Length of Stay in Home Care Before and After the 1997 Balanced Budget Act

Abstract

ContextPrior to 1997, home health agencies (HHAs) were reimbursed on a fee-for-service basis and had incentives to provide more services. The 1997 Balanced Budget Act (BBA) reduced payments for home care services to help control Medicare spending.ObjectiveTo examine the length of stay in home care before and after the 1997 BBA.Design and SettingCross-sectional study of home care patients in the 1996 and 1998 National Home and Hospice Care Surveys, which surveyed 1053 HHAs in 1996 and 1088 HHAs in 1998.PatientsNationally representative random sample of home care patients with Medicare coverage in 1996 (4127 patients) and 1998 (4051 patients).Main Outcome MeasureLength of stay in home care (based on the number of days a patient was enrolled in home care services).ResultsFrom 1996 to 1998, unadjusted median length of stay decreased by 16 days for all home care patients (60-44 days, P = .002). The decrease affected for-profit HHAs more than not-for-profit HHAs (111-55 days [51% decrease, P = .002] vs 46-36 days [22% decrease, P = .042]). In a Cox proportional hazards model of time to discharge from home care, post-BBA year (1998) was associated with a shorter length of stay in home care (adjusted hazard ratio [aHR] for home care discharge, 1.39 [95% confidence interval {CI}, 1.19-1.61]), and for-profit status was associated with a longer length of stay in home care (aHR, 0.82 [95% CI, 0.71-0.94]) after adjusting for patient demographics, diagnoses, and functional status.ConclusionAfter the 1997 BBA, length of stay in home care decreased among Medicare patients, particularly among those receiving care from for-profit HHAs.

Impact of Changes in Medicare Home Health Care Reimbursement on Month-to-Month Home Health Utilization Between 1996 and 2001 for a National Sample of Patients Undergoing Orthopedic Procedures

“…12 Although there was a reduction in the proportion of patients selected for HH care, for the conditions studied, there was no evidence that differential access to HH care was reduced for more vulnerable patients. Confirming the findings of other authors, there were significantly larger reductions in the number of visits at for-profit HH agencies 8 and for dual-eligible patients, 23 older patients and female patients. 24 Implementation of other concurrent Medicare or regulatory policies potentially limits the interpretation of these findings (see Appendix Table A2).…”

“…Based on prior literature, 8 we hypothesized that forprofit HH agencies might respond differentially to the policy or that potentially costlier patients (eg, patients who were elderly, poor, female, had more comorbidity, or were discharged first to SNF or RH) might be treated differentially. These hypotheses were tested by adding interaction variables between the covariate(s) of interest and the policy spline variables.…”

“…4,12 These reports have either described detailed (eg, quarterly) changes in utilization 6 for the aggregate population of HH users or have examined selected subpopulations but using highly aggregated time periods. 4,[7][8][9]12 Because other regulatory policies were implemented during the same time period as the HH policies (see Appendix Table A2, which can be found on the Medical Care website, www.lww-medicalcare.com), other authors have expressed concern about the potential confounding of other policies on changes in HH utilization. 13 To better correlate HH policy implementation with changes in HH utilization, we selected a sample with sufficient size so that month-to-month variation in utilization could be analyzed.…”

“…Prior literature has described differential response to HH policy for vulnerable patients. 8 We further set out to evaluate whether the policy response differed by discharging institution or HH agency structure and whether subgroups of patients were differentially affected, including whether patients were first discharged to institutional postacute care (eg, SNF or RH). To accomplish these aims, we selected a 100% sample for each of these cohorts (JR and FX).…”

The Balanced Budget Act of 1997 and U.S. Hospital Operations

“…Angelelli et al (2002), Gage (1999), andMcCall et al (2003) examined the impact of BBA on the use of different types of postacute care services. McCall et al (2002) and Murkofsky et al (2003) examined the effects of BBA home health care reimbursement changes on use of these services. Miller, Dunn and Richter (1999) examined changes in graduate medical education support, and Mohr et al (1999) examined the effects of outpatient payment changes on rural hospitals.…”