Demonstration to Maintain Independence and Employment: What Is It, and Who Is Participating?

1
Demonstration to Maintain Independence and
Employment What Is It, and Who Is
Participating?

• Steve Hrybyk
• CMS Project Officer
• NCHSD Conference Presentation
• September 2007
• Chicago, Illinois

2
What is the DMIE?

• A demonstration that tests whether improved
  health care coverage and employment services for
  working adults with a potentially disabling
  condition can improve their employment and reduce
  dependency on federal disability benefit
  programs.
• Potentially disabling conditions are physical or
  mental impairments that meet the SSA disability
  criteria.
• Examples include severe mental illness, diabetes,
  HIV/AIDS.

3
DMIE Background

• Authorized by the Ticket to Work and Work
  Incentives Improvement Act of 1999
• Allows CMS to award funds to states to design,
  implement, and evaluate projects that meet DMIE
  criteria
• Funds awarded to two states under earlier
  solicitation
• District of Columbia
• Mississippi
• Funds awarded to four states under most recent
  solicitation
• Kansas
• Texas
• Minnesota
• Hawaii

4
Eligibility Requirements

• Participants must be
• 16 to 64 years old
• Employed at least 40 hours per month and earning
  at least minimum wage
• Project funds cannot be used to supplant funds
  from other programs
• States conduct an independent evaluation of their
  DMIE project

5
DMIE Policy Questions

• For individuals with a potentially disabling
  condition, can a program of medical assistance
  and employment support
• Improve or maintain health status?
• Enhance quality of life?
• Promote or sustain employment?
• Reduce dependence on federal disability programs
  (e.g., SSDI, SSI)?

6
Evaluation Design

• All DMIE projects will have
• Two-group randomized design
• Sufficient sample size to detect modest impact
  effects
• These rigorous design features add credibility to
  the evaluation findings

7
DMIE Evaluation (2 parts)

• National-Level Conducted by Mathematica Policy
  Research (MPR)
• State-Level Kansas, Minnesota, Texas, and
  Hawaii each have an independent evaluator

8
National Evaluation

• Builds on state evaluations
• Includes uniform data set (UDS) to collect
  standardized information across states
• Links federal administrative data on earnings,
  SSDI/SSI participation, and Medicaid claims data
• Analyzes quantitative data and synthesizes
  lessons learned across DMIE states

9
State-Level Evaluation

• Kansas evaluation being conducted by the
  University of Kansas (Jean Hall)
• Minnesota evaluation being conducted by the Lewin
  Group (Karen Linkins)
• Texas evaluation being conducted by the
  University of Texas at Austin (Tom Bohman)
• Hawaii evaluation being conducted by the
  University of Hawaii (Denise Uehara)

10
Study Population by State
State Study Population (Enrollment Targets Ttreatment, Ccontrol)
Kansas Employed adults in the statewide high-risk insurance pool people who are uninsurable in the private market(T200 C200)
Minnesota Employed adults with severe mental illness in three counties (T1,500 C500)
Texas Employed adults in Houston with a severe mental illness or a behavioral diagnosis occurring with a physical diagnosis (T800 C625)
Hawaii Employed adults with diabetes in the city and county of Honolulu (T267 C267)
11
DMIE Interventions by State
State DMIE Program Intervention
Kansas Adds wrap-around services to existing high-risk insurance pool benefits. Advantages include (1) lower out-of-pocket costs (550 per month), (2) enhanced benefits (dental, vision), and (3) case management
Minnesota Includes (1) wellness navigator who assesses needs and develops employment plan, (2) comprehensive medical services, and (3) employment/peer support services
Texas Includes (1) enhanced medical, mental health, chemical dependency, and dental services (2) case management, and (3) employment support
Hawaii Includes (1) pharmacist counselors to help manage medication adherence, (2) life coaches to support personal goal planning, and (3) wellness services (nutritionist, fitness trainer, diabetes counselor)
12
Kansas DMIE

• Started enrollment in April 2006
• Reached target enrollment of 400 participants
  (200 treatment 200 control) across two cohorts
  in late 2006
• State evaluation team collected baseline survey
  data and conducted a preliminary analysis of
  participant characteristics

13
Kansas DMIE Baseline Characteristics, Cohort 1
(n208)

• Slightly more women (52) with a mean age of 50.5
  years
• 71 reported self-employment wide range of
  earnings and job types
• 98 self-identified as non-Hispanic white
• No significant differences in age, gender, race,
  or employment type between treatment and control
  groups
• Source Kansas DMIE 2006 Annual Summary
  Evaluation Report

14
Kansas DMIE Baseline Health Status, Cohort 1

• Similar mental health composite scores for
  treatment and control group (49.5 and 49.9)
  anything under 50 considered to be below average
  for the population in Kansas
• Physical health composite scores were slightly
  higher (i.e., healthier) for the control group
  than for the treatment group (44.1 vs. 41.7)
• Source Kansas DMIE 2006 Annual Summary
  Evaluation Report

15
Kansas DMIE Service Utilization Findings

• Very strong demand for dental care (not covered
  for control group in the existing high-risk
  insurance plan)
• Pent-up demand for vision care (also not covered
  in existing plan) and prescription drugs (lower
  co-payments with DMIE)

16
Texas DMIE

• Started enrollment in April 2007 and has made
  rapid progress in recruitment
• 558 participants (313 treatment 245 control)
  enrolled as of Sept. 4, 2007
• State evaluation team collected baseline survey
  data on first cohort, now being analyzed

17
Minnesota DMIE

• Started enrollment in December 2006
• 274 participants (211 treatment 63 control)
  enrolled as of Sept. 4, 2007
• Baseline survey data are being collected

18
Hawaii DMIE

• Recruitment expected to begin in October 2007
• Employers will play an important role as partners
  in the demonstration
• The state is pilot testing a pharmacist
  counseling intervention to help participants
  manage their medications

19
Final Report on the National Evaluation

• Will address the following questions
• Did the projects work?
• Were there differential benefits?
• What helped, and what got in the way?
• To what extent did each states evaluation
  influence the DMIE program?
• What are the lessons for CMS and for other
  states?

20
For More Information

• Download the DMIE Issue Brief at
• www.mathematica-mpr.com/disability/
  medicaidbuy-in.asp
• For state DMIE newsletters and reports
• Go to www.mig-rats.org
• Search for DMIE