HHS Releases Study Showing HCBS Wait List Effects on Costs, Institutionalization
June 13, 2014 12:05 PM
The U.S. Department of Health and Human Services (HHS) recently released a study titled Impacts of Waiting Periods for Home and Community-Based Services on Consumers and Medicaid Long-Term Care Costs in Iowa (the Study). The Study sought to examine the extent waiting for Home and Community-Based Services (HCBS) impacts nursing home stays, hospitalizations, and overall Medicaid long-term services and supports (LTSS) spending. HHS chose Iowa for the Study as ample waiver application data was available, and this data included waiting periods ranging from 3 to 25 months.
According to sources cited in the Study, 1915(c) HCBS waiver enrollment has increased at a rate of 6 percent each year; by 2009, there were 3.3 million 1915(c) HCBS enrollees. However, by 2011, “a little over half a million people” were on waiting lists nationally, with an average wait time to receive services at approximately two years.
The Study aimed to answer the following questions:
Do longer wait times for HCBS services increase incidences of nursing home stays and acute care hospitalizations?
Do longer wait times for HCBS services increase Medicaid LTSS spending?
Are the above increases more pronounced for those who are high-risk for nursing home placement at the time of their waiver application?
The Study looked at data on waiver applicants in Iowa from January 2002 through September 2007. It analyzed data from three waivers for the non-elderly adult population: the Brain Injury (BI), Health and Disability (H & D), and Physical Disability (PD) waivers. All waivers require nursing home eligibility. Additionally, BI enrollees must have an applicable brain injury. H &D enrollees must have income above 100 percent but not higher than 300 percent of the Supplemental Security Income (SSI) threshold for Iowa. PD enrollees must not be eligible for the Intellectual Disability (ID) waiver, be able to self-direct their services, have a physical disability, and be over the age of 18.
All three waivers provide: emergency response services, home and vehicle modifications, in addition to personal care services for both activities of daily living and instrumental activities of daily living. Additionally, the BI waiver provides supported employment services and community living, while the H & D waiver also provides homemaker services, respite, and meals. Per beneficiary per month (PBPM) expenditures of each waiver are capped at $2,868 for the BI waiver, between $922 and $3,267 for the H&D waiver, depending on the qualifying level of care, and $672 for the PD waiver.
In Iowa, people receive HCBS waiver services and are placed off of the waiting lists on a first come, first served basis. Priority is not given to individuals with greater need.
The Study analyzed waiting list applicants after 36 months of first applying in terms of: 1) actual enrollment in the waiver services; 2) long-term nursing home stays (90 days or more); 3) acute care hospitalizations; and 4) total monthly Medicaid LTSS expenditures.
Enrollment. Applicants that had a short wait time for waiver services (six months or less) enrolled for waiver services at a rate of 65 percent, while those who had a long wait time (exceeding six months) only enrolled at a rate of 42 percent. The individual waivers also saw higher enrollments comparing the short wait group with the long wait group (Bi waiver: 69 percent vs. 50 percent, H&D Waiver 65 percent vs. 42 percent), and PD Waiver (53 percent vs. 36 percent). For details, see Table A.6, here.
Nursing home stays. Those who faced short wait times had a statistically significant lower risk of having a long-term nursing home stay than those facing long wait times (7.6 percent vs. 10.1 percent, p = 0.07), with the most pronounced difference among the BI waiver applicants (5.5 percent vs. 10.4 percent, p = 0.04). Among the population at high-risk of being placed in a nursing home due to their age, the difference between the short and long wait times was greater (7.2 percent versus 13.9 percent, p = 0.01), with the most pronounced difference among the PD waiver applicants (12.2 percent vs. 16.6 percent, p = 0.02). For details, see Table IV.2, here.
Acute Care Hospitalizations. The Study showed that wait time did not have a statistically significant effect on hospitalizations. For details, see Table IV.3, here.
Medicaid LTSS Expenditures. Application waiver costs. PBPM expenditures for services associated with the application waiver were $122 greater among those with short wait times versus those with longer wait times (p < 0.01) for all waiver groups. This was expected given that quicker access to HCBS would generate more expenditures. The same p values were seen in the individual waiver groups as well ($247 greater in the BI waiver population, $105 greater in the H & D waiver population, and $42 greater in the PD waiver population), as well as among both the high-risk ($146 higher) and low-risk ($101) pools.
Other waiver costs. The data also suggest that beneficiaries spend more in other waivers while they are waiting to receive the waiver services for which they are applying. PBPM Medicaid LTSS expenditures increased by $52 (p = 0.02) for all waiver groups, and there was also a statistically significant increase of $134 (p = 0.03) among the BI waiver population. The higher risk group experienced other waiver costs higher by $58 (p = 0.01), and there was also a significant increase of $115 among the BI waiver population.
Long-term nursing home stay costs. PBPM expenditures for long-term nursing home stays was lower by $56 (p = 0.09) for all waiver groups, and there was also a statistically significant PBPM cost savings of $132 for the BI waiver group. Among all waivers, the short wait group saw PBPM savings of $111 (p = 0.01), and there was also a statistically significant PBPM cost savings of $152 for the PD waiver group.
For details, see Table IV.4, here.
The National Council on Medicaid Home Care – a NAHC affiliate - voices concern about the continued growth of the waitlists nationally. In recent news, Michigan Gov. Rick Snyder announced his intention to eliminate the wait lists in his state, and North Carolina’s waitlists were profiled.
While the Study didn’t show that wait lists had a statistically significant impact on hospitalizations, it did show that longer stays contributed to a rise in nursing home stays as well as costs associated with those stays. While most of those on waitlists currently reside in the home and community, this trend threatens to undermine states’ gains in rebalancing away from institutional care. Home care agencies should continue to lobby their states for the reduction and elimination of these wait lists.