High-quality home health agencies are 'out of reach' for Medicare beneficiaries of color

New research from the University of Minnesota School of Public Health (SPH) examines the association between Medicare home health patients' race and income status and the quality of care they receive from home health agencies.

The study, led by SPH assistant professor Shekinah Fashaw-Walters, used Medicare data from 2016 to examine how individual- and neighborhood-level racial, ethnic, and socioeconomic status is associated with the use of high-quality agencies. The quality of home health care agencies was determined using a federal five-star rating system. "High-quality" agencies received 3.5 stars or higher.

"The inequities that we find in this study are most likely driven by racism, especially given our finding that large portions of the disparity are related to neighborhood-level factors," said Fashaw-Walters.

The study found that:

• Black and Hispanic patients had a 2.2% and a 2.5% lower probability of high-quality home health agency use, respectively, compared with their white counterparts within the same neighborhoods.
• Low-income patients had a 1.2% lower probability of high-quality home health agency use compared with higher-income counterparts, and patients residing in neighborhoods with higher proportions of marginalized residents had a lower probability of high-quality agency use.
• Some 40-77%of the disparities in high-quality agency use were attributable to neighborhood-level factors.

This study serves as a call to action for policy makers and the Medicare home health program to urgently consider reducing racial and socioeconomic disparities in access to high-quality home health care. Mitigating these disparities will require policies that dismantle structural and institutional barriers of racism, incentivize serving the underserved, and reallocate resources to the most vulnerable areas and patient populations. Ensuring equitable access to quality care for all older adults means taking the necessary steps to put high-quality home health agencies within the reach of the most marginalized.

"Change is needed in the Medicare home health program to ensure equitable access for all Medicare beneficiaries," said Fashaw-Walters. "Changes should be prioritized before payment-altering initiatives, such as Home Health Value-Based Purchasing, are fully implemented, because similar market-based reforms in the past have been shown to exacerbate health disparities."

Fashaw-Walters plans to conduct future research focused on the impact of market-based reforms, such as public reporting and the Home Health Value-Based Purchasing program, and agency performance to understand how inequities in home health care access contribute to inequities in client health and wellbeing.