Over the last several decades, states have been working to rebalance their long-term services and supports (LTSS) systems by devoting a greater proportion of Medicaid spending to home and community-based services (HCBS) instead of institutional care.1 Rebalancing efforts are driven by beneficiary preferences for HCBS, the fact that HCBS are typically less expensive than comparable institutional care, and states’ community integration obligations under the Americans with Disabilities Act and the Olmstead decision.2 While most states continue to rely on § 1915(c) waivers to expand beneficiary access to Medicaid HCBS, a significant number of states (13 in FY 2014 and 16 in FY 2015) report that incentives built into their managed LTSS programs are expected to increase beneficiary access to HCBS.3 As a result, measuring LTSS rebalancing is an important means of determining the extent to which Medicaid managed LTSS programs are achieving their intended goals. This fact sheet provides a brief overview of quality measures related to LTSS rebalancing; it is not an exhaustive review of quality measures in this area. Table 1 summarizes some of the existing measures, with specific examples provided in Tables 2, 3, and 4. A companion issue brief summarizes key themes from a roundtable discussion of issues related to the assessment of rebalancing in capitated Medicaid managed LTSS programs.4
Some existing quality measures focus on the extent of community integration experienced by people with LTSS needs. These measures generally survey individual beneficiaries by asking them to report on factors such as their level of satisfaction with where they currently live, their ability to choose where they live, the degree of control they have over their daily activities, the amount of community involvement they have in their work and leisure activities, and whether they are receiving adequate services to support their needs (Table 2). One of the more long-standing sets of these measures, dating to 1997, is the National Core Indicators (NCI).5 The NCI presently are used in 39 states in programs that serve people with developmental disabilities; one NCI domain focuses on individual outcomes, including community inclusion. More recently, the NCI-Aging and Disabilities has been developed to survey seniors and people with physical disabilities about similar issues. The NCI-Aging and Disabilities survey was piloted in three states in 2014, and the year one survey will take place in 2015.6
Some Medicaid managed LTSS programs include measures related to LTSS rebalancing. For example, several of the capitated financial alignment demonstrations for dual eligible beneficiaries7 require states to report on the number or percentage of beneficiaries living in institutional or community-based settings, those transitioning between institutional and community-based settings, and those experiencing decreases in personal care hour authorizations (Table 3). Some of these measures are specified in the memoranda of understanding between the Centers for Medicare and Medicaid Services (CMS) and the states that authorize the demonstrations, while others are still to be determined in the three-way contracts between CMS, the state, and the health plans. As illustrated in Table 3, these measures vary among the states. In most of these demonstrations, one or two of these measures is included in the subset of measures used to determine whether health plans can earn back their quality withhold funds. Although LTSS rebalancing is not among CMS’s § 1915(c) HCBS waiver quality measures,8 CMS’s 2013 guidance requires states to have a “comprehensive quality strategy” in Medicaid managed LTSS waivers. 9 Reporting requirements related to LTSS rebalancing are included in a few states’ managed LTSS demonstrations (Table 4). In addition, the evaluation of Kansas’ § 1115 managed LTSS demonstration must assess whether the demonstration reduces the percentage of beneficiaries in institutions by providing additional HCBS and the impact of including LTSS in the capitated benefit, with a subfocus on HCBS. CMS also has awarded Testing Experience and Functional Assessment Tools grants to states to use health information technology to develop HCBS quality measures.10
Measuring LTSS rebalancing remains a gap in assessing HCBS quality, with work to develop these measures continuing. In August 2014, the National Quality Forum (NQF) Measure Applications Partnership “emphasiz[ed] that new and improved measures are needed to evaluate community integration/inclusion and participation” for dual eligible beneficiaries and identified this area as among the “high priority measure gaps.”11 NQF is accepting nominations in late 2014 for a multi-stakeholder committee to create a conceptual framework, conduct an environmental scan, identify gaps, and recommend measure development efforts as part of its two-year Quality Measurement for HCBS project.12
Table 1: Examples of Quality Measures Related to LTSS Rebalancing and Community Integration | |
Type of Measure | Type of Information Collected |
Beneficiary surveys |
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Numeric reporting requirements |
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As additional states express interest in implementing managed LTSS programs, the design, use, and interpretation of quality measures related to LTSS rebalancing will be an important aspect of evaluating these programs. Although some measures in this area exist, LTSS measures generally are not as well developed as those for care provided in clinical settings, and work is continuing in this area. Along with measuring the extent to which beneficiaries are served in community-based settings as opposed to institutions, it also is important to assess whether the services provided in community-based settings are adequate to support beneficiary needs. Along with evaluating whether and how community integration is achieved, additional areas in which quality measures important to people who use LTSS could be further developed include those related to beneficiary satisfaction, quality of life, and disability accessibility. Quality measures play an important role in ensuring that information is available to adequately assess whether HCBS programs, including managed LTSS, are achieving their intended goals.
Table 2: Selected Quality Measures Related to Community Integration | ||
Source |
Year |
Measures |
National Core Indicators (for people with developmental disabilities) | In use since 1997; currently used in 39 states |
|
National Core Indicators – Aging and Disabilities | Piloted in 3 states in 2014; year 1 survey in 2015 |
|
Agency for Healthcare Research and Quality Environmental Measure Scan | 2007 |
|
University of California, San Francisco Center for Personal Assistance Services Selected Inventory of Quality-of-Life Measures for LTSS Participant Experience Surveys | 2012 |
|
SOURCES: National Core Indicators, available at http://www.nationalcoreindicators.org/; National Core Indicators – Aging and Disabilities State Initiative (Sept. 2014), http://www.nasuad.org/initiatives/national-core-indicators-aging-and-disabilities; Agency for Healthcare Research and Quality, Medicaid Home and Community-Based Services Measure Scan (July 2007), available at http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/hcbsreport/index.htmll; H. Stephen Kaye, Center for Personal Assistance Services, University of California San Francisco, Selected Inventory of Quality-of-Life Measures for Long-Term Services and Supports Participant Experience Surveys (Dec. 2012), available at http://dredf.org/Personal-experience-domains-and-items.pdf. |
Table 3: Selected Quality Measures Related to Rebalancing in States’ Capitated Financial Alignment Demonstrations for Dual Eligible Beneficiaries | |
State | Measures |
CA |
|
IL |
|
MA |
|
MI |
|
NY |
|
OH |
|
SC |
|
TX |
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VA |
|
WA |
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NOTES: * indicates quality withhold measure. CA, OH, MI, SC, TX, and VA’s MOUs also indicate that CMS will work closely with state to monitor other measures related to community integration.SOURCE: KCMU analysis of states’ financial alignment demonstration memoranda of understanding with CMS, available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/ApprovedDemonstrationsSignedMOUs.html. |
See generally Kaiser Commission on Medicaid and the Uninsured, Medicaid Beneficiaries Who Need Home and Community-Based Services: Supporting Independent Living and Community Integration (March 2014), available at https://www.kff.org/medicaid/report/medicaid-beneficiaries-who-need-home-and-community-based-services-supporting-independent-living-and-community-integration/; Kaiser Commission on Medicaid and the Uninsured, Medicaid Home and Community-Based Services Programs: 2010 Data Update (March 2014), available at https://www.kff.org/medicaid/report/medicaid-home-and-community-based-service-programs/.
See generally Kaiser Commission on Medicaid and the Uninsured, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid: 15 Years After the Supreme Court’s Olmstead Decision (June 2014), available at https://www.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/.
Kaiser Family Foundation, Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015 at 29 (Oct. 2014), available at https://www.kff.org/medicaid/report/medicaid-in-an-era-of-health-delivery-system-reform-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2014-and-2015/.
Kaiser Commission on Medicaid and the Uninsured, Assessing Rebalancing in Capitated Medicaid Managed Long-Term Services and Supports Programs (Jan. 2015), available at https://www.kff.org/medicaid/issue-brief/rebalancing-in-capitated-medicaid-managed-long-term-services-and-supports-programs-key-issues-from-a-roundtable-discussion-on-measuring-performance/.
National Core Indicators, available at http://www.nationalcoreindicators.org/.
National Core Indicators – Aging and Disabilities, http://www.nasuad.org/initiatives/national-core-indicators-aging-and-disabilities.
See generally Kaiser Commission on Medicaid and the Uninsured, Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS (July 2014), available at https://www.kff.org/medicaid/issue-brief/financial-alignment-demonstrations-for-dual-eligible-beneficiaries-compared/.
CMS, Modifications to Quality Measures and Reporting in § 1915(c) Home and Community-Based Waivers (March 2014), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/3-CMCS-quality-memo-narrative.pdf. Measure areas include level of care determinations; service plan adequacy; provider qualifications; abuse, neglect, and exploitation; financial accountability; and state oversight.
CMS, Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long-Term Services and Supports Programs at 6, 15 (May 2013), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf.
CMS, Testing Experience and Functional Assessment Tools, available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Grant-Programs/TEFT-Program-.html.
National Quality Forum, 2014 Input on Quality Measures for Dual Eligible Beneficiaries (Aug. 2014), available at http://www.qualityforum.org/Publications/2014/08/2014_Input_on_Quality_Measures_for_Dual_Eligible_Beneficiaries.aspx.
National Quality Forum, Quality Measurement for Home and Community-Based Services, available at http://www.qualityforum.org/ProjectDescription.aspx?projectID=77692.