Medicare funding for home health care declines

There?s no place like home, unless you need some medical care there. In that case, Medicare says, ?There?s no place like a nursing home.?
At a time when the demand for home care is going up, Medicare?s support for it is going down, a trend that started with the Balanced Budget Act of 1997 and was given another kick in 2002 when home health agencies received an additional across-the-board cut in Medicate home-health payments.
In an open letter to the U.S. Senate Finance Committee, a bipartisan group of senators acknowledged that ?rapid growth in home health care spending in the 1990s understandably prompted the Congress and the administration to initiate changes that were intended to slow this growth in spending and make the program more cost-effective and efficient.?
The June 2003 letter goes on to say, however, that draconian cuts in home-health spending did more than slice away fat; they sliced away sinew and bone. It notes that by 2003, more than 3,400 home-health agencies had closed or stopped serving Medicare beneficiaries and that ?Medicare patients receiving home health care dropped by 1.3 million ? more than one-third.?
The letter expresses the hope that further cuts can be avoided. From the looks of the new legislation (bearer of the prescription-drug benefit), the letter did not have much effect.

Forced out by changes
Lynn Kalert, a registered nurse, tried to deal with the original cuts and the subsequent changes in the rules designed to ?make the program cost-effective.? What she found (as the senators also argued) was that cost efficiencies and the paperwork to document them all had nothing to do with good medical practice. And so she left.
?I did home health care for 10 years, at a time when there were no restrictions on it,? she said. ?I could walk into extremely stressful situations and help. By the time I left, around 1997, I was having to teach children how to do wound care because Medicare wouldn?t cover my time to do it. It broke my heart.?
Kalert noted that the regulations for care were not negligent in terms of what a patient might expect in terms of overall time allotted for non-hospital recovery or rehabilitation. It was just where the time had to be taken that mystified her.
?Medicare would cover 120 days in a nursing home after discharge from a hospital, but nothing for home care,? she said. ?If you wanted to stay in your home in Fort Collins and not have to go stay in an approved nursing home in Denver, you had to sue.?
Even as Medicare-supported home care has declined, however, demand has gone up, with the unintended consequence of creating large medical debt for people who would prefer to recover and rehabilitate in their own homes.
?The demand for home health care is greater than ever,? said Nancy Driskill, a registered nurse with Consultants for Aging Families. ?Older people are discovering that they are not living to the end of their days without health problems. At some point, almost everyone is going to need some skilled care.?
(Skilled care, incidentally, as defined in the Medicare lexicon is that which must be given or supervised by registered nurses ? the very people getting regulated out of Medicare-supported home care.)
Driskill noted that, in the past, it seemed inevitable that that skilled care would be delivered in a nursing home. Now there are choices. In her business, Driskill and her associate, Linda Henry, help families deal with what is possible (and affordable) in the realm of care.

Three ways to pay
?There are generally three ways that people pay for skilled home care,? she said. ?Some insurance policies have provisions for private home care. Another option is private pay, at $13 to $22 per hour. Medicare has been severely limited by the regulations.?
None of these options is particularly appealing. Insurance is expensive, as is private pay. As Driskill explained it, if you need a presence for six hours a day, then in a year you would have paid enough to put two people in a nursing home.
Then there is Medicare, and there the devil is in the definitions. ?Home-bound,? for example (what one has to be to get skilled home care), requires that the beneficiary be certified by a physician as having a disabling condition, unlikely to improve, which requires that the beneficiary depend on assistance for at least three of the five activities (curiously left undefined) of daily living. Oddly, the guidelines also state that the beneficiary must not regularly work in a paid position full-time or part-time outside the home.
Translated into more practical terms as Kalert saw them, a home-bound person would be allowed to get to a doctor?s office (with great difficulty), but not to church and not to get an ice cream on a sunny day. The home-bound had better stay at home or lose their benefits.
Like Kalert, Hospice of Larimer County bowed out of the home care business, deciding instead to focus on end-of-life home care instead of care designed for recovery.
?Home health care and hospice care require two different licenses,? said Evan Hyatt, marketing manager. ?The state basically said that if we did not serve more home care clients, we would lose that license, and so we redefined our mission to be the best hospice provider in the county.?
A unique subset of home health care, hospice (as described on the Medicare Rights Center Web site (www.medicarerights.org ) ?neither shortens nor prolongs life. Instead, it concentrates on improving the quality of life as much as possible.? The assumption is that ?suffering does not have to be an inevitable part of advanced illness.? However, hospice, too, must conform to clear guidelines in order to qualify as a Medicare benefit.
?Insurance ? and Medicare is our largest insurer ? sees you as ?hospice appropriate? or not,?? Hyatt said. ?That means that the person will die within six months, considering the normal progression of the disease.?
He also pointed out that, because individuals rarely conform to medical averages, one might go in and out of hospice several times in the course of the disease. Larimer County Hospice evaluates patients after three months.
The Medicare benefit for home health care may also (in time) need a dose of reevaluation itself. Kalert, who observed firsthand the positive value of home care, thinks that the pendulum will swing back because of increased demand.
Driskill thinks that maybe the entire definition of home care will expand as an aging population begins to grapple with just how it would like to age.
?I think our generation can figure this out,? she said. ?It?s just now beginning to hit us that having it all and getting it all is not the end of everything. It may be that we will be forced to quit making medicine responsible for our health because we can?t afford it. People are adaptive and will find new ways to take care of themselves.?

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