High-quality home health agencies are frequently out of reach for the most vulnerable Medicare patients, according to new research published Monday in the journal Health Affairs.
Patients who receive home health services from high-quality agencies – those with high star ratings – typically have fewer hospitalizations and other adverse health events. However, black, Hispanic, and low-income patients use these high-performing providers at a lower rate than white, higher-income patients.
According to the Health Affairs study, this is true even after controlling for patients' unique clinical characteristics.
"[Differences] in access persist even after patients' health status and care needs are taken into account, indicating a true racial, ethnic, and socioeconomic disparity in access to higher-quality home health agencies," the study's authors explained.
The researchers examined Medicare files, OASIS records, and neighborhood-level datasets to investigate access to high-quality agencies among various patient populations. In total, they examined over 3.1 million Medicare-enrolled home health patients aged 65 and older who had a start-of-care assessment in 2016.
Home health patients living in congregate settings, such as assisted living facilities, were excluded by the researchers (ALFs). They also concentrated on Black and Hispanic patients, leaving out Asian, American Indian, and other racial groups.
Contextually, the team decided to investigate the relationship between race, economic status, and use of high-quality agencies because there is still a lot that is unknown about disparities in non-institutional care models.
"Additionally, home health is a unique health care service in that 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. "As a result, much remains to be discovered about the relationship between the local neighborhood and potential disparities in access to high-quality home health agencies based on race, ethnicity, and income."
The study's sample included 3.1 million Medicare beneficiaries, with 81 percent being white, 12 percent being black, and 7 percent being Hispanic. Approximately 26% were low-income.
In total, 46 percent – nearly half – of the sample population received services from high-quality home health agencies.
"Black and Hispanic home health patients lived in neighborhoods with a higher average number of home health agencies per 1,000 older adults, but a lower proportion of those were high-quality home health agencies," the researchers noted.
After controlling for individual characteristics, Black home health patients had a 5.6-percentage-point lower likelihood of using a high-quality home health agency, while Hispanic patients had a 10.9-percentage-point lower likelihood. When compared to their counterparts, low-income patients had a 2-percentage-point lower probability.
After controlling for neighborhood, Black home health patients had a 2.2-point lower probability of using a high-quality home health agency, while Hispanic patients had a 2.5-point lower probability. Patients with low income had a 1.2-percentage-point lower chance.
The study did not reveal why these statistical differences exist.
Furthermore, the researchers made it clear that they were not attempting to draw causal conclusions.
"Despite the fact that the star measures were 'risk adjusted' in an attempt to control for differences in patient populations across home health agencies, our analyses were unable to distinguish 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 wrote.
In general, investigating these issues now is critical because home health spending is expected to rise in the coming years. Examining disparities within home health populations is also important in light of the upcoming expansion of the Home Health Value-Based Purchasing (HHVBP) Model.
"These programs are 'colorblind' market-based reforms designed to reward high-quality home health agencies while penalizing low-quality providers," the researchers wrote. "However, similar programs in home health and other settings have been shown to exacerbate health disparities."
