Florida's Medicaid AIDS waiver: an assessment of dimensions of quality

Some State Medicaid agencies have implemented home and community-based waiver programs targeting acquired immunodeficiency syndrome (AIDS) patients. Under these initiatives, State Medicaid agencies can provide home and community-base services to persons with AIDS (PWA) as an alternative to more costly Medicaid-covered institutional care. This article evaluates quality of care under the Florida Medicaid waiver for PWA along two dimensions: program effectiveness and client satisfaction. Clients are generally satisfied with their case managers and the range and availability of services. Case managers appear to be well trained. Moreover, the probability of turnover is quite low, despite heavy caseloads and high mortality. The major difficulty faced by clients adn case managers relates to the process of becoming Medicaid eligible.     

Do Medicaid Home and Community Based Service Waivers Save Money?

This article estimates the potential savings to the Medicaid program of using 1915c Home and Community Based Services (HCBS) waivers rather than institutional care. For Medicaid HCBS waiver expenditures of $25 billion in 2006, we estimate the national savings to be over $57 billion, or $57,338 per waiver participant in 2006 compared with the cost of Medicaid institutional care (for which all waiver participants are eligible). When taking into account a potential 50% “woodwork effect” (for people who might have refused institutional services), the saving would be $21 billion. This analysis demonstrates that HCBS waiver programs present significant direct financial savings to Medicaid long-term care (LTC) programs.     

Do Medicaid home and community based service waivers save money?

This article estimates the potential savings to the Medicaid program of using 1915c Home and Community Based Services (HCBS) waivers rather than institutional care. For Medicaid HCBS waiver expenditures of $25 billion in 2006, we estimate the national savings to be over $57 billion, or $57,338 per waiver participant in 2006 compared with the cost of Medicaid institutional care (for which all waiver participants are eligible). When taking into account a potential 50% "woodwork effect" (for people who might have refused institutional services), the saving would be $21 billion. This analysis demonstrates that HCBS waiver programs present significant direct financial savings to Medicaid long-term care (LTC) programs.     

Medicaid policies for the hospice care needed by people with Alzheimer's disease

This study surveyed the state Medicaid programs and the state affiliates of the National Hospice Organization to identify Medicaid policies that improve the quality of hospice care provided to Medicaid recipients with Alzheimer's disease (AD). Medicaid programs should expand their use of the home and community-based care waiver programs to include specialized services that allow people with AD to remain at home and to assist family members with their care. Among these services are homemaker services, personal care, a range of respite care, home-delivered meals, and companion services. These waiver programs also allow states to establish more generous eligibility standards for waiver services, enabling more people with AD to quality for waiver coverage than would qualify for the traditional Medicaid program.     

Dually eligible individuals with AIDS: characteristics and health services use

This paper explores the prevalence and health care utilization of dually eligible Medicare and Medicaid participants among New Jersey Medicaid recipients with AIDS using linked administrative data. Merged Medicaid claims and AIDS surveillance data were used to analyze participation in the Medicare program by Medicaid recipients in New Jersey diagnosed with AIDS who received services between January 1988 and March 1996. We found that nearly 30% of Medicaid participants had Medicare claims during the observation period, suggesting that Medicare is becoming an important payer of HIV care among individuals eligible for Medicaid. Traditionally disadvantaged groups such as women and racial minorities were less likely to be dually eligible for Medicare, reflecting differences in survival and in eligibility requirements for Social Security Disability Insurance (SSDI). Controlling for other characteristics, dually eligible individuals had shorter lengths of stay and had lower charges per inpatient stay than Medicaid only enrollees. Dual eligibles were also more likely to use antiretroviral (ARV) drugs and were more consistent users of ARV treatment measured by the proportion of time on ARV therapy. Our study suggests that persons with AIDS who may qualify for Medicare because of their disability are different than individuals who only received Medicaid reimbursed services in terms of their health care utilization. Further research is needed to determine the cause of such differences which may include socioeconomic differences between dual eligibles and Medicaid only eligibles, dissimilarities in health status between the two groups, and variation in aspects of insurance coverage particularly in the choice and reimbursement of office-based physicians.     

Home-care use and expenditures among Medicaid beneficiaries with AIDS

This article compares the use and cost of home-care services among traditional Medicaid recipients with acquired immunodeficiency syndrome (AIDS) and among participants in a statewide Human Immunodeficiency Virus (HIV)/AIDS-specific home and community-based Medicaid waiver program in New Jersey, using Medicaid claims and AIDS surveillance data. Waiver program participation appears to mitigate racial and risk group differences in the probability of home-care use. However, the program's successes are confined to its enrollees of which subgroups of the AIDS population are underrepresented. Our findings suggest the need to expand access to home-care programs to racial minorities and injection drug users (IDUs) with HIV/AIDS.     

Medicaid home and community-based care waiver programs: providing services to people with AIDS

The authors present the results of a survey demonstrating how Medicaid programs use the home and community-based waiver programs to provide services to people with acquired immunodeficiency syndrome (AIDS) and to other targeted groups. The survey identified a number of waiver services that are effective at meeting the care needs of people with AIDS, such as case management, personal care, respite care, home intravenous therapy, attendant care, hospice, and home-delivered meals. The study demonstrates that in addition to the AIDS-specific waiver program, State Medicaid programs use the home and community-based care waiver programs for the elderly and disabled to provide services to people with AIDS because of their disability status.     

Health and federal budgetary effects of increasing access to antiretroviral medications for HIV by expanding Medicaid

OBJECTIVES. This study modeled the health and federal fiscal effects of expanding Medicaid for HIV-infected people to improve access to highly active antiretroviral therapy. METHODS: A disease state model of the US HIV epidemic, with and without Medicaid expansion, was used. Eligibility required a CD4 cell count less than 500/mm3 or viral load greater than 10,000, absent or inadequate medication insurance, and annual income less than $10,000. Two benefits were modeled, "full" and "limited" (medications, outpatient care). Federal spending for Medicaid, Medicare, AIDS Drug Assistance Program, Supplemental Security Income, and Social Security Disability Insurance were assessed. RESULTS: An estimated 38,000 individuals would enroll in a Medicaid HIV expansion. Over 5 years, expansion would prevent an estimated 13,000 AIDS diagnoses and 2600 deaths and add 5,816 years of life. Net federal costs for all programs are $739 million (full benefits) and $480 million (limited benefits); for Medicaid alone, the costs are $1.43 and $1.17 billion, respectively. Results were sensitive to awareness of serostatus, highly active antiretroviral therapy cost, and participation rate. Strategies for federal cost neutrality include Medicaid HIV drug price reductions as low as 9% and private insurance buy-ins. CONCLUSIONS: Expansion of the Medicaid eligibility to increase access to antiretroviral therapy would have substantial health benefits at affordable costs.     

State efforts to expand Medicaid-funded family planning show promise

The US government provides 90% of the cost of family planning (FP) services to people eligible for Medicaid, while states contribute the rest and set eligibility ceilings. In the past, only families on welfare received Medicaid, but broader eligibility criteria were created to cover low-income pregnant ("expansion") women until 60 days postpartum, and several states received waivers to extend services beyond this limit. Eight states offer expansion women an additional 2-5 years of FP services, one state offers FP services for 2 years to all women losing regular Medicaid, and four states extend FP services to all low-income women not previously covered by Medicaid. In addition, California provides solely state-funded FP services to women and men with incomes below 200% of the poverty level. Some of these approaches pose outreach challenges, and states have adopted different strategies to extend eligibility to the target population. Data on program enrollment indicate that the state efforts have the potential to reach large numbers of women and to support the work of nonprofit FP clinics. The next step, to expand the program to other states, would be facilitated if Congress obviated the need for states to seek an expansion waiver. Rhode Island's program quickly improved birth intervals for women with Medicaid-funded births so that they were virtually identical to those of privately-insured women and prevented 1443 Medicaid-eligible deliveries, saving $14.3 million through a program that cost $5.7 million from 1994 to 1997.     

Medicaid policies for AIDS-related hospital care

With hospital services comprising an important part of care related to acquired immunodeficiency syndrome (AIDS), and all Medicaid programs becoming major payers of these services, Medicaid policies affect the care that Medicaid recipients with AIDS receive. Many States pay hospitals on the basis of prospective payments that do not vary with patient diagnosis. In contrast, Medicaid programs using diagnosis-related group (DRG) payment methods adjust payments to reflect the greater cost of AIDS care. At least 12 Medicaid programs limited the number of paid inpatient hospital days during 1992; Medicaid recipients with AIDS could easily exceed such limits.     

Providing access to home care for disabled children: Minnesota's Medicaid model waiver program

Home care programs for severely disabled, usually technology-dependent, children got a boost in 1981 when the Federal Government gave States permission to use Medicaid to fund home care under the Medicaid model home- and community-based waiver (2176). The model waiver program was unique because it eliminated the bias toward hospitalization by waiving parental income and assets when determining eligibility for children cared for at home and by allowing Medicaid to cover needed home care services. In 1985 Minnesota received Federal approval for the model waiver, and the results are detailed in this report. Although the waiver could provide funding for up to 50 children, after 2 years only 24 children had received approval. Stringent and complex eligibility criteria acted as barriers to accessing the model waiver. In addition, the interaction between the waiver and the State's health care system contributed to inconsistencies in eligibility. This interaction demonstrates the difficulty of administering publicly funded programs in the current health care environment. Recommendations are made for adjusting criteria for eligibility in the waiver program. Unresolved problems facing technology-dependent children on home care programs are discussed.     

State Medicaid programs offering personal care services

Two Medicaid programs offer personal care services: (1) the Title XIX Personal Care Services (PCS) optional State plan benefit; and (2) the 1915(c) home and community-based services (HCBS) waivers. By 1998-1999, 26 States offered the PCS optional State plan benefit; 45 offered personal care services via a waiver(s). Nationwide, the former program was larger. The latter was the more popular administrative mechanism, possibly because it more reliably controls growth. States vary dramatically in terms of Medicaid personal care. Medicaid personal care participants per 1,000 State population ranged from 7.33 to 0.04. Per capita expenditures ranged from $91.21 to $0.02.     

President seeks 3 percent increase in AIDS funding for '98

President Clinton's spending proposals for 1998 include increased funding for AIDS research, care, and treatment, as well as initiatives to help people return to work if their multidrug therapy is effective. Some AIDS advocates are still disappointed with this funding level and predict that there will be a shortage of funds available to provide adequate services to HIV/AIDS patients. Advocates also expressed concern over reduced Medicaid spending since many AIDS patients rely completely on Medicaid for health care. The spending proposal keeps Federal funding for the network of State AIDS drug assistance programs at $167 million despite the demand for multidrug treatments. The budget includes $634 million for AIDS-related programs at the Centers for Disease Control and Prevention (CDC) and $1.54 billion for AIDS-related research directed through the National Institutes of Health (NIH) Office of AIDS Research. The total cost of AIDS care, research, and prevention reaches nearly $8.9 billion. Funding proposals for each agency and allocations for the Ryan White CARE Act are outlined.     

Medicaid 1915(c) home and community-based services waivers: a national survey of eligibility criteria, caps, and waiting lists

With 43 states reporting budget deficits in 2002, there is increasing interest in the cost controls methods that state governments use on the 229 Medicaid home and community-based services (HCBS) waiver programs which, in 2001, provided services to more than 830,000 persons and cost more than $14.2 billion. This paper reports findings from a national survey of all waiver programs regarding cost containment strategies used in 2002. Responses from 76 percent of all waivers show that 57 percent used some type of financial cap, 33 percent used more restrictive financial eligibility criteria than for institutional services, and the vast majority of states limited the number of waiver slots available. Overall, the waiver programs reported that 157,640 persons were on waiting lists in 2002. These findings provide an important basis for comparison between states because the use of these strategies may restrict individuals' choice of services and result in unnecessary institutionalization.     

Medicaid AIDS waivers: seeking cost effective financing of AIDS care

The epidemic of Acquired Immunodeficiency Syndrome (AIDS) emerged at a time of transition in American health care and health care policy. The waiver of traditional Medicaid limitations on home and community-based health care services for persons with AIDS has been utilized by several states attempting to demonstrate models of care where quality of life as well as financial concerns are addressed. The Medicaid AIDS Waiver programs in New Jersey and Florida note promising results in the cost-effectiveness of such programs when compared with traditional Medicaid. Variations in patient participation by geographic area and demographic characteristics indicate areas for future improvement in program accessibility.     

Association Between Perinatal Medical Expenses and a Waiver to Increase Florida Healthy Start Services Within Florida Medicaid Programs: 1998 to 2006

To assess the association between perinatal care expenditures and a Medicaid waiver to increase Florida Healthy Start services among Florida Medicaid non-managed care organization (non-MCO) program enrollees. We assessed perinatal care expenditures from Medicaid claims and encounter data among non-MCO enrollees with increased risk pregnancies who gave birth in Florida during 1998?C2006. We used a pre-post design to compare adjusted perinatal medical expenditures among women who received Healthy Start care coordination (n?=?41,067) to women who were not contacted by the Healthy Start program after screening (n?=?24,282). We calculated adjusted average costs and difference-in-differences using marginal estimates from multivariable linear mixed regression models. From the pre-waiver (January 1998?CJuly 2001) to the late-post waiver (July 2004?CDecember 2006), all prenatal medical costs increased $274 among care coordination participants and decreased $601 among women not contacted by the Healthy Start program, equaling a $875 increased cost difference between care coordination and no contact groups. During this same time period, delivery related expenditures increased $395 less among care coordination participants compared to women not contacted by Healthy Start. Additionally, infant medical care costs during days 29?C365 decreased by an average of $240 less among the care coordination compared to the no contact group. The Medicaid waiver may have decreased delivery costs, but medical costs were increased following the waiver when considering all perinatal care. Further exploration of factors associated with the decreased delivery costs may help develop more efficient prenatal support programs.     

Medicaid home and community-based services: national program trends

Long-term care (LTC) policymakers face mounting pressures to expand Medicaid home and community-based services while the cost of institutional provision continues to rise and consume the bulk of Medicaid LTC spending. This paper presents the latest program trends in the three Medicaid home and community-based services programs (waivers, home health, and state-plan personal care) and reports a national survey of cost control policies used on waiver programs in 2002. The findings show slowing annual rates of participation growth on individual programs, widespread use of cost controls on waivers including waiting lists, and the persistence of large interstate variations in Medicaid's provision of these services.     

Identifying a Sample of HIV-Positive Beneficiaries From Medicaid Claims Data and Estimating Their Treatment Costs

Objectives. We sought to identify people living with HIV/AIDS from Medicare and Medicaid claims data to estimate Medicaid costs for treating HIV/AIDS in California. We also examined how alternate methods of identifying the relevant sample affect estimates of per capita costs.Methods. We analyzed data on Californians enrolled in Medicaid with an HIV/AIDS diagnosis reported in 2007 Medicare or Medicaid claims data. We compared alternative selection criteria by examining use of antiretroviral drugs, HIV-specific monitoring tests, and medical costs. We compared the final sample and average costs with other estimates of the size of California’s HIV/AIDS population covered by Medicaid in 2007 and their average treatment costs.Results. Eighty-seven percent (18 290) of potentially identifiable HIV-positive individuals satisfied at least 1 confirmation criterion. Nearly 80% of confirmed observations had claims for HIV-specific tests, compared with only 3% of excluded cases. Female Medicaid recipients were particularly likely to be miscoded as having HIV. Medicaid treatment spending for Californians with HIV averaged $33 720 in 2007.Conclusions. The proposed algorithm displays good internal and external validity. Accurately identifying HIV cases in claims data is important to avoid drawing biased conclusions and is necessary in setting appropriate HIV managed-care capitation rates.In 2010, the White House Office of National AIDS Policy outlined an ambitious National HIV/AIDS Strategy for the United States that called for evaluation strategies that would “obtain data (core indicators) that capture the care experiences of people living with HIV without substantial new investments.”1 Surveillance systems already in place in each state provide the Centers for Disease Control and Prevention with comprehensive data on incident HIV and AIDS cases.2 However, much less is known about the medical treatments received by people living with HIV/AIDS and the cost of those treatments.Much of the cost of HIV/AIDS treatment is borne by public insurance programs, principally Medicaid and Medicare. These 2 programs provide health insurance for more than half of people living with HIV/AIDS who are receiving care.3,4 The importance of Medicaid as a source of funding for HIV/AIDS treatment of low-income persons will grow substantially after full implementation of the Affordable Care Act, which eliminates the additional disability requirement for Medicaid eligibility in states accepting the Medicaid expansion, thereby extending coverage to nondisabled, low-income people living with HIV/AIDS in those states.Because of its prominent role in insuring low-income people living with HIV/AIDS, Medicaid can provide a rich source of data on the types and costs of treatments delivered to some of the most vulnerable individuals with HIV/AIDS. Insurance claims data can potentially allow us to monitor HIV/AIDS treatment without substantial new investments because most claims data are stored as computerized records. Claims data provide a comprehensive picture of medical care received from a variety of providers in multiple settings (outpatient, inpatient, laboratory, pharmacy), contain procedure codes that detail the services provided, and include cost of the treatment. By contrast, medical records tend to have smaller scope, in terms of both numbers of patients and services covered. Furthermore, medical records most often lack payment information.Insurance claims data can provide information on a large number of individuals, even among those with relatively low-prevalence conditions, which is valuable in reducing the variability of estimates of per capita expenditures. However, the greater precision afforded by large administrative data sets is of little value if estimates are based on an inappropriate sample. Claims data are primarily designed for billing purposes; thus, they generally lack clinical detail important for selecting cases with a particular disease.3,5 For example, claims data will document whether a laboratory test was performed, but not the test result. Therefore, analysts must rely on the diagnosis information on insurance claims.6 Professional medical records specialists code diagnoses on inpatient claims, leading to greater accuracy and reliability of diagnosis information coming from inpatient stays. However, diagnosis coding is more error-prone in the outpatient sector, which has accounted for an increasing percentage of HIV/AIDS care since 1996 when antiretroviral medication (ARV) began to dramatically reduce hospitalization for HIV/AIDS.7 This has increased the challenges of identifying people living with HIV/AIDS from insurance claims data.We applied a practical algorithm for identifying people living with HIV/AIDS in insurance claims data to estimate Medicaid costs for treating HIV/AIDS in California. We also examined how alternate methods of identifying the relevant sample affect estimates of per capita costs.