Medicare home health before and after the BBA

Health Affairs

Volumn 20, Issue 3, 2001, Pages 189-197

  McCall, Nelda ^a   Komisar, Harriet L ^b   Petersons, Andrew ^a   Moore, Stanley ^a  

^a Laguna Research Associates   (United States)

^b GEORGETOWN UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AGED; ARTICLE; BUDGET; COMPARATIVE STUDY; ECONOMICS; FEMALE; GOVERNMENT; HEALTH CARE COST; HEALTH CARE POLICY; HEALTH SERVICES RESEARCH; HOME CARE; HUMAN; LEGAL ASPECT; MALE; MEDICARE; STATISTICS; UNITED STATES; UTILIZATION REVIEW;

AGED; BUDGETS; FEMALE; HEALTH EXPENDITURES; HEALTH POLICY; HEALTH SERVICES RESEARCH; HOME CARE SERVICES; HUMANS; MALE; MEDICARE; UNITED STATES; UNITED STATES CENTERS FOR MEDICARE AND MEDICAID SERVICES;

EID: 0035346519     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.20.3.189     Document Type: Article

References (25)

1. Potential problems are analyzed in B. Gage, Medicare Home Health and the IPS: Is Access a Problem? (Washington: Urban Institute, April 1999); H. Komisar and J. Feder, The Balanced Budget Act of 1997: Effects on Medicare's Home Health Benefit and Beneficiaries Who Need Long-Term Care (Washington: Georgetown University Institute for Health Care Research and Policy, February 1998); and Lewin Group, Implications of the Medicare Home Health Interim Payment System of the 1997 Balanced Budget Act (Washington: National Association for Home Care, March 1998). Studies of changes include U.S. General Accounting Office, Medicare Home Health Benefit: Impact of Interim Payment System and Agency Closures on Access to Service, Pub. no. GAO/HEHS-98-238 (Washington: GAO, September 1998); Medicare Payment Advisory Commission, Report to the Congress: Selected Medicare Issues (Washington: MedPAC, June 1999); MedPAC, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2000); GAO, Closures Continue, with Little Evidence Beneficiary Access Is Impaired, Pub. no. GAO/HEHS-99-120 (Washington: GAO, May 1999); B.M. Smith, K.A. Maloy, and DJ. Hawkins, An Examination of Medicare Home Health Services: A Descriptive Study of the Effects of the Balanced Budget Act Interim Payment System on Access to and Quality of Care (Washington: George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, September 1999); and Office of Inspector General, Medicare Beneficiary Access to Home Health Agencies (Washington: U.S. Department of Health and Human Services, October 1999).
2. Potential problems are analyzed in B. Gage, Medicare Home Health and the IPS: Is Access a Problem? (Washington: Urban Institute, April 1999); H. Komisar and J. Feder, The Balanced Budget Act of 1997: Effects on Medicare's Home Health Benefit and Beneficiaries Who Need Long-Term Care (Washington: Georgetown University Institute for Health Care Research and Policy, February 1998); and Lewin Group, Implications of the Medicare Home Health Interim Payment System of the 1997 Balanced Budget Act (Washington: National Association for Home Care, March 1998). Studies of changes include U.S. General Accounting Office, Medicare Home Health Benefit: Impact of Interim Payment System and Agency Closures on Access to Service, Pub. no. GAO/HEHS-98-238 (Washington: GAO, September 1998); Medicare Payment Advisory Commission, Report to the Congress: Selected Medicare Issues (Washington: MedPAC, June 1999); MedPAC, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2000); GAO, Closures Continue, with Little Evidence Beneficiary Access Is Impaired, Pub. no. GAO/HEHS-99-120 (Washington: GAO, May 1999); B.M. Smith, K.A. Maloy, and DJ. Hawkins, An Examination of Medicare Home Health Services: A Descriptive Study of the Effects of the Balanced Budget Act Interim Payment System on Access to and Quality of Care (Washington: George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, September 1999); and Office of Inspector General, Medicare Beneficiary Access to Home Health Agencies (Washington: U.S. Department of Health and Human Services, October 1999).
3. Potential problems are analyzed in B. Gage, Medicare Home Health and the IPS: Is Access a Problem? (Washington: Urban Institute, April 1999); H. Komisar and J. Feder, The Balanced Budget Act of 1997: Effects on Medicare's Home Health Benefit and Beneficiaries Who Need Long-Term Care (Washington: Georgetown University Institute for Health Care Research and Policy, February 1998); and Lewin Group, Implications of the Medicare Home Health Interim Payment System of the 1997 Balanced Budget Act (Washington: National Association for Home Care, March 1998). Studies of changes include U.S. General Accounting Office, Medicare Home Health Benefit: Impact of Interim Payment System and Agency Closures on Access to Service, Pub. no. GAO/HEHS-98-238 (Washington: GAO, September 1998); Medicare Payment Advisory Commission, Report to the Congress: Selected Medicare Issues (Washington: MedPAC, June 1999); MedPAC, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2000); GAO, Closures Continue, with Little Evidence Beneficiary Access Is Impaired, Pub. no. GAO/HEHS-99-120 (Washington: GAO, May 1999); B.M. Smith, K.A. Maloy, and DJ. Hawkins, An Examination of Medicare Home Health Services: A Descriptive Study of the Effects of the Balanced Budget Act Interim Payment System on Access to and Quality of Care (Washington: George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, September 1999); and Office of Inspector General, Medicare Beneficiary Access to Home Health Agencies (Washington: U.S. Department of Health and Human Services, October 1999).
4. Potential problems are analyzed in B. Gage, Medicare Home Health and the IPS: Is Access a Problem? (Washington: Urban Institute, April 1999); H. Komisar and J. Feder, The Balanced Budget Act of 1997: Effects on Medicare's Home Health Benefit and Beneficiaries Who Need Long-Term Care (Washington: Georgetown University Institute for Health Care Research and Policy, February 1998); and Lewin Group, Implications of the Medicare Home Health Interim Payment System of the 1997 Balanced Budget Act (Washington: National Association for Home Care, March 1998). Studies of changes include U.S. General Accounting Office, Medicare Home Health Benefit: Impact of Interim Payment System and Agency Closures on Access to Service, Pub. no. GAO/HEHS-98-238 (Washington: GAO, September 1998); Medicare Payment Advisory Commission, Report to the Congress: Selected Medicare Issues (Washington: MedPAC, June 1999); MedPAC, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2000); GAO, Closures Continue, with Little Evidence Beneficiary Access Is Impaired, Pub. no. GAO/HEHS-99-120 (Washington: GAO, May 1999); B.M. Smith, K.A. Maloy, and DJ. Hawkins, An Examination of Medicare Home Health Services: A Descriptive Study of the Effects of the Balanced Budget Act Interim Payment System on Access to and Quality of Care (Washington: George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, September 1999); and Office of Inspector General, Medicare Beneficiary Access to Home Health Agencies (Washington: U.S. Department of Health and Human Services, October 1999).
5. Potential problems are analyzed in B. Gage, Medicare Home Health and the IPS: Is Access a Problem? (Washington: Urban Institute, April 1999); H. Komisar and J. Feder, The Balanced Budget Act of 1997: Effects on Medicare's Home Health Benefit and Beneficiaries Who Need Long-Term Care (Washington: Georgetown University Institute for Health Care Research and Policy, February 1998); and Lewin Group, Implications of the Medicare Home Health Interim Payment System of the 1997 Balanced Budget Act (Washington: National Association for Home Care, March 1998). Studies of changes include U.S. General Accounting Office, Medicare Home Health Benefit: Impact of Interim Payment System and Agency Closures on Access to Service, Pub. no. GAO/HEHS-98-238 (Washington: GAO, September 1998); Medicare Payment Advisory Commission, Report to the Congress: Selected Medicare Issues (Washington: MedPAC, June 1999); MedPAC, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2000); GAO, Closures Continue, with Little Evidence Beneficiary Access Is Impaired, Pub. no. GAO/HEHS-99-120 (Washington: GAO, May 1999); B.M. Smith, K.A. Maloy, and DJ. Hawkins, An Examination of Medicare Home Health Services: A Descriptive Study of the Effects of the Balanced Budget Act Interim Payment System on Access to and Quality of Care (Washington: George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, September 1999); and Office of Inspector General, Medicare Beneficiary Access to Home Health Agencies (Washington: U.S. Department of Health and Human Services, October 1999).
6. Potential problems are analyzed in B. Gage, Medicare Home Health and the IPS: Is Access a Problem? (Washington: Urban Institute, April 1999); H. Komisar and J. Feder, The Balanced Budget Act of 1997: Effects on Medicare's Home Health Benefit and Beneficiaries Who Need Long-Term Care (Washington: Georgetown University Institute for Health Care Research and Policy, February 1998); and Lewin Group, Implications of the Medicare Home Health Interim Payment System of the 1997 Balanced Budget Act (Washington: National Association for Home Care, March 1998). Studies of changes include U.S. General Accounting Office, Medicare Home Health Benefit: Impact of Interim Payment System and Agency Closures on Access to Service, Pub. no. GAO/HEHS-98-238 (Washington: GAO, September 1998); Medicare Payment Advisory Commission, Report to the Congress: Selected Medicare Issues (Washington: MedPAC, June 1999); MedPAC, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2000); GAO, Closures Continue, with Little Evidence Beneficiary Access Is Impaired, Pub. no. GAO/HEHS-99-120 (Washington: GÅO, May 1999); B.M. Smith, K.A. Maloy, and DJ. Hawkins, An Examination of Medicare Home Health Services: A Descriptive Study of the Effects of the Balanced Budget Act Interim Payment System on Access to and Quality of Care (Washington: George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, September 1999); and Office of Inspector General, Medicare Beneficiary Access to Home Health Agencies (Washington: U.S. Department of Health and Human Services, October 1999).
7. Potential problems are analyzed in B. Gage, Medicare Home Health and the IPS: Is Access a Problem? (Washington: Urban Institute, April 1999); H. Komisar and J. Feder, The Balanced Budget Act of 1997: Effects on Medicare's Home Health Benefit and Beneficiaries Who Need Long-Term Care (Washington: Georgetown University Institute for Health Care Research and Policy, February 1998); and Lewin Group, Implications of the Medicare Home Health Interim Payment System of the 1997 Balanced Budget Act (Washington: National Association for Home Care, March 1998). Studies of changes include U.S. General Accounting Office, Medicare Home Health Benefit: Impact of Interim Payment System and Agency Closures on Access to Service, Pub. no. GAO/HEHS-98-238 (Washington: GAO, September 1998); Medicare Payment Advisory Commission, Report to the Congress: Selected Medicare Issues (Washington: MedPAC, June 1999); MedPAC, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2000); GAO, Closures Continue, with Little Evidence Beneficiary Access Is Impaired, Pub. no. GAO/HEHS-99-120 (Washington: GAO, May 1999); B.M. Smith, K.A. Maloy, and DJ. Hawkins, An Examination of Medicare Home Health Services: A Descriptive Study of the Effects of the Balanced Budget Act Interim Payment System on Access to and Quality of Care (Washington: George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, September 1999); and Office of Inspector General, Medicare Beneficiary Access to Home Health Agencies (Washington: U.S. Department of Health and Human Services, October 1999).
8. The GAO (1999) and OIG reports found few access problems, but the MedPAC and George Washington University reports indicate that agencies were excluding sicker beneficiaries or limiting their care.
9. MedPAC, Report to the Congress, 1999.
10. Ibid., data adjusted for the increase in the Consumer Price Index.
11. Duggan v Bowen, 691 F.Supp. 1487 (D.D.C. 1988).
12. Komisar and Feder, The Balanced Budget Act of 1997; and Lewin Group, Implications of the Medicare Home Health Interim Payment System.
13. This limit was 112 percent of the average cost per visit for free-standing agencies by discipline. The six home health disciplines are skilled nursing, physical therapy, occupational therapy, speech language pathology, medical social services, and home health aide.
14. Costs for each discipline did not have to be lower, as costs above the limit for one discipline could be offset by costs below the limit for another and still be under the aggregate per visit limit.
15. GAO, Medicare Home Health Utilization Expands while Program Controls Deteriorate, Pub. no. GAO/ HEHS-96-16 (Washington: GAO, March 1996); and GAO, Long Term Care: Baby Boom Generation Presents Financing Challenges, Pub. no. GAO/HEHS98-107 (Washington: GAO, March 1998).
16. GAO, Medicare Home Health Utilization Expands while Program Controls Deteriorate, Pub. no. GAO/ HEHS-96-16 (Washington: GAO, March 1996); and GAO, Long Term Care: Baby Boom Generation Presents Financing Challenges, Pub. no. GAO/HEHS98-107 (Washington: GAO, March 1998).
17. The BBA defines "intermittent" skilled nursing as "skilled nursing care that is either provided or needed on fewer than 7 days each week, or less than 8 hours of each day for periods of 21 days or less (with extensions in exceptional circumstances...)." Balanced Budged Act of 1997, Sec. 4612(a). The DHHS study did not yield a new definition of "homebound" that was considered superior to existing law and recommended that the existing policy be retained.
18. The IPS reduced the national per visit cost limitations per discipline from 112 percent of the mean to 105 percent of the median per visit costs for free-standing home health agencies. For old agencies (those with a twelve-month cost reporting period ending in FY1994), the per beneficiary limit was set at 98 percent of the blended (75 percent agency, 25 percent census region) average cost per beneficiary based on cost reporting periods ending in FY 1994. For new agencies the per beneficiary limitation was set at the national median of per beneficiary limitations. The Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCESAA) for FY 1999 raised the per visit limitation from 105 percent to 106 percent of the median. It also raised the per beneficiary limitation for some new agencies and old agencies whose per beneficiary limitations were less than the national median. Per beneficiary limitations for providers whose first cost reporting period began during FY 1999 were set at 75 percent of the median national per beneficiary limitation.
19. Health Insurance Portability and Accountability Act of 1996, P.L 104-191, Sec. 232.
20. Agencies have five months to file a cost report after the end of their cost reporting period, and intermediaries generally do not make settlement determinations until approximately eighteen months after receiving the cost report. In practice, there are often further delays because of late submission of cost reports and other administrative issues. For additional details, see GAO, Overpayments Are Hard to Identify and Even Harder to Collect, Pub. no. GAO/HEHS/AIMD-00-132 (Washington: GAO, April 2000).
21. Diagnoses selected were those that occurred most frequently in the home health claims database or were of interest for other reasons. The diagnoses and their codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) are diabetes, 250; hypertensive disease, 401-405; heart failure, 428; cardiac disrythmias, 427; chronic ischemic heart disease, 414; cerebrovascular diseases, 430-438; osteoarthritis and related disorders, 715; chronic airway obstruction, 496; skin ulcers, 707; and fractured femur, 820-821, 9053.
22. S.K. Long, K. Liu, and C. Rimes, Home Care Services under Medicare and Medicaid: Is There Evidence of Medicare Maximization? (Washington: Urban Institute, August 1999).
23. GAO, Closures Continue.
24. Congressional Budget Office, Estimated Budgetary Impact of H.R. 2015 (Public Law 105-33), The Balanced Budget Act of 1997 (Washington: CBO, 12 August 1997).
25. H.L Komisar, J.M. Lambrew, and J. Feder, Long-Term Care for the Elderly: A Chart Book (New York: Commonwealth Fund, December 1996).