Evolution of the home health care market: The expansion and quality performance of multi-agency chains

Objective To examine the growth and evolution of the home health agency (HHA) market and to compare quality performance across HHA ownership categories. Data Source Agency characteristics were extracted from Medicare cost reports and Provider of Services file. Quality of care and patient characteristics were extracted from Quality of Patient Care Star Ratings and HHA Public Use File. Study Design Agency- and state-level analyses were conducted to describe HHA market trends. Patient characteristics and quality measures were compared across ownership categories of interest. Data Collection/Extraction Methods All Medicare-certified HHAs in operation, 2005-2018. Principal Findings Over the study period, the HHA sector grew substantially, increasing from 7899 to 10 818 agencies, and chain-owned HHAs doubled in number from 903 (11.4% of all agencies) to 1841 (17.0%). In 2018, across agency types, for-profit nonchain agencies were the largest category both in the number of agencies (67.8%) and the number of Medicare enrollees served (40.7%). Additionally, for-profit nonchain agencies grew most in total number, from 4293 (54.3%) to 7337 (67.8%), while for-profit chain agencies grew most in the number of Medicare enrollees served, from 439 998 (12.9%) to 1 082 385 (28.3%). Regarding patient composition, for-profit nonchain agencies served the highest proportion of dual eligible beneficiaries (42.2%) and African-Americans (27.9%) among all agency types. Regarding quality performance, a higher star rating is significantly (P < .01) associated with chain agency status. Moreover, chain HHAs performed better on self-reported process measures, and risk-adjusted self-reported outcome measures; however, they performed worse on risk-adjusted claims-based outcome measures. These results were similar across for-profit and nonprofit chain agencies. Conclusion Chains play a growing role in the home health sector. Substantial differences in geographic distribution, patient composition, and quality performance were observed between chain- and nonchain HHAs. Examining the growth and performance of multi-agency chains can help inform quality reporting and monitoring, assess payment adequacy, and facilitate greater transparency and accountability within the HHA marketplace.