High-quality home health agencies are often out of reach for the most vulnerable Medicare patients, new findings published Monday in the journal Health Affairs reveal.
Typically, patients receiving home health services from high-quality agencies – those that do well on star ratings – experience fewer hospitalizations and other adverse health events. But Black, Hispanic and low-income patients tend to use these high-performing providers less frequently than white, higher-income counterparts.
That’s true even when controlling for patients’ unique clinical characteristics, according to the Health Affairs study.
“[Differences] in access exist even after patients’ health status and care needs are adjusted for, thus indicating a true racial, ethnic and socioeconomic disparity in access to higher-quality home health agencies,” the study’s researchers explained.
To explore access to high-quality agencies among different patient populations, the researchers analyzed a combination of Medicare files, OASIS records and neighborhood-level datasets. Overall, they looked at more than 3.1 million 65-and-older Medicare-enrolled home health patients with a start-of-care assessment in 2016.
Researchers excluded home health patients living in congregate settings such as assisted living facilities (ALFs). They also focused on Black and Hispanic patients, excluding, for instance, individuals from Asian, American Indian or other racial groups.
Contextually, the team decided to explore the correlation of race, economic status and use of high-quality agencies because much remains unknown about disparities in non-institutional care models.
“Furthermore, home health is a unique health care service in that the care is delivered in patients’ homes rather than in a centralized, physical location such as [a] doctor’s office, hospital or nursing home,” the researchers wrote. “Therefore, much remains to be learned about the association between the local neighborhood and potential disparities in access to high-quality home health agencies by race, ethnicity and income.”
Out of the 3.1 million Medicare beneficiaries included in the study’s sample, 81% were white, 12% were Black and 7% were Hispanic. About 26% were low income.
Overall, 46% of the sample population – nearly half – received services from high-quality home health agencies.
“Black and Hispanic home health patients lived in neighborhoods with a greater average number of home health agencies per 1,000 older adults, but a smaller percentage of those were high-quality home health agencies,” the researchers noted.
After individual characteristics were adjusted for, Black home health patients had a 5.6-percentage-point lower probability of high-quality home health agency use, while Hispanic patients had a 10.9-percentage-point lower probability. Low-income patients had a 2-percentage-point lower probability compared with their counterparts.
After controlling for neighborhood, Black home health patients had a 2.2-percentage-point lower probability of high-quality home health agency use, while Hispanic patients had a 2.5-percentage-point lower probability. Low-income patients had a 1.2-percentage-point lower probability.
The study itself didn’t confirm why these statistical differences occur.
Additionally, researchers carefully noted they weren’t attempting to draw causal conclusions.
“Although the star measures were ‘risk adjusted’ in an attempt to control for differences in patient populations across home health agencies, our analyses could not untangle whether disadvantaged patients were more likely to gain access to low-quality home health agencies and whether agencies that serve disadvantaged patients were more likely to receive low quality scores,” they stated.
Generally, exploring these issues now is important because home health spending is projected to grow in the coming years. Examining disparities within home health populations is likewise important due to the upcoming Home Health Value-Based Purchasing (HHVBP) Model expansion.
“These programs are ‘colorblind’ market-based reforms intended to reward home health agencies for high-quality care while penalizing providers with lower quality,” the researchers wrote. “However, similar programs have been shown to exacerbate health disparities in home health and other settings.”
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