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Original Investigation
Health Care Policy and Law
July 2017

Association of Cost Sharing With Use of Home Health Services Among Medicare Advantage Enrollees

Author Affiliations
  • 1Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
  • 2Department of Health Policy, Vanderbilt University, Nashville, Tennessee
  • 3Providence VA Medical Center, Providence, Rhode Island
JAMA Intern Med. 2017;177(7):1012-1018. doi:10.1001/jamainternmed.2017.1058
Key Points

Question  Do copayments reduce the use of home health care among older adults?

Findings  In this case-control study of 36 Medicare Advantage plans, increased copayments for home health care were not associated with changes in the proportion of enrollees receiving home health care, the number of home health episodes per user, or home health days per user.

Meaning  We found no evidence that imposing copayments meaningfully reduces the use of home health care, but such cost sharing may add substantially to the burden of out-of-pocket spending among frail older adults.

Abstract

Importance  Several policy proposals advocate introducing copayments for home health care in the Medicare program. To our knowledge, no prior studies have assessed this cost-containment strategy.

Objective  To determine the association of home health copayments with use of home health services.

Design, Setting, and Participants  A difference-in-differences case-control study of 18 Medicare Advantage (MA) plans that introduced copayments for home health care between 2007 and 2011 and 18 concurrent control MA plans. The study included 135 302 enrollees in plans that introduced copayment and 155 892 enrollees in matched control plans.

Exposures  Introduction of copayments for home health care between 2007 and 2011.

Main Outcomes and Measures  Proportion of enrollees receiving home health care, annual numbers of home health episodes, and days receiving home health care.

Results  Copayments for home health visits ranged from $5 to $20 per visit, which were estimated to be associated with $165 (interquartile range [IQR], $45-$180) to $660 (IQR, $180-$720) in out-of-pocket spending for the average user of home health care. The increased copayment for home health care was not associated with the proportion of enrollees receiving home health care (adjusted difference-in-differences, −0.15 percentage points; 95% CI, −0.38 to 0.09), the number of home health episodes per user (adjusted difference-in-differences, 0.01; 95% CI, −0.01 to 0.03), and home health days per user (adjusted difference-in-differences, −0.19; 95% CI, −3.02 to 2.64). In both intervention and control plans and across all levels of copayments, we observed higher disenrollment rates among enrollees with greater baseline use of home health care.

Conclusions and Relevance  We found no evidence that imposing copayments reduced the use of home health services among older adults. More intensive use of home health services was associated with increased rates of disenrollment in MA plans. The findings raise questions about the potential effectiveness of this cost-containment strategy.

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