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Guest blog: Initiative ponders path for home healthcare in the future

July 14, 2014
by Steve Landers, MD, MPH
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Guest blog
Steve Landers, MD, MPH

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A house-call from a physician or nurse might sound like a scene from “Leave it to Beaver,” but in today’s evolving health system, home health is poised to play a key role in the future of care delivery. As the number of older Americans increases and as hospitalizations and care for those with chronic conditions continues to strain an already costly healthcare system, moving more care to the home has the potential to achieve better outcomes at a lower price tag.

Unsurprisingly, older Americans generally wish to spend their golden years in place. Unfortunately, aspects of the current Medicare payment and regulatory approach for home health have become obstacles. The home health benefit is overly complex, and the amount of paperwork is almost nonsensical; good doctors and nurses are spending too much time on paperwork instead of helping people.

At the same time, program integrity in home health is a critical issue that has not been addressed adequately at the federal level. We are seeing the bad acts of the few besmirch the good work done by the majority of home health providers.

Stronger program entry and participation standards are needed to ensure that agencies are delivering high-quality care to all patients who need services. Further, appropriate incentives need to be put in place, regardless of payer, to fairly compensate compliant home health agencies for both delivering quality patient care and for reducing Medicare expenses for hospitalization and nursing facility care by helping more people stay healthy at home.

The current Medicare home health program unnecessarily limits services to those who meet confusing and limiting “homebound” and “skilled” nursing and therapy needs. The homebound requirement, in particular, can make effective treatment difficult because many high-risk individuals with ongoing needs may have periods of improvement when they are no longer strictly “homebound.” They are then excluded from home health. This creates gaps in their care, resulting in a greater risk for the patient. Other patients may benefit from home-based models as an alternative to hospitalization or nursing facility transfer, but they cannot receive this care due to current policies some believe are overly narrow.

Moreover, the traditional Medicare program is a system that provides little incentive for coordinated care. The result is a system of fragmented care that is neither person-centered nor efficient. Home visiting nurses, social workers, navigators and health coaches, for example, could help reduce fragmentation and improve the coordination during transitions in care from hospital to home or in other high-risk situations. The existing payment system, however, limits their ability to be care integrators and coordinators for key Medicare beneficiary groups. Current proposals to reform Medicare through “accountable care” and “managed care” models that emphasize value over volume may help, but they will not be enough to achieve the vision of home-centered care without specific changes to the home health benefit and payment reform proposals linked to home health. 

Despite these challenges, 84 percent of Medicare home health patients rate their overall care a “9” or a “10” on a 10-point scale. Nevertheless, policymaker concerns about rising costs, regional variation in service use and the potential for fraud have led to payment cuts, new regulatory hurdles and policy proposals that ultimately could harm home health patients, a group that is older, sicker and poorer than the general Medicare population. It is critical, now more than ever, that policymakers, patients, home health leaders and other healthcare stakeholders reflect on the full body of research and analysis to support a comprehensive understanding of the challenges and opportunities associated with efforts to appropriately optimize home health care for older Americans and those with disabilities. 

Over the next 40 years, America’s 85-and-over population is expected to increase by more than 300 percent. Some are looking to reform post-acute care as a means to lower Medicare spending. Although attention to post-acute care and home health care’s role in it is key and timely, it is only the tip of the iceberg of what our nation must do.

An Alliance for Home Health Quality and Innovation initiative called The Future of Home Health Project is pulling together a broad community of contributors for research, analysis and discussion to examine the current role of home healthcare with the goal of improving understanding of the role it should play in the future. By identifying important infrastructure, workforce, research, technology and policy needs, the project is designed to equip policymakers, healthcare providers and the public with the information needed to help ensure that America’s seniors and those with disabilities receive the best care possible, and in the comfort and dignity of their own homes.

Steve Landers, MD, MPH, is president and CEO of VNA Health Group and chairman of the board of directors for the Alliance for Home Health Quality and Innovation.