HCBS Waiver: Economic Utility and Related Health Outcomes: Preliminary Literature Review

The Olmstead v L. C. 527 U.S. 581 (1999) decision requiring that individuals with disabilities must “. . .  receive public benefits and services in the most integrated setting appropriate to their needs,” established a number of responsibilities on the part of states. As the primary funding source for supporting individuals with disabilities and long-term care needs, Medicaid shoulders the brunt of responsibility for helping states fulfill such obligations, primarily through funding and implementation of Home and Community-Based Services (HCBS) waivers. 
Medicaid-funded HCBS waivers provide coverage for community services that help minimize loss of function in areas of daily living (e.g., ADLs/IADLs) that directly affect health status (LeBlanc, Tonner, & Harrington, 2001) and, by association, ability to fully participate in the community (Allen & Mor, 1997; Cope, C., 2006). By providing these services, HCBS waivers enable people with various disabilities and substantial long-term care needs to remain in the community (Centers for Medicare and Medicaid, 2005; Davitt, Kay, Bagati, & Graub, 2002).  To monitor, improve, and build a case for continuing their programs, Medicaid and HCBS program managers must have a clear understanding of healthcare utilization and expenditures for this population (Powers, 2005).

Specifically, as a result of federal policies such as the New Freedom Initiative and Deficit Reduction Act of 2005, program managers need to ensure that these programs have the intended outcome of   “. . . effectively foster[ing] independence and participation in the community for Americans with disabilities (Bush, 2001).” One important means for doing this is to ensure that health conditions and healthcare concerns are appropriately addressed and that secondary health conditions are prevented through appropriate use of personal assistance services.

Research has shown a relationship between personal assistance service needs met and the amount of social resources available. Those with fewer unmet needs typically have more social resources (Desai, Lentzner, & Weeks, 2001; Kennedy, 2005; Newcome, Kang, LaPlante, & Kaye, 2005). Moreover, individuals who report unmet needs for personal assistance needs also have a higher probability of experiencing adverse events than those whose needs are met. Adverse consequences include running out of food, because they could not get to the store, going hungry, missing doctor’s appointments, and being unable to go other places (LaPlante, Kay, Kang, & Harrington, 2004). This suggests a correlation between community participation and personal assistance services. Individuals who have unmet or undermet needs for personal assistance are less likely to be able to participate in the community.
 
While the success of HCBS waivers has been measured and documented for outcomes related to waivers (Anderson & Mitchell, 1997; Beaulieu, 1991; Harrington, Carrillo, Wellin, & Norwood, 2000; Shireman & Rigler, 2004), limited research has addressed the cost utility and success of HCBS waivers in helping maintain or improve the health of individuals with disabilities so that they may fully participate in the community. Fox and Kim (2004) examined the effect of enrollment in an HCBS waiver for individuals with physical disabilities on ambulatory, hospital inpatient, and long-term care services and costs. In addition, three state agencies in Maine analyzed healthcare utilization as quality indicators for HCBS waivers (Fralich, Gray, Olsen & Ziller, 2005). However, no one has investigated these factors specifically for those moving out of institutions. 

Further, no standardized and comprehensive evaluation system for cost utility and effectiveness in achieving community participation has been proposed. This leaves state Medicaid programs to either improvise their own measurement or not evaluate the effectiveness and outcomes directly. In many states, ongoing fiscal constraints limit resources available to conduct program evaluations, suggesting a strong need to design and implement an assessment strategy for use by state Medicaid programs to monitor and evaluate healthcare utilization and expenditures for HCBS waiver recipients. These assessment strategies should determine states’ effectiveness in achieving the goals of recently implemented federal policies such as, The Olmstead v. L .C. 527 U.S. 581 (1999), the New Freedom Initiative (The White House. Presidential Announcement of New Freedom Initiative), the NFI implementing Executive Order 1327 (The White House. 2001 Executive Order 13217 Regarding Community-Based Alternatives for Individuals With Disabilities), the report on HSS implementation of Executive Order 13217 (National Archives and Records Administration) and the Deficit Reduction Act of 2005 (S. 1932, Deficit Reduction Act of 2005) (PUBLIC LAW 109–171-FEB, 8, 2006, 109th Congress).

References
Allen, S. & Mor, V. (1997).The prevalence and consequences of unmet need. Contrasts between older and younger adults with disability. Medical Care, 35 (11),1132-48.
Anderson, K. & Mitchell, J. (1997). Expenditures on services for persons with acquired immunodeficiency syndrome under Medicaid home and community-based waiver program. Medical Care, 35(5), 425-439.

Beaulieu, J. E.  (1991). Results of the assessment of Kentucky’s Medicaid Home and Community-Based Services waiver. Home Health Care Services Quarterly, 12(3), 33-57.
Bush, G. W. (2001). Executive Order 13217: Community-based alternatives for individuals with disabilities. Available online: http://www.whitehouse.gov/news/releases/2001/06/20010619.html

Centers for Medicare and Medicaid. (2005). Promising practices. Available online: http://www.cms.hhs.gov/PromisingPractices/

Cope, C. (2006). Longterm Care Roadmap for Medicaid Reform. Centers for Medicare and Medicaid.  Available online: http://www.hcbs.org/moreInfo.php/nb/doc/1563/Long-term_Care_Roadmap_to_Medicaid_Reform

Davitt, J., Kaye, L., Bagati, D, & Graub, P. (2002). Beneficiary profiles and service consumption patterns in an urban Medicaid Home and Community-Based Waiver program. Care Management Journals, 3(2), 84-90.

Desai, M., Lentzner, H., & Weeks, J. (2001). Unmet need for personal assistance with activities of daily living among older adults. The Gerontologist, 41(1), 82-88.

Fox, M., & Kim, K. M. (2004). Evaluating a Medicaid Home and Community-Based Physical Disability Waiver. Family and Community Health, 27(1), 37-51.

Harrington, C., Carrillo, H., Wellin, V., & Norwood, F. (2000). 1915(c) Medicaid Home and Community-Based Waiver participants, services and expenditures, 1992-1998, based on HCFA 372 form data [Report to the Health Care Financing Administration Under Contract Number 500-97-0002]. San Francisco, CA: University of California.

Kennedy, J. (2005). Unmet and undermet need for activities of daily living and instrumental activities of daily living assistance among adults with disabilities: Estimates from the 1994 and 1995 disability follow-back surveys. Medical Care, 39(12),1305-1312.

LeBlanc, A., Tonner, M., & Harrington, C. (2000). Medicaid 1915(c) Home and Community-Based Waivers across states. Health Care Financing Review, 22(2), 159-174.

Newcomer, R., Kang, T., LaPlante, M., &  Kaye, S. (2005). Living quarters and unmet need for personal care assistance among adults with disabilities. Journal of Gerontology, 60B(4), S205-S213.

Powers, A. (2005). Introduction to program evaluation. Retrieved February 24, 2007, http://www.cdc.gov/nchstp/tb/Program_Evaluation/Guide/Webinar/Eval_101_1_AP22.ppt#315

Shireman, T. & Rigler, S. (2004).  Penny wise, pound wise: A comparison of Medicaid expenditures for Home and Community-Based Services versus nursing facility care for older adults. Home Health Care Services Quarterly, 23(4), 15-28.