What are the latest legislative actions from the 106th Congress?

Who’s minding your business on the Hill?

By no means have the ill effects of the Balanced Budget Act of 1997 been rolled back for home health care, but the industry has made some significant strides in the House and Senate during the 106th Congress.

"Congress has come to the realization that it cut too much," says Eric Sokol, deputy director for government affairs for the National Association for Home Care (NAHC) in Washington, DC. "So I think there is currently an appetite to provide home care with some type of relief. [But] in what facet? That remains the question."

At the beginning of this year, he explains, the home care industry received a message from Congress that it "wanted to see home health working together." The result, Sokol says, has been a list of five or six key provisions that would be necessary for a comprehensive home health relief bill.

"Now we have a lot of bills that encompass one or two or even three of the provisions that the industry has identified. Each bill brings its own piece to the puzzle," he continues, "and we want to give the Senate Finance and Ways and Means [Committee] the raw pieces with which to cobble together a comprehensive bill."

The Home Health Access Preservation Act of 1999 (HR 1917), sponsored by Reps. Jim McGovern (D-MA), Tom Coburn (R-OK), and Robert Weygand (D-RI), is one such example, says Ann Howard, executive director for the American Federation of Home Health Agencies in Silver Spring, MD. "This bill moves in the right direction," she says, referring to its provisions allowing providers three years in which to make interest-free overpayment repayments and providing home care with $250 million in outlier payments over three years.

Even so, Howard expresses concern about the overall uncertainty of outlier funding. "Agencies won’t know if they’ll get paid up front or how much they will get paid. What’s more, this bill doesn’t focus on agencies that, without these payments, wouldn’t be able to care for these patients."

Rep. Bill Coyne’s (D-PA) bill, HR 2240, the Medicare Home Health Access Restoration Act of 1999, also scores high marks with both Howard and Sokol.

Yet Howard, who admits to liking this bill "a lot," would prefer that "[Coyne] not tinker around with the upper per-beneficiary limits. It increases the lid for agencies under the national average to 90% in 1999 and up to 100% in 2002. But the problem I have with this is that new home health agencies have problems that are just as serious, and in some states, more serious than older home health agencies. I think if you’re increasing the per-beneficiary limits for older agencies, you should also do it for the newer ones.

"They [home health agencies] need relief, and this provision isn’t it. Whenever you start fooling around with per-beneficiary limits for old agencies that are above the per-beneficiary limits I get nervous because you don’t know what they will come up with next," she adds.

The best bill in the House, according to Howard, is Rep. Bernie Sanders’ (I-VT) HR 2361, the Medicare Home Health Care Restoration Act of 1999. "It eliminates the whole interim payment system [IPS]," says Howard. "But is it politically feasible? No, but we like it anyway."

On the other side of the congressional floor, the Senate has been hard at work drafting pro-home care legislation. S 1310, the Home Health Equity Act of 1999 sponsored by Sens. Kit Bond (R-MO) and Susan Collins (R-ME), seems the best offering to date.

"What’s not to like about it?" asks Howard. "I hope it has a good chance of passing, but it’s up to us to increase those chances."

Sens. James Jeffords (R-VT) and Jack Reed (D-RI) have also made some significant strides with the introduction of S 1358, the Preserve Access to Care in the Home Act of 1999 (PATCH). Reps. Bob Riley (R-AL) and Bob Etheridge (D-NC) recently introduced the companion bill HR 2546, which is identical in language to that of S 1358.

This bill would establish a waiver of per-beneficiary limits for individual outlier patients based on criteria established by the secretary of Health and Human Services, among other provisions. The problem with that, Howard points out, is that "the secretary would get to define the terms and what those terms would be are vague."

Late entrants

Sen. Connie Mack (R-FL) has joined the fray with his Medicare Home Health Beneficiary Equity and Payment Simplification Act of 1999 (S 1414).

This proposed piece of legislation takes a new look at the old problem by creating four patient categories each with a specific payment. "The home health agency would then receive one payment up front according to whatever category the admitted patient is in," explains Howard. "That’s it for the year, and that is a great cause for concern. What happens when a person’s status changes?"

Those categories are:

1.Post-hospital short-stay beneficiaries.

These are people who have had one hospitalization in the two weeks prior to admittance to the home health agency and have had at least one illness or injury which is postoperative or post-trauma. The patient must have a prognosis of prompt and substantial recovery, says Howard, who notes that the wage-adjusted reimbursement level for this is $2,603.

2. Medically stable, long-stay beneficiaries.

These patients haven’t been in the hospital within the six months prior to admittance to a home health agency and have one or more illnesses or injuries requiring medical treatment and have one or more activities of daily living (ADL) deficiencies, says Howard. The reimbursement is $3,335 (wage-adjusted).

3. Medically complex, long-stay beneficiaries.

Patient has had two or more hospital admissions within a year prior to admission, one or more illness or injury that required acute medical treatment, and one or more ADL deficiencies. Wage-adjusted reimbursement is $4,228.

4. Medically unstable and complex high-use beneficiaries.

These people, says Howard, have had two or more hospitalizations within the six months prior to admission, at least one illness or injury requiring acute care, and two or more ADL impairments. Wage-adjustment payment for such patients is $21,864.

"It’s a rather crude division of categories," Howard points out, noting the gap between the third and fourth levels. "I’m not criticizing the bill, it’s just that we’d like to see it attached to the Collins/Bond and Jeffords bills with the best of all three."

The latest entrant in the legislative race to save home care is HR 2628, the Medicare Home Health Services Equity Act of 1999, which was introduced by two Republican congressmen from Oklahoma: J.C. Watts and Wes Watkins. This proposed legislation would eliminate the 15% reduction and would offer home health agencies retroactive relief from IPS overpayments. The bill would specifically prevent the Health Care Financing Administration (HCFA) from demanding reimbursement of any overpayment accrued prior to the fiscal year in which the agency received actual notice from HCFA as to its per-beneficiary limit.

The Watts bill also provides several redresses for per-beneficiary limits whereby exceptions would be granted for agencies that can prove they provide care in medically undeserved areas or act as the sole community provider.

Agencies able to prove that they have incurred reasonable costs above the approved per-beneficiary limits would also be granted exceptions provided they are able to show that these additional costs were attributable to additional regulatory burdens established after FY 1994. Per-visit limits would be increased to 108% of the median, and patients would be allowed to choose their own home health care provider by forcing HCFA to develop a means of prorating the per-beneficiary limit should the patient choose another agency.

Future prospects

According to Howard, there seems to be more ground for consensus on the Senate than in the House. No matter the location for consensus, Sokol stresses that each bill has its merits and "all help home care to varying degrees. We want to embrace all of them in hope that they provide the raw materials for a comprehensive bill."

Rolling back the tide of anti-home care legislation must be looked at as an evolving process, says Sokol. "Ultimately, whatever they [Congress] do won’t be enough or solve all our problems, but I think we are in line to receive at least some consideration.

At this point, the squeaky wheel gets the grease, and so I would encourage agencies to contact their members of Congress and present anecdotal evidence as to access problems and beneficiaries who haven’t been receiving the same level of care to which they are accustomed.

"We need to make this as beneficiary-centric as possible and put a human face on the issue," he says. "Whoever shows the most pain will be farther up in the receiving line."