Changes in Regional Variation of
Medicare Home Health Care Utilization
and Service Mix for Patients
Undergoing Major Orthopedic
Procedures in Response to Changes in
John D. FitzGerald, W. John Boscardin, and Susan L. Ettner
has been documented. Under Medicare’s Home Health Interim and Prospective Pay-
regional variation were instituted.
Objective. To examine the impact of Medicare reimbursement policy on regional
variation in HH care utilization and type of HH services delivered.
Research Design. We postulated that the reimbursement changes would reduce re-
gional variation in HH services and that HH agencies would respond by reducing less
skilled HH aide visits disproportionately compared with physical therapy or nursing
visits. An interrupted time-series analysis was conducted to examine regional variation
among HH users.
Subjects. A 100 percent sample of all Medicare recipients undergoing either elective
Results. Before the reimbursement changes, there was great variability in the prob-
ability of HH selection and the number of HH visits provided across regions. In re-
sponse to the reimbursement changes, though there was little change in the variation of
probability of HH utilization, there were marked reductions in the number and vari-
ation of HH visits, with greatest reductions in regions with highest baseline utilization.
HH aide visits were the source of the baseline variation and accounted for the majority
of the reductions in utilization after implementation.
Conclusions. The HH interim and prospective payment policies were effective in
reducing regional variation in HH utilization.
Key Words. Medicare, home health care, regional variation
rHealth Research and Educational Trust
Between 1986 and 1996, there was dramatic growth in Medicare home health
(HH) utilization, increasing from $2.6 billion per year (3 percent of Medicare
Part A expenditures) to $17.5 billion per year (13 percent of Part A expen-
ditures). This resulted from growth in both the annual number of beneficiaries
served (increasing from 1.6 to 3.6 million) and the average number of annual
visits per beneficiary (increasing from 23 to 79 visits per beneficiary) (105th
Congress United States of America 1998).
in utilization of HH services (Kenney and Dubay 1992; Welch, Wennberg,
and Welch 1996; McCall et al. 2001). Welch, Wennberg, and Welch (1996)
reported greater variation in utilization of HH services than either skilled
if so, how often to use HH care.’’
The significant regional variation raised concern within Congress and at
the Office of Inspector General (OIG) that much of this regional variation
could be attributable to either inefficient or fraudulent practices. Beginning
July 1995, the OIG working with other agencies initiated Operation Restore
documented examples of fraud and abuse (Health Care Financing Admin-
istration 1995). The program was expanded nationwide in 1997.
In addition to these regulatory efforts, Congress passed the Balanced
Budget Act of 1997, and the Centers for Medicare and Medicaid Services
(CMS) implemented the HH Interim Payment System (IPS) on October 1,
1997 (with refinements starting October 1, 1998), and the HH Prospective
Payment System (PPS) on October 1, 2000 (105th Congress United States of
The IPS reduced the aggregate per-visit limit on payments from 112
percentofnationalmean historical coststo105 percentofthenationalmedian
costs. As per-visit limits do little to control the growth in number of visits per
beneficiary, per-beneficiary limits were also implemented.
Address correspondence to John D. FitzGerald, M.D., Ph.D., Assistant Professor, Division of
Rheumatology, Department of Medicine, David Geffen School of Medicine, University of Cal-
CA 90095-1670; e-mail: firstname.lastname@example.org. W. John Boscardin, Ph.D., Associate Ad-
junct Professor, is with the University of California–San Francisco, San Francisco, CA. Susan L.
Ettner, Ph.D., Professor, is with the Division of General Internal Medicine & Health Service
Research, Department of Medicine, David Geffen School of Medicine, University of California,
Changes in Regional Variation of Medicare Home Health Care Utilization1233
variation (105th Congress United States of America 1998). This was accom-
plished by blending agencies’ historical mean per-beneficiary cost with stan-
means. (SeeTable S1 in the appendix fordetails.)These policies were phased-
in based on each agency’s fiscal year end. Under the PPS, implemented on
October 1, 2000, HH care was organized into 60-day episodes of care for HH
resource groups (HHRGs) (Health Care Financing Administration 2000).
The Congressional Medicare Payment Advisory Commission (MED
PAC) and several independent groups have described reductions in HH care
after implementation of the IPS and PPS policies (MEDPAC 1999; McCall
et al. 2001, 2003a, 2003b; Komisar 2002; Schwartz et al. 2002; Liu, Long, and
Dowling 2003; Murkofsky et al. 2003; Murtaugh et al. 2003; Spector, Cohen,
and Pesis-Katz 2004).
In our prior analyses focusing on postacute care HH patients, we re-
ported the reduction in HH utilization for patients undergoing major ortho-
examine how these changes in reimbursement policy affected regional vari-
ation overtime, as wellashow the reimbursement changesaffected themix of
skilled HH services delivered.
As described in more detail in our prior studies (FitzGerald et al. 2007), we
opted to select a 100 percentnational sample for twowell-defined cohorts that
are commonly associated with postacute care. This permitted sufficient power
to conduct month-to-month analyses across the various Balanced Budget Act
policy periods between 1996 and 2001 so that policy implementation dates
could be better correlated with temporal changes in utilization.
We selected patients undergoing elective joint replacementsurgery (JR)
asa group that oughttobesensitive topolicychangesgiven thehigh degreeof
clinical discretion about the venue of postacute care. We also selected patients
undergoing surgical repair of hip fracture (FX) as they undergo similar pro-
the IPS, 61 percent of JR and 43 percent of FX patients received HH care
during the 120-day postoperative period (FitzGerald et al. 2006).
1234 HSR: Health Services Research 44:4 (August 2009)
Patients undergoing JR surgery were identified by diagnosis-related
study sample was confirmed by ICD-9 procedure codes 81.51–81.55. Patients
undergoing joint replacement for clearly nonelective reasons were excluded
Sensitivity analyses conducted using the full JR sample did not meaningfully
change findings andthereforeonlyresultsforthe clinicallydefinedelective JR
sample are presented.
Patients undergoing surgical repair of hip fracture were identified with
an ICD-9 diagnosis of 820.xx in any 1 of the 10 diagnostic code positions.
Surgical repair of hip fracture was confirmed with the hip replacement codes
81.51–81.53 or pinning codes 79.35, 79.15, or 78.55. Patients treated nonsur-
gically for hip fracture were excluded.
Descriptors of the patient population are described in the appendix in
Data Source. Medicare claims were obtained for all acute care hospital
and HH bills for patients undergoing either joint replacement surgery or
surgical repair of hip fracture between January 1, 1996, and December 31,
2001. Acute care hospital, RH, and SNF claims were abstracted from the
Medicare Provider Analysis and Review (MEDPAR). HH claims were
abstracted from the HH Standard Analytic File.
Probability of HH Utilization. Admission to HH care was identified to begin
within 7 days of discharge from either the acute care hospital or one of the
contiguous postacute care institutions (SNF or RH). Patients meeting the
above criteriaweredefined asreceivingHHcare.Trendsintheprobabilityof
HH care were initially analyzed separately for patients discharged directly to
was no difference in change in regional variation by type of HH admission,
these patient groups were combined into a single measure (any HH use) for
the final models.
Number of HH Visits. To parallel the 60-day PPS reimbursement structure and
60- and 120-day episodes of care were created. Episodes terminated with
Changes in Regional Variation of Medicare Home Health Care Utilization1235
either the end of the 60- or 120-day interval, rehospitalization, death, or a
break in service 47 days. When the HH claim ‘‘to’’ and ‘‘from’’ dates
straddled the end date of the episode, the number of visits was prorated
proportionally. HH care was completed within 60 and 120 days of HH
admission, respectively, for 93 and 98 percent of patients undergoing JR and
Type of HH Visits. Type of HH visit (physical therapy, nursing service vs. HH
aide) was extracted from the HH standard analytic files. Before July 1999, the
revenue center line item reported the number of visits corresponding to the
type of service. Thereafter the methodology changed to reflect 15-minute
intervals and under PPS certain revenue center codes were deleted. For the
analysis of service type, we elected to focus on the Interim Payment Policy
period (October 1997–October 1998), when the largest reduction in HH
services occurred and CMS used a uniform methodology for identifying type
of HH service.
To describe regional variation over time, we first describe detailed regional
(state-by-state) variation in HH utilization using select timepoints correlating
presented on maps of the United States.
The 10 CMS regions are used to summarize regional variation in order
to describe detailed temporal (month-to-month) variation in HH utilization.
Each CMS region includes several states. CMS identifies each region by the
city where the regional office is located. (See Figure S1, map of the United
States, in the appendix for descriptions of the CMS regions.)
We then describe detailed temporal (month-to-month) variation in HH
use for the CMS regions. Monthly trends in regional HH utilization are based
on regression analyses that included 67 binary calendar month indicators
(March 1996–September 2001) that represent the month of admission to HH
care after the inpatient or last contiguous institutional discharge, with March
the acute care hospitalization, using 120-day episodes, the first two and last
three months of HH data contain incomplete episodes and are dropped from
1236 HSR: Health Services Research 44:4 (August 2009)
Throughout the text and in the tables, results were derived using four
splinevariablestoseparately representeach ofthefourpolicyperiodsinplace
of the monthly calendar variables. (Spline variables describe the average
change across the policy period and smooth month-to-month variation;
Marsch and Cormier 2001.)
The analyses controlled for patient, institutional, HH, and regional charac-
teristics as follows.
Patient Covariates. Patient demographic factors included age at the time of
surgery (by pentile), gender, and race (Caucasian, African American, or
reported median income in the patient’s zipcode of residence after matching
patient and Census zip codes. Patient receipt of state aid (e.g., dual eligible
patients where states elect to buy into Medicare benefits on behalf of patients)
was also included in the models.
Patient medical characteristics included original reason for Medicare
entitlement (aged,disabled, end-stage renal disease, or disabled and end-stage
renal disease). Medical comorbidities identified from the 10 MEDPAR
diagnostic codes were categorized into 19 categories using the Charlson
comorbidity index (Deyo, Cherkin, and Ciol 1992).
Surgical characteristicsvariedbyindication.Forpatientsundergoing JR,
FX patients, the indications included replacement vs. pinning and whether in-
hospital complications were noted (DRG 210 vs. 211).
Institutional Covariates. For probability of selection models, the analyses
adjusted for characteristics of the discharging inpatient, SNF, or RH
institution. The institutional characteristics included teaching status (acute
care hospital only), profit status, day of discharge, relative size (within own
venue of care), and rural vs. urban status.
HH Covariates. For the number of HH visit models, the analyses adjusted for
characteristics of the HH provider. Characteristics included HH profit status,
the age of HH agency, and whether it operated under a certificate of need or
simple business licensure.
Changes in Regional Variation of Medicare Home Health Care Utilization1237
Other Regional Covariates. Postacute care supply variables by zip code
(number of SNF beds, RH beds, HH nurses, and HH aides) were matched
to hospital zip codes. All values were per capita adjusted by including the per
zip code total population aged 65 years or older in the model using the 2000
U.S. Census data. The county-level Medicare managed care market
penetration rates for 1999 reported by the Centers for Medicare and
Medicaid Statistics were also included (Centers for Medicare & Medicaid
Probability of HH Utilization. The probability of HH utilization accounting for
using nested logistic regression models. (See Figure S2 in appendix.) Upper
and lower bounds of the estimates were calculated using bootstrap
methodology (500 iterations) (Efron and Tibshirani 1993; Mooney and
Number of HH Visits. The numbers of HH visits per 60- or 120-day episode of
HH care were modeled using linear regressions with random effects for HH
agency. As results from 60- and 120-day analyses were similar, only results
from 120-day analyses are presented.
All models adjusted for patient demographic, clinical, socioeconomic,
regional, and institutionalcovariates. Duetothelarge sizeofthestudy cohort,
estimates were deemed significant only when po.0001 or when the absolute
upper or lower limits of the bootstrap estimate distribution (as described
above) did not include the value tested in the null hypothesis. STATA version
was created using ArcGIS version 9.2 (ArcGIS 2007).
From the MEDPAR database, 1,567,779 JR cases (for indication other than
hip fracture) with hospital discharge dates between March 1, 1996, and Sep-
tember 30, 2001, were identified. In all, 102 patients died before discharge. A
total of 186,659 discharges (12 percent) were excluded where the elective
nature of the surgery was unclear from the coded diagnoses (including a
1238 HSR: Health Services Research 44:4 (August 2009)
majority of revisions). An additional 9,674 patients were excluded who had
Sensitivity analyses with and without the above exclusions did not reveal
meaningful differences, and results for the more tightly defined cohort are
presented. For the number of HH visits, 228 patients were excluded who died
either while at SNF or RH or within 7 days of discharge (and no HH care
provided). (See Figure S2 in appendix for summary data flow.)
A total of 1,164,946 cases of hip fracture treated surgically were iden-
tified. Patients who died before hospital discharge (n5628), whose postacute
care venue was unclear (n56,147), or who died either while at SNF or RH or
within 7 days of discharge (n59,158) were excluded from analysis.
Discharges with missing covariate data (3–6 percent of data depending
upon the covariates included) were dropped from analyses.
Probability of HH Selection
Although probability of HH selection varied by region, there was little re-
gional variation in responsiveness to changes in reimbursement policies.
Elective Joint Replacement. Probability of HH selection varied by region with
the highest probabilities of selection in March 1996 in Boston, Atlanta, and
San Francisco regions (73, 69, and 69 percent, respectively), and the lowest
probabilities were in the Chicago, Seattle, and Kansas City regions (52, 53,
and 54 percent, respectively), with the national mean at 61 percent (Table 1).
As previously reported (FitzGerald et al. 2006), under IPS, the national mean
fell from 61 percent in March 1996 to 54 percent in October 1998, thereafter
remaining essentially flat through September 2001. There was little variation
in responsiveness to the policy across regions. Thus, by September 2001, the
same regions occupied the top three and bottom three rankings, with the
exception of Dallas surpassing Kansas City in the bottom rankings.
Hip Fracture. Similar findings were observed for the hip fracture population.
There was variation by region in baseline utilization but little variation in
response to the policy changes. The highest probabilities of selection were in
the San Francisco, New York, and Atlanta regions (52, 50, and 50 percent,
respectively) and the lowest probabilities in the Kansas City, Chicago, and
Denver regions (31, 36, and 39 percent, respectively), with the national mean
at 44 percent. As previously reported, under IPS, the national mean fell to 35
percent, recovering to 41 percent by October 2000 and then falling again
Changes in Regional Variation of Medicare Home Health Care Utilization1239
AdjustednProportion of Patients Receiving Home Health (HH) Care after Inpatient Orthopedic Surgeryw,z
After Elective Joint Replacement Surgery
After Surgical Treatment for Hip Fracture
(Difference from national mean)
nMultivariate analyses adjusted for patient, institutional, HH, and regional covariates as outlined in Methods section.
wRegions sorted by proportion of HH utilization after elective joint replacement surgery during March 1996.
1240HSR: Health Services Research 44:4 (August 2009)
slightly to 39 percent by September 2001 (FitzGerald et al. 2006). There was
remarkably little variation in response to the policy across regions, so that by
September 2001 the regions had the same rank order and only two regions
had briefly changedinternalrankorder during thefollow-upbefore returning
to the original rank order.
Number of HH Visits during a 120-Day Episode of Care
Elective Joint Replacement. As documented by other authors, there had been
significant variation in utilization of HH services before the reimbursement
changes (McCall et al. 2001, 2003a,b; Komisar 2002; Liu, Long, and
Dowlingy 2003; Murkofsky et al. 2003; Murtaugh et al. 2003; Schlenker,
Powell, and Goodrich 2005).
The maps in Figure 1 illustrate that in March 1996, for JR patients HH
agencies were providing on average 420 visits per 120-day episode of HH
care in 75 percent of illustrated states. There was a significant drop in the
mean number of HH visits after implementation of the IPS, with agencies
now providing an average of 420 visits per episode in only 21 percent of
states. After implementation of PPS, there was further reduction, so that no
states had an average of 20 or more visits per episode of HH care.
the adjusted mean number of HH visits per 120-day episode of HH care was
31.4 in the Dallas region but only 14.9 in the Seattle region (Table 2 and
Figure 2a). In other words, the Dallas HH agencies were providing an
additional 7.4 visits over the national mean of 24.0 visits (1.31 times greater),
while Seattle HH agencies were providing 9.0 fewer visits than the national
mean (0.62 times lower).
As the graph indicates (Figure 2a), the significant regional variation in
the mean number of HH visits decreased over time, with the greatest
reduction in variation occurring under IPS and during the transition to PPS.
As a measure of change in regional variation, we examined the difference
episode across the time periods. The magnitude of the absolute difference
from the national mean fell in all 10 of the CMS regions across the time
periods, while the relative magnitude of the deviation from national fell in 6
out of 10 regions.
Surgical Repair of Hip Fracture. Among FX patients, there was greater
variation across CMS region in the baseline number of HH visits per
Changes in Regional Variation of Medicare Home Health Care Utilization1241
episode. In March 1996, the adjusted mean number of HH visits provided in
the Dallas region was 72.5 but only 28.0 in the Seattle region; these figures,
respectively, represented 25.4 visits over and 19.0 visits under (or 1.54 times
as high and 0.60 times as low) as the national mean (Table 2 and Figure 2b).
Elective Joint Replacement
Adjusted number of HH visits
After Elective Joint Replacement
Adjusted number of HH visits
After Hip Fracture
Start of r-IPS
Start of PPS
End of Study
Start of IPS
Surgical Repair of Hip Fracture
120-Day Episode of Care by State
Adjusted Number of Visits among Home Health Users during
1242 HSR: Health Services Research 44:4 (August 2009)
AdjustednMean Number of Home Health (HH) Visits during a 120-Day Episode among HH Usersw,z
After Elective Joint Replacement Surgery
After Surgical Treatment for Hip Fracture
CMS region (Difference from national mean)
nMultivariate analyses adjusted for patient, institutional, HH, and regional covariates as outlined in methods section.
wRegions sorted by proportion of HH utilization after elective joint replacement surgery during March 1996.
Changes in Regional Variation of Medicare Home Health Care Utilization1243
HH month of admission
Number of HH visits
HH month of admission
Number of HH visits
Mean Number of HH Visits per 120-Day Episode after Surgical Management
of Hip Fracture by Region
(a) Adjusted Mean Number of Home Health (HH) Visits per 120-
1244 HSR: Health Services Research 44:4 (August 2009)
The magnitude of this difference diminished dramatically over the
following years, with the greatest absolute reductions occurring under
the IPS. By September 2001, the adjusted mean number of HH visits in
the Dallas region was 37.3 (13.1 visits over, remaining 1.54 times as high
as the national mean), while the number of visits in Seattle fell to 18.3
(6.0 visits under and 0.75 times as low as the national mean). The absolute
magnitude of the deviation from the national mean fell in 9 out of 10 regions,
and the relative magnitude of the deviation from national fell in 7 out of 10
Regional Variation in HH Visits by Type of HH Service
Variation in Type of HH Service before IPS (October 1997). The significant
regional variation in number of HH visits before IPS was largely attributable
to regional variation in the number of HH aide visits, with less variability in
the number of physical therapy or nursing visits.
As noted above, among JR patients before IPS, there was significant
variation in total number of HH visits ranging from 30.3 to 13.7. (Slightly
different means are noted as a result of differences in spline modeling for this
smaller temporal sample frame.) The mean number of HH aide visits across
regions ranged 10.3–2.5; with less variation in the mean number of PT visits
(range 11.6–7.3) or nursing visits (range 9.1–3.4). (All differences were
significantly different by bootstrap estimation.)
Among FX patients admitted to HH agency in October 1997, the mean
number of visits ranged from 57.9 to 20.3. The majority of this variation in
care was again attributable to variation in the number of HH aide visits,
ranging between 28.5 and 5.3 visits per region, with less variation in the
number of PT visits (range 14.6–8.4) or nursing visits (range 17.2–6.6). (All
differences were significantly different by bootstrap estimation.)
Change in Variation in Type of HH Service after IPS (October 1997–October
1998). The large reductions in total number of visits following the
introduction of the IPS were explained primarily by greater reductions in
HH aide visits and to a lesser extent nursing visits.
Among JR patients, the total adjusted mean number of visits per
episode under IPS fell from 21.9 to 17.7 (a 19 percent reduction) between
October 1997 and October 1998. By type of visit, the number of HH
aide visits fell from 5.3 to 3.3 (39 percent reduction), while nursing visits
fell from 6.5 to 5.1 (21 percent reduction) and physical therapy visits fell
Changes in Regional Variation of Medicare Home Health Care Utilization1245
Oct-97 Oct-98 Oct-97Oct-98 Oct-97Oct-98Oct-97Oct-98Oct-97Oct-98Oct-97Oct-98Oct-97Oct-98Oct-97Oct-98Oct-97Oct-98Oct-97Oct-98Oct-97Oct-98
tober 1998 by Type of Visit for Patient Undergoing Elective Joint Replacement
Surgery. (b) Reduction in Home Health Visits between October 1997 and Octo-
(a) Reduction in Home Health Visits between October 1997 and Oc-
1246HSR: Health Services Research 44:4 (August 2009)
from 10.1 to 9.3 (8 percent reduction). By visit type, the 2.1 fewer HH aide
visits, 1.3 fewer nursing visits, and 0.8 fewer physical therapy visits,
respectively, accounted for 52, 29, and 18 percent of the 4.3 fewer total
HH visits provided. (All differences were significantly different by bootstrap
Among FX patients, the total adjusted mean number of visits under IPS
fell from 39.3 to 28.2 (a 28 percent reduction). By type of visit, the number of
HH aide visits fell from 15.3 to 8.8 (42 percent reduction), while nursing visits
fell from 11.8 to 8.6 (28 percent reduction) and physical therapy visits fell
from 12.2 to 10.9 (11 percent reduction). By visit type, the 6.5 fewer HH aide
visits, 3.3 fewer nursing visits, and 1.4 fewer physical therapy visits,
respectively, accounted for 58, 29, and 12 percent of the 11.1 fewer total
HH visits provided. (All differences were significantly different by bootstrap
Before implementation of the BBA, there was significant regional variation in
HH usage with greater variation in the number of HH visits per beneficiary
than variation in number of beneficiaries selected for HH care after major
orthopedic surgery. This variation in number of HH visits was driven pri-
marily by variation in the number of HH aide visits.
These results reported hereinsupportthe earlier IPS findings by McCall
et al. (2003a,b) and related findings by Murtaugh et al. (2003), who reported
that between 1997 and 2001 among a 1 percent sample of all HH users (both
chronic and postacute care patients), there was a 79 percent reduction in HH
aide visits but only a 42 percent reduction in skilled visits (physical therapy
Before the BBA, the number of visits per beneficiary had been uncon-
strained. As elucidated by McKnight (2006), with the IPS per-beneficiary
limits based on a blend of agency and regional historical costs, agencies with
high average historical costs relative to national average costs faced greater
pressure to restrain costs per beneficiary than agencies with lower historical
greater pressure to reduce visits per user on agencies with high utilization.
Porrell, Liu, and Brungo (2006) correlated agency low historical per benefi-
ciary limits with subsequent market share expansion and high limits with
market share contraction. Owing to the regional variation in utilization and
Changes in Regional Variation of Medicare Home Health Care Utilization1247
greater reductions in regions with greater HH utilization.
With the implementation of PPS, the number of visits per episode and
regional variation fell even further. For these physical therapy–intense HH
episodes of care, reimbursement under PPS was generous, with average pay-
Therefore, the reduction in number of visits after orthopedic surgery under
PPS was attributable to the incentive structure of prospective payments rather
than reimbursement cuts.
Policy makers have long been concerned that regional variation was
the IPS and PPS reduced regional variation and that under IPS, this was
if these reductions were primarily reductions in inefficient services. Some
authors have reported that reductions in HH care use, in general, were not
associated with poorer patient clinical outcomes or satisfaction (McCall et al.
2004; Schlenker, Powell, and Goodrich 2005). However, McCall et al. (2002)
did report that for HH patients between 1997 and 1999, there was increased
use of SNF, emergency room use, and mortality after HH admission, though
no change in hospital readmission rates.
Peng, Navaie-Waliser, and Feldman (2003) reported that at time of HH
discharge, patients had a significant number of dependencies, as well as anx-
iety and depression. Brega et al. (2005) reported that African American and
nonwhite Hispanic HH patients had poorer functional outcomes than Cau-
casian patients at discharge.
With reductions in HH visits and in particular HH aide services, it is
likely there would be increased burdens upon informal care from family
members, which may disproportionately burden vulnerable HH patients.
Peng, Navaie-Waliser, and Feldman (2003) reported that Hispanic and Asian
patients reported greater disabilities at time of discharge, and that African
American patients were less likely to have informal care available than Cau-
casian patients. McKnight (2006) reported that reductions in HH utilization
were partly offset by increased out-of-pocket payments, and that low-income
beneficiaries experienced larger reductions in HH care after implementation
of IPS, arguing for potential loss in welfare though no poorer outcomes were
noted. Schwartz et al. (2002) reported that in rural HH agencies 81 percent
of HH beneficiaries reported increased demands on informal care and
heightened concern about older and frail beneficiaries (Lin and Meit 2005).
For certain vulnerable patient groups, particularly those with limited informal
1248 HSR: Health Services Research 44:4 (August 2009)
care options, earlier discharge under these BBA policies could have adverse
Our findings need to be interpreted carefully. Only two conditions were
studied, although these represent a significant proportion of postacute care
services. Caution should be used extrapolating these findings to other groups
of HH patients.
Furthermore, several other policies were concurrently implemented,
which either directly (Operation Restore Trust, HH surety bonds, civil pen-
alties for physicians inappropriately prescribing HH services and a 6-month
Policy) impacted HH utilization and might explain some of the observed
changes over time. (See Tables S1 and S2 for summary.) However, with the
exception of Operation Restore Trust, no policies had differential regional
implementation or regulation, so any potential temporal–regional bias is un-
likely to be substantial. Furthermore, the above month-to-month analyses
demonstrate that changes in utilization correlate well with BBA implemen-
In summary, theIPS and PPS reduced regional variation in HH services
after major orthopedic surgery. Under IPS, this was largely attributable to
reductions in lesser skilled services. Other authors have documented no con-
current reductions in patient outcomes. However, reducing services could
result in increased burden on informal care, and for those beneficiaries with
little social support, this could have adverse implications. To the extent that
these reductions may have reduced ineffective care, these findings suggest
that tailoring policies to target areas of high utilization may be an effective
Joint Acknowledgment/Disclosure Statement: Drs. FitzGerald and Boscardin’s
effort was partly supported by K08 HS13168 from the Agency for Healthcare
Research and Quality. Dr. FitzGerald and Dr. Ettner’s effort was partly sup-
ported by an Arthritis Investigator Award from the Arthritis Foundation.
Changes in Regional Variation of Medicare Home Health Care Utilization1249
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Changes in Regional Variation of Medicare Home Health Care Utilization1251
SUPPORTING INFORMATION Download full-text
Additional supporting information may be found in the online version of this
Appendix SA1: Author Matrix.
Figure S1. Map of CMS Regions.
Figure S2. Conceptual Model for Nested Logistic Statistical Model.
Table S1. Home Health Reimbursement and Related Policy Changes.
Table S2. Other Concurrent Policies.
Table S3. Elective Joint Replacement and Hip Fracture Patient Char-
acteristics before Implementation of Home Health Policy Changes.
Please note: Wiley-Blackwell is not responsible for the content or func-
tionality of any supporting materials supplied by the authors. Any queries
(other than missing material) should be directed to the corresponding author
for the article.
1252 HSR: Health Services Research 44:4 (August 2009)