Date of Award


Document Type

Campus Access Dissertation

Degree Name

Doctor of Philosophy (PhD)



First Advisor

Laura L. Hayman

Second Advisor

Ling Shi

Third Advisor

Janice Foust


Background: The Medicare home health (HH) program has long been troubled by cost and regulatory problems. An important stakeholder in the program – the Medicare Payment Advisory Commission – claimed that the benefit has been overused for supportive needs and pointed to increased admissions that were not preceded by inpatient discharges in the prior 14 days as evidence. On January 1, 2020, Medicare reduced payment for these ‘community’ admissions, a significant change that raised questions such as: 1) What empirical evidence existed for the overuse; 2) What were the patient, home health agency (HHA), and marketplace characteristics of community admissions; and 3) Will the policy be effective or have unintended consequences? Concerns about HH are complicated by demographic, regulatory, and economic differences, reduced hospitalizations, increased chronicity, health disparities, marketplace pressures, and fraud and abuse.

Objectives: The objectives of this study were to understand the reasons for the development of and the empirical foundation of the community admission payment reduction policy. This was undertaken by pursuing four research aims using a nursing theory of health information and analytical tools from the disciplines of health policy, health economics, health disparities research, and health statistics. Data Sources: Medicare HH and inpatient claims for 2016; county level patient socio-economic status (SES) data; home health agency and marketplace data.

Methods: Descriptive analyses and multivariable logistic regressions to test hypotheses that community admissions were: 1) positively associated with patient SES disadvantages; 2) negatively associated with the ratio of Medicare beneficiaries to HHA counts at the state level; 3) positively associated with for-profit HHAs; and 4) negatively associated with years of HHA Medicare certification. Statistical significance was set at P= 0.01.

Results: For patient characteristics females compared to males had a higher likelihood of community admissions (OR = 1.114, P <0.001); for racial groups minorities compared to Whites had higher likelihoods of community admissions (ORs of Blacks 1.201, Hispanics 1.440, Asians 1.599, all p-values <0.001); for age groups compared to 65-69, years under-65 (OR= 1.484, p=0.002) and 90+ (OR=1.171, p <0.001) had higher likelihoods of community admissions; patients dually eligible for Medicare and Medicaid (OR= 1.358, p <0.001) and those living in counties with poverty levels greater than 0-14 percent (OR’s ranged from 1.10 to 1.619, all p-values <0.001) had higher likelihoods of community admissions. For HHA characteristics for-profit HHAs (OR=1.247, p= <0.001) were associated with a higher likelihood of community admissions. In contrast, compared to HHAs that obtained Medicare certified within 0-12 years, older HHAs had a lower association with community admissions (OR’s ranged from 0.894 to 0.836 and p-values from 0.002 to <0.001) while larger HHAs compared to the smallest group of 1-394 annual admissions had lower associations with community admissions (OR’s ranged from 0.951 to 0.890 and p-values 0.001 to 0.003). While the state level ratio of beneficiaries to HHAs did not reach the statistical significance test threshold the ORs for the two groupings with the highest ratios of beneficiaries to HHAs were 0.807 and 0.835 with P-values of 0.013 and 0.021, respectively, which suggests that the ratio was an important characteristic.

Conclusion: Because the HHA characteristics of for-profit status, fewer years of Medicare certification, and smaller size are associated with a higher likelihood of community admissions it is possible that the Medicare policy of reduced payment for these admissions may not be effective since the policy does not address these factors and HHAs may be motivated to lower costs and maintain profits. Also, because patient characteristics indicating SES disadvantage are associated with a higher likelihood of community admissions these patients may not be able to obtain the services necessary for allowing them to stay safe and healthy at home. If their health deteriorates and they end up using more expensive substitute services harm could result to the patients affected through loss of independence and exposure to nosocomial risks and to the Medicare program in increased costs. While this cannot be ascertained until after the policy has been in effect, it should be analyzed when possible. If problems are found alternative policies such as a national certificate-of-need should be considered.


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