Medicare Home Health Services 1989-1994: Patterns of Benefit Use Among Chronically Disabled Elders

03/04/1999

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. ** p<0.05
  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. ** p<0.05
  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. * p<0.05 ** 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]

Preview
Download

"medhhs.pdf" (pdf, 322.66Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®