Medicare Advantage Reimbursement Structures Impact Home Health Delivery and Outcomes

ABSTRACT

Objectives: Medicare Advantage (MA) plans provide fewer home health (HH) services than traditional Medicare (TM), but MA plans vary in how they reimburse HH agencies. Like TM, episodic MA plans allow agencies to determine the number and type of visits. Alternatively, per-visit MA plans dictate a specific number of visits and which disciplines provide them. This study examined differences in HH care delivery and patient outcomes among TM, episodic MA, and per-visit MA plans.

Study Design: Secondary analysis of HH agency data from January 2019 to December 2022.

Methods: For 285,297 HH stays, we used inverse probability of treatment weighting regression to compare TM vs each MA plan type and per-visit vs episodic MA plans. We examined HH length of stay; number of visits from nursing, therapy disciplines, social work, and aides; transfer to an inpatient facility during HH; improvement in self-care and mobility function; and community discharge.

Results: Compared with TM, both MA plans had shorter stays and fewer visits from nursing, therapy, and aides, and episodic MA plans had fewer social work visits. Comparing MA plans with each other, per-visit MA had 2.3% shorter stays, 3.0% more physical therapy visits, and 6.8% fewer social work visits vs episodic MA. Differences in outcomes between MA and TM varied by MA plan type, but compared with TM, per-visit MA had a 6% higher likelihood of inpatient transfers (95% CI, 1.02-1.10). Comparing MA plans, per-visit MA had a 12% higher likelihood of inpatient transfers (95% CI, 1.06-1.18) than episodic MA.

Conclusions: Episodic MA plans, which allow HH agencies flexibility in determining visit delivery, may have fewer adverse inpatient transfer outcomes compared with MA plans that dictate the amount and type of care provided.

Am J Manag Care. 2025;31(11):In Press

Takeaway Points

Medicare Advantage (MA) plans that restrict home health agencies’ ability to determine the number and type of visits delivered may have more adverse patient outcomes compared with traditional Medicare and MA plans that provide episodic payments.

• MA plans that dictate the number and types of visits for home health providers have the shortest stays, fewest social work visits, and highest percentage of transfers to inpatient facilities during the home health stay.
• Home health agencies negotiating with MA plans can seek episodic payments to allow flexibility in determining care delivery and minimize adverse outcomes.

In 2023, Medicare Advantage (MA) enrollment surpassed traditional Medicare (TM) enrollment for the first time.¹ MA is the private managed care alternative to TM, where private companies receive a capitated amount of federal funding per enrollee to cover beneficiaries’ health care costs.² MA insurers are incentivized to reduce costs to improve margins, and they frequently employ cost-saving strategies that are not commonly used by TM, such as prior authorization, limited provider networks, cost sharing, and lower payments to providers.^2-8 Despite these strategies, MA plans are attractive to enrollees because they offer additional benefits such as vision and dental coverage, often with no additional premium compared with TM.^8,9 However, MA costs the federal government 22% more—greater than $2300—per beneficiary annually, due in part to potential upcoding by MA plans to make enrollees appear sicker and garner higher payments.^2,10-12 Additionally, there are concerns that MA insurers excessively deny care and do not adequately pass savings to enrollees through benefits.^4,13

Millions of beneficiaries receive home health (HH) services annually when a provider certifies that they are homebound and require intermittent nursing and/or rehabilitation care.² In multiple studies, beneficiaries with MA were less likely to receive HH than similar patients with TM.^4,14,15 When they do receive HH, beneficiaries with MA plans receive care from lower-quality agencies, have shorter stays, and receive fewer visits from nurses, therapists, and other staff.^4,14-19 However, despite these MA patients receiving fewer services, their outcomes are mixed. Two studies found that compared with similar patients with TM, patients with MA were less likely to improve in function during HH,^17,20 and another study found higher risk of mortality for MA patients who have had a stroke.¹⁶ Other studies, however, suggest positive effects for patients with MA, including fewer costly readmissions and more days at home after HH.^15,16

One contributor to the mixed findings in the literature may be the heterogeneity among MA plans. Nearly 4000 MA plans are available nationwide, and the average beneficiary can choose from 43 separate plans.⁹ Although all MA plans must include an HH benefit, how the benefit is structured varies. One study compared HH use and length of stay (LOS) between MA plans with different cost-sharing structures, prior authorization requirements, and plan types (ie, health maintenance organization, preferred provider organization, or Special Needs Plan).⁴ However, these characteristics primarily impact HH admissions through restricted provider networks and administrative burdens at the start of care and do not account for MA plan reimbursement structure, which has substantial implications for HH agency operations during the stay. HH leaders have qualitatively described challenges with MA utilization management and differing reimbursement mechanisms in HH and how they complicate care delivery,²¹ but no quantitative work to our knowledge has examined the different MA reimbursement structures.

This study categorizes MA plans into 2 groups, episodic MA and per-visit MA, to acknowledge major differences in how HH agencies are reimbursed and to better capture the impacts of plan reimbursement structure on agency operations and patient outcomes. Similar to TM, episodic MA plans pay agencies a lump sum to cover all costs anticipated during an authorized 60-day episode.²² Although the agency’s total HH payment is typically less from an episodic MA insurer than TM,⁴ episodic payments allow the agency to determine the number of visits, distribution of visits across the stay, and which disciplines (ie, nursing, physical therapy, occupational therapy, speech therapy, social work, and/or HH aides) are necessary for each patient’s care plan. In contrast, per-visit MA plans dictate the total number of visits—and the number of visits per discipline—that are covered during a specified duration of days, and the agency must seek reauthorization to add covered days or for additional visits for any individual discipline, which is unique to per-visit plans and increases administrative burden on the agency.²¹ Per-visit MA plans thus have more administrative requirements and offer minimal flexibility for the agency to determine how many visits, and from which disciplines, each patient receives. However, because each individual HH company has separate negotiations with MA insurers, it is unknown how frequently MA contracts include episodic vs per-visit payments. Additionally, it is unknown whether disparate reimbursement structures lead to differences in HH service delivery or outcomes when comparing MA plans with TM or when comparing MA plans with each other.

This study is the first to our knowledge to acknowledge the 2 primary ways that MA plans are structured to reimburse HH agencies when evaluating differences in HH care delivery and patient outcomes between TM and MA. By examining differences across TM, episodic MA, and per-visit MA plans, we aim to inform future regulatory and policy efforts, negotiations between HH providers and MA plans, and, potentially, beneficiary decisions during enrollment.

METHODS

Data and Patient Cohort

We partnered with a large national nonprofit company that provided deidentified data on HH stays from 102 locations in 19 states. Stays represent individual plans of care for a single injury or illness. As described in a previous publication,¹⁷ data included the Outcome and Assessment Information Set (OASIS), number of visits by discipline, insurance plan, and occurrence of inpatient transfers during the stay. We included patients 65 years and older who were covered by TM or MA from January 2019 through December 2022. We included stays with complete admission and discharge assessments, from which we calculated LOS. To remove stays that provided only intermittent maintenance care, we included stays with up to 2 certified episodes. Episodes are standard time periods for which payers certify plans of care before requiring recertification to continue the care plan. Medicare’s new Patient-Driven Groupings Model (PDGM) implemented separate 30-day payment periods within 60-day episodes for TM in January 2020, but PDGM did not change the 60-day episode certification time frame.²²

Payer Groups

We indicated whether each stay was covered by TM, an episodic MA plan, or a per-visit MA plan using the specific plan entered in our partner’s billing system. For MA plans, our partner indicated whether its local contract with the MA insurer was structured to provide episodic vs per-visit payments.

Outcomes

For care delivery, we included LOS, defined as the number of days between admission and discharge, as well as the number of visits from the following disciplines: nursing, physical therapy, occupational therapy, speech therapy, social work, and HH aides. Patient outcomes included transfer to an inpatient facility during the stay, discharge to the community (vs an institution), and dichotomous indicators of functional improvement on OASIS self-care and mobility scores. Function scores are calculated at admission and discharge by totaling 9 validated items that have been used in multiple studies^17,23,24 to rate independence with self-care (eg, grooming, dressing, bathing, feeding) and mobility (eg, transfers, locomotion/ambulation).

Covariates

To account for differences between TM, episodic MA, and per-visit MA patients,²⁵ we controlled for a comprehensive set of demographic, clinical, social, and environmental characteristics.¹⁷ Demographics included age, sex, and self-reported race and ethnicity. We indicated whether patients received postacute services vs community-entry HH.²⁶

Clinical factors included admission self-care and mobility scores, level of cognitive impairment, pain that interferes with activity, history of falls, cognitive or behavioral symptoms (ie, memory deficits, impaired decision-making, verbal disruption, physical aggression, or disruptive behavior), levels of dyspnea, and incontinence.^27-29 We calculated Elixhauser Comorbidity Index scores from active diagnoses at admission.^17,30 We also indicated whether the patient had 2 or more hospitalizations in the previous 6 months, was taking 5 or more medications, or had a pressure ulcer or surgical wound at admission.

Social factors included whether HH was provided in the community (eg, home or assisted living) vs an institution (eg, long-term care), whether the patient lived alone, and the availability of assistance at home. Environmental characteristics^27,31-33 included rurality of patients’ zip codes³⁴ and Social Deprivation Index (SDI) scores,³⁵ with higher scores indicating more socioeconomic disadvantage across categories including employment, poverty, housing, and transportation access.

Analysis

To account for differences between groups, we used inverse probability of treatment weighting (IPTW), a robust method that reduces selection bias by calculating treatment weights reflecting the propensity of being in the TM, episodic MA, or per-visit MA group based on all demographic, clinical, social, and environmental factors detailed earlier.^36,37 After calculating weights, we verified that samples were balanced.³⁸

We estimated differences in care delivery and patient outcomes between TM and both MA plan types using linear regression for LOS, negative binomial models for visit counts, and logistic regression for dichotomous outcomes. In each model, we included IPTW weights and an indicator for whether the stay spanned PDGM implementation, which changed reimbursement incentives for TM.³⁹ We included year and office location fixed effects to account for the course of the COVID-19 pandemic and declines in HH visits that occurred after PDGM implementation.^39,40 Location fixed effects also accounted for varying geographical impacts of the pandemic and any differences in processes for managing each plan type between offices. Finally, we used robust SEs to account for multiple stays for the same patient across the study.

To estimate differences between episodic MA and per-visit MA plans, we used post hoc linear hypothesis tests that accounted for the weighted model, clustering, and robust SEs. We also conducted multiple sensitivity analyses. First, we ran all models with IPTW that excluded social, environmental, and OASIS-based clinical covariates, similar to published methods.^4,16 We also ran all models using 2022 data only to reduce COVID-19 contamination. Analyses were conducted in RStudio 2024.09.0 (Posit Software, PBC) with significance at a 2-sided α less than .01. This study was exempted by the University of Washington Institutional Review Board.

RESULTS

We had complete data for 285,297 HH stays, of which 178,195 (62.5%) were covered by TM, 43,299 (15.2%) were episodic MA stays, and 63,803 (22.4%) were per-visit MA. There were significant differences between the 3 groups for all demographic, clinical, social, and environmental factors (Table 1). TM patients were the oldest and most likely to identify as non-Hispanic White; per-visit MA patients were more demographically similar to TM patients than to episodic MA patients. Although differences in clinical and social factors varied, TM patients were the most complex in terms of cognitive and functional impairments, dyspnea, incontinence, pressure ulcers, falls, and behavioral symptoms. Conversely, MA patients had higher rates of social risk factors such as living alone, having no assistance, and living in more socioeconomically disadvantaged communities. The IPTW approach was successful in balancing covariates between all groups (Figure 1).³⁸

Results for adjusted differences in care delivery variables are shown in Table 2, with relative differences expressed as percentages. Compared with TM, episodic MA stays were 0.98 days shorter (95% CI, –1.29 to –0.67), equating to a 2.1% difference. Per-visit MA stays were 1.99 days shorter (95% CI, –2.24 to –1.75), or 4.3% shorter, than TM stays. Patients in both MA plans had fewer visits from nursing and all therapy disciplines compared with TM patients. Although episodic MA patients had 3.8% more social work visits (95% CI, 1.00-1.07) than TM patients, per-visit MA patients had 3.3% fewer social work visits than TM patients (95% CI, 0.94-0.99). Compared with TM, patients in both MA plans had fewer HH aide visits (9.6% fewer for episodic MA [95% CI, 0.84-0.97] and 8.1% fewer for per-visit MA [95% CI, 0.87-0.97]).

When comparing MA plans, per-visit MA patients had shorter LOS by 1.02 days (95% CI, –1.37 to –0.66), or 2.3%, compared with episodic MA. Per-visit MA plan patients had 3.0% more physical therapy visits than episodic MA plan patients (95% CI, 1.01-1.05), but there were no differences in nursing or other therapy visits between MA plans. Per-visit MA plan patients had 6.8% fewer social work visits compared with episodic MA patients (95% CI, 0.90-0.97), but HH aide visits were similar.

ORs for patient outcomes across plans are included in Figure 2. Compared with TM, episodic MA patients had 8% lower odds of improving in mobility function (95% CI, 0.87-0.98), 6% lower odds of improving in self-care function (95% CI, 0.88-0.99), no difference in community discharge, and 5% lower odds of transferring to an inpatient facility during the HH stay (95% CI, 0.90-0.99). Compared with TM, per-visit MA patients had no difference in functional improvement but had 6% higher odds of discharging to the community (95% CI, 1.02-1.10) and 6% higher odds of transferring to an inpatient facility (95% CI, 1.02-1.10). When comparing MA plans with each other, the only statistically significant difference was 12% higher odds of inpatient transfers for per-visit MA vs episodic MA patients (95% CI, 1.06-1.18).

Results of sensitivity analyses without adjustment across clinical, social, and environmental domains are shown in eAppendix Table 1 (eAppendix available at ajmc.com). Less-adjusted models had different results for care delivery and patient outcomes compared with primary analyses. Unlike primary analyses, these models found that differences in function between episodic MA and TM were not significant, but community discharge differences were significant. Differences in community discharge between per-visit MA and TM were no longer significant in less-adjusted models. Sizes of other significant effects also varied. Compared with primary analyses, 2022 sensitivity analyses found similar results for care delivery except for fewer differences in social work visits. Unlike primary analyses, these models found that differences in inpatient transfers and community discharge between MA and TM plans in 2022 were not significant, but there were better functional outcomes for per-visit MA compared with episodic MA plans.

DISCUSSION

This is the first study to our knowledge to estimate differences in HH care delivery and patient outcomes between TM and MA that accounts for the different ways MA insurers reimburse HH agencies. To strengthen the analysis, we accounted for demographic, clinical, social, and community differences between patients across insurer groups. We found substantial differences among TM, episodic MA, and per-visit MA patients across all domains. Consistent with prior literature,^4,17,20 TM patients were the most clinically complex, but MA patients, especially those with episodic MA, were more likely to be from marginalized racial and ethnic groups and have higher social risk. Notably, many studies comparing care delivery and outcomes between TM and MA do not account for differences in clinical severity measures or social determinants of health.^15,16,36 Especially considering that our results differed when models were not robustly adjusted, these findings highlight the importance of including social determinants and OASIS-based clinical factors in addition to standard adjustment for comorbidity indices and demographics.^4,15,16,36

Consistent with previous work, we found shorter LOS and fewer visits from nursing, therapy, and HH aides for both MA plan types compared with TM.^15,17 In adjusted analyses, per-visit MA patients had the shortest LOS and the fewest visits from nursing, speech therapy, and social work compared with TM patients, whereas episodic MA patients had the fewest visits from physical and occupational therapy and HH aides. Per-visit MA plans had more physical therapy visits and fewer social work visits over shorter stays for similar patients compared with episodic MA plans. These differences are likely related to how per-visit MA plans dictate specific numbers of visits by discipline (eg, via commercially available or proprietary care guidelines) vs how episodic MA plans allow agencies to determine the types and numbers of visits.

Differences in patient outcomes comparing MA and TM were mixed, however; worse outcomes were often seen for the MA plan that had the fewest visits from disciplines that target that specific outcome. For example, episodic MA plans had the fewest physical and occupational therapy visits alongside the worst functional improvement outcomes. Whereas episodic MA plans allow agency flexibility in determining visit mix, per-visit MA plans had the fewest social work and nursing visits and relatively more physical therapy visits than episodic MA but the most adverse inpatient transfer events. This may be related to per-visit MA restrictive preauthorization processes that limit the HH agency’s ability to send the discipline that can better address the specific issue that ultimately causes the inpatient transfer. The higher number of physical therapy visits for per-visit MA stays compared with episodic MA was consistent in 2022 sensitivity analyses, which also found better functional outcomes for per-visit vs episodic MA. However, the optimal number of visits and mix of visits by discipline remain unknown, and future work should examine direct relationships between care delivery variables and HH outcomes.

Limitations

Although our data from a nonprofit HH company provided unique information on MA plan structures, each HH company negotiates separate reimbursement contracts with MA plans. Thus, the mix of MA reimbursement structures varies, and these findings may not generalize to all agencies. We might expect larger differences in the distribution of episodic vs per-visit MA plans, as well as in care delivery and patient outcomes, from for-profit agencies that are more likely to prioritize cost containment.^41-43 Future work with data from additional HH providers will be essential for determining whether findings extend to all patients. We could not account for use of third-party intermediaries contracted by MA plans to manage care, so findings do not reflect heterogeneity in other MA utilization management processes.

Although differences between TM and MA patients in our sample were similar to those seen in the literature, no comprehensive description of all MA patients receiving HH is available, so we cannot assess how our sample compares to the entire HH MA population.^4,44 The SDI measures community deprivation, but no data on dual Medicare/Medicaid eligibility were available to adjust for socioeconomic status at the individual level. We also did not have hospital data to include measures of hospital readmissions after HH or to account for factors related to a preceding hospital stay. Finally, although IPTW is a robust approach to reducing selection bias, we could only adjust for observed covariates, and unmeasured differences likely still exist between payer types.

CONCLUSIONS

In the first study to our knowledge examining episodic vs per-visit payments by MA insurers, we found both MA plans had fewer nursing, therapy, and HH aide visits vs TM. Compared with episodic MA, per-visit MA patients received less social work but more physical therapy. Although differences in outcomes between TM and MA varied by MA plan type, per-visit MA plans had more adverse inpatient transfer outcomes than episodic MA plans. MA plans that allow HH agencies flexibility in determining the delivery of visits may have fewer adverse outcomes compared with MA plans that dictate the amount and type of care provided. Therefore, HH agencies negotiating with MA insurers may want to prioritize episodic payments that have reduced administrative burdens and potentially fewer adverse outcomes than per-visit MA contracts.

Author Affiliations: University of Washington Department of Rehabilitation Medicine (RAP, TMM), Seattle, WA; BAYADA Home Health Care (AD, MPJ), Moorestown, NJ; Widener University (JMS), Chester, PA.

Source of Funding: This work was supported by the Learning Health Systems Rehabilitation Research Network through a grant to Brown University from the Eunice Kennedy Shriver National Institute of Child Health and Human Development project number 5P2CHD101895-04.

Author Disclosures: Drs D’Alonzo and Johnson are employed by BAYADA Home Health Care, a home health agency. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RAP, AD, MPJ, JMS, TMM); acquisition of data (RAP, AD, MPJ); analysis and interpretation of data (RAP, AD, JMS, TMM); drafting of the manuscript (RAP, MPJ); critical revision of the manuscript for important intellectual content (RAP, AD, MPJ, JMS, TMM); statistical analysis (RAP); provision of patients or study materials (RAP, MPJ); obtaining funding (RAP, MPJ); administrative, technical, or logistic support (RAP); and supervision (RAP).

Address Correspondence to: Rachel A. Prusynski, DPT, PhD, University of Washington Department of Rehabilitation Medicine, 1959 NE Pacific St, Box 356490, Seattle, WA 98195. Email: rachelp1@uw.edu.

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