Apologies for the startling but true headline. We need to draw your attention to a problem affecting one-quarter to one-third of people who need home health. That is the percentage of people who need it but tell the doctor or discharge planner, “No thank you. I’ll do fine on my own.” Multiple large studies published recently report that people who do this could be making a grave error.1-3
When a patient meets Medicare’s definition of homebound, home health sends nurses and therapists to the home for repeated visits spread over days, weeks, or even months. Recent studies have tracked tens of thousands of people who were offered the service when discharging from the hospital. Most people agree to have a nurse or therapist visit their home, but about one-third refuse. The studies compared the medical outcomes of people refusing home health to those of people accepting the referral.
It turns out that patients who refuse home health do not save money. On average, their healthcare costs $15,233 more in the following twelve months compared to the people who accepted the service. They prove twice as likely to have hospital readmissions in the following month. Their one-year mortality rate scores 25% higher compared to the people who accepted home health!
Who Refuses Home Health?
The profile of who is refusing home health may surprise you. They tend to be younger, healthier, and better educated than their more adherent counterparts. This makes the differences in outcomes all the more striking. Of course, some of the increase in healthcare spending would be due to the fact that the home health group was older and sicker. After mathematically adjusting for this difference between the two groups, researchers concluded that the service caused $6,433 per person in one-year savings.
Home Health Saves Money in the Following Months
An expert round-table explored the question of why people are turning down home health. The United Hospital Fund published their conclusions.4 Perhaps people are trying to save money for themselves or just not be wasteful. However, when people qualify, as in these studies, Medicare pays 100% of allowable charges. Medicare-certified agencies are not allowed to balance bill. Traditional Medicare does not apply deductibles, co-pays, or cost-sharing of any kind to home health benefits, and Medicare Advantage plans largely follow that model as well. The services save Medicare thousands of dollars in just one year due to better health outcomes. Patients who end up receiving more care in other settings will likely incur additional expenses personally while wasting money for Medicare.
Medicare-Certified Home Health is More than Custodial Care
Panelists also suspected that people refusing referrals may be confusing Medicare-certified home health with custodial care focused on cleaning, bathing, and cooking. The recommendation is that health care professionals offering home health should use phrases such as “I’d like to send a nurse to your home,” rather than “I would like to send home health,” given the level of confusion around the term.
Going Home Is Not the Final Step in Healing
Another contributing factor may be that people refuse home nursing simply because they see it as an inconvenience, an affront to their independence, or an invasion of privacy. People may be assuming that as long as they are not in the hospital or skilled nursing facility, they must be fine. That’s why it is so important for everyone over age 65 and everyone who cares for an elderly person to know that people who turn down home health are 25% more likely to die in the following year.
- Xiao R, Miller J, Zafirau W, et al. Impact of home health care on health care resource utilization following hospital discharge: a cohort study. The American Journal of Medicine. 2018; 131 (4): 395-407.
- Quality Insights. New Jersey Home Health Readmission Report. US Dept Health Human Services. 2016; Pub QI-C3-112015.
- Topaz M, Kang Y, Holland D, et al. Higher 30-day and 60-day readmission among patients who refuse post-acute care services. American Journal of Managed Care. 2015; 21 (5): 414-433.
- Levine C, Lee T. “I can take care of myself!” Patients’ refusals of Home Health Care Services. A report from a Roundtable Sponsored by United Hospital Fund and the Alliance for Home Health Quality Innovation. 2017 May; ii – 19.