Medicaid State Plan Personal Care Services

Abstract

Policymakers face mounting pressures from consumer demand and the 1999 Olmstead Supreme Court decision to extend formal (paid) programs that deliver personal care to the elderly, chronically ill, and disabled. Despite this, very little is known about the largest program that delivers personal care: the Medicaid State Plan personal care services (PCS) optional benefit. This paper presents the latest available national program (participant and expenditure) trend data (1999–2002) on the Medicaid PCS benefit and findings from a national survey of eligibility and cost control policies in use on the program. The program trends show that, over the study period, the number of states providing the Medicaid PCS benefit grew by four (from 26 to 30), and national program participation, adjusted for population growth, increased by 27%. However, inflation-adjusted program expenditures per participant declined by 3% between 1999 and 2002. Findings from the policy survey reveal that between 1999 and 2002 there was a marked decline in the range of services provided, and by 2004, almost half the programs operated a cap on the hours of services provided.     

State Discretion and Medicaid Program Variation in Long-Term Care

Summary

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.     

An Examination of the Woodwork Effect Using National Medicaid Long-Term Services and Supports Data

A common concern in long-term services and supports (LTSS) policy is the “woodwork effect,” which has two components: (1) more people will use publicly funded services if access to home- and community-based services (HCBS) is expanded; and (2) the additional beneficiaries will increase the growth rate of LTSS expenditures. Medicaid LTSS beneficiary and utilization data starting in 1999 indicate modest growth in beneficiaries and expenditures, after adjusting for inflation and the number of people with functional impairments. The data do not provide strong evidence that the shift in Medicaid funding toward HCBS significantly increased or decreased overall Medicaid LTSS spending.     

Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability.

Design and methods: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS.

Results: New expenditures for PAS are estimated to be $1.4–$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA).

Implications: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

Comparing States' Medicaid Nursing Facilities and Home and Community-Based Services Long-Term Care Programs: Quality and Fit with Inclination,Capacity, and Need

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.     

Medicaid Beneficiaries' Access to Residential Care Settings

Residential care settings (RCSs) are community-based housing and supportive services providers. Medicaid beneficiaries' access to RCSs is of concern to policymakers and other stakeholders because most people prefer community-based to institutional services and RCSs are generally less expensive than nursing homes. To better understand Medicaid beneficiaries' access to state-licensed RCSs, we examined Medicaid policies in 50 states and the District of Columbia, interviewed seven subject-matter experts, and conducted four state case studies informed by reviews of state policies and interviews with 27 stakeholders. Factors identified as influencing Medicaid beneficiaries' access to RCSs include Medicaid reimbursement rates for RCS services, the supply of Medicaid-certified RCSs and RCS beds, and policies that affect RCS room and board costs for Medicaid beneficiaries. Shifting Medicaid spending toward community-based instead of institutional care may require attention to these interrelated issues of RCS payment, supply, and room and board costs.     

Medicaid Home and Community-Based Services: How Consumer Access Is Restricted by State Policies

State Medicaid programs have expanded home and community-based services (HCBS). This article compares trends and variations in state policies for Medicaid HCBS programs in 2005 and 2010. State limitations on financial eligibility criteria and service benefits have remained stable. Although the use of consumer direction, independent providers, and family care providers has increased, some states do not have these options. The increased adoption of state cost control policies have led to large increases in persons on waiver wait lists. Access could be improved by standardizing and liberalizing state HCBS policies, but state fiscal concerns are barriers to rebalancing between HCBS and institutional services.     

Medicaid Funding for Assisted Living Care: A Five-State Examination

Medicaid waiver programs financing assisted living care are examined in five states to gain insights about program implementation, accomplishments, and challenges. Documents, augmented with stakeholder interviews, are used to describe income eligibility, options for supplementing payments to facilities, risk adjustment payment levels, and participation. Needs determination and waiver-based payments are in place. Eligibility and funding levels are complicated by room and board allocations that are linked to the federal benefit rate for Supplemental Security Income. Provider participation may be diminishing. Many recipients have to accept shared occupancy as program payments are insufficient for single units.     

The Woodwork Effect in Medicaid Long-Term Services and Supports

This paper examines annual real per capita Medicaid long-term services and supports (LTSS) expenditures (in 2010 $) over the period 1995 to 2010. Medicaid community LTSS expenditures increased substantially. If that trend constituted a woodwork effect, expenditures on institutional services should have declined more slowly than community expenditures increased, resulting in total expenditures increasing over time. Such a woodwork effect is observed for the population with intellectual and developmental disabilities (IDD) but not for the non-IDD population, composed of persons with disabilities other than IDD, including older persons. During this time period, the goals for serving people with IDD changed; institutional and community cost-neutrality rules were relaxed (and with that concerns over a woodwork effect), and instead goals of community involvement and participation were emphasized for all eligible persons. For the non-IDD population, tighter adherence to cost-neutrality rules and controls over nursing home reimbursements may have helped avoid a woodwork effect as community expenditures increased. With the passage of the Americans with Disabilities Act in 1990, goals have changed for people with disabilities of all ages, and the notion of a simple trade-off between institutional and community service costs that constitutes the woodwork effect must be complemented with a much broader idea of cost analysis that values independence and community participation for people with disabilities of all ages.     

Distribution and Utilization of Home- and Community-Based Long-Term Care Services for the Elderly in North Carolina

ABSTRACT

Provision of home- and community-based long-term care is a growing concern at the national, state, and local levels. As more persons grow old, the need for these services is expected to rise. This analysis examines the distribution and utilization of three home- and community-based long-term care programs in North Carolina for each of the state's 100 counties. Maps were generated to examine how counties differed in respect to service utilization among the elderly. Great variability was found in number of elderly utilizing the services across the state as well as the percent of Medicaid- and/or age-eligible persons who utilized the programs. Multivariate modeling for associations to service utilization was only possible for one of the long-term care programs. Results indicated that living alone, being non-white, and having a mobility and self-care limitation were all positively related to utilization. Percent of persons 85 years or older and the ratio of institutionalized long-term care beds were negatively associated with utilization. It was concluded that states must engage in concerted efforts to ensure equity in access to home- and community-based long-term care.     

Long-Term Care Administrators' Perceptions of the Ombudsman Program in the State of Missouri

The presence of a long-term care ombudsman in a long-term care or nursing facility helps prevent abusive or neglectful situations before they start. Almost all Missouri long-term care facility administrators responding to the survey reported that they were aware of the ombudsman program; however, only half currently house an ombudsman in their facility. Respondents aware of the program were significantly more likely to currently accommodate an ombudsman in their facility, and those managing larger facilities were significantly more likely to currently have an ombudsman present. Given the numerous changes in the long-term care system, the need for more ombudsman advocates in this setting is crucial.     

Transition from Home Care to Nursing Home: Unmet Needs in a Home- and Community-Based Program for Older Adults

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.     

Beneficiary Work: The Hidden Labor of Medicaid Users Pursuing Cross-State Moves

For users of Medicaid personal care assistance (PCA) services and their families, interstate variation in eligibility and service availability act as structural barriers to cross-state movement. However, program users desire and pursue cross-state moves. In this article, we provide a grounded theory analysis of 18 interviews with Medicaid PCA users with physical disabilities who expressed desire for or pursued cross-state moves. Our analysis identified six forms of previously unnamed and unrecognized work. As PCA users plan or pursue cross-state moves, they are also (1) assessing service ecosystems, (2) finding the right door, (3) persisting through the bureaucratic gauntlet, (4) advocating for systems cooperation, (5) reestablishing networks of support, and (6) responding to service gaps/lapses. Collectively, we describe this hidden labor as beneficiary work, the unremunerated work that program users must do in order to retain access to benefits for which they qualify. Beneficiary work, while hidden, is not optional; it is necessary for continued access to community and broadly, for survival. Identifying and describing beneficiary work expands on Feminist and interactionist perspectives on disability, poverty, and work, and highlights the need for changes to Medicaid policy that address PCA users as mobile citizens.     

Experience,Knowledge, and Concerns About Long-Term Services and Supports: Implications for Financing Reform

Using the 2014 Survey of Long-Term Care Awareness and Planning, this article examines Americans’ experiences, knowledge, and concerns about long-term services and supports (LTSS) and actions they are willing to take if they become disabled. The survey included 15,298 non-institutionalized respondents aged 40 to 70 years drawn from a nationally representative sample. Although many reported some experience with LTSS, knowledge of how LTSS worked was low. Respondents reported widespread concerns about becoming disabled. They preferred informal care over paid care, with a strong desire to remain in their homes. These results can be used to design reform initiatives and to motivate political support.     

Medicaid physician fees and the quality of medical care of Medicaid patients in the USA

When enacted in 1965, the original Medicaid legislation sought to finance access to mainstream medical care for the poor. I use data on visits to office-based physicians from the National Ambulatory Medical Care Survey in four years—1989, 1993, 1998 and 2003—to test the extent to which this goal has been achieved. Specifically, I test whether this goal has been achieved more in states that pay higher fees to physicians who treat Medicaid patients compared to states that pay lower fees. By comparing the treatment of Medicaid patients to that of privately-insured patients and by using state fixed effects, I am able to estimate the effects of changes in the generosity of Medicaid physician payment within a state on changes in access to care for Medicaid patients, therefore separating Medicaid’s effect on access to health care from any correlation between the Medicaid fee and other attributes of the state in which a patient lives. Using this method, I examine the effect of Medicaid fees on whether or not an office-based physician accepts Medicaid patients, on the fraction of a physician’s practice that is accounted for by Medicaid, and on the length of visit times with physicians. Results imply that higher Medicaid fees increase the number of private physicians, especially in medical and surgical specialties, who see Medicaid patients. Higher fees also lead to visit times with physicians that are more comparable to visit times with private pay patients.

Health care innovations for homeless families: Emerging opportunities under Medicaid and the Affordable Care Act

Prior to the Patient Protection and Affordable Care Act of 2010 (the ACA), the US health care system left many low-income families facing limited access to medical care, struggling with high-health costs, or lacking health insurance altogether. The ACA aims to increase access to care, improve the quality of care, and lower total health care costs. While the ACA can benefit all individuals and families, it has significant potential for expanding and improving services for those experiencing homelessness. This paper describes specific opportunities under the ACA and Medicaid that can be used to strengthen services for homeless families and provides examples of efforts under way. It also offers guidance for how homeless service agencies can effect change in their respective states. The examples described here are promising approaches to strengthening homeless services. Pursuing these ideas for homeless families will require initiative, creativity, and perseverance, but recent progress is encouraging.     

养老服务的逻辑、实现方式与治理路径

养老服务是不同供给主体将不同内容、质量和价格的养老产品或项目,以不同的方式配送到不同需求老年群体的过程。不同供给主体基于责任驱动和利益驱动,为需求主体提供适应性养老服务,是养老服务的基本逻辑。养老服务的实现,是在特定地域、特定的社会关系网络中,通过优化配置养老服务资源,聚集整合养老服务资本,来保障有质量、有尊严的老年生活。鉴于养老服务供给的多元性和需求的复杂性,养老服务的治理则需要运用先进的合作治理与参与治理理念、选择科学的治理工具和现代化的治理技术,保障养老服务供给与需求的适应性匹配,进而保障养老服务实现方式的有序运行。     

Provider and Care Workforce Influences on Quality of Home-Care Services in England

Abstract

A key trend in home care in recent years in England has been movement away from “in-house” service provision by local government authorities (e.g., counties) towards models of service commissioning from independent providers. A national survey in 2003 identified that there were lower levels of satisfaction and perceptions of quality of care among older users of independent providers compared with in-house providers. This paper reports the results of a study that related service users views of 121 providers with the characteristics of these providers. For the most part, characteristics associated with positive perceptions of quality were more prevalent among in-house providers. Multivariate analyses of independent providers suggested that aspects of the workforce itself, in terms of age and experience, provider perceptions of staff turnover, and allowance of travel time, were the most critical influences on service user experiences of service quality.     

Linking Elderly to Holistic Care Services through Integrated Communication Technology: The Personal Emergency Link Service Rendered by the Senior Citizen Home Safety Association in Hong Kong

Through a Personal Emergency Link system, the Senior Citizen Home Safety Association has rendered 24-hour care to more than 111,000 service users in Hong Kong who are mostly vulnerable seniors and chronic invalids living alone or living with their elderly spouses/caregivers only. This article will describe how the Personal Emergency Link system is used to link seniors living in the community. Measures taken to prevent failure of the system will be described. With the use of different technology applications, many human touches and warm caregiving are rendered to the elderly and needy.     

An Elder Care Training Needs Assessment Among Employee Assistance Program Staff Employed by New York State Government:

A mail survey of 224 EAP staff members employed by various departments of New York State government explored the issue of elder care. Self-report questionnaire data evaluated training history competence to handle employed caregiver problems/questions, and individual department commitment. Major findings generally replicated those of a previous regional study conducted with 95 Western New York EAP staff members. Survey results showed: (1) EAP staff members estimated that one in five employees currently provides care for an older dependent; (2) the majority (56.9%) of staff members have not received any training relevant to elder care; (3) self-assessed competence to handle elder care problems was low for 13 of 17 problem-solving domains constituting the Elder Care Competence Index (ECCI); (4) the few (14.9%) EAP staff members with extensive (two or more sessions) elder care training experience achieved ECCI scores nearly 150% higher than staff members without such training, p < .001; (5) most (73.0%) departments have not dealt with elder care in any formal way and only 3.6% of the EAP staff believe this inaction to be appropriate; and (6) department commitment to the issue of elder care is predictive of both training (p < .01) and staff competence (p < .01). The implications for training, policy, and future research are discussed.