Measuring State Medicaid Home Care Participation and Intensity Using Latent Variables

Gonçalves, Judite; Konetzka, R. Tamara

doi:10.1177/0733464818786396

Cited by 12 publications

(10 citation statements)

References 33 publications

(40 reference statements)

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“…Some expansion to healthier individuals has nonetheless occurred, but the increased intensity of funding for sicker individuals-consistent with the goal of keeping people out of nursing facilities-has been the more pronounced trend. 4 Many waivers are meant to provide HCBS options for frail, elderly beneficiaries with long-term care needs. In this study, we focus on the subset of the elderly who are enrolled in both Medicare and Medicaid, known as "dual eligibles," who are often physically and cognitively impaired, are disproportionately from racial or ethnic minority groups, and have high use of health care services and costs.…”

Section: Introductionmentioning

confidence: 99%

“…Policy makers take pains to avoid a “woodwork” effect where people who otherwise would not receive services are encouraged by the availability of HCBS to sign up. Some expansion to healthier individuals has nonetheless occurred, but the increased intensity of funding for sicker individuals—consistent with the goal of keeping people out of nursing facilities—has been the more pronounced trend 4 …”

Section: Introductionmentioning

confidence: 99%

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Outcomes of Medicaid home‐ and community‐based long‐term services relative to nursing home care among dual eligibles

Konetzka

Jung

Gorges

et al. 2020

Health Services Research

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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.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Outcomes of Medicaid home‐ and community‐based long‐term services relative to nursing home care among dual eligibles

Konetzka

Jung

Gorges

et al. 2020

Health Services Research

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“…directed toward providing an alternative to more expensive nursing facility care, and policymakers take pains to avoid a "woodwork" effect where people who otherwise wouldn't receive services are encouraged by the availability of HCBS to sign up. Some expansion to healthier individuals has nonetheless occurred, but the increased intensity of funding for sicker individuals--consistent with the goal of keeping people out of nursing facilities--remains the more pronounced trend (2).…”

Section: Introductionmentioning

confidence: 99%

A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles

2019

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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.

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“…As the generosity of Medicaid HCBS programs can be considered in two dimensions, the size of the populations they serve and the intensity of the services they provide to each user once access is granted, 21,26,30 we measured Medicaid HCBS generosity by its breadth and intensity. Breadth was defined as the proportion of FFS older duals who used any HCBS in a given year, which captured realized access to Medicaid HCBS.…”

Section: Methodsmentioning

confidence: 99%

“…Intensity was calculated as the average monthly HCBS spending per HCBS user per enrolled month with adjustment for Area Wage Index and is intended to reflect the amount of services used by individuals conditional on receiving HCBS. This approach of constructing HCBS generosity measures has been validated through factor analysis in a previous study 21,26,30 . For both HCBS breadth and intensity, individual HCBS utilization information from MAX data was aggregated to the county level, and the utilization and spending of HCBS included both state‐plan HCBS and waiver programs.…”

Section: Methodsmentioning

confidence: 99%

Medicaid home‐ and community‐based services and discharge from skilled nursing facilities

Wang

Temkin‐Greener

Simning

et al. 2021

Health Services Research

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Objective To examine the association between the generosity of Medicaid home‐ and community‐based services (HCBS) and the likelihood of community discharge among Medicare‐Medicaid dually enrolled older adults who were newly admitted to skilled nursing facilities (SNFs). Data Sources National datasets, including Medicare Master Beneficiary Summary File (MBSF), Medicare Provider and Analysis Review (MedPAR), Medicaid Analytic eXtract (MAX), minimum data set (MDS), and publicly available data at the SNF or county level, were linked. Study Design We measured Medicaid HCBS generosity by its breadth and intensity and described their variation at the county level. A set of linear probability models with SNF fixed effects were estimated to characterize the association between HCBS generosity and likelihood of community discharge from SNFs. We further stratified the analyses by the type of index hospitalizations (medical vs surgical events), age group, and the Medicaid cost‐sharing policy for SNF services. Data Extraction Methods The final analytical sample included 224 229 community‐dwelling dually enrolled older duals who were newly admitted to SNFs after an acute inpatient event between October 1, 2010, and September 30, 2013. Principal Findings We observed substantial cross‐sectional and over‐time variations in HCBS breadth and intensity. Regression results indicate that on average, a 10 percentage‐point increase in HCBS breadth was associated with a 0.7 percentage‐point increase (P < 0.01) in the likelihood of community discharge. Such relationship could be modified by individual factors and state policies: significant effects of HCBS breadth were detected among medical patients (0.7 percentage‐point, P < 0.05), individuals aged older than 85 (1.5 percentage‐point, P < 0.01), and states with and without lesser‐of policies (0.5 and 2.3 percentage‐point, respectively, P < 0.05). No significant relationship between HCBS intensity and community discharge was detected. Conclusions Higher Medicaid HCBS breadth but not intensity was associated with a greater likelihood of community discharge, and such relationship could be modified by individual factors and state policies.

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Measuring State Medicaid Home Care Participation and Intensity Using Latent Variables

Cited by 12 publications

References 33 publications

Outcomes of Medicaid home‐ and community‐based long‐term services relative to nursing home care among dual eligibles

Outcomes of Medicaid home‐ and community‐based long‐term services relative to nursing home care among dual eligibles

A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles

Medicaid home‐ and community‐based services and discharge from skilled nursing facilities

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