1. Medicaid home care payments for children with special health care needs: A Structural Equation Model Approach Yichen Zhang, PhD Candidate, MS, Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX Omolola Adepoju, PhD, MPH, United Health Group, Sugar Land, TX Charles Phillips, PhD, MPH, Department of Health Policy and Management, School of Public Health, Texas A&M Health Science Center, College Station, TX

2. Outline Background Objective Methods Results Conclusions

3. Background The management of children with special needs can be very challenging and expensive –Nationally, 1 in every 5 households affected –Texas, > 1 million children in this category Medicaid Personal Care Services (PCS) –Provides ADL and IADL assistance to patients who due to impairments require assistance in personal care. –PCS provided to 0.25% of all children receiving Texas Medicaid. –Account for >5% of total Medicaid spend in State –On average, Texas spent $31,570 on healthcare services per child receiving PCS versus $1,571 per child not receiving PCS (Miller et al., 2010)

4. Objective This study models the determinants of Medicaid home care payments –For children with special health care needs receiving PCS. –Structural Equation Modeling (SEM) to estimate the effects of children’s strengths and needs on total expenditures for Medicaid home care. –Shed light both on direct and indirect cost drivers for this group of children –The potential impacts on formal and informal care and health care services usage, and provide justification for the need of these services.

5. Methods Data –Texas Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program –Retrospectively Children ages 4-20 –Receiving PCS through Medicaid PCS –6-month period (September 2008- April 2009) –Texas’ 11 Health Regions –Total 2,760 assessments

6. Methods Endogenous Measures Home care payments: Total Texas Medicaid PCS payments for Home care Level of intellectual disability. Externalizing behaviors PCS hours Rehabilitation Exogenous Measures Age Region Medical Conditions Health Impairments Cognitive Problems Activities of Daily Living (ADL)

7. Methods Analysis –Conceptual model –Descriptive analysis Frequencies, Means and standard deviation –Child characteristics, clinical conditions and functional measures –Structural Equation Model Medical conditions Health impairments cognitive problem Activities of Daily Living Behaviors PCS hours Rehabilitation

8. Results CharacteristicsResponseFrequencyPercentage GenderMale115542.3 Female157757.7 Intellectual DisabilityNo ID Diagnosed142351.6 ID diagnosed133748.4 RehabilitationNo rehabilitation service received116642.2 Rehabilitation service received159457.8 RegionLow cost region (1,2,5,7,8,9)133148.2 High cost region (3,4,6,10,11)142951.8 MeanStd DevMinMax Age12.074.92420 ADL Limitation scale5.273.26010 Authorized PCS hours25.4815.011.25157.75 Externalizing behaviors2.402.79013 Medical conditions1.411.35010 Health Impairments1.241.5409 Cognitive problems6.953.81012 Home payments (US$)12,10317,9910174,869 Table 1: Characteristics of Sample Children Receiving Medicaid Personal Care Services (PCS; n= 2760)

9. Results Table 2: Maximum Likelihood Parameter Estimates for the Final Cost Model

10. Health Impairment -0.04 0.24** -0.19** Age Externalizing Behaviors 0.39** -0.24** Cognitive Problems 0.28** Rehabilitation 0.11** -0.33** 0.26** Hours -0.08** 0.07** -0.12** Intellectual Disability Activities of Daily Living 0.04** 0.32** 0.15** Region 0.31** Medical Conditions 0.06** 0.09** Log pay Final SEM model Figure 1: Corrected, best fit structural equation mode (n=2760). Standardized coefficients are presented. E’s are associated errors. *p<0.05 **p>|z|<0.05 statistical significance level

11. Results Direct pathways significantly related to total payments for home care: –the receipt for rehabilitation services –the level of PCS hours –the presence of externalizing behaviors, and Indirect Pathways: –Cognitive problems –Age Direct + Indirect Pathways –residence in a high cost health region –the presence of an ID diagnosis; –the level of activity limitations as measured by the ADL scale –Medical conditions

12. Conclusion The most important drivers of home care expenditures for children –Among those elements of the model that have both meaningful direct and indirect effects Medical Conditions, Intellectual Disability, Region, And ADL Function The only one of these factors that may be within the sphere of policy manipulation is the difference among costs in different regions.

13. Strengths & Limitations SEM may allow researchers to develop and test more elaborate models than single equation modeling Limitations: –Potential endogeneity –Relies on actual payments –Data are limited to one class of children and one state

14. References Elliott TR, Phillips CD, Patnaik A, et al. Medicaid Personal Care Services and Caregivers' Reports of Children's Health: The Dynamics of a Relationship. Health Services Research. 2011;46(6pt1):1803-1821. Miller TR, Elliott TR, McMaughan DM, et al. Personal Care Services Provided to Children with Special Health Care Needs (CSHCN) and Their Subsequent Use of Physician Services. Disability and Health Journal. 2013;6(4):317-324. Phillips CD, Patnaik A, Dyer J, et al. Children And Medicaid Personal Care Services (PCS) In Texas, 2009.. Texas A&M Health Science Center School Of Rural Public Health, Texas A&M University College Of Education And Human Development, Texas A&M University Public Policy Research Institute 2010. Phillips CD, Patnaik A, Moudouni DK, et al. Summarizing Activity Limitations in Children with Chronic Illnesses Living in the Community: a Measurement Study of Scales Using Supplemented Inter RAI Items. BMC Health Serv Res. 2012;12:19.

15. Thank you! Questions? Comments? For more information, Please read: Adepoju OE, Zhang Y, Phillips CD. Modeling the determinants of Medicaid home care payments for children with special health care needs: A structural equation model approach. Disabil Health J. 2014 Oct;7(4):426-32. doi: 10.1016/j.dhjo.2014.05.003. Epub 2014 Jun 7.