What Did We Learn from the Balancing Incentive Program?

Karon, Sarita L.; Knowles, Molly

doi:10.1093/ppar/pry014

Cited by 13 publications

(16 citation statements)

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“…Additionally, formal recognition of these relationships may help to preserve them, for example, in the context of staff attrition over time. Other BIP‐related impacts, such as technology enhancements, may be inherently more sustainable because they are embedded in the health care infrastructure 3 …”

Section: Discussionmentioning

confidence: 99%

“…Long‐term services and supports (LTSS) are critical services for persons with limitations in activities of daily living. Efforts to rebalance or shift LTSS funding from nursing homes to home‐ and community‐based services (HCBS) have intensified in recent years 1‐3 . HCBS now accounts for more than half of national Medicaid LTSS spending, although this ratio varies considerably across states 4 .…”

Section: Introductionmentioning

confidence: 99%

“…Published evaluations have primarily used quantitative data or the perspectives of state administrators who led BIP implementation 8‐11 . This research has shed light on several future research directions, including the sustainability of BIP impacts beyond programming and infrastructure, stakeholder collaboration, and a need for outcome measures beyond fiscal rebalancing metrics (e.g., HCBS quality), including measures that permit cross‐state comparisons 3,8,9 …”

Section: Introductionmentioning

confidence: 99%

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Perceived impacts of a Medicaid rebalancing initiative to increase home‐ and community‐based services

Siconolfi

Ahluwalia

Friedman

et al. 2021

Health Services Research

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Objective To assess governmental and nongovernmental stakeholders' perceived impacts of a Medicaid home‐ and community‐based services (HCBS) rebalancing initiative, the Balancing Incentive Program (BIP). Data Sources Governmental stakeholders (Medicaid administrators) and nongovernmental stakeholders (service providers and consumer advocates) (n = 30) from eight states that participated in BIP. Study Design We conducted key informant interviews. Data Collection Interviews followed a semi‐structured guide and were professionally transcribed. We thematically coded transcripts using an iterative codebook with a priori and emergent codes. Principal Findings Stakeholders reported that BIP participation had a range of impacts on the HCBS ecosystem, often beyond the mandated structural reforms. BIP activities were believed to have changed the culture of HCBS in some states, for example, at the level of state administration or in the provision of HCBS to consumers. Stakeholders also described significant improvements in cross‐stakeholder relationships and communication, for example, in the context of troubleshooting consumers' unmet needs or improvements in the states' responsiveness to providers' inquiries. Stakeholders believed that within‐state data harmonization undertaken through Core Standardized Assessment (CSA) was a positive impact of BIP, particularly with regard to its utility for administrative data, care planning, and patient‐centeredness. Two stakeholders also voiced concerns regarding the validity of spending‐based rebalancing metrics. The impacts that stakeholders attributed to BIP may help create a more sustained rebalancing environment through their changes to the ecosystem, including infrastructure upgrades, data harmonization, collaboration across stakeholders and agencies, more patient‐centeredness, and greater recognition of HCBS. Conclusions Our findings highlight additional BIP impacts to monitor over the longer term and to consider in evaluations of future rebalancing efforts. Some potential impacts of BIP are more readily quantified (e.g., HCBS spending), while others are less likely to be formally assessed (e.g., improved stakeholder cooperation). These latter impacts are likely instrumental to future rebalancing efforts.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Perceived impacts of a Medicaid rebalancing initiative to increase home‐ and community‐based services

Siconolfi

Ahluwalia

Friedman

et al. 2021

Health Services Research

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“…60 These findings suggest that efforts similar to Medicaid's Balancing Incentive Program, which provides incentives for states to meet certain HCBS funding allocation benchmarks, might be beneficial for health systems aiming to expand HCBS. 62 In recent years, VHA has made concerted efforts to address issues related to accessing HCBS. In 2016, VHA launched the Veteran-Directed Home and Community-Based Services, a participant-directed program for Veterans with high levels of need for assistance, as well as the Medical Foster Home Program for Veterans with cognitive and physical impairments.…”

Section: Discussionmentioning

confidence: 99%

Long‐term care service mix in the Veterans Health Administration after home care expansion

Jacobs

Trivedi

Lorenz

et al. 2021

Health Services Research

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Objective: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home-and community-based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non-VHA user Medicare population that was not exposed to HCBS expansion efforts.Data Sources: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012. Study Design:We conducted a retrospective-matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference-in-differences approach with a person fixed-effects estimator.Data Collection/Extraction Methods: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services.Principal Findings: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long-term care (0.7% points, 95% CI: À0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: À0.011, 0.0125). VHA users received more hours of unpaid care post-Millennium Act (1.48, 95% CI: À0.232, 3.187), though this effect was not significant once we introduced controls for mental health.Conclusions: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.

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“…We sought to understand the reasons why some eligible states applied, and others did not. Only a handful of other papers have evaluated BIP, with a focus on implementation strategies (Karon et al, 2015, 2016; Watts et al, 2015; Wiener et al, 2015), and LTSS spending (Lester et al, 2015). Evaluations of similar HCBS transition programs intended to rebalance funds to home-based settings, such as the Money Follows the Person (MFP) demonstration program, also focus on implementation and outcomes, but do not examine the underlying reasons for initial application (Denny-Brown et al, 2015; Irvin et al, 2016, 2017).…”

Section: Introductionmentioning

confidence: 99%

Factors Explaining State Differences in Applying for a Recent Long-Term Care Program that Promotes Aging in Place: Perspectives of Medicaid Administrators

et al. 2020

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Older adults in need of assistance often prefer to remain at home rather than receive care in an institution. To meet these preferences, Medicaid invited states to apply for the Balancing Incentive Program (BIP), a program intended to “rebalance” Medicaid-financed long-term services and supports to Home- and Community-Based Services (HCBS). However, only about half of eligible states applied. We interviewed Medicaid administrators to explore why some states applied for BIP whereas others did not. Supportive state leadership and the presence of other programs supporting community-based care were positively related to BIP application. Opposing policy priorities and programs competing for similar resources were negatively related to BIP application. Because states most likely to apply already had policy goals and programs supporting HCBS, BIP may inadvertently widen disparities across states, pushing those on the margins ahead and leaving the ones that are worst off in HCBS support to fall even further behind.

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What Did We Learn from the Balancing Incentive Program?

Cited by 13 publications

References 1 publication

Perceived impacts of a Medicaid rebalancing initiative to increase home‐ and community‐based services

Perceived impacts of a Medicaid rebalancing initiative to increase home‐ and community‐based services

Long‐term care service mix in the Veterans Health Administration after home care expansion

Factors Explaining State Differences in Applying for a Recent Long-Term Care Program that Promotes Aging in Place: Perspectives of Medicaid Administrators

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