GUEST COLUMN
The survival of home care in the new millennium
Can it continue, and even flourish?
By Cathy Frasca, RN, BSN, FACHCA
Vice President, Home Health Services
South Hills Health System
Homestead, PA
Over 10 years ago, an article titled "Home care grows in spite of pitfalls" appeared in Modern Healthcare. This, I fear, is to be our destiny.
In my more than 30 years in this industry, I have learned that the changes and challenges confronted by others in the health care industry pale in comparison to what we in home care face. It seems that as soon as we overcome one obstacle, a greater one looms on the horizon. The interim payment system (IPS), OASIS, ORYX, prorating, Wedge audits, surety bonds, sequential billing, per-visit and per-beneficiary limits, the list goes on. No wonder we in the industry have the perception that our government is trying to put us all out of business. Are we paranoid or is there some basis to this belief?
When I started in home care I found the Health Care Financing Administration (HCFA) to be supportive and helpful as both an advisor and consultant. There seemed to be a sincere willingness on its part to come to a mutual understanding of and assist in the implementation of home care regulations. We had a mutual respect for each other, one that was cemented by a common goal, to deliver quality patient care.
That all changed, however, as reports of fraud and abuse inflicted a blight on our industry. Certainly those who abuse the system are an embarrassment to us all, scarlet letters that I believe will be erased over time. But seemingly overnight, fairly or unfairly, almost every home care provider was perceived as dishonest. It’s been this notion, together with the government’s attempt at balancing the federal budget, that has resulted in what appears to be an all-out war against our industry.
Even though fraudulent providers were few in numbers, they managed to steal a significant amount from the Medicare home health program, a fact that was widely covered by the media. Perhaps this media attention explains why even though similar violations had been discovered within the nursing home industry, HCFA’s response to the home care industry was far more severe: HCFA chose to treat every provider as suspect and to over-regulate and under-reimburse the industry to the point where it’s impossible for agencies to survive. The result is that already more than 1,000 home health agencies nationwide have been forced to close their doors, while many more have had to reduce their services and costs to the point where patient care may be jeopardized.
Looking back, the battle really began with the Staggers lawsuit against HCFA. While the National Association of Home Care (NAHC) not only won its case but also recovered all its court costs in the process, it doesn’t appear that HCFA learned anything from the ordeal. Instead, HCFA retaliated against the home care industry by unilaterally changing home care’s Medicare reimbursement from an aggregate to per-discipline basis.
The results of this throughout the industry were devastating. Many highly qualified, experienced, and capable administrators were either demoted or terminated when negative variances in their agencies’ bottom lines were taken as a sign of poor performance rather than what they were — an unprecedented, inappropriate, and unpredictable action by HCFA. Not long after, when HCFA was forced to reverse its decision, the administrators’ replacements were then hailed for "turning the bottom line around."
Acting responsibly
Just who should be held responsible for the flagrant examples of abuse and the significant losses that resulted within Medicare’s home care program? Should only the providers who are now being penalized be made accountable, or should HCFA, which had the responsibility of overseeing the program, share in the blame?
Consider that several years ago HCFA designated regional fiscal intermediaries (FIs) for the expressed purpose of ensuring Medicare’s home care regulations and reimbursement policies would be applied consistently and appropriately. Had HCFA and the FIs been doing their jobs, I don’t believe such a nationwide, widespread disparity in home care reimbursement could have occurred. How else to explain, other than with a lapse on the part of HCFA and its FIs, that in some states there are an average of 20 to 40 visits per admission, per patient, while in other states, agencies report hundreds of visits per admission for similar diagnoses?
These inequities should have been uncovered years ago and immediately corrected. While many home care providers, including my own agency, have reported fraud and abuse throughout the years, our complaints fell on deaf ears. Perhaps if early intervention had taken place, the huge scandals that have tainted our industry could have been averted. But now, with the home care IPS as proposed by HCFA, significant inconsistencies among home care providers will continue to be perpetuated.
As a result, regions such as western Pennsylvania, which has the highest percentage of elderly residents of any place in the country and thus the greatest need for an appropriate level of home care reimbursement, is being penalized. As a region, it has one of the lowest utilization rates (the number of visits per admission) in the nation, yet it will receive one of the lowest reimbursement ceilings. Meanwhile, states with higher, more costly utilization rates will be rewarded with higher reimbursement ceilings.
Over the course of my career, I have met many highly qualified and caring individuals at HCFA, but lately, as a provider, I have found the organization to be more of a hindrance than an asset to our industry.
In still another example of HCFA run amok, after more than 30 years of achieving outstanding ratings from licensures, certification, and accreditation surveys our agency received a compliance audit in August 1998, and even though I had heard Wedge-audit horror stories from colleagues, the full impact of the lack of a democratic process didn’t hit me until I was directly involved.
Now I fully realize the necessity of monitoring the appropriateness of care, and I am also aware that there’s a difference between isolated human errors and flagrant abuses of the Medicare home care reimbursement system, but what shocked me most were the tactics applied to the audit process. For example, should a provider decide to appeal a denial, the agency could then be hit with a 100% review of claims, which until completed would mean suspension of the agency’s payments. When the government threatens to cut your funding while it reviews each and every one of your claims, it certainly counts as a significant disincentive to challenging the government even if you as a provider know you’re in the right.
I wonder sometimes if HCFA realizes that Medicare is an entitlement program and should be made readily accessible to those who qualify. Perhaps the acronym HCFA would be more appropriate if it stood for Hold Cash Flow Arbitrarily. I am not alone in this belief. Congressman William Coyne (D-PA), and senators Arlen Specter (R-PA) and Rick Santorum (R-PA), among others, attested that HCFA has strayed too far from its original imperative — to provide needed health care services in an appropriate, cost-effective setting.
The intent of Congress was and still is to provide Medicare reimbursement for home care services to those who are essentially homebound and require intermittent skilled care. "Bedfast or house-bound" was not Congress’s intent, nor were patients, who with assistance are able to leave their homes, meant to be denied reimbursement.
For the first time in the history of the home health industry, we have significant bipartisan support, and when Congress adjourned last October, a majority of key legislators had either sponsored or cosponsored an IPS reform bill. Perhaps that sent a strong message to the president and HCFA that the intent of Congress will be fulfilled by those who will be held accountable.
HCFA claims it needs to cut costs in home care because industry expenditures are increasing beyond belief. But do administrators in HCFA understand institutional care is far more costly than its home care cousin. Are they aware that significant reductions in acute care length of stay and reimbursement have resulted in patients leaving the hospital before they are ready, and, accordingly, these same people require more follow-up care at home?
Even so, the home environment, coupled with family support systems, are the most cost-effective means of delivering many health care services. However, if Medicare reimbursement continues to be slashed these programs will be unable to continue. It’s becoming increasingly important that home care focuses its efforts on public education and sending a strong message that we, our patients, and their families — all members of the voting public — can effect change through the legislative process and turn this situation around. After all, the government is currently revamping the IRS. Why shouldn’t HCFA be next?
I have always fought for what I believe, and now as I near retirement, I am vowing to work with any organization that will fight for the survival of home care. I have every confidence that the right things will be done for the right reasons. We have a duty to ensure that our patients have ready access to quality home care services. We must see to it that Medicare funds are used appropriately, and we must do all of this in a cost-effective manner.
In the future, home care will focus increasingly on providing a full spectrum of integrated home health and in-home support services. Medicare and non-Medicare providers will partner to offer patients ready access to one-stop shopping — a complete package of quality, cost-effective home care, hospice, and support in-home services.
No doubt we have our work cut out for us, and perhaps there is no better place to start than by convincing our legislators to reform or at least place a moratorium on IPS. After all, you can’t provide access to quality home care if you’re out of business. Together with our legislators, the president, and HCFA, we will turn this disaster around.
[Contact Cathy Frasca at South Hills Health System, 1800 West St., Homestead, PA 15120. Telephone: (412) 464-6244.]
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