Association of Cost Sharing With Use of Home Health Services Among Medicare Advantage Enrollees

Abstract

Importance: Several policy proposals advocate introducing copayments for home health care in the Medicare program. To our knowledge, no prior studies have assessed this cost-containment strategy.

Objective: To determine the association of home health copayments with use of home health services.

Design, setting, and participants: A difference-in-differences case-control study of 18 Medicare Advantage (MA) plans that introduced copayments for home health care between 2007 and 2011 and 18 concurrent control MA plans. The study included 135 302 enrollees in plans that introduced copayment and 155 892 enrollees in matched control plans.

Exposures: Introduction of copayments for home health care between 2007 and 2011.

Main outcomes and measures: Proportion of enrollees receiving home health care, annual numbers of home health episodes, and days receiving home health care.

Results: Copayments for home health visits ranged from $5 to $20 per visit, which were estimated to be associated with $165 (interquartile range [IQR], $45-$180) to $660 (IQR, $180-$720) in out-of-pocket spending for the average user of home health care. The increased copayment for home health care was not associated with the proportion of enrollees receiving home health care (adjusted difference-in-differences, -0.15 percentage points; 95% CI, -0.38 to 0.09), the number of home health episodes per user (adjusted difference-in-differences, 0.01; 95% CI, -0.01 to 0.03), and home health days per user (adjusted difference-in-differences, -0.19; 95% CI, -3.02 to 2.64). In both intervention and control plans and across all levels of copayments, we observed higher disenrollment rates among enrollees with greater baseline use of home health care.

Conclusions and relevance: We found no evidence that imposing copayments reduced the use of home health services among older adults. More intensive use of home health services was associated with increased rates of disenrollment in MA plans. The findings raise questions about the potential effectiveness of this cost-containment strategy.

Figure 1.. Unadjusted Monthly Rate of Home Health Days per Enrollee in the 12 Months Before and 12 Months After the Introduction of Copayments

Figure 2.. Disenrollment Rates From Case and Control Plans by Duration of Home Health Care During the Year Before the Copayment Increase