Home Health Care Reimbursement Fails to Address Cognitive Impairment Needs


Older adults with CI were found to require a significantly higher number of visits during home health care episodes, particularly skilled nursing visits.

 Julia G. Burgdorf, PhD, postdoctoral fellow, department of health policy and management, Johns Hopkins Bloomberg School of Public Health

Julia G. Burgdorf, PhD

Adjustments to Medicare-funded home health care (HHC) may threaten access to care for community-dwelling older adults with cognitive impairment (CI), a recent study concluded, as investigators found that those in this patient population were more likely to require successive HHC episodes. 

The cohort study included a total of 1214 Medicare beneficiaries receiving HHC between 2011 and 2016, 43.9% of whom had CI. When studying patients with CI, investigators found they were 45% more likely to experience recurrent HHC episodes (adjusted OR, 1.45 [95% CI, 1.01-2.09]; P <.05) and received 2.82 total additional visits (P <.001) within 60 days of an index HHC episode.

The average age of patients was 81.6 years, with women accounting for 62.5% of patients. In addition to requiring more family caregiver support, those with CI received a significantly higher number of visits, including 1.39 additional nursing visits (95% CI, 0.49-2.29; P = .003), 0.72 additional physical therapy visits (95% CI, 0.15-1.05; P = .01), and 0.60 additional occupational therapy visits (95% CI, 0.15-1.05; P = .01) within 60 days of HHC episode start of care.

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“Recent changes to the Medicare HHC payment system do not account for patient CI and reduce reimbursement for later episodes in a sustained spell of HHC,” lead author Julia G. Burgdorf, PhD, postdoctoral fellow, department of health policy and management, Johns Hopkins Bloomberg School of Public Health, and colleagues wrote. “Our results raise the possibility that these policies may create a financial disincentive to serving beneficiaries with CI—potentially reducing their access to HHC. Additionally, our findings confirm the recognized need for supportive home-based services for community-dwelling older adults with CI.”

Revisions, performed under the Patient-Driven Groupings Model (PDGM), included lower reimbursement for HHC episodes not immediately preceded by hospitalization, a shortened payment period from 60 days to 30 days for an HHC episode, and the determination of reimbursement by clinical grouping and comorbidity category, which are not influenced by a patient’s known CI or dementia diagnosis.

Limitations of the study included the failure to address comorbidities such as heart disease and diabetes, which may contribute to elevated care needs, as well as the small sample size in relation to the larger population of Medicare beneficiaries. Additionally, investigators tracked visits during the first 120 days of the HHC episode, which may not accurately reflect patterns over a longer period of time.

“This study offers a contrasting image to previous work suggesting that HHC patients with CI have lower resource use than patients without such impairment,” Burgdorf et al said. “Findings from the present study indicate that CMS [Centers for Medicare and Medicaid Services] should carefully monitor the potential unintended consequences of PDGM for beneficiaries with cognitive impairment and/or diagnosed dementia, particularly in regard to their access to, and outcomes during, HHC.”

As Medicaid and private pay also pose barriers to care for this patient population, investigators stressed the need to ensure access their access to HHC. Additional research will be required to assess whether CI can be a determinant of reimbursement under PDGM.

Burgdorf JG, Amjad H, Bowles KH. Cognitive impairment associated with greater care intensity during home health care. Alzheimer’s Dement. Published online August 24, 2021. doi:10.1002/alz.12438
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