PUBLIC HEALTH POLICY BRIEF
Local Medicaid Home- and Community-Based Services Spending and Nursing Home Admissions of Younger Adults We used fixed-effect models to examine the relationship between local spending on home- and communitybased services (HCBSs) for cash-assisted Medicaid-only disabled (CAMOD) adults and younger adult admissions to nursing homes in the United States during 2001 through 2008, with control for facility and market characteristics and secular trends. We found that increased CAMOD Medicaid HCBS spending at the local level is associated with decreased admissions of younger adults to nursing homes. Our findings suggest that states’ efforts to expand HCBS for this population should continue.(Am J Public Health. 2014;104:e15–e17. doi:10. 2105/AJPH.2014.302144)
Kali S. Thomas, PhD, Laura Keohane, MS, and Vincent Mor, PhD
SINCE THE 1999 OLMSTEAD decision,1 there has been a number of initiatives aimed to provide individuals with disabilities increased access to long-term care (LTC) options, primarily through expansion in home- and communitybased services (HCBSs). Although research has investigated the effect of HCBS growth on the Medicare population of nursing home residents,2---9 there has been little attention given to the relationship between younger nursing home residents and Medicaid HCBS expenditures. As states face growing pressure in how to best allocate their Medicaid budgets, it is important that we have sound research guiding these decisions. Recently, a published study suggested that younger adults’ rates of nursing home admission were not related to Medicaid HCBS spending.10 Two prominent limitations may have led to this null finding: (1) rather than measuring spending for younger adults, the 2011 study used total state Medicaid LTC spending, and (2) the analyses were conducted at the state level, thereby missing market and facility characteristics influencing this relationship. We reexamined this question by using more refined data: Medicaid LTC spending on cash-assisted Medicaidonly disabled (CAMOD) adults at the local level and nursing home admission assessment data aggregated to the facility level. We hypothesized that increasing investment in Medicaid HCBSs for CAMOD adults would be related to a decrease in the share of younger adult nursing home admissions.
November 2014, Vol 104, No. 11 | American Journal of Public Health
METHODS Our data came from the LongTerm Care: Facts on Care in the US Web site (http://LTCfocus.org),11 maintained by Brown University School of Public Health, which compiles longitudinal nursing home, resident, and state policy data. We merged these data with information from the Medicaid Atlas of Health Care, developed by the Office of the Assistant Secretary for Planning and Evaluation through a contract with the Urban Institute and its subcontractors, the University of California, San Diego, and Velir Studios. The Medicaid Atlas aggregates the Medicaid Analytic eXtract data to a Medicaid Atlas Local Area (MALA). The MALAs are defined as metropolitan statistical areas. Counties not assigned to a metropolitan statistical area are included in a “rest of the state” MALA yielding a total of 452 unique MALAs. The dependent variable, percentage of admissions younger than 65 years, came from http://LTCfocus.org and was derived from facility-aggregated admission assessment data. Our independent variable came from the Medicaid Atlas: spending on HCBS as a percentage of total Medicaid LTC spending at the MALA-level for CAMOD, nonelderly beneficiaries. Among Medicaid beneficiaries, this group is most similar in eligibility criteria across states and excludes individuals dually eligible for Medicare and Medicaid and individuals enrolled in managed care.12,13
From the LTCfocus.org data, we controlled for time-varying variables that reflect the capacity as well as the financial health of the facilities, which may influence the decision to provide services to younger adults: payer mix (proportion of Medicaid residents and Medicare managed care admissions), occupancy rate, and the average state Medicaid per diem rate. To address competition, we included the annual nursing home Herfindahl Index and the number of home health agencies per 1000 older adults in the county. To control for the use of nursing homes that specialize in rehabilitation and therefore may attract younger adults, we included nurse staffing levels and the number of admissions per bed to reflect the churning of rehabilitation patients through the nursing home. We also included the number of CAMOD users of LTC in the MALA to control for demand. These variables are all time-varying. We estimated a 2-way fixedeffects model (year and facility fixed effects) to examine the relationship between the proportion of Medicaid dollars going toward HCBS for CAMOD beneficiaries and the proportion of younger adult admissions from 2001 to 2008. The unit of analysis was the facility-year from a sample of 15 588 free-standing nursing homes, and standard errors were clustered at the facility level.
RESULTS During the study period, there was an increase in both the
Thomas et al. | Peer Reviewed | Public Health Policy Brief | e15
PUBLIC HEALTH POLICY BRIEF
60 55.8
55.5 53.4
50
48.7
52.6
56.6
52.1
49.4
Percentage
40
Our findings suggest that states should continue their efforts to expand HCBS for this population. In addition, states should target areas with low rates of HCBS access and utilization for the population younger than 65 years in an effort to reduce potential unnecessary nursing home placement. j
About the Authors
30
20
11.2
11.7
12.5
13.8
13.4
13.3
13.1
14.1
10 Medicaid spending Admission younger than 65 y
0 2001
2002
2003
2004
2005
2006
2007
2008
Year Note. CAMOD = cash-assisted Medicaid-only disabled beneficiaries; HCBS = home- and community-based services. Proportion of Medicaid spending on HCBS for the CAMOD population is a Medicaid Atlas Local Area–level average. Percentage of admissions younger than 65 years is a facility-level average.
FIGURE 1—Increase in the proportion of Medicaid spending on home- and community-based services for the cash-assisted Medicaid-only disabled beneficiary population and the percentage of admissions to nursing homes younger than 65 years, by year: United States, 2001–2008.
Kali S. Thomas and Vincent Mor are with the Department of Veterans Affairs Medical Center, and Center for Gerontology and Healthcare Research, Brown University, Providence, RI. Laura Keohane is with the Department of Health Services, Policy, and Practice, Brown University. Correspondence should be sent to Kali S. Thomas, PhD, Brown University, Box G-S121(6), Providence, RI 02912 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted on June 23, 2014. Note. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
Contributors All authors made substantial contributions to the conceptualization and design, analysis and interpretation of data, and drafting and revision of content.
Acknowledgments proportion of Medicaid HCBS spending on CAMODs and the average proportion of younger adult admissions (Figure 1). Multivariate model results suggest that facilities in MALAs that increased the proportion of the HCBS spending for CAMODs saw a decreased proportion of younger adult admissions (b = –0.009; P = .003), with control for facility, market, and state characteristics (Table 1). Specifically, every 1percentage-point increase in the proportion of Medicaid spending on HCBS was associated with a 0.009-percentage-point decrease in the proportion of admissions to nursing homes that were younger adults. With this estimate,
increasing the average proportion of MALA-level HCBS spending by 10% is associated with approximately at least 2480 fewer admissions of younger adults in 2008.
DISCUSSION We found that when we used more refined data, a relationship between the proportion of CAMOD Medicaid HCBS spending and younger adult nursing home admissions does exist. The overall trend of increased nursing home use by younger persons likely reflects large increases in the use of nursing homes for rehabilitative care. However, in multivariate
e16 | Public Health Policy Brief | Peer Reviewed | Thomas et al.
analysis, when we controlled for these characteristics, facilities in areas with an increased proportion of local Medicaid HCBS spending on CAMODs experienced decreased rates of younger adult nursing home admission. A major strength of this study was the use of an 8-year longitudinal data set. Also, we controlled for national trends and facility and market characteristics, and tested for the effect of changes in Medicaid HCBS investments over time, thereby addressing some potential endogeneity. These findings are more robust than those of earlier studies that have examined these issues with cross-sectional or state-level data.
This work was supported by the National Institute on Aging (P01AG-027296) and the Agency for Healthcare Research and Quality (T32 HS-000011).
Human Participant Protection This research involved the study of existing publicly available aggregated data such that participants cannot be identified and was therefore exempt from institutional review board review.
References 1.
Olmstead v. L.C., 527 U.S. 581 (1999).
2. Pande A, Laditka SB, Laditka JN, Davis D. Aging in place? Evidence that a state Medicaid waiver program helps frail older persons avoid institutionalization. Home Health Care Serv Q. 2007; 26(3):39---60. 3. Mor V, Zinn J, Gozalo P, Feng Z, Intrator O, Grabowski DC. Prospects for transferring nursing home residents to the community. Health Aff (Millwood). 2007; 26(6):1762---1771. 4. Mitchell G, Salmon JR, Polivka L, Soberon-Ferrer H. The relative benefits
American Journal of Public Health | November 2014, Vol 104, No. 11
PUBLIC HEALTH POLICY BRIEF
TABLE 1—Multivariate Model Examining the Relationship Between Medicaid Home- and Community-Based Services Spending on the Cash-Assisted Medicaid-Only Disabled Beneficiary Population and the Percentage of Admissions Younger Than 65 Years: United States, 2001–2008 Variable
b (Robust SE)
Spending on CAMODs going toward HCBS, % Residents funded by Medicaid, %
–0.009** (0.003) 0.024*** (0.003)
Proportion of Medicare managed care admissions
0.266*** (0.007)
Occupancy rate
–0.036*** (0.004)
Adjusted state Medicaid payment rate
–0.011*** (0.003)
Proportion of nurses that are RNs
–0.515* (0.248)
CNA hours per resident day
–0.098*** (0.027)
Number of admissions per bed
–0.053 (0.043)
Number of 1000 CAMOD beneficiaries in the MALA Herfindahl index Number of home health agencies in the county
0.022 (0.048) –3.875*** (0.709) 1.856*** (0.253)
per 1000 older adults Note. CAMOD = cash-assisted Medicaid-only disabled beneficiaries; CNA = certified nursing assistant; HCBS = home- and community-based services; MALA = Medicaid Atlas Local Area; RN = registered nurse. Model includes time and facility fixed effects. Standard errors clustered at the facility level. *P < .5; **P < .01; ***P < .001.
and cost of Medicaid home- and community-based services in Florida. Gerontologist. 2006;46(4):483---494. 5. Muramatsu N, Yin H, Campbell RT, Hoyem RL, Jacob MA, Ross CO. Risk of nursing home admission among older Americans: does states’ spending on home and community-based services matter? J Gerontol B Psychol Sci Soc Sci. 2007;62:S169---S178. 6. Hahn EA, Thomas KS, Hyer K, Andel R, Meng H. Predictors of low-care prevalence in Florida nursing homes: the role of Medicaid waiver programs. Gerontologist. 2011;51(4):495---503. 7. Thomas KS, Mor V. Providing more home-delivered meals is one way to keep older adults with low care needs out of nursing homes. Health Aff (Millwood). 2013;32(10):1796---1802.
analysis. Am J Public Health. 2011; 101(9):1735---1741. 11. Brown University School of Public Health. Long-Term Care: Facts on Care in the US. Available at: http://ltcfocus.org. Accessed January 6, 2014. 12. Gilmer TP, Kronick RG. Differences in the volume of services and in prices drive big variations in Medicaid spending among US states and regions. Health Aff (Millwood). 2011;30(7):1316---1324. 13. Kronick R, Gilmer TP. Medicare and Medicaid spending variations are strongly linked within hospital regions but not at overall state level. Health Aff (Millwood). 2012;31(5):948---955.
8. Thomas KS, Mor V. The relationship between Older Americans Act Title III state expenditures and prevalence of low-care nursing home residents. Health Serv Res. 2013;48(3):1215---1226. 9. Thomas KS. The relationship between Older Americans Act in-home services and low-care residents. J Aging Health. 2014;26(2):250---260. 10. Miller NA. Relations among homeand community-based services investment and nursing home rates of use for working-age and older adults: a state-level
November 2014, Vol 104, No. 11 | American Journal of Public Health
Thomas et al. | Peer Reviewed | Public Health Policy Brief | e17
Local Medicaid Home- and Community-Based Services Spending and Nursing Home Admissions of Younger Adults We used fixed-effect models to examine the relationship between local spending on home- and communitybased services (HCBSs) for cash-assisted Medicaid-only disabled (CAMOD) adults and younger adult admissions to nursing homes in the United States during 2001 through 2008, with control for facility and market characteristics and secular trends. We found that increased CAMOD Medicaid HCBS spending at the local level is associated with decreased admissions of younger adults to nursing homes. Our findings suggest that states’ efforts to expand HCBS for this population should continue.(Am J Public Health. 2014;104:e15–e17. doi:10. 2105/AJPH.2014.302144)
Kali S. Thomas, PhD, Laura Keohane, MS, and Vincent Mor, PhD
SINCE THE 1999 OLMSTEAD decision,1 there has been a number of initiatives aimed to provide individuals with disabilities increased access to long-term care (LTC) options, primarily through expansion in home- and communitybased services (HCBSs). Although research has investigated the effect of HCBS growth on the Medicare population of nursing home residents,2---9 there has been little attention given to the relationship between younger nursing home residents and Medicaid HCBS expenditures. As states face growing pressure in how to best allocate their Medicaid budgets, it is important that we have sound research guiding these decisions. Recently, a published study suggested that younger adults’ rates of nursing home admission were not related to Medicaid HCBS spending.10 Two prominent limitations may have led to this null finding: (1) rather than measuring spending for younger adults, the 2011 study used total state Medicaid LTC spending, and (2) the analyses were conducted at the state level, thereby missing market and facility characteristics influencing this relationship. We reexamined this question by using more refined data: Medicaid LTC spending on cash-assisted Medicaidonly disabled (CAMOD) adults at the local level and nursing home admission assessment data aggregated to the facility level. We hypothesized that increasing investment in Medicaid HCBSs for CAMOD adults would be related to a decrease in the share of younger adult nursing home admissions.
November 2014, Vol 104, No. 11 | American Journal of Public Health
METHODS Our data came from the LongTerm Care: Facts on Care in the US Web site (http://LTCfocus.org),11 maintained by Brown University School of Public Health, which compiles longitudinal nursing home, resident, and state policy data. We merged these data with information from the Medicaid Atlas of Health Care, developed by the Office of the Assistant Secretary for Planning and Evaluation through a contract with the Urban Institute and its subcontractors, the University of California, San Diego, and Velir Studios. The Medicaid Atlas aggregates the Medicaid Analytic eXtract data to a Medicaid Atlas Local Area (MALA). The MALAs are defined as metropolitan statistical areas. Counties not assigned to a metropolitan statistical area are included in a “rest of the state” MALA yielding a total of 452 unique MALAs. The dependent variable, percentage of admissions younger than 65 years, came from http://LTCfocus.org and was derived from facility-aggregated admission assessment data. Our independent variable came from the Medicaid Atlas: spending on HCBS as a percentage of total Medicaid LTC spending at the MALA-level for CAMOD, nonelderly beneficiaries. Among Medicaid beneficiaries, this group is most similar in eligibility criteria across states and excludes individuals dually eligible for Medicare and Medicaid and individuals enrolled in managed care.12,13
From the LTCfocus.org data, we controlled for time-varying variables that reflect the capacity as well as the financial health of the facilities, which may influence the decision to provide services to younger adults: payer mix (proportion of Medicaid residents and Medicare managed care admissions), occupancy rate, and the average state Medicaid per diem rate. To address competition, we included the annual nursing home Herfindahl Index and the number of home health agencies per 1000 older adults in the county. To control for the use of nursing homes that specialize in rehabilitation and therefore may attract younger adults, we included nurse staffing levels and the number of admissions per bed to reflect the churning of rehabilitation patients through the nursing home. We also included the number of CAMOD users of LTC in the MALA to control for demand. These variables are all time-varying. We estimated a 2-way fixedeffects model (year and facility fixed effects) to examine the relationship between the proportion of Medicaid dollars going toward HCBS for CAMOD beneficiaries and the proportion of younger adult admissions from 2001 to 2008. The unit of analysis was the facility-year from a sample of 15 588 free-standing nursing homes, and standard errors were clustered at the facility level.
RESULTS During the study period, there was an increase in both the
Thomas et al. | Peer Reviewed | Public Health Policy Brief | e15
PUBLIC HEALTH POLICY BRIEF
60 55.8
55.5 53.4
50
48.7
52.6
56.6
52.1
49.4
Percentage
40
Our findings suggest that states should continue their efforts to expand HCBS for this population. In addition, states should target areas with low rates of HCBS access and utilization for the population younger than 65 years in an effort to reduce potential unnecessary nursing home placement. j
About the Authors
30
20
11.2
11.7
12.5
13.8
13.4
13.3
13.1
14.1
10 Medicaid spending Admission younger than 65 y
0 2001
2002
2003
2004
2005
2006
2007
2008
Year Note. CAMOD = cash-assisted Medicaid-only disabled beneficiaries; HCBS = home- and community-based services. Proportion of Medicaid spending on HCBS for the CAMOD population is a Medicaid Atlas Local Area–level average. Percentage of admissions younger than 65 years is a facility-level average.
FIGURE 1—Increase in the proportion of Medicaid spending on home- and community-based services for the cash-assisted Medicaid-only disabled beneficiary population and the percentage of admissions to nursing homes younger than 65 years, by year: United States, 2001–2008.
Kali S. Thomas and Vincent Mor are with the Department of Veterans Affairs Medical Center, and Center for Gerontology and Healthcare Research, Brown University, Providence, RI. Laura Keohane is with the Department of Health Services, Policy, and Practice, Brown University. Correspondence should be sent to Kali S. Thomas, PhD, Brown University, Box G-S121(6), Providence, RI 02912 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted on June 23, 2014. Note. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
Contributors All authors made substantial contributions to the conceptualization and design, analysis and interpretation of data, and drafting and revision of content.
Acknowledgments proportion of Medicaid HCBS spending on CAMODs and the average proportion of younger adult admissions (Figure 1). Multivariate model results suggest that facilities in MALAs that increased the proportion of the HCBS spending for CAMODs saw a decreased proportion of younger adult admissions (b = –0.009; P = .003), with control for facility, market, and state characteristics (Table 1). Specifically, every 1percentage-point increase in the proportion of Medicaid spending on HCBS was associated with a 0.009-percentage-point decrease in the proportion of admissions to nursing homes that were younger adults. With this estimate,
increasing the average proportion of MALA-level HCBS spending by 10% is associated with approximately at least 2480 fewer admissions of younger adults in 2008.
DISCUSSION We found that when we used more refined data, a relationship between the proportion of CAMOD Medicaid HCBS spending and younger adult nursing home admissions does exist. The overall trend of increased nursing home use by younger persons likely reflects large increases in the use of nursing homes for rehabilitative care. However, in multivariate
e16 | Public Health Policy Brief | Peer Reviewed | Thomas et al.
analysis, when we controlled for these characteristics, facilities in areas with an increased proportion of local Medicaid HCBS spending on CAMODs experienced decreased rates of younger adult nursing home admission. A major strength of this study was the use of an 8-year longitudinal data set. Also, we controlled for national trends and facility and market characteristics, and tested for the effect of changes in Medicaid HCBS investments over time, thereby addressing some potential endogeneity. These findings are more robust than those of earlier studies that have examined these issues with cross-sectional or state-level data.
This work was supported by the National Institute on Aging (P01AG-027296) and the Agency for Healthcare Research and Quality (T32 HS-000011).
Human Participant Protection This research involved the study of existing publicly available aggregated data such that participants cannot be identified and was therefore exempt from institutional review board review.
References 1.
Olmstead v. L.C., 527 U.S. 581 (1999).
2. Pande A, Laditka SB, Laditka JN, Davis D. Aging in place? Evidence that a state Medicaid waiver program helps frail older persons avoid institutionalization. Home Health Care Serv Q. 2007; 26(3):39---60. 3. Mor V, Zinn J, Gozalo P, Feng Z, Intrator O, Grabowski DC. Prospects for transferring nursing home residents to the community. Health Aff (Millwood). 2007; 26(6):1762---1771. 4. Mitchell G, Salmon JR, Polivka L, Soberon-Ferrer H. The relative benefits
American Journal of Public Health | November 2014, Vol 104, No. 11
PUBLIC HEALTH POLICY BRIEF
TABLE 1—Multivariate Model Examining the Relationship Between Medicaid Home- and Community-Based Services Spending on the Cash-Assisted Medicaid-Only Disabled Beneficiary Population and the Percentage of Admissions Younger Than 65 Years: United States, 2001–2008 Variable
b (Robust SE)
Spending on CAMODs going toward HCBS, % Residents funded by Medicaid, %
–0.009** (0.003) 0.024*** (0.003)
Proportion of Medicare managed care admissions
0.266*** (0.007)
Occupancy rate
–0.036*** (0.004)
Adjusted state Medicaid payment rate
–0.011*** (0.003)
Proportion of nurses that are RNs
–0.515* (0.248)
CNA hours per resident day
–0.098*** (0.027)
Number of admissions per bed
–0.053 (0.043)
Number of 1000 CAMOD beneficiaries in the MALA Herfindahl index Number of home health agencies in the county
0.022 (0.048) –3.875*** (0.709) 1.856*** (0.253)
per 1000 older adults Note. CAMOD = cash-assisted Medicaid-only disabled beneficiaries; CNA = certified nursing assistant; HCBS = home- and community-based services; MALA = Medicaid Atlas Local Area; RN = registered nurse. Model includes time and facility fixed effects. Standard errors clustered at the facility level. *P < .5; **P < .01; ***P < .001.
and cost of Medicaid home- and community-based services in Florida. Gerontologist. 2006;46(4):483---494. 5. Muramatsu N, Yin H, Campbell RT, Hoyem RL, Jacob MA, Ross CO. Risk of nursing home admission among older Americans: does states’ spending on home and community-based services matter? J Gerontol B Psychol Sci Soc Sci. 2007;62:S169---S178. 6. Hahn EA, Thomas KS, Hyer K, Andel R, Meng H. Predictors of low-care prevalence in Florida nursing homes: the role of Medicaid waiver programs. Gerontologist. 2011;51(4):495---503. 7. Thomas KS, Mor V. Providing more home-delivered meals is one way to keep older adults with low care needs out of nursing homes. Health Aff (Millwood). 2013;32(10):1796---1802.
analysis. Am J Public Health. 2011; 101(9):1735---1741. 11. Brown University School of Public Health. Long-Term Care: Facts on Care in the US. Available at: http://ltcfocus.org. Accessed January 6, 2014. 12. Gilmer TP, Kronick RG. Differences in the volume of services and in prices drive big variations in Medicaid spending among US states and regions. Health Aff (Millwood). 2011;30(7):1316---1324. 13. Kronick R, Gilmer TP. Medicare and Medicaid spending variations are strongly linked within hospital regions but not at overall state level. Health Aff (Millwood). 2012;31(5):948---955.
8. Thomas KS, Mor V. The relationship between Older Americans Act Title III state expenditures and prevalence of low-care nursing home residents. Health Serv Res. 2013;48(3):1215---1226. 9. Thomas KS. The relationship between Older Americans Act in-home services and low-care residents. J Aging Health. 2014;26(2):250---260. 10. Miller NA. Relations among homeand community-based services investment and nursing home rates of use for working-age and older adults: a state-level
November 2014, Vol 104, No. 11 | American Journal of Public Health
Thomas et al. | Peer Reviewed | Public Health Policy Brief | e17
