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The benefits of expanding funding for Medicaid home-and community-based long-term care services (HCBS) relative to institutional care are often taken as self-evident. However, little is known about the outcomes of HCBS, especially for racial and ethnic minorities who tend to use HCBS more, and for people with dementia who may need high intensity care. Using national Medicaid claims data on elderly dual-eligibles, we found that overall hospitalization rates were similar for HCBS and nursing facility users, despite nursing facility users generally being sicker as reflected in their claims history. Among HCBS users, blacks were more likely to be hospitalized than whites, and the gap widened among blacks and whites with dementia. Also, conditional on receiving HCBS, Medicaid HCBS spending was higher for whites than non-whites; higher Medicare and Medicaid spending on hospitalizations for blacks and Hispanics did not offset this difference. Our findings suggest that HCBS need to be carefully targeted to avoid adverse outcomes and that the racial disparities in access to high-quality institutional long-term care are also present in HCBS. Policymakers should consider the full costs and benefits of shifting care from nursing facilities to HCBS and the potential implications for equity.States have expanded Medicaid funding for HCBS largely through 1915(c) waivers(1). Under the waiver mechanism, Medicaid beneficiaries obtain access to HCBS only if their needs meet a nursing facility level of care.

Objective To assess the accuracy of nursing home self‐report of major injury falls on the Minimum Data Set (MDS). Data Sources MDS assessments and Medicare claims, 2011‐2015. Study Design/Methods We linked inpatient claims for major injury falls with MDS assessments. The proportion of claims‐identified falls reported for each fall‐related MDS item was calculated. Using multilevel modeling, we assessed patient and nursing home characteristics that may be predictive of poor reporting. We created a claims‐based major injury fall rate for each nursing home and estimated its correlation with Nursing Home Compare (NHC) measures. Principal Findings We identified 150,828 major injury falls in claims that occurred during nursing home residency. For the MDS item used by NHC, only 57.5 percent were reported. Reporting was higher for long‐stay (62.9 percent) than short‐stay (47.2 percent), and for white (59.0 percent) than nonwhite residents (46.4 percent). Adjusting for facility‐level race differences, reporting was lower for nonwhite people than white people; holding constant patient race, having larger proportions of nonwhite people in a nursing home was associated with lower reporting. The correlation between fall rates based on claims vs the MDS was 0.22. Conclusions The nursing home‐reported data used for the NHC falls measure may be highly inaccurate.

Background Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients. Objective To compare outcomes after ALS and BLS in out-of-hospital medical emergencies. Design Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use. Setting Traditional Medicare. Patients 20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure. Measurements Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years. Results Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI. Limitation Only Medicare beneficiaries from nonrural counties were studied. Conclusion Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS. Primary Funding Source National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.

Background: The US government relies on nursing home-reported data to create quality of care measures and star ratings for Nursing Home Compare (NHC). These data are not systematically validated, and some evidence indicates NHC’s patient safety measures may not be reliable. Objective: The objective of this study was to assess the accuracy of NHC’s pressure ulcer measures, which are chief indicators of nursing home patient safety. Research Design: For Medicare fee-for-service beneficiaries who were nursing home residents between 2011 and 2017, we identified hospital admissions for pressure ulcers and linked these to the nursing home-reported data at the patient level. We then calculated the percentages of pressure ulcers that were appropriately reported by stage, long-stay versus short-stay status, and race. After developing an alternative claims-based measure of pressure ulcer events, we estimated the correlation between this indicator and NHC-reported ratings. Subjects: Medicare nursing home residents with hospitalizations for pressure ulcers. Measures: Pressure ulcer reporting rates; nursing home–level claims-based measure of pressure ulcer events. Results: Reporting rates were low for both short-stay (70.2% of 173,043 stage 2–4 pressure ulcer hospitalizations) and long-stay (59.7% of 137,315 stage 2–4 pressure ulcer hospitalizations) residents. Black residents experienced more severe pressure ulcers than White residents, however, this translated into having slightly higher reporting rates because higher staged pressure ulcers were more likely to be reported. Correlations between our claims-based measure and NHC ratings were poor. Conclusions: Pressure ulcers were substantially underreported in data used by NHC to measure patient safety. Alternative approaches are needed to improve surveillance of health care quality in nursing homes.

Objective: To provide the first plausibly causal national estimates of health outcomes for older dual-eligible recipients of Medicaid HCBS relative to nursing home care and to explore possible mechanisms for the effect. Data Sources: We use 2005 and 2012 Medicaid Analytic eXtract (MAX), a national compilation of Medicaid claims, merged with Medicare claims to identify hospital admissions, our main outcome variable. Study Design: We model the effects of HCBS using a longitudinal instrumental variables framework. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long-term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated. Population Studied: 1,312,498 older adults (65+) dually enrolled in Medicaid and Medicare and are using long-term care. We also examine heterogeneity of effects by race/ethnicity and the presence of dementia. Principal Findings: HCBS users have 10 percentage points higher (P < .01) annual rates of hospitalization than their nursing home counterparts when selection bias is addressed; rates of potentially avoidable hospitalizations are 3 percentage points higher (P < .01). These differences persist across races, dementia status, and intensity of HCBS spending. Conclusions: Shifting Medicaid long-term care funding for older adults from nursing homes to HCBS, while well-motivated, results in the unintended consequence of substantially higher hospitalization rates for older dual eligibles. The quality and/or quantity of services may be inadequate for some HCBS recipients. Hospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes-not just expansion-need more attention.

Objective: To compare the performance of Medicaid legacy, Medicaid new generation, and Medicare claims on data analytic tasks. Data Sources: Medicaid Analytic eXtract (MAX) claims (legacy) of 100% beneficiaries in 2011 (all states except Idaho), 2012 (all states), 2013 (28 states), and 2014 (17 states); 2016 Transformed Medicaid Statistical Information System Analytic Files (TAF) claims (new generation) of 100% beneficiaries from all states; Medicare claims of 20% beneficiaries in 2011-2014, 2016.Study Design: We focused on the chain of events that starts with an out-of-hospital medical emergency and ends with hospital death or survival to discharge. We developed six data quality indicators to assess ambulance variables; linkage between claims; external cause of injury code reporting; and death reporting on hospital discharge status codes. For the latter, we estimated injury severity and modeled its association with death in the Medicare population. We used the model to compare reported versus expected deaths by injury severity in the Medicaid population.Datasets were compared by state and fee-for-service versus managed care.Data Extraction Methods: Medicare and Medicaid beneficiaries with emergency ambulance transports.Principal Findings: Medicare claims had high performance across indicators and states; MAX claims substantially underperformed on multiple indicators in most states. For example, most states reported external cause codes for over 90% of Medicare but less than 15% of Medicaid injury cases. Medicaid fee-for-service did not consistently perform better than Medicaid managed care. Compared with MAX, TAF claims performed significantly better on some indicators but continued to have poor external cause code reporting. Finally, MAX and TAF managed care records reported deaths at discharge in the range of expected deaths; however, fee-for-service claims might have underreported high-severity injury deaths.Conclusions: New generation Medicaid claims performed better than legacy claims on some indicators, but much more improvement is needed to allow high-quality policy analysis.