Last September, the AARP Public Policy Institute, The Commonwealth Fund, and The SCAN Foundation released the first-ever State Scorecard on Long-Term Services and Supports (LTSS). It has been heartening to see the positive response to this project from state officials, advocates, and private-sector organizations. Yet while the Scorecard started a discussion about state LTSS performance, it did not explain why states ranked high, low, or somewhere in between.
To address this question, we set out to study several states to learn about the factors that distinguish a high-ranking from a low-ranking state. We conducted site visits in the top-ranked state (Minnesota), a middle-ranked state (Idaho), and a low-ranked state (Georgia). Several factors stood out.
One factor was each state’s approach to moving the delivery of Medicaid services away from institutions and toward the home and community-based services (HCBS) that most consumers prefer. Both Minnesota and Idaho have longstanding initiatives and policies to shift public spending from nursing homes to HCBS. In Minnesota, a comprehensive array of HCBS is offered through the state's Medicaid managed care program. Policymakers in Idaho decided to do away with waiting lists for HCBS—which transformed the state’s mode of service delivery by keeping people who wanted to remain at home out of nursing homes. Georgia, however, continues to spend the great majority of its Medicaid LTSS dollars on nursing homes. Consider this Scorecard finding: two-thirds of new Medicaid LTSS beneficiaries in Georgia enter nursing homes. By contrast, only one-third of beneficiaries do so in Idaho and only 17 percent do so in Minnesota.
The Centers for Medicare and Medicaid Services is now offering financial incentives for states to shift the balance of their Medicaid spending toward HCBS, making this an opportune time for states to make this change. For example, the Balancing Incentives Payment Program provides grant funding to states that spend less than 50 percent of their Medicaid LTSS dollars on HCBS. New Hampshire was the first state to take advantage of the program, and other states should consider it as a cost-effective way to move toward HCBS. CMS also is in the process of finalizing regulations to implement the Community First Choice program, which will serve as another federal financial incentive for states to move toward greater use of HCBS.
Across the three case study states, the publically sponsored Aging and Disability Resource Centers (ADRCs) and/or state single point of entry systems functioned very differently. Ideally, these centers help people of all income levels and all types of disability learn about the LTSS options that are available in the state and streamline their ability to access services. On the Scorecard’s indicators of access to care, Minnesota ranked first, Idaho ranked last, and Georgia was in the middle at 24. In a high-functioning system such as Minnesota’s, the ADRC is a single source providing access to a wide array of services, including information and referral, screening, both functional and financial eligibility determinations, and nursing home pre-admission and transition services.
By contrast, at the time of Scorecard data collection, Idaho’s ADRC consisted primarily of a Web site that contained limited information about available services. (The state has plans to make better use of its Area Agencies on Aging, so that consumers in the state will have a place to go for information about services.) In Georgia, the functions of the ADRCs are also less robust than those performed in Minnesota.
The only area in which all three case study states scored in the first or second quartile of performance was in offering residential alternatives to nursing homes. Minnesota and Idaho have supported access to assisted living and family care homes by using their Medicaid programs to support these options. They ranked first and third, respectively, on this Scorecard indicator. Offering a range of residential choices helps people who might have difficulty staying in their own homes avoid a more restrictive nursing home placement. While Georgia provides fewer options than Minnesota and Idaho, it recently passed legislation to clarify the expected level of care that will be provided in assisted living facilities. This action will help consumers shop for the setting most appropriate for their individual needs.
The Scorecard found that all states have areas of strength on which they can build as well as challenges to overcome. The case studies, which are available for free download on longtermscorecard.org, may provide a useful tool for states that are seeking ways to improve their performance.
Visit longtermscorecard.org to download the case studies.