Reinvesting in home and community-based services

How the Biden Administration’s $1.9 trillion relief bill will impact Medicaid in Massachusetts

The American Rescue Plan Act (ARPA) — a COVID-19 relief and recovery package — was signed into law by President Joseph Biden last month. Among the $1.9 trillion relief bill’s provisions is a temporary enhanced federal matching percentage (FMAP) for Medicaid home and community-based services. The FMAP is the proportion of every Medicaid dollar spent paid for by the Federal government. Massachusetts could receive as much as $409.2 million during the one-year period covered.

Prof. Miller discusses COVID-19 relief bill

“One of ARPA’s goals is to strengthen state efforts to help seniors and people with disabilities live in their homes and communities rather than in nursing homes or other institutional settings,” said Edward Alan Miller, PhD, a fellow at the Gerontology Institute at UMass Boston and professor in the university’s Department of Gerontology. “The imperative to do so has been underlined by the COVID-19 pandemic which increased demand for safe, high quality alternatives to institutional settings where morbidity and mortality threats from the virus are greatest.”

Organizations serving vulnerable populations — AARP Massachusetts, the Dignity Alliance of Massachusetts and Disability Advocates Advancing our Healthcare Rights — gathered stakeholders statewide recently to look at how this new funding could be directed in Massachusetts and, in particular, expanding and strengthening home and community-based services. Miller was among the speakers to address the group.

The Centers for Medicaid and Medicare Services (CMS) had already allowed states certain flexibilities in meeting the COVID-19 crisis through the option to adopt temporary changes to their Medicaid programs covering home and community-based services. Furthermore, prior legislation had increased the federal matching rate by 6.2 percentage points across Medicaid services for the duration of the Coronavirus emergency. ARPA increased the federal matching rate by an additional 10 percentage points for home and community-based services (HCBS), specifically. The federal government typically pays for half of Massachusetts Medicaid costs. Combined with the early increase, 66.2% of the Commonwealth’s HCBS costs would be paid for by the federal government under ARPA for one year.

“Key stakeholders see the value of the flexibility ARPA provides to address needs across a range of services and populations needing home and community-based support,” says Miller. “There is particular interest in improving the work conditions of direct care workers, including raising wages and benefits to increase their quality of life and improve recruitment and retention. These are issues that directly impact the quality of care delivered.”

In addition, care recipients and advocates view the ARAP legislation as an opportunity to fund the additional services and supports necessary to maintain older adults and younger people with physical disabilities, developmental disabilities, and severe mental illness at home and in the community, not just during the pandemic but beyond.

One key area the legislation does not detail is whether changes considered by states need to be shared, reviewed, or approved in advance by the federal government. The Massachusetts Office of Health and Human Services is waiting for guidance from CMS before finalizing or implementing plans to take advantage of the enhanced federal match. Although the funding period began April 1, 2021, the state would not lose money if plans were not implemented by that date.

 “Developing strategies and processes that best enable states to take advantage of ARPA’s enhanced federal matching funds would give them a leg up should substantial additional resources become available through the American Jobs Plan and other potentially forthcoming federal legislation,” said Miller. Critical to success is consultation with community stakeholders to outline plans on how to expend the additional revenues in the most effective way possible to the greatest benefit of care recipients, their families, and the front-line staff who care for them.”

How Massachusetts Can Become a Living Laboratory for Aging

Reposted from The Boston Globe 

Let’s measure what’s going on in cities and towns so we can identify how a community’s aging circumstances change over time.

Historically speaking, population aging is new and presents a growing, largely untapped resource. Aging is something we all have in common, and we can leverage that collective reality to create moon-landing levels of advancements. We need a mindset that sees the older population as a solution and opportunity, not a burden or cause for panic.
One of the keys to seizing this opportunity is to measure what’s going on in our cities and towns and identify how a given community’s aging circumstances change over time. This goes far beyond simple head counts of how many are over 65. It requires granular information on a community-by-community level to really be effective.
My research team at the Gerontology Institute in the McCormack Graduate School of Policy and Global Studies at the University of Massachusetts Boston has been creating such tools for nearly a decade, with support from the Tufts Health Plan Foundation. We started in Massachusetts, collecting detailed data, most recently in 2018, about older adults living in every one of the Commonwealth’s 351 cities and towns, and we then produced similar information for Rhode Island, New Hampshire, and Connecticut. All this information can be found in our Healthy Aging Data Reports, available at healthyagingdatareports.org.

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Nursing Home Reimbursement: A case study

The current financing structure of Pennsylvania nursing homes is not sustainable

Nursing homes play a critical role delivering long-term services and supports (LTSS) to older adults and individuals under the age of 65 with disabilities. Despite this, these facilities face serious threats to their financial viability. A new report documents the increasingly important role nursing homes play in Pennsylvania, the key demand and supply factors affecting nursing home performance, and highlight implications for the financial viability of nursing homes going forward.

Edward Alan Miller

Editor-in-chief Edward A. Miller

Using data from a variety of sources, the researchers demonstrate that the demand for nursing home care is expected to increase, but the reimbursement level from Medicaid — the growing source of payment for nursing home residents — is causing a financial strain on these institutions. The report, “The Case for Funding: What is Happening to Pennsylvania’s Nursing Homes,” was written by researchers with the LeadingAge LTSS Center @ UMass Boston and funded by The Jewish Healthcare Foundation.

Data between 2010 and 2018 indicate that nursing homes are serving lower income individuals with more challenging diagnoses, including more severe cognitive impairment and psychiatric illness, as length of stay and occupancy has declined. Coupled with Medicaid as a payment source for increasing numbers of residents, the researchers expect to see more nursing homes face financial challenges in the coming years.

“The current financing structure supporting nursing home care in Pennsylvania is not sustainable,” says Edward Alan Miller, PhD, one of the report’s authors and Professor of Gerontology at UMass Boston. “Unless the reimbursement rates paid by the Medicaid program are brought more in alignment with the costs of providing high quality care in a safe manner, providers will face increasing challenges caring for Pennsylvania’s most vulnerable residents.”

Data on professional and support staff in nursing homes also indicate a concerning trend:

  • Even as patients are presenting with more challenging diagnoses, overall staff hours among direct care workers have remained relatively unchanged over the last ten years and RN hours have declined slightly.
  • Compensation for direct care workers has remained relatively flat, increasing by only 1.9% per year from 2012 to 2019. When adjusted for the medical consumer price index, real wages have declined an average of .78% annually during the time examined.
  • While certain individual quality metrics have improved — such as declines in the numbers of bed sores — overall aggregated quality scores have not.Marc Cohen, PhD

“The growing gap between what facilities need, as reflected in charges, and the Medicaid reimbursement rate has come at a time when nursing homes are being asked to care for an increasingly complex and frail mix of residents,” says Marc Cohen, PhD, one of the report’s authors and Co-Director of the LeadingAge LTSS Center @ UMass Boston. “The result has been increased cost shifting to individuals and families who must pay for care privately or take on additional caregiving responsibilities. Nursing home services represent a critical component in Pennsylvania’s continuum of care. Our study demonstrates that more needs to be done to support them.”

How do we build a culture of person-centered care for older adults?

A new report shows that whether care preferences for older adults are considered is heavily influenced by race, income, and other variables.

 “When thinking about your experiences with the healthcare system over the past year, how often were your preferences for care taken into account?”

This question was posed in a healthcare study to approximately 20,000 people over the age of 50 and living across the U.S. The University of Michigan Health and Retirement Study (HRS) is a longitudinal panel study surveying a representative sample of Americans. This ongoing study provides valuable data that researchers are using to address important questions about the challenges and opportunities of aging. The HRS is one of the first to explore the issue of person-centered care. Marc Cohen, PhD

In one of the first studies to examine this new data, three researchers analyzed responses to the question of healthcare preferences in a recent report on person-centered care. The researchers — Marc Cohen Ph.D., Ann Hwang M.D., and Jane Tavares Ph.D.— wanted to understand how aging adults experience care, if their preferences are acknowledged, and whether their experiences vary by race and ethnicity, wealth and income, and/or insurance status.

“The delivery of person-centered care — defined as care that is guided by individuals’ preferences, needs, and values — is an important factor in high-quality healthcare systems,” says Hwang.

Despite the healthcare industry’s assertions that it is becoming more patient-centered, the researchers found that one-third of all older adults (age 50 and over) said their care preferences were “never” or only “sometimes” considered.

Using 2016 HRS data — the most recent data available — the survey revealed stark disparities based on race and ethnicity. While 8% of White respondents said their needs and preferences were  never considered, 16% of Black and 27% of Hispanic respondents gave that answer. The researchers also found that, across all service settings, people who felt that the health system never took account of their care preferences were more likely to forego medical care. They visited a doctor fewer times and were less likely to use home care and outpatient surgery services. The largest impact was on use of prescription medications: they were 39% less likely to use prescription medications. Continue reading

“Older Adults and COVID-19: Implications for Aging Policy and Practice”

New webinar explores the impact of the pandemic on older adults

View the full slide set here, and a video recording from the 2.5 hour webinar is available here.

Edward Alan Miller, Gerontology Department Professor and Editor-in-Chief of the Journal of Aging & Social Policy (JASP), led the webinar “Older Adults and COVID-19: Implications for Aging Policy and Practice” based on a JASP special issue and book of the same title. The February webinar drew more than 500 registrants from around world to learn about the ramifications of the pandemic for older adults and their families, caregivers, and communities.

Edward Alan Miller

Editor-in-chief Edward A. Miller

“We are extremely gratified with how the webinar turned out, drawing participants and viewers from throughout the United States and globally,” said Miller. “It illustrates how the problems and issues brought to the fore by the pandemic will continue to reverberate well beyond the present day to the years to come.”

The ongoing COVID-19 pandemic has prompted an outpouring of scholarly work on the effect of the pandemic on various populations. Older adults – as well as their formal and informal caregivers – have received a disproportionate share of the pandemic’s impacts. Direct exposure to the virus led to a higher rate of hospitalization and death among older populations, particularly in nursing homes and other congregate living environments. This reality prompted mandates meant to mitigate the virus’ effects on older adults and which, in turn, led to unintended consequences, such as increased social isolation, enhanced economic risk, delays in receiving medical treatment and other supports, and latent ageism.

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Boston’s Older Population: Increasing in Racial Diversity, but Quality of Life is Shaped by Racism, Discrimination

A new report from UMass Boston identifies aging equity among Boston residents

The number of Boston residents aged 60 and older has increased by more than one-third in the last eight years and more than half of older residents are persons of color. However the experiences of these older residents differ substantially depending on race, ethnicity and gender, and challenges their abilities to thrive.

A new report, “Aging Strong for All: Examining Aging Equity in the City of Boston,” by researchers at the University of Massachusetts Boston, documents disparities across three dimensions that impact quality of life — economic security, health, social engagement — and identifies opportunities for stakeholders to ensure an environment in which “aging strong” is possible for all Boston residents. Jan Mutchler

“It has never been more critical to strategically pursue greater equity in the aging experience of Boston residents,” says Jan Mutchler, PhD, director of the Center for Social and Demographic Research on Aging at UMass Boston, a professor in the Department of Gerontology and one of the study’s authors. “The numbers of older adults are increasing and stakeholders share a growing recognition of the powerful ways in which inequity, racism, and discrimination shape health outcomes and the aging experience, amplifying the need to examine and remediate disparities in aging.”

The report identifies substantial disparities across racial and ethnic groups, such as:

Economic security

  • Poverty rates are especially high among Asian Americans and Latinos, and more than one-third of these residents age 60 or older live in households with incomes below the federal poverty line.
  • Sizable gaps differentiate racial groups. For example, while a similar share of non-Hispanic White, Black and Native American people aged 66 or older receive Social Security benefits, percentages receiving Social Security are considerably lower for Latinos and Asian Americans.
  • Housing costs in Boston place a heavy burden on older residents and half or more of renters age 60 or older pay more than 30% of their incomes for housing. Fewer homeowners bear such a heavy cost burden for housing, but older Black, Latino and Native American homeowners are at amplified risk for being cost-burdened.

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