New Research Sheds Light on Homebound Seniors' Healthcare Utilization and Spending

In 2015, homebound seniors accounted for about 11% of total Medicare fee-for-service spending but they were only 5.7% of the Medicare fee-for-service patient population.

Homebound seniors are more frequent users of hospital-based care and have higher Medicare spending than non-homebound seniors, a new research article says.

In the study, homebound was defined as leaving home once per week or less. There are an estimated two million homebound seniors in the country. Homebound adults are often medically complex, with high levels of dementia and chronic disease.

The new research article, which was published by the Journal of General Internal Medicine, features data collected from nearly 6,500 adults aged 70 years and older with Medicare fee-for-service coverage. A primary source of data for the study was the National Health and Aging Trends Study (NHATS), which conducts annual in-person interviews of Medicare beneficiaries or proxy respondents for information such as living arrangements, health conditions, and functional status.

The research article, which examined data from 2011 to 2017, has several key data points.

• About 40% of homebound seniors had a hospitalization annually compared to about 20% of non-homebound seniors
   
• Total annual Medicare spending is more than $11,000 higher for homebound seniors compared to non-homebound seniors
   
• In 2015, homebound seniors accounted for about 11% of total Medicare fee-for-service spending but were only 5.7% of the Medicare fee-for-service patient population
   
• Homebound seniors account for nearly 14% of Medicare beneficiaries in the 95% percentile of Medicare fee-for-service spending
   
• In the year following the NHATS interview, homebound seniors compared to non-homebound seniors were more likely to have a potentially preventable hospitalization (14.8% versus 4.5%) and more likely to have an emergency room visit (54.0% versus 32.6%)
   
• After adjusting the data for demographic, clinical and geographic characteristics, homebound seniors were less likely to have an annual primary care visit or specialist visit compared to non-homebound seniors

"Homebound older adults use more hospital-based care and less outpatient care than the non-homebound, contributing to higher levels of overall Medicare spending," the study's co-authors wrote.

Interpreting the data

Homebound seniors are not receiving home health services that could offset the lack of outpatient services, the lead author of the study said in a prepared statement. "When we adjusted for demographic, clinical, and geographic differences, we found the homebound have a negligible increase in the probability of having a home health visit compared to the non-homebound, suggesting that the gap in outpatient care is not being addressed by a home-based care model within Medicare. It's concerning but not surprising; the finding is consistent with well-known barriers in Medicare to accessing home health services," said Benjamin Oseroff, a third-year medical student at Icahn School of Medicine at Mount Sinai.

Home-based primary care would likely benefit homebound seniors, the study's co-authors wrote. "The lower rate of primary care utilization we observe may partially explain our finding that the homebound experience more potentially preventable hospitalizations than the non-homebound and higher spending. Previous research suggests increasing access to home-based primary care may lower hospitalizations and overall spending for the homebound, depending on the intervention type."

Targeting homebound seniors for enhanced care would decrease Medicare spending, the study's co-authors wrote. "We find that homebound older adults in 2015 accounted for 11.0% of Medicare spending among those over 70 despite making up only 5.7% of this population. The homebound are even more concentrated among the top spenders, making up 13.6% of those in the 95^th percentile or above of Medicare spending. Our findings suggest that the homebound, a group often invisible to the healthcare system, may be an important population to target for quality improvement and to reduce Medicare spending."

Telehealth could improve care for homebound seniors, but it has limitations for this population of patients, the study's co-authors wrote. "Telemedicine provides another alternative to in-person visits, though recent experiences during the COVID-19 pandemic highlight the challenges of virtually reaching homebound older adults."

One of the study's co-authors who helped write a journal article on telehealth barriers for homebound seniors said in a prepared statement that there are several telehealth difficulties to overcome. "The types of barriers we uncovered ran the gamut from lack of broadband access to lack of support help to use the technology, and cognitive and sensory impairments. In this population, older age may compound some of the inequalities that this population is already facing. A high-tech solution will not always work for this high-need, medically and socially complex population," said Katherine Ornstein, PhD, MPH, an adjunct associate professor of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai.

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