U.S. Department of Health and Human Services
Medicare Home Health Services 1989-1994: Patterns of Benefit Use Among Chronically Disabled Elders
Beth Jackson, Ph.D., The MEDSTAT Group
Pamela Doty, Ph.D., Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation
March 4, 1999
PDF Version: http://aspe.hhs.gov/daltcp/reports/medhhs.pdf (26 PDF pages)
This presentation--given at the Gerontological Society of America, Philadelphia, Pennsylvania on November 1998--was prepared by the Office of Social Services Policy with the U.S. Department of Health and Human Services. The research was funded through contract #HHS-100-96-0001 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the MEDSTAT Group. For additional information, you may visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Pamela Doty, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Pamela.Doty@hhs.gov.
The 1994 National Long-Term Care Survey
- Funded by the National Institute on Aging
- Data collected by Duke University and Bureau of the Census
- Earlier surveys: 1982, 1984, 1989
- 1999 NLTCS planned
The 1994 National Long-Term Care Survey
- Disabled Medicare population
- Aged 65 and older
- Telephone screening to identify disabled (ADLs and IADLs)
- In-person interviews of the disabled
- Consistency of data elements across surveys
- Linked to Medicare claims data
- Cross-sectional estimates of the community-dwelling elderly
- Ability to examine trends
| Number and Percent of Medicare Beneficiaries Using Medicare Home Health Services by Disability Status, 1989 and 1994 |
| | Disabled Users | Non-Disabled Users | All Medicare Beneficiary HH Users |
| 1989 Calendar Year | 804,089(16.9%) | 781,721(3.2%) | 1,585,810(5.4%) |
| 1994 Calendar Year | 1,362,529 (27.6%) | 1,216,945 (4.6%) | 2,579,474 (8.2%) |
| Percent Increase 1989-1994 | 69% | 44% | 63% |
| SOURCE: 1989 and 1994 National Long-Term Care Surveys and HCFA Administrative Claims.NOTE: Percentages in parentheses represent proportion of group using Medicare home health services, i.e., 16.9% of disabled elders used home health services in 1989.Disability is defined as 1+/6 chronic ADLs or 1+/9 chronic IADLs (use of assistive devices not included in the definition of disability.) |
| Changes in Medicare Home Health Use Between 1989 and 1994, By Disability Status |
| | 1989 | 1994 | Percent Increase: 1989-1994 |
| Mean (Median) Visits Per User in Calendar Year |
| Disabled | 40.3 (21) | 106.3 (52) | 164% (148%) |
| Non-Disabled | 21.7 (11) | 34.5 (20) | 59% (82%) |
| Total | 31.1 (15) | 72.5 (32) | 133% (113%) |
| Mean (Median) Visits Per Episode in Calendar Year |
| Disabled | 32.9 (16) | 96.2 (44) | 192% (175%) |
| Non-Disabled | 19.6 (11) | 32.4 (18) | 65% (63%) |
| Total | 26.6 (13) | 66.8 (27) | 151% (108%) |
| Mean (Median) Visits Per Episode in Calendar Year, Extended |
| Disabled | 69.6 (24) | 273.1 (72) | 292% (200%) |
| Non-Disabled | 28.4 (12) | 59.0 (25) | 107% (108%) |
| Total | 50.3 (17) | 154.9 (49) | 208% (188%) |
| SOURCE: 1989 and 1994 National Long-Term Care Surveys and HCFA Administrative Claims. The parameters of a home health episode are defined by a minimum of a "clean" period of 60 days both before the first home health claim and 60 days following the last home health claim. In this table, some episodes are "extended" to include HH utilization outside the calendar year but associated with episodes in force at the beginning and/or end of calendar year.Definition of disability: 1+ chronic ADLs/6 or chronic incontinence or 1+ chronic IADLs/9; assistive devices not included in the definition of disability. |
| Changes in Medicare Home Health Expenditures Between 1989 and 1994, By Disability Status |
| | 1989 | 1994 | Percent Increase: 1989-1994 |
| Mean (Median) Home Health Expenditures Per Person in Calendar Year |
| Disabled | $2,031 (1,103) | $6,245 ($3,439) | 207% (212%) |
| Non-Disabled | $1,156 ($602) | $2,220 ($1,281) | 92% (113%) |
| Total | $1,599 ($825) | $4,350 ($2,112) | 172% (156%) |
| Mean (Median) Home Health Expenditures Per Episode in Calendar Year |
| Disabled | $1,655 ($875) | $5,654 ($2,626) | 242% (200%) |
| Non-Disabled | $1,043 ($565) | $2,085 ($1,148) | 100% (103%) |
| Total | $1,368 ($684) | $4,006 ($1,825) | 192% (167%) |
| Mean (Median) Home Health Expenditures Per Episode in Calendar Year, Extended |
| Disabled | $3,408 ($1,120) | $13,393 ($4,766) | 293% (290%) |
| Non-Disabled | $1,474 ($646) | $3,633 ($1,625) | 146% (151%) |
| Total | $2,502 ($915) | $8,888 ($2,720) | 255% (197%) |
| SOURCE: 1989 and 1994 National Long-Term Care Surveys and HCFA Administrative Claims. The parameters of a home health episode are defined by a minimum of a "clean" period of 60 days both before the first home health claim and 60 days following the last home health claim. In this table, some episodes are "extended" to include HH utilization outside the calendar year but associated with episodes in force at the beginning and/or end of calendar year. Definition of disability: 1+ chronic ADLs/6 or chronic incontinence or 1+ chronic IADLs/9; assistive devices not included in the definition of disability. |
| Contribution of the Disabled and Non-Disabled Elderly Populations to Increases in Medicare Home Health Between 1989 and 1994 Calendar Years |
| Type of Increase 1989-1994 | Increase Accounted for by Disabled | Increase Accounted for by Non-Disabled |
| 63% Increase in Beneficiaries Using Home Health Services | 56.20% | 43.80% |
| 50% Increase in Total Number of Home Health Episodes | 55.31% | 44.69% |
| 275% Increase in Total Number of Home Health Visits | 82.00% | 18.00% |
| 338% Increase in Total Home Health Expenditures | 79.43% | 20.56% |
| Characteristics of Disabled HH Users and Non-Users, 1994 |
| Characteristic | HH Users | HH Non-Users | P-Value |
| Mean Age | 79.9 | 77.7 | .05 |
| Percent Female | 72.3 | 68.3 | .05 |
| Percent White | 84.0 | 85.8 | NS |
| Percent Married | 35.9 | 43.8 | .05 |
| Mean ADLs/5 | 1.81 | 1.0 | .05 |
| Mean IADLs/9 | 4.9 | 3.2 | .05 |
| Percent Cognitively Impaired | 24.7 | 16.4 | .05 |
| Percent Incontinent | 16.9 | 7.0 | .05 |
| Percent Indiv/Spouse Income $15,000+ | 34.9 | 44.4 | .05 |
| Percent Lives with Others | 66.2 | 72.8 | .05 |
| Percent of Medicaid/SSI | 23.0 | 17.7 | .05 |
| Characteristics of Disabled HH Users and Non-Users, 1994, Continued |
| Characteristic | HH Users | HH Non-Users | P-Value |
| Percent with Diabetes | 24.0 | 17.5 | .05 |
| Percent with Cancer | 10.1 | 8.1 | NS |
| Percent Paralyzed | 11.5 | 7.4 | .05 |
| Percent Suffered Stroke | 14.1 | 7.9 | .05 |
| Percent Suffered Heart Attack | 5.6 | 4.5 | NS |
| Mean Number Prescription Medications | 3.9 | 3.0 | .05 |
| Mean Hours of Care Per Week From Informal Sources | 32.3 | 20.3 | .05 |
| Mean Hours of Care Per Week From Formal Sources | 11.6 | 4.7 | .05 |
| SOURCE: 1994 National Long-Term Care Surveys and HCFA Administrative Claims. NOTE: Disability defined as 1+ chronic ADL/6 or 1+ chronic IADL/9 or evidence of incontinence. Use of an assistive device without the need for personal assistance is not considered sufficient evidence of disability. |
| Variables Entered Into Home Health Regression Analyses |
| Beneficiary Characteristics |
- Age
- Race
- Number of ADLs
- Cognition
- Income
- Medicaid/SSI Status
- Cancer
- Stroke
- Number of Prescription Meds
- SNF Use
| - Sex
- Marital Status
- Number of IADLs
- Continence
- Living Arrangement
- Diabetes
- Paralysis
- Heart Attack
- Number of Hours of Informal Care
- Inpatient Use
|
| Environmental Variables |
- HCFA Region
- % HH Agencies Proprietary in State
| - HCBS $ Per Capita in State
- Number Nursing Home Beds/1,000 in State
|
| Statistically Significant Predictors of Medicare Home Health Use Among Disabled Medicare Beneficiaries Aged 65+, 1989 and 1994 |
| Predictor | 1989 | 1994 |
| Age | Older | Older |
| Number of ADLs | More Disability | More Disability |
| Number of IADLs | More Disability | More Disability |
| Living Arrangement | ----- | Lives Alone |
| Diabetes | Diabetic | ----- |
| Number of Prescription Meds | More Meds | More Meds |
| Region | New England, Pacific vs. Mid-Atlantic | New England, East South Central vs. Mid-Atlantic |
| Inpatient Services | Inpatient Use | Inpatient Use |
| SNF Services | ----- | SNF Use |
| HCBS $ in State | Average $ vs Low/Very Low $ | ----- |
| # Nursing Home Beds/1,000 in State | ----- | More Beds |
| Statistically Significant Predictors of Medicare Home Health Visits Among Disabled Medicare Beneficiaries Aged 65+ Who Used Medicare Home Health Services, 1989 and 1994 |
| Predictor | 1989 | 1994 |
| Number of ADLs | More Disability | More Disability |
| Number of IADLs | ----- | More Disability |
| Continence | ----- | Others Manage |
| Income | ----- | $15,000 |
| HCFA Region | New England, East South Central vs. Mid-Atlantic | New England, East South Central vs. Mid-Atlantic |
| % HH Agencies Proprietary in State | ----- | Larger Proportion Proprietary |
| Number of Nursing Home Beds/1,000 in State | ----- | More Beds |
| SOURCE: 1989 and 1994 National Long-Term Care Surveys and HCFA Administrative Claims. |
| Statistically Significant Predictors of Medicare Home Reimbursement Among Disabled Medicare Beneficiaries Aged 65+ Who Used Medicare Home Health Services, 1989 and 1994 |
| Predictor | 1989 | 1994 |
| Number of ADLs | More Disability | More Disability |
| Number of IADLs | ----- | More Disability |
| Continence | ----- | Others Manage |
| Income | ----- | $15,000 |
| HCFA Region | New England, East South Central vs. Mid-Atlantic | New England, East South Central vs. Mid-Atlantic |
| % HH Agencies Proprietary in State | ----- | Larger Proportion Proprietary |
| SOURCE: 1989 and 1994 National Long-Term Care Surveys and HCFA Administrative Claims. |
| Percent of 65+ Medicare Beneficiaries With Home Health Use by Home Health Use Type and Disability Status, Calendar 1994 |
| Disability Status | Home Health Visit Type |
| HH Aide | HH Skilled Nurse | Other Therapies | Any* |
| Not Disabled | 2.0 | 4.7 | 2.4 | 5.0 |
| IADL Only | 9.6 | 18.5 | 9.8 | 19.3 |
| 1-2 ADLs/5 | 22.3 | 32.4 | 17.9 | 33.0 |
| 3+ ADLs/5 | 34.3 | 45.3 | 28.4 | 47.0 |
| Total 65+ | 4.2 | 7.9 | 4.3 | 8.3 |
| SOURCE: 1994 National Long-Term Care Surveys and HCFA Administrative Claims. * Excludes DME and supplies. |
| Mean Number of Home Health Visits* (For Those with Any Home Health Utilization) by Home Health Use Type and Disability Status, Aged 65+ Medicare Beneficiaries, 1994 |
| HH Use Type | Not Disabled | IADL Only | 1-2 ADLs/5 | 3+ ADLs/5 | Total 65+ |
| Aide | 13.1 | 17.9 | 64.3 | 92.7 | 35.7 |
| Skilled Nursing | 19.6 | 28.2 | 37.6 | 48.5 | 28.7 |
| Other Therapies | 5.2 | 5.1 | 8.0 | 14.8 | 7.4 |
| Any* | 38.0 | 51.3 | 109.9 | 156.1 | 71.8 |
| SOURCE: 1994 National Long-Term Care Surveys and HCFA Administrative Claims. * Excludes DME and supplies. |
| Distribution of Home Health Visit* Types By Disability Status, Age 65+ Medicare Beneficiaries, 1994 |
| HH Use Type | Not Disabled | IADL Only | 1-2 ADLs/5 | 3+ ADLs/5 | Total 65+ |
| Aide | 34.5% | 35.0% | 58.5% | 59.4% | 49.7% |
| Skilled Nursing | 51.7% | 55.1% | 34.2% | 31.1% | 40.0% |
| Other Therapies | 13.8% | 10.0% | 7.3% | 9.5% | 10.3% |
| Any* | 100.0% | 100.1%** | 100.0% | 100.0% | 100.0% |
| SOURCE: 1994 National Long-Term Care Surveys and HCFA Administrative Claims. * Excludes DME and supplies. ** Rounding error. |
| Proportion of HH Episodes By Type of Episode, 1989 and 1994: All Medicare Beneficiaries, Aged 65+ |
| Types of Home Health Episodes | 1989 | 1994 |
| Prior Hospital Stay Only | 45.1% | 40.0% |
| Prior and Interim Hospital Stay | 17.4% | 19.0% |
| Interim Hospital Stay Only | 9.8% | 14.2% |
| Some Interim Hospital Stay | 27.1% | 33.2% |
| No Hospital Stay | 27.7% | 26.8% |
| SOURCE: 1989 and 1994 National Long-Term Care Surveys and HCFA Administrative Claims. |
| Proportion of HH Episodes By Type of Episode, 1989 and 1994: Disabled Medicare Beneficiaries, Aged 65+ |
| Types of Home Health Episodes | 1989 | 1994 |
| Prior Hospital Stay Only | 35.3% | 29.4% |
| Prior and Interim Hospital Stay | 18.2% | 20.8% |
| Interim Hospital Stay Only | 14.1% | 20.2% |
| Some Interim Hospital Stay | 32.3% | 41.1% |
| No Hospital Stay | 32.3% | 29.6% |
| SOURCE: 1989 and 1994 National Long-Term Care Surveys and HCFA Administrative Claims. |
| Proportion of HH Episodes By Type of Episode, 1989 and 1994: Non-Disabled Medicare Beneficiaries, Aged 65+ |
| Types of Home Health Episodes | 1989 | 1994 |
| Prior Hospital Stay Only | 56.2% | 52.4% |
| Prior and Interim Hospital Stay | 16.4% | 16.8% |
| Interim Hospital Stay Only | 4.8% | 7.1% |
| Some Interim Hospital Stay | 21.3% | 23.9% |
| No Hospital Stay | 22.5% | 23.7% |
| SOURCE: 1989 and 1994 National Long-Term Care Surveys and HCFA Administrative Claims. |
Medicare Home Health IPS Simulation
- Estimated Average per Beneficiary Cost Limit
- By Census region
- 1994 data
- Cost limits deflated to 1994 dollars
- Identify Characteristics of Beneficiaries Who Would Exceed the Per Beneficiary Cost Cap
| Characteristics of Disabled* Medicare Beneficiaries Who Would Have Exceeded the Home Health IPS Limit |
| | Less Than or Equal to Cap (N=406) | Exceeds Cap (N=402) |
| Mean Age | 80.02 | 79.95 |
| Percent Female | 70.88 | 72.09 |
| Percent White** | 89.22 | 83.04 |
| Percent Married | 37.47 | 38.06 |
| Mean # of ADLs** | 1.45 | 2.58 |
| Mean # of IADLs** | 4.43 | 6.16 |
| Percent Cognitively Impaired** | 18.32 | 31.14 |
| Percent Others Manage Incontinence** | 11.36 | 26.97 |
| Percent with $15,000+ Indiv/Spouse Income** | 41.34 | 31.86 |
| Percent Lives with Others** | 63.55 | 72.28 |
| Percent on Medicaid/SSI | 22.13 | 22.48 |
| Percent with Diabetes | 22.33 | 26.03 |
| Percent with Cancer | 10.44 | 10.75 |
| Percent Paralyzed** | 8.48 | 15.90 |
| Percent Suffered a Stroke** | 14.21 | 19.77 |
| Percent Suffered a Heart Attack | 7.91 | 7.91 |
| SOURCE: 1994 National Long-Term Care Surveys and HCFA Administrative Claims. * One or more ADLs out of five or one or more IADLs out of nine; chronicity included, assistive device not included. ** p0.05 |
| Characteristics of Disabled* Medicare Beneficiaries Who Would Have Exceeded the Home Health IPS Limit, Continued |
| | Less Than or Equal to Cap (N=406) | Exceeds Cap (N=402) |
| Mean # of Prescription Medicines** | 3.74 | 4.37 |
| Mean # Hours of Care from Informal Sources** | 27.77 | 40.97 |
| Mean # Hours of Care from Formal Sources** | 10.34 | 17.93 |
| Percent Used Inpatient Services | 63.40 | 61.25 |
| Percent Used SNF Services** | 11.10 | 16.72 |
| HCBS in State:- Percent High- Percent Average- Percent Low | 20.1326.5153.35 | 19.3227.6653.03 |
| Mean Percent Proprietary HH Agency in State** | 43.81 | 48.85 |
| Mean # of NH Beds/1000 in State** | 53.14 | 56.45 |
| SOURCE: 1994 National Long-Term Care Surveys and HCFA Administrative Claims. * One or more ADLs out of five or one or more IADLs out of nine; chronicity included, assistive device not included. ** p0.05 |
| Percent of Medicare Home Health Users Exceeding the IPS Per Beneficiary Limit, by Disability Status |
| | Percent Exceeding Limit* |
| No Functional Disability | 20.1% |
| IADL Disability Only | 29.7% |
| 1 ADL/5 | 48.0% |
| 2 ADLs/5 | 51.9% |
| 3+ ADLs/5 | 66.1% |
| SOURCE: 1994 National Long-Term Care Surveys and HCFA Administrative Claims. * p.05 |
Statistically Significant* Predictors of Exceeding Medicare Home Health IPS Cost Limit Among Disabled** Medicare Beneficiaries
- Number of ADLs
- Number of IADLs
- Lower Income ($15,000)
- West South Central Region
- SNF Use
- From States with Larger Percentage of Proprietary HHAs
SOURCE: 1994 National Long-Term Care Surveys and HCFA Administrative Claims. * p0.05 ** One or more ADLs out of five or one or more IADLs out of nine.
Policy Discussion
- Chronically disabled using Medicare HH benefit not a new phenomenon
- Rate of increase greater among disabled
- Disabled more likely to use both aides and skilled nursing
- Evidence of medical complexity among disabled users
- Over half of disabled users with ADL deficits exceed IPS per person limit
- Implications for possible cost-shifting to Medicaid for dual eligibles
To obtain a printed copy of this report, send the full report title and your mailing information to:
U.S. Department of Health and Human ServicesOffice of Disability, Aging and Long-Term Care PolicyRoom 424E, H.H. Humphrey Building200 Independence Avenue, S.W.Washington, D.C. 20201FAX: 202-401-7733Email: webmaster.DALTCP@hhs.gov
RETURN TO:
Office of Disability, Aging and Long-Term Care Policy (DALTCP) Home [http://aspe.hhs.gov/_/office_specific/daltcp.cfm]Assistant Secretary for Planning and Evaluation (ASPE) Home [http://aspe.hhs.gov]U.S. Department of Health and Human Services Home [http://www.hhs.gov]
