Just how does HCFA define 'balanced'?

Not the same meaning as the word in the dictionary

By Susan Craig Schulmerich, RN, MS, MBA

Executive Director

Montefiore Medical Center Home Health Agency

The word "balanced" as defined by The Random House College Dictionary is: "being in harmonious or proper arrangement." There has been great fanfare and rhetoric about how fortunate the American people are to have the first balanced budget in 30 years. This is true; however, is a balanced budget counterbalanced at the expense of the medically frail and elderly worth the sacrifice?

With the advent of Medicare and Medicaid in 1965, the federal government changed the landscape of medical care for the elderly and indigent. This change was made with little forethought as to the potential for fraud, abuse, and misuse of a program that was intended to better the lives of so many Americans. Unfortunately, unscrupulous, unethical, and unprincipled charlatans have denigrated the reputation and good work of those providers who are engaged in providing health care to the medically needy. As is common in bureaucratic circles, a broad brush is used to paint a picture of widespread fraud and abuse in the Medicare home care industry. Without a doubt, there are fraudulent, abusive providers working in the community, but they are in the minority. They deserve the harshest of punishments; however, the Balanced Budget Act of 1997 will have calamitous effects on more than just the unethical agencies. Among the casualties will be patients and their families as Medicare home care programs are chaotically dismantled.

Montefiore Medical Center Home Health Agency, the first hospital-based home health agency in the United States, is faced with serious - perhaps terminal - financial consequences as a result of the BBA. The ability to meet patient needs will be severely compromised under the onerous provisions of the BBA. As a result of all the effects of the BBA, there are estimates within the home care industry that 50% of the agencies currently operating will be out of business by year's end. Truthfully, that is a conservative estimate.

Over the last decade, home care has been the vehicle by which thousands of elderly people have avoided nursing home placement. Home care has provided the elderly with a means to maintain their dignity and delicate independence; it has allowed them to make their own decisions and direct their own destiny; it has permitted them to remain in the safety and comfort of familiar surroundings: the home.

One measure of the success of a society is how it treats its older members. The BBA, in its present form, is a scathing indictment of a society that has lost its compassion, understanding, and appreciation for its elders.

The members of the Senate Finance Committee need to put themselves in this position: an octogenarian, mentally competent, and self-directing, with incapacitating rheumatoid arthritis of the hands and a neurogenic bladder that requires twice a day straight catheterization in order to empty accumulated urine. The patient is not physically able to perform the procedure, while the only relative, a daughter, approaching Medicare eligibility, lives in another state and works full time. For 31¼2 years, home care nurses have visited the patient every day, twice a day, to perform the procedure. The patient has never had a urinary tract infection while on home care. A home care agency caring for patients with needs such as these will not be adequately reimbursed under the BBA. In fact, at some point, there would likely be no reimbursement.

Who's discriminating?

An undated letter from Nancy-Ann Min DeParle, Administrator of HCFA, sent to all home health agencies serving Medicare reads in part, "HHAs [home health agencies] in Medicare are not allowed to discriminate against Medicare enrollees. If an HHA accepts non-Medicare enrollees at a given level of severity, it must also accept Medicare enrollees at similar levels of severity. HHAs that provide services to non-Medicare patients while refusing services to similarly situated Medicare patients risk having their provider agreements terminated and being barred from billing Medicare."

If an agency cannot discharge a patient because a payer decides not to pay for care provided or an agency cannot avoid the admission of a patient it knows it will not receive adequate reimbursement for, how long do you think the organization will stay in business? Actually, Min DeParle's letter could be interpreted to be in violation of the Constitutional Amendment prohibiting involuntary servitude. It would seem that she misses the point that other payers pay for care rendered.

Should a patient be forced into a nursing home to receive care that can be provided efficiently and effectively in the community? Is there enough capacity in the long-term facility to absorb the influx of thousands of patients? Will there be sufficient beds available in acute care hospitals to accommodate increasing lengths of stay as postacute institutional services are sought for patients that heretofore would have been discharged to home care? After the Medicare nursing home benefit has been exhausted, Medicaid tax dollars will be used to pay for nursing home costs. Where are the savings?

And most important, where is the harmony and proper arrangement in the Balanced Budget Act of 1997 for the elderly of this country?