Physicians begin fighting back

Is a major change brewing in home care?

The current approach to health care is inherently wrong, says Timothy Aitken, the new CEO/chairman of Clark, NJ-based Transworld Home Health Care.

Sure, managed care has helped reduce the expense of providing care to patients, but at what cost? The fact is, physicians’ hands are often tied when it comes to making decisions on patient care, relying instead on a bean counter stuck in some managed care company’s office halfway across the country. It appears some in the home care industry have had enough and are prepared to do something about it.

Aitken refers to Transworld Home Health Care as a hodgepodge of companies that are there by accident as much as anything else. The company provides nursing services, home infusion, and durable medical equipment in the Eastern United States, with hopes of increasing its market penetration there.

"Everybody pursues the almighty dollar, but health care is, dare I say it, rather different," he notes. "When you get gatekeepers sitting in their financial offices, or even worse, junior people in financial offices with little or no knowledge of health care, and they are acting as the gatekeepers to the access of health care, you’ve got a pretty crazy situation developing. I think many physicians are going to be saying ‘Why can’t we organize ourselves as the gatekeepers?’ and indeed they should."

In fact, that’s exactly what is happening. At its most recent House of Delegates conference, the American Medical Association (AMA) passed a pair of resolutions directly relating to physician control.

The resolution, passed on to the Health Care Financing Administration (HCFA), asks that all home health services not be provided to the patient until the attending physician orders the services.

This is in response to the fact that physicians find that some services are put in after the fact, Joanne Schwartzberg, MD, tells Home Infusion Therapy Management. She is the director of the department of geriatric health at the AMA. "Physicians are asked to approve the service, and they didn’t know anything about it and may or may not have felt it was appropriate."

The resolution was passed onto HCFA, which tells HITM that there is "no news" at this time on the resolution.

Schwartzberg notes that specifics would need to be worked out for any such requirement.

"What kind of documentation do you need?" she asks. "Are you talking about written documentation mailed and signed? That could be impossible, but there should be a sense of review and the medical necessity points raised before medical service is provided."

Aitken feels the recent trends in health care in general have created the problem.

"I think the problem historically is that the physicians have been driven totally by financials that said ‘admit to hospital’ because the government never gave them any alternatives," he says. "But if you say ‘admit where you think is appropriate,’ then ‘admit to home’ would be considerably more appropriate than admit to hospital [in many cases]."

He adds that the key to home care continuing its growth and importance in the face of the changing economics of home care is to deal with patients with higher and higher acuity.

"That necessarily means infusion," he says.

AMA not done yet

Schwartzberg notes that the AMA House of Delegates recently adopted a report titled "On-site physician home health care." The report addresses the need for physician house calls, so attending physicians can see first-hand what is happening with the patient, rather than relying exclusively on a paper trail or telephone contact.

"Physicians are somewhat out of the loop in regards to what is happening in home care," says Schwartzberg. "They would like to know a little more about what is going on so they can make better decisions."

The following is just some of the information on patients that physicians would like to be provided with routinely:

• a printout of exactly what services will be provided;

• what the charges are for those services.

The report also notes that a medical director should be required for each home health agency or home infusion company.

"Basically, home health is the only kind of health delivery institution that does not have a medical director to oversee the general policies and procedures for quality improvement of the agency," she says.

She adds that such a requirement by HCFA could help reduce fraud, which is apparently number one on the agency’s recent agenda.

"I think home health is so incredibly vulnerable to fraud at this point because physicians aren’t integral in the decision making of the institution," Schwartzberg says. "The AMA’s efforts are directed toward finding a way for physicians to be available to the agencies on a regular basis. Right now, physician involvement is too distant for the kind of patients that are being cared for."