Abstract
Presented are 1986 data and trend data (1974-86) on the use and cost of home health agency services rendered to aged and disabled Medicare beneficiaries. Since 1974, reimbursements for these services have grown more rapidly than overall Medicare expenditures. From 1974 to 1986, Medicare expenditures for these services increased from $141 million to $1.8 billion, an average annual rate of 24 percent. HHA reimbursements, however, continue to represent only a small proportion (3.6 percent in 1986) of all Medicare expenditures.
Introduction
Congress established the Medicare home health agency (HHA) benefit as a less intensive and less costly alternative to short-stay hospital inpatient care. HHA services covered by Medicare include intermittent part-time skilled nursing care; physical, occupational, or speech therapy; part-time home health aide services; medical social services; and durable medical equipment. To be eligible for HHA services, Medicare enrollees must be confined to their, homes1 and must have a plan of treatment developed by the attending physician. The health care must include intermittent part-time skilled nursing care or physical/speech therapy, and the HHA services must be provided by an agency participating in the Medicare program.
The Omnibus Budget Reconciliation Act of 1980 (Public Law 96-499) stimulated the use of HHA benefits by removing the HHA 100-visit limit, eliminating the 3-day prior hospital stay under hospital insurance, and permitting proprietary HHA's to operate in States not having licensure laws. Medicare's hospital prospective payment system (PPS) also had an impact on the use of HHA services. The effect of these changes are examined in this article.
Analysis
We focus on the number of persons served, visits, and amount of visit charges and reimbursements to measure the use and cost of HHA services. The data are classified by selected calendar years 1974 through 1986 (Table 1); age, sex, and Medicare status (Table 2); type of visit (Table 3); and principal diagnosis (Table 4).
Table 1. Trends in the use and cost of home health agency services under Medicare, by selected years of service: Calendar years 1974-86.
Year of service | Persons served | Visits | Total charges in thousands | Visit charges | Reimbursements | ||||||||
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Number in thousands | Per 1,000 enrollees | Number in thousands | Per person served | Per 1,000 enrollees | Amount in thousands | Per visit | Per person served | Per enrollee | Amount in thousands | Per person served | Per enrollee | ||
1974 | 392.7 | 16 | 8,070 | 21 | 340 | $147,499 | $137,406 | $17 | $350 | $6 | $141,464 | $360 | $6 |
1976 | 588.7 | 23 | 13,335 | 23 | 520 | 312,325 | 292,697 | 22 | 497 | 11 | 289,851 | 492 | 11 |
1978 | 769.7 | 28 | 17,345 | 23 | 639 | 500,747 | 474,498 | 27 | 617 | 18 | 435,322 | 566 | 16 |
1980 | 957.4 | 34 | 22,428 | 23 | 788 | 770,703 | 734,718 | 33 | 767 | 26 | 662,133 | 692 | 23 |
1982 | 1,171.9 | 40 | 30,787 | 26 | 1,044 | 1,296,454 | 1,232,684 | 40 | 1,052 | 42 | 1,104,715 | 943 | 37 |
1983 | 1,351.2 | 45 | 36,844 | 27 | 1,227 | 1,657,024 | 1,596,989 | 43 | 1,182 | 53 | 1,398,092 | 1,035 | 47 |
1984 | 1,515.9 | 50 | 40,337 | 27 | 1,324 | 1,982,033 | 1,843,706 | 46 | 1,216 | 61 | 1,666,253 | 1,099 | 55 |
1985 | 1,588.6 | 51 | 39,742 | 25 | 1,279 | 2,124,312 | 2,040,697 | 51 | 1,285 | 66 | 1,773,048 | 1,116 | 57 |
1986 | 1,600.2 | 50 | 38,359 | 24 | 1,208 | 2,190,238 | 2,102,253 | 55 | 1,314 | 66 | 1,795,820 | 1,122 | 57 |
SOURCE: Health Care Financing Administration, Office of Research and Demonstrations: Data from the Division of Program Studies.
Table 2. Home health agency services under Medicare for persons served, visits, charges, and reimbursements, by age, sex, and Medicare status: Calendar year 1986.
Age, sex, and Medicare status | Persons served | Visits | Total charges in thousands | Visit charges | Reimbursements | ||||||||
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Number in thousands | Per 1,000 enrollees | Number in thousands | Per person served | Per 1,000 enrollees | Amount in thousands | Per visit | Per person served | Per enrollee | Amount in thousands | Per person served | Per enrollee | ||
Total | 1,600 | 50.4 | 38,359 | 24.0 | 1,208 | $2,190,238 | $2,102,253 | $55 | $1.,314 | $66 | $1,795,820 | $1,122 | $57 |
Age | |||||||||||||
Under 65 years | 102 | 34.4 | 2,905 | 28.6 | 982 | 169,611 | 158,816 | 55 | 1,562 | 54 | 136,932 | 1,347 | 46 |
65-66 years | 102 | 25.9 | 2,279 | 22.3 | 578 | 132,105 | 126,946 | 56 | 1,242 | 32 | 107,902 | 1,056 | 27 |
67-68 years | 94 | 26.7 | 2,154 | 22.8 | 609 | 124,041 | 119,603 | 56 | 1,266 | 34 | 101,605 | 1,075 | 29 |
69-70 years | 109 | 32.9 | 2,512 | 23.0 | 757 | 145,041 | 139,544 | 56 | 1,277 | 42 | 118,794 | 1,087 | 36 |
71-72 years | 125 | 40.1 | 2,939 | 23.5 | 939 | 168,655 | 162,754 | 55 | 1,299 | 52 | 138,069 | 1,102 | 44 |
73-74 years | 133 | 47.5 | 3,147 | 23.7 | 1,124 | 179,501 | 173,131 | 55 | 1,301 | 62 | 147,769 | 1,111 | 53 |
75-79 years | 350 | 62.9 | 8,324 | 23.8 | 1,493 | 473,123 | 456,208 | 55 | 1,302 | 82 | 388,811 | 1,110 | 70 |
80-84 years | 301 | 84.4 | 7,202 | 24.0 | 2,023 | 409,340 | 394,139 | 55 | 1,311 | 111 | 336,169 | 1,119 | 94 |
85 years or over | 283 | 96.7 | 6,896 | 24.3 | 2,352 | 388,821 | 371,112 | 54 | 1,310 | 127 | 319,769 | 1,128 | 109 |
Sex | |||||||||||||
Male | 579 | 43.2 | 13,548 | 23.4 | 1,011 | 780,831 | 745,178 | 55 | 1,286 | 56 | 637,327 | 1,100 | 48 |
Female | 1,021 | 55.7 | 24,811 | 24.3 | 1,353 | 1,409,406 | 1,357,075 | 55 | 1,329 | 74 | 1,158,493 | 1,135 | 63 |
Medicare status | |||||||||||||
Aged | 1,499 | 52.0 | 35,454 | 23.7 | 1,231 | 2,020,626 | 1,943,437 | 55 | 1,297 | 68 | 1,658,888 | 1,107 | 58 |
Disabled | 102 | 34.4 | 2,905 | 28.6 | 982 | 169,611 | 158,816 | 55 | 1,562 | 54 | 136,932 | 1,347 | 46 |
SOURCE: Health Care Financing Administration, Office of Research and Demonstrations: Data from the Division of Program Studies.
Table 3. Distribution of home health agency charges and visits under Medicare, by type of charge and visit: Calendar years 1974 and 1986.
Type of charge and visit | 1974 | 1986 | Average Annual percent increase, 1974-86 | ||
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Number or amount | Percent | Number or amount | Percent | ||
Visit charges in thousands | $137,406 | 100.0 | $2,102,253 | 100.0 | 25.5 |
Nursing care | 89,989 | 65.5 | 1,146,225 | 54.5 | 23.6 |
Home health aide | 28,187 | 20.5 | 570,302 | 27.1 | 28.5 |
Physical therapy | 15,439 | 11.2 | 278,492 | 13.2 | 27.3 |
Other1 | 3,790 | 2.8 | 107,186 | 5.1 | 32.1 |
Visits in thousands | 8,070 | 100.0 | 38,359 | 100.0 | 13.9 |
Nursing care | 5,217 | 64.6 | 19,395 | 50.6 | 11.6 |
Home health aide | 1,888 | 23.4 | 12,713 | 33.1 | 17.2 |
Physical therapy | 784 | 9.7 | 4,631 | 12.1 | 16.0 |
Other1 | 181 | 2.2 | 1,629 | 4.2 | 20.1 |
Average charge per visit | $17.03 | NA | $54.80 | NA | 10.2 |
Nursing care | 17.25 | NA | 59.10 | NA | 10.8 |
Home health aide | 14.93 | NA | 44.86 | NA | 9.6 |
Physical therapy | 19.69 | NA | 60.14 | NA | 9.8 |
Other1 | 20.94 | NA | 65.80 | NA | 10.0 |
Includes speech or occupational therapy, medical social services, and other health disciplines.
NOTE: NA is for not applicable.
SOURCE: Health Care Financing Administration, Office of Research and Demonstrations: Data from the Division of Program Studies.
Table 4. Home health agency services under Medicare for persons served, total charges, and reimbursements, by principal diagnosis: Calendar year 1986.
Principal diagnosis | ICD-9-CM1 code | Persons served | Total charges | Reimbursements | ||
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Amount in thousands | Per person served | Amount in thousands | Per person served | |||
Total, all diagnoses | — | 1,589,202 | $2,170,118 | $1,365 | $1,778,767 | $1,119 |
Leading diagnoses | — | 396,402 | 573,422 | 1,446 | 471,048 | 1,188 |
Acute, ill-defined cerebrovascular disease | 436 | 90,217 | 176,136 | 1,952 | 144,746 | 1,604 |
Congestive heart failure | 428.0 | 76,110 | 94,259 | 1,238 | 77,103 | 1,013 |
Fracture, unspecified, of neck of femur, closed | 820.8 | 39,617 | 52,506 | 1,325 | 43,662 | 1,102 |
Chronic airway obstruction, not classified | 496 | 36,567 | 43,993 | 1,203 | 36,575 | 1,000 |
Essential hypertension, unspecified | 401.9 | 34,420 | 42,461 | 1,233 | 34,065 | 989 |
Diabetes mellitus, adult or unspecified type | 250.00 | 29,655 | 38,703 | 1,305 | 32,558 | 1,097 |
Pneumonia, organism unspecified | 486 | 25,020 | 28,444 | 1,136 | 23,319 | 932 |
Bronchus and lung, unspecified | 162.9 | 23,580 | 23,011 | 975 | 19,065 | 808 |
Acute myocardial infarction, unspecified site | 410.9 | 21,277 | 21,989 | 1,033 | 17,895 | 841 |
Incontinence of urine | 788.3 | 19,937 | 51,915 | 2,603 | 42,055 | 2,109 |
All other diagnoses | — | 1,192,800 | 1,596,695 | 1,338 | 1,307,718 | 1,096 |
International Classification of Diseases, 9th Revision, Clinical Modification.
SOURCE: Health Care Financing Administration, Office of Research and Demonstrations: Data from the Division of Program Studies.
The data in Table 1 can be used to measure changes in the use of HHA benefits for the 4 years prior to the start of the PPS (1980-83) and for a similar period of time following the implementation of the PPS (1983-86). (PPS started in October 1983.) The number of persons served using HHA benefits rose from 957,400 in 1980 to 1,351,200 in 1983, an average annual rate of growth of 12.2 percent; the comparable figure for the period 1983-86 was only 5.8 percent. Similarly, persons served per 1,000 enrollees rose from 34 to 45 during the period 1980-83, an average annual increase of 9.8 percent. From 1983 through 1986, the increase was only 3.6 percent. HHA visits rose at an annual rate of 18.0 percent from 1980 through 1983, compared with a rise of only 1.3 percent during the period 1983-86. Both visits per person served and per 1,000 enrolled increased in the pre-PPS period, but fell during the PPS period. Thus, for the measures presented in Table 1, the rate of use of HHA services was less during the PPS period than prior to PPS.
The slower rate of growth in the use of Medicare HHA services following the implementation of PPS may reflect a variety of possible causes, such as:
The sharp decline among Medicare beneficiaries in the discharge rate from short-stay hospitals during the PPS period. On the other hand, the reduced lengths of hospital stay following the PPS could have resulted in greater need and use of HHA services following discharge.
The slower growth of Medicare HHA use during the period 1983-86 may be representing movement toward a new level of equilibrium following the spurt during the period 1980-83 caused by the 1980 OBRA legislation.
The competing growth in HHA use outside the Medicare sector, for example, in the Medicaid and private pay sectors (U.S. Department of Health and Human Services, 1987).
The proportion of aged persons receiving HHA services increased in each successive age group (Table 2). The rate of persons served per 1,000 enrollees rose from 25.9 for those 65-66 years of age to 96.7 for those 85 years or over, an increase of 273 percent. There was a similar rise in the number of visits per 1,000 enrollees, from 578 for those 65-66 years of age to 2,352 for persons 85 years or over, an increase of 307 percent. In contrast, visits per person and reimbursements per person increased only slightly with age.
The proportion of females using HHA services (56 persons served per 1,000 enrollees) was 29 percent higher than that of males (43 persons served per 1,000 enrollees). Females had one-third more visits per 1,000 enrollees than did males, 1,353 and 1,011 respectively. By sex, visits per person were nearly the same.
The proportion of the aged using HHA services (52 per 1,000 enrollees) was 51 percent higher than the proportion among the disabled (34 per 1,000 enrollees). In contrast, the disabled had a 21 percent higher rate of visits per person served than did the aged (29 versus 24).
A substantial change occurred during the period 1974-86 in the distribution of visits and charges by type of HHA visit (Table 3). Visits of home health aides, physical therapists, speech and occupational therapists, and other health disciplines increased from 35 percent of all visits to nearly one-half of all visits during that period. A similar shift is evident in the proportion of visit charges by type of HHA visit. At the same time, there was a corresponding relative decrease in the use of nursing care services during the period 1974-86. The proportion of nursing care visits to all visits dropped from 64.6 percent in 1974 to 50.6 percent in 1986. Similarly, the proportion of nursing care visit charges dropped from 65.5 percent in 1974 to 54.5 percent in 1986.
Charges per visit for physical therapy increased from almost $20 in 1974 to slightly over $60 in 1986, and other types of visits increased by similar amounts (Figure 1).
The 10 leading principal diagnoses of persons using HHA services accounted for 25 percent of all persons using HHA services and 26 percent of both total charges and reimbursements, derived from Table 4.
The most frequent principal diagnosis (5.7 percent) for all persons using HHA services was acute, ill-defined cerebrovascular disease. Other circulatory system diagnoses were heart diseases—congestive heart failure (4.8 percent) and acute myocardial infarction, unspecified site (1.3 percent). Another common condition, fracture, unspecified, of neck of femur, closed, accounted for 2.5 percent of all persons served using HHA services. Persons with these cardiovascular and orthopedic conditions probably used HHA services following a hospital stay.
Footnotes
The Omnibus Budget Reconciliation Act (OBRA) of 1987 (Public Law 100-203) specifically defines homebound; it was previously defined in the Health Care Financing Administration's program guidelines. The OBRA 1987 provision became effective January 1, 1988.
Reprint requests: Martin Ruther, Health Care Financing Administration, Office of Research and Demonstrations, Room 2502 Oak Meadows Building, 6325 Security Boulevard, Baltimore, Maryland 21207.
Reference
- U.S. Department of Health and Human Services. Report to Congress: Impact of the Medicare Hospital Prospective Payment System, 1985 Annual Report. Washington: United States Government Printing Office; Aug. 1987. HCFA Pub. No. 03251. Office of Research and Demonstrations, Health Care Financing Administration. [Google Scholar]