Perceived Impacts of a Medicaid Rebalancing Initiative to Increase Home- and Community-Based Services

Published in: Health Services Research (2021). doi: 10.1111/1475-6773.13696

by Daniel Siconolfi, Sangeeta C. Ahluwalia, Esther M. Friedman, Debra Saliba, Regina A. Shih

Read More

Access further information on this document at Wiley Online Library

This article was published outside of RAND. The full text of the article can be found at the link above.


To assess governmental and nongovernmental stakeholders' perceived impacts of a Medicaid home- and community-based services (HCBS) rebalancing initiative, the Balancing Incentive Program (BIP).

Data Sources

Governmental stakeholders (Medicaid administrators) and nongovernmental stakeholders (service providers and consumer advocates) (n = 30) from eight states that participated in BIP.

Study Design

We conducted key informant interviews.

Data Collection

Interviews followed a semi-structured guide and were professionally transcribed. We thematically coded transcripts using an iterative codebook with a priori and emergent codes.

Principal Findings

Stakeholders reported that BIP participation had a range of impacts on the HCBS ecosystem, often beyond the mandated structural reforms. BIP activities were believed to have changed the culture of HCBS in some states, for example, at the level of state administration or in the provision of HCBS to consumers. Stakeholders also described significant improvements in cross-stakeholder relationships and communication, for example, in the context of troubleshooting consumers' unmet needs or improvements in the states' responsiveness to providers' inquiries. Stakeholders believed that within-state data harmonization undertaken through Core Standardized Assessment (CSA) was a positive impact of BIP, particularly with regard to its utility for administrative data, care planning, and patient-centeredness. Two stakeholders also voiced concerns regarding the validity of spending-based rebalancing metrics. The impacts that stakeholders attributed to BIP may help create a more sustained rebalancing environment through their changes to the ecosystem, including infrastructure upgrades, data harmonization, collaboration across stakeholders and agencies, more patient-centeredness, and greater recognition of HCBS.


Our findings highlight additional BIP impacts to monitor over the longer term and to consider in evaluations of future rebalancing efforts. Some potential impacts of BIP are more readily quantified (e.g., HCBS spending), while others are less likely to be formally assessed (e.g., improved stakeholder cooperation). These latter impacts are likely instrumental to future rebalancing efforts.

Research conducted by

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.