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Homebound Demonstration Project Off To A Slow Start

Published on Thu Nov 18, 2004

Medicaid confusion, lack of resources keep HHAs from participating.

The new pilot project testing the home care benefit without a homebound requirement for severely disabled beneficiaries hasn't exactly started off with a bang - at press time, only one patient had been enrolled in the month-and-a-half-old project.
 
The Centers for Medicare & Medicaid Services confirms that home health agencies in the demo states (Colorado, Massachusetts and Missouri) have thus far billed only one patient under the demonstration project that began in October. That patient is in Colorado, specifies intermediary Cahaba GBA.
 
That's after a series of outreach meetings with HHAs and beneficiary advocacy groups in September, and direct mailings sent via certified mail to HHAs, a CMS official says.
 
Agencies seem reluctant to participate in the project for a number of reasons:

 

  • Resources. The beneficiaries targeted by the project are severely and permanently disabled, need help with three to five activities of daily living, need permanent skilled nursing care, need a daily attendant, and require personal or technological assistance to leave the home. The idea is targeting younger (under typical Medicare age) disabled beneficiaries, the CMS official notes.
     
    These types of patients are extremely resource-intensive to care for, notes Mary Schantz with the Missouri Alliance for Home Care. And there are no extra funds under the prospective payment system allocated for demo patients, says Ellen Caruso of the Home Care Association of Colorado. HCAC considers the project an "unfunded mandate," Caruso tells Eli.

     
  • Staffing shortages. Colorado agencies don't have the nurses and therapists to serve their existing populations, let alone new resource-intensive ones, Caruso says.

     
  • Medicaid. Considerable confusion persists regarding duplication of services with Medicaid programs furnishing aide services, Schantz says. HHAs worry they will have to furnish Medicaid's level of aide services if they take on demo patients.

     
  • Skilled need. HHAs worry that once they take on a patient who has a permanent skilled need, they can never discharge the patient, the CMS source says. Or they fear the patient wouldn't qualify for Medicare home care to begin with because she doesn't require intermittent skilled care.
     
    Fears defused: HHAs should rest assured that at least the latter two reasons shouldn't get in the way of identifying and serving demo patients, the CMS official says. When agencies pick up a patient, they don't have to take on every service that keeps that patient functioning at her "baseline" level. Instead, they furnish services that now are required in the home care plan, leaving in place the usual support the patient receives from private pay, Medicaid, family, etc., the staffer explains.
     
    In other words, HHAs don't suddenly have to start furnishing multiple daily aide services. Medicaid and other programs should continue furnishing the aide services they normally would provide.
     
    But whether state Medicaid officials have gotten that message is unclear, Schantz worries. Questions on dual eligibles and duplicating services "have not fully been answered," she says.
     
    In a similar vein, HHAs aren't picking up demo patients to treat the permanent skilled need that qualifies them for the project, the CMS official explains. Instead, some sort of acute need would qualify them for the Medicare home care benefit under the project.
     
    Like with normal home care patients, HHAs would pick up a patient for the acute care need and discharge her when she meets the treatment goals, the CMS staffer details. The permanent skilled need that is part of her "baseline" condition wouldn't be resolved by the home health episode and wouldn't affect the discharge.

    Potential Pool Kiddie-Sized

    In addition to HHA concerns, participation in the demo might be low because there are relatively few beneficiaries who will qualify for the project. Many people meeting the criteria already reside in nursing homes, the CMS official points out. Or many of the younger disabled beneficiaries may have a job, which disqualifies them from the project, Schantz adds.
     
    Some beneficiaries may prefer their Medicaid benefits, the CMS source notes. Or folks who qualify may not feel well enough to leave the house beyond the usual allowances anyway, suggests Bob Wardwell with the Visiting Nurse Associations of America.
     
    Red tape probably isn't keeping folks out, given that all agencies have to do to participate is include "HHDEMO" in the remarks field of their RAPs and claims for participants.
     
    CMS plans more outreach to drum up interest in the project, the staffer says. Emails to HHAs, conference calls with agencies and beneficiary advocacy groups, and publicizing the demonstration Web site (    www.cms.hhs.gov/researchers/demos/homehealthindependence.asp) are all on the agenda.

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