and Other Vascular System Disease/Disorders            
95 Cerebral Hemorrhage 47 1.0 617 0.6 485 0.5
96 Ischemic or Unspecified Stroke 274 5.9 3,714 3.4 3,195 3.3
97 Precerebral Arterial Occlusion and Transient Cerebral Ischemia 235 5.0 4,002 3.7 3,687 3.9
98 Cerebral Atherosclerosis & Aneurysm 47 1.0 896 0.8 761 0.8
99 Cerebrovascular Disease, Unspecified 4 0.1 128 0.1 145 0.2
100 Hemiplegia/Hemiparesis 41 0.9 324 0.3 257 0.3
101 Cerebral Palsy and Other Paralytic Syndromes 9 0.2 58 0.1 66 0.1
102 Speech, Language, Cognitive, Perceptual Deficits 14 0.3 183 0.2 135 0.1
103 Cerebrovascular Disease Late Effects, Unspecified 33 0.7 284 0.3 225 0.2
104 Vascular Disease with Complications 99 2.1 1,248 1.1 1,169 1.2
105 Vascular Disease 288 6.2 4,428 4.1 4,544 4.8
106 Other Circulatory Disease 185 4.0 2,891 2.6 2,887 3.0
  Pulmonary System Disease/Disorders            
107 Cystic Fibrosis - - 3 0.0 4 0.0
108 Chronic Obstructive Pulmonary Disease 339 7.3 5,745 5.3 6,131 6.4
109 Fibrosis of Lung and Other Chronic Lung Disorders 63 1.4 1,249 1.1 1,006 1.1
110 Asthma 69 1.5 1,990 1.8 1,621 1.7
111 Aspiration and Specified Bacterial Pneumonias 68 1.5 921 0.8 716 0.7
112 Pneumococcal Pneumonia, Empyema, Lung Abscess 17 0.4 226 0.2 209 0.2
113 Viral and Unspecified Pneumonia, Pleurisy 287 6.2 5,468 5.0 4,530 4.7
114 Pleural Effusion/Pneumothorax 94 2.0 1,512 1.4 1,312 1.4
115 Other Lung Disorders 320 6.9 6,983 6.4 5,669 5.9
  Eyes and Vision Disorders            
116 Legally Blind 1 0.0 48 0.0 50 0.1
117 Major Eye Infections/Inflammations 5 0.1 74 0.1 53 0.1
118 Retinal Detachment 6 0.1 106 0.1 90 0.1
119 Proliferative Diabetic Retinopathy and Vitreous Hemorrhage 34 0.7 336 0.3 238 0.2
120 Diabetic and Other Vascular Retinopathies 37 0.8 719 0.7 593 0.6
121 Retinal Disorders, Except Detachment and Vascular Retinopathies 34 0.7 1,207 1.1 1,206 1.3
122 Glaucoma 102 2.2 2,670 2.4 2,779 2.9
123 Cataract 248 5.3 6,951 6.4 6,113 6.4
124 Other Eye Disorders 330 7.1 9,446 8.6 8,061 8.4
  Ears, Nose, and Throat Disorders            
125 Significant Ear, Nose, and Throat Disorders 9 0.2 172 0.2 165 0.2
126 Hearing Loss 40 0.9 906 0.8 913 1.0
127 Other Ear, Nose, Throat, and Mouth Disorders 318 6.8 7,595 7.0 6,820 7.1
  Renal System Disorders            
128 Kidney Transplant Status 21 0.5 64 0.1 41 0.0
130 Dialysis Status 127 2.7 1,052 1.0 727 0.8
131 Renal Failure 381 8.2 3,845 3.5 2,875 3.0
132 Nephritis 11 0.2 119 0.1 88 0.1
  Other Genitourinary System Disorders            
133 Urinary Obstruction and Retention 159 3.4 1,905 1.7 1,853 1.9
134 Incontinence 27 0.6 549 0.5 610 0.6
135 Urinary Tract Infection 177 3.8 4,232 3.9 4,021 4.2
136 Other Urinary Tract Disorders 217 4.7 2,884 2.6 2,768 2.9
137 Female Infertility - - 1 0.0 2 0.0
138 Pelvic Inflammatory Disease and Other Specified Female Genital Disorders 9 0.2 583 0.5 536 0.6
139 Other Female Genital Disorders 22 0.5 1,474 1.3 1,490 1.6
140 Male Genital Disorders 180 3.9 1,595 1.5 1,564 1.6
b Pregnancy/Child Birth Complications            
141 Ectopic Pregnancy - - - - - -
142 Miscarriage/Abortion - - 2 0.0 4 0.0
143 Completed Pregnancy With Major Complications - - 1 0.0 - -
144 Completed Pregnancy With Complications 1 0.0 3 0.0 8 0.0
145 Completed Pregnancy Without Complications (Normal Delivery) - - 3 0.0 2 0.0
146 Uncompleted Pregnancy With Complications - - 5 0.0 2 0.0
147 Uncompleted Pregnancy With No or Minor Complications - - 12 0.0 9 0.0
168 Extremely Low Birth weight Neonates - - - - - -
169 Very Low Birth weight Neonates - - - - - -
170 Serious Perinatal Problem Affecting Newborn - - 20 0.0 23 0.0
171 Other Perinatal Problems Affecting Newborn 3 0.1 19 0.0 9 0.0
172 Normal, Single Birth - - 4 0.0 4 0.0
  Dermatological Disorders            
148 Decubitus Ulcer of Skin 34 0.7 523 0.5 636 0.7
149 Chronic Ulcer of Skin, Except Decubitus 105 2.3 1,330 1.2 1,605 1.7
150 Extensive Third-Degree Burns - - - - 2 0.0
151 Other Third-Degree and Extensive Burns 4 0.1 23 0.0 24 0.0
152 Cellulitis, Local Skin Infection 149 3.2 2,424 2.2 2,710 2.8
153 Other Dermatological Disorders 209 4.5 7,171 6.6 8,909 9.3
  Fractures, Other Injuries and Poisoning            
154 Severe Head Injury - - 13 0.0 14 0.0
155 Major Head Injury 23 0.5 454 0.4 368 0.4
156 Concussion or Unspecified Head Injury 34 0.7 869 0.8 855 0.9
157 Vertebral Fractures without Spinal Cord Injury 30 0.6 943 0.9 877 0.9
158 Hip Fracture/Dislocation 47 1.0 1,454 1.3 1,514 1.6
159 Major Fracture, Except of Skull, Vertebrae, or Hip 48 1.0 910 0.8 934 1.0
160 Internal Injuries 8 0.2 68 0.1 76 0.1
161 Traumatic Amputation 28 0.6 98 0.1 85 0.1
162 Other Injuries 362 7.8 8,476 7.8 8,858 9.3
163 Poisonings and Allergic Reactions 32 0.7 683 0.6 694 0.7
b,c Treatment Complications and Status            
164 Major Complications of Medical Care & Trauma 143 3.1 1,639 1.5 1,538 1.6
165 Other Complications of Medical Care 49 1.1 598 0.5 547 0.6
166 Major Symptoms, Abnormalities 1,529 32.8 31,169 28.5 29,015 30.4
167 Minor Symptoms, Signs, Findings 1,133 24.3 23,656 21.7 21,593 22.6
174 Major Organ Transplant Status 10 0.2 49 0.0 36 0.0
175 Other Organ Transplant/Replacement 7 0.2 66 0.1 56 0.1
176 Artificial Openings for Feeding or Elimination 54 1.2 708 0.6 467 0.5
177 Amputation Status, Lower Limb/Amputation Complications 10 0.2 101 0.1 98 0.1
178 Amputation Status, Upper Limb - - 1 0.0 1 0.0
179 Post-Surgical States/Aftercare/Elective 216 4.6 3,778 3.5 3,828 4.0
  Miscellaneous            
180 Radiation Therapy 24 0.5 365 0.3 330 0.3
181 Chemotherapy 10 0.2 111 0.1 91 0.1
182 Rehabilitation 108 2.3 1,566 1.4 1,569 1.6
183 Screening/Observation/Special Exams 644 13.8 15,588 14.3 15,664 16.4
184 History of Disease 33 0.7 776 0.7 842 0.9
TABLE D-4: Ambulatory Care Sensitive Conditions by Provider Relationship, Recipients Ages 3-17, 2005
  Provider Relationship
  # Recipients     Spouse     Parent     Other Relative     Non-Relative  
Ambulatory Care Sensitive Conditions (ACSCs) for those <age 18 are also referred to as Pediatric Quality Indicators (PQIs) (see http://qualityindicators.ahrq.gov). Recipient counts are limited to IHSS recipients not in Medicaid managed care during calendar year 2005. Recipients of Spouse providers were excluded from the analysis. PQIs related to new births, and those <age 3 are not included. Available claims data did not permit the assignment of PQIs for pediatric heart surgery mortality, pediatric heart surgery volume, and postoperative wound dehiscence.
Total Recipients Age 3-17 11,002   7,845 1,449 1,768
Total Recipients w/any Hospitalization 1,439 na 1,118 166 155
Total Recipients w/any ACSC Stay 171 na 128 19 24
ACSC Inpatient Diagnoses
Accidental puncture and laceration 3 na 1 1 1
Decubitus ulcer 4 na 3 - 1
Foreign body left in after procedure - na - - -
Iatrogenic pneumothorax in non-neonates 1 na - 1 -
Postoperative hemorrhage & hematoma 5 na 3 1 1
Postoperative respiratory failure 35 na 28 3 4
Postoperative sepsis 7 na 4 1 2
Selected infection due to medical care 13 na 13 - -
Transfusion reaction - na - - -
Asthma admission rate 34 na 22 5 7
Diabetes short-term complication admission rate 5 na 2 - 3
Gastroenteritis admission rate 33 na 26 4 3
Perforated appendix admission rate 5 na 5 - -
Urinary tract infection admission rate 34 na 27 3 4
TABLE D-5: Ambulatory Care Sensitive Conditions by Provider Relationship, Recipients Ages 18 and Older, 2005
Recipients Age 18-64 Provider Relationship
  # Recipients     Spouse     Parent     Other Relative     Non-Relative  
Ambulatory Care Sensitive Conditions (ACSCs) for those age 18 and over are also referred to as Prevention Quality Indicators (see http://qualityindicators.ahrq.gov). Recipient counts are limited to IHSS recipients not in Medicaid managed care during calendar year 2005. Recipients of Parent providers were excluded from the analysis.

* The records with cardiac procedure codes can be included in the table.
** The records with immunocompromised state procedure codes can be included in the table.
*** The following ICD-9 codes were used: 3536, 9059, 99760~99762, 99769, V4970~V4977, V521.
Total Recipients Age 18-64 123,813 6,282 18,625 40,304 58,602
Total Recipients w/any Hospitalization 28,881 1,923 2,627 9,468 14,863
Total Recipients w/any ACSC Stay 8,046 530 609 2,804 4,103
ACSC Inpatient Diagnoses
Diabetes, short-term complication 277 18 39 78 142
Perforated Appendix 26 4 4 10 8
Diabetes, long-term complication 1,141 105 71 438 527
COPD 1,080 37 33 355 655
Hypertension* 172 8 2 75 87
Congestive Heart Failure* 1,897 142 94 724 937
Dehydration 396 23 36 114 223
Bacterial Pneumonia 2,069 127 226 676 1,040
Urinary Infection** 1,045 80 138 320 509
Angina* 197 9 7 82 99
Diabetes, uncontrolled 167 11 8 54 94
Adult Asthma 847 37 41 292 477
Lower Extremity Amputation*** 17 2 1 7 7
Recipients Age 65+ Provider Relationship
# Recipients Spouse Parent Other Relative Non-Relative
Total Recipients Age 65 or Older 206,579 4,156 na 108,371 94,052
Total Recipients w/any Hospitalization 57,188 1,480 na 28,602 27,106
Total Recipients w/any ACSC Stay 17,507 451 na 8,884 8,172
ACSC Inpatient Diagnoses
Diabetes, short-term complication 109 1 na 57 51
Perforated Appendix 51 - na 28 23
Diabetes, long-term complication 1,394 70 na 700 624
COPD 1,767 41 na 786 940
Hypertension* 415 2 na 205 208
Congestive Heart Failure* 5,410 151 na 2,780 2,479
Dehydration 1,123 23 na 532 568
Bacterial Pneumonia 5,021 130 na 2,660 2,231
Urinary Infection** 2,277 38 na 1,169 1,070
Angina* 308 9 na 144 155
Diabetes, uncontrolled 163 7 na 84 72
Adult Asthma 1,122 19 na 608 495
Lower Extremity Amputation*** 5 - na 3 2

Appendix E. Physician, Outpatient Department, and Emergency Room Use and Expenditures

TABLE E-1: Adjusted Medicaid-Paid Medical Care Use, Excluding Emergency Room Use, by IHSS Recipients,a 2005
Predictors Age 3-17
n=11,002
Age 18-64
n=123,813
Age 65 or More
n=206,579
  Odds Ratio   95% CI   Odds Ratio   95% CI   Odds Ratio   95% CI
SOURCE: Unpublished tables derived from California Department of Health Care Services, Medicaid claims. Events shown under count actual use as they exclude stays paid for fully by non-Medicaid sources.
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. Any ER user counts were as follows: age 3-17, age 18-64, age 65+.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with a score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Unduplicated count of health conditions grouped into 23 subcategories using HCCs.
  7. Reference is Non-Relative provider, "na" means the provider type was not included in the model.
Recipient Characteristics
Female Recipient 0.94   0.76-1.15   0.95   0.90-1.01   0.94   0.91-0.98  
Hispanicb 1.23 0.96-1.57 1.12 1.04-1.20 0.99 0.94-1.03
Black 1.21 0.90-1.61 0.95 0.89-1.01 0.76 0.72-0.80
Asian/Other 1.08 0.75-1.54 1.23 1.11-1.36 0.99 0.95-1.04
Household size (1-5) 1.03 0.93-1.13 0.97 0.95-1.00 1.03 1.01-1.04
3+ Cognitive Limitationsc 1.41 1.07-1.86 0.98 0.88-1.09 0.98 0.88-1.09
3+ ADL Limitationsd 0.78 0.59-1.02 0.92 0.86-0.98 0.92 0.88-0.96
Respiratory Limitationse 0.71 0.52-0.98 0.85 0.76-0.96 0.83 0.77-0.90
Number Health Conditionsf   32.8 27.3-39.3 10.6 10.2-11.0 7.54 7.37-7.71
Provider Relationshipg
Spouse na na 1.99 1.69-2.33 1.48 1.29-1.71
Parent 1.73 1.35-2.22 0.86 0.80-0.93 na na
Other Relative 0.96 0.69-1.34 1.10 1.03-1.18 1.08 1.04-1.12
Total Authorized Hours 1.00 1.00-1.00 1.00 1.00-1.00 1.00 1.00-1.00
County Characteristics
Per Capita Income 0.98 0.97-1.00 0.99 0.99-0.99 1.00 1.00-1.00
New IHSS Recipients 0.12 0.09-0.17 0.06 0.06-0.07 0.04 0.04-0.04
Model Goodness of Fit
-2Log Likelihood 2728   35594   89729  
Maximum Rescaled R2 0.838   0.735   0.661  
TABLE E-2: Mean Medicaid-Paid Physician Expenditures by IHSS Recipients,a 2005
Variable Age 3-17 Age 18-64 Age 65 or More
n Mean Std Dev n Mean Std Dev n   Mean   Std Dev
SOURCE: Derived from the California Department of Health Care Services, Medicaid claims, vendor group 5 (physicians, and physician groups, nurse practitioner, surgi-centers, rural health clinics).
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The number of care recipients does not equal the number of eligible recipients due to the absence of vendor group 5 claims.
All Recipients   8,534         102,857         161,276      
Grand Total     1,057     2,379       1,126     2,884     317   1,391  
  Average $/month   110 343   136 458   35 188
Spouse na     5,804     3,543    
  Period Mean Total $   na na   1,240 3,556   415 1,747
  Average $/month   na na   148 474   48 242
Parent 6,424     13,010     na    
  Period Mean Total $   1,104 2,483   754 2,007   na na
  Average $/month   111 362   81 258   na na
Other Relative 992     34,881     84,007    
  Period Mean Total $   944 1,829   1,227 3,159   311 1,350
  Average $/month   96 211   143 474   35 193
Non-Relative 1,118     49,162     73,726    
  Period Mean Total $   887 2,179   1,139 2,779   319 1,418
  Average $/month   112 324   145 485   35 179
Continuing Recipients 7,566     87,634     145,053    
Grand Total   1,085 2,381   1,120 2,815   316 1,407
  Average $/month   106 332   121 419   32 172
Spouse na     4,928     2,996    
  Period Mean Total $   na na   1,198 3,422   414 1,809
  Average $/month   na na   128 441   41 167
Parent 5,768     11,933     na    
  Period Mean Total $   1,131 2,492   730 1,943   na na
  Average $/month   108 359   73 232   na na
Other Relative 863     29,133     74,883    
  Period Mean Total $   948 1,742   1,225 3,073   306 1,346
  Average $/month   91 176   128 444   31 169
Non-Relative 935     41,640     67,174    
  Period Mean Total $   927 2,176   1,148 2,748   322 1,452
  Average $/month   101 262   129 439   33 175
New IHSS Recipients 968     15,223     16,223    
Grand Total   838 2,349   1,161 3,254   329 1,240
  Average $/month   142 415   224 631   62 296
Spouse na     876     547    
  Period Mean Total $   na na   1,475 4,230   416 1,359
  Average $/month   na na   255 617   86 475
Parent 656     1,077     na    
  Period Mean Total $   866 2,396   1,019 2,600   na na
  Average $/month   138 385   169 446   na na
Other Relative 129     5,748     9,124    
  Period Mean Total $   917 2,336   1,236 3,563   350 1,381
  Average $/month   129 367   214 596   63 330
Non-Relative 183     7,522     6,552    
  Period Mean Total $   682 2,187   1,087 2,941   293 997
  Average $/month   167 535   235 678   59 215
TABLE E-3: Mean Medicaid-Paid Outpatient Department Expenditures by IHSS Recipients,a 2005
Variable Age 3-17 Age 18-64 Age 65 or More
n   Mean     Std Dev   n   Mean     Std Dev   n   Mean     Std Dev  
SOURCE: Derived from the California Department of Health Care Services, Medicaid claims, vendor group 6 (hospital outpatient departments, organized outpatient clinics).
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The number of care recipients does not equal the number of eligible recipients due to the absence of vendor group 6 claims.
All Recipients   6,476         72,861         98,875      
Grand Total   965 8,633   574 2,856   179 628
  Average $/month   95 740   67 322   20 77
Spouse na     4,141     2,402    
  Period Mean Total $   na na   613 1,911   219 903
  Average $/month   na na   69 216   25 97
Parent 4,974     8,397     na    
  Period Mean Total $   1,037 9,783   596 6,154   na na
  Average $/month   99 831   64 567   na na
Other Relative 700     23,456     49,490    
  Period Mean Total $   772 1,807   600 2,220   176 567
  Average $/month   75 199   67 264   19 73
Non-Relative 802     36,867     46,983    
  Period Mean Total $   686 2,277   548 1,987   180 670
  Average $/month   87 308   68 286   20 80
Continuing Recipients 5,853     62,189     87.846    
Grand Total   985 9,060   566 2,936   179 635
  Average $/month   91 769   58 295   18 75
Spouse na     3,518     1,999    
  Period Mean Total $   na na   582 1,811   206 887
  Average $/month   na na   57 169   20 81
Parent 4,534     7,676     na    
  Period Mean Total $   1,062 10,231   590 6,389   na na
  Average $/month   97 867   58 561   na na
Other Relative 633     19,706     43,475    
  Period Mean Total $   748 1,664   588 2,143   175 556
  Average $/month   69 164   59 223   18 69
Non-Relative 686     31,289     42,372    
  Period Mean Total $   699 2,402   544 1,964   182 693
  Average $/month   72 242   59 247   19 81
New IHSS Recipients 623     10,672     11,029    
Grand Total   774 1,865   621 2,335   176 569
  Average $/month   131 351   120 443   32 93
Spouse na     623     403    
  Period Mean Total $   na na   789 2,393   284 978
  Average $/month   na na   136 379   50 150
Parent 440     721     na    
  Period Mean Total $   784 1,802   664 2,554   na na
  Average $/month   119 267   132 616   na na
Other Relative 67     3,750     6,015    
  Period Mean Total $   994 2,834   663 2,587   183 640
  Average $/month   132 398   113 415   31 99
Non-Relative 116     5,578     4,611    
  Period Mean Total $   610 1,318   569 2,108   158 395
  Average $/month   176 549   120 441   31 77

Appendix F. Home Care and Nursing Home Expenditures and Use

TABLE F-1 Unadjusted Probability of Medicaid-Paid Nursing Home Stays, 2005
(Excludes IHSS Recipients in Managed Care)
Provider Type Any Nursing Home Stays
No Yes Total % Yes
SOURCE: Derived from Medicaid claims maintained by the California Department of Health Care Services. Nursing home use identified by vendor codes 47 (ICF-DD), and 80 (nursing facility).
Recipients Age 3-17
Parent 7,759 26 7,785 0.33%
Other Relative   1,446 3 1,449 0.21%
Non-Relative 1,763 5 1,768 0.28%
Total 10,968 34 11,002 0.31%
Recipients Age 18-64
Spouse 6,116 166 6,282 2.64%
Parent 18,375 250 18,625 1.34%
Other Relative 39,370 934 40,304 2.32%
Non-Relative 56,785 1,817 58,602 3.10%
Total   120,646     3,167     123,813     2.56%  
Recipients Age 65 +
Spouse 3,853 303 4,156 7.29%
Other Relative 102,811 5,560 108,371 5.13%
Non-Relative 86,924 7,128 94,052 7.58%
Total 193,588 12,991 206,579 6.29%
TABLE F-2: Adjusted Medicaid-Paid Nursing Home Use by Adult IHSS Recipients, 2005a
(Excludes IHSS Recipients in Managed Care)
Predictors Age 18-64
n=123,813
Age 65 or More
n=206,579
  Odds Ratio   95% CI   Odds Ratio   95% CI
SOURCE: Derived from Medicaid claims maintained by the California Department of Health Care Services. Nursing home use was identified using vendor codes 47 ICF-DD), and 80 (nursing facility). The number of nursing home users age 3-17 not included as the group was too small for reliable logistic models. Nursing home users age 18-64, or age 65+ may not equal the number of actual users, if the use was paid solely from non-Medicaid sources.
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with a score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. HCC refers to Hierarchical Condition Classification, collapsed into 23 subgroups, count is unduplicated number of these groupings.
  7. Reference is Non-Relative provider, “na” means the provider type was not included in the model.
Intercept        
Recipient Characteristics
Female Recipient 0.71   0.66-0.76   0.99   0.95-1.03  
Hispanicb 0.90 0.82-1.00 0.88 0.84-0.92
Blackb 1.01 0.92-1.10 1.18 1.12-1.25
Asian/Otherb 0.75 0.65-0.88 0.83 0.79-0.88
Householdsize (1-5) 0.97 0.94-1.01 0.96 0.94-0.97
3+ Cognitive Limitationsc 0.46 0.37-0.57 1.15 1.03-1.28
3+ ADL Limitationsd 1.42 1.30-1.56 1.34 1.28-1.40
Respiratory Limitationse 0.95 0.84-1.08 1.02 0.95-1.09
Number Health Conditionsf   1.26 1.25-1.27 1.27 1.26-1.28
Provider Relationshipg        
Spouse 0.73 0.61-0.86 0.88 0.78-1.00
Parent 0.58 0.50-0.67 na na
Other Relative 0.81 0.74-0.88 0.74 0.71-0.77
Total Authorized Hours 1.00 1.00-1.01 1.01 1.00-1.01
County Characteristics
Per Capita Income 1.01 1.01-1.02 1.00 0.99-1.00
New IHSS Recipients 0.89 0.81-0.99 0.80 0.75-0.85
Model Goodness of Fit
-2Log Likelihood 26721   89629  
Maximum Rescaled R2 0.104   0.094  
TABLE F-3: Logarithm Transformed Mean Medicaid-Paid Monthly HCBS Waiver Expenditures by IHSS Recipients, 2005a
Predictors Provider Relationship
Age 3-17g
n=50
Age 18-64
n=5,258
Age 65+
n=35,205
B   Pr > |t|   B   Pr > |t|   B   Pr > |t|  
* p<0.05, ** p<0.01, *** p<0.001, **** p<0.0001
SOURCE: Derived from California Department of Health Care Services, Medicaid claims, 2005, vendor codes 71 (HCBS), 73 (AIDS waiver), 81 (MSSP).
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The Medicaid expenditures used as the basis for this analysis include reimbursement for personal assistance/home care.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 Cannot perform without human assistance. The measure is a dummy variable yes = have three or more ADLs each with a score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Number of persons in household, including other IHSS recipients, excludes non-IHSS children <age 14.
  7. HCC refers to Hierarchical Condition Classification, collapsed into 23 subgroups, count is unduplicated number of these groupings.
  8. Reference is Non-Relative provider, “na” means the provider type was not included in the model.
Intercept   4.877   *   5.903   ****   6.077   ****
Recipient Characteristicsb
Female Recipient 0.477   -0.110 * -0.064 ****
Hispanic 0.281   -0.066   -0.316 ****
Blacka 0.885   -0.071   -0.304 ****
Asian/Other -1.399   0.147   -0.060 ****
3+ Cognitive Limitationsc   -0.492   0.124   0.059  
3+ ADL Limitationsd -1.357   0.154 ** 0.112 ****
Respiratory Limitationse -1.626 * 0.793 **** -0.133 ****
Household size (1-5+)f 0.334   0.014   0.014 *
Sum HCCsg 0.099   -0.040 **** -0.025 ****
IHSS Providersh
Spouse Provider na   0.208   -0.079  
Parent Provider -0.256   0.422 *** na  
Relative Provider 0.126   -0.019   0.069 ****
Total Authorized Hours 0.002   0.000   -0.000 ***
County Characteristics
Per Capita Income -0.012   0.008 * 0.006 ****
>Interactions
Spouse x Sum HCC na   -0.049   0.004  
Parent x Sum HCC 0.003   -0.019   na  
Relative x Sum HCC -0.043   -0.004   -0.009 *
New IHSS Recipients 0.998   0.313 **** 0.407 ****
Model Goodness of Fit
Adjusted R2 0.050   0.053 **** 0.049 ****
TABLE F-4: Logarithm Transformed Mean Monthly Medicaid-Paid IHSS Expenditures by IHSS Recipients, 2005a
Predictors Age 3-17g
n=3,936
Age 18-64
n=114,626
Age 65+
n=198,593
B   Pr > |t|   B   Pr > |t|   B   Pr > |t|  
* p<0.05, ** p<0.01, *** p<0.001, **** p<0.0001
SOURCE: Derived from California Department of Health Care Services, Medicaid claims, 2005, vendor code 89 (IHSS).
  1. Sample includes all eligible IHSS recipients, excluding those in managed care for one month or more in 2005. The Medicaid expenditures used as the basis for this analysis include reimbursement for personal assistance/home care.
  2. Reference is White.
  3. Cognition is defined by: memory, orientation, and judgment. Each scored 1 independent; 2 able to perform, but needs verbal assistance such as reminders, guidance, or encouragement; 5 cannot perform without human assistance. Scores three and four not used. The measure is a dummy variable yes = have three cognitive measures each with a score five.
  4. ADLs refers to activities of daily living (i.e., bathing and grooming; dressing; transferring; bowel, bladder and menstrual; eating). Each task is scored on a four or five point scale: 1 and 2 as per above, 3 Can perform with some human direct physical assistance from the provider, 4 Can perform with a lot of human assistance, 5 cannot perform without human assistance. The measure is a dummy variable yes = have 3 or more ADLs each with a score of three or more indicating the need for human assistance.
  5. Breathing is scored 1 independent, 5 cannot perform without human assistance, 6 paramedical services needed. The measure is the presence/absence of a breathing item with a score of five or more.
  6. Number of persons in household, including other IHSS recipients, excludes non-IHSS children <age 14.
  7. HCC refers to Hierarchical Condition Classification, collapsed into 23 subgroups, count is unduplicated number of these groupings.
  8. Reference is Non-Relative provider, “na” means the provider type was not included in the model.
Intercept   4.938   ****   5.021   ****   4.993   ****
Recipient Characteristicsb
Female Recipient 0.097 **** 0.032 **** 0.028 ****
Hispanic 0.051   0.071 **** 0.004  
Black a 0.058   0.131 **** 0.047 ****
Asian/Other 0.101 * 0.077 **** 0.004 ****
3+ Cognitive Limitationsc   -0.274 **** -0.497 **** -0.690 ****
3+ ADL Limitationsd 0.424 **** 0.259 **** 0.209 ****
Respiratory Limitationse 0.101 ** 0.040 **** -0.022 ****
Household size (1-5+)f -0.018   -0.021 **** -0.012 ****
Sum HCCsg 0.012   0.001   -0.003 ****
IHSS Providersh
Spouse Provider na   -0.945   -0.921 ****
Parent Provider -0.900 **** -0.053 **** na  
Relative Provider 0.083 * 0.062 **** 0.054 ****
Total Authorized Hours 0.008 **** 0.010 **** 0.011 ****
County Characteristics
Per Capita Income 0.012 **** 0.011 **** 0.012 ****
Interactions
Spouse x Sum HCC na   0.005   -0.004  
Parent x Sum HCC -0.004   -0.001   na  
Relative x Sum HCC -0.010   0.000   0.003 ***
New IHSS Recipients 0.023   0.060 **** 0.037 ****
Model Goodness of Fit
Adjusted R2 0.478 **** 0.644 **** 0.638 ****
TABLE F-5: Logarithm Transformed Mean Monthly Medicaid-Paid Nursing Home Expenditures by IHSS Recipients, 2005
(Excludes Recipients in Managed Care)
Recipients All Ages Age 3-17 Age 18-64 Age 65 or More
n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev   n Mean   Std Dev  
SOURCE: Derived from California Department of Health Care Services, Medicaid claims with vendor codes of 47 (ICF-DD) or 80 (nursing facility) indicating nursing home inpatient claims.
All Recipients   16192       34       3167         12991      
Grand Total     12209   15930     45102   66090     12292   17390     12103   15121
  Mean $/months     3625 8691   16890 45835   3245 7469   3683 8643
Spouse 469       na       166     303    
  Mean Total $   10273 16012   na na   10574 16089   10108 15993
  Mean $/month     2848 7610   na na   2785 8921   2882 6801
Parent 276     26     250     na    
  Mean Total $   19421 32711   43702 70460   16896 24806   na na
  Mean $/month     5266 17709   17392 50365   4004 8643   na na
Other Relative 6497     3     934     5560    
  Mean Total $   11854 15162   26480 12769   11822 15959   11851 15024
  Mean $/month     3245 7908   4195 2505   2783 6244   3322 8154
Non-Relative 8950     5     1817     7128    
  Mean Total $   12346 15622   63558 65007   12057 16887   12384 15150
  Mean $/month     3891 8849   21897 36348   3420 7715   3999 9061
Continuing Recipients 14305     32     2663     11610    
  Total   12714 16411   47273 67530   12991 18189   12555 15507
  Mean $/months     3729 8923   17853 47117   3297 7685   3789 8833
Spouse 402     na     146     256    
  Mean Total $   10796 16864   na na   10933 16808   10718 16928
  Mean $/month     2968 8065   na na   2928 9471   2991 7160
Parent 245     25     220     na    
  Mean Total $   20823 33896   45443 71340   18025 25402   na na
  Mean $/month     5589 18658   18086 51277   4169 8937   na na
Other Relative 5770     3     788     4979    
  Mean Total $   12266 15507   26480 12769   12402 16504   12236 15344
  Mean $/month     3352 8023   4195 2505   2863 6444   3429 8245
Non-Relative 7888     4     1509     6375    
  Mean Total $   12888 16129   74305 69747   12764 17795   12879 15567
  Mean $/month     3985 9106   26636 40147   3432 7882   4102 9313
New IHSS Recipients 1887     2     504     1381    
  Total   8381 10918   10374 14423   8598 11675   8299 10632
  Mean $/months     2839 6625   1491 2047   2972 6204   2792 6778
Spouse 67     na     20     47    
  Mean Total $   7130 8853   na na   7948 9157   6782 8798
  Mean $/month     2126 3852   na na   1743 2320   2288 4356
Parent 31     1     30     na    
  Mean Total $   8342 17921   175 --   8614 18162   na na
  Mean $/month     2706 5972   44 --   2794 6053   na na
Other Relative 727     --     146     581    
  Mean Total $   8583 11575     --   8693 12190   8555 11426
  Mean $/month     2396 6877     --   2351 5025   2407 7272
Non-Relative 1062     1     308     753    
  Mean Total $   8324 10301   20572 --   8594 10806   8197 10089
  Mean $/month     3191 6590   2939 --   3364 6848   3121 6489

Notes

1 If a recipient had “L” (leave of absence, n=599) or an “I” (interim eligible, n=72) status in all listed months in 2005, they were not eligible for inclusion.

2 Several decision rules were adopted to address persons with multiple providers in any month or who changed provider types during the year: (i) If any individual appears in the Parent/Spouse group for any month in the year, they were classified as in the Parent/Spouse group, regardless of any other combination of providers. This corresponds to the assumption of “an intention to treat.” (ii) If the recipient-provider relationship is missing in all eligible months they were classified into the Non-Relative group. (iii) If an individual appears in a combination of Other Relative and Non-Relative groups during the year, they are classified as in the Other Relative group. This again assumes an intention to treat. (iv) If an individual has a combination of Other Relatives (e.g., minor/adult child, or Other Relatives) during the year, they are classified as having an Other Relative provider. If they had multiple Non-Relative providers in the year, they were classified in the Non-Relative provider group.

3 Additional county-level attributes were considered and tested in earlier analyses. These included alternative long-term care service supply measures like nursing homes, ICF-MR, adult care facilities, residential care facilities for the elderly; proxy measures for personal assistance labor supply like the per capita number of racial/ethnic minorities, and proxy measures for service demand like the per capita number of aged. These measures are associated with IHSS participation in counties, but they do have consistent associations with the choice of provider types for recipients in the IHSS program itself. For this reason they have not been used in the final models.

Location- & Geography-Based Data
State Data