Department of Applied Economics, University of Minnesota, Minneapolis.
Duke-Margolis Institute for Health Policy, Duke University, Washington, DC.
JAMA Health Forum. 2024 Nov 1;5(11):e243767. doi: 10.1001/jamahealthforum.2024.3767.
The home health agency (HHA) market has seen increasingly more change in ownership transactions. Little is known about the organizational characteristics and quality of care of HHAs after ownership has changed.
To examine whether an HHA change in ownership was associated with different quality-of-care outcomes, patient volume, and staffing levels.
DESIGN, SETTING, AND PARTICIPANTS: Using current HHA change of ownership files linked to publicly available Medicare HHA data, this staggered difference-in-differences analysis evaluated ownership change transactions of Medicare-certified HHAs from quarter 1 of 2016 to quarter 4 of 2019. Pretransaction and posttransaction HHA characteristics and quality-of-care outcomes were compared between HHAs that changed ownership and up to 8 matched controls. The transactions in the main analysis included (1) when an HHA remained as for-profit with a change in ownership and (2) when an HHA changed from nonprofit/public to for-profit ownership. The data were analyzed between November 2023 and September 2024.
The primary outcomes were HHA-quarter measures of star ratings, the individual quality measures that compose the star ratings based on the Outcome and Assessment Information Set, and claims-based quality metrics, such as hospitalizations and emergency department visits. The secondary outcomes included HHA year measures of Medicare patient volume, per capita payments, and staffing levels (full-time equivalents and minutes per visit).
The main dataset included 294 Medicare-certified HHAs that changed ownership, matched with 2330 controls. In 3 years after an ownership change, quarterly star ratings increased by 0.18 (95% CI, 0.05-0.31) relative to matched controls, with greater increases among HHAs that converted from nonprofit/public to for-profit. No significant improvement was observed in the 60-day rates of hospital admissions or outpatient emergency department visits. Further, no significant changes were observed in the number of Medicare beneficiaries, but per capita payments increased within 2 years post-ownership change. Significant reductions were observed in full-time equivalents of registered nurses (-17% [95% CI, -31% to -3%]) and home health aides (-26% [95% CI, -39% to -13%]), as well as per-visit minutes for skilled nursing care (-5% [95% CI, -9% to -1%]), physical therapy (-3% [95% CI, -5% to 0%]), and home health aide care (-11% [95% CI, -15% to -6%]).
In this difference-in-differences analysis of Medicare-certified HHAs, ownership change was associated with higher star ratings and Medicare per capita payments, but not with claims-based quality measures. Reduction in staffing levels after ownership change raises concerns about implications for quality of care.
家庭保健机构（HHA）市场的所有权交易发生了越来越多的变化。在所有权发生变化后，关于 HHA 的组织特征和护理质量知之甚少。
研究 HHA 的所有权变更是否与不同的护理质量结果、患者量和人员配备水平有关。
设计、地点和参与者：使用当前的 HHA 所有权变更文件与公开可用的 Medicare HHA 数据相关联，这项交错差异差异分析评估了 Medicare 认证的 HHA 的所有权变更交易，从 2016 年第一季度到 2019 年第四季度。在所有权变更前后，将变更所有权的 HHA 与多达 8 个匹配对照进行比较。主要分析中的交易包括：（1）当 HHA 保持营利性并发生所有权变更时，以及（2）当 HHA 从非营利/公共转为营利性所有权时。数据分析于 2023 年 11 月至 2024 年 9 月进行。
主要结果是 HHA 季度的星级评定、构成星级评定的个体质量指标，以及基于结果和评估信息集的基于索赔的质量指标，如住院和急诊就诊。次要结果包括 HHA 年的 Medicare 患者量、人均支付额和人员配备水平（全职等效人员和每次就诊的分钟数）。
主要数据集包括 294 家变更所有权的 Medicare 认证 HHA，与 2330 个对照匹配。在所有权变更后的 3 年内，季度星级评定相对于匹配对照增加了 0.18（95%CI，0.05-0.31），非营利/公共转为营利性的 HHA 增幅更大。在 60 天内的住院率或门诊急诊就诊率没有观察到显著改善。此外，在所有权变更后 2 年内，医疗保险受益人数没有显著变化，但人均支付额增加。注册护士的全职等效人员（-17%[95%CI，-31%至-3%]）和家庭保健助手（-26%[95%CI，-39%至-13%]）以及每次就诊的熟练护理时间（-5%[95%CI，-9%至-1%]）、物理治疗（-3%[95%CI，-5%至 0%]）和家庭保健助手护理（-11%[95%CI，-15%至-6%]）显著减少。
在这项对 Medicare 认证 HHA 的差异差异分析中，所有权变更与更高的星级评定和 Medicare 人均支付额相关，但与基于索赔的质量指标无关。所有权变更后人员配备水平的减少引起了对护理质量影响的关注。
