Is High-Quality Home Health Care “Out of Reach” for Black Medicare Beneficiaries?

January 31, 2023

Home health agencies (HHAs) are an important source for skilled nursing care, with 3.1 million traditional Medicare beneficiaries receiving such services in 2020. Two potentially important advantages of home health are: (1) patient preference for recovery at home; and (2) lower costs to beneficiaries, since there is no cost sharing for home health in Medicare. However, studies have documented lower access to high-quality HHAs for Black beneficiaries, with resulting disparities in outcomes. In a recent study, Fashaw-Walters and colleagues reported that access to high-quality HHA services was “out of reach” for Black Medicare beneficiaries and other vulnerable populations. This finding is at odds with our own research, published in a recent Commonwealth Fund Issue Brief, where we found no significant difference in access to high-quality HHAs between White and Black beneficiaries. To better understand these divergent findings and implications, we examine differences in the research designs of the two studies and then explore how these differences can lead to different conclusions.

Studies Differ in Terms of Research Design

• Assessment of different patient populations. To qualify for home health benefits in Medicare, a beneficiary must be considered homebound and require skilled nursing or therapy services. Beneficiaries may receive home health care after a hospital stay, after an institutional post-acute care stay (e.g., skilled nursing facility), or be admitted without a prior hospital or post-acute care stay (“community admits”). We focused on patients receiving home health directly following a hospital stay, while the Fashaw-Walters study examined all users of home health services.
  In addition, our study focused on beneficiaries in traditional fee-for-service Medicare and excluded those enrolled in Medicare Advantage (MA), while Fashaw-Walters and colleagues included both beneficiary types. There is some evidence that MA plans tend to include lower quality HHAs in their networks.

• Definition of “high-quality” HHAs. In both studies, Medicare beneficiaries were identified as receiving high-quality home health care if they received care from a high-quality HHA, and high-quality HHAs were determined based on the Medicare Quality of Patient Care star rating system, which uses HHA assessments and Medicare claims data to determine high-quality status. Our study defined high-quality HHAs as those with 4+ stars in the quarter the beneficiary was admitted to the HHA, while the Fashaw-Walters study identified high-quality HHAs as those that maintain an average rating of 3.5+ stars over twelve quarters.
• Time periods studied. Over time, access to a high-quality HHA may change as quality ratings and care patterns shift. In our Issue Brief, we examined Medicare beneficiaries use of high-quality HHAs between 2017 and 2020, while the Fashaw-Walters study was based primarily on HHA data from 2016.

Exhibit 1: Differences in Research Design between the Two Studies

Explanations for Divergent Findings Between the Two Studies

As a step toward understanding the differing findings between the two studies, we conducted a brief investigative analysis in which we assigned a beneficiary to a high-quality HHA if the beneficiary was admitted to an HHA that had 3.5+ stars, although we continued to only examine HHA quality rating in the quarter of beneficiary admission to the HHA. While the identification of high-quality HHAs is only one of a number of differences in methodological approaches between the two studies, this analysis allowed us to focus on two factors:

• Home health quality is lower among community and post-acute care admits. Home health care quality is lower for those Medicare beneficiaries admitted from the community or a post-acute care setting as compared to those admitted from a hospital (Exhibit 2). Most Medicare beneficiaries receiving home health were admitted from the community or a post-acute setting: In 2016, 70 percent of Black HHA users (61% from community and 9% from post-acute care) and 67 percent of White HHA users (56% and 11%) were admitted from one of these settings.  While the share of home health admits coming from the community or a post-acute care setting did not change for Black beneficiaries between 2016 and 2020, it increased for White beneficiaries.
• Black beneficiaries’ access to a high-quality HHA increased over time. The proportion of Black beneficiaries admitted to high-quality HHAs from the community or a post-acute care setting increased by 7 percentage points (pp) from 2016 to 2020 (Exhibit 3), while the proportions for White beneficiaries increased by 1pp, and decreased by 1pp for All Other beneficiaries. There was also an increase in the proportion of admissions to high-quality HHAs for Black beneficiaries admitted to HHA from a hospital but a decrease for both White beneficiaries and All Other beneficiaries.

As a result of these factors, overall disparities in accessing high-quality HHAs have diminished between White and Black beneficiaries since 2016 (Exhibit 3).  Between 2018 and 2020, there was little difference in the percent of Black and White beneficiaries admitted to a high-quality HHA following a hospital stay.

Exhibit 2: Proportion of All Fee-for-service HHA Admissions that are to a High-Quality HHA by Race and Source of Admission, 2016-2020

 

Source: Authors’ analysis using 2016-2020 Medicare fee-for-service claims data.

Notes: pp = percentage point; HHA = Home Health Agency; STACH = Short-Term Acute Care Hospital. PAC = Post-Acute Care. PAC includes Long-Term Care Hospitals, Inpatient Rehabilitation Facilities, and Skilled Nursing Facilities. To identify HHA admits from a STACH, we examined the 30 days following STACH discharge for a HHA admission. High-quality HHA is defined as having at least 3.5-star rating.

 

Exhibit 3: Difference in Proportion of High-Quality Fee-for-service HHA Admissions between Black and White Beneficiaries by Source of Admission to HHA, 2016-2020

Source: Authors’ analysis using 2016-2020 Medicare fee-for-service claims data.

Notes: High-quality HHA has at least 3.5-star rating. HHA = Home health agency; STACH = Short-Term Acute Care Hospital; PAC = Post-Acute Care. PAC includes Long-Term Care Hospitals, Inpatient Rehabilitation Facilities, and Skilled Nursing Facilities.

Discussion

In our recent Commonwealth Fund Issue Brief, we found no evidence of differential access to high-quality HHAs between White and Black beneficiaries, in contrast to a recently published study. Exploring the methodologies revealed that differences in home health admission type and period of study can explain, to some extent, the divergent findings. Our examination highlights two important factors in assessing home health use and, more generally, post-acute care trends and outcomes: (1) patient heterogeneity; and (2) dynamic changes in post-acute care.

Patient heterogeneity. Home health patients and the types of services they receive vary. These services may include social work, nursing care, occupational therapy, physical therapy, and speech therapy. Some Medicare beneficiaries receive home health care as they recover from an acute care hospital stay, during a period in which they are homebound and unable to obtain outpatient care in an ambulatory setting.  Others, more frail or long-term immobile patients, may also require skilled nursing or therapy but rely more on home health for daily care.

Researchers should consider these different home health populations when conducting research on post-acute care trends and outcomes. Our analysis focused specifically on those who were admitted to an HHA following a hospitalization, because we were interested in shifting patterns in post-acute care use, specifically post-hospital shifts from skilled nursing facilities to HHAs, during the COVID-19 Public Health Emergency (PHE). Fashaw-Walters and colleagues included all HHA users in their study to assess inequalities in access to high-quality home health care across racial, ethnic, and socioeconomic dimensions. Researchers should consider assessing the populations separately, depending on their study questions, so as to not mask any policy or other important findings.

Policy makers should also consider home health populations separately.  For example, Congress is considering the creation of a single Medicare payment system for the different post-acute care settings. However, the appropriateness of including home health admits from the community into such a system with post-acute care is unclear, given the different clinical profile and needs of these beneficiaries from those discharged from a short-term acute care hospital.

Dynamic changes in post-acute care. We show that access to high-quality HHAs for Black beneficiaries has improved over time, particularly among those admitted from the community or a post-acute care setting. The difference in time periods examined between the two studies is of unique importance due to the COVID-19 PHE, which affected health care utilization decisions. The Medicare program instituted regulatory waivers due to the COVID-19 PHE that improved access to home health in 2020, although trends towards greater use of high-quality HHA among Black beneficiaries appear prior to the PHE.  In addition, the HHA and Skilled Nursing Facility Medicare payment systems underwent significant revisions in January 2020 and October 2019, respectively, which has likely shifted post-acute care use and patient mix. Growing use of value-based payment approaches will also impact post-acute care use. As a result, post-acute care use patterns will continue to change.

Our focus on home health admits from hospitals and our use of more recent data may explain the divergent findings between our study and the Fashaw-Walters study. However, other unassessed factors may play a role as well, including access differences to high-quality HHAs between Medicare Advantage and Traditional Medicare.  The growing popularity of MA, particularly among minorities, has the potential to also change Medicare beneficiaries’ access to high-quality home health, which is another dynamic that should be carefully assessed and monitored.

Conclusion

Despite a closing gap in Black-White beneficiary differential access to high-quality HHAs, we still observe lower overall use of high-quality HHAs for those Black beneficiaries admitted from the community or a post-acute care setting. Our aggregate examination of trends also may hide disparities for certain types of patients or communities. Therefore, trends in Black beneficiaries’ use of high-quality HHAs should be monitored to assess whether these trends continue, particularly once the COVID-19 waivers end. There is also heterogeneity in HH use within the other racial and ethnic groups. Here, we focus on Black beneficiaries, but future work should examine changes in HHA use by other races and ethnicities, which tend to have lower rates of admissions to high-quality HHAs. Recognizing the changing home health and post-acute care landscape, more research is needed to identify areas where disparities persist and their underlying causes, such as availability of high-quality HHAs and differential treatment practices.

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