Fewer Hospitalized Medicare Beneficiaries Are Receiving Recommended Home Health Care

In 2022, more than 2.71 million hospitalized Medicare patients (21%) — both traditional Medicare and Medicare Advantage beneficiaries — received a referral for home health care. But research suggests many did not receive their needed care. Data from 2016 show that only 54 percent of hospitalized Medicare beneficiaries referred for home health care received it. Low fulfillment rates for home health referrals can lead to patients being readmitted to the hospital and sometimes death. In this blog post, we look at how many hospitalized Medicare patients received home health care, even when referred for it, and how those rates differ across beneficiaries’ gender, race, dual eligibility status, and geography.

Fewer Hospitalized Beneficiaries Referred to Home Health Receive Services

Overall home health referral fulfillment rates decreased from 66 percent to 59 percent between 2016 and 2022. This trend was observed before and during the COVID-19 public health emergency and occurred across all racial and ethnic groups. The overall decrease was largely driven by the significant decline (7.2 percentage points) in the rate for white beneficiaries. We observed racial and ethnic disparities in fulfillment rates over that period, although they narrowed slightly. Beneficiaries dually enrolled in Medicare and Medicaid had lower rates of home health referral fulfillment compared to those not dually enrolled. (All differences reported above were statistically significant at the 5 percent level.)

Geographic Disparities in Home Health Fulfillment Rates

We classified Medicare beneficiaries’ residence on an urban–rural spectrum. Home health referral fulfillment rates were 2 percentage points lower in rural areas compared to large metropolitan areas and 3 percentage points lower compared to medium-sized metropolitan areas in 2016, which were statistically significant at the 5 percent level. However, fulfillment rates fell most among beneficiaries in large metropolitan areas between 2016 and 2022 (7.3 percentage points). As a result, the discrepancy in home health fulfillment rates between large metropolitan areas and rural areas decreased.

Using the Robert Graham Center Social Deprivation Index (SDI), we divided counties into three groups. The SDI is a geographic composite measure of demographic characteristics (poverty; education achievement; single-parent households; rented, overcrowded housing; car ownership; and employment) used to quantify the socioeconomic variation in health outcomes across the United States. The first group represents counties with the least deprivation and the last represents those with the greatest deprivation. We observe lower home health referral fulfillment rates in beneficiary counties with higher social deprivation, likely because home health requires social and in-home support, which may be more lacking in deprived areas. This pattern remained consistent across years, as home health referral fulfillment rates fell similarly across groups. We then examined fulfillment rates by racial and ethnic groups within SDI groups. Black beneficiaries had the lowest home health fulfillment rate within all three groups, followed by Hispanic beneficiaries. Among Hispanic beneficiaries, the rate of home health referral fulfillment varies greatly across SDI groups — a 3.3 percentage-point difference between the least deprivation and the midrange and a 9.1 percentage-point difference between the least deprivation and the most.

Discussion

Research has shown that unfulfilled home health referrals are associated with higher hospital readmission and mortality rates. Our finding — that the rates of people receiving home health care after being referred for such care has decreased — could have serious consequences for hospitalized Medicare beneficiaries.

The trends we observed could be driven by several factors. Prior literature has cited insufficient staff and resources as a potential reason for low home health fulfillment rates. Many home health agencies closed over the past decade and the number of active home health agencies has steadily decreased since 2013, which has led to decreased access to home health care. In addition, the discrepancies we found across race and ethnicity and SDI are supported by extensive research documenting the inadequate care available to these populations. Relatedly, home health agencies may behave selectively in allocating resources by avoiding economically disadvantaged areas and patients they view as more costly.

The literature also has noted that patients’ preferences may lead to forgoing home health care altogether because of their belief that home health care is unnecessary or of low value, an aversion to having health care practitioners in the home, or a general lack of trust in health care providers.

Our analysis included the start of the COVID-19 public health emergency, which created disruptions in hospital discharge patterns. COVID-19-related factors that may have affected home health referral fulfillment rates include Medicare waivers put in place that expanded access to home health care and, relatedly, greater use of telehealth during an episode of care. While these events may have played a role, the decline in rates started prior to 2020, suggesting that COVID-19 was not solely responsible but could have compounded the effects via, for example, staffing challenges at home health agencies.

Falling home health referral fulfillment rates point to a systemic problem that requires the attention of providers and policymakers. Hospitals could follow up with beneficiaries after discharge and take steps to ensure referrals are fulfilled. Expanded use of telehealth and potential revisions to how home health workers are paid may help alleviate the impact of staff shortages. Finally, the Centers for Medicare and Medicaid Services could consider publicly reporting home health fulfillment rates to hold hospitals and agencies more accountable for providing continuous care.