Congress struggles to come up with BBA compromise
By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON The National Association for Home Care’s (NAHC; Washington) Eric Sokol, deputy director of congressional affairs, describes the status of budget talks between Congress and the White House as the beginning of the endgame. But with nine of 13 appropriations bills yet to be completed by Congress and the White House, and Congress badly split on a range of issues, the outcome of those talks is anything but certain.
Later this week, Rep. Bill Thomas’ (R-CA) House Ways and Means Health Subcommittee will hear from the General Accounting Office (GAO; Washington), the Congressional Budget Office (CBO; Washington), and the Medicare Payment Advisory Commission (MedPAC) on the need to scale back parts of the Balanced Budget Act of 1997 (BBA). But their message is likely to echo what they told the House Commerce Committee earlier this month.
The CBO’s Daniel Crippen told the committee that the most dramatic change in Medicare outlays has been in spending for home healthcare, which fell by 15% in 1998. He added that the CBO projected Medicare outlays for home healthcare would increase slightly this year, but has recently revised that estimate and now believes those outlays will be "several billion dollars lower than previously anticipated" in 1999 and 2000.
Crippen attributed the decline to antifraud activities, as well as an "unexpectedly cautious response" by home health agencies to the limit on average per-beneficiary payments under the interim payment system (IPS). He told the committee that while the limit only applies to aggregate payments, some agencies believe it applies to each beneficiary and are cutting off services to patients who have reached the per-beneficiary limit. "Thus, the average payment per beneficiary is well below the allowable amount," he said.
Industry representatives continue to discount the CBO’s explanation as absurd. One representative pointed to the severe staffing cuts evidenced by George Washington University’s Center for Health Services Research and Policy earlier this month (see table, p. 3).
Clinical Staffing Changes: |
|||
Staffing |
FTE % Change |
FTE % Change |
FTE % Change |
'94 '96 |
'96 '98 |
'94 '98 |
|
RN |
9% |
-29% |
-23% |
Aide |
-4% |
-41% |
-43% |
PT |
-17% |
-28% |
-40% |
OT |
3% |
-33% |
-31% |
ST |
-45% |
-30% |
-61% |
MSW |
7% |
-52% |
-49% |
Other |
-49% |
-53% |
-76% |
| Source: George Washington University School of Public Health and Human Services | |||
Clinical Diagnoses Associated with Increased Utilization: |
| Primary Diagnosis: |
| nonwhite, serious neuromuscular or degenerative disease, stroke, anemia, malnutrition or dehydration, peripheral vascular disease, urinary disease, urinary tract disorder (including incontinence), complicated wound (related to diabetes). |
| Secondary Diagnosis: |
| incontinence or neurological disease. |
| Middle | U.S. | West South | East South | ||
| Outcome | Pacific | Atlantic | Overall | Central | Central |
| Readmitted to home care 31-60 days after discharge | 8.4 | 8.9 | 11.0 | 13.5 | 19.3 |
| Readmitted to hospital | 19.6 | 22.8 | 22.4 | 23.8 | 26.0 |
| Dies within 30 days of home care discharge | 11.6 | 10.7 | 12.4 | 13.6 | 16.3 |
| Percentage by which adverse outcomes in high use regions exceed percentage of adverse outcomes in loww use regions: | |||||
| Outcome | Percentage of increase adverse outcomes | ||
| in high use regions | |||
| Readmitted to home care 31-60 days after home care discharge | 89.6 | ||
| Readmitted to hospital within 30 days of home care discharge | 17.5 | ||
| Died within 30 days of home care discharge | 34.0 | ||
| Source: Mathematica Policy Research | |||
Pressure grows for relief
Even as the CBO discounts the need to restore funds stripped by the BBA, support for BBA relief continues to mount. Most recently, Sen. Richard Durbin (D-IL), a member of the Senate Finance Committee, introduced legislation that would restore $20 billion over five years. The bill, the Health Care Preservation Act of 1999, evenly divides the $20 billion between hospitals and other providers, such as home health agencies and skilled nursing facilities.
Durbin’s bill would also eliminate the 15-minute incremental billing requirement, raise the per-visit cost limit to 112% of the median, and establish a 36-month, interest-free period to repay IPS-related overpayments. It would also delay the 15% reduction slated for Oct. 1, 2000, but only if the home health prospective payment system (PPS) is not implemented on time.
"The bill has a lot of good provisions, but our one concern is that it only delays the 15% cut in the event IPS is still in effect," said NAHC’s Jeff Kincheloe. "Since it looks likely that PPS will be implemented on time, that means we would get the 15% cut either way."
Durbin’s bill also illustrates the range of options that have now surfaced concerning the 15% cut slated for next year. While the home care industry continues to advocate outright elimination of the additional reduction, congressional aides have floated several other possible options in recent weeks. One option would postpone the reduction for one year, while another would make a 10% reduction on Oct. 1, 2000, followed by a 5% reduction one year later.
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