Loss of venipuncture hurting beneficiaries

Discharges, even deaths reported

Home care providers who warned against eliminating the Medicare venipuncture benefit now insist their dire predictions regarding the provision's impact on the most vulnerable beneficiaries have come true, according to a group of experts speaking at the National Association for Home Care's March policy conference in Washington.

The Balanced Budget Act of 1997 (BBA) officially ended the venipuncture benefit Feb. 5, 1998. Since then, state home care associations have reported thousands of patient discharges, many rehospitalizations, and even patient deaths as a result of the change.

Home health agencies also tell of downsizings largely affecting home health aide staff. Yet the industry's cries have fallen on deaf ears of the Health Care Financing Administration (HCFA), Congress, and the Clinton administration, making the chance for repeal or redress appear unlikely.

Providers and industry groups argue that home venipuncture is crucial for patients with complex medical conditions and medication regimens that require routine drug level monitoring. These patients often have chronic progressive conditions such as Alzheimer's disease, cardiac illnesses, and diabetes. Despite their underlying disease and homebound status, they may not qualify for other home health services, says Dayle Berke, Esq., director of government affairs at the National Association for Home Care (NAHC).

HCFA officials maintain the change will have limited impact. Medicare beneficiaries, they counter, can still receive venipuncture through Part B-covered lab services or by qualifying for other skilled services. Industry sources argue that lab services either do not exist in rural areas or will not perform venipuncture for reimbursement reportedly as low as $3 per visit. Additionally, some states' scope of practice regulations prohibit lab technicians from drawing blood from central catheters or other implanted intravenous access devices.

Agencies claim the massive discharges occurred only after they evaluated patients for other skilled needs. Those discharged either had no Medicare-qualified skilled need or no other payer source. Eastman, GA-based Three Rivers Home Health Services discharged 37 patients, about 7% of overall caseload, says Kaye Smith, RN, director of clinical services and co-owner. The agency found other skilled needs or payer sources for many other venipuncture recipients.

With no mobile labs in her rural service area, Smith says, the discharged patients will likely not receive home venipuncture. She attributes five rehospitalizations and one death to the benefit change.

Once again, mixed messages

Providers complain that conflicting messages from HCFA and its fiscal intermediaries confound their efforts to keep patients on service. HCFA officials say that providers can qualify venipuncture patients with management and evaluation or observation and assessment codes. Certain fiscal intermediaries, however, warn that claims attempting to qualify venipuncture patients under other codes will be denied, or in the case of management and evaluation and skilled observation, used only briefly.

HCFA reportedly sought venipuncture elimination out of a general concern about home health aide overutilization but did not specifically study its impact, says Eric Sokol, assistant director of government affairs for NAHC.

Reacting to constituent and industry concerns, U.S. Rep. Nick Rahall (D-WV) requested a Congressional Budget Office (CBO) review. CBO preliminarily estimates that eliminating venipuncture will save Medicare $140 million annually. With inflation factored in, CBO calculates a $1 billion five-year impact, or 6% of the overall $16 billion projected five-year home health-related BBA savings.

There is little impetus for change

After strong protests from both constituents and industry representatives, several members of Congress introduced bills to nullify or delay the BBA venipuncture provision. HR 3137 and S 1580, introduced by representative Robert Aderholt (R-AL) and senator Richard Shelby (R-AL), respectively, each call for an 18-month implementation delay. HR 2912, introduced by representative Rahall, would repeal the provision eliminating venipuncture. All three bills require a study of the venipuncture home health benefit and a report to Congress. At Hospital Home Health press time, HR 2912 had the most co-sponsors (96). A house majority requires 218 votes.

Despite some congressional support, sources say action during this session's remaining 45 legislative days is unlikely. Republicans and Democrats are loath to amend the hard-negotiated landmark BBA, says Sokol. And with highly publicized fraud cases and reports of explosive home health growth, Congress and White House officials remain suspicious of industry-claimed patient and agency harm, he adds.

Strategies to help turn the tide

Given those obstacles, providers may feel powerless to cause any changes. But a panel speaking at NAHC's policy conference urged agencies to keep the heat on and offered the following strategies to restore the venipuncture home health benefit:

· Involve all agencies.

Although the venipuncture elimination primarily impacts patients in Southern and largely rural states, NAHC representatives urge all agencies to adopt the issue. Many believe it is the first step in eliminating other Medicare benefits.

"It's the camel's nose under the tent. It will be something else next year," says Billy Eley, executive director of Alabama Association of Home Health Agencies in Montgomery. Some legislators reportedly believe Medicare has far exceeded its original acute care mission and plan to chip away other benefits in the future, Sokol adds.

· Couch impact in terms of beneficiaries.

Providers speaking with legislators and HCFA officials should focus their appeals on patients, sources say. Discussing agency closings, downsizings, and layoffs will not engender much sympathy given the general negativity surrounding home care.

· Urge patient participation.

Although the Alabama Association of Home Health Agencies hit the streets early and hard after the BBA's August 1997 passage, its initial public education efforts generated little interest. Eley believes the lackluster response was caused in part because "venipuncture didn't have a face on it." The association has since videotaped beneficiary testimonials about the loss of venipuncture, attracting much more interest and support.

"Unfortunately, Congress is a reactive body, [and unless we] get constituents to make noise, there probably won't be any changes," says Sokol.

· Quantify impact.

Panelists urged providers to track dis-charged patients' status and report their findings to NAHC, HCFA, and Birdie Kyle, legislative director for Rahall in Washington, DC. Panelists acknowledged that with limited agency resources, this extra effort may be challenging. However, they stressed its importance in the overall effort to restore venipuncture benefits. Some agencies have enlisted nursing students and other volunteers to follow up with discharged patients and their families.

· Educate state officials.

Several sources suggested making a case for venipuncture reinstatement through state officials. Outlining the impact of the provision's repeal on state coffers, through increased Medicaid-funded hospital and nursing home admissions may push state representatives into action.

· Enlist support from other senior groups.

Panelists urged agencies to involve other senior associations whose members may be adversely impacted by venipuncture's repeal, such as the American Association of Retired People and National Council of Senior Citizens. A multi-level grassroots campaign will improve the initiative's chance of success, they say.