Home care industry faces a full agenda in the 106th Congress

By MATTHEW HAY

HHBR Washington Correspondent

WASHINGTON The conventional wisdom in much of the major media in recent weeks has been that not much will happen in Washington until the impeachment of President Clinton is settled in the Senate. But the betting on Capitol Hill is that the impeachment will be wrapped up later this month or early next month and that both parties will be anxious to move on to significant legislative matters, including healthcare. Some Capitol Hill aides predict the Republican majority in the House will be especially anxious to see this occur because of the growing view reflected in public opinion polls that they have been focused solely on the impeachment.

"We are hopeful that with such a slim majority in the House, the Republicans will be anxious to show they can do something besides impeach presidents and that we will have a pretty busy year where healthcare is concerned," a top aide to the House Ways and Means Committee told HHBR. "I think the reason the Republicans lost some seats was because they weren’t doing things people care about, and people care about healthcare."

Nobody is quite certain precisely what this will mean for the home care industry, however. "There is a lot of speculation that what took place in the area of home health last fall was Round One because the industry is still facing the 15% cut next year, and, as it is, they are already pretty beleaguered," said the Ways and Means aide. "But nobody has described to me what Round Two will look like yet."

Before it adjourned last year, Congress passed a home health provision as part of its year-end budget agreement that altered the per-visit and per-beneficiary limits and delayed by one year the 15% across-the-board reduction in home health reimbursement originally scheduled for Oct. 1. But the home care industry took little solace in those measures after working all year to bring about a moratorium on the interim payment system (IPS).

"One of the encouraging things that did take place when Congress passed those measures," noted the National Association for Home Care’s (NAHC; Washington) Jeff Kincheloe, "was that a number of key members went on record pointing out that the steps Congress was taking did not repair the problem and that they would have to revisit home health this year."

Exactly what form these "next steps" will take is the question the home care industry is now facing. Home care representatives told HHBR last week that the industry will likely renew its efforts to eliminate — or at least further delay — the 15% across-the-board reduction, but all sides agree that is going to be an uphill fight. "We would love to see the 15% reduction eliminated and the per beneficiary limits suspended because we think we can achieve the required savings without them," said one home care representative. "But that is probably unrealistic."

The Ways and Means staffer agreed. "When you look at the budgetary pressures that now exist," said the aide, "you realize how tight it is going to be because you basically have a firewall that has been drawn between domestic spending and a new push for increased military spending." The aide pointed out that Clinton recently announced sizable increases in military spending, and the Republicans are already pushing for even greater increases.

"Finding a few billion dollars to deal with some of the things we did in home health as part of the Balanced Budget Act that were probably too severe got a lot harder over the winter because now Medicare is basically competing head-to-head with people that are trying to figure out how to keep our Air Force pilots from bailing out," the aide said. "The problem is that many of the cuts in the (Balanced Budget Act of 1997) were backloaded, and now we are starting to get closer to the back."

One potential remedy to the problems confronting the home care industry that both industry representatives and Capitol Hill aides believe has a reasonable chance of passage is some form of outlier policy for medically complex patients and chronically ill patients that have seen their services curtailed by the per-beneficiary limits.

"I’m certain that will be a major focus of our attention, but exactly what form that legislation will take it is too early to tell," said Kincheloe. Several House members are already working on versions of an outlier policy but those bills were described last week as very preliminary.

Concern over the fate of medically complex patients intensified in recent weeks in the wake of a Medicare Appeals Court ruling that overturned the judgements of an administrative law judge regarding skilled nursing services that were provided to a Medicare beneficiary between 1995 and 1996. The Medicare Appeals Court ruled that the care provided to the beneficiary was not covered by Medicare because it had no predetermined endpoint and as a result could not be termed "intermittent."

"In essence, this is one of those patients they are saying is too ill’ to receive home health, services and they are basically consigning her to a nursing home," said Kincheloe. "If it is not daily care, you don’t need a definable endpoint and you can receive care indefinitely, but in her case, she required care every day."

The first hearing scheduled in the House Ways and Means Committee will take place later this month and will address the progress being made on the Year 2000 computer modifications affecting Medicare as well as Social Security and other government programs. With the implementation of the prospective payment system (PPS) for home health contingent on the Health Care Financing Administration’s (HCFA; Baltimore) successful completion of its Year 2000 computer updates, the home care industry will be watching this hearing closely.

The Senate Finance Committee has yet to schedule any hearings, but a Senate Finance Committee aide told HHBR last week that the committee will likely hold hearings in the area of healthcare early in the session.

The home care industry will also be keeping an eye on the next set of recommendations from the Medicare Payment Advisory Commission (MedPAC) (see related story) and the Bipartisan Commission on the Future of Medicare. The Bipartisan Commission has been tasked with drawing up solutions to the long-term threats facing Medicare’s solvency, and some observers believe it might recommend a co-payment for home health services. In addition, the commission may recommend an increase in the eligibility age for Medicare, which would strip millions of beneficiaries of home health services.

Home care representatives said last week that the industry has yet to completely set its agenda for this session of Congress. Some industry representatives expressed the concern that Congress might take the view that the problems confronting home health were already addressed last year. "That is the problem with settling for a partial fix," remarked one of them. "But the fact is that you sometimes have to take what you can get at the moment."