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Rebalancing Long-Term Care Services and Supports

February 24, 2014 11:00 AM

In 2009, approximately 1.3 million Medicaid enrollees with disabilities and chronic conditions received Medicaid-financed long-term care services and supports (LTSS) in institutional settings. The Centers for Medicare & Medicaid Services (CMS) has been promoting efforts to reduce dependence on institutional care and expand access to home- and community-based services (HCBS). This gives Medicaid beneficiaries greater choice in where they live and from whom they receive services, and to deliver LTSS that are integrated, effective, efficient, and person-centered.

At the Rebalancing Long-Term Care Services and Supports forum at Mathematica Policy Research on Thursday, February 20 in Washington, DC, panelists discussed the progress of these rebalancing efforts. The panel experts were Paul Saucier, Truven Health Analytics; Carol Ivin and Denise Hoffman, Mathematica Policy Research; and Michael Smith, Centers for Medicare & Medicaid Services.

Saucier shared various data points on expenditures from Medicaid to HCBS and percentages of spending and disbursement in participating states. The overall conclusion Saucier presented was overwhelming. “Significant and steady national progress has been made on balancing over the last 20 years,” he said. “There is no indication that a plateau or natural limit has been reached, as the bar continues to rise.” Of particular note is that progress has been much greater for individuals with intellectual/developmental disabilities than other population groups.

Irvin expanded on Saucier’s data with a summary of the national Money Follows the Person (MFP) program. Mathematica examined the progress those states using MFP have had in rebalancing, as well as those who combined MFP with the newer Balancing Incentive Program (BIP). Irvin found that states spent their MFP funds on a variety of initiatives, including helping people access community-based services, financing the provision of services, and supporting provider workforce initiatives. Those states that include BIP resources have taken rebalancing initiatives to the next level, building up infrastructure, innovations, and systems initiatives started under MFP.

A key discovery is that MFP is associated with an increase in the proportion of total long-term care expenditures flowing to HCBS. By 2010, the share of long-term expenditures for home and community services was 2.5 percent higher on average among the initial 30 states than if MFP had never been implemented.

One of the factors constraining the size of MFP programs is the lack of affordable and accessible housing that is considered an alternative to senior care facilities. Hoffman shared findings from a look at the Non-Elderly Disabled Housing Choice Voucher Program. The program was designed to provide rental assistance for non-elderly people with disabilities living in an institution, and community support services for voucher recipients. The lack of finding and securing appropriate housing units appears to be the most significant barrier to the program’s success, though the transition rates show promise in five successful areas in the nation: Baltimore and Baltimore County in Maryland, Cincinnati, Ohio, and Snohomish and Tacoma in Washington. As such, the vouchers are a promising resource for facilitating independent living if the housing barriers can be overcome.

Irvin noted afterward three issues that policymakers should be looking at based on the findings presented at the forum. “First, they need to carefully consider whether and how to maintain the transition and rebalancing programs designed by the Money Follows the Person programs after the demonstration grant ends. Through this demonstration, I think states have learned how hard it is to transition low-income individuals with disabilities who need a great deal of assistance figuring out what is needed for them to have the choice of living in the community,” she said. To sustain these programs, states need to be working with CMS to identify ways to fund the transition services that low-income individuals need, either through waivers or administrative funds or some other source, though Irvin said she didn’t know what could be done at the Federal level to make the maintenance of transition program easier for states.

“Second, policymakers need to continue to work on growing and strengthening the direct service workforce, the people who provide personal assistance services,” continued Irvin. “While I agree with [Saucier] that technological improvements have made it easier for some to live in the community, we still need a lot of personal assistance providers and these providers need to improve the quality of their services, particularly as the baby boomers age.

“Third, policymakers need to remember that people with disabilities want choices on where they live and I think Medicaid and housing agencies (along with other social service agencies) need to work more closely together to create more affordable and accessible housing. I think the housing issue requires a lot of interagency collaboration.”

Irvin noted that the evaluation did open a new avenue of research. “The evaluation wasn’t able to address family caregivers, and what roles they play and effects on them when a family member transitions,” she said. “I think we need to understand this dimension better to understand how to design effective respite programs. A number of states are moving into managed long-term care (so long-term care providers [both institutional and community-based] are at risk) and this area will need a lot of research to understand the cost and quality implications.” Irvin said she is aware that some work to measure the quality of HCBS is in progress, but that work is in its earliest stages. “Right now we do not have a good way of measuring the quality of community-based long-term services and supports. I know there is interest in studying racial disparities in access to HCBS, however.”


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