Essay : New Medicare rule endangers access for home care patients
For thousands of homebound and chronically ill older Massachusetts citizens, getting the home care they need just became more challenging in ways that will have cost implications for the entire delivery system and care implications for patients.
Since the dawn of Medicare, it has been a requirement that a physician "certify" in writing that their patient needs home health care, and that the patient meets Medicare's rules to qualify for the benefit. These rules state that patients must be sick enough to require skilled nursing care or physical therapy and that the patient must also be unable to leave home without assistance ("homebound").
A new regulation now adds to this already cumbersome process by requiring that the same homebound patient must get "certified" for such services during an in-person face-to-face meeting, and the meeting be documented by the physician, most likely their primary care physician, in a narrative that explains the need for care.
On the surface the new requirement may seem innocuous, but Medicare knows that doctors will resist additional paperwork (they already have) which will reduce valid homecare orders for patients. If agencies provide homecare without appropriately filled out paperwork, the agency will not get paid, or worse, homecare will not be provided at all — not a surprising outcome when you consider Medicare's unstated goal is to lower cost — even though lack of homecare may jeopardize a patient's health and even though care in the home is the most cost-effective place to deliver care.
The regulations have clearly set a standard that makes total compliance impossible. If patients are homebound, then Medicare is either suggesting that patients make extraordinary efforts to visit their doctor, or that doctors start making house calls, wasting valuable time better spent serving many patients.
For patients who are in nursing homes for a short stay following a hospitalization, it is almost impossible to get the documentation the Medicare program is requiring. One national nursing home ownership group with several Massachusetts locations distributed a memo falsely stating that this is a homecare agency requirement. In truth, home health agencies and their patients will be punished for physicians not filling out paperwork to Medicare's new standards, and visits to patients will not happen and/or homecare agencies will not be paid.
These regulations, which were slated to take effect January 1, 2001, were initially delayed due to serious concerns about physicians' readiness to comply and the impact that the requirement will have on severely ill patients. The regulations took effect April 1, 2011. The concerns remain. The Massachusetts Medical Society, which represents physicians, and the Massachusetts Hospital Association have joined Home care in questioning the expanse of this new requirement
At a time when our state has embraced a policy of Community First for elders and others with disabling conditions, the enforcement of this rule is causing a train wreck that is setting policy and provider collaboration back many years. Medicare needs to do the right thing for these chronically ill patients and cancel its ill-advised directive, and Congress needs to repeal the legislative language from which these regulations are derived.
While the battle rages, the Vineyard Nursing Association will work with the Island physicians to assist with the new requirements, and of course, we will continue to serve our patients needs no matter the cost.
Bob Tonti is chief executive of the Vineyard Nursing Association. Patricia Kelleher is the executive director of the Home Care Alliance of Massachusetts