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

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

Posted on on July 16, 2021

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


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.

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