CAROL L. SCHAFFER
THE REGULATORY STRUCTURE OF HOME HEALTH CARE IN THE UNITED STATES
ABSTRACT. Home health care in the United States is highly developed involving, for example, complex therapies and durable medical equipment. Access to home care has been shaped by government reimbursement policies requiring recipients to be homebound and in need of intermittent services under medical direction. Due to strict and extensive documentation for reimbursement the Medicare regulatory structure has stifled innovation in the field of home care. Other factors affecting the provision and growth of home care services include the Joint Commission on Accreditation of Health Care Organizations, changes in hospital reimbursement policies, and the role of physicians in integrating and coordinating home care services. Key Words: Diagnostic Related Group (DRG), reimbursement,
home health care,
Medicare regulations The general assumption among health care providers is that patients prefer to receive care in their own homes. The experience of hospitalization, no matter how excellent the care received, cannot match that of being surrounded by the comforts of one's own home. Familiar surroundings, animals, people, and things, all help the course of illness to be a bit more bearable. More importantly the type of care required is often more custodial than skilled in nature. Despite all the high tech advances we have made in medicine, the bulk of real care needs continues to be custodial in nature. MARKET SEGMENTS AND THEIR INTEGRATION Home health care in the United States is traditionally associated with home care nurses. Specifically, the public thinks of home care as being delivered through either a Visiting Nursing Association or a Medicare Certified Agency. Both of these views are correct; however, a broader conception of home health care involves viewing the system as composed of three market segments. Home Health Care Professionals
The first segment consists of home health care professionals. In addition to home care nurses, these professionals include physical, occupational, and speech therapists, medical social workers, and home health aides. Both professionals and paraprofessionals are reimbursed through the Medicare program as well as by Medicaid and commercial insurance carriers. In the United States insurance reimbursement drives the health care delivery system and has been instrumental in the development of home health care.
Journal of Cross-Cultural Gerontology 8: 407-416, 1993. 9 1993 Kluwer Academic Publishers. Printed in the Netherlands.
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CAROLL. SCHAFFER
Infusion Therapy A second segment of the home care market is infusion therapy. An infusion therapy provider is basically a pharmacy with associated nursing, delivery and reimbursement services. Infusion therapy involves the compounding and administration of intravenous medications and formulations such as total parenteral nutrition. The nurses employed in the infusion therapy program are proficient in the delivery of solutions. This program requires nurses well versed in the care and management of state-of-the-art central venous catheters and other high technology devices for the delivery of solutions. Infusion therapy providers are reimbursed under Part B of Medicare as well as by Medicaid and private payors.
Durable Medical Equipment~Respiratory Therapy The third segment of the home care market is durable medical equipment and respiratory therapy. These services are product-focused and only minimally involve service providers. One such provider is the respiratory therapist. The program is reimbursed under Part B of Medicare as well as Medicaid and private insurance companies. The limitation on service is directly related to the lack of reimbursement for the service component. These three segments as well as hospice care reasonably describe the full range of services involved in home care in the United States.
Types of Providers Home health care is provided by many types of providers, including governmental, non-profit, for-profit, and proprietary. Infusion and respiratory therapy/durable medical equipment companies are either for-profit or non-profit. All of these services may be provided in hospital operated or free-standing settings. In the United States, different providers deliver these services even though the patient relies upon all three programs to meet his needs. For example, a patient receiving home health care might need the services of a registered nurse for wound care, oxygen from a respiratory company, and an intravenous antibiotic from an infusion company. The integration of these three services is ideally accomplished at a single coordination point. To a large extent this type of coordination, including that for care provided after discharge, occurs in hospitals. In the future, more will occur in the outpatient setting. UNITED STATES GOVERNMENTAL INFLUENCE ON CARE The governmental reimbursed programs are generally quite rigid and strongly limit the program creativity that is possible through home health care. The private pay and commercial pay markets have taken the lead in forging
THEREGULATORYSTRUCTURE
409
creativity through their willingness to pay for innovative programs of care, such as home intravenous antibiotics. More information on this point will be covered later in the section covering reimbursement issues. It suffices to say that the government's view of home care is as an add-on cost to other programs. While this may not be the intent, the government's focus on reimbursement methods such as the diagnostic related group or DRG encourages continued emphasis upon hospital reimbursement. This orientation inhibits the development of home care' s full potential as a substitute for in-patient care. In addition, the main need of patients is for custodial care, mainly bathing, dressing, and assistance in can-ying out the activities of daily living. Unfortunately, Medicare and other insurance companies do not reimburse for these services alone but rather reimburse for a very limited amount of such personal care services only in conjunction with skilled care services. This provision encourages patients to use skilled care to obtain even a limited amount of personal care, so that the patient can remain in a home setting. REIMBURSEMENT POLICIES Perhaps the most difficult aspect of home care's growth to understand is how reimbursement has limited the expansion of home care. The Medicare system of reimbursement has guaranteed that the hospital is central to the reimbursement system. Payments under DRGs are made to hospitals for the treatment of specific diagnoses. This system of reimbursement ensures that the hospital will be reimbursed even if alternatives such as home care would be equally effective. As a consequence, home health care expenses are purely additive costs to the United States health care system and can not be expected to lower the overall cost of health care. This type of reimbursement inadvertently discourages more cost effective sites of treatment. For example, the Medicare program historically reimbursed for the treatment of an infection with antibiotics in the hospital but will not reimburse for the drug at home. The lack of reimbursement from Medicare results in patients receiving a full course of antibiotic treatment in the hospital as opposed to the home unless an enlightened hospital administrator reimburses a home care provider for these services. Commercial insurance providers that do not pay on the basis of DRGs have long since discovered the cost effectiveness of home care and have regularly employed this option. To remedy this situation, the government might consider revamping the entire DRG system and move to a program of reimbursement that encourages care in the least costly environment. One approach under discussion is the concept of bundling. Under such an approach, the hospital or other entity receives a flat sum for care, and the delivery of services is performed in the least costly environment which is safe for the patient. A cost-based system of reimbursement for operations including rehabilitation hospitals, subacute facilities and home care would be eliminated. Instead, governmental reimbursement would be tendered to an institution for an episode of illness. Some challengers to this concept cite their fear that hospitals would maintain bureaucracy at all costs and
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CAROL L. SCHAFFER
fail to use more cost effective sites of care, even though to do so would be in their economic interest. A key aspect of home health care important to consumers is access. Each of the three components of home health care will be reviewed in regard to this issue. ACCESS TO HOME CARE IN THE UNITED STATES Access to home health care services is somewhat limited by strict reimbursement rules under Medicare. Patients in need of home care agency services must meet certain requirements including home-bound status, need for intermittent services, need for skilled services, and medically directed care. Private payors by and large follow the requirement that an agency be Medicare certified. Some will accept accreditation by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). Others require both Medicare certification and accreditation before the agency can provide care. The Medicare critera mentioned above, i.e., home-bound status, need for intermittent services, need for skilled services, and medically directed reasonable and necessary care, have been the source of litigation and sore points between providers and payors. In the past, the issue of homebound status was continuously reviewed by payors. The issue surrounds the degree of mobility which a patient demonstrates before he/she is deemed ineligible for services. While patients need not be bed-bound, their mobility must be considerably impaired for them to remain qualified for home care. Otherwise the patient is expected to go to an outpatient facility for treatment. Trips to the physician's office, as well as some additional outings, will not revoke home-bound status. The important point is government reimbursable home care should not be performed as a matter of patient convenience. Instead, it should be required because a patient is homebound. The policy underlying this requirement is economic. It is clearly more cost effective to treat patients in environments where more than one patient can be treated at a time. Recent guidelines have been proposed to clarify the meaning of homebound. These proposals advance the concept of tracking the number of hours a patient spends away from home as the basis for determining homebound status. From a practical standpoint, determining how long the patient is at home versus outside would be difficult because the providers of care only work with patients on an intermittent basis. The second criterion is the patient's need for intermittent services. Patient needs must be able to be met on an intermittent as opposed to on a continuous basis. The definition of intermittent services has recently been enforced by litigation forwarded by the National Association of Home Care. This litigation challenged the inconsistency between the governmental payor's propensity to reimburse in a fashion that excluded care which was clearly defined under the Medicare law as intermittent. The definition of intermittent care is outlined below.
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411
"Intermittent Care": Up to and including 28 hours per week of skilled nursing and home health aide services combined provided on a less than daily basis; Up to 35 hours per week of skilled nursing and home health aide services combined which are provided on a less than daily basis, subject to review by fiscal intermediaries on a case by case basis, based upon documentation justifying the need for and reasonableness of such additional care; or Up to and including full-time (i.e., eight hours per day) skilled nursing and home health aide services combined which are provided and needed severn days per week for temporary, but not indefinite, periods of time up to 21 days with allowances for extensions in exceptional circumstances where the need for care in excess of 21 days is finite and predictable.
-
-
-
Impact on Care Provided in Excess of "Intermittent" or "Part-time" Care. Home health aide and/or skilled nursing care in excess of amounts of care which meet these definitions of part-time or intermittent may be provided to a home care beneficiary or purchased by other payers without bearing on whether the home health aide and skilled nursing care meets the Medicare definitions of part-time or intermittent. EXAMPLE: A beneficiary needs skilled nursing care monthly for a catheter change and the home health agency also renders needed daily home health aide services 24 hours per day which will be needed for a long and indefinite period of time. The HHA bills Medicare for the skilled nursing and home health aide services which were provided before the 35th hour of service each week and bills the beneficiary (or another payer) for the remainder of the care. If the intermediary determines that the 35 hours of care are reasonable and necessary, Medicare would then cover the 35 hours of skilled nursing and home health aide visits.
Application Of This Policy Revision A beneficiary must meet the longstanding and unchanged qualifying criteria for Medicare coverage of home health services, before this policy revision becomes applicable to skilled nursing services and/or home health aide services. The definition of "intermittent" with respect to the need for skilled nursing care where the beneficiary qualifies for coverage based on the need for "skilled nursing care on an intermittent basis" remains unchanged. Specifically: -
-
This policy revision always applies to home health aide services when the beneficiary qualifies for coverage; This policy revision applies to skilled nursing care only when the beneficiary needs physical therapy or speech therapy or continued occupational therapy, and also needs skilled nursing care; and If the beneficiary needs skilled nursing care but does not need physical therapy or speech therapy or occupational therapy, the beneficiary must still meet the longstanding and unchanged definition of "intermittent" skilled nursing care in order to qualify for coverage of any home health services.
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From the Medicare Home Health Agency Manual published by the Department of Health and Human Services 1992 PB 92--055299 pg, 15.16-15.17. According to this definition patients may receive a greater intensity of care for periods of time when they need it. The successful litigation advanced by the National Association of Home Care enforces the regulatory definition of intermittent care. Access to home health care has increased for many needy patients. Nevertheless confusion about the definition of intermittent services has limited access to home care for others. As a consequence home care is mainly a viable option for patients fortunate enough to have household members available to provide most of their care or for patients whose illness is not so debilitating that intermittent services are insufficient to meet their needs. The third criterion - skilled services - is confusing, but generally refers to services which require the skill and training of a registered or licensed practical nurse. To make this definition operational, Medicare has defined a series of activities which it considers skilled. This criterion also limits access to home care because a nurse's more valuable assessment skills are more difficult to justify than the performance of tasks such as giving injections. Many challenges to reimbursement of providers by fiscal intermediaries have surfaced as payors challenge the necessity of a nurse's skills or believe family members or the patient can be taught to perform these activities. The final criterion is medically directed, reasonable and necessary care. The Medicare program requires that a physician certify and re-certify the medical necessity of such services. This requirement exists in spite of the fact that physicians are not reimbursed for this activity. Such lack of reimbursement to physicians for certification limits access to home care, as physicians are reluctant to spend time on non-reimbursed services. LACK OF ENCOURAGEMENT FOR INNOVATION IN HOME HEALTH CARE The current Medicare and Medicaid programs strongly discourage the development of innovative programs that could substantially reduce health care costs. An example of this can be found in the infusion therapy market segment. Currently infusion therapy is limited mainly to total parenteral nutrition and enteral therapy under Medicare's Part B reimbursement program. Under such programs, a patient must fall under the prosthetic device benefit. This means that the use of infusion and enteral therapy must be used to replace a non-functional organ. The balance of available programs such as home intravenous antibiotics and other therapies are not generally reimbursed by Medicare. In 1988, the Medicare Catastrophic Act included the addition of a broad range of such services which would have provided coverage. Unfortunately, this act was rescinded and reimbursement never emerged. As a consequence, Medicare patients do not have access to intravenous antibiotics, pain management, and other therapies routinely reimbursed under commercial insurance coverage. This lack of
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reimbursement continues to escalate hospital costs as Medicare patients under limited hospitalization reimbursement unnecessarily remain in the hospital. These same patients could be treated for less cost at home in an environment in which they would be far more comfortable. Finally, respiratory therapy/durable medical equipment has been under constant reimbursement scrutiny. Periodically the government revisits its payment methodology and proposes additional changes. Perhaps most troubling is the impact of reduced reimbursement under Medicare which causes companies to re-evaluate their ability to employ providers such as respiratory therapists. While patients have been able to receive durable medical equipment and respiratory therapy, the threat of reduced access looms with continuous reimbursement reductions under the Medicare program. DOCUMENTATION MANDATES UNDER MEDICARE Documentation is essential for reimbursement under the Medicare program. This documentation frequently involves duplication of information and many hours of completing forms. Medicare has carefully prescribed the documentation requirements for home care nursing agencies, i.e., HCFA forms 485, 486, 487 and possibly a 488, if additional medical information is required. In addition to completing these forms, the agency must fill out forms in compliance with physician's orders and submit them to the physician for signature. Physicians should receive a final copy of the treatment plan and must be notified about a patient's progress at least every 60 days, when recertification is required. The abundance of paperwork makes communication from home care agencies to physicians possible, but most physicians are annoyed by ongoing communication and have difficulty integrating it into their medical plans. Further, the lack of reimbursement for reviewing medical orders is understandably troubling to physicians. Although the physician is expected to order the treatments, he rarely knows the reimbursement rules or the rules of the payor. As a consequence, nursing agencies have taken on the burden of completing the forms after a first nursing evaluation visit and then asking the physician to sign appropriate orders. While this arrangement works practically, the physician is not as involved in the process as one would desire. Perhaps increased physician involvement in home care visits would be ideal to remedy this situation. Some slight encouragement for physician home visits may be available, as reimbursement for home visits increases under the Resource Based Relative Value Scale (RBRVS) system of reimbursement for physicians under Medicare. Reimbursement is, however, limited to actual physician house calls. Similar to home health care agencies, infusion companies and respiratory therapy/durable medical equipment suppliers must provide certification and recertification reports. These Statements of Medical Necessity and Certification Forms are the primary means of communication between the provider and the physician. In the interim, practitioners from companies call the physician with changes in orders and other pertinent information.
414
CAROL L. SCHAFFER QUALITY IN HOME HEALTH CARE
Quality has been a recent focus in all health care as well as in home health care. In 1988, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) introduced a new manual devoted exclusively to the accreditation of home health care. This major breakthrough caused the home care industry rapidly to develop uniform standards. Prior to this program home care quality had been random and unstandardized. Accredition represents a significant step in providing insurance companies and others with criteria upon which providers of care can be selected. In fact, JCAHO accreditation has been employed by providers as a marketing tool in their sales calls with payors, and in the last few years most insurance companies have included JCAHO accreditation as a requirement. Home care agencies have generally needed Medicare certification to quality as a provider of services for other insurance companies. Infusion therapy and respiratory therapy/durable medical equipment industries do not have a similar rigorous independent accreditation program. As a consequence, the JCAHO process has become intensely popular with this market segment to signify the provision of a quality service. Beyond establishing a base line standard of quality for the home care industry, the accreditation process heralds the way for national measurement criteria such as patient care outcomes. In the near future we will be able to review such patient outcome criteria as the rate of hospital re-admissions after home care. Such measurable patient outcome information will do much for the establishment of home care as a credible provider of quality care. JCAHO is a mandatory accreditation program for hospital-based agencies. Mandatory accreditation for hospital-based agencies is founded upon the notion that consumers of care should not be forced to distinguish between a JCAHO accredited hospital and an un-accredited program. In fact the results of the home care accreditation process can adversely impact the hospital's accreditation. PHYSICIANS AND HOME CARE AGENCIES Presently physicians are not very involved in home care, The lack of reimbursement for physician services related to documentation and medical review and the limited reimbursement for physician home visits is a serious constraint on the development of positive physician-home care agency relationships. To make matters worse, physicians remain legally liable for the care of patients in the home, even though they have minimal control over the delivery process. Finally, some physicians are threatened by home care, as they perceive it to be directly competitive with their own office visits. In fact, in some rural communities home care may adversely impact a physician's income through decreased office visits when a nurse visits the patient at home, Much improvement could occur if reimbursement for physician involvement existed for the documentation aspects, and more reasonable reimbursement were
THEREGULATORYSTRUCTURE
415
available for physician home visits. Physicians also require education in these matters. Beyond reimbursement, communications between home care nurses and physicians would improve relationships. Unfortunately, a call from the home care nurse has frequently been viewed as a non-reimbursable event. Perhaps physician education and understanding of how to use the home care nurse as their own eyes and ears in the home might modify some of the negative attitudes. Despite physician complaints regarding limited home care reimbursement, physicians have supported the growth of home care as demonstrated by the projection of home care as a 9.8 billion dollar industry by the end of 1993 (Rak 1992). INTEGRATION AND COORDINATION DURING HOSPITALIZATION From the perspective of the hospital home care should provide continuity of care for patients as well as a new source of income. As hospitals deal with an increasingly limited definition of hospitalization, home care brings the opportunity to bridge care into the community. The program also offers an opportunity to increase the hospital's fiscal health by maximizing savings under the DRG system. In other words, if hospitals are able to discharge patients quicker into the home, the dollars earned under the DRG form of reimbursement are earned earlier in the hospitalization. Such an approach to earlier hospital discharges permits the hospital to operate a smaller number of units more efficiently. The hospital can also derive new income from the home health care operation. In addition to this aspect of integration, hospitals should examine how to successfully bridge their services. One key way to create this type of integration is through home care coordinators. Home care coordinators are highly skilled registered nurses and therapists who early in the admission match the needs of patients with home care systems. Coordinators act as facilitators and educators about the ever-changing home care environment. Typically hospital based programs use these types of coordinators to perform intake coordination at the hospital with one goal being to decrease the length of stay in the hospital. Hospitals should review legal issues that differentiate intake coordination from discharge planning. Legal questions have been raised about the presence in hospitals of discharge planners from outside nursing agencies, whose discharge planning services on behalf of the hospital could be construed as a form of kickback. SUMMARY Home health care exists in three market segments in the United States. These three segments include home care professionals, home infusion therapy, and home respiratory therapy/durable medical equipment. These services are best delivered when coordinated through a central system which involves nurses planning for the home care needs of patients prior to their discharge from the
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CAROLL. SCHAFFER
hospital. There are various types of providers including governmental, non-profit, forprofit and proprietary. The United States government has strongly influenced the development of home care through the Medicare program. From the government's point of view, home care is an additional cost to the Medicare system because hospitalization is reimbursed under a diagnostic related group which fixes reimbursement for a diagnosis. Since the payment for hospitalization is fixed irrespective of the length of hospitalization, all other payments to home care agencies are viewed as additional expenses. If the DRG did not exist, then home care could be reimbursed as a substitute for hospitalization at a lower cost. Access to home care in the United States is limited by Medicare reimbursement rules which restrict services to those requiring reasonable and necessary care, who are home-bound, and who require skilled intermittent care under the direction of a physician. Litigation by such organizations as the National Association of Home Care has prompted changes in the interpretation of reimbursement guidelines to benefit patients. Innovation in home care has mainly developed under the private pay reimbursement system. Under the private pay sector new programs delivered in the home are reimbursed on the basis of quality and cost effectiveness. Quality in home health care is a critical factor. Recent developments from the Joint Commission on Accreditation of Health Care Organizations have helped to standardize the measurement of quality. Finally, physicians have endorsed the advancement of home care services. A critical aspect of a sound home care program resides in coordination between the patients, in-patient caregivers and home care providers. One way to achieve coordination is through the use of nurses and therapists who plan for a patient's discharge and bring all necessary services together. REFERENCES Department of Health and Human Services 1992 PB 92-055299. Medicare Home Health Agency Manual. Baltimore. Rak, K. 1993 Home Health Line (April 28) XVIII: 40. CCF Health Care Ventures, Inc. The Cleveland Clinic Foundation 9775 Rockside Road - Suite 270 Cleveland, Ohio 44125, U.S.A.
THE REGULATORY STRUCTURE OF HOME HEALTH CARE IN THE UNITED STATES
ABSTRACT. Home health care in the United States is highly developed involving, for example, complex therapies and durable medical equipment. Access to home care has been shaped by government reimbursement policies requiring recipients to be homebound and in need of intermittent services under medical direction. Due to strict and extensive documentation for reimbursement the Medicare regulatory structure has stifled innovation in the field of home care. Other factors affecting the provision and growth of home care services include the Joint Commission on Accreditation of Health Care Organizations, changes in hospital reimbursement policies, and the role of physicians in integrating and coordinating home care services. Key Words: Diagnostic Related Group (DRG), reimbursement,
home health care,
Medicare regulations The general assumption among health care providers is that patients prefer to receive care in their own homes. The experience of hospitalization, no matter how excellent the care received, cannot match that of being surrounded by the comforts of one's own home. Familiar surroundings, animals, people, and things, all help the course of illness to be a bit more bearable. More importantly the type of care required is often more custodial than skilled in nature. Despite all the high tech advances we have made in medicine, the bulk of real care needs continues to be custodial in nature. MARKET SEGMENTS AND THEIR INTEGRATION Home health care in the United States is traditionally associated with home care nurses. Specifically, the public thinks of home care as being delivered through either a Visiting Nursing Association or a Medicare Certified Agency. Both of these views are correct; however, a broader conception of home health care involves viewing the system as composed of three market segments. Home Health Care Professionals
The first segment consists of home health care professionals. In addition to home care nurses, these professionals include physical, occupational, and speech therapists, medical social workers, and home health aides. Both professionals and paraprofessionals are reimbursed through the Medicare program as well as by Medicaid and commercial insurance carriers. In the United States insurance reimbursement drives the health care delivery system and has been instrumental in the development of home health care.
Journal of Cross-Cultural Gerontology 8: 407-416, 1993. 9 1993 Kluwer Academic Publishers. Printed in the Netherlands.
408
CAROLL. SCHAFFER
Infusion Therapy A second segment of the home care market is infusion therapy. An infusion therapy provider is basically a pharmacy with associated nursing, delivery and reimbursement services. Infusion therapy involves the compounding and administration of intravenous medications and formulations such as total parenteral nutrition. The nurses employed in the infusion therapy program are proficient in the delivery of solutions. This program requires nurses well versed in the care and management of state-of-the-art central venous catheters and other high technology devices for the delivery of solutions. Infusion therapy providers are reimbursed under Part B of Medicare as well as by Medicaid and private payors.
Durable Medical Equipment~Respiratory Therapy The third segment of the home care market is durable medical equipment and respiratory therapy. These services are product-focused and only minimally involve service providers. One such provider is the respiratory therapist. The program is reimbursed under Part B of Medicare as well as Medicaid and private insurance companies. The limitation on service is directly related to the lack of reimbursement for the service component. These three segments as well as hospice care reasonably describe the full range of services involved in home care in the United States.
Types of Providers Home health care is provided by many types of providers, including governmental, non-profit, for-profit, and proprietary. Infusion and respiratory therapy/durable medical equipment companies are either for-profit or non-profit. All of these services may be provided in hospital operated or free-standing settings. In the United States, different providers deliver these services even though the patient relies upon all three programs to meet his needs. For example, a patient receiving home health care might need the services of a registered nurse for wound care, oxygen from a respiratory company, and an intravenous antibiotic from an infusion company. The integration of these three services is ideally accomplished at a single coordination point. To a large extent this type of coordination, including that for care provided after discharge, occurs in hospitals. In the future, more will occur in the outpatient setting. UNITED STATES GOVERNMENTAL INFLUENCE ON CARE The governmental reimbursed programs are generally quite rigid and strongly limit the program creativity that is possible through home health care. The private pay and commercial pay markets have taken the lead in forging
THEREGULATORYSTRUCTURE
409
creativity through their willingness to pay for innovative programs of care, such as home intravenous antibiotics. More information on this point will be covered later in the section covering reimbursement issues. It suffices to say that the government's view of home care is as an add-on cost to other programs. While this may not be the intent, the government's focus on reimbursement methods such as the diagnostic related group or DRG encourages continued emphasis upon hospital reimbursement. This orientation inhibits the development of home care' s full potential as a substitute for in-patient care. In addition, the main need of patients is for custodial care, mainly bathing, dressing, and assistance in can-ying out the activities of daily living. Unfortunately, Medicare and other insurance companies do not reimburse for these services alone but rather reimburse for a very limited amount of such personal care services only in conjunction with skilled care services. This provision encourages patients to use skilled care to obtain even a limited amount of personal care, so that the patient can remain in a home setting. REIMBURSEMENT POLICIES Perhaps the most difficult aspect of home care's growth to understand is how reimbursement has limited the expansion of home care. The Medicare system of reimbursement has guaranteed that the hospital is central to the reimbursement system. Payments under DRGs are made to hospitals for the treatment of specific diagnoses. This system of reimbursement ensures that the hospital will be reimbursed even if alternatives such as home care would be equally effective. As a consequence, home health care expenses are purely additive costs to the United States health care system and can not be expected to lower the overall cost of health care. This type of reimbursement inadvertently discourages more cost effective sites of treatment. For example, the Medicare program historically reimbursed for the treatment of an infection with antibiotics in the hospital but will not reimburse for the drug at home. The lack of reimbursement from Medicare results in patients receiving a full course of antibiotic treatment in the hospital as opposed to the home unless an enlightened hospital administrator reimburses a home care provider for these services. Commercial insurance providers that do not pay on the basis of DRGs have long since discovered the cost effectiveness of home care and have regularly employed this option. To remedy this situation, the government might consider revamping the entire DRG system and move to a program of reimbursement that encourages care in the least costly environment. One approach under discussion is the concept of bundling. Under such an approach, the hospital or other entity receives a flat sum for care, and the delivery of services is performed in the least costly environment which is safe for the patient. A cost-based system of reimbursement for operations including rehabilitation hospitals, subacute facilities and home care would be eliminated. Instead, governmental reimbursement would be tendered to an institution for an episode of illness. Some challengers to this concept cite their fear that hospitals would maintain bureaucracy at all costs and
410
CAROL L. SCHAFFER
fail to use more cost effective sites of care, even though to do so would be in their economic interest. A key aspect of home health care important to consumers is access. Each of the three components of home health care will be reviewed in regard to this issue. ACCESS TO HOME CARE IN THE UNITED STATES Access to home health care services is somewhat limited by strict reimbursement rules under Medicare. Patients in need of home care agency services must meet certain requirements including home-bound status, need for intermittent services, need for skilled services, and medically directed care. Private payors by and large follow the requirement that an agency be Medicare certified. Some will accept accreditation by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). Others require both Medicare certification and accreditation before the agency can provide care. The Medicare critera mentioned above, i.e., home-bound status, need for intermittent services, need for skilled services, and medically directed reasonable and necessary care, have been the source of litigation and sore points between providers and payors. In the past, the issue of homebound status was continuously reviewed by payors. The issue surrounds the degree of mobility which a patient demonstrates before he/she is deemed ineligible for services. While patients need not be bed-bound, their mobility must be considerably impaired for them to remain qualified for home care. Otherwise the patient is expected to go to an outpatient facility for treatment. Trips to the physician's office, as well as some additional outings, will not revoke home-bound status. The important point is government reimbursable home care should not be performed as a matter of patient convenience. Instead, it should be required because a patient is homebound. The policy underlying this requirement is economic. It is clearly more cost effective to treat patients in environments where more than one patient can be treated at a time. Recent guidelines have been proposed to clarify the meaning of homebound. These proposals advance the concept of tracking the number of hours a patient spends away from home as the basis for determining homebound status. From a practical standpoint, determining how long the patient is at home versus outside would be difficult because the providers of care only work with patients on an intermittent basis. The second criterion is the patient's need for intermittent services. Patient needs must be able to be met on an intermittent as opposed to on a continuous basis. The definition of intermittent services has recently been enforced by litigation forwarded by the National Association of Home Care. This litigation challenged the inconsistency between the governmental payor's propensity to reimburse in a fashion that excluded care which was clearly defined under the Medicare law as intermittent. The definition of intermittent care is outlined below.
THE REGULATORYSTRUCTURE
411
"Intermittent Care": Up to and including 28 hours per week of skilled nursing and home health aide services combined provided on a less than daily basis; Up to 35 hours per week of skilled nursing and home health aide services combined which are provided on a less than daily basis, subject to review by fiscal intermediaries on a case by case basis, based upon documentation justifying the need for and reasonableness of such additional care; or Up to and including full-time (i.e., eight hours per day) skilled nursing and home health aide services combined which are provided and needed severn days per week for temporary, but not indefinite, periods of time up to 21 days with allowances for extensions in exceptional circumstances where the need for care in excess of 21 days is finite and predictable.
-
-
-
Impact on Care Provided in Excess of "Intermittent" or "Part-time" Care. Home health aide and/or skilled nursing care in excess of amounts of care which meet these definitions of part-time or intermittent may be provided to a home care beneficiary or purchased by other payers without bearing on whether the home health aide and skilled nursing care meets the Medicare definitions of part-time or intermittent. EXAMPLE: A beneficiary needs skilled nursing care monthly for a catheter change and the home health agency also renders needed daily home health aide services 24 hours per day which will be needed for a long and indefinite period of time. The HHA bills Medicare for the skilled nursing and home health aide services which were provided before the 35th hour of service each week and bills the beneficiary (or another payer) for the remainder of the care. If the intermediary determines that the 35 hours of care are reasonable and necessary, Medicare would then cover the 35 hours of skilled nursing and home health aide visits.
Application Of This Policy Revision A beneficiary must meet the longstanding and unchanged qualifying criteria for Medicare coverage of home health services, before this policy revision becomes applicable to skilled nursing services and/or home health aide services. The definition of "intermittent" with respect to the need for skilled nursing care where the beneficiary qualifies for coverage based on the need for "skilled nursing care on an intermittent basis" remains unchanged. Specifically: -
-
This policy revision always applies to home health aide services when the beneficiary qualifies for coverage; This policy revision applies to skilled nursing care only when the beneficiary needs physical therapy or speech therapy or continued occupational therapy, and also needs skilled nursing care; and If the beneficiary needs skilled nursing care but does not need physical therapy or speech therapy or occupational therapy, the beneficiary must still meet the longstanding and unchanged definition of "intermittent" skilled nursing care in order to qualify for coverage of any home health services.
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From the Medicare Home Health Agency Manual published by the Department of Health and Human Services 1992 PB 92--055299 pg, 15.16-15.17. According to this definition patients may receive a greater intensity of care for periods of time when they need it. The successful litigation advanced by the National Association of Home Care enforces the regulatory definition of intermittent care. Access to home health care has increased for many needy patients. Nevertheless confusion about the definition of intermittent services has limited access to home care for others. As a consequence home care is mainly a viable option for patients fortunate enough to have household members available to provide most of their care or for patients whose illness is not so debilitating that intermittent services are insufficient to meet their needs. The third criterion - skilled services - is confusing, but generally refers to services which require the skill and training of a registered or licensed practical nurse. To make this definition operational, Medicare has defined a series of activities which it considers skilled. This criterion also limits access to home care because a nurse's more valuable assessment skills are more difficult to justify than the performance of tasks such as giving injections. Many challenges to reimbursement of providers by fiscal intermediaries have surfaced as payors challenge the necessity of a nurse's skills or believe family members or the patient can be taught to perform these activities. The final criterion is medically directed, reasonable and necessary care. The Medicare program requires that a physician certify and re-certify the medical necessity of such services. This requirement exists in spite of the fact that physicians are not reimbursed for this activity. Such lack of reimbursement to physicians for certification limits access to home care, as physicians are reluctant to spend time on non-reimbursed services. LACK OF ENCOURAGEMENT FOR INNOVATION IN HOME HEALTH CARE The current Medicare and Medicaid programs strongly discourage the development of innovative programs that could substantially reduce health care costs. An example of this can be found in the infusion therapy market segment. Currently infusion therapy is limited mainly to total parenteral nutrition and enteral therapy under Medicare's Part B reimbursement program. Under such programs, a patient must fall under the prosthetic device benefit. This means that the use of infusion and enteral therapy must be used to replace a non-functional organ. The balance of available programs such as home intravenous antibiotics and other therapies are not generally reimbursed by Medicare. In 1988, the Medicare Catastrophic Act included the addition of a broad range of such services which would have provided coverage. Unfortunately, this act was rescinded and reimbursement never emerged. As a consequence, Medicare patients do not have access to intravenous antibiotics, pain management, and other therapies routinely reimbursed under commercial insurance coverage. This lack of
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reimbursement continues to escalate hospital costs as Medicare patients under limited hospitalization reimbursement unnecessarily remain in the hospital. These same patients could be treated for less cost at home in an environment in which they would be far more comfortable. Finally, respiratory therapy/durable medical equipment has been under constant reimbursement scrutiny. Periodically the government revisits its payment methodology and proposes additional changes. Perhaps most troubling is the impact of reduced reimbursement under Medicare which causes companies to re-evaluate their ability to employ providers such as respiratory therapists. While patients have been able to receive durable medical equipment and respiratory therapy, the threat of reduced access looms with continuous reimbursement reductions under the Medicare program. DOCUMENTATION MANDATES UNDER MEDICARE Documentation is essential for reimbursement under the Medicare program. This documentation frequently involves duplication of information and many hours of completing forms. Medicare has carefully prescribed the documentation requirements for home care nursing agencies, i.e., HCFA forms 485, 486, 487 and possibly a 488, if additional medical information is required. In addition to completing these forms, the agency must fill out forms in compliance with physician's orders and submit them to the physician for signature. Physicians should receive a final copy of the treatment plan and must be notified about a patient's progress at least every 60 days, when recertification is required. The abundance of paperwork makes communication from home care agencies to physicians possible, but most physicians are annoyed by ongoing communication and have difficulty integrating it into their medical plans. Further, the lack of reimbursement for reviewing medical orders is understandably troubling to physicians. Although the physician is expected to order the treatments, he rarely knows the reimbursement rules or the rules of the payor. As a consequence, nursing agencies have taken on the burden of completing the forms after a first nursing evaluation visit and then asking the physician to sign appropriate orders. While this arrangement works practically, the physician is not as involved in the process as one would desire. Perhaps increased physician involvement in home care visits would be ideal to remedy this situation. Some slight encouragement for physician home visits may be available, as reimbursement for home visits increases under the Resource Based Relative Value Scale (RBRVS) system of reimbursement for physicians under Medicare. Reimbursement is, however, limited to actual physician house calls. Similar to home health care agencies, infusion companies and respiratory therapy/durable medical equipment suppliers must provide certification and recertification reports. These Statements of Medical Necessity and Certification Forms are the primary means of communication between the provider and the physician. In the interim, practitioners from companies call the physician with changes in orders and other pertinent information.
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CAROL L. SCHAFFER QUALITY IN HOME HEALTH CARE
Quality has been a recent focus in all health care as well as in home health care. In 1988, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) introduced a new manual devoted exclusively to the accreditation of home health care. This major breakthrough caused the home care industry rapidly to develop uniform standards. Prior to this program home care quality had been random and unstandardized. Accredition represents a significant step in providing insurance companies and others with criteria upon which providers of care can be selected. In fact, JCAHO accreditation has been employed by providers as a marketing tool in their sales calls with payors, and in the last few years most insurance companies have included JCAHO accreditation as a requirement. Home care agencies have generally needed Medicare certification to quality as a provider of services for other insurance companies. Infusion therapy and respiratory therapy/durable medical equipment industries do not have a similar rigorous independent accreditation program. As a consequence, the JCAHO process has become intensely popular with this market segment to signify the provision of a quality service. Beyond establishing a base line standard of quality for the home care industry, the accreditation process heralds the way for national measurement criteria such as patient care outcomes. In the near future we will be able to review such patient outcome criteria as the rate of hospital re-admissions after home care. Such measurable patient outcome information will do much for the establishment of home care as a credible provider of quality care. JCAHO is a mandatory accreditation program for hospital-based agencies. Mandatory accreditation for hospital-based agencies is founded upon the notion that consumers of care should not be forced to distinguish between a JCAHO accredited hospital and an un-accredited program. In fact the results of the home care accreditation process can adversely impact the hospital's accreditation. PHYSICIANS AND HOME CARE AGENCIES Presently physicians are not very involved in home care, The lack of reimbursement for physician services related to documentation and medical review and the limited reimbursement for physician home visits is a serious constraint on the development of positive physician-home care agency relationships. To make matters worse, physicians remain legally liable for the care of patients in the home, even though they have minimal control over the delivery process. Finally, some physicians are threatened by home care, as they perceive it to be directly competitive with their own office visits. In fact, in some rural communities home care may adversely impact a physician's income through decreased office visits when a nurse visits the patient at home, Much improvement could occur if reimbursement for physician involvement existed for the documentation aspects, and more reasonable reimbursement were
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available for physician home visits. Physicians also require education in these matters. Beyond reimbursement, communications between home care nurses and physicians would improve relationships. Unfortunately, a call from the home care nurse has frequently been viewed as a non-reimbursable event. Perhaps physician education and understanding of how to use the home care nurse as their own eyes and ears in the home might modify some of the negative attitudes. Despite physician complaints regarding limited home care reimbursement, physicians have supported the growth of home care as demonstrated by the projection of home care as a 9.8 billion dollar industry by the end of 1993 (Rak 1992). INTEGRATION AND COORDINATION DURING HOSPITALIZATION From the perspective of the hospital home care should provide continuity of care for patients as well as a new source of income. As hospitals deal with an increasingly limited definition of hospitalization, home care brings the opportunity to bridge care into the community. The program also offers an opportunity to increase the hospital's fiscal health by maximizing savings under the DRG system. In other words, if hospitals are able to discharge patients quicker into the home, the dollars earned under the DRG form of reimbursement are earned earlier in the hospitalization. Such an approach to earlier hospital discharges permits the hospital to operate a smaller number of units more efficiently. The hospital can also derive new income from the home health care operation. In addition to this aspect of integration, hospitals should examine how to successfully bridge their services. One key way to create this type of integration is through home care coordinators. Home care coordinators are highly skilled registered nurses and therapists who early in the admission match the needs of patients with home care systems. Coordinators act as facilitators and educators about the ever-changing home care environment. Typically hospital based programs use these types of coordinators to perform intake coordination at the hospital with one goal being to decrease the length of stay in the hospital. Hospitals should review legal issues that differentiate intake coordination from discharge planning. Legal questions have been raised about the presence in hospitals of discharge planners from outside nursing agencies, whose discharge planning services on behalf of the hospital could be construed as a form of kickback. SUMMARY Home health care exists in three market segments in the United States. These three segments include home care professionals, home infusion therapy, and home respiratory therapy/durable medical equipment. These services are best delivered when coordinated through a central system which involves nurses planning for the home care needs of patients prior to their discharge from the
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hospital. There are various types of providers including governmental, non-profit, forprofit and proprietary. The United States government has strongly influenced the development of home care through the Medicare program. From the government's point of view, home care is an additional cost to the Medicare system because hospitalization is reimbursed under a diagnostic related group which fixes reimbursement for a diagnosis. Since the payment for hospitalization is fixed irrespective of the length of hospitalization, all other payments to home care agencies are viewed as additional expenses. If the DRG did not exist, then home care could be reimbursed as a substitute for hospitalization at a lower cost. Access to home care in the United States is limited by Medicare reimbursement rules which restrict services to those requiring reasonable and necessary care, who are home-bound, and who require skilled intermittent care under the direction of a physician. Litigation by such organizations as the National Association of Home Care has prompted changes in the interpretation of reimbursement guidelines to benefit patients. Innovation in home care has mainly developed under the private pay reimbursement system. Under the private pay sector new programs delivered in the home are reimbursed on the basis of quality and cost effectiveness. Quality in home health care is a critical factor. Recent developments from the Joint Commission on Accreditation of Health Care Organizations have helped to standardize the measurement of quality. Finally, physicians have endorsed the advancement of home care services. A critical aspect of a sound home care program resides in coordination between the patients, in-patient caregivers and home care providers. One way to achieve coordination is through the use of nurses and therapists who plan for a patient's discharge and bring all necessary services together. REFERENCES Department of Health and Human Services 1992 PB 92-055299. Medicare Home Health Agency Manual. Baltimore. Rak, K. 1993 Home Health Line (April 28) XVIII: 40. CCF Health Care Ventures, Inc. The Cleveland Clinic Foundation 9775 Rockside Road - Suite 270 Cleveland, Ohio 44125, U.S.A.
