©Truven Health Analytics Inc. All Rights Reserved. 1 Jessica Kasten and Rebecca Woodward August 14 th - 15 th 2014 Minnesota LTSS Service Access Study: Findings from Years 1 and 2

©Truven Health Analytics Inc. All Rights Reserved. 2 Minnesota is National Leader in Publicly-funded LTSS Ranked 1st in AARP Scorecard in overall performance across multiple dimensions, both in the 2011 and 2014 editions Increased shares of people receiving LTSS in the community Ranked 3 rd on Medicaid per-person spending specific to HCBS (2012) 1

©Truven Health Analytics Inc. All Rights Reserved. 3 Purpose of Study  Authorized by 2011 Legislature  If there were impacts of rate changes, how much?  What other factors were relevant to access?  How do findings support development of access measures for a DHS Dashboard? The main purpose was to ascertain the extent to which provider rate changes affected recipients’ ability to access LTSS.

©Truven Health Analytics Inc. All Rights Reserved. 4 Study Period Timeline for Provider Rate Change Effects

©Truven Health Analytics Inc. All Rights Reserved. 5 Three Phases of Study Close collaboration with DHS Background and Selection of Access Measures Exploratory analysis of trends and encounter data Multivariate analysis

©Truven Health Analytics Inc. All Rights Reserved. 6 6 Phase 1 Background on Service Access and Selection of Measures

©Truven Health Analytics Inc. All Rights Reserved. 7 Background on Service Access and Selection of Measures, 2012  Literature Review related to measurement of access in health care and LTSS  Review of how access to LTSS is assured in managed care o Interviewed MN MCO key informants  Proposed several measure domains to explore in the quantitative analysis: 1.Comparison of services used to services authorized, with a significant discrepancy indicating an access constraint 2.Service utilization 3.Provider availability  Measures described in discussion of multivariate analysis Truven Health gathered and synthesized background materials to inform the selection of LTSS service access metrics.

©Truven Health Analytics Inc. All Rights Reserved. 8 MCOs’ Perspectives on Access  Semi-structured telephone interviews (December February 2013) using protocol approved by DHS  MCOs use numerous methods to assure access to LTSS  MCOs use several sources to assess their enrollees’ access to LTSS  MCOs generally did not think the rate changes affected access  Some did not think providers could sustain further cuts  Some thought the increase in PCA requirements adversely affected provider availability

©Truven Health Analytics Inc. All Rights Reserved. 9 9 Phase 2 Exploratory Analysis of Trends and Encounter Data

©Truven Health Analytics Inc. All Rights Reserved. 10 Service Use Trends  Selected services based on multiple criteria (e.g. policy interest, adequate data, offered by multiple programs, etc.) o Personal Care Assistance (PCA) o Private Duty Nursing (PDN) o Skilled Nurse Visit (SNV) o Homemaker o Consumer Directed Community Supports (CDCS)  Examined number of recipients using the service and amount of service used over the study period  Examined by delivery system (FFS and managed care)  Average number of people using the service increased both in FFS and managed care for PCA, homemaker, and CDCS  Trends not consistent between FFS and managed care for PDN or SNV

©Truven Health Analytics Inc. All Rights Reserved. 11 Encounter Data Review  Reviewed encounter claims for the 5 services included in the trends analysis  Reviewed most relevant claims fields with particular focus on units of service  Most important finding for multivariate analysis was the significant number of outliers in units of service for some services in some years o Addressed by trimming the outliers to reasonable amounts based on DHS billing guidelines

©Truven Health Analytics Inc. All Rights Reserved. 12 ©Truven Health Analytics Inc. All Rights Reserved. 12 Phase 3 Multivariate Analysis

©Truven Health Analytics Inc. All Rights Reserved. 13 Multivariate Analysis Overview  Statistical study of 2 or more variables of interest at the same time  Include factors such as geographic area, age of recipient, level of likely LTSS need, etc.  Main focus was rate effects (FYs )  Explored same set of services from Phase 2, except for CDCS o CDCS presented methodological challenges  Included large number of State data sources  Added Rural Urban Commuting Area (RUCA) classification of geographic areas What has been the impact of rate changes, relative to other potential correlates, on access to LTSS in Minnesota?

©Truven Health Analytics Inc. All Rights Reserved. 14 Multivariate Outcome Variables Multivariate Model Access Measure as Dependent Variable Access Measure Description Service Authorized Amount vs. Used Measure 1 (FFS Only)% difference between authorized and used amounts of LTSS Service X, with access constraint defined as a discrepancy of >15% UtilizationMeasure 2Out of those eligible, use or non-use of LTSS Service X within a given yearly quarter Measure 3Out of service users, amount (units) of LTSS Service X used within a given yearly quarter Provider Availability Measures 4a and 4bNumber of enrolled LTSS providers per county (4a) and participating LTSS providers per county (4b) Measures 5Ratio of unique recipients to unique participating LTSS providers

©Truven Health Analytics Inc. All Rights Reserved. 15 Explanatory Variables Zip code characteristics (e.g. RUCA) Provider rate changes Recipient characteristics that vary over time (e.g. age) Recipient characteristics that do not vary over time (e.g. gender, race)

©Truven Health Analytics Inc. All Rights Reserved. 16 Measure 1 Results: Discrepancy Between Authorized and Used Amounts of Service

©Truven Health Analytics Inc. All Rights Reserved. 17 Measure 2 Results: Use vs. Non-Use of Service

©Truven Health Analytics Inc. All Rights Reserved. 18 Measure 3 Results: Amount of Service Used

©Truven Health Analytics Inc. All Rights Reserved. 19 Measure 4a Results: Enrolled Provider Counts

©Truven Health Analytics Inc. All Rights Reserved. 20 Measure 4b Results: Participating Provider Counts

©Truven Health Analytics Inc. All Rights Reserved. 21 Measure 5 Results: Ratio of Unique Recipients to Unique Participating Providers

©Truven Health Analytics Inc. All Rights Reserved. 22 Multivariate Summary  Designed and analyzed access measures tailored to available data and DHS’ interests  Novel approach with few, if any, precedents  Most of the measures showed some rate change effects with Measure 3 (amounts of service used) showing the largest effects  Provider availability measures showed the least rate change effects  PCA appears to be the service, of the four examined, most greatly affected by the rate changes  Other factors such as age, level of LTSS need, and geographic area had much larger influence than the rate changes on access in Measures 1 and 2, but comparable or smaller-sized effects in Measure 3  Enrollment in managed care often has a larger effect on access measures as compared to the effects of other factors

©Truven Health Analytics Inc. All Rights Reserved. 23 Study Limitations  Main focus and charge were to determine whether there were rate change effects  Not able to explore whether other statistical approaches might explain the access measures better (i.e. better “fit” to data)  With no available control group, an observational study like this shows associations, not causation  Difficult to control for policy or programmatic changes (e.g. PCA reform)  Likely other factors we have neither identified nor controlled for  Presence of an informal caregiver  Level of LTSS need for people without assessments

©Truven Health Analytics Inc. All Rights Reserved. 24 Next Steps  Development of technical appendix  Consider which measures best lend themselves to Dashboard metrics and what the most useful “drill-down” variables should be  Age group  Geographic location (RUCA, county, other)  Program (waiver, home care)  Develop Dashboard and test measures

©Truven Health Analytics Inc. All Rights Reserved. 25 COMMENTS AND QUESTIONS

©Truven Health Analytics Inc. All Rights Reserved. 26 More than Data. Answers. Jessica Kasten Rebecca Woodward