title: Medicare home health payment reform may jeopardize access for clinically complex and socially vulnerable patients.
abstract: The Affordable Care Act directed Medicare to update its home health prospective payment system to reflect more recent data on costs and use of services-an exercise known as rebasing. As a result, the Centers for Medicare and Medicaid Services will reduce home health payments 3.5 percent per year in the period 2014-17. To determine the impact that these reductions could have on beneficiaries using home health care, we examined the Medicare reimbursement margins and the use of services in a national sample of 96,621 episodes of care provided by twenty-six not-for-profit home health agencies in 2011. We found that patients with clinically complex conditions and social vulnerability factors, such as living alone, had substantially higher service delivery costs than other home health patients. Thus, the socially vulnerable patients with complex conditions represent less profit-lower-to-negative Medicare margins-for home health agencies. This financial disincentive could reduce such patients' access to care as Medicare payments decline. Policy makers should consider the unique characteristics of these patients and ensure their continued access to Medicare's home health services when planning rebasing and future adjustments to the prospective payment system.
authors.affiliation: Robert J. Rosati (rrosati@centerlight.org) is vice president of clinical informatics at CenterLight Healthcare, in the Bronx, New York. Prior to working at CenterLight Healthcare, he was vice president of clinical informatics at the Visiting Nurse Service of New York (VNSNY) when the study was conducted.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Rosati
authors.affiliation: David Russell is a senior evaluation scientist at the VNSNY, in New York City.
authors.forename: David
authors.initials: D
authors.lastname: Russell
authors.affiliation: Timothy Peng is director of business intelligence and outcomes at the VNSNY.
authors.forename: Timothy
authors.initials: T
authors.lastname: Peng
authors.affiliation: Carlin Brickner is associate director of biostatistics at the VNSNY.
authors.forename: Carlin
authors.initials: C
authors.lastname: Brickner
authors.affiliation: Daniel Kurowski is a research analyst at the VNSNY.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kurowski
authors.affiliation: Mary Ann Christopher is president and CEO of the VNSNY.
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Christopher
authors.affiliation: Kathleen M. Sheehan is vice president for public policy of the Visiting Nurse Associations of America, in Washington, D.C.
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Sheehan
mesh_terms: D017050:Episode of Care; D018166:Health Care Reform / Q000191:economics*; D006297:Health Services Accessibility / Q000191:economics*; D018574:Home Care Agencies / Q000191:economics*; D006801:Humans; D008134:Long-Term Care / Q000191:economics; D006278:Medicare / Q000191:economics*; D058991:Patient Protection and Affordable Care Act / Q000191:economics*; D011445:Prospective Payment System / Q000191:economics*; D012051:Reimbursement Mechanisms / Q000191:economics*; D014481:United States; D035862:Vulnerable Populations
keywords: Health Spending; Home Care; Long-Term Care; Medicare; Special Populations