Correspondence

Medicare Home Health Care Services

N Engl J Med 1997; 336:226-228January 16, 1997

Article

To the Editor:

Recent regulatory changes have allowed a larger number of Medicare beneficiaries to receive more covered home health care visits, some over lengthy episodes of care. However, a focus on visits rather than patients or episodes of care appears to have led Welch et al. (Aug. 1 issue)1 to announce prematurely the conversion of Medicare to a long-term care entitlement. As with other health care services, a relatively small number of patients are responsible for a large proportion of home health care visits and expenses covered by Medicare, while a substantial majority receive smaller amounts of care. In 1992, for example, 74 percent of Medicare beneficiaries received care lasting less than 4 months and averaging 42 days.2 By no definition can this be considered long-term care.

Furthermore, duration alone cannot be used to define long-term care — i.e., care that meets the needs of those with functional disabilities. Some beneficiaries have medical conditions that require skilled services over a period of months or years. It is not logical to conclude that caring for these patients at home is medically unnecessary or that their home health care visits, although removed in time from their discharge from the hospital, do not prevent the costly use of other services and adverse health outcomes.

The article may mislead readers on other counts as well. Evidence is mixed concerning the substitution of paid care for family-provided care, with most studies showing that paid care sustains the continued provision of family support.3 Moreover, few would argue that family members should be providing technical, skilled health care services to patients with acute and chronic illnesses. Positive correlations between home health care and hospital use, instead of contradicting a substitution effect, verify the old tautology that areas well-endowed with health care resources are well-endowed with health care resources. The study's high-discretion diagnosis-related groups (DRGs) are not specified but are unlikely to replicate the discharge-diagnosis lists sensitive to home care that were developed for other studies. Offhand remarks linking geographical variation with fraud divert attention from the larger challenge of redesigning payment policies to encourage cost-effective care.

Finally, there is an inherent difficulty in legitimizing only those Medicare home health care visits that constitute “transitional” rather than long-term care. Many Medicare beneficiaries have both medical and disability-related needs. Some of the most promising innovations in the delivery system are integrated models of care combining disparate funding streams and allowing flexible service combinations that recognize this fact. Operating within predetermined budget constraints, such models can eliminate the need to make artificially sharp distinctions among acute, post-acute, and supportive services.

Penny Hollander Feldman, Ph.D.
Visiting Nurse Service of New York, New York, NY 10021

Christine E. Bishop, Ph.D.
Brandeis University, Waltham, MA 02254-9110

3 References

1
Welch HG, Wennberg DE, Welch WP. The use of Medicare home health care services. N Engl J Med 1996;335:324-329
Full Text | Web of Science | Medline

2
Goldberg HB, Schmitz RJ. Contemplating home health PPS: current patterns of Medicare service use. Health Care Financ Rev 1994;16:109-130
Web of Science | Medline

3
Tennstedt SL, Crawford SL, McKinlay JB. Is family care on the decline? A longitudinal investigation of the substitution of formal long-term care services for informal care. Milbank Q 1993;71:601-624
CrossRef | Web of Science | Medline

To the Editor:

The conclusion that Welch et al. reach is one the home health care industry has been well aware of for some time: that given the lack of a cohesive policy on long-term care in this country, Medicare's home health care benefit has, by default, filled the vacuum. The evolution of home health care is a result of deliberate congressional action (the elimination of the requirement that a patient have been previously hospitalized) and changing medical practice (a shift in technology from institutional to outpatient and home settings). As a front-line observer of this evolution, I question the validity of the conclusion that home health care services do not, in many instances, substitute for institutional care. Welch et al. looked only at data from a six-month period in 1993 before concluding that there was no statistically significant difference between patients who had received home health care and those who had not. A historical review would present a different picture — hospital admissions and lengths of stay have decreased over the time that the use of home health care has grown most rapidly. In 1982, for example, the number of hospital days per 1000 Medicare beneficiaries was 3889. By 1993, this figure had dropped to 2474. Over the same period, the number of Medicare home health care visits per 1000 beneficiaries increased from 1054 to 4842. Although the availability and increased technological capability of home care may not have been responsible for the shift (the use of DRGs certainly had a role), they made the shift possible.

It is simplistic of the authors to suggest that the issue is lax oversight by authorizing physicians or a lack of consensus as to the interpretation of the home health care benefit. The real issue is that as long as we lack a national policy on long-term care, we will continue to blame patients and providers for their attempts to piece something together.

Ellen Rothberg, R.N.
Home and Health Care Association of Massachusetts, Boston, MA 02116

To the Editor:

On behalf of the Visiting Nurse Associations of America (VNAA), we are responding to the article by Welch et al. The VNAA is concerned that readers will conclude that limiting Medicare home health care to short-term episodes will lead to cost containment. We disagree. In the absence of such care, many patients would be placed in nursing homes or hospitalized, which would inevitably increase national health care costs.

The primary goal should be providing high-quality, cost-effective care at each stage of a patient's treatment. Controlling overutilization is essential to this process. Reports from the General Accounting Office (GAO) and the Office of the Inspector General attribute the rapid growth of expenditures for home health care to overutilization. The article's findings support this argument: 61 percent of visits were made to enrollees who received care for six months or more. In contrast, 21 percent of all episodes of care (i.e., 120 days after admission) extend beyond 165 days.1 The vast majority of Visiting Nurse Association (VNA) patient episodes last four months or less (77 percent).1 VNAs also average 29 percent fewer visits per long-term episode than do all other agencies combined.2 These data demonstrate that the volume of visits (not the number of patients) is highest in the long-term period.

The VNAA cautions policy makers who review the study not to draw conclusions about utilization rates for the entire industry. Such rates vary substantially among different types of agencies. The VNAA supports the industry's prospective-payment plan, which would create cost effectiveness at each stage of care. Restricting Medicare home health care would increase costs. Several state Medicaid programs for long-term home care have produced considerable savings by enabling more beneficiaries to receive care with the available Medicaid dollars.3 “On a per-beneficiary basis, home- and community-based care is considerably less expensive than nursing-facility care,” noted a GAO report.3

Finally, 59 percent of home health care episodes covered by Medicare begin within 30 days after a patient is hospitalized,4 which illustrates how home care “steps in” and alleviates the need for inpatient care.

Janice Treml, M.P.H., R.N.
Visiting Nurse Associations of America, Denver, CO 80210

Emilie Deady, M.S.N., R.N.
Visiting Nurse Association of Northern Virginia, Arlington, VA 22206

4 References

1
Prospective Payment Assessment Commission analysis. Washington, D.C.: Prospective Payment Assessment Commission, November 1995.

2
Study funded by VNAA. Cambridge, Mass.: Abt Associates, 1996.

3
Medicaid long term care: successful state efforts to expand home services while limiting costs. Washington, D.C.: General Accounting Office, August 1994.

4
Prospective Payment Assessment Commission report. Washington, D.C.: Prospective Payment Assessment Commission, June 1996.

To the Editor:

I feel that it is absolutely necessary to abolish physician ownership of nursing care companies. It is curious that when home nursing agencies were owned by entities such as not-for-profit hospitals, home nursing was not the booming business that it is today. It is only now, when home nursing care provides direct income to the physician owners, that home nursing is being so widely used.

Peter D. de Ipolyi, M.D.
Stehlin and de Ipolyi Oncology Clinic, Houston, TX 77002-8299

Author/Editor Response

The authors reply:

To the Editor: Drs. Feldman and Bishop suggest that our focus on visits (which translate to expenditures given a fixed set of prices) rather than patients led to an erroneous conclusion that Medicare home health care has become primarily a long-term care program. Because we were principally interested in where the dollars were spent (the question we believe to be most germane to public policy), we chose visits. Given that 61 percent of the visits were to enrollees receiving six months or more of services, we concluded that Medicare home health care has become a long-term care program — and, according to Ms. Rothberg, the industry has been aware of this for some time.

Our evaluation of the substitution of home health care for acute care services was criticized by Ms. Rothberg for lacking a historical context and by Drs. Feldman and Bishop for its choice of DRGs. Ms. Rothberg combines two distinct time periods. While the introduction of a prospective-payment system in the early 1980s did decrease the average length of stay, this reduction was accompanied by a contemporaneous decrease in the use of home health care services.1 The dramatic increase in home health care occurred in 1988–1989 and was related to changes in the Medicare manual. The high-variation medical DRGs in our study included conditions such as congestive heart failure and pneumonia — exactly the conditions found in most lists of ambulatory-sensitive conditions. The 18 DRGs were empirically selected as those most frequently involving home care after discharge. Although there has probably been some substitution in the past,2 we were more interested in the current system and found little there.

We concur with Treml and Deady and de Ipolyi that ownership status is an important issue. For-profit home health care agencies deliver more services per episode than not-for-profit agencies.3 Although we cannot comment on whether physician ownership (or for that matter ownership by nurses or physical therapists) would increase the number of services per episode, this has been found to be the case in the delivery of other health care services.4

Treml and Deady support the enactment of a prospective-payment system for Medicare home health care. However, we are less than sanguine about the ability of this regulatory change to contain the growth of home health care. The coefficient of variation of the number of patients receiving home health care per 1000 enrollees across metropolitan statistical areas (MSAs) was 27.4, larger than that for hospital admissions or physicians' services. Although a prospective-payment system would be likely to decrease the number of visits per episode, plausibly the numbers of users per 1000 enrollees in low-use MSAs would increase dramatically. Thus, a prospective-payment system could actually increase expenditures for home health care.

Finally, in our study we explicitly avoided making value judgments about the worth of home health care. We do not dispute that these services may be valued by patients and providers, nor do we blame those trying to do the best they can to piece together care from a fragmented system. Instead, we simply intended to describe where the money is going and let policy makers and the public at large make their own judgments about its worth.

David E. Wennberg, M.D., M.P.H.
Maine Medical Assessment Foundation, Manchester, ME 04351

H. Gilbert Welch, M.D., M.P.H.
Department of Veterans Affairs, White River Junction, VT 05009

4 References

1
House Committee on Ways and Means. Overview of entitlement programs. Washington, D.C.: Government Printing Office, 1994. (Publication no. WMCP:103-27.)

2
Kenney GM. Understanding the effects of PPS on Medicare home health use. Inquiry 1991;28:129-139
Web of Science | Medline

3
Goldberg HB, Schmitz RJ. Contemplating home health PPS: current patterns of Medicare service use. Health Care Financ Rev 1994;16:109-130
Web of Science | Medline

4
Mitchell JM, Scott E. Physician ownership of physical therapy services: effects on charges, utilization, profits, and service characteristics. JAMA 1992;268:2055-2059
CrossRef | Web of Science | Medline

Citing Articles (1)