Analysis: Medicare Advantage limits home health care

A study of nearly 300,000 Medicare beneficiaries suggests that Medicare Advantage patients receive fewer home health visits and have worse outcomes compared with traditional Medicare recipients.

UW Medicine health services researcher Rachel Prusynski and her colleagues examined the growing impact on health care of private Medicare Advantage plans offered to adults 65 and over as an alternative to the plan provided by the federal government. The study appeared March 1 in JAMA Health Forum. 

Home health care is a small but critical part of the care system designed to keep patients out of long-term care or nursing facilities by authorizing care and therapy visits at the patient’s residence.

“Across the board, patients with Medicare Advantage plans are getting less home health care,” said Prusynski, an assistant professor of rehabilitation medicine and a researcher at the University of Washington School of Medicine's Center for Health Workforce Studies. 

Medicare Advantage beneficiaries now number about 30 million, recently surpassing the number of traditional Medicare recipients in the United States. There are nearly 4,000 Medicare Advantage plans offered by insurance companies. In some ways, such as with dental and vision coverage, these plans allow for more services than the federal government’s Plans A and B. But Medicare Advantage plans also tend to have restrictions that affect costs for hospital and outpatient services, such as copays, limits on approved services and network coverage, and policies that require preauthorization of care in many instances. 

Home health is particularly important for older Americans and often isn’t needed until a patient is in dire medical straits. In 2021, 3 million traditional Medicare recipients received home health care at a cost of $17 billion. It’s unclear how much home health care costs for Medicare Advantage patients, although Prusynski’s findings suggest the figure is likely less.

Prusynski was awarded a grant to study data provided by a large home health operator. The researchers examined anonymous patient information from 2019-22 for more than 285,000 home health recipients 65 or older. The data spanned 102 home health company locations in 19 states.

The team found that Medicare Advantage patients had shorter home health lengths of stay, fewer visits by nursing and therapy clinicians and home health aides, lower rates of improvement in self-care and mobility function, and higher rates of discharge to the community from home health. 

The authors said that higher rates of community discharge, combined with lower functional improvement, may adversely affect patients’ independence and increase their caregivers’ burden for people with Medicare Advantage coverage.

“We know that the amount of cognitive impairment or the amount of help a patient has at home really impacts their outcomes,” Prusynski said. “We were able to robustly adjust for some of those differences and started to see that these challenges in the health system are trickling down to patients — and that Medicare Advantage is limiting some care. That is not only providing money for the health insurance companies, but it is making care outcomes potentially worse for patients.”

Data showed that Medicare Advantage patients had 3% lower odds of improving mobility, 4% lower odds of being able to care for themselves and were 5% more likely to be discharged to the community despite less functional improvement. Medicare Advantage patients received 1.62 fewer days length of treatment on average. 

“These are small percentages, but we controlled for all the differences between these two patient populations,” Prusynski said. “Even if patients had the same level of medical complexity, the same challenge getting around their house, the same level of support at home, the same caregiver support — even comparing apples to apples — Medicare Advantage patients still got fewer services and they didn't improve in their functional scores as much as traditional Medicare patients.” 

The researchers’ findings, Prusynski said, support assertions that Medicare Advantage plans appear to ration the clients’ care, including home health, and to be oriented more toward profitability than patient well-being.

“One of the primary motivators for studies like this is the fact that health providers have been experiencing these burdens from Medicare Advantage plans for years,” she said. “These limits on what they can provide patients is a specific problem with Medicare Advantage.”

This work was supported by the Learning Health Systems Rehabilitation Research Network through a grant to Brown University from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (5P2CHD101895-04).

Related: Download video soundbites with Prusynski discussing the study findings.

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