State-based variations in risk of institutional placement among dually eligible non-elderly adults with intellectual...

Long-term services and supports (LTSS) include various paid institutional and personal care, comprising nearly 28.3 % of Medicaid spending, with significant variability in home and community-based services (HCBS) eligibility across states.

To examine the impact of state of residence and HCBS spend on risk of institutional placement on a particularly vulnerable population, dual-eligible non-elderly adults with intellectual/developmental disabilities (IDD).

A retrospective cohort study was conducted to determine the hazard ratio of institutional placement based on Medicaid and Medicare data. We examined CMS Medicaid Analytic eXtract files with linked 2008-2012 Medicare data from California, Florida, New York, Ohio, and Pennsylvania. Eligible participants were 159,275 dual-eligible adults aged 18-to-64 years living in community settings who were continuously enrolled in Medicaid and had ICD-9 codes for ID in any inpatient, outpatient, or long-term encounter.

Among study participants, 4.4 % (n = 6975) had an eventual institutional placement claim. Subjects with institutional placement were more likely to be older, female, sicker, and have more claims for acute, ambulatory, and short-term care. In both unadjusted and adjusted analysis, risk of institutional placement was highest among those living in Ohio (HR 1.86 [1.70-2.04], P < 0.0001) and California (HR 1.50 [1.37-1.64], P < 0.0001) compared to Florida. Risk was lower for every $10,000 increase in HCBS spend at baseline. Black, Hispanic, and Other subjects had lower risks than While subjects, CONCLUSIONS: Our findings suggest that continued investments in HCBS and better access may decrease reliance on costly institutional care for non-elderly disabled adults who may need long-term care for decades.