Rethinking Medicare home health

Health & Aging Health Access & Equity Health Care Industry Health Care Policy Health Insurance

健康与老龄化 健康获取与公平 医疗保健行业 医疗保健政策 健康保险

Home health care is an important component of Medicare.

家庭医疗保健是医疗保险的重要组成部分。

In 2023, about 2.7 million beneficiaries in Traditional (i.e., fee-for-service) Medicare received home health care from over 12,000 home health providers at a total cost of $15.7 billion.

2023 年，约 270 万传统（即按服务收费）医疗保险受益人从 12,000 多家家庭医疗服务提供者处获得家庭医疗保健，总费用达 157 亿美元。

Medicare home health services consist of skilled nursing, physical therapy, occupational therapy, speech therapy, aide services, and medical social work delivered in patients’ homes.

医疗保险家庭健康服务包括在患者家中提供的熟练护理、物理治疗、职业治疗、言语治疗、辅助服务和医疗社会工作。

Compared to institutional alternatives, home health is often viewed as clinically appropriate, patient preferred, and less costly.

与机构替代方案相比，家庭保健通常被认为临床上合适、患者首选且成本较低。

At the same time, elevated profit margins and persistent concerns about overuse and fraud have fueled debates about whether and how to reform the Medicare home health system.

与此同时，利润率的提高以及对过度使用和欺诈的持续担忧引发了关于是否以及如何改革医疗保险家庭医疗系统的争论。

Yet there is little consensus on how the program is performing or how it should evolve.

然而，对于该计划的执行情况或应如何发展，几乎没有达成共识。

Liran Einav (Stanford University), Amy Finkelstein (MIT), Yunan Ji (Georgetown University), and Neale Mahoney (Stanford University) argue that these debates stem in part from a more fundamental issue: Medicare home health lacks a clear, agreed-upon objective.

Liran Einav（斯坦福大学）、Amy Finkelstein（麻省理工学院）、Yunan Ji（乔治敦大学）和 Neale Mahoney（斯坦福大学）认为，这些争论部分源于一个更根本的问题：医疗保险家庭健康缺乏明确的、商定的目标。

The program appears to try to serve multiple purposes: (1) mitigating costs by substituting for institutional post-acute care, (2) covering the costs of treatment and recovery from acute health events for home-bound patients, and (3) providing in-kind, long-term services and supports for frail older adults.

该计划似乎试图达到多种目的：(1) 通过替代机构急性后护理来降低成本，(2) 支付居家患者的急性健康事件的治疗和康复费用，以及 (3) 为体弱的老年人提供实物、长期服务和支持。

This last objective overlaps with the domain of Medicaid long-term services and supports.

最后一个目标与医疗补助长期服务和支持的领域重叠。

In particular, “community-based” home health episodes, those initiated without a preceding hospital stay, are more consistent with a population receiving ongoing supportive care than a population recovering from an acute medical event.

特别是，“基于社区”的家庭健康事件，即那些在没有住院之前就开始的事件，与从急性医疗事件中恢复的人群相比，更符合接受持续支持性护理的人群。

The authors assess how well current program design aligns with each of these objectives, and discuss reforms that might help the program better meet them.

作者评估了当前计划设计与每个目标的契合程度，并讨论了可能有助于该计划更好地实现这些目标的改革。

For example, if Medicare home health is viewed as coverage for standard medical services—just delivered at home—the authors conclude that beneficiaries should probably face copays or other cost sharing, as they do for other Medicare services.

例如，如果医疗保险家庭健康被视为标准医疗服务的承保范围（仅在家中提供），作者得出的结论是，受益人可能应该面临共付额或其他费用分摊，就像他们对其他医疗保险服务所做的那样。

(Currently, home health does not require cost sharing.) Likewise, if the primary goal of home health is to reduce use of costly institutional care, then it might make sense for home health eligibility rules to align more closely with eligibility requirements for Medicare coverage in institutional settings.

（目前，家庭健康不需要费用分摊。）同样，如果家庭健康的主要目标是减少昂贵的机构护理的使用，那么家庭健康资格规则与机构环境中医疗保险覆盖的资格要求更紧密地结合可能是有意义的。

And if Medicare home health is meant to serve as long-term care insurance, the authors recommend considering “cash-for-care” approaches, used in a number of European countries, that would give beneficiaries discretion over how to allocate a fixed budget for long-term care services.

如果医疗保险家庭健康旨在作为长期护理保险，作者建议考虑在许多欧洲国家使用的“现金换护理”方法，这将使受益人自行决定如何为长期护理服务分配固定预算。

The authors stress that the attractiveness of any of these reforms depends critically on the perceived goal (or goals) of the Medicare home health benefits.

作者强调，任何这些改革的吸引力在很大程度上取决于医疗保险家庭健康福利的感知目标。

There is no single “right” answer for the optimal use of each possible tool; the decision depends on how different goals are weighed in the design.

对于每种可能的工具的最佳使用，没有单一的“正确”答案；该决定取决于设计中如何权衡不同的目标。