Use of Home-Based Medical Care and Disparities

Objectives: To examine the volume of home-based medical care (HBMC) visits made to frail older adults between 2011 and 2014 and sex, racial, ethnic, frailty-related comorbidity, and geographic disparities in HBMC use. Design: Observational study using secondary data. Setting: 5% Medicare claims for 2011 to 2014. Participants: Medicare beneficiaries. Measurements: Usage rates of HBMC of frail Medicare beneficiaries were compared using descriptive statistics and multivariate logistic regression. Results: From 2011 to 2014, use of HBMC increased from 8.7% to 10.1% in beneficiaries with medium comorbidity and from 14.2% to 15.7% in those with high comorbidity. After adjustment for multiple factors, blacks were 21% more likely (95% confidence interval (CI)=17–25%, p<.001) to use HBMC, and Asians were 31% less likely (95% CI=24–38%, p<.001) to use HBMC than whites. Women were 24% more likely (95% CI=21–27%, p<.001) to use HBMC than men. Rural residents were 78% less likely (95% CI=76–79%) than those in the largest metropolitan county to receive HBMC. Nurse practitioners made 40% of HBMC visits to rural residents, and internists made 32% of HBMC visits in large metropolitan counties. There were substantial geographic variations in the use of HBMC in frail older adults; the national usage rate was 11%, and 7 states had rates less than 5%. Conclusion: Although there was a small increase in the use of HBMC between 2011 and 2014, the majority of eligible home-limited individuals have not received medical care at home, particularly rural residents and those living in underserved states. More HBMC practices are needed, and programs may need to integrate telemedicine to expand HBMC in rural communities.