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Medicaid in Residential Care - Executive Summary

Publication Date

Angela M. Greene, MS, MBA, Joshua M. Wiener, PhD, Galina Khatutsky, MS, Ruby Johnson, MA, MS, and Janet O'Keeffe, DrPH

RTI International

September 2013

This report was prepared under contract #HHSP23320095651WC between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Research Triangle Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office_specific/daltcp.cfm or contact the ASPE Project Officer, Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201.  Her e-mail address is: Emily.Rosenoff@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

 

Residential care facilities (RCFs) are important providers of long-term care (LTC) services. RCFs provide services and room and board to persons with chronic illnesses and physical or mental impairments who need assistance with activities of daily living (ADLs), such as bathing and dressing, and help with health-related services, such as managing medications. In 2010, approximately 31,100 RCFs served 733,300 residents of all ages with a wide range of LTC needs. The National Survey of Residential Care Facilities (NSRCF) finds that 43 percent of RCFs have at least one resident for whom Medicaid pays for their LTC services and Medicaid pays for at least some of the LTC services of 19 percent of residents.

An important goal of the Medicaid program is for lower-income Medicaid beneficiaries to receive care and services comparable to non-Medicaid beneficiaries. The characteristics of RCFs that can serve Medicaid beneficiaries are determined by a complex interplay of state licensing and regulatory requirements and Medicaid policy.

 

Research Questions

This study has two purposes: (1) to determine whether and how facilities that serve Medicaid beneficiaries differ from those that do not; and (2) to determine whether and how RCF residents receiving Medicaid-covered RCF services differ from residents not receiving Medicaid coverage. Specific research questions are:

  • Do facilities participating in Medicaid differ from non-participating facilities in characteristics such as living arrangements, staffing levels, and costs? Do the characteristics of facilities in which Medicaid beneficiaries live differ from those in which non-Medicaid residents live?

  • Do Medicaid and non-Medicaid RCF residents differ in demographic characteristics, health and functional status, and service use?

  • What factors predict RCFs' participation in Medicaid?

 

Data and Methods

This study uses merged facility and resident data from the 2010 NSRCF, which was sponsored by the U.S. Department of Health and Human Services (the National Center for Health Statistics, the Office of the Assistant Secretary for Planning and Evaluation, the Agency for Healthcare Research and Quality), the U.S. Department of Veterans Affairs, and other federal agencies. The survey focuses on facilities that serve older people and younger people with physical disabilities. As a result, facilities that exclusively served people with severe mental illness or people with intellectual and developmental disabilities were excluded.

We defined facilities as participating in Medicaid if a respondent reported that at least one resident had some or all of his or her LTC services paid by Medicaid in the 30-day period prior to the survey. Medicaid residents were defined as residents for whom Medicaid paid for any of their LTC services provided at the facility in the 30-day period prior to the survey. For this study, we merged the NSRCF facility and resident files so that resident-level analysis could be conducted including resident and facility characteristics that are not included in the public use file.

Data are presented from several perspectives using different units of analysis so as to provide a full understanding of RCFs and their residents. For analyses of resident characteristics, we analyze the resident file and interpretation is straightforward. Amore complex approach is required to fully understand facilities because a large number of RCFs are small (4-10 beds), but only a relatively small proportion of residents live in these facilities. More specifically, 50 percent of RCFs are small, but they serve only 10 percent of residents (Park-Lee et al., 2011). Conversely, although only about half of RCFs are larger than ten beds, they account for 90 percent of residents. Thus, a simple analysis of facilities will give disproportionate weight to the small facilities even though they serve only a small proportion of residents. To address this problem, we show facility characteristics from two perspectives. First, we analyze facility characteristics with the facility as the unit of analysis. Second, to present a perspective that more closely aligns with the number of persons served and to represent the perspective of RCF residents, we also analyze the facility characteristics at the resident level. For these analyses, we match residents with the characteristics of the facilities in which they live and present the facility characteristics with the resident as the unit of analysis. For these types of analyses, we refer to "the facilities in which residents live." This type of analysis can be thought of as facility analyses weighted by the number and type of residents.

 

Results: Facilities

Medicaid facilities are similar to non-Medicaid facilities on many, but not all, facility characteristics. Medicaid-participating facilities are smaller than non-Medicaid facilities; Medicaid residents are much less likely than non-Medicaid residents to live in facilities with 100 or more beds. In addition, only about a fifth of RCFs reported having a dementia or Alzheimer's special care unit or only serving residents with Alzheimer's disease; however, fewer Medicaid RCFs have a dementia care unit or only serve persons with Alzheimer's disease (Table ES-1a and Table ES-1b), which is possibly indicative of the younger age of Medicaid residents who are less likely to have dementia.

TABLE ES-1a. Facility Characteristics, by Medicaid Status: Residential Care Facilities
Characteristics of Residential Care Facilities Total RCF
Facilities
  N=2,302 (%)  		   Non-Medicaid  
Facilities
N=1.292 (%)		 Facilities Serving Any
  Residents on Medicaid  
N=998 (%)		   Significance  
Test p-value
Alzheimer's disease services
   Facility has a dementia or Alzheimer's special care unit or only serves adults with dementia or Alzheimer's disease   17.3 20.2 13.5 ***
Facility living quarters1
   Rooms or apartments that are rooms designed for one person 28.0 27.7 28.4 ns
   Rooms or apartments that are rooms designed for two or more persons 19.6 17.2 23.7 **
   Rooms or apartments that are studios or 1-3 bedroom apartments 52.5 55.1 47.9 ***
SOURCE: RTI analysis of the 2010 NSRCF.
NOTES:
  1. For the facility-level table, percentage of each type of facility living quarters is calculated as the ratio of the total number of units for each type of living quarters for all facilities divided by the total number of units for all facilities.

**p0.05, ***p0.001, ns: not significant, p>0.1.

 

TABLE ES-1b. Facility Characteristics, by Medicaid Status: Facilities Where Residents Live
Characteristics of Facilities Where Residents Live All Residents
  N=8,094 (%)  		 Non-Medicaid
Facilities
  N=6,122 (%)  		 Medicaid
  Residents  
N=1,904 (%)		   Significance  
Test p-value
Alzheimer's disease services
Facility has a dementia or Alzheimer's special care unit or only serves adults with dementia or Alzheimer's disease   36.5 40.3 20.0 ***
Resident lives in a:
Room designed for one person 31.6 32.8 26.6 ***
Room designed for two or more persons 26.9 22.5 45.5 ***
Studio or 1-3 bedroom apartment 41.5 44.7 27.9 ***
SOURCE: RTI analysis of the 2010 NSRCF.
**p0.05, ***p0.001, ns: not significant, p>0.1.

One policy concern is whether RCFs offer the level of privacy expected in a "homelike" environment and whether the level of privacy offered differs by Medicaid status. The living quarters of Medicaid facilities offer less privacy than non-Medicaid facilities: apartments are more likely to be offered in the non-Medicaid facilities (82.8 percent) compared to Medicaid facilities (76.3 percent). Moreover, Medicaid residents are much more likely than non-Medicaid residents to live in multiperson rooms: slightly less than half of Medicaid residents live in rooms that serve two or more persons, whereas just over a quarter of Medicaid residents live in apartments.

FIGURE ES-1. Direct Care Staffing: Facility Level and Facilities Where Residents Live, by Medicaid Status
Facility Level Analysis
FIGURE ES-1a shows a comparison of the direct care staffing hours per resident per day for all direct care staff, all nursing care staff, personal care aides and administrators. Data are presented at the facility level and the resident level. BAR CHART: Medicaid Facilities--All direct care staff (4.1), All nursing care (0.2), Personal care aide direct care (2.8), Administrator/Assistant Administrator direct care (1.1); Non-Medicaid Facilities--All direct care staff (4.2), All nursing care (0.3), Personal care aide direct care (3.1), Administrator/Assistant Administrator direct care (0.8).
For the chart on facilities serving any residents on Medicaid, differences are not statistically significant at a probability p0.05.
Facilities in Which Residents Live
FIGURE ES-1b shows a comparison of the direct care staffing hours per resident per day for all direct care staff, all nursing care staff, personal care aides and administrators. Data are presented at the facility level and the resident level. FIGURE ES-1a shows a comparison of the direct care staffing hours per resident per day for all direct care staff, all nursing care staff, personal care aides and administrators. Data are presented at the facility level and the resident level. BAR CHART: Facilities in which Medicaid residents live--All direct care staff (2.5), All nursing care (0.2), Personal care aide direct care (1.9), Administrator/Assistant Administrator direct care (0.4); Facilities in which non-Medicaid residents live--All direct care staff (2.3), All nursing care (0.3), Personal care aide direct care (1.8), Administrator/Assistant Administrator direct care (0.2).
  For the chart on facilities where Medicaid and non-Medicaid residents live, all differences are statistically significant at p0.05 or less.  
SOURCE: RTI International analysis of the NSRCF.

Whether a Medicaid-eligible individual is served in a nursing home or an RCF depends, among other factors, on a state's nursing home level of care criteria and whether RCFs can admit or retain people who need nursing home-level services. Admission and discharge policies vary little by facility payment status. Among those admission policies that are of interest to researchers and policy makers, a larger proportion of Medicaid facilities admit individuals who need skilled nursing care, including daily monitoring for a health condition, or have a substance abuse problem. A smaller proportion of Medicaid RCFs admit residents who are unable to leave the facility in an emergency without help, are regularly incontinent, and have moderate to severe cognitive impairment.

Facility services offered are mostly the same by Medicaid status and when significant differences exist, a higher proportion of Medicaid RCFs provide the service. Specifically, more Medicaid facilities than non-Medicaid facilities offer services that may be aimed at a younger population, such as transportation to sheltered workshops and educational programs, social services counseling, and case management services. A higher proportion of Medicaid facilities provide skilled nursing services and daily health monitoring, perhaps reflecting that some states allow facilities to serve residents who require nursing home levels of care under Medicaid home and community-based services (HCBS) waivers. Data at the resident level show a higher proportion of Medicaid residents than non-Medicaid residents receiving each service--with the exception of ADL assistance, incontinence care, and social and recreational activities inside and outside the facility.

An important measure of facility adequacy in meeting residents' needs is the availability of direct care staff. Direct care staffing hours per resident per day do not vary between Medicaid and non-Medicaid facilities (Figure ES-1). Of note, however, is that although staffing ratios in Medicaid and non-Medicaid facilities are not different when facilities are the unit of analysis, the number of direct care hours per resident per day is slightly higher in the facilities in which Medicaid residents live than in the facilities where non-Medicaid residents live.

One of the attractions of RCFs to residents and to state policy makers is that they charge less than nursing homes. Although Medicaid does not cover room and board in these facilities, states can reimburse services in RCFs. The NSRCF facility survey did not collect information on Medicaid payment rates; however, it did collect the average monthly base rate facilities generally charge residents and amount charged sampled residents. The monthly rate charged for a single individual living in a one-bedroom apartment or private room is significantly higher in non-Medicaid RCFs ($3,500 and $2,993, respectively) than in Medicaid RCFs ($2,912 for a one-bedroom apartment and $2,587 for a private room) (Figure ES-2). Similarly, the average total charge to non-Medicaid residents in the month prior to the survey is significantly higher than that charged to Medicaid residents, with non-Medicaid residents paying approximately $1,200 per month more.

  FIGURE ES-2. Average Base Rate at the Facility Level and Average Total Amount Facility Charged Residents in the Month Prior to the Survey, by Medicaid Status  
FIGURE ES-2a shows the average facility charge and the average amount charged residents in the 30 days before the survey, by Medicaid status. BAR CHART: A one bedroom apartment for a regular unit--Medicaid Facilities ($2,912), Non-Medicaid Facilities ($3,500), Total ($3,284); A room designed for one person for a regular unit--Medicaid Facilities ($2,587), Non-Medicaid Facilities ($2,993), Total ($2,811). FIGURE ES-2b shows the average facility charge and the average amount charged residents in teh 30 days before the survey, by Medicaid status. BAR CHART: Total charges last month--Medicaid Facilities ($2,183), Non-Medicaid Facilities ($3,402), Total ($3,166).
SOURCE: RTI International analysis of the NSRCF.
NOTE: Differences shown are statistically significant at p0.001.

This study conducted a multivariate logistic regression analysis of predictors of Medicaid participation by RCFs. The odds of facilities participating in Medicaid are higher in states that cover residential care services through Medicaid state plan personal care and in states that cover residential care through both HCBS waiver and state plan personal care. Somewhat surprisingly, state coverage of RCF services only through Medicaid HCBS waivers is not a statistically significant predictor of Medicaid participation, suggesting that the need to serve persons with a nursing home level of care may be a deterrent to participation. The odds that a facility will participate in Medicaid are lower if the facility is located in an urban area. The odds of participating in Medicaid also decrease as the percentage of residents with Alzheimer's disease or other dementia increases in a facility. Moreover, the odds of a facility participating in Medicaid decline as the number of residential care beds in the facility increases (i.e., the larger the facility, the less likely it is to accept Medicaid residents). The direct care staff ratio, for-profit ownership, being part of a chain, and having a high percentage of high-privacy units are not statistically significant predictors of Medicaid participation.

 

Medicaid vs. Non-Medicaid Residents

Medicaid residents are more likely to be younger, male, to have never married, to be racial and ethnic minorities (non-White), and to have lower levels of education compared to non-Medicaid residents. Medicaid and non-Medicaid residents differ very little with respect to three common chronic health conditions--arthritis, stroke, and congestive heart failure; whereas, a higher proportion of Medicaid residents have diabetes.

Of particular policy relevance because it relates to need for services is whether and how residents differ on disability levels. Medicaid and non-Medicaid residents are similar on ADLs and instrumental activity of daily living (IADL) impairments. On the other hand, Medicaid residents are significantly more likely than non-Medicaid residents to have severe mental illness or intellectual and developmental disabilities, but are less likely to have Alzheimer's disease and other dementias (Figure ES-3). A higher proportion of Medicaid than non-Medicaid residents exhibit problem behaviors such as being verbally and physically abusive. Among residents exhibiting at least one behavior problem, Medicaid residents are more likely to have a prescription for medications to control their behavior or reduce agitation.

FIGURE ES-3. Residential Care Facility Residents' Cognitive and Mental Health, by Medicaid Status
FIGURE ES-3 shows the proportion of residential care facility residents with cognitive and mental health diagnoses, by Medicaid status. BAR CHART: Alzheimer's disease/other dementia--Medicaid Residents (34.8), Non-Medicaid Residents (43.9); Intellectual/developmental disabilities--Medicaid Residents (11.0), Non-Medicaid Residents (1.6); Serious mental illness--Medicaid Residents (18.9), Non-Medicaid Residents (4.9).
SOURCE: RTI International analysis of the NSRCF.
NOTE: Differences shown are statistically significant at probability p0.001.

 

Conclusions

For many policy-relevant characteristics, Medicaid and non-Medicaid facilities and residents are similar, especially in ADL and IADL disability levels and services offered and used. Although a more detailed analysis is required for a more definitive answer, the lack of differences in staffing levels suggests that Medicaid residents may not be disadvantaged relative to non-Medicaid residents in the availability of facility direct care personnel.

On four dimensions, however, there are important differences. First, Medicaid residents are more likely to be under age 65 and to have severe mental illness and intellectual and developmental disabilities; non-Medicaid residents are more likely to be aged 65 and older and to have Alzheimer's disease and other dementias. Consistent with that difference, non-Medicaid facilities are more likely to have dementia or Alzheimer's special care units or to exclusively serve people with Alzheimer's disease. A question for further research is how well equipped RCFs are to provide services to people with severe mental illness, intellectual and developmental disabilities, and Alzheimer's disease. Second, Medicaid residents are much more likely to have living arrangements that offer less privacy than non-Medicaid residents. In particular, almost half of Medicaid residents live in multiperson rooms compared to less than a quarter of non-Medicaid residents. Third, although Medicaid reimbursement levels are not available from the survey, data are available on facility charges. Although staffing levels are very similar, non-Medicaid facilities charge substantially more than Medicaid facilities, although the reasons for this difference is not clear. Fourth, and finally, Medicaid residents exhibit more behavioral problems and are prescribed more medications to control those behaviors than are non-Medicaid residents, raising questions about facility staffing and training levels in these facilities.

 

The Full Report is also available from the DALTCP website (http://aspe.hhs.gov/office_specific/daltcp.cfm) or directly at http://aspe.hhs.gov/daltcp/reports/2013/FacBenDif.htm.
Topics
Assisted Living Facilities & Residential Care
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