One in five Medicare beneficiaries requires home health care after a hospital stay, but a recent analysis based on Medicare claims data found a significant decline in recommended post-discharge care over a six-year period.
According to a Commonwealth Fund analysis, home health referral fulfillment rates declined from 66% to 59% between 2016 and 2022. Poor fulfillment of home health referrals is linked to increased readmissions and mortality rates among both Medicare and Medicare Advantage beneficiaries. The authors noted that this trend could have serious implications for hospitalized Medicare beneficiaries.
Journalists can use the data provided in this analysis, as well as other Medicare claims data, to track compliance rates in their communities and further hold hospitals and home care agencies accountable.
Why is this important?
The researchers found that home health services declined most among white beneficiaries (7.2 percentage points), but declines were also seen among black and Hispanic patients. Regardless of race, dual beneficiaries (those eligible for both Medicare and Medicaid) were less likely to accept home health referrals than Medicare-only beneficiaries.
When considering the social deprivation index (a geographic composite measure of poverty, education, housing, employment, and other demographic characteristics), home health referral rates were lower in counties with higher social deprivation. For all beneficiaries, rates declined in rural areas, large metropolitan areas, and mid-sized metropolitan areas.
The decline of home health care is both an aging and health equity issue. Lack of adequate services can lead to increased readmissions within 30 days of discharge, and increased morbidity and mortality. Research shows that patients from disadvantaged communities are at higher risk of not receiving the services they need, and often experience worsening physical and mental decline after hospitalization.
How Medicare Home Health Care Works
Traditional Medicare has strict rules about receiving home health care. However, if part-time or intermittent skilled services are provided and the patient is deemed homebound, payment will be made for this service. Skilled care can include wound care, intravenous or nutritional therapy, monitoring of unstable health conditions, and physical occupational or speech therapy. Many studies have found that home health care is usually less expensive and more convenient than inpatient care in a hospital or skilled nursing facility, and is equally effective.
A physician or other clinician (such as a nurse) must meet with the patient in person before a referral for home health services is made. When appropriate, providers refer home health care to a Medicare-certified home health agency. Patients can choose from a list of agencies in their area. Restrictions also apply to maintain this benefit, such as limits on time spent away from home other than for medical appointments.
What is causing this change?
The researchers cited several factors that may be contributing to the decline in home health referral fulfillment.
Lack of staff and resources — Since 2013, the number of active home health agencies has steadily declined, reducing access to care. Many racial and ethnic groups lack adequate care, widening health care disparities. An independent study found that some home health agencies exhibit selection bias, avoiding socioeconomically disadvantaged areas and high-cost patients. Patient reluctance to use home health care was also a potential factor. Some may consider these services unnecessary or not provide enough value. Others do not want outside caregivers in their homes or generally distrust health care providers.
The decline in home health services was evident even before the COVID-19 pandemic began, and while the crisis contributed to the decline, the authors suggest other factors, such as staffing shortages and low wages for workers, also contributed to the issue.
“Declining home health referral fulfillment rates indicate a systemic problem that requires the attention of health care providers and policymakers,” the report states. To mitigate this potential crisis, the report suggests improving hospital follow-up on referrals, increasing the use of telehealth, and revising home health payment structures.
