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Cost Sharing and Home Health Care.

Home health care has been one of the fastest-growing parts of the Medicare program, with spending doubling on these services between 2001 and 2014.1 In 2014, roughly 3.4 million Medicare beneficiaries received home health care at a total cost to Medicare of $17.7 billion.1 In an attempt to limit spending on home health care, some Medicare Advantage plans have introduced cost sharing. When patients have to pay some part of the cost of their care through a deductible or copayment, standard theory suggests that they will cut back on services. Although traditional fee-for-service Medicare beneficiaries face no cost sharing for home health care, various proposals have been made to introduce cost sharing for home health care into traditional Medicare.2 In this issue of JAMA Internal Medicine, Li et al3 provide novel evidence on home health cost sharing in Medicare Advantage plans. Although Medicare Advantage plans differ from traditional Medicare in important ways, the authors’ results provide a window into how Medicare beneficiaries responded to the introduction of home health cost sharing. The authors identified 18 plans that introduced copayments between 2007 and 2011 and matched them to 18 control plans that maintained no cost sharing for home health visits. The introduction of a home health copayment was not significantly associated with the number of enrollees receiving home health care, the number of home health episodes, or the number of home health days per users. The authors3 did find that high users of home health care were more likely to leave Medicare Advantage, and this effect was consistently stronger among those beneficiaries in plans with cost sharing. These results suggest home health cost sharing is not an effective cost containment strategy. Given a large health policy literature showing that cost sharing decreases use, these results are somewhat surprising. However, there are reasons to be cautious with these results, especially in applying them to traditional Medicare. First, home health care services vary in their effectiveness, with some episodes of services offering considerable value. Although cost sharing can potentially limit wasteful or inefficient home health care, it is a blunt instrument that can discourage high-value as well as low-value services. This may explain why during the 4 years that the 18 Medicare Advantage plans studied by Li et al3 introduced cost sharing, the overall proportion of Medicare Advantage plans with home health copayments actually decreased from 21.8% to 12.6%. The idea that home health care episodes vary in their effectiveness is well-understood by policy analysts. Home health is one of the few services that does not have a copayment or deductible in traditional Medicare. The Medicare Payment Advisory Commission recently recommended applying perepisode cost sharing in fee-for-service Medicare specifically to those home health episodes that were not preceded by a hospitalization or post–acute care stay.1 The rationale is that these particular home health episodes are of lower value and more discretionary relative to post–acute care home health episodes that might substitute for high-cost institutional services. Home health use has increased substantially since 2002, with a 60% increase in the number of episodes and most of the growth has been in episodes not preceded by a hospitalization.1 From a benefit design perspective, the key issue is being able to selectively apply cost sharing to those relatively ineffective services. A second reason to be cautious with these results is that cost sharing is just one potential arrow in the broad Medicare Advantage quiver to manage home health care use. As Li et al3 note, Medicare Advantage plans can use a range of utilization management strategies that are not allowed in fee-forservice Medicare, such as prior authorization and preferred networks. Thus, it is unclear whether the control plans that did not introduce cost sharing introduced other mechanisms to limit home health care spending. Li et al3 were unfortunately not able to account for the use of these other strategies in their analyses. Thus, the lack of a significant relationship between cost sharing and home health care use may have 2 very different explanations. Either cost sharing by Medicare Advantage plans does not reduce home health use or plans that do not use cost-sharing to limit home care costs may use other strategies. To resolve this issue, future research will need to more completely account for plan attributes in studying this issue. Third, the plans that introduced home health cost sharing are not random. These plans may have introduced cost sharing in anticipation of an increase in home health spending. Li et al3 were able to show relatively equal trends in use across the plans that did and did not institute cost sharing in Related article page 1012 Research Original Investigation Sharing and Home Health Service Use Among Medicare Advantage Enrollees