Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access

Abstract

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated.

Context: Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors.

Methods: We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design.

Findings: After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use.

Conclusions: Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

Keywords: access; home health; public reporting; quality; racial inequities.

Figure 1

Within‐Neighborhood Individual‐level Racial, Ethnic, and Socioeconomic Gaps in High‐Quality Home Health Agency Use Before and After Public Reporting. Abbreviations: AAPI, Asian American/Pacific Islander; AIAN, American Indian/Alaska Native. The authors’ analysis is of data from the 2014–2017 Medicare Beneficiary Summary File (MBSF), the 2014–2017 Outcome and Assessment Information Set (OASIS), and the 2016–2018 Care Compare website. N = 7,001,512 for start‐of‐care assessments. The unit of analysis is at the person‐quarter level. The adjusted analysis is adjusted for sex, age, Medicare Advantage status, and living alone at the time of the assessment and includes neighborhood fixed effects (FEs). High‐quality home health agencies have >3.5 stars. Low‐income identifies a beneficiary as having dual enrollment in Medicare and Medicaid and/or participation in Medicare Part‐D low‐income, cost‐sharing subsidy. The Medicare Advantage enrollment status is as defined in the MBSF. Living alone was measured using the OASIS variable for living situation.

Figure 2

Between‐Neighborhood Gaps in High‐Quality Home Health Agency Use Before and After Public Reporting and by Neighborhood Racial Composition. Abbreviations: AAPI, Asian American/Pacific Islander; AIAN, American Indian/Alaska Native; ZIP, Zone Improvement Plan. The authors’ analysis is of data from the 2014–2017 Medicare Beneficiary Summary File (MBSF), the 2014–2017 Outcome and Assessment Information Set (OASIS), and the 2016–2018 Care Compare website. Geographical data came from the 2015 American Community Survey (ACS) 5‐year estimates and the 2013 National Center for Health Statistics (NCHS) Urban–Rural Classification Scheme for Counties. N = 7,001,512 for start‐of‐care assessments. High‐quality home health agencies (HHAs) have >3.5 stars. The unit of analysis is at the person‐quarter level. The adjusted analysis is adjusted for sex, age, Medicare Advantage status, living alone, region of the country, rurality, and neighborhood poverty. Neighborhood is defined by the ZIP Code Tabulation Area (ZCTA). Neighborhoods that are predominately White, Black, Hispanic/Latine, AAPI, or AIAN must be made up of ≥65% White, Black, Hispanic/Latine, AAPI, or AIAN residents, respectively, and according to the ACS. Minority neighborhoods must be made up of ≥65% minority residents (but not be predominately Black, Hispanic/Latine, AAPI, or AIAN), whereas integrated neighborhoods are ZCTAs that do not fit in the first six categories.

Figure 3

Between‐Neighborhood Gaps in High‐Quality Home Health Agency Use Before and After Public Reporting and by Neighborhood Poverty Status. Abbreviations: AAPI, Asian American/Pacific Islander; AIAN, American Indian/Alaska Native; ZIP, Zone Improvement Plan. The authors’ analysis is of data from the 2014–2017 Medicare Beneficiary Summary File (MBSF), the 2014–2017 Outcome and Assessment Information Set (OASIS), and the 2016–2018 Care Compare website. Geographical data came from the 2015 American Community Survey (ACS) 5‐year estimates and the 2013 National Center for Health Statistics (NCHS) Urban–Rural Classification Scheme for Counties. N = 7,001,512 for the start‐of‐care assessments. High‐quality home health agencies (HHAs) have >3.5 stars. The unit of analysis is at the person‐quarter level. The adjusted analysis is adjusted for sex, age, Medicare Advantage status, living alone, region of the country, rurality, and neighborhood racial composition. Neighborhood is defined by the ZIP Code Tabulation Area. Neighborhood poverty status is operationalized using a quintile of the percentage of residents who live below 200% of the federal poverty line (FPL).