Evaluating disparities in older adult health, institutionalization, and mortality after implementation of Medicaid's Balancing Incentives Program

评估实施医疗补助平衡激励计划后老年人健康、收容和死亡率方面的差异

• 批准号: 9265937
• 负责人: Regina A Shih
• 金额: $ 88.28万
• 依托单位: RAND CORPORATION
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-04-22 至 2020-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9265937
• 关键词: Activities of Daily Living; Adult; Affect; Age; Caregivers; Caring; Characteristics; Child; Communities; County; Databases; Dementia; Distant; Elderly; Eligibility Determination; Equilibrium; Ethnic Origin; Ethnic group; Evaluation; Expenditure; Family; Family Caregiver; Family Sizes; Family member; Female; Funding; Goals; Gray unit of radiation dose; Health; Health Care Costs; Health Services Accessibility; Health Status; Heterogeneity; Home Care Services; Home environment; Incentives; Individual; Institution; Institutionalization; Link; Longevity; Measures; Medicaid; Medical; Medicare/Medicaid; Methods; Minority; Minority Groups; Nursing Homes; Outcome; Patient Self-Report; Policies; Population; Provider; Race; Research; Risk; Rural; Self Care; Services; Single-Payer System; Social Policies; Spouses; Stretching; Support System; Surveys; System; Testing; Thinness; Urban Health; base; beneficiary; community based service; contextual factors; cost; dual eligible; health disparity; informal care; mortality; neglect; patient home care; population health; preference; programs; public health relevance; racial and ethnic; racial disparity; rural area; rural residence; success; trend; urban disparity; urban residence; waiver

 DESCRIPTION (provided by applicant): Formal, or paid long term service and support (LTSS) have estimated annual costs of $211 to $306 billion in the U.S. and these expenditures are expected to rise as Baby Boomers age. Demographic trends including smaller family sizes, increased female workforce participation, and longer lifespans will reduce the availability of family caregivers, placing further burden on the formal LTSS system and especially on Medicaid, the nation's largest single payer of formal LTSS. Medicaid has been at the forefront of policy efforts to "rebalance" LTSS from institutional to home-and community-based settings. These rebalancing efforts reflect individuals' preferences to receive home- and community-based services (HCBS) and these transitions have also been shown to save about 15% in per capita LTSS spending over 10 years. In spite of this increased focus, evaluations of these rebalancing policies have largely neglected health and mortality outcomes, disparities in outcomes, and effects on older adults with specific health conditions such as dementia, who may have higher than average Medicaid expenditures. The most recently implemented rebalancing policy is the Balancing Incentive Program (BIP), which offers additional funding to states to increase access to LTSS in states that were spending less than 50% of LTSS expenditures on HCBS. We will conduct the first formal evaluation of BIP's effects on four health outcomes: self-rated health, functioning, long-term institutionalization, and mortality. There is reason to suspect that disparities in these outcomes may also be affected after BIP's implementation, as whites and minorities tend to employ very different LTSS strategies and have different levels of access to care. Similarly, individuals living in rural areas are more likey than their urban counterparts to have few or distant medical providers and fragmented care coordination, all of which limit their ability to obtain necessary care and adversely affect individual and population health outcomes. This proposal employs a mixed-method approach to (1) conduct qualitative analyses to identify states' BIP implementation stages and challenges; (2) test the effect of BIP implementation on the four health outcomes using a difference-in- difference approach that capitalizes on the quasi-experimental framework to compare states that did and did not (but were eligible to) implement BIP; (3) assess racial/ethnic and rural/urban differences in BIP's effects on health; and (4) examine whether health conditions and access to informal care (unpaid care generally provided by family), and county- or state-level access to formal care further modify the effects of BIP on health outcomes and disparities. Multiple administrative and survey databases spanning 2008-2017 will be merged to examine health outcomes for dual-eligible adults 65 years and older who live in BIP and non-BIP states. The goal of this study is to provide policymakers with rigorous analyses of BIP's effects on health and health disparities. While these analyses focus on BIP, the results have implications for HCBS more generally and for understanding how rebalancing policies influence health and health disparities in older adults.

 描述（由适用提供）：正式或有偿的长期服务和支持（LTSS）估计在美国，年度费用为211至30060亿美元，随着婴儿潮一代的年龄，这些支出预计将增加。人口趋势包括较小的家庭规模，女性劳动力参与以及寿命更长的人口趋势将减少家庭护理人员的可用性，对正式的LTSS系统，尤其是Medicaid，尤其是美国最大的正式LTSS付款人Medicaid。医疗补助一直处于政策努力的最前沿，以“重新平衡”从机构到基于社区和社区的环境。这些重新平衡的努力反映了个人对接受家庭和社区服务（HCB）的偏好，并且这些过渡也已被证明可以节省大约15％的人均LTSS在10年内花费。尽管重点增加了，但对这些重新平衡政策的评估在很大程度上忽略了健康和死亡率，结果的差异以及对具有特定健康状况（例如痴呆症）的老年人的影响，例如痴呆症，他们的医疗补助支出可能高于平均水平。最近实施的重新平衡政策是平衡激励计划（BIP），该计划为各州提供了额外的资金，以增加在HCBS上支出不到50％的LTS支出的州获得LTSS的访问权限。我们将对BIP对四个健康结果的影响进行首次正式评估：自我评估的健康，功能，长期制度化和死亡率。有理由怀疑在BIP实施后，这些结果的差异也可能受到影响，因为白人和少数群体倾向于采用非常不同的LTSS策略，并且具有不同水平的获得护理。同样，居住在农村地区的个人更像是他们的城市同行，他们的医疗服务提供者很少或遥远的医疗服务协调，所有这些都限制了他们获得必要的护理的能力，并对个人和人口健康成果产生不利影响。该提案采用混合方法的方法来（1）进行定性分析，以确定各州的BIP实施阶段和挑战； （2）使用一种差异差异方法来测试BIP实施对四个健康结果的影响，该方法利用了准实验框架，以比较（但没有资格）实施BIP的状态； （3）评估种族/族裔和农村/城市 BIP对健康的影响差异； （4）检查健康状况和非正式护理（通常由家庭提供的无偿护理）以及县或州级获得正式护理的机会进一步修改了BIP对健康结果和差异的影响。将合并跨越2008 - 2017年的多个行政和调查数据库，以检查居住在BIP和非BIP州的65岁以上的双重合格成年人的健康结果。这项研究的目的是为决策者提供对BIP对健康和健康差异的影响的严格分析。尽管这些分析的重点是BIP，但结果对HCB的影响更广泛，并了解重新平衡政策如何影响老年人的健康和健康差异。