Evaluation of the Reliability of Medicare Spending Per Beneficiary for Post-Acute Care.

BACKGROUND: A measure of episode spending, such as Medicare Spending Per Beneficiary (MSPB) is increasingly used to evaluate provider performance. Yet if the measure is unreliable, as is often true for low-volume providers, it cannot distinguish "good" from "poor" performance. OBJECTIVE: The objective of this study was to evaluate the reliability of a uniformly calculated MSPB measure for post-acute care (PAC) and the tradeoffs involved in setting a minimum case count threshold. DATA: Medicare claims for 15 million PAC episodes from April 2013 to March 2015. RESEARCH DESIGN: Given the overlap in patients treated in PAC settings, we developed a uniformly calculated MSPB measure for PAC providers that measures spending during the PAC stay and the following 30 days. We examine variation in the MSPB-PAC measure and characterize the measure's reliability and its relationship to provider case counts. RESULTS: Applied to our MSPB-PAC measure, a minimum threshold of 20 Medicare episodes as currently used by the Centers for Medicare & Medicaid Services (CMS) would not establish reasonably reliable measures and could result in drawing unduly erroneous conclusions about provider performance. The measures for home health agencies were considerably less stable and reliable than for institutional PAC providers. CONCLUSIONS: CMS should consider adopting a more stringent reliability standard for setting minimum case counts for MSPB-PAC and other measures. Its current threshold (R-statistic=0.4) reflects more random variation than differences in actual provider performance. To include as many providers as possible, CMS should consider pooling data over multiple years to avoid drawing incorrect conclusions about low-volume providers.

Certificate of need and the cost of competition in home healthcare markets.

We used 2010-16 Medicare Cost Reports for 10,737 freestanding home health agencies (HHAs) to examine the impact of home health (HH) and nursing home (NH) certificate-of-need (CON) laws on HHA caseload, total and per-patient variable costs. After adjusting for other HHA characteristics, total costs were higher in states with only HH CON laws ($2,975,698), only NH CON laws ($1,768,097), and both types of laws ($3,511,277), compared with no CON laws ($1,538,536). Higher costs were driven by caseloads, as CON reduced per-patient costs. Additional research is needed to distinguish whether this is due to skimping on quality vs. economies of scale.

Hospital ownership of postacute care providers and the cost of care.

BACKGROUND: Hospitals are facing incentives to manage the total cost of care for episodes of illness, including the costs of inpatient care as well as the cost of care provided by physicians and postacute care (PAC) providers. PAC is an especially important component of the overall cost of care. One strategy hospitals employ in managing this cost is to own PAC providers. Prior work on the relationship between PAC ownership and cost has reached mixed conclusions. PURPOSE: The aim of this study was to examine the associations between the episodic costs of care and hospital ownership of PAC providers, including skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRF). METHODOLOGY: We examine panel data on hospital ownership of PAC providers from the American Hospital Association for 2013-2015 and cost of care data from Centers for Medicare & Medicaid Services' Value-Based Purchasing Program. Using ordinary least squares, we quantify the association between a hospital's PAC ownership choice (both ownership of any PAC provider and ownership of particular types of providers) and the episodic cost of care. RESULTS: In 2015, 80% of hospitals owned some type of PAC provider. We find that ownership of SNFs and HHAs is associated with a lower episodic cost of care, whereas ownership of inpatient rehabilitation facilities is associated with higher episodic costs of care. The effects of ownership do not differ for hospitals that participate in a voluntary shared saving program (Bundled Payment for Care Improvement). CONCLUSION: The effects of PAC ownership vary by the type of PAC provider owned. Our results suggest that ownership of SNFs and HHAs may be a viable strategy for success in reimbursement programs that reward hospitals for managing the total costs for episodes of care.

Professional, friend or family?: How home care companies sell emotional care.

While there is a growing literature on home care workers, less is known about how home care companies market their services. Through a content analysis of the 19 largest U.S. home care and home health providers' websites, we examined how companies describe services, desired outcomes of care, and job responsibilities and qualifications. Companies actively market family-like relationships as central to "good care". However, companies' emphasis on unmeasurable skills such as compassion and warmth may also create exploitative work environments. Supporting "good care" requires improved data collection, industry oversight, and policy change to recognize socio-emotional care and protect a marginalized workforce.

Disparities in home health service providers among Medicare beneficiaries with stroke.

This study examined the intensity of home health services, as defined by the number of visits and service delivery by rehabilitation specialists, among Medicare beneficiaries with stroke. A cross-sectional secondary data analysis was conducted using 2009 home health claims data obtained from the Centers for Medicare and Medicaid Services' Research Data Assistance Center. There were no significant rural-urban differences in the number of home health visits. Rural beneficiaries were significantly less likely than urban beneficiaries to receive services from rehabilitation specialists. Current home health payment reform recommendations may have unintended consequences for rural home health beneficiaries who need therapy services.

Frontloading and intensity of skilled home health visits: a state of the science.

Frontloading of skilled nursing visits is one way home health providers have attempted to reduce hospital readmissions among skilled home health patients. Upon review of the frontloading evidence, visit intensity emerged as being closely related. This state of the science presents a critique and synthesis of the published empirical evidence related to frontloading and visit intensity. OVID/Medline, PubMed, and Scopus were searched. Seven studies were eligible for inclusion. Further research is required to define frontloading and visit intensity, identify patients most likely to benefit, and to provide a better understanding of how home health agencies can best implement these strategies.

The economic impact of complex wound care on home health agencies.

The cost of care for home health clients with complicated wounds frequently exceeds reimbursement received from Medicare and other payer sources. As a result, home health agencies may be reluctant to accept this type of referral. Many of the costs associated with complex wound care can be substantially reduced by appropriate use of expensive therapies and dressings and establishment of a cost-effective wound care formulary. Costs can also be reduced by collaboration with prescribing providers to ensure that orders are written generically, and avoid unnecessary nursing visits. Knowledgeable WOC nurses can play a critical role in coordinating care that is both clinically and fiscally effective. This article reviews common challenges in caring for complex wounds in the home care setting with a focus on strategies the prescribing provider and wound care clinician can use to optimize outcomes.

As long-term care insurers abandon the marketplace, what other options will appear?

Less than 20 years ago there were more than 100 major insurance companies selling long-term care insurance (LTCi). Today there are less than 30. Home care providers stood to be one of the primary recipients of LTCi payments for their services, but there's a paradox at work. Just as the baby boomers started turning 65 at a pace of 10,000 per day, the LTCi market is shrinking instead of "booming."

Social care in older people's services--facilitating the flexible use of resources.

Personal budgets in social care are a mechanism for the allocation of resources for care that permits users'greater choice and flexibility. This study was designed to explore developments in care coordination arrangements by examining the flexible use of resources. Two national surveys identified agencies with such arrangements in older people's services in advance of this agenda, described here as innovative authorities. Telephone interviews with their representatives explored salient factors in the development, focus, and operation of personal budgets. Carers were the main recipients, and there was also evidence of more appropriate use of resources structured around service users' needs. Implementation of personal budgets requires authorities to be more creative and flexible in respect of internally held budgets to meet the needs and wishes of older service users. This study provides evidence that some of these requirements have already been adopted by a few agencies.

Strategies for managing margins.

Potential Medicare and Medicaid reimbursement cuts have made it critical for home health agencies to manage their gross and net operating profit margins. Agencies need to develop tools to analyze their margins and make sure they are following best practices. Try as you may, your agency might still face the question, "Why am I not meeting my budget?" Get some answers in this session from David Berman and Andrea L. Devoti. Berman is a principal at Simione Healthcare Consultants in Hamden, CT, where he is responsible for merchant acquisitions, business valuation due diligence, and oversight of the financial monitor benchmarking tool besides serving as interim chief financial officer. Devoti is chairman of the NAHC board and President & CEO of Neighborhood Health Visiting Nurse Association in West Chester PA.

HHFMA Leadership Panel: a vision of the future.

Get the highlights of the HHFMA Leadership Panel, always a high point of the Financial Management Conference. This year home care and hospice providers face increasing pressure from Congress, CMS, MedPAC, Medicaid, and other payer initiatives to restrict service and compress margins. Yet home care and hospice will continue to bring value and quality to the health care delivery system and its patients. The dynamics created by the new health reform legislation--such as ACOs, bundling, and the home medical model--combined with the exploding Medicare and Medicaid populations and technological advances will change the face of home care and hospice. The esteemed panelists, representing a wide range of interests in home care and hospice, offer their five, ten, and 15 year vision into the future of the health care delivery system and the role home care and hospice will play.

Role of hospice and home care in a reformed care delivery system: ACOs, bundling, transitions in care, and more.

The way we deliver health care is changing fast and going in the direction of home care and hospice. This timely program addressed the threshold question of how your organization should play a part in a new arena that includes accountable care organizations, bundling of post-acute care, and integrated transitions in care. Should you be a partner with other health care sectors, assuming some of the financial risk for the success or failure of the endeavor? Should you choose instead to be an active participant or possibly a vendor to an integrated health delivery model? Join our panel as they discussed how to determine your role and gauge the community of health in which you function.

A comparison of quality measures between for-profit and nonprofit medicare-certified home health agencies in Michigan.

This exploratory study investigated the differences in the means of quality measures between for-profit and nonprofit Medicare-certified home health agencies in Michigan. The research question was: Do nonprofit agencies provide higher quality of care than for-profit agencies? Twelve publicly available quality measures were retrieved in May 2009 and used for analysis. Independent t tests found significant differences between for-profit and nonprofit agencies on 6 of the 12 measures, with for-profit agencies performing better on 5 measures. The relative value of both types of ownership should be recognized. Future research may focus on using standardized quality measures to explore further the impact of profit orientation on home health quality of care.

Changes in the Medicare home health care market: the impact of reimbursement policy.

BACKGROUND: The Balanced Budget Act of 1997 introduced 2 new reimbursement structures, the Interim Payment System (IPS, 1997-2000) and the Prospective Payment System (PPS, begun October 2000) for Medicare home health agencies (HHAs) under the fee-for-service program. OBJECTIVE: This article describes and compares the impact of these changes on the Medicare home health market from a period before the BBA through the IPS and PPS in relation to agency characteristics. RESEARCH DESIGN: A secondary analysis of 1996, 1999, and 2002 Provider of Services data was conducted on all Medicare-certified HHAs. Frequencies and rates of change were calculated by agency characteristics to describe changes in the number of active agencies through those years. Logistic regression models were used to compare factors associated with market exits under different payment systems. RESULTS: The results indicate dramatic but disproportional changes in response to the IPS and the PPS among Medicare home health care agencies. Agency closures were greater and market entries fewer during the IPS, but more branch offices/subunits were closed during the PPS. Proprietary and freestanding agencies experienced greater volatility throughout, with the greatest number of closures seen in Region VI (Dallas). CONCLUSIONS: These results demonstrate the direct impact of policy changes on the home health care market and highlight the need to evaluate policy changes to understand both intended and unintended impacts on health markets. Future research should analyze the effect of these policy changes on other healthcare providers and systems and their impact on health outcomes for Medicare beneficiaries.

Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility.

Importance: Use of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care. Objective: To investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility. Design, Setting, and Participants: A retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary's home zip code and the closest home health agency and the closest skilled nursing facility as an instrument. Exposures: Receipt of postacute care at home vs in a skilled nursing facility. Main Outcomes and Measures: Readmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode. Results: A total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean [SD] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (-2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (-1.9 percentage points; 95% CI, -12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (-$5384; 95% CI, -$6932 to -$3837; P < .001), as was total Medicare payment within the first 60 days after admission (-$4514; 95% CI, -$6932 to -$3837; P < .001). Conclusions and Relevance: Among Medicare beneficiaries eligible for postacute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.

Home health care agency staffing patterns before and after the Balanced Budget Act of 1997, by rural and urban location.

CONTEXT: The Balanced Budget Act (BBA) of 1997 and other recent policies have led to reduced Medicare funding for home health agencies (HHAs) and visits per beneficiary. PURPOSE: We examine the staffing characteristics of stable Medicare-certified HHAs across rural and urban counties from 1996 to 2002, a period encompassing the changes associated with the BBA and related policies. METHODS: Data were drawn from Medicare Provider of Service files and the Area Resource File. The unit of analysis was the 3,126 counties in the United States, grouped into 5 categories: metropolitan, nonmetropolitan adjacent, and 3 nonmetropolitan nonadjacent groups identified by largest town size. Only relatively stable HHAs were included. We generated summary HHA staff statistics for each county group and year. FINDINGS: All staff categories, other than therapists, declined from 1997 to 2002 across the metropolitan and nonmetropolitan county groupings. There were substantial population-adjusted decreases in stable HHA-based home health aides in all counties, including remote counties. CONCLUSIONS: The limited presence of stable HHA staff in certain nonmetropolitan county types has been exacerbated since implementation of the BBA, especially in the most rural counties. The loss of aides in more rural counties may limit the availability of home-based long-term care in these locations, where the need for long-term care is considerable. Future research should examine the degree to which the presence of HHA staff influences actual access and whether other paid and unpaid sources of care substitute for Medicare home health care in counties with limited supplies of HHA staff.