A Compendium of Current Federal Initiatives in Response to the Olmstead Decision. NATIONAL EVALUATION OF THE MEDICAID HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAM


Funding Organization:

  • Health Care Financing Administration (HCFA), Office of Strategic Planning

Implementing Organizations:

  • The Lewin Group
  • Subcontractors:
    • The Urban Institute
    • University of Minnesota
    • Mathematica Policy Research, Inc. (MPR)
    • The MEDSTAT Group


To design and implement a study of the impact of Medicaid home and community-based services (HCBS) programs on quality of life, quality of care, utilization and cost.


The scope of the study will include Medicaid HCBS waiver programs as well as other Medicaid-funded long-term care services. The research project will study the financing and delivery of services to older and younger people with disabilities in six states and the Medicaid financing and delivery of services for individuals with mental retardation and developmental disabilities in another six states. The specific activities of the project, divided into two phases, are described below.

Phase I is now complete, and entailed cases studies and site visits. The case studies characterized key program variables such as eligibility criteria, service use, quality of care and care management controls. As part of the case studies, site visits were made to selected states to conduct unstructured in-person interviews with state officials, home care providers, trade associations and aging and disability advocacy groups. Aggregate level data were also collected on service use, costs, participant characteristics, and satisfaction, where available. Interviews were conducted between December 1999 and July 2000.

  • The Urban Institute developed case studies of the HCBS financing and delivery system for older and younger adults with disabilities in each of six states (Alabama, Kentucky, Maryland, Michigan, Washington and Wisconsin).

  • The University of Minnesota conducted case studies in six additional states (Kansas, Indiana, Louisiana, New Jersey, Vermont, and Wyoming) for individuals with mental retardation and developmental disabilities.

  • In addition, the Lewin Group made a site visit to the Texas Star Plus program to explore its managed and capitated system for HCBS in the Houston area.

Phase II is underway and includes surveys and analyses of administrative data. Mathematica Policy Research will conduct surveys of Medicaid HCBS users. The MEDSTAT Group will also obtain administrative data (Medicare and MSIS data) to research program costs in the selected sites. The Lewin Group, the Urban Institute, and the University of Minnesota will analyze survey and administrative data to examine data on service use, costs, participant characteristics, and satisfaction.

Outcomes from each of the sites studied will be assessed by controlling for participant characteristics (e.g., age, disability level, caregiver availability) to determine the independent effect of each program on the outcomes. The features and structure of programs gathered through the process portion of the study will be used in order to compare programs with more favorable outcomes to those with lower ratings on outcomes to draw inferences on the promising program design features. This approach would treat program designs as complete packages and permit variation in more than one key dimension.

Also as part of Phase II, the characteristics and care patterns that influence outcomes at an individual level will be examined. Questions to be examined include: Does receiving more services produce a higher quality of life? Do people in residential settings have a lower quality of life than people living at home? And, are people who live alone significantly less disabled than those living with others? The study will use a quasi-experimental design that gathers data from Medicaid recipients of both developed and developing HCBS systems. Information will be collected from several sources: site visits; surveys of recipients and proxies (where necessary) each within two groups of enrollees--elderly in the community and young disabled adults); interviews with state officials, advocacy groups, provider representatives and other key stakeholders; and secondary data sources, including MSIS data, and state administrative data.

The analyses will center on four major areas for developed programs relative to developing programs, as well as the influence of individual characteristics and care patterns. The analyses will include: (1) greater access to, choice among, and autonomy related to HCBS; (2) better outcomes (including fewer avoidable hospitalizations, lower death rates, higher levels of satisfaction with life and care, less unmet need); (3) differences in patterns of care provided (fewer nursing facility admissions and more discharges from nursing facility to community, greater use of alternative residential facilities); and (4) differences in the cost of care provided (HCBS versus institutional, total health care costs, acute care spending versus long-term care spending).

Contact Information:

Lisa Alecxih, Project Director, The Lewin Group, 3130 Fairview Park Drive, Suite 800, Falls Church, VA 22042, (703)269-5542

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