State Medicaid Home and Community-Based Services Policies and Health Expenditures by Payer

This study examines the relationship between two state Medicaid home and community-based services (HCBS) policies - number of beneficiaries (Participation) and use per beneficiary (Intensity) - and individual health expenditures. Data include the 2008-2013 Medicare Current Beneficiary Survey and state-level Medicaid HCBS indicators. Two-part generalized linear models are estimated for health expenditures by payer and dual-eligibility status. The likelihood and level of Medicare expenditures are significantly lower in states in the top quartile of Participation and Intensity. Findings suggest that state Medicaid HCBS policies may impact health expenditures, with potential spillover effects on Medicare spending.

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

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.

An Examination of the Likelihood of Home Discharge After General Hospitalizations Among Medicaid Recipients

Ability to predict discharge destination would be a useful way of optimizing posthospital care. We conducted a cross-sectional, multiple state study of inpatient services to assess the likelihood of home discharges in 2009 among Medicaid enrollees who were discharged following general hospitalizations. Analyses were conducted using hospitalization data from the states of California, Georgia, Michigan, and Mississippi. A total of 33 160 patients were included in the study among which 13 948 (42%) were discharged to their own homes and 19 212 (58%) were discharged to continue with institutional-based treatment. A multiple logistic regression model showed that gender, age, race, and having ambulatory care-sensitive conditions upon admission were significant predictors of home-based discharges. Females were at higher odds of home discharges in the sample (odds ratio [OR] = 1.631; 95% confidence interval [CI], 1.520-1.751), while patients with ambulatory care-sensitive conditions were less likely to get home discharges (OR = 0.739; 95% CI, 0.684-0.798). As the nation engages in the continued effort to improve the effectiveness of the health care system, cost savings are possible if providers and systems of care are able to identify admission factors with greater prospects for in-home services after discharge.

Characteristics of Older Georgians Receiving Older Americans Act Nutrition Program Services and Other Home- and Community-Based Services: Findings from the Georgia Aging Information Management System (GA AIMS)

This descriptive study examined characteristics of older Georgians receiving Older Americans Act Nutrition Program Services and other home- and community-based services (HCBS) using state aging administrative data (N = 31,341, mean age: 76.6 ± 9.2 y, 71.2% female, 52.3% White). Home-delivered meals (HDM) was used most frequently. The characteristics of older Georgian HCBS participants varied by the type and number of HCBS received. Those receiving HDM and other in-home and caregiving services were more likely to show poorer sociodemographic, economic, and functional characteristics, and food insecurity. Those receiving multiple HCBS were most vulnerable, but showed lower level of food insecurity than those receiving single HCBS, suggesting potential combined benefits of receiving multiple programs. This study underscores the importance of documenting dynamic needs for HCBS, especially HDM, among vulnerable older adults as part of standard administrative process to identify those at high risk of institutionalization, optimize HCBS delivery and coordination, and maximize HCBS benefits.

Environmental Predictors of Unmet Home-and Community-Based Service Needs of Older Adults

Home- and community-based services (HCBS) for many older adults are an essential component of aging-in-place. Andersen developed the contemporary model used to predict service use. Researchers have modified the model to examine need. Studies that attempt to predict unmet needs have explained only 10% to 15% of the variance. This study is based on the supposition that lack of accounting for environmental factors has resulted in such small explanatory power. Through the use of 2008 Southeastern Pennsylvania Household Health Survey data, this exploratory study modeled predictors of unmet HCBS needs. Findings reveal that lack of access to healthy foods and poor housing quality have a significant relationship to unmet HCBS needs. This model predicted 54% of the variance. Results reveal environmental questions to ask, a way to identify older adults with unmet HCBS needs and environmental barriers that if addressed may reduce older adults’ eventual need for health services and HCBS.

Willingness to pay for home- and community-based services for seniors in Florida

States are increasingly interested in measuring the benefit of home- and community-based services (HCBS) programs in order to determine if continued provision of HCBS can be justified on a cost-benefit basis. This study attempts to assess the maximum dollar amount HCBS enrollees or eligible applicants are willing to pay as a measure of the value of the services to them. A contingent valuation survey was conducted on a random sample of 409 clients who were enrolled in or waitlisted for HCBS programs in Florida. Based on estimates from a random-effect model, the median and mean willingness to pay amounts are calculated to be $901 and $933 per month per person, respectively, with considerable variation across HCBS programs. The major determinants of willingness to pay include household income and individual functional status. The sizable values for willingness to pay reported in this study suggest that HCBS programs are perceived as a valuable resource for the elderly.

The Care Span: Medicaid savings resulted when community health workers matched those with needs to home and community care

The Affordable Care Act of 2010 builds on earlier efforts to expand home and community-based alternatives to institutional long-term care. Identifying people living in the community who have unmet long-term care needs and who may be at risk for entering nursing homes may be crucial to these efforts. The Arkansas Community Connector Program used specially trained community health workers to identify such people in three disadvantaged counties and connect them to Medicaid home and community-based services. The result was a 23.8 percent average reduction in annual Medicaid spending per participant during the period 2005-08. Net three-year savings to the Arkansas Medicaid program equaled $2.619 million. Similar interventions may help other localities achieve cost-saving and equitable access to publicly funded long-term care options other than institutional care.