The federal government’s introduction Thursday of quality measures for the home- and community-based services offered by assisted living and other providers comes amid “longstanding, chronic underfunding” of HCBS that has led to provider workforce shortages, senior living industry advocates told McKnight’s Senior Living Thursday.
The financial issue must be addressed, the groups said, noting, however, that they support the quality improvement effort in general.
The Centers for Medicare & Medicaid Services on Thursday released its first-ever HCBS quality measure set to help states “better understand and compare health outcomes across groups receiving home- and community-based services,” CMS Administrator Chiquita Brooks-LaSure said in a statement.
“The use of consistent quality measures across the country is another step toward reducing health disparities and ensuring that people with disabilities and older adults enrolled in Medicaid have access to and receive high-quality services in the community,” she added.
Use of the measure set is voluntary “at this time,” CMS said, but the agency said it “strongly encourages” states to use the standards to assess and improve quality and outcomes in their HCBS programs, including the Section 1915(c) waiver and other programs through which some assisted living communities provide HCBS such as personal care and supportive services to residents.
In the future, Daniel Tsai, CMS deputy administrator and director of its Center for Medicaid & Children’s Health Insurance Program Services, said Thursday in a letter to state Medicaid directors, “CMS plans to incorporate use of the measure set into the reporting requirements for specific authorities and programs, including the Money Follows the Person (MFP) program and future section 1115 demonstrations that include HCBS.”
Funding affects access
Meredith Chillemi, director of Medicaid and home- and community-based services policy at LeadingAge, told McKnight’s Senior Living that CMS’ release of the nationally standardized quality measures is a step toward ensuring that beneficiaries have information to “fully participate in creating a service plan that meets their needs and goals.”
“But knowing their options does not guarantee consumers’ ability to access needed services,” she added. “Longstanding, chronic underfunding of HCBS in our country, and the resulting workforce shortages — exacerbated by the pandemic — mean millions of older adults and families’ requests for care are going unfilled.”
Members of Congress and policymakers must take action, Chillemi said. “More support, such as a permanent HCBS Federal Medical Assistance Percentage (FMAP) bump and investments in workforce training and development to recruit and keep more workers in the sector, is critical,” she said. “Because without staff, there is no care.”
Argentum told McKnight’s Senior Living that although it backs governmental efforts to improve the quality of care delivered to assisted living residents receiving long-term services and supports through Medicaid HCBS programs, the release of the measure set “comes at a time when the majority of states provide inadequate reimbursement for HCBS programs utilized in assisted living.”
“Inadequate provider reimbursement cannot be separated from the broader issue of improvements in care quality,” the group’s statement continued.
Beyond funding, Argentum said, “the onus will be on state agencies with Medicaid oversight to demonstrate consistent program evaluation, maximize efficiencies, increase accessibility, increase quality of care, and improve resident outcomes.”
The association said it hopes to discuss further implementation of the measures and related matters with CMS officials soon.
Nationally, more than seven million people receive HCBS under Medicaid, and Medicaid-funded HCBS accounts for $125 billion annually in state and federal spending, the agency said.
Forty-eight percent of all US assisted living communities are Medicaid-certified, and more than 16% of assisted living residents rely on Medicaid to pay for daily services, according to the National Center for Assisted Living.
“Assisted living participation in HCBS programs provides thousands of seniors annually the opportunity to receive necessary care in less restrictive settings while saving federal and state governments billions of dollars in care costs compared to institutional settings,” Argentum said.
NCAL Executive Director LaShuan Bethea said the organization appreciated that CMS has made use of the measures voluntary at this point, although their use is expected to become mandatory.
“We encourage a gradual phase-in of this requirement to ensure a successful transition,” she said, adding, “NCAL will continue to advocate that we focus on the most meaningful metrics for residents as well as an alignment of quality measurement with reimbursement to incentivize more providers to participate in the Medicaid program and expand access to these services.”
What the measures cover
In addition to covering Section 1915(c) service plan and health and welfare subassurances, the measure set detailed in Tsai’s letter includes HCBS quality and outcomes in the areas of access and rebalancing.
Perhaps of most interest to assisted living providers, however, are the measures related to community integration and HCBS settings requirements as defined in the HCBS settings final rule. That rule, which has a March 17, 2023, compliance deadline for criteria not directly affected by COVID-19 public health emergency disruptions, establishes requirements for the qualities of settings in which Medicaid HCBS are provided under sections 1915(c), 1915(i) and 1915(k) of the Social Security Act.
The HCBS final settings rule requires that all home- and community-based settings are integrated and supportive of full access to the greater community; are selected by individuals from among setting options; ensure individual rights of privacy, dignity and respect, and freedom from coercion and restraint; optimize autonomy and independence in making life choices; and facilitate choice regarding services and who provides them.
First of two guidance documents
Medicaid spending on HCBS now exceeds spending on institutional services such as those provided by skilled nursing facilities, Tsai noted in his letter to state Medicaid directors. Whereas in 1990 HCBS expenditures accounted for 13% of the $31 billion in federal and state expenditures for all Medicaid LTSS, including nursing home expenditures, by 2020, HCBS expenditures accounted for $125 billion, or 62%, of the $199 billion spent nationally on Medicaid LTSS.
“However, as the number of beneficiaries receiving Medicaid HCBS and spending on HCBS has increased, so too has the need to ensure the availability and provision of high-quality services that promote positive outcomes and cost-effective delivery of care, while minimizing provider burden,” he wrote.
A 2016 report by the National Quality Forum commissioned by the Department of Health and Human Services found that HCBS lacked “any standardized set of quality measures…[and] consensus as to what HCBS quality entails” and recommended that measures be developed, Tsai said.
Information released Thursday represents the first of two planned guidance documents, he said, adding that the second document “will describe how states can use the measure set as part of their HCBS quality measurement, reporting, and improvement activities, including to meet federal requirements for their HCBS programs (such as required reporting for section 1915(c) waiver assurances and subassurances).”
Article updated July 22 to include comments from NCAL.