Patterns of Healthcare Utilization and Spending Among Homebound Older Adults in the USA: an Observational Study

Abstract

Background: Homebound older adults have complex social, medical, and financial needs, but little is known about their healthcare utilization and spending.

Objective: To characterize healthcare utilization and spending among homebound older adults.

Design: Cohort study using National Health and Aging Trends Study data linked to Medicare Fee-for-Service (FFS) claims data.

Participants: Adults aged 70 years and older with Medicare FFS coverage (n = 6468).

Main measures: In a person-year analysis, survey-weighted rates and adjusted marginal differences in inpatient, outpatient, and emergency department utilization and spending 12 months post-interview were calculated by homebound status, defined as reporting never or rarely (no more than 1 day/week) leaving home in the last month.

Key results: Compared to the non-homebound, homebound observations had lower annual unadjusted rates of accessing primary care (60.9% vs 71.9%, p < 0.001) and specialist care (61.0% vs 74.9%, p < 0.001) and higher annual rates of emergency department use (54.0% vs 32.6%, p < 0.001) and hospitalization (39.8% vs 19.8%, p < 0.001). Total annual Medicare spending was $11,346 higher among the homebound compared to the non-homebound (p < 0.001). In a single year analysis (2015), homebound older adults accounted for 11.0% of Medicare spending among those over 70 despite making up only 5.7% of this population. 13.6% of the homebound were in the 95^th percentile or above of Medicare spending in 2015. In models adjusting for demographic, clinical, and geographic characteristics, homebound status was associated with a decreased likelihood of having an annual primary care or specialist visit and $2226 additional total annual Medicare spending.

Conclusions: Homebound older adults use more hospital-based care and less outpatient care than the non-homebound, contributing to higher levels of overall Medicare spending.

Keywords: homebound; medicare; spending; utilization.

Figure 1

Percent of Medicare Fee-for-Service beneficiaries aged 70 and over with any health care utilization by category and homebound status, 2011–2017. Note: Authors’ calculations using the 2011–2016 National Health and Aging Trends Study linked with Medicare Fee-for-Service claims data (n = 18,899 person year observations). Any utilization is defined as one or more admissions/visits for each category. Estimates are survey weighted percentages.

Figure 2

Average Medicare Fee-for-Service spending among adults aged 70 and over by billing category and homebound status, 2011–2017. Note: Authors’ calculations using the 2011–2016 National Health and Aging Trends Study linked with Medicare Fee-for-Service claims data (n = 18,899 person year observations). Estimates are survey weighted averages CPI-U inflation adjusted to 2017 dollars.

Figure 3

Adjusted percentage point difference in the probability of any healthcare utilization among Medicare Fee-for-Service beneficiaries aged 70 and older by category and homebound status, 2011–2017. Note: Hb = homebound. Authors’ calculations using the 2011–2016 National Health and Aging Trends Study linked with Medicare Fee-for-Service claims data (n = 18,899 person year observations). Estimates are marginal differences from survey weighted logistic regression and 95% confidence intervals adjusted for sex, race, age, education, marital status, geographic region, metropolitan area, functional status, Medicaid enrollment, probable dementia, and Charlson Comorbidity Index.