Trying to fight fraud and stem a stunning rise in Medicare home health costs, the Clinton administration wants to change the definition of who is “homebound” and legally entitled to nurses’ visits and other services.
But advocates for the elderly and disabled say the proposed rules - part of the budget deal with Congress - are so strict they would imprison thousands of beneficiaries in their homes and could drive some families to put frail relatives in nursing homes at government expense.
Currently, Medicare recipients are considered homebound if they are unable to leave home without “considerable and taxing effort.” Rules say that trips from the home must be “infrequent or of relatively short duration.”
Under the administration proposal, homebound elderly and disabled Medicare beneficiaries would not be allowed to leave home more than five times a month, on average, for non-medical reasons. The rules would limit each trip to three hours, and the total of all absences could not exceed 16 hours, on average, in a month.
“This is penny-wise and pound-foolish,” said Howard Bedlin of the National Council on the Aging, an information clearing-house and advocacy group.
“How are they going to police it? Are they going to put a little monitor on your hip to determine whether you go to church?”
Fifty organizations have joined in petitioning the administration to reconsider.
Medicare official Tom Hoyer said the proposed rules are not aimed at restricting coverage, just an attempt to spell out the meaning of the current standards. “It captures in explicit terms what our current subjective policy requires,” Hoyer said.
In recent years, home health has become the fastest-growing Medicare benefit, and now accounts for nearly 10 percent of program spending. Some 3.6 million beneficiaries received home services in 1995.
Average visits per home health client rose from 25 in 1985 to 70 in 1995, at an average cost per visit of $63. Bringing home-care costs under control is a priority in the budget agreement.
Part of the cost spike in home health care can be traced to patients’ being sent home from the hospital earlier, but government investigators also suspect widespread overbilling, delivery of unneeded services, and other abuses.
Only Medicare beneficiaries who are homebound are legally entitled to receive home health services. Investigators, however, have found evidence of people declared homebound because they didn’t own a car. And one “homebound” beneficiary postponed treatments so she could go fishing.
“They are in the back yard gardening and shoveling and doing all kinds of stuff,” said a congressional aide who works on the issue.
Congress’ General Accounting Office has repeatedly called for a stricter definition of “homebound.”
But advocates for the elderly say the Clinton administration’s proposed limits would seriously disrupt the lives of Alzheimer’s patients in adult day care.
(Medicare and advocates for the elderly are involved in a running dispute about whether home care for such patients is currently covered.)
Other patients might be barred from spending a holiday weekend with family or attending religious services, particularly in denominations where extended worship is common.
“They seem to be trying to curtail fraud and abuse by cutting off benefits for people who really need them,” said Vicki Gottlich, a lawyer with the National Senior Citizens Law Center in Washington.
John McGann, a research analyst from Andover, Conn., said his 84-year-old mother Margaret would lose her Medicare home health benefits under the new rules, because she goes to adult day care.
“A rule like this would impact her enormously,” McGann said.
Margaret McGann suffers from several serious physical ailments, but her family is most concerned about her short-term memory loss. Her son had to unplug the kitchen range because she would forget pots on the stove.
Medicare now pays for a visit by a nurse every other week and for a home health aide twice a week. Margaret McGann also goes to adult day care twice a week, paying from her own funds.
Her son says that is her only social contact, and it has improved her mental and physical well-being.
If Medicare stopped paying for home health, Margaret McGann would pick up the cost, said her son. But that means she would deplete her assets more rapidly, eventually applying for nursing-home coverage through Medicaid.
“In a sense a change like this is self-defeating,” said John McGann.
“It just means the amount of time she could stay in the home will be shortened. The faster she uses her assets, the quicker she will have to go on Medicaid.”