Home health agencies (HHA) are an increasingly important provider of postacute care (PAC) to older? Americans. The number of HHA increased 17% in the last five years and personal home health care? expenditures increased from $12.6 billion to $40 billion from 1990 to 2003 Medicare finances care for almost 3? million HHA patients annually and almost half of these are admitted into HHAs following an acute care? hospitalization. Research has found clinical benefits for PAC HHA patients as compared to other PAC settings,? but the annual rate of hospital readmissions for PAC Medicare home health beneficiaries is persistently high, at? almost 50%. Rehospitalization increases healthcare system costs, and particularly for older adults, increases? risks for adverse physical and cognitive health outcomes. High readmission rates among PAC HHA patients? and the relative absence of studies of HHA organizational and market impacts on HHA quality call out for? research to identify factors influencing these rates. In 2000, 49% of all Medicare certified agencies were? proprietary and, over two decades, striking changes in the structure and relationships among healthcare? providers, such as increased integration, and dramatically expanded demand for PAC services, have had? implications for the competitiveness of the PAC and HHA market.
The specific aims for the dissertation work to? be supported by this grant are: 1) To quantify the impact of profit orientation on risk of poor quality PAC for? HHA patients, measured as rehospitalization risk; 2) To assess the impact of market-level PAC competition on? quality of HHA care; and 3) To assess the impact of market competition on the relationship between HHA profit? orientation and quality. Conceptually, this study asks whether a clash of organizational goals, occurring when? patient care comes at the cost of profits, results in poorer care from for-profit HHA. Also, differential availability? of market resources may affect how HHAs care for patients, as choices for resource reallocation to better? compete with other PAC providers may be detrimental to quality patient care. Do agencies act more alike,? regardless of profit orientation, under high levels of competition, or do agencies respond differently by profit? orientation? This research fills a gap in the literature by using recent data from a longitudinal census of every? patient in Medicare certified HHA (the Outcome Assessment Information Set) linked with publicly available? agency- and market-level data. This large dataset allows for control of individual-, agency- and market- level? influences on rehospitalization. Multilevel modeling will account for clustering of patients within agencies and? agencies within markets and a polytomous outcome will account for competing risks for other discharge? outcomes. Market competition from other types of PAC providers will be considered in addition to competition? from other HHA. Study results will add to the important ongoing debate about the public value of not-for-profits? and potentially inform legislators considering policy impacting healthcare competition.
