1. Medicare Home Health and The Role of Physicians Jennifer L. Wolff, Ann Meadow, Carlos O. Weiss, Cynthia M. Boyd, Bruce Leff June 2008

2. Background Variability in home health relative to other acute and post-acute settings: –Residential environment –Intermittent medical supervision –Less systematic physician involvement Medicare policy stipulates that home health patients must be under the care of a physician Frequency and impact of home health patients’ interactions with physicians not well understood –Referral into home care –Evaluation and management during home health episode

3. Questions 1.Do Medicare beneficiaries commonly incur physician visits for their evaluation and management prior to entering home health care? To what extent does this vary by acute or post-acute services use? 2.What proportion of Medicare home health patients incur one or more physician visit for their evaluation and management during the home health episode? What types of visits are most common? 3.Is physician evaluation and management during the home health episode associated with patients’ discharge destination from home care?

4. Methods: Data 2005/2006 Chronic Condition Data Warehouse - 5% Standard Analytic File (SAF) - Linked Outcome and Assessment Information Set (OASIS) Records Study Sample Inclusion Criteria: Enrolled in fee-for-service Medicare (Parts A and B) OASIS Start of Care assessment during 7/1/2005 thru 6/30/2006; discharged prior to 12/1/2006 (n=109,973) Excluded otherwise eligible participants with a surgical wound (M0482=‘1’; surgical procedure global payment rates for physician (n=35,143) N=74,462 final study sample

5. Methods: Measures Health Services Use (Administrative Claims): Inpatient Hospitalization Post-Acute Care (skilled nursing; inpatient rehabilitation) Physician Visit (evaluation and management CPT codes; BETOS codes for physician visit type) Home Health Discharge Disposition (OASIS; M0100) Socio-demographic Factors (Medicare Enrollment File): Age, gender, race, Medicaid Individual Factors (OASIS Start of Care): Health behaviors (smoking, alchohol/drug use) Function (neurological, emotional, physical) Clinical factors (sensory impairment, pain, open wound, shortness of breathe, UTI, incontinence, ostomy, obesity) Living arrangement, availability of primary caregiver

6. Time Line for Analysis Discharge Assessment (OASIS) Start of Care Assessment (OASIS) Home Health Episode 30 Days Prior to Start of Care Discharge

7. Question 1: Do Medicare beneficiaries commonly incur physician visits for their evaluation and management prior to entering home health care? To what extent does this vary by acute or post-acute services use?

8. Percent with Physician Visit* in Community, 30 Days Prior to Home Health Episode *Excludes visits in inpatient hospital, skilled nursing, inpatient rehabilitation, inpatient psychiatric, and nursing facilities, and in the emergency room) Note: N=74,462

9. Health Services Used 30 Days Prior to the Home Health Start of Care 30 Days Prior to Start of Care Total Study Sample (100%) Inpatient Hospital (INPT; 50.4%) SNF or IRF (PAC; 22.4%) Physician Visit (MD; 59.7%) XXX5.6 XX9.0 XX22.0 X13.8 XX2.7 X5.1 X29.4 12.4

10. Question 2: What proportion of Medicare home health patients incur one or more physician visit for their evaluation and management during the home health episode? What types of visits are most common?

11. Percent with Physician Visit* in Community During Home Health Episode *Excludes visits in inpatient hospital, skilled nursing, inpatient rehabilitation, inpatient psychiatric, and nursing facilities, and in the emergency room)

12. Percent of Sample with Physician Visit in Community During Episode, by Visit Type Note: Categories visits are NOT mutually exclusive. Note: N=74,462

13. Physician Evaluation and Management During Home Health Episode 30 Days Prior to Start of CareStudy Sample (100%) Physician Visit During Episode (Average=68.8%) INPTPACMD XXX 5.6 76.0 XX 9.0 68.4 XX 22.0 77.8 X 13.8 65.0 XX 2.7 74.6 X 5.1 68.3 X 29.4 69.9 12.4 50.8

14. Question 3: Is receipt of physician evaluation and management, or type of physician visit during the home health episode associated with patients’ discharge destination from home care ?

15. Community Discharge Versus Transfer to Inpatient Facility Note: N=74,462

16. Community Discharge by Health Services Prior to Start of Care 30 Days Prior to Start of Care Discharged to Community (versus inpatient facility transfer) (Average=75.0%) INPTPACMD XXX76.2 XX74.3 XX72.2 X72.3 XX73.2 X74.2 X78.5 75.7

17. Community Discharge by Physician Visit During Episode 30 Days Prior to Start of Care Community Discharge by MD Visit During Home Health Episode Difference By MD Visit (7.8%) INPTPACMDVisit (77.4%)No Visit (69.7%) XXX 79.266.712.5 XX 78.265.812.4 XX 75.859.616.2 X 76.464.711.7 XX 76.962.314.6 X 77.367.49.9 X 79.276.82.4 76.275.30.9

18. Patient Characteristics Associated with Greater Likelihood of Transfer to Inpatient Facility in Multivariate Regression Age (<65 years); Gender (Male); Race (African American); Medicaid buy in; Smoking; Obesity; Subsequent Death; Disoriented or delirious; Depressed (M0590); Skin lesion/wound; Intractible Pain; Treated for UTI in last 14 days; Shortness of Breath; Use of Respiration Equipment; Incontinence or urinary catheter; Ostomy; ADL Disability; IADL Disability; Service Mix Prior to Episode; No Physician Visit During Episode; NO DIFFERENCES: Alcohol/drug dependency, low vision, hearing impairment, living arrangement, presence of primary caregiver.

19. Odds Ratios; Receipt of Physician Visit During Home Health Episode and Transfer to Inpatient Facility *Adjusted for beneficiary socio-demographic and health characteristics. Unadjusted Adjusted*

20. Adjusted* Odds Ratios for Transfer to Inpatient Facility by Type of Physician Visit During Home Health Episode *Adjusted for beneficiary socio-demographic and health characteristics. None Physician Residential Consult Home Health (Ref.) Office Environment Supervision 34.4% 60.8% 6.0% 8.4% 2.2%

21. Summary of Findings Approximately 2/3 of home health patients incurred a physician visit for evaluation and management 30 days prior to their start of care and during the home health episode Rates of physician visits were lowest among home health patients without inpatient, post- acute, or physician care prior to the home health start of care. Physician visit during the home health episode related to discharge disposition from home health care.

22. Limitations Secondary data analysis of available information Heterogeneity of study sample; cannot generalize findings to home health patients recovering from surgical procedure Temporal algorithms of health services use do not establish ordering of physician visits in relation to other health care Cannot infer causality

23. Implications A sizeable proportion of home health patients originate from the community Variation in physician contact across origination into home care Potential opportunities for better integrating physician and home health care