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Complex Needs, Complex Costs: Assessing Medicaid Payments on a Subset of Home- and Community-Based Services for
Caitlin Koob1, Heloise Schieber2, Carolyn Foster3
1Department of Healthcare Leadership and Management (C Koob and KN Simpson), Medical University of South Carolina, Charleston, SC; Patient and Family Advisory Council for Children's Health (C Koob and H Schieber), MUSC Shawn Jenkins Children's Hospital, Charleston, SC.
Insights
Medicaid payments for home- and community-based services (HCBS) increase with child complexity. Medically Complex Children's Waiver (MCCW) enrollment significantly concentrates these payments, highlighting the cost of home-based hospital-level care.
Area of Science:
- Health Services Research
- Pediatric Healthcare Policy
- Medicaid Program Analysis
Background:
- Home- and community-based services (HCBS) are crucial for children with complex medical needs.
- Medicaid finances a significant portion of HCBS, but payment structures by complexity are not fully understood.
- Understanding these costs is vital for effective healthcare policy and resource allocation.
Purpose of the Study:
- To describe Medicaid payments for HCBS among continuously enrolled children in South Carolina.
- To analyze payment variations based on children's medical complexity levels.
- To assess the impact of the Medically Complex Children's Waiver (MCCW) on HCBS expenditures.
Main Methods:
- A cohort study analyzed 21,838 children and 1,744,294 claims from 2019-2022 in South Carolina.
- Mean annual payments for HCBS (e.g., home nursing, personal care) were calculated.
- Generalized linear models and post hoc tests examined associations between child characteristics, payments, and MCCW enrollment.
Main Results:
- Medicaid payments for HCBS significantly increased with children's medical complexity (p<0.001).
- Children with complex conditions (C-CD) incurred higher annual costs ($1,496) than those with non-complex conditions (NC-CD) ($426) or no conditions ($265).
- MCCW enrollment was associated with substantially higher adjusted mean annual payments across all complexity levels, indicating intensive care needs.
Conclusions:
- A small group of children in the MCCW account for a high concentration of Medicaid HCBS payments.
- These findings underscore the resource-intensive nature of hospital-level care provided in home and community settings.
- Restricting HCBS and waiver access may lead to increased long-term state spending through avoidable institutionalization.
Objective:
Describe Medicaid payments for a subset of home- and community-based services (HCBS) for continuously enrolled children by complexity level.
Methods:
A cohort study of 21,838 children in South Carolina (1,744,294 claims, 2019-2022). Outcomes include mean annual payments for selected HCBS (eg, home nursing, personal care, rehabilitation). Descriptive statistics, an adjusted gamma-distributed generalized linear model with a log link, and Tukey-adjusted post hoc tests examined associations between children's characteristics, payments, and the effect of South Carolina's Medically Complex Children's Waiver (MCCW) enrollment within each complexity level.
Results:
Payments increased with complexity (P<.001). Annually, children with C-CD had mean payments of $1496 (IQR: $296-$1733), followed by children with NC-CD (M=$426, IQR: $124-$428) and no CD (M=$265, IQR: $63-$261). Adjusted mean annual payments increased with complexity for children not enrolled in MCCW, from $273 (95% CI: [$256, $292]) for children with no CD, to $427 (95% CI: [$396, $460]) for children with NC-CD, and $1178 (95% CI: [$1071, $1296]) for children with C-CD (P<.001). Among those enrolled in MCCW, adjusted mean annual payments were $2571 (95% CI: [$1426, $4.637]) for children with no CD, $3335 (95% CI: [$1794, $6200]) for children with NC-CD, and $4460 (95% CI: [$3348, $5942]) for children with C-CD.
Conclusions:
A small cohort of children enrolled in MCCW account for a high concentration of Medicaid payments, reflecting the resource-intensive nature of hospital-level care delivered at home. Health policymaking should consider that restricting HCBS and waiver access may exponentially increase long-term state spending through avoidable institutional care.
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