What’s in a word? A whole lot, if it’s homebound’
Looking ahead with fear and loathing to FY 98
Homebound. To anyone who has spent time overseas in the military, the word has a lovely connotation: You’re going home.
Then there’s Medicare’s definition of the word. It has a wholly different meaning according to Medicare policy-makers, and it’s not necessarily lovely.
A provision in President Clinton’s fiscal year 1998 budget package, the redefinition of "homebound" has both hospital-based and freestanding home care providers running for cover. Or at least to the nearest consultant for clarification.
But as the specter of Operation Restore Trust (ORT) rises menacingly over HCFA headquarters amid the cry that "the sky is falling (again)," few home care providers appear to be considering two very important people in the crowd the patient, and the hospital-based agency’s internal customer: the referring physician.
A home health management services organization in Mississippi has found a way to service the needs of both those customers with a wallet-sized card for doctors that lists key points in determining a patient’s homebound status. It helps doctors understand the business of Medicare better and ensures that patients who truly are homebound get the care they need.
Developed by Charles Homan, vice president of development at Hollandale, MS-based HealthCare Visions, a management services company, the card asks five questions of a physician who is considering referring a patient to home care. (See five-question checklist, p. 70.) The questions outline the lengthy and sometimes ambiguous definition found in Section 204.1 of the Medicare Home Health Agency Manual.
Homan’s organization sought input from other home care providers before having the card printed, laminated, and trimmed to credit-card size, which will easily fit in a physician’s or administrator’s wallet.
"What led us to develop it," Homan explains, "is that we sought a preventive measure. We realized the vast exploration of Operation Restore Trust, and we wanted to protect ourselves."
But Homan adds that the card serves as more than mere insurance against accusations of Medicare fraud.
"We also wanted good relationships with physicians; we wanted to protect them as well. After all, they are the gatekeepers. They are, a lot of times, overlooked. They are assumed to know a lot of things they don’t really have a handle on."
With the re-defining of "homebound," which critics say shrouds the issue with even more ambiguity, a brief, succinct extrapolation of the regulations is like a breath of fresh air to a homebound patient’s doctor.
Joanne Schwartzberg, MD, director of Geriatric Health at the American Medical Association in Chicago and 1988 National Association for Home Care Physician of the Year, says regulation semantics only get in the way of doctors, who, after all, are required by law to certify that a patient is confined to the home (as noted in Section 204.1 of the Medicare Home Health Agency Manual).
"Doctors are concerned with the overall health of their patients. Doctors always have trouble with obscure little Medicare regulations that don’t always fit every patient. You’re talking about people who are very frail, who are taking multiple medications, have trouble moving around." Schwartzberg says.
Doctors are wary because of the ORT initiative and because home care administrators, including some in the hospital-affiliated arena, don’t always communicate effectively with the physician, Schwartzberg says.
"Doctors can be out $5,000 a crack [in federal fines], so they are suspicious. It’s very hard to read the 485, and you’ve got a lot of agencies that assume docs know a lot [about Medicare]. Doctors have a lot of knowledge of what’s happening to the patient, but they don’t know the peculiarities of Medicare laws and homebound status," she says.
The problem is almost a Catch-22, Schwartzberg says. Thanks to improved care, the health of homebound patients improves. They get better, they walk, they want to go outside. But they are penalized by restrictive regulations.
"I don’t know how they are going to re-define homebound,’" she says. "From a physician’s point of view, it’s ridiculous. The problem is that medical care has helped people who would have died in the past to remain independent at home, but not in good health. HCFA is not quite ready to figure out what to do about these people."
But they are trying. The revised definition of "homebound" in the president’s budget proposal would establish "new criteria for determining if a Medicare beneficiary’s absences from the home demonstrate that the person fails to met the confined-to-home standard,’" reads Section 11276(g), Definition of Homebound.
"Current law allows for non-medical absences that are infrequent or of short duration. Medically related absences for treatment that cannot be furnished in the home do not affect an individual’s homebound status. This proposal requires that an individual demonstrate the existence of a condition that restricts the ability to leave the home for more than an average of 10-16 hours per calendar month for purposes other than to receive medical treatment that cannot be provided in the home. The proposal further defines infrequent’ to mean an average of five or fewer absences per calendar month and short duration’ to mean absences of three or fewer hours on average per absence."
One problem with the proposed definition, critics like NAHC say, is that while current law allows for infrequent absences of short duration, the proposal referring to absences averaging "10-16 hours per calendar month" may be interpreted to combine these two limitations. At the same time, the 10-16 hour reference may be interpreted in a way that indicates restrictions for leaving the home begin only after that period, since the word "restrict" is not the equivalent of "prevent."
Checklist helps busy doctors
Confused? We thought so. But think about a patient who suffers some kind of dementia, or who perhaps is 80 years old and afflicted with congestive heart failure. Could they define their own status? Now consider the doctor who has 30 or more patients in home care in addition to his or her regular caseload. A short checklist, like the one below, starts looking like a pretty good idea.
Source: HealthCare Visions, Hollandale, MS.
The checklist then informs the user that if any of the above questions were answered "not correct," the patient may not be considered homebound. Users also are advised to contact the company with any questions.
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