Variation by Disability in State Predictors of Medicaid 1915c Waiver Use and Expenditures

A comparative analysis of state adoption of the Community First Choice program

Over the last several decades, policymakers have focused on rebalancing Medicaid-funded long-term services and supports toward home and community-based services (HCBS). The Patient Protection and Affordable Care Act (ACA) included several opportunities for states to further promote HCBS options. One optional opportunity for states to expand Medicaid HCBS was the 1915(k) Community First Choice (CFC) program. To date, eight states have elected to add CFC as a Medicaid benefit. This study utilized comparative case studies to identify the factors that influenced states' adoption of CFC. Results highlight the important role that state bureaucrats, economic concerns, and existing HCBS programs had on states' decisions to adopt CFC.

Predicting State Investment in Medicaid Home- and Community-Based Services, 2000-2011

Although state use of Medicaid home- and community-based services (HCBS) to provide long-term services and supports to older adults and individuals with physical disabilities continues to increase, progress is uneven across states. We used generalized linear models to examine state factors associated with increased allocation of Medicaid dollars to HCBS for the period 2000 to 2011. We observed enhanced growth in states that began the period with limited investment in HCBS, as reflected in significant year trends among these states. The political environment appeared to be an important influence on states' investment for states with limited initial allocation to HCBS, as was housing affordability, a policy amenable variable. There continues to be wide variation in states' relative investment, calling for additional policy attention and research.

The Impact of Certificate-of-Need Laws on Nursing Home and Home Health Care Expenditures

Over the past two decades, nursing homes and home health care agencies have been influenced by several Medicare and Medicaid policy changes including the adoption of prospective payment for Medicare-paid postacute care and Medicaid-paid long-term home and community-based care reforms. This article examines how spending growth in these sectors was affected by state certificate-of-need (CON) laws, which were designed to limit the growth of providers and have remained unchanged for several decades. Compared with states without CON laws, Medicare and Medicaid spending in states with CON laws grew faster for nursing home care and more slowly for home health care. In particular, we observed the slowest growth in community-based care in states with CON for both the nursing home and home health industries. Thus, controlling for other factors, public postacute and long-term care expenditures in CON states have become dominated by nursing homes.

Social work decision-making: need factors of older adults that affect outcomes of home- and community-based services

The purposes of this study were to examine social work decision-making outcomes of home- and community-based services (HCBS) referrals provided to older adults with unmet physical and psychosocial needs discharged from acute care to a community setting, and to understand older adults' (N=247) responses to receiving referrals for HCBS. Older adults with inadequately or marginally met basic needs was a statistically significant predictor of the number of HCBS referrals home health social workers provided to older adult clients (p < .01). The adapted three-step models were statistically significant: activities of daily living model [F(15) = 1.95, p < .05] and instrumental activities of daily living model [F(15) = 2.06, p < .05]. Most older adults accepted the HCBS referrals provided to them at the time of the social work home visit. Implications for practice were suggested for clinical social workers.and case managers providing HCBS referrals to older adults with unmet physical and psychosocial needs discharged from acute care or skilled care to community settings.

Cost-efficiency in Medicaid long-term support services: the role of home and community based services

Growth in home and community based services (HCBS) has been implicated in rising long-term care expenditure in the Medicaid program. Its efficiency impact has not been tested. Using Stochastic Frontier Analysis (SFA) and panel data methods, we evaluated the cost efficiency of long-term support services (LTSS) provided by state Medicaid agencies and examined its association with intensity of HCBS use. We compared the efficiency of state funded HCBS programs with federal waiver programs. We found substantial variation in cost efficiency of LTSS programs by states, but all showed improvement over time related to increased HCBS use. Higher participation in federal waivers programs yielded additional improvements in cost-efficiency. Results indicate that increasing HCBS services targeted at “high need” population and developmentally disabled individuals would improve efficiency in LTSS delivery. These results reveal the importance of measuring and comparing efficiencies across Medicaid funded LTSS programs, as we introduce reforms in the LTSS delivery system. We recommend that Medicaid agencies invest in the development of improved data sources for the estimation of cost efficiencies of their programs.

Relations among home- and community-based services investment and nursing home rates of use for working-age and older adults: a state-level analysis

OBJECTIVES

I examined state-level rates of nursing home use for the period from 2000 to 2007.

METHODS

I used multivariate fixed-effects models to examine associations between state sociodemographic, economic, supply, and programmatic characteristics and rates of use.

RESULTS

Nursing home use declined among older adults (aged ≥65 years) in more than two thirds of states and the District of Columbia but increased among older working-age adults (aged 31-64 years) in all but 2 states. State characteristics associated with these trends differed by age group. Although relatively greater state investment in Medicaid home- and community-based services coupled with reduced nursing home capacity was associated with reduced rates of nursing home care for adults aged 65 years and older, neither characteristic was associated with use among older working-age adults. Their use was associated with state sociodemographic characteristics, as well as chronic disease prevalence.

CONCLUSIONS

Policy efforts to expand home- and community-based services and to reduce nursing facility capacity appear warranted. To more fully extend the Supreme Court's Olmstead decision's promise to older working-age adults, additional efforts to understand factors driving their increasing use are required.

End-of-life care in U.S. nursing homes: nursing homes with special programs and trained staff for hospice or palliative/end-of-life care

BACKGROUND

The degree to which nursing homes have internal programs for hospice and palliative care is unknown. We used self-reported data from the 2004 National Nursing Home Survey (NNHS) to estimate the prevalence of special programs and (specially) trained staff (SPTS) for hospice or palliative/end-of-life care in U.S. nursing homes. Factors associated with the presence of SPTS for hospice or palliative/end-of-life care were identified.

METHODS

We merged 2004 NNHS data for 1174 nursing homes to county-level data from the 2004 Area Resource File and to Nursing Home 2004 Online Survey, Certification, and Reporting data. chi(2) tests and logistic regression models were applied.

RESULTS

Twenty-seven percent of U.S. nursing homes reported (internal) SPTS for hospice or palliative/end-of-life care. After controlling for covariates, we found nonprofit status, being in the southern region of the United States, having an administrator certified by the American College of Health Care Administrators, contracting with an outside hospice provider, and having other specialty programs to be associated with a greater likelihood of nursing homes having SPTS for hospice or palliative/end-of-life care. The largest effects were observed for nursing homes with programs for behavioral problems (adjusted odds ratio [AOR] 3.59; 95% confidence interval [CI] 2.40, 5.37) and for pain management (AOR 5.92; 95% CI 4.09, 8.57).

CONCLUSION

The presence of internal SPTS for hospice or palliative/end-of-life care is prevalent in U.S. nursing homes, and may be preceded by hospice contracting and/or the implementation of specialty programs that assist nursing homes in developing the expertise needed to establish their own palliative care programs.

Medicaid 1915(c) Waiver Use and Expenditures for Persons Living With HIV/AIDS

States' use of Medicaid 1915(c) waiver services for persons living with HIV/AIDS (PLWHA) has been limited. The authors examine state-level factors related to the decision to offer waiver services, as well as waiver use and expenditures in states offering waivers for PLWHA. They use fixed effects cross-sectional time series models to explore these state factors. States with Democratic governors were more likely to offer waiver services and were found to have higher rates of use and greater expenditures and to devote a larger share of long-term care dollars to waiver services for PLWHA. State supply of both institutional and residential care beds was negatively related to use and expenditures. Medicaid community-based care has been found to be related to improved outcomes and reduced costs of care. Ways to foster 1915(c) waiver expansion are important so as to increase access to care for PLWHA.