Health care reform/future of home health

HealthyNurse · Dec 18, 2010

The face-to-face encounter must occur with the certifying physician within 90 days prior to the SOC or within 30 days after the SOC. The reason for the visit be related to the primary reason for home health care. So, in your example above, the patient would have to return for another physician visit and be evaluated for the weakness. This will definitely impact the patient population that my agency serves. We get many hospital referrals with initial orders from the hospitalist and then have to identify the physician that will sign the cert. Usually, the hospitalist will not agree to sign the cert because they are not following the patient. Often, the certifying physician may be a primary care doc who has not seen the patient for quite some time. Or, if they have seen the patient, it may not have been due to the primary reason for home health care. I also worry about the amount of documentation that will be required from the physician to indicate that there has been a face-to-face encounter. I see this as a deterrent for the physician to refer to home health care in the first place, if it is a patient that they are on the fence about needing services. And we all know how clueless most physicians are about the benefits of home health and recoginizing when services may be beneficial.

I don't think there are necessarily any new procedures for auditing. Home health care is the fastest growing health care sector in the US, with national expenditures increasing by 9% in 2008 (latest yr with available info on CMS). With that much growth and a large national focus on reducing Medicare costs overall, there has been increased scrutiny of agencies. I believe that it is justified scrutiny because there IS an enormous amount of fraud that takes place in this industry. Many of us have experienced this first-hand with agencies that we or our colleagues have worked for. I think there needs to be more stringent requirements about who can start a home health agency. In my area, it seems like a new one pops up everyday. Many of the owners have no or little experience in the home health industry and are clueless about what it takes to deliver safe, high quality care.

Personally, I think the future looks bleak for smaller, private agencies. There are just too many changes that are occuring in health care in general and in the home health industry specifically for these agencies to stay afloat long-term. Many of the health care reform inititatives that will impact home health care are soon to be in CMS test pilots around the country. Bundled payments are a inititative where CMS will directly reimburse a hospital for a patient's entire episode of care across the continuum related to a diagnosis. So, if a patient is admitted for CHF, the hospital receives a lump sum. The hospital (or other contractal organization) is then responsible for reimbursement of all care that is necessary for that patient. If the patient needs home health care after their in-patient stay, the contractual organization will directly reimburse the home health agency. How will agencies be chosen? Probably a combination of their existing relationships with an agency and the quality outcomes that an agency can demonstrate. I think that there will remain an element of patient choice, but I'm not sure in what way. I don't think that smaller agencies will be able to have the same relationships that a larger, hospital-based agencies would with large health systems. Bundled payments are anticipated to be a monumentous change to the Medicare reimbursement structure for all health care organizations.

Also on the horizon are Accountable Care Organizations (ACOs). ACOs will consist of several types of health care providers and organizations (including home health agencies) that have the ability to provide care across the contiuum. ACOs are another type of payment reform model that allows participating providers to share in cost savings. ACOs promote disease management and there is also a large focus on quality outcomes. Again, I find it doubtful that most smaller agencies will have the marketing resources, relationships, or demonstrated outcomes to be chosen to participate in ACOs.

There is also a shift in the home health industry toward disease management models. While some smaller agencies may be able to pull this off successfully, most will probably lack the resources necessary to do so.

pnhopeful · Dec 19, 2010

Thanks for the reply!