Why many Medicare beneficiaries are not getting prescribed home health care

One in five Medicare beneficiaries need home health care following hospitalization. However, a recent analysis based on Medicare claims data found recommended post-discharge care declined significantly over six years.

Fulfillment rates for home health referrals dropped from 66% to 59% between 2016 and 2022, according to The Commonwealth Fund analysis. Unfulfilled home health referrals are associated with more hospital readmissions and higher death rates among both Medicare and Medicare Advantage recipients. The authors noted that this trend could seriously impact hospitalized Medicare beneficiaries.

Journalists can use the data provided in this analysis and other Medicare claims data to track fulfillment rates in their communities and to hold hospitals and home care agencies more accountable.

Why this matters

Researchers observed the largest decline in home health care services among white beneficiaries (7.2 percentage points), but decreases were also seen among Black and Hispanic patients. Dual eligibles, those who qualify for both Medicare and Medicaid, were less likely to fulfill a home care referral than Medicare-only beneficiaries, regardless of race.

When the social deprivation index - a geographic composite measure of demographic characteristics like poverty, education level, housing, and employment - was factored in, home health referral fulfillment rates were lower in counties with more social deprivation. Among all beneficiaries, rates fell in rural, large and medium-sized metropolitan areas.

The decline in home health care is both an aging and a health equity issue. Lack of appropriate services can lead to more frequent rehospitalizations within 30 days of discharge and increased morbidity and mortality. Patients in more socially disadvantaged communities are at greater risk of not receiving needed services, according to research, yet they often suffer worse physical and mental decline after being hospitalized.

How home health care works under Medicare

Traditional Medicare has stringent rules about receiving home health care. However, they do pay for this service if it is provided with part-time or intermittent skilled services and a person is considered homebound. Skilled care includes wound care, intravenous or nutritional therapy, unstable health status monitoring, and physical occupational or speech therapy. Numerous studies find home health care is usually less expensive, more convenient, and as effective as inpatient care in a hospital or skilled nursing facility.

A physician or other clinician, like a nurse practitioner, must meet face-to-face with a patient before making a referral for home health care services. If appropriate, a provider will order home health care from a Medicare-certified home health agency. Patients may choose from a list of agencies in their area. Restrictions, like limited time away from home except for medical appointments, also apply to maintain this benefit.

What is causing this shift?

Researchers cited several factors which may be contributing to decreased fulfillment of home health care referrals:

• Insufficient staff and resources - the number of active home health agencies has steadily decreased since 2013, causing reduced access to care.
• Inadequate care is available to many racial and ethnic groups, leading to greater discrepancies in care. Independent research finds selection bias among some home health care agencies to avoid certain low socioeconomic areas and higher-cost patients.
• Patient reluctance to use home health care was also a potential factor. Some people may believe these services are unnecessary or don't offer enough value; some don't want outside caregivers in their homes or may generally distrust health care providers.

This decrease in home health services was apparent even before the start of the COVID-19 pandemic. While that crisis played a role in the decline, the authors suggest that other factors, including staffing shortages and low worker pay, contributed to this issue.

"Falling home health referral fulfillment rates point to a systemic problem that requires the attention of providers and policymakers," the report said. They suggest better hospital follow-up on referrals, increased use of telehealth, and revisiting the home health care payment structure to help alleviate this potential crisis.

Resources

• Medicare Post-Acute Care and Hospice - by Geography & Provider
• Eligibility for Home Health - Medicare Interactive
• Home health star ratings and datasets - Centers for Medicare and Medicaid
• Home Care Association of America
• National Association for Home Care and Hospice