Medicare Advantage Contributes to Racial Disparities in Home Health Use Near End-of-life

Outcomes

1. Participants will be able to understand the basic differences between Traditional Medicare and Medicare Advantage.

2. Participants will be able to describe how MA enrollment impacts home health utilization across racial groups

Key Message

Medicare Advantage (MA) enrollment is growing among Black and Hispanic populations however little is known about how MA enrollment impacts HH utilization across racial groups. This study shows that MA creates new disparities in HH utilization with Hispanic older adults disproportionately impacted. Future research must explain the mechanisms of the unexplained differences in HH utilization at the end of life.

Abstract

Medicare Advantage (MA) enrollment is growing, particularly among Black and Hispanic populations(1). While racial and ethnic disparities in Home Health (HH) access and outcomes have been documented (2,3), little is known about the impact of MA enrollment on HH utilization across racial groups. This is particularly important given the integral role that HH plays in the care of older adults in the last year of life (4).

Objective

To assess the differences in end-of-life HH use and length of stay in TM versus MA across racial and ethnic groups.

Methods

Using a 100% Medicare cohort of 2,153,793 2019 decedents (785,585 in MA), we fit a linear probability model predicting HH use and, among HH users, HH length of stay in the last year of life. We measured the average number of days in HH per 100 eligible days (i.e., at home, not in hospice) in the last year of life. We then compared HH use by racial groups in TM vs. MA. All models included county-level fixed-effects and adjusted for individual characteristics and neighborhood-level deprivation.

Results

In the last year of life, the use of HH was substantially lower in MA vs. TM for Hispanic decedents (32.8 vs. 41.6%, P < 0.001), as well as Asian/Pacific Islander decedents (31.4 vs. 39.9%, p < 0.001). Among HH users, Hispanic decedents received 30.2 fewer days (p < 0.001), Black decedents 19.9 fewer days (p < 0.001) and Asian/Pacific Islanders 16.2 fewer days (p < 0.05) of HH in MA vs. TM at the EOL. Differences of this magnitude were not seen across other racial/ ethnic groups.

Conclusion

Enrollment in MA appears to be widening racial and ethnic disparities in HH utilization at the EOL, particularly for Hispanic older adults. Future research must strive to understand the causes and consequences of these disparities in HH utilization in the MA program.

References

(1) Meyers, D. J., Mor, V., Rahman, M., & Trivedi, A. N. (2021). Growth In Medicare Advantage Greatest Among Black And Hispanic Enrollees: Study examines the extent to which growth in Medicare Advantage is being driven by increased participation of racial/ethnic minorities and other traditionally marginalized groups. Health Affairs, 40(6), 945-950. (2) Jones, T., Luth, E. A., Cleland, C. M., & Brody, A. A. (2024). Race and Ethnicity Are Related to Undesirable Home Health Care Outcomes in Seriously Ill Older Adults. Journal of the American Medical Directors Association, 25(6), 104983. (3) FASHAW‐WALTERS, S. A., Rahman, M., Gee, G., et al. (2023). Potentially more out of reach: public reporting exacerbates inequities in home health access. The Milbank Quarterly, 101(2), 527-559. (4) Bylander J. Community-Focused Health Care For The Seriously Ill. Health Aff Proj Hope. 2019;38(3):344-346. doi:10.1377/hlthaff.2019.00111