Impact of New York State's Medicaid MLTC Program on Nursing Home Use Among Older Adults With Dementia

A study published in JAMA Network Open evaluates the impact of New York State's Medicaid-managed long-term care program (MLTC) on nursing home use among older adults with dementia, finding that mandatory enrollment was associated with decreased nursing home use and may help prevent or delay nursing home placement.

The demand for long-term services and supports (LTSS) in the US has risen due to the aging population and increasing LTSS needs for individuals with dementia. As informal caregiving for people with dementia becomes unsustainable, state Medicaid programs play a crucial role in addressing the challenges of dementia care quality and costs. 

This cohort study collected individual-level longitudinal data from the Medicare Master Beneficiary Summary File and Minimum Data Set 3.0 to measure total annual days of long-term care nursing home use among New York State Medicare beneficiaries, excluding days in acute care settings and rehabilitation stays covered by Medicare.

The study included Medicare beneficiaries 65 years and older in New York between 2011 and 2019, excluding those under 65 or who died during the study period or lived outside New York State. New York City residents were also excluded due to insufficient pre-study period data. Researchers categorized dual-enrollment status and identified individuals with dementia using the Chronic Conditions Data Warehouse indicator.

Longitudinal models were estimated to evaluate the association of MLTC with changes in nursing home use among dual enrollees with dementia, adjusting for various individual characteristics and regional factors. The study hypothesized that mean estimated annual nursing home days would be lower under a scenario where MLTC was implemented compared to a scenario with no MLTC implementation.

The study included 463 947 Medicare beneficiaries with dementia living in New York State from 2011 to 2019, totaling 1645 076 person-years. Beneficiary characteristics varied with 50.2% under 85 years, 64.4% women, 35.6% men, and 39.3% dually enrolled in Medicaid, while racial demographics included 0.1% American Indian/Alaska Native, 1.4% Asian/Pacific Islander, 6.5% Black, 3.9% Hispanic/Latino, and 87.0% non-Hispanic White. Most beneficiaries were diagnosed with dementia less than 5 years, with long-term care nursing home users being older and having a higher prevalence of chronic conditions. The implementation of MLTC was associated with a decrease in long-term care nursing home use among dual enrollees with dementia and increased total days of nursing home use in certain years post-implementation.

Many states are expanding Medicaid MLTSS programs which are becoming increasingly important in delivering long-term care. Despite limited evidence on the implications of MLTSS on nursing home use, a study found that older adults with dementia in New York State heavily relied on nursing homes, but MLTC implementation was associated with decreased nursing home use among dual enrollees with dementia. Consumer satisfaction measures for MLTC were not negatively impacted, and the rollout of mandatory MLTC in New York showed increased enrollment without compromising care quality. MLTC may have contributed to lower nursing home use through programs like CDPAS, which allow individuals to direct their services and hire caregivers. Future evaluations should examine the impact of MLTSS on disparities in long-term care quality and access for people with dementia.

“In the context of growing concerns about the quality and cost of long-term care, MLTSS offers a potential solution to manage costs and improve consumer choice of services and setting,” said researchers. “The findings of this cohort study suggest that implementation of New York State’s MLTC program was associated with decreased nursing home use among dual enrollees with dementia. Further work is needed to evaluate how transitions to MLTSS have affected the setting and quality of care for people living with dementia, including the extent to which HCBS may substitute for nursing home care.” 

Reference
Harrison JM, Sheng F, Josberger RE, et al. Changes in nursing home use following Medicaid-supported expanded access to home- and community-based services for older adults with dementia. JAMA Netw Open. 2023;6(7):e2322520. doi:10.1001/jamanetworkopen.2023.22520