New research sheds light on healthcare utilization and spending by homebound older adults

In 2015, homebound seniors accounted for about 11% of total fee-for-service Medicare spending, but they made up only 5.7% of Medicare’s fee-for-service patient population.

Homebound older people use hospital care more frequently and have higher health insurance costs than non-homebound older people, a new research paper said.

In the study, home confinement was defined as leaving home once a week or less. There is a valued two million elderly people confined to their homes in the country. Homebound adults are often medically complex, with high levels of dementia and chronic disease.

The new research paper, which was published by the Journal of General Internal Medicine, features data collected from nearly 6,500 adults ages 70 and older with fee-for-service Medicare coverage. One of the primary data sources for the study was the National Health and Aging Trends Study (NHATS), which conducts annual in-person interviews with Medicare beneficiaries or proxy respondents to obtain information such as living conditions, health conditions and functional status.

The research paper, which looked at data from 2011 to 2017, has several key data points.

  • About 40% of homebound seniors were hospitalized each year, compared to about 20% of non-homebound seniors
  • Total annual Medicare spending is more than $11,000 higher for homebound seniors compared to non-homebound seniors
  • In 2015, homebound seniors accounted for about 11% of total fee-for-service Medicare spending, but represented only 5.7% of Medicare’s fee-for-service patient population.
  • Homebound seniors make up nearly 14% of Medicare beneficiaries in the 95% percentile of fee-for-service Medicare spending
  • In the year following the NHATS interview, homebound seniors compared to non-homebound seniors were more likely to have a potentially preventable hospitalization (14.8% versus 4.5%) and more likely to have an emergency room visit (54.0% vs. 32.6%)
  • After adjusting data for demographic, clinical, and geographic characteristics, homebound older adults were less likely to have an annual primary care or specialist visit compared to non-homebound older adults

“Homebound seniors use more inpatient care and less outpatient care than non-homebound seniors, contributing to higher levels of overall Medicare spending,” the study co-authors wrote. .

Interpret the data

Homebound older people are not receiving home health services that could make up for the lack of outpatient services, the study’s lead author said in a prepared statement. “When we adjusted for demographic, clinical and geographic differences, we found that homebound people have a negligible increase in the likelihood of having a home health visit compared to non-homebound people, suggesting that the gap in ambulatory care is not being closed by a home care model within Medicare. This is concerning but not surprising; the finding is consistent with Medicare’s well-known barriers to accessing services home health,” said Benjamin Oseroff, a third-year medical student at Icahn School of Medicine at Mount Sinai. .

Home-based primary care would likely benefit housebound older people, the study co-authors wrote. “The lower rate of primary care utilization we observe may partly explain our finding that homebound people experience more potentially avoidable hospitalizations than non-homebound and higher expenditures. Previous search suggests that increasing access to home-based primary care can reduce hospitalizations and overall expenditures for homebound people, depending on the type of intervention.

Targeting homebound older adults for improved care would reduce Medicare spending, the study co-authors wrote. “We find that in 2015, homebound seniors accounted for 11.0% of Medicare spending among people over age 70, despite making up only 5.7% of that population.e percentile or greater of Medicare spending. Our findings suggest that homebound people, a group often invisible to the healthcare system, may be an important population to target for quality improvement and to reduce Medicare spending.”

Telehealth could improve care for the homebound elderly, but it has limitations for this patient population, the study co-authors wrote. “Telemedicine offers another alternative to in-person visits, although recent experiences during the COVID-19 pandemic highlight the challenges of reaching homebound seniors virtually.”

One of the co-authors of the study who participated in the writing of a a newspaper article on barriers to telehealth for homebound seniors said in a prepared statement that there are several challenges to overcome when it comes to telehealth. “The types of barriers we found ran the gamut, from lack of broadband access, to lack of help using technology, to cognitive and sensory impairments. In this population, older age may exacerbate some of the inequities this population already faces. A high-tech solution will not always work for this high-need, medically and socially complex population,” said Katherine Ornstein, PhD, MPH, Adjunct Associate Professor of Geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai.

Related: Home health aides undervalued in the US healthcare system

Christopher Cheney is the Clinical Care Editor at HealthLeaders.

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