Effect of PACE on Costs, Nursing Home Admissions, and Mortality: 2006-2011. 2. Results for Medicare and Medicaid Expenditures Using the Second Comparison Group of Matched HCBS Waiver Enrollees Alone

03/01/2015

Since some of the previous studies looking at expenditures under PACE used HCBS waiver enrollees alone as a comparison group, we repeated our analysis of Medicare and Medicaid expenditures using the second matched comparison group comprised of HCBS waiver enrollees alone (matched sample B). Both pooled and state-specific results from this analysis are presented in Tables 9-12. Broadly, the main findings across all eight states are essentially the same as for the main comparison group--actual expenditures under PACE are consistently higher-than-predicted expenditures. The positive difference for Medicare expenditures is statistically significant in five intervals, where the magnitude of the difference ranges from $243 to $784 PBPM (the negative difference of $42 in the first interval is now much smaller and not statistically significant, with the NH entrants no longer in the comparison group). Actual Medicaid expenditures PBPM under PACE are significantly higher in all seven intervals, with the magnitude of the Medicaid spending gap decreasing over time from over $2,016 to $1,284, as predicted expenditures increase (Table 9). Consequently, combined actual expenditures also significantly exceed predicted expenditures in all intervals, with the magnitude of the difference ranging from $1,323 to $1,974. Overall, with the second comparison group strategy, the magnitude of the estimated positive expenditure gap (higher actual payments under PACE) are much larger, consistent with lower expenditures in the comparison group with NH entrants excluded from it.

As before, for the state-specific results, the sample sizes in most of the later cost intervals, for example, all cost intervals from month 37 of the followup period onwards, were rather small. Hence, the state-specific results need to be interpreted with caution. None of the Medicare cost differences were significant in California, but actual Medicaid payments significantly exceeded predicted expenditures in all intervals,and by a larger magnitude of over $3,000, compared to the results before (Table 10). In Massachusetts (we discuss results through month 36 or the first six intervals only, since the number of PACE enrollees drops to 66 or below in the later intervals), once again, half the Medicare cost differences were not significant, and the Medicaid spending gap was positive and significant in all intervals--decreasing over time from $1,931 to $844 (Table 11). As before, the results for New York differed from those for the other states. Actual Medicare expenditures PBPM were significantly higher-than-predicted expenditures in seven of the 11 intervals by $748-$1,264. The Medicaid spending gap of $273-$644 was positive and significant in the first two intervals, but decreased over time, becoming negative in the last three intervals with magnitudes of $177-$377, with the negative difference of $214 in the fifth interval being statistically significant (Table 12). For all three states, combined actual expenditures exceeded predicted expenditures in all intervals, with the difference being statistically significant in most intervals.

As for the analysis involving the first matched comparison group, we checked if the state-specific impact estimates for Medicare, Medicaid and total expenditures were significantly different from each other in the analysis involving the second matched comparison group comprised of HCBS recipients only. As before, the impact estimates for Medicaid expenditures were significantly different from each other in all state-to-state comparisons, while the impact estimates for Medicare expenditures tended to differ across states in fewer intervals (results not shown). Comparing California and Massachusetts, the impact estimates for Medicare expenditures were significantly different from each other at the 10 percent level in the sixth interval only, impact estimates for Medicaid expenditures differed significantly in all intervals, and impact estimates for combined expenditures were different in the first five of the six intervals reported for Massachusetts. Comparing California and New York, the impact estimates for Medicare expenditures were significantly different from each other at the 10 percent level in the first three and the sixth intervals, impact estimates for Medicaid expenditures differed significantly in all intervals, and impact estimates for combined expenditures were different in all but the sixth interval. Finally, comparing Massachusetts and New York, the impact estimates for Medicare expenditures were significantly different from each other at the 10 percent level only in the first three intervals, impact estimates for Medicaid expenditures differed significantly in all intervals, and impact estimates for combined expenditures were different only in the fourth interval.

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