Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

Operating Practices Of High-Cost And 

Low-Cost Home Health Agencies 

@ SERVICE$ 

& ‘ha 

* + 

JUNE GIBBS BROWN ~. 

;	

# Inspector General 

‘5 

%. ~

+-- FEBRUARY 1997 ‘~di+a > OEI-04-93-00261 
--

EXECUTIVE SUMMARY


PURPOSE 

To determine how operating practices of home health agencies may influence the 

average number of visits per Medicare beneficiary. 

BACKGROUND 

Medicare expenditures for home health services have increased from $3.3 billion in 

1990 to $15 billion in 1995 a nearly 5 fold increase in just 5 years. Expenditures 

vary drastically, however, among individual home health agencies (HHAs), as do 

average number of visits per beneficia~. The average number of visits per beneficia~ 

for all Medicare-certified home health agencies increased from 50 in 1993 to 58 in 

1994. 

In previous OIG studies of home health, we determined that differences in 

characteristics of home health agencies, characteristics of beneficiaries served, 

diagnoses, and quality did not fully explain the wide variation in utilization among 

home health agencies. Agencies with a low average number of visits are providing 

appropriate, adequate care as well as those with a high average number of visits. 

Under Operation Restore Trust (ORT), the Department of Health and Human 

Services k examining the home health industry ;O identify and correct fraud, waste and 

abuse. This inspection is part of ORT. 

METHODOLOGY 

We sent a mail survey to 300 randomly-selected home health agencies throughout the 

nation to obtain data on their operating practices and philosophies. About 65 percent 

(194) of the 300 agencies we surveyed completed and returned the questionnaire. 

Eighty of the respondents were high-cost agencies, and the remaining 114 were lowcost. High-cost were those agencies whose average number of visits per beneficiary 

was above the national average and low-cost agencies were those whose average fell 

below the national average. We also performed an analysis of HCFA data to 

determine changes in the average number of visits between 1993 and 1994. 

FINDINGS 

Differences In The Average Number Of Visits Provided By High And LuwCost 

Home Health Agencies Widened Considerably Between 1993 And 1994 

In 1993, the high-cost home health agencies made 55 more visits (85 visits) per 

beneficiary, on average, than did low-cost agencies, which averaged 30 visits. In 1994, 

this difference had widened to 69 visits per beneficia~, which is the difference 

between 102 visits by high-cost agencies and 33 visits by low-cost agencies. 

i 
Operating Practices Do Not Explain Widening Variation In Number Of Visits 

b Both high and low-cost agencies had written policies and procedures. 

b	 High and low-cost agencies’ mission or philosophy statements tended to be 

similar in content. 

w	 High and low-cost agencies relied heavily on their own staff to make the initial 

determination that a person meets eligibility criteria for Medicare home health, 

rather than on physicians. 

➤❨ High and low-cost agencies reported serving patients whose conditions were 

acute, chronic, and high-tech, in approximately the same proportion. 

b Nearly all high and low-cost agencies had a formal quality assurance program. 

b	 High and low-cost agencies provided a similar mix of services, e.g., skilled 

nursing, physical therapy, occupational therapy, speech pathology therapy, 

medical social services, and aide services. 

b	 The major source of payment for high and low-cost home health agencies was 

Medicare fee-for-service. 

High-Cost Home Health Agencies Tended To Be For-Profit And Freestanding 

Entities 

Home health agencies at the higher end of the cost range tended to be for-profit and 

freestanding organizations. The percentage of high-cost agencies that were for-profit 

entities was almost five times that of low-cost agencies. The percentage of high-cost 

home health agencies that were freestanding was four times that for low-cost agencies. 

CONCLUSION 

The gap between high and low-cost home health agencies in average number of visits 

per Medicare beneficiary continues to widen. Generally, program operations are 

similar in both high and low-cost agencies and do not explain the variation. 

Determining when it is appropriate and medically necessary to provide Medicare 

home health services is often ambiguous and largely discretionary. This inspection and 

other audits and inspections on home health continue to suggest a need for greater 

control over the provision of Medicare home health services. If control cannot be 

achieved through more effective management oversight, then statutory or regulatory 

changes may be needed to protect the Medicare program from excessive or 

inappropriate payments in this area. 

ii 
TABLE OF CONTENTS


PAGE


EXECUTIVE suMMARY


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


FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5


● Differences In Average Visits Widened Considerably In One Year . . . . . . . . . . . 5 

● operating Practices Do Not Explain Widening Variation . . . . . . . . . . . . . . . . . . 6 

● High-Cost HHAs Tend To Be For-Profit And Freestanding . . . . . . . . . . . . . ...9


CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...12


APPENDICES


Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l


Analysis Of Respondents Vs. Non-Respondents . . . . . . . . . . . . . . . . . . . . . . . . . B-1

--

INTRODUCTION


PURPOSE 

To determine how operating practices of home health agencies may influence the 

average number of visits per beneficiary. 

BACKGROUND 

Home health care is nursing, therapeutic, medical social, and aide services provided in 

a person’s home. Home health care allows people with limited mobility to live 

independently while still receiving professional health care sewices. All home health 

services must be specified in a plan of care certified by a physician. 

Title XVIII, Section 1861, of the Social Security Act authorized Medicare Part A 

payments for home health care. For beneficiaries who do not have Part A 

entitlement, home health services may be covered by Medicare Part B. To receive 

Medicare reimbursement, home health agencies (HHAs) must provide a skilled care 

semice to a homebound beneficiary on a part-time or intermittent basis. 

Growth of Home Health Care 

Medicare expenditures for home health care increased dramatically in recent years. 

To illustrate, between 1990 and 1995 Medicare expenditures for home health care 

grew from $3.3 billion to $15.1 billion a nearly 5 fold increase in just 5 years. 

Between 1992 and 1993, Medicare expenditures for home health care increased by 78 

percent. During this period, expenditures for home health care by all insurance 

sources in the United States increased by 23.8 percent. In contrast, HCFA’S Office of 

the Actuary estimated that the cost of hospital care increased by 6.7 percent between 

1992 and 1993. Likewise, expenditures for physician care increased by 5.8 percent 

between 1992 and 1993. 

Variation in Cost of Care Among Home Health Agencies 

Medicare expenditures for home health care per beneficiaries varied significantly 

among home health agenciesl in recent years. Importantly, the variation in 

reimbursement was not explained by differences in diagnosis, cost per visit, quality of 

care, or beneficiary characteristics such as age, gender, and race. Home health 

agencies at both extremes of the spectrum of average reimbursement met Conditions 

‘Variation Among Home Health Agencies In Medicare Payments For Home Health Services 0EI-04-93-

1

--

--

of Participation, which suggests they are doing an adequate job of meeting 

beneficiaries’ needs. 

Most of the variation in reimbursement was explained by variations in the number of 

home health visits per beneficiary among home health agencies. Medicare regulations 

allow beneficiaries to receive an unlimited number of home health visits, and some 

home health agencies provided five times more visits per beneficiary on average than 

other home health agencies. 

On average, about two thirds of 6803 home health agencies provided home health 

care with 33 visits per beneficiary in 1993. The remaining one third of the agencies 

averaged 81 visits per beneficiary. The high-visit home health agencies were more 

likely to be proprietary, for-profit and unaffiliated. 

Concern About High-Cost Home Health Agencies 

The wide variation among home health agencies in number of visits per beneficiary 

raised serious questions about possible differences in operating policies and practices 

of high and low-cost agencies. During a prior inspection, we looked at quality of care, 

among other things, of low-cost and high-cost home health agencies. We used the 

only available proxies for quality which were and are available from HCFA and other 

reliable sources complaints against an agency, survey deficiencies, and accreditation 

status. With respect to these measures, we found that low-cost home health agencies 

provided care that was comparable in quality to that provided by high-cost home 

health agencies, but they did so with fewer visits per beneficiary. If the high-cost 

agencies lowered the average number of visits per beneficiary to 33, we estimated that 

Medicare savings would have been approximately $5 billion in 1995. 

This report describes the differences and similarities in operating practices of high and 

low-cost home health agencies. The operating practices used by low-cost agencies 

might provide examples that high-cost agencies could use to keep cost down without 

adversely affecting quality of care. 

METHODOLOGY


Sample Selection 

We randomly selected 300 Medicare certified home health agencies in the United 

States from HCFA’S National Claims History Repository. Before sampling, we 

stratified the 1993 universe of 6803 home health agencies into two categories lowcost and high-cost agencies. We based the two categories on average number of visits 

made to beneficiaries. We considered home health agencies that made fewer than the 

national average of 50 visits per beneficiary in 1993 to be low-cost. We considered 

those that made more visits than the national average to be high-cost. We sampled 

150 home health agencies from both the high and low groups. 

2

A detailed description of our sampling method is contained in Appendix A. 

In addition to the survey of home health agencies, we performed an analysis of data 

from the common working file maintained by HCFA to determine changes in the 

average number of visits from 1993 to 1994. 

Data Ccdlection And Analysis 

We used a standardized questionnaire to collect data on operating practices of 

sampled high and low-cost home health agencies. We mailed our survey instrument to 

each of the-300 sampled agencies. About65 percent (194) of the 300 home health 

agencies completed and returned our questionnaire. To assure that our analysis was 

based on the most current data, we used 1994 utilization data for all home health 

agencies appearing in our sample. Of the 194 agencies that responded, 114 (59 

percent) were low-cost home health agencies. The remaining 80 respondents, (41 

percent) were high-cost agencies. 

In terms of average number of visits per beneficiary, the home health agencies that 

responded to our survey were representative of the home health agency universe in 

the United States. (See Table 1.) 

Comparison 

HHAs Below The National 

Average 

HHAs Above The National 

Average 

TOTAL HHAs 

TABLE 1 

Of Sample HHAs To HHAs 

Average Number Of Vits Per Bae6c&y 

1994 Data 

Universe 

Number % 

4,720 59 

3,246 41 

7,966 100 

Nationally 

Sample 

Number % 

114 59 

80 41 

194 100 

About 35 percent (106) of the 300 sampled home health agencies did not respond to 

our sumey. An analysis of respondents and non-respondents showed that the 

possibility of bias due to non-response is limited, based on our sampling criteria. Our 

non-response analysis is in Appendix B. 

We used a dBase file to organize and analyze numerical data obtained from the 194 

home health agencies. We aggregated the data to obtain comparisons of operating 

practices of low-cost agencies as a group to those of high-cost agencies as a group. 

3


II 
To compare the philosophy or mission statements of the home health agencies, we 

performed a content analysis of those statements. To perform the content analysis we 

first examined all of the statements and compiled a list of all major terms, phrases and 

concepts. We then grouped the terms, phrases, and concepts into four major 

categories. We then aggregated the number of terms, phrases, and concepts in each 

of the four major categories for both the high and low-cost groups. We then 

performed a statistical significance test on the total “scores” for both groups. 

We conducted t-tests on all findings in the report. 

To provide a greater sense of what low-cost home health agencies are doing with 

regard to operating practices, we performed a case study of seven low-cost home 

health agencies. Our findings are shown in a supplemental report, “Operating 

Practices Of Low-Cost Home Health Agencies: Seven Case Studies,” 0EI-04-93-

00263. 

OPERATION RESTORE TRUST 

This inspection was part of the President’s Operation Restore Trust initiative. The 

purpose of Operation Restore Trust (ORT) is to identify and prevent fraud, waste and 

abuse in the Medicare and Medicaid programs. ORT is a joint initiative involving the 

Health Care Financing Administration, Administration on Aging, Office of Inspector 

General, and various State agencies. In 1995, ORT began targeting home health 

agencies, nursing homes, hospices, and durable medical equipment suppliers in five 

States for evaluations, audits, and investigations. The five States are Florida, New 

York, Texas, Illinois, and California. These States account for about 40 percent of the 

nation’s Medicare and Medicaid beneficiaries and program expenditures. 

We conducted this inspection in accordance with the Quality Standards for Inspections 

issued by the President’s Council on Integrity and Efficiency. 

4

FINDINGS


DIFFERENCES IN THE AVERAGE NUMBER OF VISllll PROVIDED BY 

HIGH AND LOW-COST HOME HEALTH AGENCIES WIDENED 

CONSIDERABLY BETWEEN 1993 AND 1994 

As reported in our prior report on variation in home health cost among home health 

agencies (OEI-04-93-00260),2 the difference in cost per beneficiary is largely explained 

by the number of visits an agency makes to a beneficiary. 

Figure 1 below shows that the difference in average visits made by high-cost and lowcost agencies has widened considerably between 1993 and 1994. To illustrate, in 1993 

the high-cost agencies made 55 more visits per beneficiary, on average, than did lowcost agencies. In 1994, this difference had widened to 69 visits per beneficiary. 

FIGURE 1 

AVERAGE NUMBER OF VISITS 

BY HIGH AND LOW-COST HHAs 

# of Vidt= P-r Beneflolary 

120-

1ooas 

60-

60-

40-

20-

0-

1993 1994 

= LOW-COST HHA8 = HIGH-COST HHA8 

‘Ibid., Page 16 

5

Nationally, the average cost per beneficiary for home health service was $3,495 in 

1994. ~e80high-cost home health agencies semed72,351 Medicare beneficiafiesat 

an average cost of $5,407 in 1994. Conversely, the 114 low-cost agencies sexved 

112,996 Medicare beneficiaries at an average cost of $2,270. 

OPERATING PRACTICES DO NOT EXPLAIN WIDENING VARIATION IN 

NUMBER OF VISITS 

High And ImwCost Home Health Agencies Had Written Policies And Procedures 

All of the home health agencies in both the high and low-cost groups had written 

policies and procedures. The policies and procedures, which were generally similar in 

content and scope, provided guidance on important operating practices such as 

determining eligibility for Medicare home health services and other important aspects 

of program operations. We observed that the written guidance included criteria for 

determining the homebound status of a beneficiary. Further, the eligibility criteria of 

the agencies generally mirrored the criteria contained in the Health Care Financing 

Administration’s manual for Medicare home health services, the HIM-11 (Health 

Insurance Manual), now called the HCFA PUB. 11. 

Likewise, 77 of 80 home health agencies in the high-cost group, and all 114 agencies in 

the low-cost group had written policies and procedures on monitoring patient services 

and progress, and on discharging beneficiaries. 

High And Low-Cost Home Health Agencies’ Mission Or Philosophy Statements 

Tended To Be Similar In Content 

All home health agencies responding to our survey had written statements on their 

mission or philosophy for providing home health care. The statements of both high 

and low-cost groups of agencies were essentially the same. To illustrate, both groups 

emphasized such things as the importance of providing quality care, preventing or 

shortening institutionalization, providing a continuum of care after a hospital stay, and 

collaborating with other health care providers in the service area or community. 

High And Low-Cost Home Health Agencies Relied Heavily On Their Own Staff To 

Make The Initial Determination That A Person Meets Eligibility Criteria For 

Medicare Home Health SeMces 

In making the initial determination that a beneficiary is eligible to receive Medicare 

home health services, both high and low-cost agencies used essentially the same 

approach. Table 2 shows that both groups of agencies relied most heavily on their 

own personnel to make the initial determination that a beneficiary was eligible, rather 

than on physicians or others. However, Medicare regulations require that a physician 

certify that home health services are appropriate and necessary by signing a Plan of 

Care for a beneficiary. A home health agency cannot provide home health services 

without a signed Plan of Care. 

6 
TABLE 2


Initial Determination of Patient Eligibility 

~&@i&illy Determines Eligibility Low-Cost HHAs High-Cost HHAs 

,~~r ,~bme ‘Health Services Number % Number % 

Physicians I 1 I 1 I 3 I 4 

HHA Personnel I 96 I 84 I 66 I 83 

Both Physicians & HHA Personnel I 14 I12I1OI13 

Other (e.g., hospital staff) 3 3 0 0 

TOTAL 114 100 79 100 

No Response To Question o 1 

High And Low-Cost Home Health Agencies Reported Senring Patients With Similar 

Conditions 

Both high and low-cost home health agencies reported that they served patients who 

needed acute, chronic, and high-tech home health service. The agencies which 

responded to our survey defined acute, chronic and high-tech care as follows. The 

definitions of these three categories incorporated length of time a beneficiary is to be 

served, stability of a beneficiary’s condition, level of services a beneficiary needs, or a 

combination of those factors. 

Acute care: In general, the agencies defined acute care patients as those 

needing short-term, yet intensive services. Such care could be both skilled and 

non-skilled to obtain a stable condition for a patient. Such care typically 

follows a hospital stay or exacerbation of a condition. 

Chronic care: Generally, the agencies defined chronic care patients as those 

needing long-term, less frequent services than acute care to prevent 

exacerbation for a patient whose condition is generally stable. 

High-tech care: The agencies defined high-tech care patients as those needing 

specialized treatments and services. Such care includes intravenous therapy, 

complex wound care, chemotherapy, ventilators, and procedures and services 

carrying a higher risk and requiring sophisticated skills and training. 

The mix of such patients served by the high and low-cost groups of home health 

agencies we surveyed was about the same (see Table 3). We did not determine 

whether or not the patient mix differences between high and low-cost home health 

agencies were statistically significant. 

7

II 

1 Patient Condition


I


Condition Category I


Acute 

Chronic 

I 

High-Tech 

, 

TOTAL 

TABLE 3 

Mix Served By High And Low-cost HHAs 

I 

Low-Cost HHAs I High-Cost HHAs 

(Avg. % of Patients) (Avg. % of Patients) 

62 59 

33 33 

1 

5 8 

100 100 

Nearly All High And Low-Cost Home Health Agencies Had A Formal Quality 

Assurance Program 

About 98 percent of the 80 high-cost agencies, and 99 percent of the 114 low-cost 

agencies that responded to our survey told us they have a quality assurance program. 

High And Low-Cost Home Health Agencies Provided A Similar Mix Of SeMces 

The percentage of high and low-cost home health agencies providing different types of 

home health service was about the same (see Table 4), except for hospice care and a 

catch-all category called “other”. A smaller percentage of agencies in the high-cost 

group provided hospice care and “other” services than did low-cost agencies. 

TABLE 4 

Percentage Of EEL% ProvidingEach Type Of Semite 

Low-cost High-Cost 

HHAs HHAs 

Nursing


Physical Therapy


Occupational Therapy


Speech Pathology Therapy


Medical Social Services


Aide Services


Hospice


100 100 

96 96 

82 80 

86 89 

87 90 

100 100 

29 8 

Other (e.g., DME, nutrition counseling) 35 10 

8 
The Major Source Of Payment For Patients Served By Both High And Low-Cost 

Home Health Agencies Was Medicare Fee-For-Semite. 

Table 5 summarizes the source of payment for patients served by high and low-cost 

home health agencies. Essentially, all operated under a fee-for-service system. 

Notably, none of the 80 high-cost agencies said they served Medicare managed care 

patients, as compared to 15 percent of the low-cost agencies that do service such 

patients. 

TABLE 5 

Percentage Of HHAs That Reported Patient Populations XnEach Common 

Payment Category 

IISOURCE OF PAYMENT I 114 Low-Cost HHAs I 80 High-Cost HHAs 

Medicare Fee-For-Service I 100 I 100 

Medicaid 89 83 

IIMedicare Managed Care I 15 I o 

[ Other (e.g., private insurance) 91 89 

A HIGHER PERCENTAGE OF HIGH-COST HOME HEALTH AGENCIES 

THAN LOW-COST HOME HEALTH AGENCIES OPEIUTED AS FOR-PROFIT 

AND FREESTANDING ENTITIES 

We previously reported that home health agencies at the higher levels of the range of


average reimbursement per beneficiary tended to be for-profit, freestanding


organizations .3 The 194 home health agencies that responded to our sumey


confirmed that finding.


The percentage of high-cost home health agencies that were for-profit entities was


almost five times that of low-cost home health agencies (58 percent as compared to 12


percent). This is illustrated in Figure 2.


3

Ibid., Page 11 

9 

II 
FIGURE 2


TYPE OF OWNERSHIP 

High-Cost vs. Low-Cost HHAs 

80% 

e8.4% 

eos 67.6% 

40% 

20% 

o% 

HIGH-COST HHAs LOW-COST HHA8 

_ For-Profit = Non-Profit EEEl Publio 

Figure 3 shows that the percentage of high-cost home health agencies that were


freestanding was four times that for low-cost home health agencies (56 percent as


compared to 13 percent). Freestanding agencies are those that are not at%liated with


or part of another health-care entity, such as a visiting nurses association, a


government or voluntary agency, a rehabilitation facility, a hospital, or a skilled nursing


facility.


10

FIGURE 3


HHA FACILITY TYPES 

Affiliated vs. Freestanding 

%of HHA8 

1 00% 

a7% 

80% 

60% 66% 

40% 

20% 

o% 

HIGH-COST HHA8 LOW-COST HHA8 

_ Affiliated = Freestanding 

For-profit and freestanding home health agencies accounted for much of the 

increasing gap in average visits per Medicare beneficiary between high and low-cost 

agencies. 

Our sample of 194 home health agencies included 60 that operated on a for-profit 

basis. In 1994, the 60 for-profit home health agencies averaged 94 visits per 

beneficiary while the 134 non-profit and public home health agencies averaged 47. 

Likewise, our sample included 60 home health agencies that operated as a 

freestanding entity. These agencies averaged 93 visits per beneficiary as compared to 

an average of 47 visits per beneficiary for affiliated home health agencies. 

11

CONCLUSION 

The gap betsveen high-cost and low-cost home health agencies in average number of


visits per Medicare beneficiary continues to widen. In our previous inspections, we


found that factors such as beneficiary characteristics, agency characteristics, primary


diagnoses, and proxies for quality did not explain the wide variation in average number


of visits per beneficiary made by home health agencies. We have continued to look


for other explanations.


In this inspection, we examined operating policies, procedures, and practices as a


possible explanation for the difference. We found, however, that generally program


operations are similar in high-cost and low-cost agencies. Where we observed minor


differences in operations, they did not explain the differences in average number of


visits per Medicare beneficiary among home health agencies. We have not found an


explanation for the variation in average number of visits. Despite this, we will


continue to analyze this variation in other inspections and to look for explanations.


Determining when it is appropriate and medically necessary to provide Medicare


home health services is often ambiguous and largely discretionary. This inspection and


other audits and inspections on home health services continue to suggest a need for


greater control over the provision of Medicare home health services. If control cannot


be achieved through more effective management oversight, then statutory or


regulatory changes may be needed to protect the Medicare program from excessive or


inappropriate payments in this area.


12

--

APPENDIX A


METHODOLOGY 

Sample Selection 

We randomly selected 300 Medicare certified home health agencies in the United 

States from HCFA’S National Claims History Repository. Before sampling, we 

stratified the 1993 universe of 6803 HHAs into two categories low-cost and high-cost 

HHAs. We based the two categories on average number of visits made to 

beneficiaries. We considered HHAs that made fewer than the national average of 50 

visits per beneficiary in 1993 to be low-cost. We considered those that made more 

visits than the national average to be high-cost. We randomly sampled 150 HHAs 

from both the high and low strata. 

Data Collection And Analysis 

We used a standardized questionnaire to collect data on operating practices of


sampled high and low-cost HHAs. We mailed our survey instrument to each of the


300 sampled HHAs. About 65 percent (194) of the 300 HHAs completed and


returned our questionnaire. To assure that our analysis was based on the most current


data, we used 1994 utilization data for all HHAs appearing in our sample. Of the 194


HHAs that responded, 114 (59 percent) were low-cost HHAs. The remaining 80


respondents, (41 percent) were high-cost agencies. In terms of average number of


visits per beneficiary, the HHAs that responded to our sumey were representative of


the HHA universe in the United States. We did not independently verify the data


reported by the respondents.


We used a dBase file to organize and analyze numerical data obtained from the 194


HHAs. We aggregated the data to obtain comparisons of operating practices of low-


cost HHAs as a group to those of high-cost HHAs as a group.


To compare the philosophy or mission statements of the HHAs, we performed a


content analysis of those statements. To perform the content analysis we first


examined all of the statements and compiled a list of all major terms, phrases and


concepts. We then grouped these terms, phrases, and concepts into four major


categories. We then aggregated the number of terms, phrases, and concepts in each


of the four major categories for both the groups, and performed a statistical


significance test on the total “scores” for both the high and low-cost groups.


We conducted t-tests on all findings in the report.


A-1

APPENDIX B


AN ANALYSIS OF RESPONDENTS VS. NON-RESPONDENTS 

A consideration in surveys of this type is whether the results may be biased by significant 

differences between non-respondents and respondents. To determine whether significant 

differences exist in this survey, we compared average number of visits per beneficiary by 

HHA and size of HHAs. Our analysis revealed no significant difference. Therefore, the 

possibility of bias due to non-response is limited. 

To test for bias in respondents versus non-respondents, we used a Two-way Contingency 

Table Analysis with the Chi-Square Test. We calculated the expected values for 

respondent HHAs and non-respondent HHAs assuming that respondent HHAs and nonrespondent HHAs are independent. 

For our test of bias by average number of visits per beneficia~ and size of HHAs, we 

chose an alpha value of .05 with 1 degree of freedom. That produced a Chi-Square 

value of 3.84146. 

Our test statistic was .049 for our analysis by average number of visits per beneficiary by 

HHA. This leads us to a conclusion that classification of respondent and non-respondent 

HHAs are independent by average number of visits per beneficiary. 

NON-RESPONDEITI’ ANALYSIS 

BY AVERAGE NUMBER OF VISITS PER BENEFICIARY 

BY HOME HEALTH AGENCY 

I Sample II#of \#of NonRespondents Respondents I II I 

HHAs Above the National Mean of 125 (41.7%) 

58 Visits per Beneficiary ~ 

HHAs Below the National Mean of 175 (58.3%) 

58 Visits per Beneficiary ~ 

TOTALS 300 (loo%) 194 (loo%) 106 (loo%) 

B-1

Our test statistic for our analysis by size of HHA was 0.642. This also leads us to a 

conclusion that classification of respondents and non-respondents are independent. 

NON-RESPONDENT ANALYSIS 

BY SIZE OF HOME HEALXH AGENCY 

Sample	 # of # of NonRespondents Respondents 

HHAs That Served 500 or Less 102 (34.0%) 64 (33%) 38 (35.8%) 

Medicare Beneficiaries in 1994 

HHAs That Sewed 501 to 999 98 (32.6%) 66 (34%) 32 (30.2%) 

Medicare Beneficiaries in 1994 

HHAs That Served 1000 or More 100 (33.3%) 64 (33%) 36 (34.0%) 

Medicare Beneficiaries in 1994 

TOTALS 300 (loo%) 194 (loo%) 106 (loo%) 

Our non-response analysis showed, however, that our survey results contained no 

significant bias in terms of average number of visits per beneficiary, and size of HHA. 

B-2