Medicaid HCBS Fails to Promote Patients’ Independence, Study Finds

McKnight’s Home Care | By Adam Healy
 
A senior in HCBS care is comforted by a family member
Home support services are intended to help patients live independently in their communities, but new research has found that it may actually have the opposite effect.
 
The reason, according to the Health Affairs study, is that home- and community-based services (HCBS) are predominantly based on fee-for-service (FFS) payment models, which prioritize quantity, and not quality, of care. Specifically, FFS models reimburse providers based on the number of hours of service they provide. As a result, many patients and providers rely on home-based services that promote dependence on caregivers. Value-based models, on the other hand, incentivize care quality, according to the study, which can promote independence. 
 
“Medicaid HCBS is stuck in a fee-for-service world that rewards more hours instead of the outcomes that matter most to beneficiaries — namely, independence and community inclusion,” the study said. “In fact, HCBS providers are disincentivized to support independence, as it reduces billable hours and provider payments.”
 
One way to fix this problem is to invest in supports that allow patients to live without reliance on caregivers. More than 80% of FFS expenditures for high-cost HCBS users go toward in-person support services, and less than 1% is for home modifications and other technology that encourages independence, according to the study. Shifting this ratio will reduce billable hours and better integrate people into their communities. As examples, durable medical equipment such as bathroom hand rails, assistive technology like dressing aids, and wearable devices like fall detectors help people live independently — a cheaper alternative than some personal caregiver services.
 
Spending on long-term services and supports has gradually shifted away from institutional care toward HCBS. Ultimately, to create a system that promotes independent living, the researchers recommend utilizing person-centered, value-based models that focus on quality measures rather than billable hours.
 
“It will take time for the HCBS system to embrace an independence first approach,” the study said. “We must start now to rebuild a system where independence and community integration is prioritized, supported, valued and rewarded.”