Consumers as victims of health care system

By Cathy Frasca, RN, BSN, FACHCA

Vice President, Home Health Services

South Hills Health System

Homestead, PA

Consulting Editor, Hospital Home Health

(Editor’s note: Hospital Home Health Consulting Editor Cathy Frasca, a leader in the home care industry as head of a large hospital-based home health agency, takes on the Clinton administration, legislators, and payers on behalf of consumers.)

The government struggles to save Medicare and reduce the federal deficit. Providers ratchet down their costs to meet increasing payer demands and expectations. Yet something important is being overlooked in all this clamor to reform the health care system: the consumer.

Key players espouse the need and right for consumers to have a choice in their health care delivery system. But as managed care continues to evolve into the dominant model, the only choice the consumer will have is to select their payer. All other choices, including their physician, hospital, home care, and other care and services will be confined to those within that payer’s direct control.

Consumers are becoming victims of the very industry that is supposed to care for them.

On the surface, many insurance plans appear to meet all consumer needs. But, unfortunately, plans have a tendency not to invest in health promotion and wellness at one end of the spectrum, and long-term care at the other end. As a health care professional with a chronic heart condition, I had requested authorization from my HMO for cardiac rehab services to prevent the need for a third angioplasty. (I had already received two angioplasties within four weeks one year ago and wanted to avoid the need to repeat this costly procedure that had required a one-week inpatient hospital stay with each of these procedures.)

Even though my primary physician and cardiologist had both agreed that cardiac rehab was indicated, the medical director of my managed care insurer determined that this was not necessary unless I had a heart attack or required another angioplasty or open-heart surgery. So even though cardiac rehab would be the least costly route to take, my insurer, like most HMOs, is not geared toward health promotion and wellness care, but only toward illness.

My choice of physician and hospital are restricted to those who are in my managed care plan. I have the right to change my insurer, but am reluctant to do so at this time as I am not certain what restrictions may be imposed upon me by another HMO. I am confident that no matter what plan I choose, the focus will be directed only to illness rather than wellness.

How would Medicare patients cope?

I use my situation as one example of how a seasoned health care professional as a consumer was unable to influence an HMO to accept health promotion and wellness as a covered service. How would a typical Medicare patient cope with this type of situation? They would most likely do whatever their primary physician would advise, and ultimately whatever their HMO would agree to cover.

Prior to the 1996 election, President Clinton had been viewed as the candidate who would preserve and protect the Medicare program. Dole lost that election primarily because he was viewed as a danger to preserving the Medicare benefit. Home care, one of the least costly and most effective health care delivery systems, had strong bipartisan support prior to the presidential election. After the election, this support immediately began to erode through proposed changes in the Medicare home care benefit, such as the current push to move the home care benefit from Part A to Part B.

Co-insurance is another change that would deny coverage to our most vulnerable elderly population. This also would place an unnecessary risk and costly burden on home care providers, who would have to collect these fees.

Even though Medicare home care expenditures represent only a small fraction of total health care expenditures, and even though family support systems supplement home care services at no cost to taxpayers, home care has become a target for unrealistic cost reductions. It is assumed that consumers are ill-prepared, unwilling, or unaware of these proposed changes and will not fight this until it is too late to do so.

A giant step in the wrong direction

Government pressure to ratchet down the Medicare home care cost caps and require a costly prior hospital stay to qualify for home care services is not only a significant step backward, but also is another way of denying access to home care services to the most vulnerable of our population.

Congress and the Clinton administration justify clamping down on home care because of the cases of fraud and abuse. This is most unfortunate. The unscrupulous few who abused the system should remain in jail forever. But the government played a part in this scenario, too. After all, fiscal intermediaries paid the claims.

For example, when the average number of visits per admission nationwide had been around 15-40 and the abusers generated several hundred visits per admission for similar diagnoses, some action should have been taken then. I know many colleagues who reported these abuses to deaf ears. Now we all suffer with inappropriate restrictions that will hurt the consumer most of all. Many Medicare beneficiaries are unaware they will be required to pay more out of pocket for fewer home care visits and other needed health care services.

There is a misconception that the elderly can afford to pay more out of pocket for their health care services. "Spending down" into poverty has happened far too often through the years to elderly people who did have large amounts of money that was eventually consumed by costly nursing home stays. The primary reason is that our government has never recognized long-term care as an acceptable need for reimbursement under the Medicare program. Now, to add insult to injury, the government is denying access to the most needed, least costly health care delivery system — home care.

As a home care provider and a Medicare-eligible consumer, I would urge my colleagues to help consumers help themselves by preventing any cost reductions in home care coverage. A large amount of federal dollars is being directed to government-owned and funded health care systems that compete directly with the private sector. I believe that our veterans, active military personnel, and Native Americans, currently served through health care systems funded by the federal government, should have the right to choose their health care services wherever they desire. Many are currently subsidizing their health care in the private sector.

We will find that billions of dollars can be saved through reductions and possible eventual elimination of the military, veterans administration, and Native American health care systems.

Who represents the patients?

Why are any of us in health care in the first place? It used to be to meet the needs of our "patients" (now referred to as customers, clients, and consumers). Who truly represents the interests and needs of our patients today? Too many providers are concerned about meeting the needs of other "customers," such as the payers, physicians, regulators, other providers, etc. We need to get back on track and convince all key players (including the government) that the patient is our primary "customer" and meeting total patient needs must be our primary goal.

Yes, efficiency and cost reductions are necessary, but these cost reductions should be directed away from home care, which has been proven to be the least costly, most effective health care delivery system. And, the home is the preferred site of care by the majority of consumers — especially the elderly.

Let’s work with each other — payers, providers, physicians, regulators — to redirect our focus to health promotion and wellness, so the Medicare population of years to come can contribute as useful members of society as long as possible.

Why not bring the consumer into the planning process to ensure that their rights are truly preserved? Consumers need to be protected and supported so they will no longer be victims of our changing health care system.