GW study shows home care in sharp decline
GW study shows home care in sharp decline
By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON Home health advocates are hoping to get significant mileage from a major study by George Washington University’s Center for Health Services Research and Policy that shows a beleaguered home healthcare industry in the wake of the Balanced Budget Act of 1997 (BBA). "This is the first evidence we have seen of an imploding benefit," said Home Health Services and Staffing Association (HHSSA; Washington) counsel Jim Pyles. "The GW study shows that patients who need the care the most are simply going without it because agencies are laying off staff."
The study’s lead author, Barbara Markham Smith, detailed the study’s findings, which she had previewed earlier in the year before the Senate Permanent Committee on Investigations, at the National Press Club in Washington, DC, Sept. 14. The study, which was funded by HHSSA and the National Association for Home Care (Washington), examined 28 home health agencies from nine different states.
The study concluded that Congress should postpone the 15% cut scheduled for Oct. 1, 2000, until definitive data on the effects of the current reductions can be assessed. In her remarks, Smith pointed out that the Congressional Budget Office included that 15% reduction in its original projected BBA savings of $16 billion over five years. The CBO’s revised estimate is now $48 billion.
Overall, the number of Medicare beneficiaries admitted to care among the agencies studied, as a percentage of all patients, has declined 21% since 1996. Medicare 1998 revenue among the agencies studied has declined by 25% from 1994 levels reflecting lower payments and utilization for Medicare beneficiaries.
According to Smith, the BBA has resulted in certain efficiencies in the delivery of home care. Such as more case management, higher levels of nursing supervision, more goal and outcomes orientation with patients, encouragement of greater patient independence, and reduction of administrative costs.
But she was quick to point out that those efficiencies have been accompanied by major disruptions, as well as other unanticipated effects. For example, the new home health payment methodology is exacerbating regional variations in the health status characteristics of home care beneficiaries, even though it was designed in part to increase national uniformity, she said. This has hit home health agencies in the South the hardest because they lack the capacity to alter their case mix as agencies in other regions. As a result, beneficiaries in that region may experience more difficulty gaining access to home care services, she said.
Smith also said that as a result of changes made by the BBA, sicker patients are being discharged earlier from all components of the healthcare delivery system. That, in turn, may be leading to a patient population that is "unwanted by everyone." She added that some hospitals may soon abandon the pattern of subsidizing home health agencies that are losing money and that other types of cross-subsidization may also evaporate.
Among the study’s other major findings were these items:
• The majority of agencies participating in the study have altered their case mix or practice patterns to conform utilization to reimbursement. Diabetics, particularly complex diabetics, appear to be the most affected by changes in admission practices and reductions in the level of care.
• Chronically ill beneficiaries may experience greater fragmentation of care among providers and more disruptions in care as a result of payment changes.
• Administrative constraints on utilization may affect access by sicker beneficiaries to appropriate levels of home care.
Pyles said the study is the first and only field study that shows the effect the interim payment system (IPS) has had on patients. "It shows that no agency of any auspices are able to treat these sicker patients," he said, adding that the study’s most dramatic finding is that certain diagnoses — diabetes patients, congestive heart failure patients, chronic pulmonary disorder patients, multiple sclerosis patients — have largely disappeared from the home health patient mix. "Those patients are not there any more," he asserted. "That is dramatic.
"The fact that staffing at home health agencies between 1994 and 1998 decreased by 76% is also an astonishing finding," he added. "That reduction has occurred almost exclusively in highly specialized areas, such physical therapy and medical social work, which means that now even patients still getting care are not getting specialized care."
The researchers recommend that additional studies be completed to track beneficiaries’ ability to obtain home care and to evaluate the effects of changed patterns of care on beneficiary health status. Because of findings indicating that IPS has created distortions in utilization data, the study also warns that the prospective payment system should not rely on utilization data from 1998-1999.
In addition to postponing any further cuts, the study also recommends that the IPS be modified to adequately account for the costs of medically complex patients and that guidelines to fiscal intermediaries and physicians should be clarified to mitigate administrative barriers to beneficiary access to care.
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