What are true MFP results? A clearer picture emerges
Fiscal Fitness: How States Cope
What are true MFP results? A clearer picture emerges
There is a lot of current interest in the "rebalancing" of state long-term care systems between nursing facilities and home and community-based care. However, to know how far you've come, you've got to know where you started out.
Now, a new report provides data on where states stood before implementation of the Money Follows the Person (MFP) demonstration, a federal initiative launched in 2005. The program was extended in 2010 as part of the Patient Protection and Affordable Care Act.
The May 2010 report from Mathematica Policy Research, The Starting Point: The Balance of State Long-Term Care Systems Before the Implementation of the Money Follows the Person Demonstration, says that in 2005, of the 2.79 million Medicaid beneficiaries who used long-term care services in MFP grantee states, 60% received home and community-based care services (HCBS). However, HCBS accounted for only 38% of spending for total long-term care services.
It's important to establish a baseline of currently existing services, as the MFP program aims to transition long-term care users out of institutions and into HCBS settings, says Carol V. Irvin, PhD, a senior researcher at Mathematica and co-author of the report. The report is the fourth in a series, and is part of a comprehensive evaluation of MFP.
Whereas previous work has been based on the aggregate reports that states send to the Centers for Medicare & Medicaid Services (CMS), Mathematica's research was based on person-level data.
"When you use aggregate data, you as a researcher are constrained with what you can do with that information," says Dr. Irvin. "With person-level data, we can slice and dice the data in ways you just can't do with state aggregate data. That is where our contribution comes in with our work." The researchers were able to look at the balance of subgroups within HCBS, such as differences between individuals new to long-term care vs. those who had been in for at least two years.
State-plan vs. waiver
States that already have large percentages of long-term care users receiving HCBS when they launched the MFP program typically offer these as state-plan services, as opposed to waiver services. "When a state offers personal care assistance or home health services as a state-plan service, it is essentially offered to everybody in Medicaid. So, it is much more readily available," explains Dr. Irvin.
While most programs do have a referral process or some type of check to confirm the recipient actually needs personal care or home health services, it is much easier for individuals to access the services than if they are offered only through a waiver program. In that case, only those people eligible for the waiver services can access those services.
"In many states, waivers are small programs and may be limited to one geographic region. So, accessing those services can be more difficult," says Dr. Irvin. "That's one way a state can limit access to something like personal care or home health, although you do see states that have decided to make a very strong commitment to their waiver programs, with programs that are very generous and provide a very comprehensive array of services."
Fiscal evaluation is tricky
"On both the state and federal level, the fiscal issue is something that we don't have a good sense of right now," says Dr. Irvin. "It's a little too early. A lot of the focus has been on getting the programs up and going."
Dr. Irvin says that states need to be careful about measuring what she calls "the counterfactual." In other words, you are looking at what would have happened if MFP had not existed.
"How you measure that is tricky, and there is a whole art to that," says Dr. Irvin. "States that need to have a very quick answer for policymakers don't always pay enough attention to that aspect of their calculation."
Trying to figure out what the state of things would have been if a program had never been put into place, says Dr. Irvin, is something that evaluators struggle with all the time. "Many times, that is an important factor in your ability to measure the outcome," she says.
Researchers looked at three years leading up to the implementation of MFP in 2008 to establish a baseline. Future research will compare 2005-2007 with multiple years in the MFP period.
"If we see any large differences that we can't explain with other events, such as the advent of other programs, then we will assume that MFP had a role," says Dr. Irvin. For instance, if the proportion of individuals using HCBS was increasing 4% a year before MFP was implemented, and then increased 10% a year afterward, and there is nothing else to explain that increase, then at least some of that increase would be attributed to MFP.
Going state by state
The size of HCBS programs varies widely across states. Expenditures on HCBS ranged from 13% to 59% of total long-term care spending. The proportion of HCBS users ranged from 24% to 83%.
Because of this large variability, researchers will need to determine the overall impact of MFP in each individual state. "If we can identify particular states where we do see an impact, that's going to be very important," says Dr. Irvin.
If a particular state devoted a large proportion of its long-term care dollars to HCBS before MFP was ever implemented, things may not change a lot in that state. In other states, though, MFP might be critical to tipping the balance of long-term care spending toward HCBS.
"We are going to have to evaluate results state-by-state. But because we are a national evaluator, we will have to come up with an overall statement on MFP's result on cost and health outcomes with a lot of caveats," says Dr. Irvin. For example, researchers will be noting whether a much larger impact was seen in particular types of states.
Further complicating the conclusions is the fact that states are also working on nursing home diversion programs, in addition to MFP programs. "These are becoming bigger and more prominent and established. And those are some of the very same trends we are looking at with MFP," says Dr. Irvin. "We are looking at whether we will be able to satisfactorily control for that."
It may be difficult to pinpoint what percentage of the changes to attribute to MFP, as opposed to a nursing home diversion program. "That is why our evaluation of MFP is going to be multifaceted," says Dr. Irvin. "We are not looking at just the state-level impact. We are looking at the individual level as well. That's probably where some of our strongest work is going to be."
The goal is to determine the impact on an individual's utilization of health care services, and the cost and quality of that care. In order to do this type of evaluation, states are collecting quality-of-life data on MFP participants, right before they transitioned to community living and after one or two years.
"Some of that work will be particularly important in answering 'What is the impact of MFP?'" says Dr. Irvin.
Is it cost-effective?
The 21 states without MFP programs in place have another chance to apply, as a result of the program's extension. "So, there is an opportunity for more states to benefit from this program. But we know that due to budget issues, many states have not gotten the extra waiver slots they wanted to expand their MFP programs. Some of the programs are being heavily affected," says Dr. Irvin.
States without MFP programs still need to pay their share of the program costs, even though much of the cost will be covered with enhanced federal dollars.
"Some will say that they are not prepared to do that, but we hope not all of them," says Dr. Irvin. "We hope that there will be a number who apply, but it is a very tough fiscal environment right now. There is no doubt about that."
There is now a strong sense that HCBS is the right thing to do for people, but is this kind of effort also cost-effective? "At this point, the jury is still out in terms of whether community living makes sense from a fiscal point of view," says Dr. Irvin. "You can think of all kinds of additional risks that someone might face if they don't have constant care by their side."
To assess this aspect of community living, researchers will examine how various quality-of-care measures differ from institutional and home settings. These will include mortality, preventable hospitalizations, emergency department visits, and the overall cost of care.
"Can we demonstrate that when an individual is living in the community, the overall health care costs are less than if that individual is in a facility? The research community is not convinced that we have the data that demonstrate that," says Dr. Irvin. "It takes money to have someone living in the community as well."
When an individual is living in a facility, Medicaid is not only paying for their health care, but also room and board. That is not the case when that person moves to the community.
"Is that a cost savings right there? Or is it just a matter of costs getting shifted to another program or to the family?" asks Dr. Irvin. "Are your health costs, in fact, less when you are out in the community, or are they more because you are more likely to have a fall or an accident or infection? These are all things that we will look at."
Contact Dr. Irvin at (617) 301-8972 or [email protected].
There is a lot of current interest in the "rebalancing" of state long-term care systems between nursing facilities and home and community-based care. However, to know how far you've come, you've got to know where you started out.Subscribe Now for Access
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