Did Utilization of High-Excellent HHAs Transform All through the COVID-19 Pandemic?
Being familiar with whether or not there are disparities in accessing large-excellent HHAs is crucial to understanding health results amongst selected teams of HHA people.5 Our success drop light on designs of HHA use by internet site top quality, shifts in people patterns throughout the pandemic, and the differential affect of COVID-19 on specific groups of HHA end users. (As previously described, to improved isolate the effects of COVID-19 on PAC use patterns, we attempted to control for the affect of concurrent Medicare payment reforms concentrated on HHAs and SNFs.)
There were 4.8 million discharges to HHAs in our databases 40 percent of them were discharged to a substantial-high quality HHA, 1 with a good quality of client care star rating of 4 stars or increased.6 All through the COVID-19 period, we discover that the likelihood of making use of a substantial-good quality HHA amplified among the Black beneficiaries, relative to non-Black beneficiaries, by 2.5 percentage points (Appendix Tables A4 and A5). The use of significant-excellent HHAs by dually suitable beneficiaries relative to individuals who ended up not dually qualified did not transform considerably in the course of the pandemic.
All through the COVID-19 pandemic, postacute treatment options have helped ease the stress on hospitals by caring for people with and with no COVID-19.7 The aim of this evaluation was to recognize changes in styles of healthcare facility transfer fees for non-COVID-19 people to household wellness agencies and other PAC configurations during the pandemic relative to trends in the prepandemic period. We also required to look at how these designs altered for Black beneficiaries, twin eligibles, and significant-need populations.
We locate that all through the pandemic, charges of HHA use between classic Medicare beneficiaries has enhanced amongst 5 and 6 proportion factors across all non-COVID-19 populations, with analogous, but scaled-down, reductions in SNF use premiums through the identical time. The shift to HHA possible displays worries between medical professionals and people about the risk of COVID-19 infection in SNFs and variations facilitated by regulatory waivers for HHA use, which expanded the definition of “homebound” employed in eligibility dedication, authorised telehealth and telecommunication in area of in-individual residence visits, and permitted far more practitioner types to certify and recertify eligibility for residence health care.8 These waivers diminished barriers to HHAs among the all Medicare beneficiaries. In simple fact, in independent analyses not demonstrated, we locate that in the course of the pandemic, much less individuals had been discharged household with out any home wellness care. Thus, advancement in HHA use for the duration of the pandemic has likely been owing not only to significantly less SNF use but also to reductions in sufferers discharged home with no PAC.
We obtain somewhat better possibility-modified use of HHAs for Black beneficiaries relative to non-Blacks, and that this variation improved by a compact amount (< 1.0 percentage point) during the pandemic. We also find that Black beneficiaries were more likely to use a high-quality HHA during the pandemic than non-Black beneficiaries. The reason for this pattern is unclear and is an area for future research. We note that our findings contrast with those of recent studies that found disparities between Black and white adults in access to high-quality HHAs,9 a discrepancy that could be explained by differences in methodology — for example, focusing on transfers to PAC from a hospital versus community-based admissions examining data on transitions during the pandemic versus prepandemic data looking at traditional Medicare beneficiaries only versus all beneficiaries, including Medicare Advantage enrollees.
Conversely, we find lower risk-adjusted use of HHAs and higher SNF use for dual eligibles relative to beneficiaries with traditional Medicare only. In addition, dually eligible beneficiaries experienced a smaller increase in HHA use during the COVID-19 period relative to Medicare-only beneficiaries and experienced no significant change in the use of high-quality HHAs during the same period. The smaller increase in HHA use among the dually eligible could be explained by some home health services being covered under Medicaid (therefore not observed in our data). A disproportionate share of nursing home residents are also Medicaid beneficiaries, who may be more likely to receive care from the colocated SNF. Additionally, high-need beneficiaries, who may require a more supervised environment, as offered in inpatient PAC settings, were more likely to use SNFs compared with HHAs.
The waivers most certainly played a role in accelerating the use of HHAs in traditional Medicare, and the value of their continuation postpandemic will be debated. Increased use of telehealth and greater flexibility around eligibility for home health care would likely lead to more patients being sent home from the hospital with intensive home-based rehabilitation. Because home health care is less expensive than other PAC and does not require a beneficiary deductible or copayment, a continued shift to home health may reduce Medicare and beneficiary spending on PAC. It also may increase patient satisfaction among those who prefer to receive care in the home rather than an inpatient facility.
The full effect of a shift to HHA care depends on several factors:
- Savings to Medicare and beneficiaries depend on the extent to which home health care is substituted for more expensive inpatient PAC instead of patients being discharged home with no PAC.
- The effects of increased HHA use on patient outcomes will be critical to understanding whether (and for whom) expanded access to HHA care would have clinical and financial benefits. For example, failure to match patients to the appropriate PAC setting based on their clinical needs may result in hospital readmissions and other adverse patient outcomes that also may increase spending.
- A decline in SNF use may cause some of these facilities to incur increased financial stresses and close. Advocates have raised the alarm that the nursing home industry — which is linked to SNFs and covered by low Medicaid reimbursement rates — is under significant stress from the pandemic.10
Moving forward, it will be important to monitor and evaluate the effects of shifts in PAC use to help develop appropriate policies that support access to high-quality, cost-effective PAC for all beneficiaries.