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Experts share their insights
With the century coming to a close, it just wouldn’t be complete without a look at the home health industry and how it has fared over the past 100 years. Because hindsight is 20/20, Hospital Home Health asked a few experts in the field to talk not only about what they felt were the most important events or changes to hit home care in the past century, but where they saw the industry headed. Here’s what they had to say:
- Jo Burdick, RN, MSN, executive director, MeritCare Home Care, Fargo, ND
"Cars. Truly, if we’re talking about the century and the delivery of home care, without them we wouldn’t have the home care we have today. Things like the BBA [Balanced Budget Act of 1997] and IPS [the interim payment system] are dramatically impacting us now, but I don’t feel they are any comparisons in terms of overall impact to what happened [at the beginning of this century]. Without the car, if nurses were going to make home visits, they were either walking or taking a horse and buggy, and now with our portable technology it allows for a much greater range of services.
"As for the future, I think home care will be fine. [The prospective payment system is] a huge bump in the road, but people who know home care know we can’t live without it and we will find ways to make the industry work. If you don’t think that’s the case, then I would say you have larger challenges in your agency as far as reorganization. You need then to look at what you need to do and get out there and do it.
"For years I think too many home care agencies have been living beyond their means, and many have been doing so — well beyond their means. Certainly, there will be challenges, and I hope that we as an industry don’t have to decrease access to care.
"A study has shown that a greater number of home care visits doesn’t necessarily equate with better outcomes. We have an average of about 30 to 40 visits per beneficiary as opposed to a much higher national average. So while other agencies have been drastically hit, we’ve had to change very little, and I know that we will be OK."
- Elizabeth Hogue, JD, Elizabeth Hogue Chartered, Burtonsville, MD
"I think the biggest development in the last century has to be the development of the Medicare home care benefit. It created a huge momentum for the industry development as well, in many respects, as acting as a stone around the neck of home care providers. When the history of home care is written, it will be very interesting to see how the role of the Medicare home care benefit, especially in view of BBA, will be evaluated. I think it will show that we took a detour from the path that we should have taken.
"With respect to the future, it is absolutely out of sight. I go all over the country saying that to people, and sometimes I’m not sure they believe me. But from my perspective, home care is the answer. Every sign I see points to that conclusion for the future. The entitlement mentality that our parents have doesn’t exist in the baby boomer generation.
"They have money, and the thing they are most willing to spend it on is health care. They will demand to remain at home and won’t go quietly to nursing homes. I regret a lot of the extreme language that we are still seeing in the home care press talking about devastation and demolition. It’s true that a lot of agencies have gone out of business, and I deeply regret that. But, on the other hand, there are some very strong home health agencies that are almost hidden at this point because they don’t want to publicly say, We’re doing great’ when others are suffering. I know there is strength in the industry and everything points to a positive future."
- Ann Howard, executive director, American Federation of Home Health Agencies, Silver Spring, MD
"I think the most important thing to hit home care in the past century was the enshrinement of home care as part of the health care continuum with the passage of Medicare in 1965. That was the best thing to happen. The worst thing, I would have to say, is the Balanced Budget Act of 1997.
"As for the future, home care has some very severe problems, which need to be addressed legislatively, or its benefits could become shadows of their former selves. I hope Congress will come to its senses and see the imperative to putting resources back into home care. Ultimately, the health care delivery system will move back into the home because it’s clinically and economically the most effective and absolutely consumer-preferred. I think there is need for home care, and it will always be here. It’s just going to be a rocky road getting to the top."
- Larry Leahy, MHA, CHCE, director of program integrity, Beaumont Home Health Service, Victoria, TX
"The most important was the Medicare benefit. Without that program, we would not have had the growth in home care. The second most important thing is the BBA, which cut the Medicare benefits down. So really, Medicare has proven to be a double-edged sword to some extent. When doing residency in early 80s, prior to DRGs being implemented, home care was still very small. The Medicare benefit has been the most important item to help — and sometimes hinder — the industry.
"My opinion is that the home care industry is becoming the locus of health care in the 21st century. I base this on technology advancements and cost. A couple of weeks back, [National Public Radio] had a feature on the differences on end-of-life care and the costs of that care throughout the United States. From the statistics, the areas of the country that have lower costs are the ones that are emphasizing home and hospice care. It used to be that Americans would spend 85% of their health care Medicare benefit dollars in the last three months of their life because you went into hospital and stayed in intensive care until you died.
"It’s gotten somewhat frustrating in that if Medicare is to survive to 2050, you can’t do it through the traditional acute care systems. Home care should be the center. I think it will bounce back but will look different with fewer freestanding agencies and more of a business focus along with the caring focus and a tremendous amount of technology that will be developed to care for patients at home."
- Dan Lerman, MHSA, president, Center for Hospital Homecare Management, Memphis, TN
"I would definitely say it is the government’s reimbursement of home care services, meaning not everyone needs to pay for it out of pocket. Now this is being expanded with reimbursements from a growing segment of nongovernment insurance programs. As for the future of the industry, I think hospital home care is in the middle of a two- to five-year cycle of contraction but that afterward it will be bouncing back for the long term. I see a tremendous upside to growth."
- Susan Schulmerich, RN, MS, MBA, executive director, Montefiore Medical Center Home Health, Bronx, NY
"I’d have to say it was the enactment of Medi-care and Medicaid in 1965. The reason we are even dealing with the BBA is because of what happened then. Prior to 1965, there were vast segments of the population who needed home care but had no access to it.
Turning point for home care relief
"I think in the year 2000 the turning point is going to occur for home care relief and from the effects of the BBA, and I suspect that what will happen is another growth spurt in home care utilization. In part because of the baby boomers, but I also think that will be a matter of a certain relaxation or relief from the scrutiny and the dissection of the industry by government and HCFA, in particular. Much as what happened when the Stark lawsuit was settled, agencies will once again not be intimidated into not taking patients that are too costly."
- Greg Solecki, vice president, Henry Ford Home Health, Detroit
"My immediate knee-jerk response has to be the involvement of Medicare that came about in the 1960s, for better and for worse. Unfortunately, we are experiencing the for worse’ right now. When Medicare expanded to the home health benefit and said it no longer required prior hospitalization, it created a niche that allowed home health to be accessible to broader markets.
"As much as I hate to admit it, it has infused certain safeguards for quality and how we make sure providers are doing a quality job. I do think, still on the positive side, it could have a very promising future if [Health and Human Services] and Congress were to finally get the strategic importance of home health care.
"Medicare’s involvement has a huge impact on the industry and when we began to see the growth, it became more mainstream and wasn’t a cottage industry hidden away; it made the industry more visible.
Overdependent on reimbursement?
"As for the for worse’ side, our industry has become so dependent on Medicare reimbursement that I’m afraid it’s defined itself in Medicare terms. I often hear managers and nurses say they can’t visit a patient because there’s no skilled care. The fact is that our business is to provide care in the home and if the patient wants us to do it, we should do it. How they pay for it is the patient’s issue.
"I don’t think as an industry that we can say that since there’s no skilled care needed and they’re not homebound, we can’t provide home care for a patient. The answer we should be giving the patient is that your insurance — in this case, Medicare — may not pay for this. It’s a very subtle nuance, but I think we’ve missed that nuance.
"On the for worse’ again, unfortunately with Medicare, conditions of participation have increased almost exponentially in terms of the number of standards and things that are looked at. It’s also increased the cost considerably as the government continues to add OASIS [Outcome and Assessment Information Set] and 485s and two-week documentation of supervision. These are all things that increased administrative costs but the success of reimbursement is contingent upon keeping A&G as low as possible and putting money into discipline-specific reimbursable care. But to keep up with these increasingly stringent conditions of participation, we have increased the cost and we may end up pricing ourselves right out of the market. How long before it’s cheaper to send a patient to a nursing home?
"I think the Medicare program has become a behemoth that we don’t know how to extricate ourselves from. Our industry has become so inextricably intertwined with our industry’s paradigm of what service should be, that it almost has become impossible to separate the two.
"There are some who feel that if home health care weren’t provided by a Medicare agency, the patient is being robbed. I contend that patients can get top-notch home health care regardless of whether an agency does an annual program evaluation, especially where there are other checks and balances in place like in a hospital home care agency.
"OASIS is the worst thing that has ever happened to our industry. It will give us data that may bear out in the end for the industry, but it’s like killing a mosquito with a blowtorch.
"As for the future, I think that with the advent of Medicare+Choice programs, we’re beginning to see a refreshing departure from the obstructed Medicare approach. I think if the new programs are continued to be given a certain degree of freedom it can give us a refreshing departure.
"Those providers that are strong and expert will find ways to provide their value-added care through arenas other than those which are Medicare-certified. I think we’ll see an increase in private pay opportunities. We Americans have discretionary income. We see Americans pull $5,000 out of their pockets for liposuction, and those with discretionary spending abilities will spend money on the home health care that Medicare won’t provide.
"Initially with managed care programs, we’ve seen the emergence of home care light, and I think that in the future we may see home care gold, a different and better type of home care that may even be reimbursed by Medicare. From the integrated delivery system perspective I see a lot of promise, despite the naysayers who feel BBA has finally enlightened hospitals as to the foolhardiness of having their own home health care centers.
"We’re beginning to see some progress, and BBA was a temporary setback. It’s about evolving into a mindset of the right care at the right place at the right time for the right money."
• Jo Burdick, RN, MSN, Executive Director, MeritCare Home Care, 720 Fourth St., Route 103, Fargo, ND 58122. Telephone: (701) 234-4892.
• Ann Howard, Executive Director, American Federation of Home Health Agencies, 1320 Fenwick Lane, No. 100, Silver Spring, MD 20910. Telephone: (301) 588-1454.
• Larry Leahy, MHA, CHCE, Director of Program Integrity, Beaumont Home Health Service, No. 1621, 1501 Mockingbird Lane, Suite 404, Victoria, TX 77904. Telephone: (361) 578-0762.
• Dan Lerman, MHSA, President, Center for Hospital Homecare Management, 111 S. Highland St., Suite 286, Memphis, TN 38111. Telephone: (800) 266-3583.
• Susan Schulmerich, RN, MS, MBA, Executive Director, Montefiore Medical Center Home Health, 1 Fordham Plaza, Bronx, NY 11001. Telephone: (718) 405-4400.
• Greg Solecki, Vice President, Henry Ford Home Health, 1 Ford Place, 4C, Detroit MI 48202. Telephone: (313) 874-6500.