Evaluation of MMA Section 702 Demonstration: Clarifying the Definition of Homebound

This project has been completed. The contractor developed a beneficiary survey and conducted site visits and other qualitative data collection. The survey was not administered due to low enrollment in the demonstration. The project plan was modified to address selected research questions, including several that can be answered using information from home health agencies in the demonstration States. Medicare submitted the final Report to Congress in January 2008 (a technical report is available at www.cms.hhs.gov/Reports/downloads/homebound.pdf). The Secretary did not recommend program policy changes, noting that "the complex set of barriers to enrolling beneficiaries . . . are an indication that successful adoption of the eligibility change envisioned in the legislation faces serious impediments." Information from qualitative data collection and the home health agency survey indicated that barriers included the extensive criteria for enrollment laid out in the legislation, concerns on the part of providers that financing might be inadequate, low interest on the part of beneficiaries in changing their care arrangements, and others. The project also produced an examination of the role of payment outliers in the context of the evaluation findings. To the extent that the characteristics of the demonstration target population and the outlier population overlap, then the demonstration concept may be viable and CMS's outlier policy could play a role in ensuring access to care for this population. Using administrative data, the analysts identified proxy demonstration patients in multiple states, and explored how they compared with patients who qualified for an outlier payment. They found that the proxy demonstration target group is small, and only a small fraction of proxy demonstration patients generate outlier payments, so there is little overlap. Financial outliers include patients with relatively few limitations in functioning, and lower mortality, but they use more home health resources than the proxy demonstration patients. Agencies that serve a disproportionate share of outlier patients had atypical characteristics; they tended to be located in urban areas, to serve relatively few Medicare home health patients, had no association with a hospice, had low costs per visit for nursing and aide services, and generally provided high numbers of such services to their patient caseload overall. Agencies that provided care to a high percentage of proxy demonstration patients differed less noticeably from the general population of HHAs.