Asset spend-down in nursing homes. Methods and insights

States With Medically Needy Pathways: Differences in Long-Term and Temporary Medicaid Entry for Low-Income Medicare Beneficiaries

Medically needy pathways may provide temporary catastrophic coverage for low-income Medicare beneficiaries who do not otherwise qualify for full Medicaid benefits. Between January 2009 and June 2010, states with medically needy pathways had a higher percentage of low-income beneficiaries join Medicaid than states without such programs (7.5% vs. 4.1%, p < .01). However, among new full Medicaid participants, living in a state with a medically needy pathway was associated with a 3.8 percentage point (adjusted 95% confidence interval [1.8, 5.8]) increase in the probability of switching to partial Medicaid and a 4.5 percentage point (adjusted 95% confidence interval [2.9, 6.2]) increase in the probability of exiting Medicaid within 12 months. The predicted risk of leaving Medicaid was greatest when new Medicaid participants used only hospital services, rather than nursing home services, in their first month of Medicaid benefits. Alternative strategies for protecting low-income Medicare beneficiaries' access to care could provide more stable coverage.

Recent Health Care Use and Medicaid Entry of Medicare Beneficiaries

Purpose of the Study

To examine the relationship between Medicaid entry and recent health care use among Medicare beneficiaries.

Design and Methods

We identified Medicare beneficiaries without full Medicaid or use of hospital or nursing home services in 2008 (N = 2,163,387). A discrete survival analysis estimated beneficiaries' monthly likelihood of entry into the full Medicaid program between January 2009 and June 2010.

Results

During the 18-month study period, Medicaid entry occurred for 1.1% and 3.7% of beneficiaries who aged into Medicare or originally qualified for Medicare due to disability, respectively. Among beneficiaries who aged into Medicare, 49% of new Medicaid participants had no use of inpatient, skilled nursing facility, or nursing home services during the study period. Individuals who recently used inpatient, skilled nursing facility or nursing home services had monthly rates of 1.9, 14.0, and 38.1 new Medicaid participants per 1,000 beneficiaries, respectively, compared with 0.4 new Medicaid participants per 1,000 beneficiaries with no recent use of these services.

Implications

Although recent health care use predicted greater likelihood of Medicaid entry, half of new Medicaid participants used no hospital or nursing home care during the study period. These patterns should be considered when designing and evaluating interventions to reform health care delivery for dual-eligible beneficiaries.

Higher Medicare SNF care utilization by dual-eligible beneficiaries: can Medicaid long-term care policies be the answer?

OBJECTIVE

To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies.

DATA SOURCES/COLLECTION

We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009.

STUDY DESIGN

We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending.

PRINCIPAL FINDINGS

Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps.

CONCLUSIONS

Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid.

The Focus of Long-Term Care in the United States: Nursing Home Care

Les grandes étapes de l'évolution des soins institutionnels aux États-Unis, de 1960 à 1985, ont été marquées par l'adoption de Medicaid et de Medicare (hausse rapide du nombre de lits), des tentatives de planification nationale de la santé (croissance ralentie du nombre de lits), et le programme de paiement prospectif (DRG) s'appliquant aux hôpitaux (proportion accrue de personnes handicapées parmi les patients). Les préoccupations concernant les politiques institutionnels, au milieu des années 80, étaient principalement: le juste équilibre entre les coûts privés et les coûts collectifs, l'appauvrissement d'un certain nombre de personnes âgées exigeant de longs traitements, l'amélioration de la qualité des soins, et un parti-pris en faveur du financement des soins institutionnels de longue durée en institution. Les changements de politiques survenus au cours des dernières années ont permis de régler les problèmes de qualité et le parti-pris institutionnel. Les questions touchant l'équilibre entre les coûts et l'appauvrissement sont demeurées irrésolues. Les centres d'hébergement approuvés par Medicaid et Medicare different des centres non-conventionnés en ce qu'ils offrent davantage de services, sont mieux pourvus en personnel infirmier et ont un plus grand nombre de résidents souffrant d'incapacité et de problèmes de comportement. En 1985, les principales sources de fonds servant à couvrir les frais des centres d'hébergement nationaux étaient Medicaid et les revenue personnels alors que le financement de Medicare était minimal.

Nursing Home Quality as a Common Good

A long-standing assumption among economists is that nursing home quality is common across Medicaid and private-pay patients within a shared facility. However, there has been only limited empirical work addressing this issue. Using a unique individual level panel of residents of nursing homes from seven states, we exploit both within-facility and within-person variation in payer source and quality to examine this issue. We also test the robustness of these results across states with different Medicaid and private-pay rate differentials. Across various identification strategies, our results are consistent with the assumption of common quality across Medicaid and private-paying patients within facilities.

Home-and community-based alternatives to nursing homes: services and costs to maintain nursing home eligible individuals at home

This study analyzes home- and community-based services (HCBS) use patterns and determines the costs of purchasing in-home services comparable to those offered by SCAN(R), a Social HMO. METHODS. Administrative data on 8,229 nursing home certifiable members were used to profile use patterns; a telephone survey gathered data on the market value of these services. RESULTS. Frail Social HMO members used a variety of HCBS to remain independent at home. These individuals would spend an average of $4,900 out of pocket per year to purchase equivalent HCBS, if they were not enrolled in the Social HMO. DISCUSSION. Findings suggest that the costs of maintaining a Social HMO member at home are modest and affordable, yet offer a substantial benefit, particularly to low- and moderate-income older people. With the aging of the population, an integrated medical and social program, such as the Social HMO, offers a viable policy solution.

Explaining state Medicaid nursing home reimbursement

Medicaid nursing home reimbursement methods and per diem rates affect costs, quality, equity, and access. State rate-setting is a laboratory of policymaking, which can inform state and federal Medicaid reform initiatives. This paper explains state Medicaid nursing facility rates in 1979-1994. Findings suggest that prospective facility-specific methods constrained rates in some but not all periods, particularly when older cost-reports were employed in rate-setting. Analysis failed to show that prospective class rate-setting methods constrained rate increases. Findings suggest that the efficacy of reimbursement methodology to control rates depends upon wider health care policy trends and that future facility-level analyses should consider policy contexts as between states.