Abstract
Intermittently since 2001, Medicare has provided a percentage increase over standard payments to home health agencies that serve rural beneficiaries. Yet the effect of rural add-on payments on the supply of home health agencies that serve rural communities is unknown. Taking advantage of the pseudo–natural experiment created by varying rural add-on payment amounts over time, we used data from Home Health Compare to examine how the payments affected the number of home health agencies serving rural counties. Our results suggest that while supply changes are similar in rural counties adjacent to urban areas and in urban counties regardless of add-on payments, only higher add-on payments (of 5 percent or 10 percent) keep supply changes in rural counties not adjacent to urban areas on pace with those in urban counties. Our findings support the recent shift from broadly applied to targeted rural add-on payments but raise questions about the effects of the amount and eventual sunset of these payments on the supply of home health agencies serving remote rural communities.
Nearly twelve thousand Medicare-certified home health agencies served 3.4 million fee-for-service beneficiaries in 2017.1 The vast majority of beneficiaries live in counties served by at least one agency, and overall use of home health care is similar, on average, between rural and urban beneficiaries.1–3 However, some studies suggest that there are disparities in access to home health care for beneficiaries living in the most remote rural communities or communities with relatively few agencies, as well as for specific populations.3–10 Yet as rural counties experience faster growth than urban counties in the population older than age sixty-five,11 the availability of home health care is critical.
Providing home health care to beneficiaries in rural communities presents a unique set of challenges. Low concentrations of patients are often dispersed over large geographic areas, which results in long travel times for staff and increased costs for home health agencies.12 Thus, it is unsurprising that average margins are often smaller for agencies serving rural populations than for those serving urban ones.1 Recruiting and retaining a workforce to provide home health care in rural communities can also be difficult.12 As a result, the agencies might not be able to serve all rural beneficiaries, initiate care in a timely manner, deliver the full complement of covered services, or provide enough visits to facilitate high-quality outcomes.4–10,13,14 This is concerning, since rural home health patients are sicker and more at risk for hospitalization than their urban counterparts are.15
In recognition of the challenges involved in operating in rural communities, Medicare has intermittently provided rural add-on payments. These payments provide a percentage increase in standard episode and per visit payments and are available to home health agencies located in both rural and urban counties for providing services to beneficiaries living in rural communities. From 2001 to the present, the amount of the rural add-on payments has varied from 0 percent to 10 percent, based on the political climate and budgetary considerations ( exhibit 1).
EXHIBIT 1.
Payment adjustments for home health agencies serving rural Medicare beneficiaries, 2001–22
| Effective date | Rural add-on payment | Associated policy |
|---|---|---|
| Apr 2001–Apr 2003 | 10% | Benefits Improvement and Protection Act of 2000 |
| May 2003–Mar 2004 | 0% | —a |
| Apr 2004–Mar 2005 | 5% | Medicare Prescription Drug, Improvement, and Modernization Act of 2003 |
| Apr 2005–Dec 2005 | 0% | —a |
| Jan–Dec 2006 | 5% | Deficit Reduction Act of 2005 |
| Jan 2007–Mar 2010 | 0% | —a |
| Apr 2010–Dec 2016 | 3% | Affordable Care Act of 2010 |
| Jan–Dec 2017 | 3% | Medicare Access and CHIP Reauthorization Act of 2015 |
| Jan–Dec 2018 | 3% | Bipartisan Budget Act of 2018 |
| Jan 2019–Dec 2022 | Varies based on population density and home health utilization and phases out over 2–4 years | Bipartisan Budget Act of 2018 |
SOURCE Authors’ compilation. NOTES The rural add-on payment amount represents a percentage increase added to standard sixty-day episode and per visit payments for home health care to home health agencies that serve rural Medicare beneficiaries. For 2019, the payment amount was 1.5 percent for rural counties with high home health utilization, 4.0 percent for low-density rural counties without high home health utilization, and 3.0 percent for all other rural counties. Add-on payment amounts drop by 1 percent annually starting in 2020, until they are phased out. The amounts for 2020–22 are planned and will go into effect unless additional legislation is passed that amends them.
Not applicable.
Research on the introduction of prospective payment for home health agencies suggests that markets are responsive to payment incentives.16–18 However, whether rural add-on payments have encouraged more of the agencies to serve rural communities specifically has not been well examined. Furthermore, concerns have been raised about the broad application of rural add-on payments, as they have historically rewarded agencies that serve rural counties with disproportionately high utilization.2 In response to these concerns, the Bipartisan Budget Act of 2018 introduced revised targeting for 2019–22 that accounts for population density and use of home health care in determining the amount of the add-on payment. Yet the appropriate amount of add-on payments to maintain or increase the supply of home health agencies in underserved rural communities is unknown.
Therefore, we conducted the first longitudinal study of the impact of rural add-on payments on the supply of home health agencies that serve rural communities. By taking advantage of the pseudo–natural experiment of varying rural add-on payments and using publicly available data from the Centers for Medicare and Medicaid Services (CMS), we explored whether the presence and amount of rural add-on payments have increased the number of the agencies serving rural counties as compared with urban counties, beyond the overall growth experienced in the home health market over time.
Study Data And Methods
STUDY DESIGN AND DATA SOURCES
We performed a secondary analysis of administrative data from CMS to assess the county-level supply of home health agencies in the period 2002–17 with respect to varying rural add-on payments and urban-rural status. We linked publicly available data from Home Health Compare and the CMS Geographic Variation Public Use File. The former source contains data from reports filed quarterly by Medicare-certified agencies—data that are used to publish quality indicators on the Home Health Compare website for consumers. In addition, each quarterly report contains information on ZIP codes of beneficiaries served during the twelve-month reporting period, as well as on services offered by the agency. The Geographic Variation Public Use File contains summary annual data on Medicare fee-for-service beneficiaries, utilization, and costs at the county level.
VARIABLES
Key independent variables were the interactions between twelve-month time periods and urban-rural status. To capture changes in rural add-on payments, we matched effective dates of the payments as closely as possible with available data for twelve-month time periods from Home Health Compare. Of the sixteen time periods used in the analysis, twelve matched rural add-on time frames exactly. Minor discrepancies occurred when twelve-month time periods from Home Health Compare did not match effective add-on payment periods: Two time periods had one-month discrepancies in coverage (May 2003 and March 2004), one had a two-month discrepancy (April and May 2004), and one had a three-month discrepancy (March 2005 and January and February 2006).
We created three categories of urban-rural status, using a two-step process. First, we categorized all counties as urban or rural based on how CMS designates counties as rural for eligibility for the rural add-on payments, by using core-based statistical areas. We allowed the CMS designation for urban-rural status to vary over time. Second, we further classified counties designated as rural by CMS into adjacent or not adjacent to urban areas using 2013 Urban Influence Codes, recognizing that rural add-on payments may have a differential impact on the supply of home health agencies in rural counties located near urban areas versus more remote rural counties.
The population-adjusted number of the agencies serving a county was the outcome of interest. We derived this measure of supply using methodology consistent with one of the Medicare Payment Advisory Commission’s measures for evaluating access to home health care.1 First, we calculated the number of unique Medicare-certified agencies that served a county in each twelve-month time period using the ZIP codes served by each agency and a ZIP code–county crosswalk. Then we standardized the measure by dividing the counts of the agencies by the population of fee-for-service Medicare beneficiaries in each county for the calendar year that was most closely aligned with the twelve-month period.
We included control variables to account for other factors that might influence the supply of home health agencies. County-level control variables from the Geographic Variation Public Use File included the number of fee-for-service Medicare beneficiaries, average beneficiary age, percentage of female beneficiaries, average Hierarchical Condition Categories score (a measure of estimated future costs of health care using prior claims experience), and percentage of beneficiaries eligible for Medicaid in each year. We controlled for county-level inpatient hospital days, skilled nursing facility days, and outpatient visits covered by Medicare per thousand fee-for-service beneficiaries, as the use of these services may drive referrals to or serve as substitutes for home health care. In addition to county-level market characteristics, we included state-level indicators for whether a certificate-of-need law or a moratorium on the certification of new home health agencies was present, because these regulations influence the opening of new agencies and the expansion of existing ones. We included a state dummy variable to account for geographic variation and unobserved state-level differences that might influence agency markets.
ANALYSIS
The unit of analysis was the county. We used a mixed-effects multiple linear regression modeling approach to assess the population-adjusted number of home health agencies that served each county by urban-rural status for each time period. We ran the model first using the dichotomous specification of urban-rural status (urban versus rural) and then using the three-category specification (urban, urban-adjacent rural, and non-urban-adjacent rural). We used a time period dummy variable as a fixed effect to control for growth in the home health market over time and other time-varying Medicare payment changes (for example, rebasing and market-basket updates, explained below) that were applied to all agencies during the study period. In addition, we used a random-effects specification to allow for correlation between observations by county across time periods. We also controlled for county-level health care market characteristics; state-level regulations; and state fixed effects, as described above. We report interactions between time period and urban-rural status as key findings because these interactions represent the impact of rural add-on payments based on urban-rural status, beyond overall change in supply over time and other universally applied payment changes.
We conducted four sensitivity analyses to test the robustness of our results. First, we replaced urban-rural status with the revised rural add-on payment categories, which accounted for both population density and recent utilization (that is, urban, rural—high utilization, rural—low density without high utilization, and rural—all other). This analysis allowed for the examination of changes in supply, specifically among rural counties with low utilization. Second, we excluded states with extremely high growth during the study period and those in which there were state-wide moratoria on certifying new home health agencies, as these states might have had an outsize influence on results. Third, we used full-service home health agencies as a more restrictive outcome than all agencies. We defined full-service agencies as those that offered all six services that are covered under Medicare’s home health benefit: skilled nursing, physical therapy, occupational therapy, speech therapy, medical social work, and home health aide services. Fourth, we restandardized the number of agencies per county by all Medicare beneficiaries (fee-for-service Medicare plus Medicare Advantage beneficiaries) and added a control for county-level Medicare Advantage penetration.
Analyses were conducted using Stata, version 13.1.
LIMITATIONS
This study had several limitations. First, the supply of home health agencies is a necessary, but not sufficient, measure for understanding potential disparities in access to home health care at the county level. Home Health Compare data do not include how many beneficiaries were served by the agencies in each ZIP code, which prevented us from calculating the volume of services provided. Thus, we could not examine the capacity of the agencies, which would have offered a more nuanced measure of supply.
Second, our approach might have overestimated the supply if an agency did not serve the entire county or had limited capacity. Equally, our approach might have underestimated the supply if an agency included a county in its service area but did not serve any beneficiaries there during the reporting period.
Third, the accuracy of ZIP code reporting is not known.
Fourth, slight discrepancies between time periods from Home Health Compare and the effective dates of rural add-on payments introduced measurement error that may have biased our estimates toward zero.
Fifth, despite advanced notice of payment changes for many time periods and prior evidence of relatively rapid responsiveness of home health markets to other payment policy changes,16–20 home health agencies might not have been able to open in and expand into rural counties quickly—for example, because of their inability to hire staff rapidly. Therefore, consideration of adjacency to an urban area is important as urban-adjacent rural counties may be served by rural and urban agencies.
Finally, while changes in the numbers of agencies may be significant, magnitudes might not be large enough to indicate changes in the supply of agencies that result in differences in capacity and thus changes in access that beneficiaries can perceive.
Study Results
Before a 2015 update of rural designations, 35 percent of the 3,143 US counties were considered urban and 65 percent were considered rural, according to the designation CMS uses to apply rural add-on payments. After the update, the shares were 37 percent and 63 percent, respectively. Before the update, 54 percent of rural counties were considered to be adjacent to urban areas and 46 percent were not, while after the update the shares were 53 percent and 47 percent, respectively. Across all years, 94 percent of counties with no home health agencies were rural. On average, rural counties had higher population-adjusted numbers of home health agencies than urban counties did (exhibit 2). During the study period, the population-adjusted number of home health agencies increased more for urban-adjacent than for non-urban-adjacent rural counties.
EXHIBIT 2.
Average population-adjusted numbers of home health agencies serving a county, by urban-rural status, 2002–17
|
SOURCE Authors’ analysis of data from Home Health Compare and the Geographic Variation Public Use File of the Centers for Medicare and Medicaid Services (CMS). NOTES The numbers of home health agencies are adjusted for the number of fee-for-service Medicare beneficiaries in each county. Urban-rural status is based on eligibility for rural add-on payments from CMS using core-based statistical areas and further specified by urban adjacency using Urban Influence Codes. Rural add-on payments are shown in exhibit 1.
Nearly 99 percent (3,105) of the counties had data available for control variables for the fully adjusted regression models. Time-period fixed effects indicated rapid year-to-year growth in the home health market through 2010 (exhibit 3). After 2010 the overall supply of home health agencies became more stable, though some significant year-to-year upswings and downswings occurred. Before 2010 the highest year-to-year growth rate in the number of agencies per 1,000 beneficiaries was 0.27, in 2006. After 2010 the largest year-to-year change was a decrease of 0.15, in 2017.
EXHIBIT 3.
Adjusted changes in the county-level supply of home health agencies, 2002–17
| Change in average number of agencies per 1,000 beneficiaries per county | |||
|---|---|---|---|
|
|
|||
| Time period | Rural add-on payment | Year-to-year | Cumulative |
| Jun 2002–May 2003 | 10% | —a | (ref) |
| Jun 2003–May 2004 | 0% | 0.12**** | 0.12**** |
| Mar 2004–Feb 2005 | 5% | 0.10**** | 0.22**** |
| Mar 2005–Feb 2006 | 0% | 0.18**** | 0.40**** |
| Jan 2006–Dec 2006 | 5% | 0.27**** | 0.67**** |
| Jan–Dec 2007 | 0% | 0.15**** | 0.82**** |
| Jan–Dec 2008 | 0% | 0.15**** | 0.97**** |
| Jan–Dec 2009 | 0% | 0.00 | 0.97**** |
| Apr 2010–Mar 2011 | 3% | 0.15**** | 1.12**** |
| Jan–Dec 2011 | 3% | −0.11**** | 1.01**** |
| Jan–Dec 2012 | 3% | −0.03 | 0.98**** |
| Jan–Dec 2013 | 3% | 0.09**** | 1.07**** |
| Jan–Dec 2014 | 3% | −0.08*** | 0.99**** |
| Jan–Dec 2015 | 3% | 0.14**** | 1.13**** |
| Jan–Dec 2016 | 3% | −0.05 | 1.08**** |
| Jan–Dec 2017 | 3% | −0.15**** | 0.93**** |
SOURCE Authors’ analysis of data from Home Health Compare and the Geographic Variation Public Use File of the Centers for Medicare and Medicaid Services, and of state certificate-of-need regulations. NOTES The analysis accounts for the correlation across counties over time using random effects specification and adjusts for urban-rural status (urban, urban-adjacent rural, and non-urban-adjacent rural), explained in the notes to exhibit 2; time period; interaction between urban-rural status and time period; state fixed effects; Medicare beneficiary characteristics and utilization at the county level; and state-level regulations on home health agency supply. Significance refers to changes in supply, comparing the current time period to the prior time period for the year-to-year column, and to changes in supply, comparing the current time period to the first time period, for the cumulative column.
Not applicable.
p < 0:01
p < 0:001
When we compared all rural counties and all urban counties, we found no significant differences by time period in the number of population-adjusted home health agencies (exhibit 4). When we compared urban-adjacent rural counties and urban counties, there were almost no significant differences by time period, which suggests that supply changes in the two groups of counties were similar, regardless of the rural add-on amount.
EXHIBIT 4.
Changes in the county-level supply of home health agencies, by urban-rural status, June 2002–December 2017
| Change in average number of agencies per 1,000 beneficiaries per county (versus urban counties) | ||||
|---|---|---|---|---|
|
|
||||
| Time period | Rural add-on payment | All rural counties | Urban-adjacent rural counties | Non-urban-adjacent rural counties |
| Jun 2002–May 2003 | 10% | (ref) | (ref) | (ref) |
| Jun 2003–May 2004 | 0% | 0.001 | 0.06* | −0.08 |
| Mar 2004–Feb 2005 | 5% | 0.04 | 0.11** | −0.07 |
| Mar 2005–Feb 2006 | 0% | −0.04 | 0.04 | −0.14** |
| Jan–Dec 2006 | 5% | 0.02 | 0.15 | −0.15 |
| Jan–Dec 2007 | 0% | −0.04 | 0.11 | −0.21* |
| Jan–Dec 2008 | 0% | −0.11 | 0.08 | −0.35** |
| Jan–Dec 2009 | 0% | −0.20 | 0.04 | −0.50**** |
| Apr 2010–Mar 2011 | 3% | −0.25* | 0.07 | −0.62**** |
| Jan–Dec 2011 | 3% | −0.21 | 0.11 | −0.63**** |
| Jan–Dec 2012 | 3% | −0.18 | 0.19 | −0.64**** |
| Jan–Dec 2013 | 3% | −0.20 | 0.16 | −0.66**** |
| Jan–Dec 2014 | 3% | −0.20 | 0.21 | −0.69**** |
| Jan–Dec 2015 | 3% | −0.19 | 0.24 | −0.67**** |
| Jan–Dec 2016 | 3% | −0.22 | 0.23 | −0.74**** |
| Jan–Dec 2017 | 3% | −0.22 | 0.22 | −0.72**** |
SOURCE Authors’ analysis of data from Home Health Compare and the Geographic Variation Public Use File of the Centers for Medicare and Medicaid Services, and of state certificate-of-need regulations. NOTES The results represent the interaction between a county’s urban-rural status and time period, with June 2002–May 2003 as the reference time period and urban as the reference for urban-rural status. The analysis accounts for correlation and adjusts for certain factors, as explained in the notes to exhibit 3. Significance refers to differences in the change in the average number of home health agencies between each time period and the reference time period.
p < 0:10
p < 0:05
p < 0:001
When we compared non-urban-adjacent rural counties and urban counties, we found no significant difference in changes in the supply of home health agencies during time periods with a 5 percent add-on payment compared to a 10 percent add-on payment. However, there was a significant difference during time periods with a 0 percent add-on payment, compared to periods with a 10 percent add-on payment. The magnitude of growth for three of the five periods with a 0 percent add-on payment versus a 10 percent add-on payment was significantly smaller for non-urban-adjacent rural counties. That is, compared to June 2002–May 2003, when the 10 percent add-on payment was in effect, the number of home health agencies per 1,000 Medicare beneficiaries declined by 0.14 for the period March 2005–February 2006, 0.35 for the year 2008, and 0.50 for the year 2009. During periods with 3 percent add-on payments (which occurred after initial rapid growth in the home health market overall), compared to urban counties, non-urban-adjacent rural counties experienced significantly larger decreases during market downswings after 2010 (online appendix exhibit A0).21
The results of all sensitivity analyses were consistent with those of the primary analysis (see the appendix).21 Time-period fixed effects indicated significant growth in the home health agency market in the first half of the study period, with slightly smaller magnitudes in the sensitivity analyses that excluded high-utilization states and states with moratoria. Time periods with 0 percent or 3 percent add-on payments were generally associated with significantly smaller increases in agencies in non-urban-adjacent rural counties compared to urban counties, while time periods with 5 percent or 10 percent add-on payments were generally not associated with significant differences. Findings from the sensitivity analysis that included Medicare Advantage beneficiaries in the population adjustment and Medicare Advantage penetration were similar and align with recent research, which suggests similarities in utilization for Medicare Advantage and fee-for-service Medicare beneficiaries within geographic regions.22
The sensitivity analysis that used revised add-on payment categories indicated that high-utilization rural counties had significantly higher growth compared to urban counties across almost all time periods, with the largest magnitudes occurring when rural add-on payments were in effect. Conversely, results for low-density rural counties without high utilization and for all other rural counties tracked with the results in the primary analysis for non-urban-adjacent rural counties, but effects for former group of counties had larger magnitudes. In the last four time periods with 3 percent add-on payments, negative coefficients for low-density rural counties without high utilization were large enough to represent a decrease in the supply of home health agencies.
Discussion
Findings from our primary and sensitivity analyses support the recent shift from add-on payments applied uniformly to rural counties to add-on payments targeting remote and underserved counties, as mandated by the Bipartisan Budget Act. However, our findings also suggest that only higher rural add-on payment amounts (for example, 5 percent or more) help increase, or at least maintain, the supply of home health agencies operating in the most remote rural counties. Even if the 4 percent add-on payment provided to low-density counties without high utilization in 2019 incentivized agencies to serve the most rural counties, any increases or maintenance in the supply achieved in 2019 might not be sustained as payments decrease and are phased out over the next three years.
When our results are interpreted, it must be considered that increasing the supply of home health agencies in the most rural communities does not necessarily translate to increased access. County-level supply of home health agencies represents only one component of access and does not consider intracounty variation or capacity. This limitation is reflected in our finding of a higher population-adjusted supply of the agencies in rural versus urban counties, even though average aggregate utilization is similar between rural and urban beneficiaries.1–3 That is, rural counties may require a higher supply of home health agencies to deliver similar amounts of care, because of capacity constraints. Furthermore, counties with no agencies or no full-service agencies are overwhelmingly rural. Access to care is also affected by referrals and certification regulations that require physicians to certify that a patient needs home health care—which can be challenging in rural areas with physician shortages.23
If we set aside the imperfect relationship between supply, capacity, and access, whether increased access is necessary remains a fundamental question. The optimal amount of home health care for Medicare beneficiaries is unknown, and home health care remains a major driver of geographic variation in Medicare spending.24–26 Thus, we cannot state conclusively that the supply of home health agencies should be increased in rural counties. That is, differences in agency supply by urban-rural status reflect counties being under- or overserved relative to each other rather than whether they meet an objective standard, and reductions in supply may be appropriate in some cases.
Revised rural add-on payments are occurring in a larger context of payment reform. A new home health prospective payment system mandated by the Bipartisan Budget Act has been implemented in 2020 to address high geographic variation and rapid growth in utilization, high average margins for home health agencies, and potentially unnecessary service provision to increase profits.1,27 CMS estimates that rural agencies will see an increase in reimbursement of 4 percent, on average, under the new model, which seems promising.28 However, the response to the new model remains to be seen. During the transition to the original prospective payment system, the early negative impacts on the use of home health care and average number of visits due to agency closures, service area contractions, and staffing decreases may have been more pronounced in rural counties compared to urban counties.18,29–32 Staffing remains a challenge for rural providers,12 and some hospital-based rural home health agencies remain operational to serve their communities despite losing money.33
Other payment policies may also affect the supply of agencies that serve rural communities. Results on quality and spending from an early evaluation of the Home Health Value-Based Purchasing demonstration are mixed, and how future downward payment adjustments to agencies will affect access to care for vulnerable populations such as rural beneficiaries remains to be seen.34 Participation in accountable care organizations (ACOs) is an option for agencies, though fewer than a third of Medicare ACOs include rural providers, and only a handful operate exclusively in rural counties.35 Rebasing and market-basket reductions are applied uniformly to all agencies and have historically had similar effects on per episode payment changes for rural and urban episodes.3 (Rebasing adjusts agency payments downward in response to coding changes unrelated to increased acuity, and market-basket reductions adjust downward annual increases tied to price inflation for goods and services purchased by agencies to provide care.) However, rebasing and market-basket reductions may have an adverse effect on access to care and specific services for high-need, vulnerable populations.36
Future research should examine the maturation of the home health market under these new and overlapping policies. Even though many policies are applied uniformly to all home health agencies, the realized impact of payment changes at the agency level will depend to an extent upon characteristics of both the agency (for example, its profit status and quality, and whether it is facility based or freestanding) and the beneficiaries it serves (such as case-mix and percentage rural).16,36–38 Additional explorations of the effects at the agency and beneficiary levels using claims data are warranted.
Amid concerns about growth in home health expenditures, it is critical to note that home health care remains a relatively low-cost service that represents about 3 percent of overall Medicare expenditures.1 For many patient populations, home health care results in improvements in self-care outcomes that are comparable to or better than outcomes achieved by inpatient rehabilitation facilities and skilled nursing facilities, at a much lower per case cost.39,40 Therefore, concerns about overuse of home health care should be balanced with the need to retain an adequate supply of home health agencies to provide these services. Providing rural add-on payments to maintain or increase the supply of agencies in the most remote rural counties, if supply translates to access, may help prevent increased use of expensive institutional postacute care.
Conclusion
The impact of rural add-on payments on the supply of home health agencies in rural counties is associated with payment amount and adjacency to urban areas. While agency supply changes over time in urban-adjacent rural counties were similar to supply changes in urban counties, agency supply changes in non-urban-adjacent rural counties were similar to supply changes in urban counties only when the add-on payment amount was 5 percent or 10 percent. Newly revised targeting of rural add-on payments allocates higher payments to rural counties with low population density and low use of home health, compared with other rural counties. While our study findings support targeted rather than broadly applied rural add-on payments, it is unknown whetherthecurrent4percentamountisenough to increase or maintain agency supply in the most rural communities. As the agencies navigate the revised targeting and phasing out of rural add-on payments along with major restructuring of the home health prospective payment system and related policies, careful monitoring of potential adverse effects on access to home health care for the most vulnerable rural beneficiaries is essential.
Supplementary Material
Acknowledgments
Previous versions of this article were presented at the Annual Meeting of the American Congress of Rehabilitation Medicine in Atlanta, Georgia, October 26, 2017; at the Northwest Rural Health Conference in Spokane, Washington, March 28, 2018; and in a poster session at the AcademyHealth Annual Research Meeting in Seattle, Washington, June 24, 2018. All authors were supported by the Agency for Healthcare Research and Quality (Grant No. R03HS024777) for this study. The opinions expressed are those of the authors and do not reflect the official position of the Agency for Healthcare Research and Quality or the Department of Health and Human Services.
Contributor Information
Tracy M. Mroz, Department of Rehabilitation Medicine, University of Washington, in Seattle.;
Davis G. Patterson, Department of Family Medicine, University of Washington.;
Bianca K. Frogner, Department of Family Medicine, University of Washington.;
NOTES
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