WASHINGTON, April 20 — Federal payments to provide home health care for the elderly have plummeted in the last two years, forcing many Medicare patients to spend more time in hospitals and nursing homes, health care providers say.
The trend has surprised and alarmed advocates for the elderly, health policy experts and many members of Congress.
New government data, compiled by the Congressional Budget Office, show that Medicare spending on home health care dropped 45 percent in the last two fiscal years — to $9.7 billion in 1999, from $14.9 billion in 1998 and $17.5 billion in 1997. The sharp decline in spending stems from changes Congress adopted in 1997 to slow the growth of Medicare. The changes limited payments to home care agencies, which provide a wide range of medical and social services to people who are so sick or disabled that they cannot leave their homes.
Senator Susan Collins, Republican of Maine, said, “The Medicare home health cutbacks have been far deeper and more wide-reaching than Congress ever intended.”
The figures from the budget office do not show how much payments to hospitals and nursing homes may have increased as a result of the cutbacks in home health care. Nor do they show how many people simply go without treatment after losing home health benefits, or how many such patients have died. But health care providers and lawyers for the elderly say they have evidence this is happening.
About 3.6 million people received home health care services through Medicare in 1997. The number dropped to 3 million in 1998 and has continued to decline, though official figures for 1999 are not yet available.
Marilyn Moon, a public trustee of the Medicare trust fund since 1995, said: “Most people were caught by surprise at the extent of the reductions. We expected home health spending to grow more slowly than in the past. But I don’t think anybody predicted an actual drop-off in dollars spent on home health care.”
A new study by the Congressional Budget Office found that “spending for home health care fell by 14.9 percent in 1998 and by an even more dramatic 34.9 percent in 1999.”
The cuts have become an issue in many Congressional elections, as politicians try to allay voters’ concerns about the future of home health care, one of the most popular Medicare benefits.
A Federal District Court found last month that home health agencies in nine states, including New Jersey,
Connecticut, California and Texas, had improperly reduced or terminated home health benefits for thousands of Medicare patients without giving them any notice of the cutbacks or of their right to appeal.
In its annual report to Congress on Medicare’s finances, the Clinton administration recently confirmed that there had been “a substantial decline in the utilization of home health care services” by Medicare beneficiaries.
The reduction in the use of home health care was one of the main reasons total Medicare spending dropped last year, for the first time in the 35-year history of the program.
If Congress takes no action, Medicare payments for home health care will be automatically cut by an additional 15 percent next year, saving at least $5 billion over five years.
Senator Collins is leading a bipartisan effort to eliminate the 15 percent cut, which she said “would seriously jeopardize access to home health services for millions of seniors.” Her bill has 38 co-sponsors — 24 Republicans and 14 Democrats, including Charles E. Schumer of New York and Robert G. Torricelli of New Jersey.
A similar effort is gaining momentum in the House, where legislation was introduced this month by Representatives Wes Watkins of Oklahoma, a Republican, and William J. Jefferson of Louisiana, a Democrat.
Carmela S. Coyle, senior vice president of the American Hospital Association, said: “In some communities, we are beginning to see a backup of patients in hospital beds because home health services are not available. Patients end up having to stay in the hospital longer. That tends to be more costly. And it’s not where patients prefer to receive their care.”
Larry Putnam, administrator of Phillips County Hospital in Malta, Mont., said: “Our hospital has been busier since the cutbacks in home health care. We attribute quite a bit of that to the fact that we can’t provide adequate home care. Patients are admitted or readmitted to the hospital or to a nursing home, and both of those are more expensive than home care. It seems to us a very short-sighted policy.”
Home health care agencies say they have been avoiding sicker patients, particularly those with multiple chronic conditions who require costly, intensive services, because it is difficult to care for them under the payment limits set by Medicare.
In early 1997, before the change in federal law, the Congressional Budget Office predicted that Medicare would spend $127 billion on home health care from 1998 to 2002. Now it says spending for such care in those years will total $58 billion, a reduction of $69 billion. That is more than four times what Congress expected to save when it passed the 1997 law.
Senator Chistopher S. Bond, Republican of Missouri, said the 45 percent cut in home health care spending was “perhaps the largest reduction for a specific type of provider that we have ever seen in Medicare.”
Laura A. Dummit, a health policy expert at the General Accounting Office, an investigative arm of Congress, said: “Estimates of home health spending have just plummeted. None of us believed home health spending could drop so much so fast.”
Judith A. Stein, director of the Center for Medicare Advocacy in Willimantic, Conn., said home health agencies “do not want to keep patients who have long-term needs,” because they are seen as too expensive. For example, she said, it has been impossible to obtain home care for one of her clients, a Medicare beneficiary in Connecticut who has lost a kidney and is blind from diabetes. “The home health agencies don’t want him or his kind,” Ms. Stein said.
Susan M. Pascoe, director of home care services at Ascension Health, one of the largest Roman Catholic health care systems in the United States, said home health agencies had become much more cautious about taking patients who required extensive care. “We are not being paid to take care of patients who need a high level of care,” said Ms. Pascoe, whose organization runs 30 home health agencies in 13 states. “It’s difficult to accept those patients and stay in business.” Ms. Pascoe said many home care agencies had adopted stricter “admission criteria,” stipulating, for example, that a patient must have a close relative who can provide some of the care. “The most needy patients, those living alone with complex needs, are being eliminated from services,” she said.
In addition, Ms. Pascoe said, many home health agencies now seek patients who need just a few weeks of care, but shun “long-term patients” — for example, stroke patients with a long rehabilitation period — who require months of care. This is consistent with findings of a federal panel, the Medicare Payment Advisory Commission, which said home health agencies were “refusing services to Medicare patients who have chronic, long-term conditions, especially diabetes.”
Medicare officials said they hoped these incentives would change under a proposed new payment system. Home health agencies would get a fixed amount of money for each 60-day “episode of care,” with payments adjusted to reflect the severity of a person’s illness. But home care experts said they believed the payments would still be inadequate to cover the costs of the sickest patients.
By Robert Pear, NY Times
