Modeling the determinants of Medicaid home care payments for children with special health care needs: A structural equation model approach

The Pediatric Personal Care Allocation Model for Home Care (PCAM): A Personal Care Case-Mix Model for Children Facing Special Health Care Challenges

Background:

State Medicaid programs in the United States provide services to children with special health care challenges through the Early Prevention, Screening, Diagnostic, and Treatment program. One element of the services provided is Medicaid Personal Care Services (PCS), which are intended to correct or ameliorate any functional impairments faced by a child or youth (C/Y) in the community. Previous research indicates that considerable variation in the allocation of PCS depends on the assessor. A case-mix model is developed that might make the distribution of such services more uniform and equitable.

Data:

The sample in this research includes 2708 C/Y aged 4 to 20 who were receiving PCS in Texas in 2008.

Results:

A case-mix model was developed that groups sample members into 33 categories based on the number of hours of PCS authorized by an assessor. The Pediatric Personal Care Allocation Model (PCAM) explains 27% of the variance in the allocation of PCS hours.

Discussion:

The implementation of the PCAM should provide guidance to assist in ensuring that C/Y facing similar functional challenges receive similar levels of PCS. However, implementation of any case-mix model is only a first step in moving to a prospective payment system for PCS.

Health services use and costs in people with intellectual disability: building a context knowledge base for evidence-informed policy

PURPOSE OF REVIEW

We summarize the research published between 2011 and 2015 in healthcare utilization and costs for persons with intellectual disabilities/intellectual developmental disorders with a particular focus on context studies for evidence-informed policy.

RECENT FINDINGS

Persons with intellectual disability show higher unmet needs and lower use of promotion and prevention services and generic health services. Use of generic psychiatric services varies across countries. Persons with intellectual disability and comorbid mental disorders have the highest rates of specialized service use, costs, and unmet needs. International and national cost-of-illness studies show the high impact of intellectual disability in the total direct health costs of mental disorders at least in Europe. On the contrary, the burden-of-illness studies show conflicting results in intellectual disability.

SUMMARY

Contextual studies of healthcare and costs have improved the knowledge base for evidence-informed planning in intellectual disability in a number of countries. However, only two of these studies have used local atlases of healthcare for improving decision making. The paucity of information on prevalence, comorbidity, and demographic indicators hampers the advance of evidence-informed policy in intellectual disability.

The Pediatric Home Care/Expenditure Classification Model (P/ECM): A Home Care Case-Mix Model for Children Facing Special Health Care Challenges

Case-mix classification and payment systems help assure that persons with similar needs receive similar amounts of care resources, which is a major equity concern for consumers, providers, and programs. Although health service programs for adults regularly use case-mix payment systems, programs providing health services to children and youth rarely use such models. This research utilized Medicaid home care expenditures and assessment data on 2,578 children receiving home care in one large state in the USA. Using classification and regression tree analyses, a case-mix model for long-term pediatric home care was developed. The Pediatric Home Care/Expenditure Classification Model (P/ECM) grouped children and youth in the study sample into 24 groups, explaining 41% of the variance in annual home care expenditures. The P/ECM creates the possibility of a more equitable, and potentially more effective, allocation of home care resources among children and youth facing serious health care challenges.

The interRAI Pediatric Home Care (PEDS HC) Assessment: Evaluating the Long-term Community-Based Service and Support Needs of Children Facing Special Healthcare Challenges

The vast majority of assessment instruments developed to assess children facing special healthcare challenges were constructed to assess children within a limited age range or children who face specific conditions or impairments. In contrast, the interRAI Pediatric Home Care (PEDS HC) Assessment Form was specifically designed to assess the long-term community-based service and support needs of children and youth aged from four to 20 years who face a wide range of chronic physical or behavioral health challenges. Initial research indicates that PEDS HC items exhibit good predictive validity—explaining significant proportions of the variance in parents’ perceptions of needs, case managers’ service authorizations, and Medicaid program expenditures for long-term community-based services and supports. In addition, PEDS HC items have been used to construct scales that summarize the strengths and needs of children facing special healthcare challenges. Versions of the PEDS HC are now being used in Medicaid programs in three states in the United States.