GWU report cites more evidence of disruption in home healthcare
GWU report cites more evidence of disruption in home healthcare
By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON Sixty-eight percent of all hospital discharge planners surveyed by the George Washington University (GWU) Center for Health Services Research & Policy reported increased difficulty in initially obtaining home health services for Medicare patients that require home healthcare, according to a report released last week. Meanwhile, only 22% of hospital discharge planners surveyed reported no changes in difficulty in obtaining or sustaining home healthcare services for Medicare beneficiaries since implementation of the interim payment system (IPS).
Those findings were included among the results of the second phase of a two-part study by GWU designed to measure the impact of payment changes mandated by the Balanced Budget Act of 1997 (BBA).
The Home Health Staffing & Services Association (HHSSA; Washington), which helped fund the study, said the findings are further evidence of a severe decrease in access to home health services for the sickest, most frail Medicare beneficiaries over the past two years. The first part of the study reported on changes in home health agency patient admitting practices, clinical practice patterns, and staffing patterns that could affect beneficiary access to care or the quality of that care.
The initial phase of the study found that the majority of home health agencies responding had altered their case mix and/or practice patterns to conform utilization to reimbursement. It also found that home health agencies located in the south generally lack the capability to alter their case mix as much as other regions. In addition, chronically ill beneficiaries were found to have experienced the highest degree of fragmented care, as well as more disruptions in care as a result of payment changes.
This phase of the study zeroed in on the experience of hospital planners in obtaining home health services for Medicare beneficiaries after discharge from the hospital since IPS was imposed in 1997.
Among the other major findings from the report were the following:
• Sixty-one percent of discharge planners surveyed reported increased difficulty in obtaining sufficient intensity of services sought in the initial placement.
• Fifty-six percent of respondents reported increases in the number of beneficiaries requiring substitute placements, primarily in skilled nursing facilities, in lieu of home health services.
• Forty-one percent of discharge planners surveyed reported increased hospital readmission rates among beneficiaries initially discharged to home health services.
• Discharge planners reported that the type of beneficiary presenting discharge problems is predictable based on the beneficiary’s service needs.
According to the report, discharge planners indicate that the most serious placement and sufficiency problems apply to chronically ill, medically complex beneficiaries, as well as those who require high intensity services over a relatively short period of time.
The beneficiaries that were found to be most affected were those with pulmonary disease, congestive heart failure, IV therapy and infusion needs, diabetes, and complex wound care needs. Notably, no hospital reported home care discharge planning difficulties for short-term, low-intensity patients.
"There is compelling evidence of differential treatment of sicker beneficiaries in response to the financial incentives of IPS that suggest problems with access to and quality of home care services for this population," the study concluded. "These findings raise significant policy questions that should be addressed in evaluating IPS and any other payment system that may be developed."
The report also argued that further studies should be conducted to track beneficiary health status through payment changes in payment methodology and also to evaluate disruptions in care and the relative cost-effectiveness of care in different settings.
"Given the evidence that sicker beneficiaries have been disproportionately affected by IPS, greater attention must be focused on structuring payment to providers to create incentives for appropriate care to higher-cost beneficiaries," the report added.
This phase of the study examined the experiences of hospital discharge planners in eight states California, Florida, Indiana, Iowa, Louisiana, Massachusetts, Pennsylvania, and Texas and focused on the availability of services, the need to substitute alternative services, and changes in hospital readmissions since the BBA. The report did not address the availability of these services when patients were discharged from non-hospital facilities, long term acute care hospitals, or through physicians’ offices.
Forty-one hospitals, ranging in size from 56 beds to 1,248 beds, participated in the study. The response rate was 87%.
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