September 28, 2023

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Did COVID-19 Have a Disparate Impact on Medicare Home Health Use?


Did Utilization of Superior-High-quality HHAs Modify All through the COVID-19 Pandemic?

Knowing regardless of whether there are disparities in accessing higher-good quality HHAs is critical to comprehension overall health results among the particular groups of HHA customers.5 Our effects shed gentle on patterns of HHA use by web page excellent, shifts in all those styles throughout the pandemic, and the differential impression of COVID-19 on specific teams of HHA buyers. (As previously described, to much better isolate the results of COVID-19 on PAC use designs, we tried to control for the affect of concurrent Medicare payment reforms concentrated on HHAs and SNFs.)

There had been 4.8 million discharges to HHAs in our database 40 per cent of them were being discharged to a significant-excellent HHA, one particular with a excellent of patient treatment star rating of 4 stars or bigger.6 For the duration of the COVID-19 interval, we discover that the chance of working with a higher-good quality HHA greater among the Black beneficiaries, relative to non-Black beneficiaries, by 2.5 share factors (Appendix Tables A4 and A5). The use of substantial-top quality HHAs by dually qualified beneficiaries relative to all those who were being not dually qualified did not transform noticeably for the duration of the pandemic.


In the course of the COVID-19 pandemic, postacute care settings have aided reduce the strain on hospitals by caring for sufferers with and devoid of COVID-19.7 The goal of this investigation was to detect alterations in patterns of clinic transfer costs for non-COVID-19 individuals to dwelling well being businesses and other PAC options in the course of the pandemic relative to developments in the prepandemic interval. We also preferred to study how these designs adjusted for Black beneficiaries, dual eligibles, and higher-want populations.

We come across that for the duration of the pandemic, costs of HHA use among the traditional Medicare beneficiaries has amplified amongst 5 and 6 share details throughout all non-COVID-19 populations, with analogous, but smaller sized, reductions in SNF use prices through the exact time. The change to HHA very likely reflects concerns amongst doctors and sufferers about the risk of COVID-19 an infection in SNFs and modifications facilitated by regulatory waivers for HHA use, which expanded the definition of “homebound” employed in eligibility perseverance, approved telehealth and telecommunication in place of in-man or woman residence visits, and authorized much more practitioner styles to certify and recertify eligibility for home wellbeing care.8 These waivers lessened boundaries to HHAs between all Medicare beneficiaries. In point, in separate analyses not revealed, we discover that for the duration of the pandemic, less people have been discharged home with no any house health care. As a result, advancement in HHA use during the pandemic has possible been because of not only to significantly less SNF use but also to reductions in clients discharged residence without PAC.

We uncover a little higher risk-modified use of HHAs for Black beneficiaries relative to non-Blacks, and that this variance improved by a modest total (< 1.0 percentage point) during the pandemic. We also find that Black beneficiaries were more likely to use a high-quality HHA during the pandemic than non-Black beneficiaries. The reason for this pattern is unclear and is an area for future research. We note that our findings contrast with those of recent studies that found disparities between Black and white adults in access to high-quality HHAs,9 a discrepancy that could be explained by differences in methodology — for example, focusing on transfers to PAC from a hospital versus community-based admissions examining data on transitions during the pandemic versus prepandemic data looking at traditional Medicare beneficiaries only versus all beneficiaries, including Medicare Advantage enrollees.

Conversely, we find lower risk-adjusted use of HHAs and higher SNF use for dual eligibles relative to beneficiaries with traditional Medicare only. In addition, dually eligible beneficiaries experienced a smaller increase in HHA use during the COVID-19 period relative to Medicare-only beneficiaries and experienced no significant change in the use of high-quality HHAs during the same period. The smaller increase in HHA use among the dually eligible could be explained by some home health services being covered under Medicaid (therefore not observed in our data). A disproportionate share of nursing home residents are also Medicaid beneficiaries, who may be more likely to receive care from the colocated SNF. Additionally, high-need beneficiaries, who may require a more supervised environment, as offered in inpatient PAC settings, were more likely to use SNFs compared with HHAs.

The waivers most certainly played a role in accelerating the use of HHAs in traditional Medicare, and the value of their continuation postpandemic will be debated. Increased use of telehealth and greater flexibility around eligibility for home health care would likely lead to more patients being sent home from the hospital with intensive home-based rehabilitation. Because home health care is less expensive than other PAC and does not require a beneficiary deductible or copayment, a continued shift to home health may reduce Medicare and beneficiary spending on PAC. It also may increase patient satisfaction among those who prefer to receive care in the home rather than an inpatient facility.

The full effect of a shift to HHA care depends on several factors:

  1. Savings to Medicare and beneficiaries depend on the extent to which home health care is substituted for more expensive inpatient PAC instead of patients being discharged home with no PAC.
  2. The effects of increased HHA use on patient outcomes will be critical to understanding whether (and for whom) expanded access to HHA care would have clinical and financial benefits. For example, failure to match patients to the appropriate PAC setting based on their clinical needs may result in hospital readmissions and other adverse patient outcomes that also may increase spending.
  3. A decline in SNF use may cause some of these facilities to incur increased financial stresses and close. Advocates have raised the alarm that the nursing home industry — which is linked to SNFs and covered by low Medicaid reimbursement rates — is under significant stress from the pandemic.10

Moving forward, it will be important to monitor and evaluate the effects of shifts in PAC use to help develop appropriate policies that support access to high-quality, cost-effective PAC for all beneficiaries.


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