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Objective: The authors explore state variation in expenditures for Medicaid community-based care services for the period 1990 to 1997., Method: A random effects panel model is used to explore the relationship between state demographic, supply, economic, programmatic, and political factors and states' Medicaid community-based care expenditures., Results: Although states increased provision of services over the study period, significant state-level variation was evident. Expenditures were positively associated with state per capita income, regulation of nursing home bed supply, and the number of Medicare home health users but were negatively related to nursing home bed supply., Conclusions: Recent legal rulings, combined with the demonstrated preferences of most individuals to receive care in the community, require policies to foster the expansion of Medicaid community-based care. The most consistent relationships that are amenable to policy intervention relate to state fiscal resources and long-term care supply regulation.

Using HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems, also known as the CAHPS Hospital Survey) data from 2,684 hospitals, the authors compare the experiences of Hispanic, African American, Asian/Pacific Islander, American Indian/Alaska Native, and multiracial inpatients with those of non-Hispanic White inpatients to understand the roles of between- and within-hospital differences in patients' perspectives of hospital care. The study finds that, on average, non-Hispanic White inpatients receive care at hospitals that provide better experiences for all patients than the hospitals more often used by minority patients. Within hospitals, patient experiences are more similar by race/ethnicity, though some disparities do exist, especially for Asians. This research suggests that targeting hospitals that serve predominantly minority patients, improving the access of minority patients to better hospitals, and targeting the experiences of Asians within hospitals may be promising means of reducing disparities in patient experience. [ABSTRACT FROM AUTHOR]

Prior research documents differences in patient-reported experiences by patient characteristics. Using nine measures of patient experience from 1,203,229 patients discharged in 2006-2007 from 2,684 acute and critical access hospitals, the authors find that adjusted hospital scores measure distinctions in quality for the average patient with high reliability. The authors also find that hospital "ranks" (the relative scores of hospitals for patients of a given type) vary substantially by patient health status and race/ ethnicity/language, and moderately by patient education and age (p < .05 for almost all measures). Quality improvement efforts should examine hospital performance with both sicker and healthier patients, because many hospitals that do well with one group (relative to other hospitals) may not do well with another. The experiences of American Indians/Alaska Natives should also receive particular attention. As HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) data accumulate, reports that drill down to hospital performance for patient subtypes (especially by health status) may be valuable. [ABSTRACT FROM AUTHOR]

State long-term care policies are directed toward a variety of goals. Concerns with expenditure control are primary. Certain states are also seeking to increase the availability of community-based care. A more balanced system would assist consumers in attaining valued goals, while being consonant with federal policy initiatives and legal rulings. The authors examine the relationship between state policies and Medicaid long-term care expenditures. These relationships are tested by multiple regression analysis, using a random effects model for 1991 through 1997. Prospective payment may moderate nursing facility expenditure growth and total long-term care expenditures. Institutional supply constraints demonstrated a positive relationship to both forms of community-based care expenditures. The authors found no evidence of Medicare maximization as a policy to constrain Medicaid expenditure growth. Finally, the authors note the importance of additional work in exploring the dynamics between state long-term care policies and expenditures for individuals with differing disabilities. [ABSTRACT FROM AUTHOR]

Since Congressional authorization in 1981, Medicaid 1915(c) home- and community-based care waivers have influenced states' efforts to transform their long-term care systems. In 1997, every state participated in the 1915(c) waiver program, while waiver expenditures, at $8.1 billion, represented 59.6 percent of all Medicaid community-based care expenditures. To explore state-level factors that appear related to these expenditures, the authors turn to a body of work on Medicaid resource allocation. They compare the influence of five factors--sociodemographic, supply, economic, programmatic, and political environment--on states' allocations to long-term care expenditures and 1915(c) waiver expenditures. The state economic environment was an important influence on total, as well as waiver expenditures. State regulation of long-term care supply demonstrated the most substantive relationship, increasing the share of dollars supporting 1915(c) waivers from 11.6 to 20.0 over the study period, all else equal. [ABSTRACT FROM AUTHOR]