Reproduced with permission of TASH. For additional information on TASH, visit their website at www.tash.org

From: TASH Newsletter Volume 2 4 Issue Number 3 March 1998

Quality in Small ICFs/MR versus WAIVER HOMES

BY JAMES W.CONROY,PH.D

A recent investigation of California's Waiver program for people with development disabilities, conducted by the Health Care Finance Administration (HCFA), produced harsh critical findings (HCFA, 1997). This piqued our interest, because we have not seen evidence of poor quality among the Coffelt class members who have moved to Waiver settings. We decided to investigate further.

HCFA is responsible for two major funding streams for people with mental retardation and developmental disabilities. One is called the ICF/MR (Intermediate Care Facilities for [people with] Mental Retardation) Program, and the other is called the HCBS Waiver (Home and Community Based Waiver) Program. The ICF/MR program is founded in a medical model of care, and is derived directly from a nursing home and institutional mindset. Waiver programs were introduced in 1981 because of evidence that medical domination of care tended to result in more costly and less person-centered situations. The intention of the Waiver program was to "waive" the extensive and medically oriented standards and inspection requirements linked to the ICF/MR program. Under a Waiver, states could receive Federal financial assistance for individualized, flexible, non-medical, community based supports.

Since the origin of the Waiver program, all scientific evidence lias supported the original evidence. Waiver programs result in cost savings and enhanced quality as compared to ICF/MR programs. The Waiver regulations required an "Independent Assessment" of the quality and cost-effectiveness of each state's Waiver (section 4442.11 of Medicaid regulations). To date, well over 100 independent assessments have been conducted. There is not a single negative finding. The independent evaluations are maintained in Baltimore at the central office of the Social Security Administration. It would, therefore, seem clear that people can be better served, and at less cost, in flexible, individually designed, non-medically dominated homes.

Nevertheless, HCFA undertook a review of California's Waiver program in 1997. It took almost 6 months to complete. When completed, a total of 91 California citizens had been visited. For a population of 35,000 Califomians in the Waiver program, this corresponds to a "margin of error" of plus or minus about 11%. (Political polls generally aim for 5% or lower.) HCFA cited "resource limitations" as the reason that it could not visit a more adequate sample. This contrasted with the fact that the California Waiver has grown from 3,000 to 35,000 people injust four years, and the annual Federal share of the cost is 255 million dollars.

Most important for our Coffelt work was the HCFA claim that their surveyors had found that "Coffelt class consumers showed significant signs of loss of functional ability or health status since being placed in the community." Since HCFA only visited 91 people, how many of them were Coffelt class members? Of the 35,000 Califomians supported under the Waiver program, approximately 1200 are Coffelt class members, or about 3%. In HCFAs random sample, 3 out of the 91 people visited would be expected (statistically) to be Coffelt class members.

How could any responsible government agency base any kind of claim on visits to 3 people? Indeed, in our opinion, it most certainly should not have done so. To us, this strongly suggested a political agenda rather than a scientific one. Our visits to thousands of Coffelt class members over the years have supported radically different conclusions than those put forth by HCFA from its visits with approximately 3 people. We definitely had to examine the issue

further. We decided to compare quality in the Waiver to the small ICF/MR program. The small ICF/MR program has not lxen criticized by HCFA studies in California, hence it would appear that HCFA finds the ICF/MR program to be acceptable in quality.

If California's Waiver program is so "bad," is the ICF/MR program (HCFAs more favored model of care) any better? This question is perfectly amenable to quantitative investigation. For similar people, are there any differences in quality and/or outcomes between the ICF/MR program and the Waiver program?

At the outset, however, we must recognize tliat the people served in the ICFs/MR and the Waiver programs are significantly different. ICFs/MR serve people with fewer independence skills and fewer challenging behaviors, and Waiver homes serve people who are more independent but have more challenging beliaviors. (We think future investigations should be aimed to find out why this is true -- it is certainly not true in ICF/ MR and Waiver programs in other states such as Connecticut and Pennsylvania.) Comparisons of quality cannot proceed until these differences are controlled for. The comparisons would be "apples and oranges." The following Table shows the differences between the two overall groups of Coffelt movers.

Differences Between the People Living in ICFs/MR and Waiver Homes

As the Table shows, the ICF/ MR participants were significantly lower on adaptive behavior abilities than the Waiver participants. This meant that the ICF/MR participants were much less capable of independent self-care. The ICF/MR participants also displayed significantly less challenging behavior that the Waiver participants. Age was similar for the two groups.

When the groups we want to compare are different, there are at least three methods available to compare "apples to apples." One is the matched comparison method, which we have used in the past (the "twin study" method). Another is purely mathematical corrections for differences in groups (analysis of covariance). A third is what we call the "similar groups" method, in which we select two groups who have similar characteristics. For the present analysis, we have used the similar groups method, partly because in prior reports, we have already used the other two methods, and partly because it is simpler to describe and interpret.

The two similar groups were composed by selecting people with characteristics that were "in between" the ICF/MR and the Waiver groups. The best groups were those whose adaptive behavior scores ranged from 30 to 50, and whose challenging behavior scores ranged from 75 to 90. When this selection was performed, we were left with 49 people in ICFs/MR and 50 people in Waiver homes. The statistical tests showed that the two subgroups were now equivalent on the most important dimensions, as shown in the following table.

For these similar groups, the important characteristics were not statistically different.

The results of our analyses for a series of outcome measures are shown in the table below.

Quality Comparisons in ICFs/MR and Waiver Homes For Two Groups of Similar Coffelt Class Members

Hence, we could proceed to compare qualities of life and service between these two similar groups.

The above Table uses boldface to show dimensions on which one type of setting or the other came out superior. The Table presents the results of t-tests, which reveal whether the difference between the two groups' averages is statistically significant. One column gives the actual t value, and the last column gives the level of significance. Any significance below .050 is considered significant. Each line in the table is discussed below.

1. The data from the Integration Scale, which counts the number of outings per week, showed that people in the Waiver homes tended to get out significantly more often than their similar peers in ICFs/MR.

2. The Self-Determination Index or Decision Control Inventory (DCI) shows that the Waiver group had significantly more control over making individual choices in their daily lives than the ICF/MR group.

3. The ratings of Physical Quality (comfort, cleanliness, attractiveness, personalization, etc.) were equal among both groups.

4. The Individualized Practices Scale, which measures the extent to which people are treated as individuals, indicates that the Waiver group found their settings to be significantly more individual oriented than the ICF/MR group.

5.On the Normalization Scale, there was no significant difference between the two groups.

6. For adoptive behavior, we found that 52 of the 99 people in this analysis hod been visited the prior year in their community homes. Hence we were able to compute the amount of skill development or loss for those 52 people over the past year. lhere was no significant change in either group in either direction.

7. The challenging behavior results were quite different. The 3.75 point improvement among the ICF/MR group was not statistically significant (this fact is not shown in the Table). However, the 19.78 point improvement among the Waiver recipients was highly significant, and was significantly different from the ICF/MR group's gain. In this sample, challenging behavior outcomes were sharply superior among Waiver participants.

8. The General Health Rating was similar for the two groups, as both Waiver people and ICF/MR people indicated that their General Health was "Good." We interpret this to mean that the two groups enjoyed approximately the same overall level of health.

9. The average number of dental visits were about the same for both groups. However, the average number of doctor visits were different, with ICF/MR people averaging 10.9 visits and Waiver people averaging 17.7 visits per year. For people with similar rating of general health, one must wonder why one group sees doctors nearly twice as often as the other.

10. On the item "How Easy is It to find Malical (are for This Person?" the responses were similar with both groups indicating "Easy." The difference between the ICF/MR average of 4.0 on our 5-point stale and the Waiver group's average of 3.5 was not statistically significant. Hence we conclude that there is no overall difference in the ease or difficulty of obtaining health care in ICFs/MR versus Waiver homes.

11. The percentage of people taking psychotropic medications was significontly different between the two groups. We found that the percentage of Waiver people taking psychotropic medications was double that of the percentage of people in the ICFs/MR. We would generally interpret this as an indication of higher quality in the ICFs/MR; however, the most appropriate interpretation may not be that simple. Even though the groups are now similar in challenging behavior (both groups average 81 points), the Waiver group gained almost 18 points in the past year. It is possible that the use of psychotropic medications played an important role in these dramatic improvements among the Waiver recipients. The final word on the appropriateness of these medications will require further research and clinical investigations; the data available to us cannot settle this question.

12. The Overall Quality of Life Rating "Now," which is usually obtained from a third party informant and includes 14 dimensions of quality, showed that people in the Waiver settings were rated as having a significantly higher quality of life than their similar peers in the ICF/MR settings.

13. Finally, we examined the average cost of each placement. Our data source was the DDS reimbursement rates for each type of community home. It is well known that Waiver reimbursement rates are lower than ICF/MR rates. That is usually justified by the fact that the two programs serve very different kinds of people.

However, the present analysis concerns two very similar groups of people. The Waiver costs average only 74% of the ICF/ MR costs in this sample. This is a large and significant difference.

These findings are obviously quite different from the conclusions reached by HCFA (1997). Out of 13 important dimensions of quality, Waiver settings were superior on 6, and ICFs/MR were possibly superior on 1. Even that one, use of psycho-tropic medications, was tempered by the possibility that the medications may have been appropriate and useful, as judged by behavioral outcomes. In any case, the weight of these data clearly favor the Waiver settings in many areas of quality, for comparable people. Finally, the Waiver program's costs are considerably lower than those for ICFs/MR for comparable people. The data show that, for comparable groups of Coffelt class members. Waiver homes tend to yield higher quality, at lower cost, than the ICF/MR model.

For additional information on these studies, contact Dr. James Conroy, The Center for Outcome Analysis, at 615-520-2007, or send an e-mail to [email protected].