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.
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