; 
I 
:  Department  of  Health and Human  Services 
I 
OFFICE  OF 
INSPECTOR  GENERAL 
GEOGRAPHICAL  VARIATION 
IN VISITS

PROVIDED  BY HOME  HEALTH 
AGENCIES

Q.  ? 
+ 
$  JUNE  GIBBS BROWN 
.
$  Inspector  General
s
% 
?+- +2@  
SEPTEMBER  1995 
~dz~ OEI-04-93-00262  OFFICE  OF INSPECTOR  GENEIU4L 
The  mission  of the  Office of Inspector  General  (OIG),  as mandated  by Public  Law 95-452, as 
amended,  is to protect  the  integrity  of the  Department  of Health  and Human  Services (HHS) 
programs  as well as the  health  and welfare  of beneficiaries  sewed  by those  programs.  This 
statutory  mission  is carried  out  through  a nationwide  network  of audits,  investigations,  and 
inspections  conducted  by three  OIG  operating  components:  the  Office  of Audit  Services,  the 
Office of Investigations,  and the  Office of Evaluation  and Inspections.  The  OIG  also informs 
the  Secretary  of HHS  of program  and management  problems  and recommends  courses  to 
correct  them. 
OFFICE  OF AUDIT  SERVICES 
The  010s  Office  of Audit  Services  (OAS)  provides  all auditing  services for HHS,  either  by 
conducting  audits  with  its own audit  resources  or by overseeing  audit work  done  by others. 
Audits  examine  the  performance  of HHS  programs  and/or  its grantees  and contractors  in 
carrying out  their  respective  responsibilities  and are intended  to provide  independent 
assessments  of HHS  programs  and operations  in order  to reduce  waste,  abuse,  and 
mismanagement  and to promote  economy  and efilciency  throughout  the Department. 
OFFICE  OF INVESTIGATIONS 
The  OIGS  Office  of Investigations  (01)  conducts  criminal,  civil, and administrative

investigations  of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of

unjust  enrichment  by providers.  The  investigative  efforts  of 01  lead to criminal  convictions,

administrative  sanctions,  or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud

control  units  which  investigate  and prosecute  fraud  and patient  abuse  in the  Medicaid  program.

OFFICE  OF EVALUATION  AND INSPECTIONS 
The  OIGS  Office  of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and 
program  evaluations  (called  inspections)  that  focus on issues of concern  to the  Department, 
the  Congress,  and the  public.  The  findings  and recommendations  contained  in these  inspection 
reports  generate  rapid,  accurate,  and up-to-date  information  on the efficiency, vulnerability, 
and effectiveness  of departmental  programs. 
OEIS Atlanta  Regional  Office staff prepared  this report  under  the  direction  of Jesse  J. 
Flowers,  Regional  Inspector  General. 
Atlanta Region  Headquarters 
Paula  Bowker,  Project  Leader  Jennifer  Antico,  Program  Specialist

Ron  Kalil, Team  Leader  Brian Ritchie,  Program  halyst

Tammy  Bonney,  Statistician  Linda  Moscoe,  Program  Analyst

Christopher  Koehler,  DRIG  Barbara  Tedesco,  Statistician

Peggy Daniel,  Program  Analyst
 Department  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
GEOGRAPHICAL  VARIATION  IN VISITS

PROVIDED  BY HOME  HEALTH  AGENCIES

*.-  9 
JUNE  GIBBS BROWN 
$ 
$ Inspector  General 
% 
5 
%--
~ 
SEPTEMBER  1995
%d~a
>
OEI-04-93-00262
 EXECUTIVE  SUMMARY

PURPOSE 
To  assess geographical  variation  in average  number  of Medicare  visits  provided  by home 
health  agencies. 
BACKGROUND 
In a prior  1995 inspection  report,  we described  significant  variation  among  home  health 
agencies  (HHAs)  in average  reimbursement  per  beneficiary.  The  highest-reimbursement 
group  of HHAs  received,  on average,  five times  more  Medicare  reimbursement  per 
beneficiary  than  did the  lowest-reimbursement  group.  The  variation  in reimbursement 
among  HHAs  was largely  caused  by variation  in the  average  number  of visits per 
beneficiary. 
This  report  identifies  geographic  locations  of high-visit HHAs.  The  Health  Care 
Financing  Administration  (HCFA),  State  survey agencies,  Regional  Home  Health 
Intermediaries  (RHHIs),  Offices  of Investigations  and  Audit  Services  in the  Office  of 
Inspector  General,  and  law enforcement  agencies  will find the  report  useful  in targeting 
resources  for  detection  and  prevention  of fraud  and  abuse. 
We  analyzed  HCFA  data  on Medicare  reimbursement  for home  health  services  in 
calendar  year  1993.  The  HCFA  data  represented  services  provided  by 6,803 HHAs  to 
over  3 million  beneficiaries. 
FINDINGS 
Nineteen  States  Had  A Larger  Concentration  Of High-Visit HHAs  Than  Other  States 
Home  health  agencies  in  19 States  exceeded  the  national  average  of 50.4 visits per 
beneficiary.  HHAs  in those  States  averaged  67.2 visits per  beneficiary  while  HHAs  in the 
remaining  34 States  averaged  36. 
Home  Health  Agencies  In The  southeastern  Region  Averaged  The  Most Visits Per 
Beneficiary 
HHAs  in Region  IV (Southeastern  Region)  averaged  70 visits per  Medicare  beneficiary. 
Seven  of the  eight  States  in Region  IV were  among  the  19 high-visit  States. 
Home  Health  Agencies  In Four  southeastern  States Averaged  Twice As Many Visits Per 
Medicare  Beneficiary  As HHAs  In All Other  States 
HHAs  in Tennessee,  Alabama,  Mississippi,  and  Georgia  combined  averaged  92.7 visits 
per  beneficiary.  All other  States  averaged  45.7 visits. 
i  About  86 percent  of the  HHAs  located  in these  four  Southeastern  States  exceeded  the 
national  average  number  of visits  per  Medicare  beneficiary  compared  to 34 percent  for 
the  rest  of the  nation. 
About  35 percent  of the  HHAs  located  in these  States  averaged  100 or more  visits per 
Medicare  beneficiary  compared  to 7 percent  of the  HHAs  in the  rest  of the  nation. 
Regardless  Of Their  Locatiorq  I-IHAs Seticed  By Regional  Home  Health  Intermediaries 
Located  In The  Southeast  Had  The  Highest Number  Of Visits Per  Medicare  Beneficiary 
Home  health  agencies  serviced  by Aetna  Life  Insurance  in Clearwater,  Florida  and  Blue 
Cross  & Blue  Shield  in Columbia,  South  Carolina  averaged  72.2 and  65.1 visits per 
Medicare  beneficiary,  respectively.  This  is about  twice the  average  of HkL%  serviced  by 
Independence  Blue  Cross  in Philadelphia,  Pennsylvania  and  Blue  Cross  in Woodland 
Hills, California,  which  had  the  lowest  average  number  of visits among  the  nine  RHHIs. 
Some  of the  HHAs  the  two Southeastern  RHHIs  semice  are  located  outside  of the 
Southeast,  suggesting  that  both  the  location  of the  HHA  and  the  identity  of the  servicing 
intermediary  are  strongly  associated  with variation  in visits. 
FUTURE  OIG  STUDIES 
In a previous  report,  Variation Among  Home  Health Agencies  in Medicare  Payments  For 
Home  Health  Services,  0EI-04-93-O0260,  we  recommended  that  HCFA  take  action  to 
eliminate  inappropriate  variation  in Medicare  reimbursement  among  HHAs.  Specifically, 
we suggested  that  HCFA  target  high-visit  HHA,s for further  review.  We  believe  the 
information  in this report  will assist HCFA  in implementing  that  recommendation. 
We  also believe  that  the  variation  in average  number  of visits by State  and  regions  raises 
questions  about  the  uniformity  of oversight  among  State  sumey  agencies,  HCFA  regional 
offices,  and  Regional  Home  Health  Intermediaries.  We  plan  to continue  our  analysis  of 
these  and  related  questions  under  Operation  Restore  Trust. 
ii  TABLE  OF  CONTENTS

EXECUTIVE  suMMARY

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3

High-Visit  HHAs  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..3

Southeaster  nRegio  n........  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

Four  Southeaster  notate  s.....  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5

Southeaster  nIntermediarie  s.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7

OIGSTUDIES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

APPENDIX 
Number  OfVisits  Among  6,803 HHAs  In All States  . . . . . . . . . . . . . . . ...  . . ..A-1

.  INTRODUCTION 
PURPOSE 
To  assess  geographical  variation  in average  number  of Medicare  visits provided  by home 
health  agencies. 
BACKGROUND 
In a prior  1995 inspection  reportl,  we described  significant  variation  among  home  health 
agencies  (HHAs)  in average  reimbursement  per  beneficiary.  The  variation  in 
reimbursement  among  HHAs  was largely  caused  by variation  among  HHAs  in the 
average  number  of visits per  beneficiary.  The  highest-reimbursement  group  of HHAs 
received,  on average,  five times  more  Medicare  reimbursement  per  beneficiary  than  did 
the  lowest-reimbursement  group.  Other  possible  causes  of the  variation,  such  as 
differences  in cost  per  visit, beneficiary  characteristics  (age,  sex, and  illness),  quality  of 
services,  and  types  of semices  appeared  to explain  little  or none  of the  variation. 
This  report  identifies  geographic  locations  of HHAs  that  average  a high number  of visits 
per  Medicare  beneficiary.  The  Health  Care  Financing  Administration  (HCFA),  State 
survey  agencies,  Regional  Home  Health  Intermediaries  (RHHIs),  Offices  of 
Investigations  and  Audit  Services  in the  Office  of Inspector  General,  and  law 
enforcement  agencies  will find the  report  useful  in targeting  resources  for  detection  and 
prevention  of fraud  and  abuse. 
METHODOLOGY 
Because  the  extreme  variation  in reimbursement  to HHAs  was strongly  linked  to the 
number  of visits made,  we used  average  visits per  beneficiary  as a proxy for  average 
reimbursement  and  focussed  this inspection  on visits. 
To  determine  the  average  number  of visits  per  beneficiary  per  ~  we  first  identified 
all HHAs  in  the  United  States  that  were  certified  to  participate  in the  Medicare 
program.  We  used  HCFAS On-line  Survey and  Certification  Reporting  System 
(OSCAR) for  1993 and  identified  6,803 HHAs. 
We  then  identified  all episodes  of care  claimed  for reimbursement  by the  6,803 HHAs 
for Medicare  beneficiaries.  We  used  HCFAS National  Claims  History  data  file and 
identified  3,263,100  episodes  of home  health  care  in 1993.  We  considered  each  episode 
of home  health  care  to be  equivalent  to one  beneficiary  served.  An  episode  is a period 
of care  with no breaks  between  visits greater  than  60 days. 
1

Vhriation Among Home Health Agencies In Medicare Payments For Home Health Services -0E144-93-I.W260 
1  We  then  calculated  the  average  number  of visits per  beneficiary  for  each  of the  6,803 
HI%%.  That  is, we divided  the  total  number  of home  health  visits that  an HHA  made  by 
the  number  of Medicare  beneficiaries  served. 
Finally, we arrayed  all 6,803 HHAs  by average  number  of visits per  beneficiary.  Next, we 
determined  the  geographic  location  of each  of the  6,803 HHAs  and  classified  them  by 
(1) State,  (2) the  10 standard  Federal  Regions,  and  (3) the  9 servicing  Regional  Home 
Health  Intermediaries  (RHHIs).  RHHIs  are  responsible  for processing  Medicare  claims 
from  HHAs.  For  the  purpose  of our  analyses,  we considered  Puerto  Rico,  Virgin  Islands, 
and  District  of Columbia  as States. 
.- -- .- --
We  conducted  our  inspection  in accordance  with the  Quality Standards for  Jnspechons 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
2
 FINDINGS

NINETEEN  STATES  HAD  A LARGER  CONCENTRA  TION  OF  HIGH-VISIT  HEW 
THAN  OTHER  STATES 
@  average,  home  health  agencies  in 19 States  exceeded  the  national  average  of 50.4 
visits per  beneficiary.  Figure  1 shows that  HHAs  in the  19 States  averaged  67.2 visits per 
beneficiary  while  HHAs  in the  remaining  34 States  averaged  36. 
Nationally,  the  average  number  of home  health  care  visits per  Medicare  beneficiary  in 
the  53 States  ranged  from  a low of 20.5 to a high of 94.9.  The  number  of visits per 
beneficiary  by HHAs  in the  19 high States  ranged  from  50.8 to 94.9. 
Appendix  A shows how HHAs  in each  State  compared  to the  national  average  of 50.4 
visits per  beneficiary. 
FIGURE  1 
AVERAGE  VISITS  PER  BENEFICIARY  BY  HHAs  IN 19 HIGH-VISIT  STATES 
COMPARED  TO  VISITS  BY  HHAs  IN ALL  OTHER  STATES 
Avg  #  Of  Visits  Per  beneficiary 
67 
/ 
36 
19  34 
Number  of  States 
3
 HOME  HEALTH  AGENCIES  IN THE  SOUTHEAS  TERN  REGION  AVERAGED 
THE  MOST  VISITS  PER  BENEFICIARY 
HHAs  in Region  IV (Southeastern  Region)  averaged  70 visits per  Medicare  beneficiary. 
Table  1 shows that  three  of the  ten  Federal  regions  exceeded  the  national  average  of 
50.4 visits per  Medicare  beneficiary  by HHAs.  The  three  regions  were  Region  IV, VI, 
and  I.  HHAs  in these  three  regions  averaged  66.9 visits per  Medicare  beneficiary  while 
HHAs  in the  remaining  seven  regions  averaged  37.8 visits. 
TABLE  1 
;:.  ,$2@lI!@U@N  l@%~Gl?  NUk@@:OF.  HOMIWIEAL&W3~ 
,.
.,:.:..::. .:.:Y...::..,..,:: .. ., ..,.:..;..:...:.,,....,,,..:::..:.P,,.,~:,.~TC~.B-~Y~~;~GION  .:,  ::::  :.:  ,  ;:
r 
REGION  STATES  IN REGION	 AVG  #  OF 
VISITS* 
II
*Average  number  of visits based  on location  of providers  rather  than  beneficiaries 
Seven  of the  eight  States  in Region  IV were  among  the  19 high-visit  States  for  home 
health  services.  Home  health  agencies  in the  seven  States  averaged  72.3 visits per 
Medicare  beneficiary  in  1993.  This was about  1.4 times  the  national  average  of 50.4 
home  health  visits per  beneficiary. 
4
 HOME  HEALTH  AGENCIES  IN FOUR  SO~  STATES  AVERAGED 
TWICE  AS MANY  VISITS  PER  MEDICARE  BENEFICIARY  AS HHAs  IN ALL 
OTHER  STATES 
The  four  States  were  Tennessee,  Alabama,  Mississippi,  and  Georgia.  Combined,  HHAs 
in the  four  Southeastern  States  averaged  92.7 visits per  beneficiary,  All other  States 
averaged  45.7 (See  Figure  2.)  The  average  number  of home  health  visits by HHAs  in 
the  four  Southeastern  States  ranged  from  88.4 to 94.9 during  1993.  Appendix  A shows 
the  average  number  of visits per  beneficiary  in each  State. 
FIGURE  2 
AVERAGE  VISITS  PER  BENEFICIARY  BY  HHAs  IN FOUR  HIGHEST-VISIT 
STATES  COMPARED  TO  VISITS  BY  HHAs  IN ALL  OTHER  STATES 
lf  Visits  Per  Beneficiary 
94.7 
88.4 
45.7 
 
TN  AL  MS  GA  All  Others 
STATES 
J  Most Of The  HHAs  Located  In The  Four  Southeastern  States  Exceeded  The  National 
Average  Number  Of Visits Per  Medicare  Beneficiary. 
Of the  541 HHAs  located  in the  four  high-visit Southeastern  States,  86 percent  (465) 
averaged  more  than  50.4 visits per  beneficiary  in 1993.  Conversely,  about  34 percent 
(2,110)  of the  6,262  HHAs  located  in the  rest  of the  nation  exceeded  50.4 visits per 
beneficiary. 
Table  2 shows the  percentage  of HHAs  in each  of the  four  States  that  exceeded  the 
national  average  number  of visits per  beneficiary.  On  average,  between  81 and  93 
percent  of the  541 HHAs  exceeded  the  national  average.  Appendix  A contains  a 
complete  list of States  showing the  percentage  of HHAs  within  those  States  that 
averaged  above  and  below  the  national  average  of 50.4 visits per  Medicare  beneficiary. 
TABLE  2 
: P~@~b~@fi!~@O@NA~ON~  @@ti~E  OF 
5~,H@41wE@m$&z13  PmMEDI@.I@BqqEFqcIARY:  , 
I 
Mississippi  93.2% 
Georgia  86.6% 
IITennessee  I  86.4%  II 
Alabama  81.6% 
Rest  of Nation  33.7% 
About  35 Percent  Of The  HHAs  Located  In The  Four  southeastern  States  Averaged  100 
Or More  Visits Per  Medicare  Beneficiary. 
Of the  541 HHAs  located  in the  four  highest-visit  States,  188 (about  35 percent)

averaged  100 or more  visits per  Medicare  beneficiary.  Only 7.1 percent  (442 of 6,262)  of

HHAs  in the  rest  of the  nation  averaged  100 or more  visits (See  Table  3).

TABLE  3 
IITennessee  I  42.5%  II 
II I  I 
Georgia  31.7% 
II
Mississippi  30.1% 
I 
I 
IIAlabama  27.2%  II 
Rest  of Nation  7.1% 
6
 REGARDLESS  OF  WHERE  THE  HHA  IS LOCATED,  HHAs  SERVICED  BY 
REGIONAL  HOME  HEALTH  INTHWEDIARIES  LOCATED  IN THE 
SOUTHEAST  HAD  THE  HIGHEST  NUMBER  OF  VISITS 
Home  health  agencies  serviced  by Aetna  Life  Insurance  in Clearwater,  Florida  and  Blue 
Cross  & Blue  Shield  in Columbia,  South  Carolina  (See  Table  4) averaged  about  twice as 
many visits per  beneficiary  as HHAs  serviced  by Independence  Blue  Cross  in 
Philadelphia,  Pennsylvania  and  Blue  Cross  in Woodland  Hills, California,  even  though 
some  of the  HHAs  they  service  are  located  outside  of the  Southeast.  This  suggests  that 
~  the  location  of the  HI-IA and  the  identity  of the  servicing  intermediary  are  strongly 
associated  with variation  in visits. 
RHHI	 AVERAGE  #  OF  HOME 
HEALTH  VISITS  PER 
MEDICARE  BENEFICIARY 
Aetna  Life  Insurance  Co.
 72.2 
Clearwater,  FL

Blue Cross  & Blue  Shield  of
 65.1 
South  Carolina

Columbia,  SC

New Mexico  Blue  Cross  and
 61.8 
Blue Shield,  Inc.

Albuquerque,  NM

Assoc Hospital  Semite  of Maine
 59.9 
South  Portland,  ME 
IASD  Health  Services  Corp.  49.9 
Des  Moines,  IA 
Health  Care  Service  Corp.  42.9 
Chicago,  IL 
Blue  Cross  and  Blue  Shield  36.9 
United  of Wisconsin 
Milwaukee,  WI 
Blue  Cross  of California  34.2 
Woodland  Hills,  CA 
Independence  Blue  Cross  32.5 
Philadelphia,  PA 
7
 The  vast  majority  of HHAs  serviced  by Aetna  in Clearwater,  Florida  and  Blue  Cross/Blue

Shield  of South  Carolina  are  located  in the  Southeastern  Region.  About  91 percent  of

HHAs  serviced  by Aetna  Cleanvater  are  in Region  IV,  and  the  remaining  9 percent  are

in other  geographic  regions.  About  89 percent  of HHAs  serviced  by South  Carolina  Blue

Cross/Blue  Shield  are  in Region  IV, and  about  11 percent  are  located  in other

geographic  regions.

The  average  number  of visits per  beneficia~  by HHAs  serviced  by Aetna  Clearwater  and

Blue  Cross/Blue  Shield  of South  Carolina  averaged  more  than  that  for  most  other

RHHIs  -- regardless  of HHA  location.  To illustrate,  the  HHAs  located  in the  Southeast

and  serviced  by Aetna  Clearwater  averaged  72.1 visits per  beneficiary.  Comparably,  the

HHAs  located  outside  the  Southeastern  Region  and  seticed  by Aetna  ClearWater

averaged  74.6 visits per  beneficiary.

Likewise,  the  HHAs  in the  Southeastern  Region  that  were  serviced  by South  Carolina 
Blue  Cross/Blue  Shield  averaged  66.8 visits per  beneficiary.  The  HHAs  located  outside 
the  Southeast  and  serviced  by South  Carolina  Blue  Cross/Blue  Shield  average  53.2 visits 
per  beneficiary.  While  the  average  of 53,2 visits per  beneficiary  is less than  that  for 
HHAs  sexviced by South  Carolina  Blue  Cross/Blue  Shield  in the  Southeast,  it is higher 
than  that  for five of the  nine  RHHIs  nationally  (See  Table  4). 
FUTURE  OIG  STUDIES 
In a previous  report,  Variation Among  Home  Health Agencies  in Medicare  Payments  For 
Home  Health  Services, 0EI-04-93-O0260,  we  recommended  that  HCFA  take  action  to 
eliminate  inappropriate  variation  in Medicare  reimbursement  among  HHAs.  Specifically, 
we suggested  that  HCFA  target  high-visit HHAs  for further  review.  We  believe  the 
information  in this  report  will assist HCFA  in implementing  that  recommendation. 
We  also believe  that  the  variation  in average  number  of visits by State  and  regions  raises 
questions  about  the  uniformity  of oversight  among  State  survey  agencies,  HCFA  regional 
offices, and  Regional  Home  Health  Intermediaries.  We  plan  to continue  our  analysis  of 
these  and  related  questions  under  Operation  Restore  Trust. 
8
 APPENDIX  A

States  are  listed  in ascending  order  based  on average 
number  of home  health  visits per  Medicare  beneficiary
. 
#  OF  AVG  #  OF  %OFHHAS  %  OF  HHAs 
STATE
 VISITS  ABOVE  THE  AVERAGING 
PER  BENE  NATIONAL  100 OR 
AVERAGE  MORE 
OF  50 VISITS  VISITS  PER 
PER  BENE  BENE 
i 
Virgin Islands
 2  o%  o% 
Minnesota
 196  13.8%  3.1% 
Wisconsin
 165  21.8%  3.070 
South  Dakota
 29  6.9%  o% 
Puerto  Rico
 44  2.3% 
Iowa
 162  17.9%  5.6% 
Dist of Columbia
 12  o%  o% 
Alaska
 12  16.7%  8.3% 
Maryland
 71  8.5%  o% 
New Jersey
 53  3.8%  o% 
Oregon
 71  14.1%  o% 
Washington
 55  14.5%  1.8$Z0 
Nebraska
 52  15.4%  3.8% 
Hawaii
 20  5.0% 
Pennsylvania
 276  1.4% 
Michigan
 157  1.9% 
New Mexico
 63  23.8%  4.8% 
California
 460  15.9%  2.4% 
Colorado
 120  32.59Z0  9.2% 
Montana
 43  16.3940  070 
North  Dakota
 31  25.8?Z0  6.5% 
A-1
 States  are  listed  in ascending  order  based  on average 
number  of home health  visits per  Medicare  beneficiary 
#  OF  AVG  #  OF  %OFHHAs  %  OF  HHAs 
STATE  VISITS  ABOVE THE  AVERAGING 
PER  BENE  NATIONAL  100 OR 
AVERAGE  MORE 
OF  50 VISITS  VISITS  PER 
PER  BENE  BENE 
A-2
 States  are  listed  in ascending  order  based  on average 
number  of home  health  visits ~er  Medicare  beneficial 
. 
%OFHHAS  %  OF  HHAs 
STATE
 ABOVE  THE  AVERAGING 
NATIONAL  100 OR 
AVERAGE  MORE 
OF  50 VISITS  VISITS  PER 
PER  BENE  BENE 
Indiana
 I 170  47.6%  10.0% 
Nevada
 I  23  56.5%  4.3$Z0 
Texas
 52.8%  13.0% 
Massachusetts
 I 143  72.7%  16.8% 
Oklahoma
 52.3%  20.3% 
Utah
 I  49  71.4%  16.3% 
I.muisiana
 I 398  70.4%  28.6% 
Georgia
 I  82  86.6%  31.770 
I 
Missksimi  73  93.2%  30.1% 
Alabama  ] 158  81.6%  27.2% 
Tennessee  I 228  86.4%  42.5V0 
A-3