Cuts Kill Home Health Care Patients Struggle To Get Help As Cash Woes Close Agencies

About the only things keeping Sunny Bond out of a nursing home are the health aides who come to her house five days a week to dress and bathe her.

Bond, who is paralyzed, went without that care for two weeks recently.

The agency that brought the nurses to her home was forced to shut down because of a change in the way Medicare reimburses home health providers.

The 51-year-old Sagle woman called three home-health services before finding one that would take her case.

“I cried when she had to close,” Bond said of Colleen Neu, owner of the Alpine Home Health Agency, which had served Bond for about a year. “I was a nervous wreck. I didn’t know what I was going to do. I don’t drive. I can’t go anywhere.”

This was a tough year to be in the home-health business - and, in many cases, to be one of their clients.

At least seven North Idaho home-health services closed in 1998, and many others have scaled back their services. Nationally, more than 1,200 home health agencies have closed or withdrawn from Medicare programs as of September, according to an industry trade group.

Most say the Balanced Budget Act of 1997, which slashed $16 billion in Medicare spending on home-health care over five years, is to blame.

“Medicare has really created a monster,” said Marianne Hull, director of Loving Care and More Home Health in Osburn - one of several agencies that have reduced their services. “We take nobody that requires extensive care. We take no long-term people. We take nobody that requires many visits.”

Under the funding changes, home-health agencies ultimately will be reimbursed by Medicare the same way hospitals are, with predetermined payments for each health service.

But that new system likely won’t take effect until 2000. Until then, agencies are reimbursed under a strict payment system that sets limits on how much can be spent on each patient. Those limits are based on regional spending averages and on how much each agency spent per patient in 1993.

The spending cuts were prompted by a federal investigation in 1997 that found rampant fraud and abuse in the home-health industry in several states.

Medicare spending on home health grew from $1 in every $40 in 1989 to $1 in every $11 in 1996, according to federal figures.

At the same time, the number of home-health visits per patient climbed from 38 to 80; and the number of agencies jumped from 5,600 in 1990 to 10,500 seven years later. Many attribute the rapid growth of home-health businesses to hospitals shaving costs by discharging patients after short stays.

Average spending and patient visits varies greatly between Idaho and Washington, where there are more regulations on home-health businesses.

Last year in Idaho, Medicare spent an average of $4,091 per patient and each patient was visited an average of 60 times. In Washington, patients cost Medicare an average of $2,772 and were visited 32 times. The national average is 73 visits and $4,705 per patient.

“The change in the legislation was a direct result of the fact that there were significant problems and significant monetary fraud and abuse in the home-health benefits,” said Pam Negri, a health insurance specialist with the Health Care Financing Administration’s Seattle bureau. The administration is responsible for overseeing Medicare.

But even Negri admits the current reimbursement system isn’t perfect, and home-health operators say it is devastating.

“It really squeezed the people who were operating efficiently,” Negri said.

Kristy Schoonmaker would agree.

Schoonmaker said she was forced to close Post Falls’ Mountain Health Home Care in July because of the Medicare reimbursement changes.

Those changes, combined with bad press about fraud in the home-health industry, cut 40 percent of her caseload, she said.

“I’m not getting back into Medicare,” said Schoonmaker, who is unemployed. “It’s just too hard. I very easily could have lost my home. It took a lot of our savings.”

The effect on business was overwhelming, she said, but it is likely to be even more detrimental for some clients.

“Rural patients are just out of luck,” Schoonmaker said. “Those big agencies cannot afford to come into rural areas. There isn’t enough turnover in caseload. They have to do quantity and there just isn’t quantity in those rural areas.”

That’s what Mullan resident Beverly Johnson found. Johnson, 60, has diabetes and multiple sclerosis, and has been a client of three home-health services since 1987.

She has been visited by aides from the Panhandle Health District since the summer, after Mountain Health shut down. But she misses having nurses in her area who she could call anytime if she had a problem. Now, her aides must travel the 60 miles from Coeur d’Alene.

“They sure make it harder for people like us to stay home,” Johnson said. “It’s hard to find people who care about more than giving you your bath.”

Many of the patients who were displaced by agency closures now are being helped by the Panhandle Health District, which operates the area’s oldest home-health service.

But even that state-funded program has an uncertain future, said Kay Kindig, home-health division administrator for the Panhandle Health District.

“I don’t know if we’ll have any reimbursement for these patients we’re seeing from other agencies,” Kindig said. “We may not get any money for the care we’re rendering them. … We intend to be able to provide the services the people need as long as we can, as long as we can make payroll.”

Making payroll was something that Chris Close, owner of Lewiston-based Able Home Health Services, said he couldn’t do.

Close, who operated an office in Hayden Lake, said he lived off his credit cards so he could keep paying his four employees, but finally had to close in September. Medicare began reimbursing him $52 instead of $78 for every patient visit, although it still cost $55 to pay his therapists, he said.

“How can I be expected to get paid $52 when I’ve got to send a nurse all the way out from here to Kellogg?” he said.

Despite the widespread closures, federal experts say there still are more agencies that treat Medicare beneficiaries now than there were in 1996.

Twelve home-health businesses on the Medicare program have closed in Idaho this year, but 69 remain, Negri said.

“There really doesn’t appear to be any access to care problems at all,” she said.

But some fear the reimbursement changes will have a chilling effect on the number of agencies that serve people on Medicare.

“Home-care agencies are not the ones that ultimately suffer,” said Paul Hill, director of nursing for the Coeur d’Alene-based August Home Health. “It’s the patients that suffer. … The patients should have the ultimate say as to where they go and who takes care of them.”

This sidebar appeared with the story: Closed North Idaho home health agencies that closed this year: Alpine Home Health, Sandpoint. Lake City Home Health, Coeur d’Alene. Mountain Home Health Care, Kellogg. Able Home Health Services, Hayden Lake. Mountain Health Home Care, Post Falls. First Call Home Health, Moscow. NEU Home Health, Cocolala.