Readmission decisions should go to agencies
PPS comment on readmissions needs clarification
By Elizabeth E. Hogue, Esq.
Elizabeth Hogue, Chartered
Burtonsville, MD
I recently wrote the Health Care Financing Administration (HCFA) to express concern about this requirement that appears in the commentary to the proposed prospective payment system (PPS):
"An HHA [home health agency] that accepts [a] Medicare-eligible beneficiary for home health care for the 60-day period and submits a bill for payment may not refuse to treat an eligible beneficiary who has been discharged from the HHA during the 60-day episode, but later requires Medicare-covered home health services during the same 60-day episode period and elects to return to the same HHA. . . ."
In other words, an HHA may be required to readmit a Medicare-eligible patient, even after it has discharged him or her, regardless of the reason for the discharge.
If implemented, this requirement could subject both patients and providers to significant risks, including physical harm. I say this because the requirement fails to address two factors, which may pose risks to beneficiaries and home health care providers:
• the reasons behind a patient’s discharge from the home health agency;
• significant changes in that beneficiary’s clinical conditions since discharge, changes that mean the patient’s clinical needs can no longer be met at home.
Besides failure to meet the eligibility requirements of the Medicare home health benefit, there are numerous reasons home health agencies can and should discharge patients — and refuse to readmit them. These reasons include, but are not limited to:
1. Agency staff members have been subjected to threats of violence or actual acts of violence when visiting the patient’s residence.
2. The patient cannot care for him- or herself, and no reliable paid or voluntary primary caregiver is available to meet the patient’s needs between home health visits.
3. The agency lacks sufficient staff to meet the patient’s needs.
4. Neither the patient nor the primary caregiver complies with the patient’s plan of care.
5. The patient’s clinical needs cannot be met through home health services, i.e. the patient requires placement in an appropriate institutional setting.
The patient’s clinical condition may, for example, change substantially after discharge, so that while home health was clinically appropriate when services were provided earlier in a 60-day period, the patient’s current clinical needs can no longer be met by the agency. In fact, the patient’s health may be compromised if readmitted.
Although I do not believe HCFA intends to subject home health agency staff to bodily harm, implementation of this requirement as written could have that effect. Agencies would be forced to readmit patients (perhaps immediately if requested) that they had discharged because of violent behavior or the threat of violence. Staff would be required to return to patients’ homes even though they knew the likelihood of continued violence was considerable.
Home health staff aren’t the only ones who may suffer. Beneficiaries, too, could come to serious harm as a result of this requirement. It is not uncommon for home health agency staff to encounter patients and/or primary caregivers who are chronically noncompliant.
In such cases, staff should document the specific instances of noncompliance, as well as counsel patients and their primary caregivers regarding these instances. If necessary, home health staff may also reteach the beneficiaries and caregivers what the proper treatment entails. Often this tactic meets with satisfactory return demonstrations from patients and the primary caregivers.
Failing any measure of success with these techniques, under the proposed requirement, patients would have to be readmitted even though the agency knows the patient or caregiver is noncompliant and that such ongoing noncompliance may result in a patient coming to harm.
Bob Wardwell, director of community post-acute care at HCFA, has indicated that among the reasons for this requirement, the organization is concerned about "patient dumping." With regard to this concern, the following points should be considered:
• Several government entities have studied whether the interim payment system results in a lack of access to the Medicare home health benefit. Those reviews consistently indicate that there is no access problem, so it seems that the rationale of the above requirement is based upon HCFA’s skepticism of the studies’ reliability.
• If properly designed, the incentives of PPS and the amount of reimbursement to home health agencies under PPS should prevent patient dumping. If PPS’s incentives and reimbursement policies do not produce this result, PPS should be redesigned so that it does.
• This requirement is fundamentally inconsistent with sound professional practice and thus, may result in harm befalling beneficiaries. Preventing such occurrences must always be the first concern and come even before such issues as "patient dumping."
The bottom line is that the question of whether to readmit a patient is unique to each situation, and home health agencies must retain the discretion to determine when it’s safe and when it isn’t. If this discretion is compromised, as suggested in the proposed PPS regulations, beneficiaries and home health staff are certainly at risk.
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