Evolution of the home health care market: The expansion and quality performance of multi‐agency chains

Abstract

Objective To examine the growth and evolution of the home health agency (HHA) market and to compare quality performance across HHA ownership categories. Data Source Agency characteristics were extracted from Medicare cost reports and Provider of Services file. Quality of care and patient characteristics were extracted from Quality of Patient Care Star Ratings and HHA Public Use File. Study Design Agency‐ and state‐level analyses were conducted to describe HHA market trends. Patient characteristics and quality measures were compared across ownership categories of interest. Data Collection/Extraction Methods All Medicare‐certified HHAs in operation, 2005‐2018. Principal Findings Over the study period, the HHA sector grew substantially, increasing from 7899 to 10 818 agencies, and chain‐owned HHAs doubled in number from 903 (11.4% of all agencies) to 1841 (17.0%). In 2018, across agency types, for‐profit nonchain agencies were the largest category both in the number of agencies (67.8%) and the number of Medicare enrollees served (40.7%). Additionally, for‐profit nonchain agencies grew most in total number, from 4293 (54.3%) to 7337 (67.8%), while for‐profit chain agencies grew most in the number of Medicare enrollees served, from 439 998 (12.9%) to 1 082 385 (28.3%). Regarding patient composition, for‐profit nonchain agencies served the highest proportion of dual eligible beneficiaries (42.2%) and African‐Americans (27.9%) among all agency types. Regarding quality performance, a higher star rating is significantly (P < .01) associated with chain agency status. Moreover, chain HHAs performed better on self‐reported process measures, and risk‐adjusted self‐reported outcome measures; however, they performed worse on risk‐adjusted claims‐based outcome measures. These results were similar across for‐profit and nonprofit chain agencies. Conclusion Chains play a growing role in the home health sector. Substantial differences in geographic distribution, patient composition, and quality performance were observed between chain‐ and nonchain HHAs. Examining the growth and performance of multi‐agency chains can help inform quality reporting and monitoring, assess payment adequacy, and facilitate greater transparency and accountability within the HHA marketplace.

Claims-Based vs Agency-Reported Patient Outcomes Among Home Health Agencies, 2013-2019

“…7,8 It has also been noted that quality varies by profit status, chain membership, and geography. [9][10][11] Our work complements the existing literature by providing an analysis of the longer-term association of HHA star ratings. We examine changes in patient-level outcomes prior to the introduction of the star ratings program (2013-2015) with several years of postexposure period follow-up (2016-2019) to assess differences between claims-based and HHA-reported measures.…”

“…Other work has examined factors contributing to variation in access and use of high-quality HHAs, finding that Black and Hispanic as well as lower-income HHA users have lower probabilities of high-quality HHA use compared with their White or higher income neighbors . It has also been noted that quality varies by profit status, chain membership, and geography …”

Home health agency adoption of quality improvement activities and association with performance

“…For example, we did not examine chain status in our analyses; chains may have greater capabilities for implementing helpful practices beyond the QI activities studied here. 44…”

“…It is also possible that high‐performing agencies reported implementing QI activities but also had other unobserved characteristics that were actually responsible for their higher Star Ratings. For example, we did not examine chain status in our analyses; chains may have greater capabilities for implementing helpful practices beyond the QI activities studied here 44 …”

Disparities in Successful Discharge to the Community Following Use of Medicare Home Health by Level of Neighborhood Socioeconomic Disadvantage

“…Medicare home health provides needed care services, such as intermittent skilled nursing care, skilled therapy, and home health aide services, to homebound Medicare beneficiaries (MedPAC, 2021). Home health care services allow older adults (ages 65 or older) to stay at their home and community, fulfilling individual preferences and reducing Medicare spending (Dick et al, 2019; Geng et al, 2020; Gregory et al, 2010; Werner et al, 2019). Based on these benefits, the use of home health care has grown substantially, of which the number of Medicare beneficiaries using home health care increased by more than 30% from 2002 to 2019 (MedPAC, 2021).…”