Chronic Conditions Remain Costly and Preventable Leading Causes of Death

According to releases from the National Center for Health Statistics, the leading causes of death in 2014 remained the same as in 2013. However, age-adjusted death rates for five leading causes declined significantly; heart disease, cancer, chronic lower respiratory diseases, diabetes, and influenza and pneumonia. Although not in the top ten leading causes, hypertension also showed a significant decrease. Death rates increased significantly for unintentional injuries, stroke, Alzheimer’s disease, suicide, and chronic liver disease and cirrhosis between 2013 and 2014.

  • Generally, for younger age groups, external causes accounted for more deaths than other causes, whereas for older age groups, chronic diseases were far more prevalent than other causes.
  • For populations aged 65 and over, heart disease was the leading cause of death, followed by cancer. 
  • Heart disease was also the leading cause of death for the population aged 85 and over.
  • Alzheimer’s disease was one of the major causes of death at the oldest ages, ranking third for those aged 85 and over.
  • Medicare beneficiaries with six or more chronic conditions account for 15% of beneficiaries but 50% of total Medicare spending (see chart below).


Clearly the data shows the impact of our aging population and chronic care needs. Fazzi uses the IHI Triple Aim framework when assisting agencies with preparing for the future now. To learn more about Triple Aim, click here.

To download a PDF of the top ten home health and hospice diagnoses from analysis of Fazzi claims data, click here.  To download a PDF of leading causes of death for three age groups; 65-74 years, 75-84 years, and 85 years and over, click here.  For chronic condition prevalence at state and county levels, click here.

Leading causes of death. For information on data and methods, including definitions of and procedures for ranking, see sources: Heron M. Deaths: Leading causes for 2014. National vital statistics reports; vol 65 no. 5. Hyattsville, MD: National Center for Health Statistics. 2016. Kochanek KD, Murphy SL, Xu JQ, Tejada-Vera B. Deaths: Final data for 2014. National vital statistics reports; vol 65 no 4. Hyattsville, MD: National Center for Health Statistics. 2016. Medicare spending on chronic conditions. See Centers for Medicare and Medicaid Services, chronic conditions charts: 2014.


Patients per Agency and Agencies per County

Source: CMS Moratoria Provider Services and Utilization Data Tool
State Number of Agencies Patients per Agency Agencies per County
Alabama 145 475 9
Alaska 10 211 3
Arizona 137 287 48
Arkansas 153 225 6
California 1,127 256 204
Colorado 122 273 20
Connecticut 86 563 32
Delaware 23 581 14
District of Columbia 33 156 33
Florida 1,059 293 73
Georgia 113 722 9
Hawaii 12 228 5
Idaho 45 292 7
Illinois 772 218 256
Indiana 203 288 19
Iowa 147 169 5
Kansas 120 216 10
Kentucky 108 509 6
Louisiana 200 331 18
Maine 30 637 6
Maryland 63 1,015 17
Massachusetts 144 720 40
Michigan 552 245 110
Minnesota 142 263 14
Mississippi 48 1,141 5
Missouri 178 340 17
Montana 27 218 2
Nebraska 67 223 9
Nevada 118 222 68
New Hampshire 37 568 12
New Jersey 56 1,695 11
New Mexico 73 213 8
New York 147 1,101 19
North Carolina 178 560 10
North Dakota 19 190 2
Ohio 447 244 30
Oklahoma 255 249 29
Oregon 67 331 7
Pennsylvania 317 434 26
Rhode Island 29 440 21
South Carolina 75 726 7
South Dakota 30 155 3
Tennessee 145 492 12
Texas 2,176 140 157
Utah 93 211 31
Vermont 14 711 3
Virginia 205 440 17
Washington 65 645 10
West Virginia 63 354 5
Wisconsin 101 350 8
Wyoming 28 128 2
National 10,377 314 60

CMS has released the Moratoria Provider Services and Utilization Data Tool which includes national, state and county level provider services data for home health. We’ve extracted the data by state for the number of home health agencies, average number of patients served per agency, and agencies per county.The data shows that between October 1, 2014 to September 30, 2015, there were 10,377 Medicare-certified agencies serving a national average of 314 patients each and an average of 60 agencies per county.

States with an active moratorium have greater than 64 agencies per county along with other indicators of potential fraud risk, including the number of providers per 10,000 Medicare FFS beneficiaries and the annual growth rate in providers.

You can access the CMS Moratoria Provider Services and Utilization Data Tool and view additional data by state.

Do you want to know the number of patients your competitors are treating? Or how many counties they serve? Visit our Business Intelligence web page or contact us to learn how you can compare your patients. For Medicare beneficiary data, visit our post-acute care use web page.

Note: In the CMS analysis, claims are used to define the geographic area(s) served by a provider rather than the provider’s practice address. Further, a provider is defined as “serving a county” if, during the one-year reference period, the provider had paid claims for more than 10 beneficiaries located in a county. A provider is defined as “serving a state” if that provider serves any county in the state.

Lynn Harlow
Partner, Director of Business Intelligence

Nothing Affects Your Reimbursement More Than Your Average Case Mix Weight


Based on Fazzi’s analysis of 2014 final home health claims data for non-LUPA episodes (based on final claim), the national average case mix is 1.046 (rounded from 1.0458). See table at right for results by state. The Department of Health and Human Services estimated that the average case mix for 2014 was 1.0465 as stated in the Federal Register¹.

Average Case Mix by State
State Average Case Mix
Alabama 1.071
Alaska 1.035
Arizona 1.069
Arkansas 1.034
California 0.975
Colorado 1.133
Connecticut 1.037
Delaware 1.046
District of Columbia 1.096
Florida 1.211
Georgia 1.105
Hawaii 1.091
Idaho 1.157
Illinois 0.983
Indiana 1.097
Iowa 1.009
Kansas 1.083
Kentucky 1.071
Louisiana 0.970
Maine 1.057
Maryland 1.110
Massachusetts 1.037
Michigan 1.095
Minnesota 1.049
Mississippi 0.993
Missouri 1.072
Montana 1.071
Nebraska 1.094
Nevada 0.995
New Hampshire 1.021
New Jersey 1.022
New Mexico 1.046
New York 1.011
North Carolina 1.093
North Dakota 0.975
Ohio 1.043
Oklahoma 0.958
Oregon 1.050
Pennsylvania 1.045
Puerto Rico 1.063
Rhode Island 1.039
South Carolina 1.114
South Dakota 1.092
Tennessee 1.139
Texas 0.964
Utah 1.144
Vermont 0.978
Virginia 1.098
Washington 1.107
West Virginia 1.136
Wisconsin 1.030
Wyoming 1.072
Source: Fazzi Analysis of 2014 Medicare Home Health Claims

Nothing affects your reimbursement more than your average case mix.

Case mix weight (CMW) can be a revealing benchmark. Low CMW can be a result of low acuity patients or inaccurate scoring. Accurate completion of OASIS assessments directly impacts the resources an agency will receive to provide services, impacts the agency’s quality scores on Home Health Compare, impacts your status on VBP, and impacts the financial status of the agency. Ultimately, OASIS directly impacts the very viability of your agency.

Not at your state’s average and you don’t know why? An audit will tell you why, and training will help you improve. Contact us for more information on Fazzi’s audit services and training options.

If you are interested in case mix by agency or county level, visit our Business Intelligence page or contact us.

¹Department of Health and Human Services. Centers for Medicare & Medicaid Services. 42 CFR Parts 409. 424, and 484 [CMS-1625-F] Medicare and Medicaid Programs; CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final Rule.

Low Utilization Payment Adjustments

Fazzi’s analysis of LUPA episodes shows not-for-profit home health agencies have the highest percentage of LUPA episodes followed by hospital-based agencies. We distributed the results by agency status then by quartiles. Agencies in the upper quartile range spanned from 8.9% to 15.0%, while those in the lowest quartile ranged from 2.3% to 8.7% of episodes. We also include the weighted national average by home health agency type.

LUPA Episodes HH

If your LUPA episodes are higher (or much lower) than your competitors, you should explore why. Causes can be due to your care management model, scheduling, or re-certification process.

We’ve shown national averages here, but you can receive individual competitor reports or competitor information by county. Data is available for home health and hospice. To request a report or pricing, please contact us.

Staffing Strategies Used by Size of Home Health Agency

Looking at home health agencies by number of patients we found that home health aides were more likely to be under contract with agencies that served over 3,000 patients.  Skilled nursing staff were more likely to be under contract in agencies with less than 500 patients.

The percent of staff FTEs for skilled nursing ranged from 45% to 58% for all Medicare-certified freestanding agencies with an average of 54%.  Staff FTEs for home health aides ranged from 14% to 24% with an average of 21%.

Contract FTEs for skilled nursing ranged from 8% to 18% with an average of 14%.  Contract FTEs for home health aides ranged from 14% to 63% (average 25%).  See percentages by agency number of patients in the second chart below.  Note: Contract hours are converted to FTEs.

Fazzi offers a variety of customized analyses and reports for home health and hospice agencies.  For more details, contact us or visit our Business Intelligence web page.

Contract FTE by Discipline

Contract FTE by Discipline

Source: Fazzi analysis of Medicare cost report data.  Most recent cost report filed was used for this analysis.  Agencies that did not report patients, FTEs, or contained outlier data were excluded, resulting in analysis of 7,095 agencies.

Medicare Payment per Hospice Patient

Average Medicare payment per patient was $13,513 for freestanding, for-profit hospices in calendar year 2013.  Visits for freestanding, for-profit hospices averaged 44.0% for skilled nursing and 50.5% for home health aides.

Medicare Payment

For financial information on your hospice competitors, contact us.

“Proprietary” and “Non-Profit” include freestanding hospices only.  Source: Fazzi Analysis of Medicare Hospice Claims CY 2013.

Medicare Discharges to Post-Acute Care

42% of Medicare beneficiaries were discharged from the hospital* to post-acute care and 17% of those were discharged to home health.

Beneficiaries receiving home health after post-acute care averaged 1.4 episodes and community-admitted beneficiaries averaged 2.6 episodes.  For all Medicare home health beneficiaries, the average episodes per user is 1.9.

Medicare Discharges

Concerned about growing your agency? It’s important to have information about referrals.  To compare referrals by source for your agency and competitors, contact us or visit our business intelligence page for more information.

* Discharges from Prospective Payment System hospitals.  Not all beneficiaries who receive PAC have a preceding hospitalization.  Source: MedPAC. Medicare post-acute care reforms. April 2015. Average episodes per user is from MedPAC’s review of 2010 datain analysis of 7,095 agencies.