GAO report tells only one side of IPS story

Is the government dishonest or just in denial?

In September, when the Office of the Inspector General’s General Accounting Office (GAO) released its study, Medicare Home Health Benefit: Impact of Interim Payment System and Agency Closures on Access to Services, the findings came as no surprise to either the Baltimore-based Health Care Financing Administration (HCFA) or home health care professionals.

On one hand, there is HCFA, which agreed with the report’s conclusion that it’s difficult to single out just how much effect any one factor — such as the interim payment system (IPS) — had on agency closings. The findings, says Thomas Hoyer, director of the Chronic Care Purchasing Policy Group for the organization’s Center for Health Plans and Providers, "certainly reflected the understanding that I have derived. The primary reports are that the distress is being felt primarily by agencies and not customers."

On the other hand are home health care industry professionals who weren’t shocked by the GAO’s findings, not because they agree with them, but rather because "you can always create a report to come up with a consensus on your existing position," says Michael Sullivan, executive director of the Indiana Association for Home and Hospice Care in Indianapolis.

Presentation counts

Sullivan says he isn’t putting much stock in the GAO’s findings because he doesn’t have any faith in the survey itself. "This is about the poorest tool I’ve ever seen. The GAO should be embarrassed," he says.

"The questionnaire was so poorly done that [the GAO] had to go through and add in percentage signs and yes’ and no’ check boxes by hand on every page. It was a joke. If this was a ninth-grade report, they would have failed," he adds.

It wasn’t only the form that Sullivan says gave him second thoughts about the report’s veracity. Also troubling to him was that the GAO faxed the form to hospital discharge planners and also to local agencies on aging. "[Those local agencies on aging] have nothing to do with placing a Medicare patient with a home health agency," he says.

Even more disturbing was that the GAO wanted a one-day turnaround on the response. "They were asking for information on how many Medicare patients the hospital discharged last year, what percentage was discharged to home health care, how many Medicare-certified home health agencies were in the area, and for a list of all of them to be faxed in with the response. They were asking for information that you just don’t have sitting around on your desk," he says.

GAO defends report

Hoyer defends the report. "This is one of those times when everyone wants to know today what they will know next year. I think the GAO did the best with the time it had, and I think it made a good contribution. [The agency] was asked to do a study in a hurry, and it acknowledged its limitations and reported it with full disclosure. I think the quality of the report is laid out in the context."

Sullivan says he isn’t buying it. Nor is he the only one irritated by how the GAO report came to its conclusions. Anita Bradberry, executive director with the Austin-based Texas Home Care Association, says she was surprised that "they didn’t interview any physicians." More than that, she says she believes the report’s timing was way off. "They certainly didn’t take into consideration that the agencies haven’t received any demand letters yet," she says, adding that she believes once Texas agencies have received them, along with their new per-beneficiary and per-visit rates, "there will be a drastic reduction in the number of agencies as well as patient access."

Home Care Association of New York State (Albany) executive director Carol Rodat agrees. As she sees it, "the GAO took a snapshot at a point in time that was too early. Agencies aren’t feeling the effects yet. I think we’re really going to see them [at the end of the year]; people are waiting until Congress recesses to make the big changes. When agencies have field-cost reports and start receiving feedback on how much they owe, that’s when you may really see the doors close."

John C. Gilliland, a health care attorney based in Crestview Hills, KY, agrees with the report’s findings — up to a point. "The sickest patients aren’t being treated now," he says, adding the clarification "because agencies can’t afford to treat them."

Similarly, Rodat has found that patient access to home care has become increasingly problematic. However, she believes the issue lies not so much with how many agencies have closed, but rather how many are left open and accepting new cases.

The latest figures from the National Association for Home Care in Washington, DC, and other trade groups such as the American Federation of Home Health Agencies in Silver Spring, MD, and the Home Care Association of America in Washington, DC, show that approximately 1,200 agencies nationwide have shut their doors.

"In truth, I think agency growth had gotten out of hand, but I don’t think we have data that definitively answer the GAO questions. I don’t believe that numbers alone are [proof] of whether there is an access problem. You could have a rural area, for example, with two providers but neither is taking wound cases. That’s an access problem in my belief," she says. "I think that without question there are access problems for patients."

Where did these numbers come from?

As for Sullivan, he says he wonders where the GAO came up with its findings on agency closures. "I don’t know if it was the OSCAR file or what, but they didn’t even call the Indiana Department of Health to get the official list of agency closures. [OSCAR, a HCFA database, is an acronym for Online Survey, Certification and Reporting System.] They’re the ones that are responsible for licensing and certifying agencies in the state, and they count 35 as having closed. The GAO went to another source and came up with 11."

No one in the home health industry would argue that agencies are the ones bearing the brunt of the IPS burden, and there’s a strong belief that as agencies suffer so do the beneficiaries. Perhaps an even stronger sentiment is that as IPS settles in, the problem posed to both agencies and Medicare beneficiaries will only grow.