{
  "study": {
    "slug": "medicare-market-saturation-2026",
    "title": "Where Medicare providers cluster: home health and DME market saturation, 2025",
    "standfirst": "In Los Angeles County, 1,847 home health agencies serve Medicare's fee-for-service population — the most of any U.S. county, at 2.12 per 1,000 beneficiaries, nearly ten times the national rate of 0.22. CMS publishes this market-saturation map for program-integrity monitoring, not as proof of fraud.",
    "desk": "access",
    "article_type": "Original Research",
    "published": "2026-06-15",
    "issue": 73,
    "doi": "10.5072/fonteum/medicare-market-saturation-2026",
    "url": "https://fonteum.com/research/medicare-market-saturation-2026",
    "methodology_version": "market-saturation/v1"
  },
  "data_as_of": "2026-06-15",
  "datasets": [
    {
      "slug": "cms-provider-data-catalog",
      "name": "CMS Provider Data Catalog",
      "publisher": "CMS — Provider Data Catalog",
      "upstream_url": null
    }
  ],
  "key_findings": [
    {
      "number": "1,847",
      "finding": "home health agencies serve Los Angeles County's Medicare population — the most of any U.S. county — at 2.12 per 1,000 fee-for-service beneficiaries, 9.9x the national rate of 0.215",
      "dataset": "cms-provider-data-catalog"
    },
    {
      "number": "0.604",
      "finding": "home health agencies per 1,000 FFS beneficiaries in California, the highest of any state and nearly triple the national 0.215; Nevada (0.517), the District of Columbia (0.381), and Texas (0.371) come next",
      "dataset": "cms-provider-data-catalog"
    },
    {
      "number": "3.45",
      "finding": "durable medical equipment suppliers per 1,000 FFS beneficiaries in Fort Bend County, Texas — the most DME-saturated large county, about 3x the national DME rate of 1.16. Home health and DME are the categories CMS singles out for program-integrity monitoring",
      "dataset": "cms-provider-data-catalog"
    },
    {
      "number": "0 of 68,068",
      "finding": "latest-period county, state, and national records carry an active CMS enrollment moratorium — none reads \"Yes\"; 68,044 read \"No\" and 24 are blank. The flag is retained from the 2013-2019 moratoria era, all lifted in January 2019: saturation here is a monitoring signal, not an enforcement action",
      "dataset": "cms-provider-data-catalog"
    },
    {
      "number": "24",
      "finding": "Medicare service categories are tracked across 3,141 counties and 15 yearly snapshots (2020-2025); this study reads the most recent annual period, 68,068 point-in-time records",
      "dataset": "cms-provider-data-catalog"
    }
  ],
  "faqs": [
    {
      "q": "What is Medicare 'market saturation'?",
      "a": "Market saturation is the ratio of Medicare providers or suppliers to fee-for-service beneficiaries in a given area and service category — in practice, providers per 1,000 beneficiaries. CMS publishes it through the Market Saturation & Utilization State-County tool so it can watch for places where the supply of a service has run well ahead of the population that needs it. A high ratio is a reason to look more closely; it is not, on its own, evidence that anything is wrong."
    },
    {
      "q": "Which county has the most Medicare home health agencies?",
      "a": "Los Angeles County. In the 2025 reference period it was served by 1,847 home health agencies — far more than any other county and five times the next-highest (Cook County, Illinois, at 365). Measured against its Medicare population, that is 2.12 agencies per 1,000 fee-for-service beneficiaries, 9.9 times the national rate of 0.215. The Texas border counties around McAllen (Hidalgo) and Brownsville (Cameron) carry the next-highest large-county rates."
    },
    {
      "q": "Does high market saturation mean there is Medicare fraud?",
      "a": "No. Saturation is an oversight and monitoring signal, not a finding. CMS built the measure to flag markets worth watching for program integrity, because some historically over-saturated categories — home health and durable medical equipment in particular — have also seen high rates of improper billing. But a high ratio can equally reflect a large referral hub, an aging population, or many small agencies. This study reports geography-level ratios only and names no provider."
    },
    {
      "q": "Why is home health and DME singled out?",
      "a": "Home health and durable medical equipment are low-overhead, high-volume Medicare categories where a single supplier can serve beneficiaries across a wide area, so they have historically attracted dense clusters of enrollees. CMS and the HHS Office of Inspector General have long monitored both for over-saturation, and the 2013-2019 enrollment moratoria targeted exactly these categories in specific metros. They top the county saturation ranking here as well."
    },
    {
      "q": "Are there any Medicare enrollment moratoria in force right now?",
      "a": "Not in this data. None of the 68,068 latest-period records carries an active moratorium: 68,044 read \"No\" and the other 24 are blank, and across all 15 yearly snapshots the only values the flag ever takes are \"No\" and blank. CMS imposed temporary statewide moratoria on new home health and ground-ambulance enrollments in several states between 2013 and 2019, then lifted all of them in January 2019. The flag remains in the file as a field, but it is inactive everywhere in this snapshot."
    },
    {
      "q": "Does this study name any agency, supplier, or clinician?",
      "a": "No. Every figure is a count or ratio at the county, state, or national level. The data CMS publishes is itself aggregate — it reports how many providers and beneficiaries are in a market, never which ones — so there is no individual provider to name, rank, or score anywhere in this study."
    },
    {
      "q": "Can I reproduce these figures?",
      "a": "Yes. Every number aggregates the public cms_market_saturation table (1,030,290 rows from the CMS Market Saturation & Utilization State-County files, snapshot release 2025-12-01) over its most recent annual period. The exact SQL — the national baselines, the county and state saturation rates, and the moratorium-flag check — is published in the reproducibility block below."
    }
  ],
  "citation": {
    "apa": "Fonteum Research. (2026, June 15). Where Medicare providers cluster: home health and DME market saturation, 2025. Fonteum Research, Issue 73. https://doi.org/10.5072/fonteum/medicare-market-saturation-2026",
    "url": "https://fonteum.com/research/medicare-market-saturation-2026"
  },
  "reproducible_sql": "-- Medicare provider market saturation as a program-integrity signal —\n-- fully reproducible query.\n--\n-- Question: where do Medicare fee-for-service (FFS) providers and suppliers\n-- cluster far past what local beneficiary demand explains? We measure, over\n-- the most recent annual reference period, the provider-to-beneficiary ratio\n-- (providers per 1,000 FFS beneficiaries) by service category and by county —\n-- the same \"market saturation\" metric CMS itself publishes for program-\n-- integrity MONITORING. High saturation is a risk/oversight signal, NOT proof\n-- of fraud. The lead figure is Los Angeles County's home health saturation:\n-- 1,847 agencies, 2.12 per 1,000 FFS beneficiaries, ~9.9x the national rate.\n--\n-- Source:\n--   public.cms_market_saturation — CMS Market Saturation & Utilization\n--     State-County, published via the CMS data catalog (data.cms.gov),\n--     Program Integrity > Market Saturation by Type of Service.\n--     1,030,290 rows across 15 yearly reference periods (2020-2025), 24 service\n--     categories, and three aggregation levels (NATION + TERRITORIES, STATE,\n--     COUNTY = 3,141 counties). Snapshot release 2025-12-01; public, read-only.\n--     License: US-Government-Works (17 U.S.C. Sec. 105).\n--     methodology_version = 'cms-market-saturation/v1'.\n--\n-- Universe: this study reads the LATEST annual period only\n--   (reference_period = '2025-01-01 to 2025-12-31', 68,068 rows) so every\n--   figure is point-in-time, not a trend. The period is resolved as\n--   max(reference_period) at query time, never hard-coded, so the figures\n--   advance when CMS publishes the next file.\n--\n-- Counting note (CRITICAL): CMS counts a provider in EVERY county where it\n--   serves at least one beneficiary, so county provider counts are presences,\n--   not distinct firms — the sum of county counts exceeds the national DISTINCT\n--   count (home health: 23,311 county presences vs 8,488 distinct agencies).\n--   We therefore compare the saturation RATE (providers per 1,000 FFS benes)\n--   across geographies, and label raw county counts as \"agencies serving the\n--   county,\" never as a share of the national total.\n\n-- ============================================================================\n-- (1) National saturation by service category, latest period.\n--     providers_per_1k = number_of_providers / FFS beneficiaries * 1000.\n--     Home health and DME are the categories CMS singles out for program-\n--     integrity monitoring; the national home health rate (0.215) is the\n--     baseline the county figures are measured against.\n-- ============================================================================\nWITH latest AS (SELECT max(reference_period) AS p FROM public.cms_market_saturation)\nSELECT\n  type_of_service,\n  number_of_providers::bigint                                          AS providers,\n  number_of_ffs_beneficiaries::bigint                                  AS ffs_benes,\n  number_of_users::bigint                                              AS users,\n  average_users_per_provider                                           AS users_per_provider,\n  total_payment::bigint                                                AS total_payment,\n  round(1000.0 * number_of_providers\n        / nullif(number_of_ffs_beneficiaries, 0), 3)                   AS providers_per_1k_ffs\nFROM public.cms_market_saturation m, latest\nWHERE m.aggregation_level = 'NATION + TERRITORIES'\n  AND m.reference_period = latest.p\nORDER BY providers_per_1k_ffs DESC NULLS LAST;\n--  Home Health             8,488 providers · 39,524,879 benes · 0.215 / 1k · $15.97B\n--  Durable Medical Equip. 45,963 providers · 39,598,270 benes · 1.161 / 1k · $27.04B\n--  Hospice                 5,024 providers · 39,475,379 benes · 0.127 / 1k · $15.41B\n--  Skilled Nursing Fac.   12,919 providers · 39,391,060 benes · 0.328 / 1k · $27.85B\n--  (the per-1k national ranking is led by physician categories — Preventive\n--   Health 5.703, Pulmonology 4.556 — which carry hundreds of thousands of\n--   billing clinicians; the program-integrity story is the COUNTY clustering\n--   of the supplier categories below, not the national physician ratio.)\n\n-- ============================================================================\n-- (2) Home health county reconciliation — county presences vs distinct firms.\n-- ============================================================================\nWITH latest AS (SELECT max(reference_period) AS p FROM public.cms_market_saturation)\nSELECT\n  (SELECT number_of_providers::bigint FROM public.cms_market_saturation m, latest\n     WHERE aggregation_level = 'NATION + TERRITORIES' AND reference_period = latest.p\n       AND type_of_service = 'Home Health')                            AS national_distinct_agencies,\n  (SELECT sum(number_of_providers)::bigint FROM public.cms_market_saturation m, latest\n     WHERE aggregation_level = 'COUNTY' AND reference_period = latest.p\n       AND type_of_service = 'Home Health')                            AS sum_county_presences\nFROM latest;\n--  national_distinct_agencies 8,488 · sum_county_presences 23,311\n--  (avg agency present in ~2.75 counties; county counts are presences.)\n\n-- ============================================================================\n-- (3) HEADLINE: home health counties by agency count (latest period).\n--     Los Angeles is the most home-health-saturated large county in the\n--     country: 1,847 agencies, 2.12 per 1,000 FFS benes (9.9x national 0.215).\n-- ============================================================================\nWITH latest AS (SELECT max(reference_period) AS p FROM public.cms_market_saturation)\nSELECT\n  county, state, geo_fips,\n  number_of_providers::bigint                                          AS agencies,\n  number_of_ffs_beneficiaries::bigint                                  AS ffs_benes,\n  number_of_users::bigint                                              AS users,\n  average_users_per_provider                                           AS users_per_agency,\n  round(1000.0 * number_of_providers\n        / nullif(number_of_ffs_beneficiaries, 0), 2)                   AS agencies_per_1k\nFROM public.cms_market_saturation m, latest\nWHERE aggregation_level = 'COUNTY' AND reference_period = latest.p\n  AND type_of_service = 'Home Health'\nORDER BY agencies DESC NULLS LAST\nLIMIT 8;\n--  LOS ANGELES   CA  1,847  872,904  72.39 u/agency  2.12 / 1k   <- lead\n--  COOK          IL    365  564,951                  0.65 / 1k\n--  ORANGE        CA    312  308,173                  1.01 / 1k\n--  DALLAS        TX    232  202,655                  1.14 / 1k\n--  SAN BERNARDINO CA   214  146,380                  1.46 / 1k\n--  HARRIS        TX    201  316,157                  0.64 / 1k\n--  RIVERSIDE     CA    178  200,452                  0.89 / 1k\n--  MIAMI-DADE    FL    172  174,283                  0.99 / 1k\n\n-- ============================================================================\n-- (4) Home health saturation RATE — top counties with a stable base\n--     (>= 20,000 FFS beneficiaries so the ratio is not a small-county artifact).\n-- ============================================================================\nWITH latest AS (SELECT max(reference_period) AS p FROM public.cms_market_saturation)\nSELECT\n  county, state,\n  number_of_providers::bigint                                          AS agencies,\n  number_of_ffs_beneficiaries::bigint                                  AS ffs_benes,\n  round(1000.0 * number_of_providers\n        / nullif(number_of_ffs_beneficiaries, 0), 2)                   AS agencies_per_1k\nFROM public.cms_market_saturation m, latest\nWHERE aggregation_level = 'COUNTY' AND reference_period = latest.p\n  AND type_of_service = 'Home Health'\n  AND number_of_ffs_beneficiaries >= 20000\nORDER BY agencies_per_1k DESC NULLS LAST\nLIMIT 9;\n--  LOS ANGELES CA 2.12 · IMPERIAL CA 1.67 · SAN BERNARDINO CA 1.46\n--  GUADALUPE TX 1.40 · CAMERON TX 1.37 · HIDALGO (McAllen) TX 1.31\n--  GRAYSON TX 1.28 · VENTURA CA 1.15 · DALLAS TX 1.14\n--  (the Texas border counties — Hidalgo, Cameron, Guadalupe — are the\n--   classic home health program-integrity corridor alongside Southern California.)\n\n-- ============================================================================\n-- (5) State-level home health saturation. California leads at 0.604 per 1,000\n--     FFS benes — nearly triple the national 0.215 and the highest of any state.\n-- ============================================================================\nWITH latest AS (SELECT max(reference_period) AS p FROM public.cms_market_saturation)\nSELECT\n  state,\n  number_of_providers::bigint                                          AS agencies,\n  number_of_ffs_beneficiaries::bigint                                  AS ffs_benes,\n  round(1000.0 * number_of_providers\n        / nullif(number_of_ffs_beneficiaries, 0), 3)                   AS agencies_per_1k\nFROM public.cms_market_saturation m, latest\nWHERE aggregation_level = 'STATE' AND reference_period = latest.p\n  AND type_of_service = 'Home Health'\nORDER BY agencies_per_1k DESC NULLS LAST\nLIMIT 8;\n--  CA 0.604 · NV 0.517 · DC 0.381 · TX 0.371 · OK 0.336 · LA 0.320 · IL 0.293 · FL 0.282\n--  (national 0.215; CA / NV / TX lead.)\n\n-- ============================================================================\n-- (6) Durable medical equipment — most-saturated large counties\n--     (>= 50,000 FFS benes). National DME rate 1.161 / 1k; these run ~3x it.\n-- ============================================================================\nWITH latest AS (SELECT max(reference_period) AS p FROM public.cms_market_saturation)\nSELECT\n  county, state,\n  number_of_providers::bigint                                          AS suppliers,\n  number_of_ffs_beneficiaries::bigint                                  AS ffs_benes,\n  round(1000.0 * number_of_providers\n        / nullif(number_of_ffs_beneficiaries, 0), 2)                   AS suppliers_per_1k\nFROM public.cms_market_saturation m, latest\nWHERE aggregation_level = 'COUNTY' AND reference_period = latest.p\n  AND type_of_service = 'Durable Medical Equipment'\n  AND number_of_ffs_beneficiaries >= 50000\nORDER BY suppliers_per_1k DESC NULLS LAST\nLIMIT 10;\n--  FORT BEND TX 3.45 · WILL IL 3.43 · MONTGOMERY TX 3.43 · PASCO FL 3.41\n--  BALTIMORE CITY MD 3.35 · SUMMIT OH 3.35 · KANE IL 3.35 · HUDSON NJ 3.34\n--  CAMDEN NJ 3.33 · DENTON TX 3.32\n\n-- ============================================================================\n-- (7) The enrollment-MORATORIUM flag — an honest empty state.\n--     CMS retains a moratorium flag on every record. In this snapshot it reads\n--     \"No\" on every row: there is NO active enrollment moratorium anywhere.\n--     The 2013-2019 statewide home health / ground ambulance moratoria were all\n--     lifted in January 2019, so saturation here is a monitoring signal only.\n-- ============================================================================\nWITH latest AS (SELECT max(reference_period) AS p FROM public.cms_market_saturation)\nSELECT coalesce(moratorium, '<null>') AS moratorium_flag, count(*) AS rows\nFROM public.cms_market_saturation m, latest\nWHERE reference_period = latest.p\nGROUP BY 1\nORDER BY 2 DESC;\n--  No        68,044\n--  <null>        24\n--  (zero rows read \"Yes\" — in this period or in ANY of the 15 periods;\n--   distinct moratorium values across the whole table = {No, NULL}.)\n\n-- ============================================================================\n-- (8) Universe reconciliation — period / aggregation-level split.\n-- ============================================================================\nWITH latest AS (SELECT max(reference_period) AS p FROM public.cms_market_saturation)\nSELECT\n  (SELECT count(*) FROM public.cms_market_saturation)                  AS all_rows,\n  (SELECT count(DISTINCT reference_period) FROM public.cms_market_saturation) AS periods,\n  (SELECT count(DISTINCT type_of_service) FROM public.cms_market_saturation)  AS service_types,\n  (SELECT count(*) FROM public.cms_market_saturation m, latest\n     WHERE reference_period = latest.p)                                AS rows_latest,\n  (SELECT count(DISTINCT geo_fips) FROM public.cms_market_saturation m, latest\n     WHERE aggregation_level = 'COUNTY' AND reference_period = latest.p) AS counties_latest\nFROM latest;\n--  all_rows 1,030,290 · periods 15 · service_types 24\n--  rows_latest 68,068 · counties_latest 3,141",
  "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)",
  "generated_by": "Fonteum — https://fonteum.com",
  "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included."
}