Does HCFA care much about home health?

What they don't know about the industry is scary

By Susan Craig Schulmerich, RN, MS, MBA

Executive Director

Montefiore Medical Center Home Health Agency

Bronx, NY

At a recent meeting of the National Association for Home Care (NAHC) in Washington, DC, a panel of Health Care Financing Administration (HCFA) staff spoke about the impending dramatic change that will take place in the home care industry. The changes they described, dismaying though not surprising to any of the attendees, caused a renewed and more potent fear to emerge, fueled by the panel members' inability to answer direct, objective questions. It was apparent that HCFA not only has little understanding of home care in general but also is blind to the immediate and long-term effects regulatory policy will have on the patients in our care.

When the administrator of HCFA and politicians assure our patients and their families that they "will not be affected" by the manifold changes that will occur over the next 18 months, HCFA betrays its naivete about home care. Politicians and HCFA lay the blame for what they call "grass roots hysteria" on home care providers. However, the pundits fail to realize that this is not hysteria, it is reality. If $16.3 billion is extracted from a program, there will be consequences to patients and providers. It would seem HCFA's consolidated ability to understand fundamental cause and effect is marred.

The analogies that can be drawn are numerous. Think of the industry as being placed in H.G. Wells' time machine and propelled backward in time to the witch hunts of 17th century Salem, MA. A handful of fraudulent home care providers have whipped the Puritans into a frenzy "to cleanse" the industry. Another analogy is McCarthyism's guilt by association. Notice once again, we're going backward in time.

Statements such as "40% of Medicare home care claims are fraudulent," from Donna Shalala, Secretary of Health and Human Services, have launched a crusade by elected officials to purge the industry of miscreants and scoundrels. There isn't a single reputable organization that disagrees with eliminating providers that sully and denigrate the industry. What seems to elude Washington is that the entire home care industry is being castigated for the minority. Rather than ferret out the few bad guys, the bureaucrats are trying to mangle the entire industry.

The substantive issue is money, not morals

Although centered on fraud and abuse, the issues are in substance about how much money is being spent on the Medicare home care benefit. With the advent of diagnosis-related groups (DRGs), hospitals sought methods to reduce lengths of stay. An obvious one was increasing utilization of home care.

Pre-DRGs, the potential of home care had been significantly underestimated. As new home care treatments and methodologies were introduced, the role and capabilities of home care emerged as an important element in the continuum of care. Intravenous (IV) infusions, such as Dobutamine, which had been thought of as only an inpatient administration, are now being accomplished in the home. Today, ventilator-dependent, peritoneal dialysis, and long-term IV antibiotic patients, to mention just a few, are safely and comfortably managed in their own homes, thus contributing to enormous savings for hospitals and payers.

Care at home also lessens the potential for acquired nosocomial infections and other risk reductions, which benefit everyone.

Federal legislators and HCFA have not appreciably altered the definition or the scope of the Medicare home care benefit unless forced to do so. When new inpatient treatment methods have evolved, Medicare has not had to be dragged kicking and screaming to pay for them. Why then is it so difficult for them to recognize advances in home care treatments and capabilities and to adequately reimburse providers for them? The simple response by the government is, "We can't control it." What a revelation! Perhaps the reason they can't control it is because they don't understand it.

Sitting behind a desk hundreds of miles from the point of care, regional and fiscal intermediaries make horrible decisions about coverage issues. Before denying coverage, why shouldn't the intermediaries be required to visit the homes of the patients and see for themselves the conditions patients and staff encounter every day? Perhaps they would understand it and then be able to "control it," if control is the ever-elusive answer.

The government maintains and publishes volumes of data and statistics. What don't they understand about the fact that the number of old people in the United States is increasing? Or that the same aging population consumes more health care than any other segment? The medically frail and elderly deserve and need to be cared for just as any other person would be. With the passage of Medicare and Medicaid, the federal government assumed the mantle of responsibility. This responsibility cannot be abrogated because the government "can't control it," whatever "it" is.