Socioeconomic disparities in the use of home health services in a Medicare managed care population

Health Services Research, Oct, 2004 by Vicki A. Freedman, Jeannette Rogowski, Steven L. Wickstrom, John Adams, Jonas Marainen, Jose J. Escarce

Home health care services are a critical part of both the long-term and acute care continuums for older Americans covered by Medicare. Use of the term "home health care" is inconsistent but often includes skilled nursing visits, home health aide visits, and various therapy services (e.g., physical, occupational, speech) delivered in a patient's home. The term may also be extended, although less frequently, to include expenditures for durable medical equipment (DME) used in the home.

Although few studies of Medicare DME utilization have been conducted, analyses of home health care often demonstrate such services to be cost-effective and lead to better outcomes than many alternative venues of care (Chen, Kane, and Finch 2000). Home health care is associated with reduced hospital stays for patients with certain conditions (Shepperd et al. 1998; Stewart et al. 1998; Mayo et al. 2000; Anderson, Rubenach et al. 2000; Anderson, Mhurchu et al. 2000; Hughes et al. 1997); and may reduce overall care costs without compromising clinical outcomes (Cummings et al. 1990; Hughes et al. 1992; Cotton et al. 2000; Skwarska et al. 2000; Stewart et al. 1998; Landefeld and Hanus 1993; von Koch et al. 2001; Mayo et al. 2000; Anderson, Rubenach et al. 2000; Anderson, Mhurchu et al. 2000). Home health care can lower the risk of functional decline and institutionalization (Martin, Oyewole, and Moloney 1994; Fabacher et al. 1994; Mayo et al. 2000; Hansen, Spedtsberg, and Schroll 1992; Stuck et al. 2002). In addition, patients usually prefer home health care over inpatient or skilled nursing care as long as the home care services can meet their needs (Cummings et al. 1990; Hughes et al. 1992).

Despite these important advantages, several studies have shown that access to home health visits has not been uniform. Income exhibits a U-shaped relationship with home health care, with higher usage among the poorest and wealthiest (Kemper 1992; Logan and Spitze 1994; Stoller and Curler 1993; Coughlin et al. 1992; Stum, Bauer, and Delaney 1996; Liu, Manton, and Aragon 2000). Results with respect to Medicaid status have been mixed, with Kemper (1992) showing no relationship and Coughlin et al. (1992) finding Medicaid eligibility improves access to home health care. Education also appears to be related to access, with lower educated seniors less likely to use paid care at home and more likely to report unmet need with respect to home health use following hospital discharge (Solomon et al. 1993; Bowles, Naylor, and Foust 2002).

With respect to device use, far fewer studies have considered economic resources. The few studies that have considered such information generally fail to show a relationship between income and device use (Norburn et al. 1995; Zimmer and Chappell 1994) and between education and device use (Agree 1999; Norburn et al. 1995; Logan and Spitze 1994; Zimmer and Chappell 1994). However, two recent studies of mobility devices suggest income does facilitate the purchase of such equipment (Mathieson, Kronenfeld, and Keith 9002) and education facilitates its use alone or in combination with formal home care services (Agree, Freedman, and Sengupta 2004).

These studies largely ignore, or exclude altogether, the growing Medicare managed care population, now numbering 20 percent of Medicare enrollees (Hileman et al. 2002). Although disagreement exists regarding which payment scheme yields better outcomes (Holtzman, Chen, and Kane 1998; Adams, Kramer, and Wilson 1995; Shaughnessy, Schlenker, and Hittle 1994a; Experton et al. 1997), several recent studies suggest that Medicare managed care home health users receive fewer home health visits and incur lower home health expenses than users in the traditional Medicare plan (Shanghnessy, Schlenker, and Hittle 1994a, 1994b; Schlenker, Shaughnessy, and Hittle 1995; Experton et al. 1997). Such differences may be attributed in part to differential case mix; Shanghnessy et al. (1995), for example, show that among Medicare enrollees, health maintenance organization (HMO) home health users had fewer impairments than users in the traditional fee-for-service plan and were somewhat younger, less likely to be female, more likely to be married, more often living with a spouse, and more likely to receive informal care.

It remains unclear, however, whether access to home health care in managed care plans is equal across socioeconomic groups. One of the only studies to examine access disparities within managed care suggests that some vulnerable groups are more likely than other patients to report problems with access to home health care (Nelson et al. 1997). Notably, the only measure of socioeconomic status considered--having a low income--predicted home health access problems; however, these disparities were largely explained by differences across income groups in health-related factors.

Thus, the nature of the link between home health access and socioeconomic status within managed care has not been investigated. At least four pathways through which socioeconomic status may operate on home health and DME access in a managed care setting are: (1) socioeconomic status affects health status, which in turn influences utilization, (2) socioeconomic status, including home ownership, affects preferences for home care and various alternatives to home care, for example informal care versus more formal residential care or nursing home settings, (3) as reflected in education, socioeconomic status influences the ability to navigate the managed care system and to adhere to treatment regimes, and (4) as reflected in income and liquid assets, socioeconomic status may influence the ability to pay out-of-pocket for care.