An Investigation of Interstate Variation in Medicaid Long-Term Care Use and Expenditures Across 40 States in 2006. D. Summary of Long-Term Care System Performance Findings

07/01/2013

In this chapter, we have examined the differences across states and subgroups using four measures: traditionally computed expenditure-based measures of the balance of institutional care and HCBS (percentage of expenditures for HCBS), a utilization-based measure (percentage of LTC users who used HCBS), a relative per-user expenditure ratio (per-user HCBS expenditures to per-user institutional care expenditures), and a measure capturing the percentage of people potentially eligible for LTC who used services. Because expenditures reflect both the amount of use and the cost of services, and because HCBS are typically less costly than institutionalization, aggregate expenditure comparisons mask key differences in utilization. We found that in 2006, about 41 percent of LTC expenditures paid for persons served were for HCBS; in contrast, almost 64 percent of LTC users used HCBS. Medicaid spent about $17,000 per user for HCBS, or about 46 cents for every dollar for persons in institutional care.

Examination of differences across states illustrate that alternative measures of LTC balance provide different perspectives on LTC utilization and expenditures. For example, of two states with the same percentage of expenditures allocated to HCBS, one may provide limited HCBS to a broad range of users whereas another may provide more expansive services to a small number of HCBS recipients. Eight states ranked in the top ten on at least one measure but among the bottom ten on another. In summary, no one perspective provides a complete picture of the role of HCBS in state Medicaid programs.

TABLE II.7. Percentage of LTC Expenditures Allocated to HCBS in 2006, Overall and by Age and System Type
State Overall Aged (65+) Enrollees with Disabilities
(<65, including ID/DD)
Enrollees <65 with ID/DD
  % HCBS     Rank     % HCBS     Rank     % HCBS     Rank     % HCBS     Rank  
Alaska 72.7 1 59.0 1 71.8 3 99.3 2
New Mexico 70.3 2 48.0 2 75.2 2 92.5 4
Washington 65.2 3 46.4 4 N/A N/A N/A N/A
Vermont 57.8 4 20.3 15 68.6 5 99.4 1
Wyoming 57.0 5 14.8 27 52.1 12 90.5 6
California 54.7 6 46.7 3 56.3 10 69.4 17
Kansas 52.5 7 22.7 10 75.6 1 78.3 11
Colorado 50.7 8 22.3 11 60.4 8 92.9 3
New York 45.3 9 36.3 5 45.8 14 57.6 24
Wisconsin 44.5 10 17.0 21 N/A N/A N/A N/A
North Carolina 43.3 11 32.0 6 68.5 6 46.0 33
Nevada 43.3 12 27.0 8 44.2 16 73.3 14
Maryland 42.8 13 16.0 23 41.0 18 89.2 7
Idaho 42.6 14 27.1 7 62.5 7 50.4 29
Virginia 42.6 15 19.4 16 45.3 15 81.4 9
All 40 (or 37) states 40.8   25.8   46.2   60.8  
Missouri 40.7 16 19.3 17 68.9 4 49.1 30
Oklahoma 40.5 17 20.9 14 38.2 21 67.9 19
Utah 38.9 18 8.6 36 15.4 37 67.7 20
Hawaii 38.5 19 14.1 28 40.1 20 90.6 5
West Virginia 38.0 20 13.6 29 41.2 17 77.6 12
Nebraska 37.4 21 16.6 22 37.0 22 69.2 18
Iowa 37.2 22 21.0 13 53.1 11 48.7 31
Tennessee 37.0 23 12.5 30 60.1 9 59.4 22
South Dakota 35.9 24 8.7 35 16.0 36 79.0 10
South Carolina 34.6 25 14.9 26 49.4 13 57.3 25
Delaware 34.0 26 10.2 31 35.5 25 75.6 13
Ohio 33.5 27 19.0 18 40.6 19 55.4 26
Connecticut 31.6 28 15.6 24 26.5 31 67.1 21
New Jersey 31.2 29 21.4 12 36.0 24 46.9 32
Florida 31.1 30 9.7 33 28.8 30 73.2 15
Illinois 30.8 31 18.9 19 33.0 28 43.7 35
Georgia 28.4 32 10.0 32 36.9 23 71.6 16
Louisiana 27.5 33 15.6 25 29.9 29 38.2 36
Indiana 27.3 34 5.9 40 34.6 26 52.6 28
Alabama 27.2 35 8.9 34 25.8 32 88.7 8
Kentucky 25.8 36 8.0 37 33.1 27 59.2 23
North Dakota 25.8 37 7.6 38 24.4 33 53.2 27
Arkansas 24.9 38 17.1 20 19.9 35 44.8 34
District of Columbia 23.2 39 25.9 9 N/A N/A N/A N/A
Mississippi 11.1 40 7.1 39 21.5 34 14.1 37
SOURCE: Mathematica analysis of 2006 MAX data for 39 states and the District of Columbia with representative FFS LTC data (excludes data from Arizona, Maine, Massachusetts, Michigan, Minnesota, Montana, New Hampshire, Oregon, Pennsylvania, Rhode Island, and Texas, and for the ID/DD analysis, District of Columbia, Washington, and Wisconsin).
NOTES: Excludes enrollees in managed LTC and those eligible for restricted Medicaid benefits only. HCBS include 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing. ILTC includes services provided in nursing homes, ICFs/IID, mental hospitals for the aged, and inpatient psychiatric facilities for people under age 21. Enrollees with ID/DD include those using ICFs/IID services and those enrolled in waivers for people with ID/DD.
N/A = Not available (in this state, people with ID/DD could not be distinguished from other enrollees).

Subgroup analyses by state suggest that differences between aged enrollees and those eligible on the basis of their disability or as people with ID/DD, were widespread across the states.

TABLE II.8. Percentage of LTC Users Receiving HCBS in 2006, Overall and by Age and System Type
State Overall Aged (65+) Enrollees with Disabilities
(<65, including ID/DD)
Enrollees <65
with ID/DD
  % HCBS     Rank     % HCBS     Rank     % HCBS     Rank     % HCBS     Rank  
Alaska 87.0 1 82.2 1 88.4 4 99.8 2
California 82.5 2 77.5 2 89.0 3 89.7 16
Washington 78.5 3 69.9 4 N/A N/A N/A N/A
Kentucky 77.5 4 73.5 3 80.0 15 96.6 5
New Mexico 76.4 5 63.5 5 89.7 2 94.0 11
Idaho 72.9 6 61.4 6 83.4 12 81.3 26
North Carolina 72.2 7 61.1 7 89.8 1 70.7 32
Colorado 69.8 8 51.6 12 84.3 11 98.6 3
Vermont 68.2 9 46.3 16 85.4 7 99.9 1
New York 68.2 10 55.5 8 80.2 14 92.0 12
Iowa 68.1 11 54.7 11 85.2 8 82.3 24
Missouri 66.4 12 55.3 10 82.6 13 70.6 34
Virginia 65.6 13 50.6 13 85.6 6 95.6 9
Kansas 65.4 14 42.4 20 87.8 5 91.9 13
Nevada 64.2 15 55.3 9 69.7 22 91.2 14
All 40 (or 37) states 63.8   51.4   77.1   85.1  
Wyoming 63.6 16 33.5 29 78.3 16 96.4 6
Alabama 61.6 17 40.1 23 84.9 9 96.1 7
South Carolina 60.2 18 42.1 21 84.8 10 77.4 29
Oklahoma 58.0 19 47.6 15 71.3 21 76.4 30
New Jersey 57.7 20 48.1 14 73.2 19 78.6 27
West Virginia 57.1 21 36.4 26 75.7 17 88.8 18
Maryland 56.7 22 29.7 31 71.5 20 97.1 4
Hawaii 56.3 23 38.2 25 67.5 24 96.0 8
Ohio 55.3 24 45.4 18 66.6 25 73.4 31
Connecticut 53.1 25 39.9 24 69.0 23 86.6 20
Illinois 52.2 26 40.8 22 56.0 34 86.6 19
Arkansas 51.4 27 45.7 17 59.0 32 67.3 35
Nebraska 51.1 28 35.6 27 64.5 28 85.2 22
Florida 50.9 29 33.6 28 60.7 30 91.2 15
Utah 49.8 30 22.2 37 44.5 36 82.7 23
Wisconsin 48.4 31 26.5 32 N/A N/A N/A N/A
Delaware 47.9 32 26.3 33 73.4 18 85.5 21
South Dakota 46.2 33 24.9 35 44.2 37 94.7 10
District of Columbia 45.3 34 42.5 19 N/A N/A N/A N/A
North Dakota 44.3 35 26.0 34 66.1 26 78.2 28
Georgia 43.4 36 24.9 36 63.6 29 89.4 17
Mississippi 41.0 37 33.3 30 59.4 31 42.0 37
Louisiana 38.1 38 20.2 38 57.0 33 51.4 36
Tennessee 35.2 39 10.7 40 65.2 27 81.4 25
Indiana 32.5 40 10.9 39 53.5 35 70.7 33
SOURCE: Mathematica analysis of 2006 MAX data for 39 states and the District of Columbia with representative FFS LTC data (excludes data from Arizona, Maine, Massachusetts, Michigan, Minnesota, Montana, New Hampshire, Oregon, Pennsylvania, Rhode Island, and Texas, and for the ID/DD analysis, District of Columbia, Washington, and Wisconsin).
NOTES: Excludes enrollees in managed LTC and those eligible for restricted Medicaid benefits only. HCBS include 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing. ILTC includes services provided in nursing homes, ICFs/IID, mental hospitals for the aged, and inpatient psychiatric facilities for people under age 21. Enrollees with ID/DD include those using ICFs/IID services and those enrolled in waivers for people with ID/DD.
N/A = Not available (in this state, people with ID/DD could not be distinguished from other enrollees).

Subgroup analyses also suggest that HCBS use appears to be most common within the Medicaid ID/DD service system, compared with those designed for the aged or people with physical disabilities. However, our estimates indicate that a much smaller percentage of people with ID/DD potentially eligible for Medicaid actually are enrolled and using HCBS. This emphasizes the importance of measuring system performance on multiple dimensions and within different service systems.

TABLE II.9. Ratio of Per-User Expenditures on HCBS Relative to Per-User Expenditures on Institutional Care in 2006, Overall and by Age and System Type
State Overall Aged (65+) Enrollees with Disabilities
(<65, including ID/DD)
Enrollees <65
with ID/DD
  Ratio     Rank     Ratio     Rank     Ratio     Rank     Ratio     Rank  
Tennessee 1.112 1 1.220 1 0.862 1 0.353 25
Wisconsin 0.927 2 0.602 3 N/A N/A N/A N/A
Wyoming 0.838 3 0.373 13 0.376 14 0.424 17
New Mexico 0.827 4 0.593 4 0.420 9 0.856 3
Indiana 0.815 5 0.530 6 0.521 4 0.496 7
Vermont 0.765 6 0.349 15 0.489 5 1.127 2
South Dakota 0.707 7 0.305 28 0.257 26 0.333 27
Utah 0.689 8 0.347 16 0.253 27 0.477 10
Nebraska 0.649 9 0.405 12 0.387 12 0.446 15
Kansas 0.644 10 0.434 10 0.534 3 0.356 23
Louisiana 0.644 11 0.737 2 0.365 15 0.609 5
Washington 0.644 12 0.459 9 N/A N/A N/A N/A
Delaware 0.608 13 0.340 19 0.234 29 0.582 6
Maryland 0.604 14 0.466 8 0.307 20 0.300 31
Virginia 0.589 15 0.327 22 0.347 18 0.457 13
Alaska 0.561 16 0.432 11 0.470 6 2.096 1
Oklahoma 0.551 17 0.324 23 0.286 22 0.717 4
Georgia 0.537 18 0.347 18 0.359 16 0.326 28
Hawaii 0.531 19 0.282 32 0.414 11 0.473 11
Colorado 0.514 20 0.305 27 0.356 17 0.320 29
New York 0.498 21 0.564 5 0.290 21 0.226 37
Ohio 0.497 22 0.347 17 0.437 8 0.488 9
West Virginia 0.494 23 0.288 30 0.261 25 0.491 8
Connecticut 0.483 24 0.319 24 0.222 31 0.390 19
North Dakota 0.478 25 0.253 35 0.199 34 0.355 24
Nevada 0.473 26 0.329 21 0.383 13 0.353 26
Illinois 0.472 27 0.364 14 0.419 10 0.374 20
Florida 0.462 28 0.226 37 0.274 23 0.294 32
All 40 (or 37) states 0.458   0.378   0.312   0.347  
Missouri 0.442 29 0.248 36 0.592 2 0.470 12
District of Columbia 0.398 30 0.514 7 N/A N/A N/A N/A
South Carolina 0.374 31 0.257 34 0.192 35 0.441 16
Iowa 0.364 32 0.294 29 0.262 24 0.235 35
New Jersey 0.359 33 0.313 25 0.235 28 0.255 34
Idaho 0.348 34 0.283 31 0.461 7 0.293 33
Arkansas 0.342 35 0.270 33 0.185 36 0.421 18
North Carolina 0.337 36 0.340 20 0.322 19 0.369 21
California 0.312 37 0.306 26 0.206 32 0.303 30
Alabama 0.260 38 0.160 39 0.075 37 0.449 14
Kentucky 0.253 39 0.087 40 0.231 30 0.367 22
Mississippi 0.191 40 0.163 38 0.204 33 0.234 36
SOURCE: Mathematica analysis of 2006 MAX data for 39 states and the District of Columbia with representative FFS LTC data (excludes data from Arizona, Maine, Massachusetts, Michigan, Minnesota, Montana, New Hampshire, Oregon, Pennsylvania, Rhode Island, and Texas, and for the ID/DD analysis, District of Columbia, Washington, and Wisconsin).
NOTES: Excludes enrollees in managed LTC and those eligible for restricted Medicaid benefits only. HCBS include 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing. ILTC includes services provided in nursing homes, ICFs/IID, mental hospitals for the aged, and inpatient psychiatric facilities for people under age 21. Enrollees with ID/DD include those using ICFs/IID services and those enrolled in waivers for people with ID/DD.
N/A = Not available (in this state, people with ID/DD could not be distinguished from other enrollees).

View full report

Preview
Download

"40State.pdf" (pdf, 787.2Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®