Changes in Medicare Home Health Use During COVID-19 and the Implications for Health Equity and Caregiver Availability

Abstract

• Issue: Given shifting home health use during the COVID-19 pandemic, studying the characteristics of Medicare home health beneficiaries with respect to race and caregiver assistance may inform efforts to address disparities in access and service use.
• Goal: To identify changes in race and acuity of home health beneficiaries between 2019 and 2020, as well as access to caregiver assistance and outcomes during home health.
• Methods: Analysis of files containing 100 percent of Medicare claims for 2019 and 2020, plus a sample of Outcome and Assessment Information Set (OASIS) assessments.
• Key Findings: Medicare beneficiaries using home health decreased by 6 percent in 2020 compared to 2019. Home health visits decreased by nearly 14 percent while patient acuity increased. Beneficiaries of color were less likely to have caregiver assistance, and a higher proportion of caregivers available to beneficiaries of color needed additional training to adequately provide assistance. Among the highest-acuity Latinx/Hispanic and Asian American beneficiaries, hospitalizations were higher when their caregivers needed training.
• Conclusion: As policymakers consider changes to the Medicare home health system, they should take into account the observed racial disparities in access to and quality of caregiver assistance, as well as the increase in patient acuity when home health visits declined.

Introduction

Home health care plays a critical role providing nursing and therapy services to patients recovering from acute hospitalizations and to frail, community-dwelling, homebound patients referred to home care by physicians. From 2002 to 2019, the number of Medicare beneficiaries using home health increased by more than 30 percent. In 2019, more than 8 percent of Medicare beneficiaries used home health care.¹

The use of home health services following a hospitalization may depend on diagnoses, comorbidities, geography, and provider availability, as well as the patient’s living situation and availability of caregiver assistance to ensure safe transitions of care. In addition, home health care use may also vary by race and socioeconomic status. Recent studies have identified a lower likelihood of discharge to home health care among Latinx/Hispanic and Asian American patients relative to white patients, and higher odds of discharge to home health care among those living in socioeconomically disadvantaged and rural areas.²

Given shifting home health care patient volumes and an increasing preference for home-based care, it is important to understand the changing characteristics of the Medicare home health care patient population. In this issue brief, we discuss changes in home health users’ characteristics between 2019 and 2020, including differences in race, gender, and overall health status. We also detail shifts in service use during 2020 that may reflect both the COVID-19 pandemic and change in the home health payment system. Finally, we examine caregiver availability to learn how needs may vary by home health users’ race, health status, and outcomes.

Key Findings

Home Health Use of Medicare Beneficiaries During the Pandemic

Consistent with overall trends in health care utilization during the COVID-19 pandemic, the number of Medicare beneficiaries using home health care decreased by 6 percent in 2020 compared to 2019. However, the gender and racial composition of home health users remained similar across both years (see the Appendix). Income-related characteristics of Medicare home health users also remained relatively consistent in 2020 (for example, percentage of households below poverty level).

The proportion of Medicare home health beneficiaries identified as dually eligible for Medicare and Medicaid benefits decreased slightly (0.8%) in 2020. Though a relatively small change, this finding indicates a shift in home health use among this subpopulation during the pandemic.

Types of services used. While demographics for Medicare beneficiaries using home health were quite similar in 2019 and 2020, the kinds of services received shifted notably.

Total visits decreased by close to 14 percent (Exhibit 1). In both years, nursing and physical therapy visits accounted for the majority of home health visits. However, the change in use of these services differed significantly: nursing visits decreased by 6 percent in 2020, compared to a 19 percent decrease in physical therapy visits.

The significant decrease in therapy service use may be because of several factors. One is a decline in elective orthopedic surgeries and other treatments generally associated with greater physical therapy needs. Another is a change in the Medicare home health payment system in January 2020: the elimination of reimbursement based on volume of services delivered, which decreased incentives for providing therapy services.

The small increase (1.4%) in the proportion of home health episodes following an acute or postacute care discharge is also notable. Home health users discharged from acute or postacute facilities generally receive care following an acute event or surgical procedure and may have significant care needs during this period. In contrast, home health patients not referred from acute or postacute care are generally homebound individuals with chronic conditions and longer-term care needs who are referred by community-based providers.

The increase in episodes from acute and postacute care may reflect an increase in use of home health following hospitalizations. Many elective inpatient procedures were postponed during 2020 because of COVID-19. When these procedures were eventually performed, beneficiaries may have had greater health care needs following inpatient care relative to similar patients prior to the pandemic.

Illness Severity Among Medicare Home Health Users During the Pandemic

Severity of illness and comorbidity was higher among Medicare home health users in 2020 than in 2019 (Exhibit 2). In both years, homebound home health users referred from the community had greater severity of illness and comorbidity than home health users admitted from hospitals and postacute facilities. This result is expected, given the longer-term chronic illness profile of homebound beneficiaries. Surprisingly, however, home health users discharged from acute and postacute care experienced a greater increase in severity of illness and comorbidity between 2019 and 2020 than homebound users did. This reflects a change in the patients entering home health following a hospitalization during the pandemic.

The shifts in nursing and therapy visits during the pandemic reflects the relative change in severity of illness for both groups of beneficiaries. The decrease in nursing and physical therapy home visits was smaller among beneficiaries admitted from hospitals and postacute facilities, possibly because of the increase in severity of illness experienced by this group during this period.

Changes in the level of severity of illness and comorbidity among Medicare home health users between 2019 and 2020 also indicated important differences between racial groups (Exhibit 3). Severity of illness and comorbidity for beneficiaries of color were significantly higher compared to white Medicare beneficiaries in both 2019 and 2020, regardless of source of admission to home health, and comorbidity levels increased between 2019 and 2020 for all racial groups. In 2019, comorbidity levels were higher for chronically ill homebound beneficiaries than they were for those admitted from acute or postacute facilities, regardless of race. However, in 2020, the level of comorbidity was higher for Latinx/Hispanic and Asian American beneficiaries after acute and postacute stays than it was for chronically ill homebound beneficiaries — a result of the greater shift in patient acuity for these groups of patients.

Differences in Caregiver Assistance

We also explored differences by race in nonagency paid and unpaid caregiver assistance and the relationship between race, caregiver assistance, severity of illness, and beneficiary outcomes during home health episodes. The purpose of these additional analyses was to identify potential differences in quality of care and beneficiary outcomes if more severely ill beneficiaries continue to be treated in home health.

Looking at all beneficiaries, regardless of race, chronically ill homebound beneficiaries had more caregiver assistance than beneficiaries who had been discharged from a hospital or postacute facility (Exhibit 4). Across all home health episodes, a higher proportion of white and Latinx/Hispanic beneficiaries had caregiver assistance compared to Black and Asian American beneficiaries. The need for caregiver training and supportive services was higher for Black, Latinx/Hispanic, and Asian American beneficiaries compared to white beneficiaries, and this need was particularly high among beneficiaries of color admitted to home health from an acute or postacute facility.

The presence of an acute hospitalization during home health episodes following a hospital or postacute care stay differed in important ways by race, severity of illness and comorbidity, and caregiver assistance (Exhibit 5). Overall, a higher proportion of Black, Latinx/Hispanic, and Asian American beneficiaries had an acute hospitalization during a home health episode compared to white beneficiaries, and the proportions were similar regardless level of caregiver assistance.

However, among beneficiaries with the highest severity of illness and comorbidity, the findings suggest that caregiver training and supportive service needs may have more of an impact on outcomes for patients of color. A higher proportion of Latinx/Hispanic, Asian American, and, to a lesser extent, Black beneficiaries had acute hospitalizations during home health episodes when caregivers were identified as needing training, as compared to when caregivers were able to provide assistance.

Conclusion

The findings indicating greater severity of illness and comorbidity among home health patients in 2020 than in 2019 are consistent with broader trends of decreased elective procedure volumes in acute hospitals. The higher comorbidity scores in 2020 may reflect the changing utilization patterns at the start of the pandemic when healthier beneficiaries with less immediate needs may have delayed care, resulting in them needing additional care when they eventually sought treatment. These findings are also consistent with hypotheses that Medicare beneficiaries who may have otherwise received postacute services in a skilled nursing facility prior to the pandemic may have instead received care through the home health benefit out of concerns over COVID-19 in institutional settings.

While sicker beneficiaries were found to have more caregiver assistance compared to healthier home health beneficiaries, a high proportion of caregivers to the very sick need training and supportive services. In particular, caregivers of high-acuity beneficiaries of color may benefit from additional training and support, particularly following an acute hospital discharge.

To improve home health, support caregivers, and reduce disparities in health care, policymakers might consider a number of actions:

• Support for initiatives aimed at reducing racial differences in hospitalization rates during home health episodes.
• Support for accessible patient and caregiver training initiatives in the patients’ and caregivers’ languages.
• Broader approaches to improving beneficiary care coordination and caregiver training during transitions from acute and postacute care to home settings. For example, the current Medicare payment systems might incorporate quality measures and payment structures that incentivize improved care coordination and patient and caregiver education.