Medicaid Reimbursement Rates and Access to Nursing Homes

Medicaid reimbursement rates vary widely around the country and at times are just 70 to 80 percent of prevailing private pay rates. These differences may create economic incentives for nursing homes to discriminate against Medicaid applicants. The 1997 National Nursing Home Survey of Current Residents provides the opportunity to develop a ratio of Medicaid to private pay rates for a nationally representative sample of 6,081 residents. Logistic regression modeling shows that even when controlling for sex, race, marital status, and functional level, residents are less likely to be on Medicaid at admission when the ratio is small than when it is close to 1.0. Older Blacks and Hispanics, and older unmarried persons, are more likely to be on Medicaid; therefore, they are more likely to face delay or denial of admission. A possible policy resolution comes from Minnesota, where an equalization law requires nursing home and welfare state officials to work together to set rates, making discriminatory practices against vulnerable groups illegal.

The Impact of Living in a Rural County With No Nursing Home on Utilization Rates and Admission Mobility Patterns

This article uses long-term care data from one state (Virginia) to examine four hypotheses: (a) Rural counties are more likely than urban counties to have no nursing facility, (b) counties without a nursing facility will have lower nursing home utilization rates than counties having a nursing facility, (c) individuals admitted to nursing facilities who originate in counties with no facility will tend to experience moves of greater distance than their counterparts originating in counties having a facility, and (d) those admitted to nursing facilities originating in counties with no facility will tend to move to more urban settings. These hypotheses were supported by the analysis. The findings suggest that access to nursing home care may be more limited for individuals who live in counties without nursing facilities. Long-term care policy makers should give careful consideration to access in their methods for determining need for nursing home care and long-term care services in rural areas.

State discretion and medicaid program variation in long-term care: when is enough, enough?

Although federal statutes and regulations establish the broad parameters within which state Medicaid programs operate, the federal government grants states substantial discretion over Medicaid and Medicaid-funded long-term care. An appreciation of resulting cross-state variation in Medicaid program characteristics, however, has been lacking in the ongoing debate over whether the federal government should further devolve responsibility for caring for the poor and disabled elderly to the states. To better inform this discussion, therefore, this article documents considerable variation, not only in terms of Medicaid program spending and recipients, but also in terms of strategies chosen to reform long-term care services and financing. Since there is little doubt that states take full advantage of current levels of discretion, advocates of devolution may want to reassess their views to consider whether existing variation has resulted in inequities addressable only through more, not less, federal involvement.

Moral hazard in nursing home use

Nursing home expenditures are a rapidly growing share of national health care spending with the government functioning as the dominant payer of services. Public insurance for nursing home care is tightly targeted on income and assets, which imposes a major tax on savings; moreover, low state reimbursement for Medicaid patients has been shown to lower treatment quality, and bed supply constraints may deny access to needy individuals. However, expanding eligibility, increasing Medicaid reimbursement, or allowing more nursing home bed slots has the potential to induce more nursing home use, increasing the social costs of long-term care. A problem in evaluating this tradeoff is that we know remarkably little about the effects of government policy on nursing home utilization. We attempt to address this shortcoming using multiple waves of the National Long-Term Care Survey, matched to changing state Medicaid rules for nursing home care. We find consistent evidence of no effect of Medicaid policies on nursing home utilization, suggesting that demand for nursing home care is relatively inelastic with respect to public program generosity. From a policy perspective, this finding indicates that changes in overall Medicaid generosity will not have large effects on utilization.

Is Telephone Screening Feasible? Accuracy and Cost-Effectiveness of Identifying People Medically Eligible for Home- and Community-Based Services

PURPOSE

To determine the accuracy of a telephone-screening system to identify persons eligible for home- and community-based long-term care.

DESIGN AND METHODS

Data from Michigan telephone screens were compared to data from in-person assessments using the Minimum Data Set for Home Care (MDS-HC). Weighted kappa statistics measured the level of agreement between the two assessments.

RESULTS

Overall, recommendations based on the telephone screen produced a marginal match compared to recommendations based on in-person assessment. "False positives" (individuals scoring as more impaired on the telephone screen than in person) occurred in 27% of all cases, while "false negatives" (individuals scoring as less impaired on the telephone screen) only occurred among 6% of the callers. Neither individual screen questions, source of information, location of the individual, timing between screen and assessment, nor temporal changes accounted for mismatches. Telephone screens resulted in an 11% savings over the cost of providing in-person assessments to all program seekers.

IMPLICATIONS

The telephone screen has utility as a broad targeting mechanism that allows agencies to avoid costly in-person assessments for all program seekers. Evidence does not support use of the telephone screen alone to determine either medical eligibility or a specific level of care.

Titrating versus targeting home care services to frail elderly clients: an application of agency theory and cost-benefit analysis to home care policy

The article summarizes the shortcomings of current home care targeting policy, provides a conceptual framework for understanding the sources of its problems, and proposes an alternative resource allocation method. Methods required for different aspects of the study included synthesis of the published literature, regression analysis of risk predictors, and comparison of actual resource allocations with simulated budgets. Problems of imperfect agency ranging from unclear goals and inappropriate incentives to lack of information about the marginal effectiveness of home care could be mitigated with an improved budgeting method that combines client selection and resource allocation. No program can produce its best outcome performance when its goals are unclear and its technology is unstandardized. Titration of care would reallocate resources to maximize marginal benefit for marginal cost.

A screening system for Michigan's home- and community-based long-term care programs

PURPOSE

To develop a screening system for Michigan's MI Choice publicly funded home- and community-based services programs, to aid in identifying both individuals eligible for services and their most appropriate level of care (LOC).

DESIGN AND METHODS

Identify assessment items from the Minimum Data Set for Home Care (MDS-HC) assessment instrument that are predictive of five LOCs determined by expert care managers: nursing home, home care, intermittent personal care, homemaker, and information and referral (without services).

RESULTS

The algorithm based on approximately 30 client characteristics agrees with expert opinions substantially better (kappa =.62) than systems based on activities of daily living and instrumental activities of daily living only (kappa <.40).

IMPLICATIONS

The screening algorithm can be used both over the telephone to identify clients who will not be fully assessed (as they are unlikely to receive services) and in person to recommend the appropriate LOC.

State long-term care screening and assessment programs

Long-term care screening and assessment programs were designed by states to control long-term care costs and to prevent unnecessary institutionalization of Medicaid participants. This study reports data collected by telephone survey of state officials in all 50 states and Washington, D.C. on state variation in LTC screening and assessment programs. The majority of the state screening and assessment programs cover an array of LTC services but this has resulted in multiple separate screening programs for different long-term care services and eligibility groups. Only three states coordinated screening and assessment across long-term care programs by operating a single state administrative agency, using uniform need criteria and standard tools, and having automated databases (Arizona, Colorado, and Maine). The design and implementation of multiple and separate screening and assessment programs in most states may create potential barriers to client access, information about services and choice of services.

Balancing resources and risk: selecting home care clients in Florida's CARES program

Selecting home care patients who would otherwise go into a nursing home always involves error: serving too many or two few. To clarify the choices program and case managers must make, we propose a risk-based alternative to current selection methods that involves scientifically-derived variable weighting and conscious choice of cut-off score for bestowing home care eligibility. We illustrate our proposal with data from Florida's Comprehensive Assessment and Review of Long-term Care Services (CARES) program. Using logistic regression we identify characteristics that distinguish clients recommended for nursing home placement from those referred to the community and use these results to estimate the risk of nursing home recommendation for each client. An approach to using these risk scores to determine eligibility is demonstrated along with assessment of the impact of alternative risk score cut-offs on denying care to as many as half or as few as 5% of clients served.

Structure and implementation of comprehensive state preadmission screening programs for nursing home applicants: 1978-1994

This paper examines the structure and implementation of comprehensive state preadmission screening (PAS) programs for nursing home applicants from 1978 to 1994 in all 50 states and the District of Columbia. A state was considered to have comprehensive PAS if a majority of nursing home applicants were screened in-person by state or contract agency staff. Twenty-six states had implemented these programs by 1994, with the most growth taking place during the 1980s. The primary changes in program structure were an increased reliance on private providers to screen a subset of applicants and a higher percentage of states screening private pay applicants. All programs but one referred or authorized the use of community-based services, while most programs diverted well over 10 percent of nursing home applicants.