Medicare Home Health Study: An Investigation on Access to Care and Payment for Vulnerable Patient Populations

Source: Centers for Medicare and Medicaid Services, Report to Congress, 2014

… In order to examine access to Medicare home health services and payment, relative to cost, for the vulnerable patient populations, the research team performed extensive analysis of both survey and administrative data. Specifically, the research team collected survey data from physicians and HHAs to examine factors associated with potential access to care issues. The surveys provided information on whether, and the reasons as to why, patients were not placed or admitted for home health services or experienced delays in receiving home health services, and information on the characteristics of patients who may have experienced access issues. … The premise of the study is that payment, relative to the cost of care, for specific patient populations may vary and that HHAs may avoid patients with characteristics that are associated with lower margins, creating potential access issues for these patients. …

….In summary, most HHAs and physicians reported that access to home health care for Medicare FFS patients in their local area was excellent or good. In addition, the survey findings suggest that much of the variation in access to Medicare home health services is associated with social and personal conditions and therefore CMS’ ability to improve access for certain vulnerable patient populations through payment policy may be limited. While the presence of margin differences in the administrative data analyzed does not mean that there are access issues, the margin differences do indicate that there may be financial incentives to select certain types of patients over others. The analysis of HHA costs involved with providing ongoing access to care to low-income Medicare beneficiaries or beneficiaries in medically underserved areas found that there may be higher costs, relative to payment, associated with providing Medicare home health services to patients who are dually eligible. In addition, the analysis of HHA costs involved in treating beneficiaries with high levels of severity of illness found that there may be subsets of these patients who may have higher costs, relative to payment, such as patients with complex wound care needs, patients who required parenteral nutrition, patients who required substantial assistance in bathing, patients with high HCC scores, beneficiaries admitted after acute or postacute stays, and patients with certain poorly-controlled conditions. However, given the recalibration of the case-mix weights in CY 2012, which adjusted the weights relative to one another, the margin differences observed in this study may have already been reduced and further analysis of 2012 cost and claims data is needed to determine the extent of the variation in margin in the current case-mix system. CMS plans to further explore margin differences across patient characteristics and possible payment methodology improvements suggested by results of this study. By decreasing margin variation within the payment system, CMS can more accurately pay for services and may decrease any potential incentives to selectively admit patients. ….