news briefs

Final rule implements 2010 HHA changes

Home health agencies will receive a slightly worse than proposed payment update from Medicare in calendar year 2010, for an average net payment decrease of 1.03%, according to the final rule released by the Centers for Medicare & Medicaid Services (CMS).

The decrease results from a 2% market basket update combined with a 2.75% reduction — the third of four reductions authorized in a prior rule to adjust for coding practices between 2000 and 2005. In response to CMS concerns that certain home health agencies are overusing outlier payments for high-cost patients, the rule caps annual outlier claims per agency at 10% and reduces the outlier payment pool to 2.5% of total payments from 5% currently. Hospital-based agencies fare much better than many agencies under the rule, with an average increase of 3.72%, since the outlier changes favor agencies with fewer outlier cases.

Study highlights background check disparities

Criminal background checks that are used to screen potential home health employees to identify potential risk for abuse, neglect, or financial exploitation may give employers and family members a false sense of security, according to a study by the AARP.

Background checks may miss records, fail to uncover some crimes, or overlook a caregiver's history of abuse or neglect that stops short of criminal conviction.

An increasing number of states — 46 states and the District of Columbia — require background checks for some or all paid home care workers. Yet these state requirements show little or no agreement on standards, according to the report. For example, some states disqualify job applicants only for past criminal offenses against vulnerable people, while others exclude them for a DUI conviction.

State, county, FBI, and other databases are not integrated and may have gaps and errors, the report concludes, and there is no single agency for families or home health agencies to consult for a comprehensive review of criminal records. Additionally, even a comprehensive criminal background check of multiple agencies shouldn't be taken as total assurance, the report warns. Elder abuse, neglect, and exploitation is under-reported.

Integration of online reporting systems and sharing information between different state agencies are two of the recommendations made by the researchers. To see a copy of the full report, go to

CMS outlier policy FAQs posted

The Centers for Medicare & Medicaid Services (CMS) has clarified information about the new CY 2010 outlier policy under the Home Health Prospective Payment System (HH PPS) that was announced in the Medicare Home Health Prospective Payment System Rate Update for CY 2010 Final Rule (CMS-1560-F). The guidance can be found in the questions and answers available in the first spotlight on the CMS web page at

Studies show decrease in senior care continuity

End of life discussions should be reimbursed

If the discharge planning community's ideal is to begin the discharge process at the door, when patients are admitted to the hospital, then community provider input is necessary for a smooth care transition.

But care continuity has been low, and it's decreasing for older adults, recent studies show.1,2

A study that examined the proportion of patients who are seen by their primary care physician during their hospitalization found a significant decline in this continuity of care, says Gulshan Sharma, MD, MPH, an associate professor at the University of Texas Medical Branch in Galveston, TX.

"The proportion declined from 50.5% to 44.3% between 1996 and 2006," Sharma says.2

The study showed an even greater decrease in continuity in cases where patients were admitted to the hospital on weekends and for those living in large metropolitan areas.2

The results were not too surprising given the changes that have taken place in the delivery of health care over the past two decades, Sharma notes.

"To improve efficiency of care, you have primary care physicians managing patients in very busy practices, and it's hard for them to go see patients who are hospitalized," he explains. "So there's been a large growth in hospitalists' positions, and these are the people who provide care for patients when they're hospitalized."

The older model of having one physician follow patients through the trajectory of their illness and care no longer is followed.

"The health care system is getting more efficient, with physicians spending more time at their part of this system, but the price you pay is fragmented care," Sharma notes.

"There's a lot of disruption in care, and there's no major effort to have a physician make sure the transition is smooth in either direction," Sharma says.

Similarly, there are no practice or economic incentives for hospitalists to follow up with patients once they've returned to the community, he adds.

"That's where a major discussion is going on: How do you make this transition smooth?" Sharma says. "One way would be through an electronic health record."

Hospital systems and community providers who can connect electronically can provide follow-up care and a smoother transition through electronic communication, he says.

But research suggests that having a primary care provider attend a patient in the hospital can improve health care outcomes. In one study, investigators found that patients with terminal lung cancer who were visited by community physicians while in the hospital were less likely to spend time in the intensive care unit (ICU) before death.1

"So it might be good for discharge planners to have a primary care physician visit patients," Sharma notes. "And discharge planning should include communication with a patient's primary care physician, so they'll know what's going on."

One reason these primary care physician visits to hospitalized patients are decreasing is that there is no reimbursement for them, Sharma says.

"Medicare won't reimburse for two physicians for the same specialty," he explains.


1. Sharma G, Freeman J, Zhang D, et al. Continuity of care and intensive care unit use at the end of life. Arch Intern Med. 2009;169:81-86.

2. Sharma G, Fletcher KE, Zhang D, et al. Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults. JAMA. 2009;301(16):1671-1680.