By Liz Seegert
Depending on the source, the home health care industry is either a boon to older adults or an industry rife with fraud and abuse. The truth, as always, lies somewhere in-between. For most part, home health care can be a cost-effective alternative to hospital or facility care, providing many clinical and skilled nursing services in a non-institutional setting. Hospitals are under intense pressure to reduce or avoid re-admissions within 30 days of patient discharge, clinicians want alternatives to institutionalized care, and insurers – especially Medicare – realize cost-savings through home-based short-term nursing and therapy services. Here are some of the things to be aware of when covering home health care:
Although “home care” and “home health care” are often used interchangeably, they are two distinct types of care:
- Home care refers to non-medical services provided by a caregiver, such as med reminders, activities of daily living such as grooming, bathing, dressing, light house keeping, running errands, preparing meals, respite care, companionship, or helping an older adult remaining socially involved. Some caregivers may be trained to do more, but are limited to certain services and tasks – for example, they can remind a patient to take his or her meds, but cannot actually dispense them.
- Home health care refers to intermittent skilled nursing care and/or rehabilitative services — for example, wound care, administering drugs to patients and setting pill boxes, or physical or occupational therapy.
CMS regulations stipulate that to be eligible for the home health benefit under Medicare, a beneficiary must:
- be homebound: “confined to the home or in an institution that is not a hospital, Medicare-participating skilled nursing facility (SNF), or Medicaid-participating nursing facility. While a beneficiary must be confined to the hom, the beneficiary does not have to be bedridden. Beneficiaries are considered homebound if leaving their residence “requires a considerable and taxing effort.”
- need part-time or intermittent skilled nursing care and/or skilled rehabilitation, or, after establishing prior eligibility, a continuing need for occupational therapy, care that is needed fewer than seven days each week, or less than eight hours of each day for periods of 21 days or less.
- be under the care of a physician and need reasonable and necessary home health services that have been certified by a physician and established in a 60-day plan of care Reasonable and necessary encompass skills or supervision of a registered nurse the skills or supervision of a registered nurse based upon the inherent complexity of the service. the condition of the beneficiary, and accepted standards of medical practice. Additionally, the home health care agency must be Medicare-certified.
Beneficiaries who meet the home health eligibility requirements are entitled to a 60-day episode of home health coverage and may receive an unlimited number of 60-day episodes, so long as they continue to meet the eligibility requirements. The National Association for Home Care and Hospice reports that in 2010, 33,000 providers delivered home health care to 12 million individuals. As of April, 2011, over 11,600 home health care companies were Medicare-certified — providing the breadth and depth of skilled and unskilled care required under CMS guidelines. McKinsey & Company reports that home care accounts for about 3 percent ($68 billion/year) of national health spending. The market is increasing by about 9 percent annually, They see technology-enabled home health care as a promising answer to high health costs, but “only if stakeholders develop more equitable reimbursement models that create greater incentives to participate in the technology-enabled home health market.”
Cost-sharing:
- none for services
- 20 percent coinsurance is required for all covered durable medical equipment and covered Part B drugs and biologics..
Medicare will not cover:
- 24-hour-a-day care at home
- Home delivered meals
- Homemaker services like shopping, cleaning, and laundry or personal care given by home health aides like bathing, dressing, and assistance in the bathroom when this is the only care needed, and when these services aren’t related to the patient’s plan of care.
The Wall Street Journal reported on a settlement in late 2012 between the federal government and consumer advocates allows Medicare patients with chronic conditions to receive skilled nursing and therapy services at home as well as in skilled-nursing and outpatient facilities. This counters long-standing CMS policy of refusing payment for these services for patients whose conditions are unlikely to improve.
Costs
Roughly 9.6 percent of Medicare fee-for-service (FFS) beneficiaries (or 3.4 million individuals) used home health services in 2010, according to a report by the Congressional Research service. The most common c onditions requiring home health care services in 2011 were diabetes, hypertension, heart failure and chronic skin ulcer.
Home health agencies say they are grossly under-reimbursed by Medicare under the current prospective payment system. Since 2009, Medicare home health funding has been reduced by 22 percent according to The Partnership for Quality Home Healthcare – a coalition of home health providers . CMS proposes to further reduce Medicare home health funding under a section of the Affordable Care Act which authorizes the Secretary of Health and Human Services to adjust funding rates as deemed appropriate between 2014 and 2017.
Despite a growing demand for all levels of home care, The median annual wage of home health aides was $20,560 in 2010. The median annual wage of personal care aides was $19,640 in 2010.
Fraud and abuse
The Visiting Nurse Associations of America said that home health care fraud and abuse occurs among a very small percentage of agencies (HHAs), and is primarily concentrated in senior-dense geographic areas like Florida, Agencies have been fined and owners prosecuted for billing Medicare for services never provided, using names of deceased physicians or stolen Medicare numbers, convincing recipients to receive unnecessary services, or providing kickbacks or other compensation for referrals. A temporary ban on new agencies was instituted in Florida to help CMS officials root out fraud in existing agencies.
Tips for reporters
Several bills making their way through Congress impact home health care, telehealth, authorized care providers and home health funding.
â—† S1332: Home Health Care Planning Improvement Act of 2013, which allows CRNPs, PAs, certified nurse midwives and others to order home health services.
â—† S 596 – Fostering Independence Through Technology (FITT) Act would establish pilot projects under the Medicare program to provide incentives for home health agencies to utilize home monitoring and communications technologies
â—† Senator Susan Collins (R-ME), Senator Bernie Saunders (I-VT) and Rep. Mike Thompson (D-CA 5) are long-time supporters of home health care and telehealth services. Their aides are usually responsive to journalists seeking comment or information.
â—† Look to the technology sector to play an increasingly important role in home health care – from remote monitoring to telehealth, to smartphone apps.
â—† The National Association for Home Care and Hospice posts nurse’s stories on their website.
â—† There are several economic angles to think about: e.g., compare hospital discharge data for your community and referral to home care services to analyze readmissions, most common conditions, costs and savings.
Resources
Visiting Nurse Associations of America: Will connect journalists with home health care and hospice providers, or national or local spokespersons to discuss advocacy, finance, regulation, or other issues.
Contact: Kathleen Sheehan, VP, Public Policy Tel. 202-384-1456 ksheehan@vnaa.org
National Association for Home Care and Hospice (NAHC)
PR Contact: Barbara D. Woolley, (202) 547-7424 bdw@nahc.org
President: Val Halamandaris, (202) 547-7424
American Telemedicine Association
Communications: Benjamin Forstag, Senior Director of Communications 202-223-1721, bforstag@americantelemed.org
Jonathan Linkous, Chief Executive Officer, 202-223-3333 jlinkous@americantelemed.org
Reports and Data
Joint Commission Position Statement on Home Health Care (2011)
Characteristics and Use of Home Health Care by Men and Women age 65 and Over: National Health Statistics Report (2012)
Medicare Current Beneficiary Survey: Searchable databases on beneficiaries access to and cost of all Medicare-reimbursed care.
CDC Database on health care use and expenditures
