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Sarah C. Massengale Files (Ford Administration)
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The original documents are located in Box 12, folder "Health - Home Health Care (2)" of
the Sarah C. Massengale Files at the Gerald R. Ford Presidential Library.
Copyright Notice
The copyright law of the United States (Title 17, United States Code) governs the making of
photocopies or other reproductions of copyrighted material. Gerald R. Ford donated to the
United States of America her copyrights in all of her husband's unpublished writings in National
Archives collections. Works prepared by U.S. Government employees as part of their official
duties are in the public domain. The copyrights to materials written by other individuals or
organizations are presumed to remain with them. If you think any of the information displayed
in the PDF is subject to a valid copyright claim, please contact the Gerald R. Ford Presidential
Library.
Some items in this folder were not digitized because it contains copyrighted
materials. Please contact the Gerald R. Ford Presidential Library for access to
these materials.
Comprehensive Health Planning Council
of Whatcom, Skagit, Island and San Juan Counties
P. O. Box 39
102 South Barker Street
(206) 336-5728
Mount Vernon, Washington 98273
February 22, 1976
Recipients of the Home Health Services Development Guide
Dear Reader:
The Comprehensive Health Planning Council is pleased to send you the
accompanying copy of the Home Health Services Development Guide. You are
receiving this Council planning document either because you have requested
the Guide prior to its publication or because the CHPC staff or Board
believed that you or your organization would have use for it. Our sending
it now as part of a bulk mailing permits the Council to distribute the
Guide at no charge to the recipients.
Two related documents cited in the Guide are in preparation and will
similarly be available at no charge if requests are received prior to
their distribution. One is a Critical Analysis of Home Health Services
Under Medicare and Medicaid. It is a document of general applicability
to the problems of under-use and under-funding of home health services
under these programs. The second document is a report on a Home Health
Services Survey. This report is more locally oriented, but it may be of
interest to agencies considering a local study of their own.
In presenting the Home Health Services Development Guide, the Council
recognizes that it is making broad recommendations that require imple-
mentation at the local-regional level, the state level, and the national
level. The CHPC cannot accomplish the necessary state and national
changes unless we are able to enlist the agreement and support of like-
minded agencies around the nation. We hope that wide distribution of the
Development Guide and the Critical Study will promote that agreement.
The Council will welcome your comments, criticism, and suggestions on
the Home Health Services Development Guide. We appreciate your interest
in this plan document.
Sincerely yours,
Andrew
Executive Director
FORD LIBRARY & GERALD
AJF:1wj
Enclosure
Scg.
f-hme health Services
HOME HEALTH SERVICES DEVELOPMENT GUIDE
November 1975
A
Comprehensive Health Planning Council
FORD LIBRARY & GERALD
of Whatcom, Skagit, Island, and San Juan Counties
102 South Barker Street
Mount Vernon, Washington 98273
The program of the Council is made possible by a grant from the
U.S. Public Health Service.
This report was assisted in part by a grant, Contract No. 74/75 - 02,
administered by the Office of Comprehensive Health Planning, Office of
Community Development, State of Washington.
Contents
Page
Foreword
1
An Introduction to Home Care
3
The Cost-Effectiveness of Home Health Services
8
The Need for Home Health Services
12
A. Studies of Need
12
B. Summary of Need Studies
15
C. Demographic Profile of Persons Over. Age 65
15
D. Demographic Profile of Persons Under Age 65
16
E. Computation of the Need for Home Health Services
16
The Use of Home Health Services
24
"System": A Useful Planning Tool
30
Findings and Reocmmendations
31
Regional Level
Findings
32
Recommendations
58
State Level
Findings
69
Recommendations
73
National Level
Findings
76
Recommendations
87
Attachments
1. Correspondence, Home Health Aide Program, Bellingham,
96
Washington.
2. Reported Savings on Hospital Costs Through Home Care.
103
Page
3. Days of Restricted Activity and Disability Per Person Per
113
Year, by Age and Sex.
4. Percent of Persons with a Chronic Condition and with
114
Specified Limitations, by Sex and Age.
5. Percent of Persons with Chronic Conditions Causing
115
Limitation in or Inability to carry on Major Activity, by
Family Income and Age.
6. Population Age 65 and Over, Four County Region and State of
116
Washington, 1970-1975.
7. Projecting the Aged Population to 1980, Four County Region
117
and State of Washington.
8. Part A Medicare Enrollment, Four County Region, State of
118
Washington, and U.S., 1968-1973.
9. Population Under Age 65, Four County Region and State of
119
Washington, 1970-1975.
10. Population Estimates, Four County Region and State of
120
Washington, 1980.
11. Correspondence, Department of Social and Health Services,
121
Olympia, Washington.
12. Correspondence, Skagit Medical Bureau, Mount Vernon,
123
Washington.
13. Decision Grid for Evaluation of Need for Care in Home Care
125
Service and Extended Care Facility.
14. Map, Home Health Services 15-Mile Radius Service Areas.
127
15. Delay of Action on Reclassification and Transfer of Nursing
128
Home Patients, Department of Social and Health Services,
Olympia, Washington.
16. "Inflation may force welfare cuts to hospital, nurse home
129
patients," Bellingham Herald, Bellingham, Washington.
17. "Medicare patients turned away," Bellingham Herald,
130
Bellingham, Washington.
18. Correspondence, CHAMPUS Program, Denver, Colorado and
131
Washington, D.C.
19. CHAMPUS beneficiary booklet excerpts.
140
GERALD LIBRARY
20. Correspondence, Indian Health Service, Portland, Oregon.
161
Foreword
The Comprehensive Health Planning Council is a non-profit corporation
incorporated in 1968. The Council acts to identify community health
needs and problems, to recommend goals and policies for the future
improvement of health and health services, to improve the coordination
of health services, to provide technical and planning assistance to
community organizations, and to inform the public and various community
agencies and groups of facts and recommendations. All of these activities
occur as part of the process of "health planning."
The Health Planning Council is funded by a federal grant which is
supplemented by funds from State, county, and local government. The
Council's budget the past fiscal year was approximately $100,000.
The Health Planning Council is an open membership organization with
over 350 members from Whatcom, Skagit, Island, and San Juan Counties.
Anyone who applies for membership is accepted. Many of these members
are active on specific committees or task forces or serve on the Board
of Trustees. Supported by a staff of professionally trained health
planners, the Council's citizen committees research health matters,
identify problems and needs, and propose recommendations to the Council's
governing body, the Board of Trustees, for adoption as health policy for
the entire region. A consumer majority is usually maintained on committees,
task forces, and the Board of Trustees to assure that consumers have an
adequate voice in the design of future changes in the health system.
This Development Guide, the third component of the Council's overall
health facilities and services plan, was developed over a period
of several years of research and study by members of the Council's
Home Health Services Task Force. Many members of the community
participated at various times on the Task Force. Here follows a
listing of the people who generously donated many hours of their
time toward the development of this Guide.
Roger Pederson, Chairman
Farmer
Mount Vernon
Consumers
Providers
Dana Jack
Arlene Adolphson
Student Counselor
Laboratory Technician
Western Washington State College
Bellingham
Bellingham
Vicki Barry
Ingeborg Utheim
Physical Therapist
Homemaker
St. Luke's Hospital
Deming
Bellingham
2
Howard Teasley
Sister Brigid Collins
Assistant Professor of Economics
Medical Social Worker
Western Washington State College
St. Joseph's Hospital
Bellingham
Bellingham
Russell Weller
Ken Culver
Administrator
Manager of Marketing
Social Security Administration
Whatcom County Physicians Service
Bellingham
Bellingham
Gertrude Fors
Home Health Agency Coordinator
Skagit County Health Department
Mount Vernon
Thelma Pierron
Executive Director
Visiting Nurse Association
Bellingham
Patty Wade
School Nurse
Burlington School District
Burlington
Staff: Robert M. Eastman, M.P.H., Assistant Director
This Development Guide is one of three related documents on home health
services published by the Comprehensive Health Planning Council. Many
of the regional findings were generated by a survey conducted early in
1975 across the region. The findings of the survey are presented in
detail in the Council's Home Health Services Survey (November 1975).
State and national findings on Medicare and Medicaid are derived from
the Council's Home Health Services Under Medicare and Medicaid: A
Critical Analysis (November 1975). These documents should be consulted
by the reader who wishes more detailed information or supporting data
for the findings found in this document.
3
An Introduction to Home Care
Definitions
The National Association of Home Health Agencies has defined home health
services as "that component of comprehensive health care whereby services
are provided to individuals and families in their place of residence for
the purpose of promoting, maintaining, or restoring health, or minimizing
the effects of illness and disability.' (1*) The National League of Nursing's
Council of Home Health Agencies and Community Health Services uses this
definition: (2)
Simply stated, home health care is bringing health and assistive
services needed by an individual or family into the home for
the purpose of preventing illness, supporting optimum health,
improving or restoring body functioning and enhancing life
and living. It includes all of the professional and health
services which may be needed for the practical and effective
care of people at home, when the home is the appropriate and
accepted environment for such care.
The terms "home care" and "home health services" are used synonymously
this Guide.
Uses for Home Care
Home care has been used in many different ways in various parts of the world.
Some of these uses include:
- Follow-up care after hospitalization.
- Restorative and maintenance-of-function care before or after instances
of inpatient care.
- Prevention of inpatient care.
- Provision of post-operative care.
- Provision of post-natal care.
- Provision of screening or case-finding services in high-density
housing projects.
- Assistance with household or personal care tasks.
The following paragraphs describe other situations in which home care is
an appropriate method of treatment. (3)
- When a coordinated team including professionals as well as
the "user" of services and the family decide together. that
home care is appropriate.
*References may be found at the end of this and all other chapters.
4
- When the "user" wants to receive care in the home environment
and the family relationships are conducive to and supportive
of proper care.
- When the home setting can contribute to a patient's recovery.
- When the home setting is both practical and effective in
improving and/or maintaining the patient's health status.
- When the acutely ill patient, either non-institutionalized or
post hospital, does not need the complex care provided by a
hospital.
- When a patient, such as one with a cardiac disorder, requires
a prolonged convalescence.
- When a patient recovering from a fracture or handicapped with
arthritis is in need of rehabilitative measures.
- When a patient with a long-term illness or chronic illness is
in need of supportive care.
- When a patient ill with a terminal illness would be happier
and can be cared for adequately at home.
Types of Home Health Services
The Council of Home Health Agencies and Community Health Services has
described two categories of "essential" services that should be provided
by home health programs and paid for by health insurance programs. (4)
Basic Essential Services
Homemaker/home health aide
Occupational therapy
Medical supplies and equipment
Physical therapy
Nursing
Speech pathology services
Nutrition
Social work services
Other Essential Services
Services that should be provided by the program directly:
Home delivered meals
Housekeeping services
Information and referral services
Patient transportation and escort services
Prescription drug delivery
Respiratory therapy services
Services that should be arranged for by the program and facilitated,
if necessary, by patient transportation services:
Audiological services
Dental services
5
Laboratory services
Ophthalmological services
Physician services
Podiatry services
Prosthetic/orthotic services
X-ray services
In addition to the two categories of essential services, a set of
"desirable" home health services should also be available in the community:
Desirable Services
Barber/cosmetology services
Pastoral services
Handyman services
Personal contact services
Heavy cleaning services
Recreation services
Legal and protective services
Translation services
Organizational Models
Home health literature usually describes the organization of home health
services according to two models. The more traditional model categorizes
services into three groups according to the scope and intensity of services
required by the patient. The most complex service category is called the
Intensive Level. At this level, the program would be characterized by the
provision and coordination of a broad range of professional and ancillary
home health services. Patients receiving care at this level would probably
require quite a variety of services in considerable quantity. At the
Intermediate Level, more stable and less demanding patients would require
fewer services and less patient care coordination than patients at the
Intensive Level. The third level, the Minimum Level, would be characterized
by the provision of the less skilled and less intensive home health services
to relatively stable and healthy patients. Homemaker/home health aide
services or housekeeping services are the services most likely to be needed
by this group of patients. These three categories of home care parallel
similar categories of hospital care: intensive, basic or general, and
post-acute skilled nursing ("extended care") services.
A newer model proposed by the Council of Home Health Agencies and Community
Health Services splits home care programs into two basic categories. (5)
The "Home Health Program 1," the more comprehensive of the two categories,
would provide home nursing and at least two of the other Basic Essential
services. In addition, this type of program should provide patient care,
consultative, administrative, and accounting and record-keeping services
for the secondary program, the "Home Health Program 2." The latter
program is characterized as providing nursing services directly while
contracting or arranging for the provision of other Basic Essential
services. Both types of Programs should attempt to provide or arrange
for the provision of the Other Essential Services.
6
Administrative Locus
Home health services can be provided and administered by virtually any
group, but services are usually provided by hospitals, health depart-
ments, independent non-profit agencies, or even nursing homes. In our
region there is an independent non-profit home health agency in Whatcom
County that will serve Medicare, Medicaid, and other patients, while the
health department-based home health agencies in Skagit and Island Counties
serve only Medicare patients. In addition, a new program funded by the
Comprehensive Employment Training Act (CETA) has been organized in
Bellingham to provide health aide/housekeeping services. Despite the
program's successful performance, the program is likely to end with the
termination of CETA funding unless other sources of funding are found.
Attachment 1 shows some of the kinds of needs the CETA-funded program
has been meeting.
Funding Sources
A variety of third-party payers will reimburse home health services.
National Programs
1. Medicare. Primarily designed for the elderly and the chronically
disabled, the Medicare program will pay for a number of home health
services: part-time skilled nursing, physical therapy, speech
therapy, occupational therapy, home health aide services, medical
social services, and medical supplies or appliances.
2. Medicaid. Designed for certain categories of needy or disabled
persons, the Medicaid program pays for those home health services
a participating state decides to include in its state Medicaid plan.
3. CHAMPUS. (Civilian Health and Medical Program of the Uniformed
Services) CHAMPUS is a federal health insurance program for
retired military personnel and the dependents of active duty
military personnel. The program will pay the major portion of
the charges for "medically necessary" home health services when
ordered by the attending physician and provided by an "authorized
provider of care."
State
1. Blue Cross of Washington/Alaska. Home health services benefits are
routinely included in both major and minor medical insurance plans.
2. Workmen's Compensation. Injured workers eligible for Workmen's
Compensation may have virtually any kind of home health service
ordered by the attending physician reimbursed by the program.
7
Local
1. Whatcom County Physicians Service. Most contracts provide limited
home health benefits.
2. Commercial Insurance Companies. A telephone survey of Skagit County
commercial insurance companies conducted late in 1974 appears to
indicate that they provide little coverage of home care services.
Of the 18 companies contacted,
4 provided no health insurance packages.
14 provided health insurance packages:
3 were known to provide coverage of home care,
5 do not provide coverage of home care, and
6 agents did not know whether home care was covered.
3. Skagit Medical Bureau. The Skagit Medical Bureau sells no contracts
with home health services benefits.
References
1. National Association of Home Health Agencies, "Statement of the
National Association of Home Health Agencies Before the Committee
on Ways and Means, U.S. House of Representatives. II Exhibit G.
(mimeo), May 23, 1974.
2. Council of Home Health Agencies and Community Health Services of the
National League of Nursing, Home Health Care. Publication No. 21-1497.
3. Ibid.
4. Council of Home Health Agencies and Community Health Services of the
National League of Nursing, Proposed Model for the Delivery of Home
Health Services. Publication No. 21-1550, pp. 2-3.
5. Ibid., pp. 3-8.
8
The Cost-Effectiveness of Home Health Services
Home visits may appear to be too expensive or too inefficient to be worth
using in this age of reliance on sophisticated medical technology, but a
number of reports and studies have demonstrated the real dollars and cents
value of home care programs. The savings generated by home care derive
mainly from reductions in the use of inpatient health facilities since
home care can prevent admissions and readmissions and shorten lengths of
stay. By reducing demand for inpatient facilities, home care also prevents
the need for construction of additional facilities. The studies to be
described have each shown the value of home care.
1. Study of Health Facilities Construction Costs (1)
In its 1972 report to Congress, the Comptroller General's office
discussed the value of home care in preventing the need for
construction of new inpatient health facilities.
Patients on home care also pay a good deal less than
the rate they would have to pay in a general hospital,
and there is a growing sentiment among medical
economists that a well-conceived home care program
could make unnecessary the construction of a
substantial number of new general hospital beds.
One source estimated that a home care program with
a caseload of 50 patients could be an adequate
substitute for construction of an equivalent
number of hospital beds occupied by patients who
require home care but not hospital care.
The Comptroller General's report discusses a number of studies that
have indicated the cost-effectiveness of home health services when
substituted for inpatient services.
a. A 1970 study prepared by the Health Economics Branch of the
Bureau of Health Services of the Public Health Service estimated
that 2.6 percent of the nation's inpatient hospital days could
be eliminated by transfer of bed patients to home care programs.
Potential savings: 5.8 million hospital days, 20,000 freed beds.
b. Several studies cited by the Comptroller General compared cost
per day for home care with cost per day for hospital care.
- Michigan Blue Cross, 1967.
$4 per day for home care,
$51 per day for hospital care.
- Pennsylvania Blue Cross,
$8 per patient day for home
1961-1970.
care. $1.3 million in inpatient
care saved, about $330 per case.
- National averages, 1963
Hospital cost per day rose from
to 1969.
$39 to $70. Home care cost per
day rose from $3 to $8.
9
2. Home Health Services in the U.S. (2)
This report prepared for the Special Committee on Aging of the
U.S. Senate discusses several instances of savings generated by
the use of home care.
a. Home Care Association of Rochester, N.Y., 1970. 42 hospital
beds released, 653 hospital admissions prevented.
b. Associated Hospital Services of N.Y., 1965. 5,000 cases of
home care reduced the volume of hospital care by 113,000
inpatient days, about 22 days per case.
C. Denver Department of Health and Hospitals, 1970. For 292 hospital
patients admitted to home care, there was a savings of 19.2 hospital
days per patient.
d. Blue Cross of Greater Philadelphia, 1961-1970. Among 3,940 home
care patients, there was a savings of 12.9 hospital days per
patient. The reduction in patient days freed 6.6 hospital beds.
3. Reported Savings on Hospital Costs Through Home Care(3)
The studies included in this packet distributed by the National
Association of Home Health Agencies describe seven different home
care programs and the savings generated by each. See Attachment 2
for details.
4. Home Care and Extended Care in a Comprehensive Prepayment Plan(4)
This excellent study examined the impact of new home care and extended
care facility (ECF) services in a Kaiser-Permanente prepaid
health plan in Oregon during 1968. The study found that:
- When actual hospital utilization in 1968 was compared
to the anticipated rates based on age-adjusted 1966
data, there was an apparent decrease of 14 percent
(7,722 hospital days).
- The Medicare population had the greatest proportionate
reduction in hospital utilization (27 percent, or 4,097
days), although the rates for the non-Medicare population
were also reduced.
- It appears that much of the apparent reduction in
hospitalization was a result of the availability of the
home care and ECF services. Data suggest that most of
these savings can be attributed to the ECF, rather than
the home care service.
- The cost of the home care service for the entire health
plan population was $1.78 per person per year; the cost
per Medicare member per year was $13.10, and per non-
Medicare member per year, $0.86. The cost per visit was
$20.99; the cost per patient day, $5.26.
10
The authors discussed an interesting impact of the new home health
and extended care services on Kaiser-Permanente's already low rate
of hospital use:
the home care and ECF services were added to a
comprehensive medical care system with a history of low
hospital utilization. Even in this setting, the addition
of new services apparently brought about a reduction in
hospital utilization. It seems reasonable to assume that
a far greater reduction might be achieved if these services
were added to a system where hospital utilization more
closely approximated the national average.
5. Older Persons After Hospitalization: A Controlled Study of Home
Aide Services (5)
This 1967 study attempted to determine the impact of health aide
services provided to patients discharged from a geriatric rehabilita-
tion hospital. Patients receiving health aide services constituted
the experimental group while a similar group of patients receiving
no health aide services was used as a control group. The study
found that:
- There was no significant difference between the two
groups' survival rates.
- The group receiving services displayed significantly
greater contentment, defined as the patient's own
assessment of his or her quality of life.
- The group receiving services required significantly
fewer days of care in long-term care facilities.
- There was no significant difference between the two
groups' rates of hospital admission.
This study shows that health aide services help reduce the use of
long-term care facilities by the elderly and increase the contentment
of persons receiving services.
6. Postoperative Care: In Hospital or at Home?
A study conducted at a teaching hospital at Cali, Columbia, attempted
to determine the impact of providing post-operative care at home to
patients receiving surgery for hernia repair, vaginal hysterectomy,
or vein stripping. The study found that the duration of convalescence
was significantly shorter for home care patients who had hernia repairs
or hysterectomies compared to similar patients who received their
post-operative care in the hospital. The cost of post-operative
care at home was 75 percent less than the cost of post-operative
care in the hospital.
GERALD FORD JBRARY
11
7. Home Care Services Through the University of Southern California
Medical Center(
A program of home care operated during 1973 in conjunction with the
University of Southern California Medical Center reported cost
savings, improvements in the quality of care, and patient and physician
satisfaction with the program. Six relatively complicated orthopedic
patients alone, transferred to the program from the hospital, saved
an estimated 270 days of hospital care, about $75,000. Two groups
of home care patients studied, one with recurrent congestive heart
failure, the other with chronic obstructive pulmonary disease,
were found to show significant reductions in hospital admissions,
hospital days, emergency room visits, regular clinic visits, and
specialty clinic visits. Savings amounted to approximately
$82,000 for these two groups of patients.
References
1. Comptroller General of the U.S., Report to the Congress, Study of
Health Facilities Construction Costs, Enclosure C. 1972, pp. 48-57.
2. Trager, Brahna, Home Health Services in the United States, A Report
to the Special Committee on Aging, United States Senate. U.S.
Government Printing Office, 1972, pp. 36-38.
3. National Association of Home Health Agencies, "Statement of the
National Association of Home Health Agencies Before the Committee
on Ways and Means, U.S. House of Representatives,' Exhibit C.
(mimeo), May 23, 1974.
4. Hurtado, Arnold V.; Greenlick, Merwyn R.; Saward, Ernest W.; Home
Care and Extended Care in a Comprehensive Prepayment Plan. Hospital
Research and Educational Trust, Chicago, Illinois, 1972, pp. 96, 98.
5. Nielsen, Margaret et al., "Older Persons After Hospitalization: A
Controlled Study of Home Aide Service." American Journal of
Public Health, 62:1094-1101, August 1972.
6. Echeverri, 0., "Postoperative Care: In Hospital or at Home?,"
International Journal of Health Services. 2:101-110, February 1972.
Reported in Medical Care Review, May 1974, p. 666.
7. "Complementary Home Care Said to Cut Cost, Improve Quality of Hospital
Therapy," Family Practice News, 5:1, May 1, 1975. Reported in Medical
Care Review, June 1975, p. 688.
12
The Need for Home Health Services
This chapter first reviews a number of studies that have attempted
to determine or estimate the need for home health services among
various population groups. The need estimates contained in the
studies are then applied to two population groups: persons under
65 years of age and persons over 65 years of age. In the next
chapter the empirically-determined need for services by these two
groups will be compared to historical patterns of utilization of
services in order to determine the extent to which the need for
services has been met.
A. Studies of Need
1. "Three Approaches to Estimating Need for Personal Care
Services (1)
This 1972 paper, written by Barbara J. Sproat, a staff
member of the Levinson Gerontological Policy Institute,
examines various National Health Survey statistics on
age-related disability as a basis for predicting the need
for personal care services among the non-institutionalized
disabled elderly. Sproat used a figure of 13.8 percent of
the non-institutional elderly as an estimate of need.
This figure represents the proportion of non-institutional
elderly unable to carry on major activity as determined by
data collected in the National Health Survey between 1965
and 1967. Sproat's paper shows that this estimate of
13.8 percent is supported by data collected in a cross-
national study conducted in Denmark, England, and the
United States and published in 1968 which showed that
10 percent of the non-institutional elderly in these three
countries were housebound or bedfast while another 5 percent
experienced serious incapacity.
Since the Sproat paper was written, however, more recent
data from the 1969-1970 National Health Survey have been
published. These data indicate that 16.4 percent of the
non-institutional elderly are unable to carry on major
activity, such as working or keeping house. (2) Thus, using
inability to carry on major activity as the basis for predicting
need, we can estimate that 16.4 percent of the non-institutional
elderly need some degree of personal care services.
In addition to the non-institutional elderly, the Sproat paper
also considered personal care service needs among the institution-
alized elderly. After reviewing 1964 data published by the
Public Health Service which estimated that 39 percent of the
residents of nursing and personal care homes may not need to
be institutionalized, Sproat proposed a more conservative
figure of 25 percent of the institutionalized elderly as an
estimate of need for (non-institutional) personal care services.
Thus, the Sproat paper leads to a need estimate of 16.4 percent
of the non-institutional elderly and 25 percent of the
institutional elderly.
13
Sproat acknowledges, however, that her estimates may be too
high in light of "home help" utilization rates reported in
several European countries. (Home help services correspond
to services provided by homemaker/home health aides.) She
writes that five to six hours of home help services per week
are reportedly provided to 15 percent of Sweden's pensioners
each year, to 7 percent in Denmark, and 6 percent in Norway.
Sproat reports that, "All three (European) counties have
experienced either a slight decrease or at least stabilization
of the rate of institutionalization among the elderly and
handicapped since their home help program became widespread."
Among non-institutionalized persons under 65 years of age, the
1969-70 National Health Survey found that 1.4 percent are unable
to carry on major activities. (3) This figure represents a need
estimate for this age group when Sproat's criterion of inability
to carry on major activity is used.
2. "Health Status of Older People, Cross-National Implications" (4)
This article reports findings of a study of the health status
of non-institutionalized older people in Britain, Denmark,
Israel, Poland, the United States, and Yugoslavia based on data
collected during the 60's. The study found that from two to
four percent of the non-institutionalized elderly in every
country studied are bedfast at home. The author reports that,
"From 4 to 8 percent of the elderly living at home, excluding
the bedfast, appear to have marked needs for help with even the
simplest physical tasks related to their self-maintenance."
Including the bedfast, we could estimate that from 6 to
12 percent of the elderly need help at home.
This study also reports on the use of long term care facilities
by the aged in Britain and Denmark, countries with well-developed
home health services. In Britain in 1969 only 2.5 percent of
the elderly were residents of long term care facilities. Denmark
bases its planning of residential and nursing home facilities
on a need estimate of 4 percent of the elderly.
3. "Home Health Services: A National Need" (5)
This position paper adopted by the Governing Council of the
American Public Health Association in 1973 is a formal expression
of the Association's viewpoint on the issue of home health services'
need. The adopted paper provides additional support for the
Sproat paper's estimates of need for services among institutionalized
patients:
Development of long-term care facilities has grown
impressively in recent years, but there is considerable
evidence that we are using many of them inappropriately.
A list of studies on the subject is attached (see
Appendix A), but in sum, they show that, in the nursing
homes studied, from 20 to 50 percent of patients could
have used less costly levels of care
14
At least 10-25 percent of the population now in
institutional homes of varying kinds could be cared
for and remain in their own homes if organized
services beyond episodic nursing and medical care
were available.
4. "European Home Health Services" (6)
Home help services were reported to have been used by 11 percent
of the elderly in Sweden during a typical week in 1969. Although
level of use does not necessarily equate with level of need, this
Swedish utilization figure provides an estimate of the volume
of home care routinely provided to the elderly in the country.
5. "Assessing the Health Care Needs of the Aged" (7)
In this study a multi-disciplinary health team reviewed the
appropriateness of residential and patient care placements
among the elderly of Monroe County, New York, during 1964.
The study found that 83.4 percent of the elderly could live
independently at home. Another 6.7 percent of the elderly
could live at home if provided with public health nursing
services.
6. Home Care and Extended Care in a Comprehensive Prepayment Plan(8)
Perhaps the most carefully conducted, controlled, and documented
study of the need for home care services was performed by the
Kaiser-Permanente Medical Care System in Portland, Oregon, during
1967-68. Extended care and Medicare-eligible home care services
were introduced into the Kaiser-Permanente prepaid group practice
plan and carefully monitored for their impact on costs and
utilization of other services. Elderly persons used Medicare-
eligible services at the rate of 31.8 patients per 1,000 elderly
enrollees, or 3.2 percent of the elderly population. It is
important to note that home help-like services were not made
available to the target group of the study. It should also be
noted that the study was conducted prior to 1969 Medicare changes,
still in effect, that restricted the use of Medicare home health
services.
Other data reported in this study show that 5.7 percent of
the elderly who were hospitalized over the course of the study
subsequently used home health services. (9) Of the group receiving
home care after hospitalization, 19 percent received home care
immediately following hospitalization while the remaining 81 percent
received home care subsequent to discharge from an extended care
facility.
The study also found that its under-65 population was referred to
home health services at the rate of 2.0 referrals per 1,000 persons
under age 65. (10) Among under-65 persons who were hospitalized,
1 percent subsequently received home health care.
15
B. Summary of Need Studies
The following table lists need estimates by study.
Study
Need Among Persons
Need Among Persons
Number
Age 65+
Under Age 65
1
16.4% noninstitutional
1.4% noninstitutional
25% institutional
6% to 15% noninstitutional,
Europe
2
6% to 12% noninstitutional
3
10% to 25% institutional
10% to 25% institutional
4
11% noninstitutional
5
6.7% noninstitutional
6
3.2% noninstitutional
2% noninstitutional
5.7% hospitalized
1% hospitalized
All
3.2% to 16.4% noninstitutional
1.4% to 2% noninstitutional
10% to 25% institutional
10% to 25% institutional
5.7% hospitalized
1% hospitalized
C. Demographic Profile of Persons Over Age 65
One's health status generally decreases with age. Attachment 3
shows that restricted activity days and bed disability days
increase markedly between age 55 and 65. Attachment 4 shows
that the prevalence of chronic conditions increases with age,
as does limitation in activity. Attachment 5 shows that the
low income elderly are at increased health risk compared to
higher income elderly; activity-limiting chronic conditions are
considerably more prevalent among the low income elderly.
It is important to note that 25 percent of the region's elderly
(over 4,800 persons) were estimated by the 1970 Census to have
incomes less than poverty level. (11) On the average, a poverty
income level for a person age 65 or more was defined in 1970
to be $1,498 per year for a farm resident, $1,757 per year for
a non-farm resident. (12) (These figures imply a monthly income
between $125 and $146.) Thus, at least 25 percent of the elderly
in our region fall on curve (A) of Attachment 5, the curve of
greatest prevalence by age of activity-limiting chronic conditions.
This particular group of elderly persons, the low income elderly,
has the greatest need for health care services and the least
ability to pay out-of-pocket expenses connected with that care.
16
Attachment 6 shows the distribution of elderly in this region
and the State between 1970 and 1975, and Attachment 7 shows
expected numbers of elderly in 1980. Attachment 8, which shows
enrollment in Part A (Hospital Insurance) of Medicare, should
be compared with Attachment 6. Such comparison shows that in 1970,
97 percent of the region's elderly were enrolled in Part A of
Medicare. These three tables establish population data to be
used in considering the need for home health services among the
elderly in this region and the State of Washington.
D. Demographic Profile of Persons Under Age 65
Attachment 9 shows population figures for the under-65 population
for this region and the State as a whole. Attachment 10 shows
population estimates for 1980.
E.
Computation of the Need for Home Health Services
Combining need and population estimates, this section computes
estimates of numbers of persons in need of home health services.
The tables which show these estimates begin on the following
page.
17
Region, Over 65
Area and
Patient
Target
Need
Persons in Need
Year
Category
Population Estimate
of Services
Region
a
1974
Noninstitutional,
19,601
16.4%
b
3,126
1980 low
over 65
22,583
3,704
C
1980 high
25,048
4,108
1974
19,601
3.2%
627
1980 low
22,583
723
1980 high
25,048
802
d
1974
Institutional,
1,429
25%
357
over 65
1974
1,429
10%
143
1974
Hospitalized,
6,414 e
5.7%
366
over 65
Region, Under 65
Area and
Patient
Target
Need
Persons in Need
Year
Category
Population
Estimate
of Services
Region
f
1974
Noninstitutional,
149,471
2%
2,989
1980 low
under 65
g
156,012
h
3,120
1980 high
168,156
3,363
1974
149,471
1%
1,495
1980 low
156,012
1,560
1980 high
168,156
1,682
i
1974
Institutional,
299
25%
75
under 65
1974
299
10%
30
j
1974
Hospitalized,
19,214
1%
192
under 65
18
Footnotes for Regional Need Estimates
a. Figure is the difference between the number of aged persons
present in the general population (21,030) and the number in
nursing homes (1,429). Latter figure is taken from the
Comprehensive Health Planning Council's Nursing Home Development
Guide, May 8, 1975, p. 34.
b. This figure is based on estimates shown in Attachment 7.
Four percent of the elderly are assumed to be nursing home
residents in 1980. In 1974, 6.8 percent of the region's
elderly were in nursing homes.
C. Ibid.
d. Comprehensive Health Planning Council of Whatcom, Skagit, Island,
and San Juan Counties, A Nursing Home Development Guide,
Mount Vernon, Washington, May 8, 1975, p. 34.
e. State of Washington, Office of Planning and Health Facilities.
Hospital Utilization Report, Olympia, Washington, 1974.
f. Figures is the difference between the number of persons present
in the general population (149,770) and the number in nursing
homes (299). Latter figure is taken from the Comprehensive
Health Planning Council's Nursing Home Development Guide,
May 8, 1975, p. 34.
g. This figure is based on estimates shown in Attachment 10. The
same proportion of under-65 persons is assumed to be present
in nursing homes in 1980 as in 1974.
h. Ibid.
i. Comprehensive Health Planning Council of Whatcom, Skagit, Island,
and San Juan Counties, A Nursing Home Development Guide,
Mount Vernon, Washington, May 8, 1975, p. 34.
j. State of Washington, Office of Planning and Health Facilities,
Hospital Utilization Report, Olympia, Washington, 1974.
19
State, Over 65
Area and
Patient
Target
Need
Persons in Need
Year
Category
Population
Estimate
of Services
State
1974
a
Noninstitutional,
328,282
16.4%
53,838
1980 low
over 65
381,592
62,581
1980 high
417,291
C
68,436
1974
332,149
3.2%
10,629
1980 low
381,592
12,211
1980 high
417,291
13,353
1974
d
Institutional,
23,198
25%
5,800
over 65
1974
23,198
10%
2,320
1974
e
Hospitalized,
124,032
5.7%
7,070
over 65
State, Under 65
Area and
Patient
Target
Need
Persons in Need
Year
Category
Population
Estimate
of Services
State
f
1974
Noninstitutional
3,091,688
2%
61,834
1980 low
under 65
3,269,696
g
h
65,394
1980 high
3,575,581
71,512
1974
3,091,688
1%
30,917
1980 low
3,269,696
32,697
1980 high
3,575,581
35,756
1974
i
Institutional,
4,932
25%
1,233
under 65
1974
4,932
10%
493
1974
Hospitalized,
j
429,898
1%
4,299
under 65
20
Footnotes for State Need Estimates
a. Figure assumes that 93.4 percent of the elderly are non-institu-
tional. See note di below.
b. Figure assumes that 4 percent of the state's elderly will be
nursing home residents in 1980.
C. Ibid.
d. Source: Washington State Office on Aging, "An Action Program
to Serve the Elderly in Washington State." (mimeo) The
Program Summary states that 6..6 percent of the state's elderly
are in nursing homes.
e. Source: State of Washington, Office of Planning and Health
Facilities, Hospital Utilization Report, Olympia, Washington, 1974.
f. Figure found by subtracting estimated institutional population
(4,932) from 1974 population shown in Attachment 9.
g. Figure assumes that 0.15 percent of the under 65 population will
be institutionalized in 1980. Base population obtained from
Attachment 7.
h. Ibid.
i. Figure derived from average daily nursing home census for 1974
less the number of elderly patients estimated in footnote a
above. The 4,932 under-65 patients represent 20 percent of the
total nursing home population.
j. Source: State of Washington, Office of Planning and Health
Facilities, Hospital Utilization Report, Olympia, Washington, 1974.
21
Summary of Need Estimates: Four County Region
(All estimates over 100 rounded to nearest hundred.)
Persons in Need of Services
Institutional
Noninstitu-
Institu-
Former
Patient
and Noninsti-
tional
tional
Hospital
Year
Category
tutional (A+B)
Only (A)
Only (B)
Patients
1974
Over 65
700 to 3,500
600 to 3,100
100 to 400
400
1980 low
700
1980 high
4,100
1974
Under 65 1,500 to 3,100 1,500 to 3,000 30 to 75
200
1980 low
1,600
1980 high
3,400
1974
All Ages 2,200 to 6,600 2,100 to 6,100 100 to 500
600
1980 low
2,300
1980 high
7,500
These figures show that home health services should have been
provided to between 2,200 and 6,600 persons in our region in 1974.
The 2,200 person figure represents a minimum based on the most
conservative need estimates. About 600 former hospital patients
should have received home health services. By 1980, home health
services will be needed by 2,300 to 7,500 persons.
22
Summary of Need Estimates: State of Washington
(All estimates rounded to nearest hundred.)
Persons in Need of Services
Institutional
Institu-
Patient
and Noninsti-
Noninstitu-
tional
Hospital
Year
Category
tutional (A+B)
tional Only (A)
Only (B)
Patients
1974
Over 65
12,900 to 59,600
10,600 to 53,800
2,300 to 5,800
7,100
1980 low
12,200
1980 high
68,400
1974
Under 65 31,400 to 63,000 30.900 to 61,800 500 to 1,200 4,300
1980 low
32,700
1980 high
71,500
1974
All Ages 44,300 to 122,600 41,500 to 115,600 2,800 to 7,000 11,400
1980 low
44,900
1980 high
139,900
Home health services should have been provided to between 44,300
and 122,600 persons across the State in 1974. Over 11,000 former
hospital patients should have received services. By 1980, between
44,900 and 139,900 persons should receive home health services.
23
References
1. Sproat, Barbara J., "Three Approaches to Estimating Need for
Personal Care Services." Levinson Gerontological Policy
Institute, Brandeis University, Waltham, Massachusetts (mimeo),
June 1972.
2. National Center for Health Statistics, Limitation of Activity
Due to Chronic Conditions. Vital and Health Statistics,
Series 10, No. 80, U.S. Government Printing Office, p. 5.
3. Ibid., pp. 5, 17.
4. Shanas, Ethel, "Health Status of Older People, Cross-National
Implications." American Journal of Public Health, 64:261-264,
March 1974.
5. American Public Health Association, "Home Health Services: A
National Need." American Journal of Public Health, 64:179-183,
February 1974.
6. Trager, Brahna, Home Health Services in the United States, A
Report to the Special Committee on Aging, United States Senate,
U.S. Government Printing Office, 1972, p. 40.
7. "Berg, Robert L. et al., "Assessing the Health Care Needs of
the Aged." Health Services Research. Spring 1970, pp. 36-59.
8. Hurtado, Arnold V.; Greenlick, Merwyn R.; Saward, Ernest W.,
Home Care and Extended Care in a Comprehensive Prepayment Plan.
Hospital Research and Educational Trust, Chicago, Illinois,
1972, p. 40.
9. Ibid. Derived from Tables 3, 5, 13, and 21.
10. Ibid., p. 40
11. U.S. Department of Commerce, Bureau of the Census, General
Social and Economic Characteristics, Washington. U.S. Government
Printing Office, Washington, D.C., 1972, Table 124.
12. Ibid:, Appendix B, p. App-30.
24
The Use of Home Health Services
A.
Use of Services by the Elderly
The following table shows the number of Medicare patients served
by home health services in our region over the past five years.
Medicare Beneficiaries Served, Region
1
Year
Regional Total
Whatcom
Skagit
Island
1970
308
183
125
0
1971
255
98
141
16
1972
301
131
140
30
1973
268
107
131
30
1974
280
95
158
27
As we saw on page 21, between 700 and 3,500 elderly persons in the
region (depending on the estimate used to predict need) should
have received home health services in 1974. The 280 persons
served met, at best, only 40 percent of the most conservative
estimate of need. In comparison with the more liberal estimate
of 3,500 persons in need, however, the 280 persons served met
only 8 percent of the need. Thus, only 8 to 40 percent of the
need for home health services among the elderly was met in 1974.
Aside from the large unmet need for home health services among the
region's elderly in 1974, the five-year utilization figures
above also show that there has been essentially no change in the
number of elderly served between 1970 and 1974. This no-growth
pattern of home health services utilization stands in rather
sharp contrast to increases in the size of the aged population
in the region and increases in the aged population's use of
institutional health services over the same period:
25
Use of Institutional Health Services by the Elderly, Four County Region
Elderly Title XIX
Number of Persons
Medicare Hospital
Nursing Home Patients
2
3
Year
4
Age 65+
Admissions
per Month
1970
19,265
5,173
706
1973
20,540
6,078
780
1974
21,031
6,414
?
Percent
Increase,
1970-73
6.6%
17.5%
10.2%
Percent
Increase,
1970-74
9.2%
24.0%
?
Unlike the use of home health services, the elderly's use of
institutional health services has increased substantially
since 1970, considerably more than the size of the elderly
population itself.
Use of home health services by Medicare beneficiaries across the
state has also been routinely lower than minimum need estimates.
The following table and chart show this pattern.
Need for Services
Persons Receiving
Percent of
5
6
7
8
Year
Maximum
Minimum
Services
Minimum Need Met
1969
53,785
9,474
5,300 to 5,700
60%
1970
54,703
9,653
4,900 to 5,600
58%
1971
55,943
9,854
4,200 to 4,500
46%
1972
57,075
10,054
5,100 to 5,300
53%
1973
58,538
10,311
6,100 to 6,800
66%
1974
59,895
10,371
7,300 to 7,700
74%
26
12.280
Number of
Need and Receipt of Home Health Services
Beneficiaries
among Medicare Beneficiaries, State of
Washington, 1969-1974.
60,000
High need estimate: 16.4 percent
50,000
of the non-institutional beneficiary
population plus 25 percent of the
institutional population.
40,000
30,000
20,000
Low need estimate: 3.2 percent of
non-institutional beneficiary
population.
10,000
Range of beneficiaries who received
home health services.
0
1969
1970
1971
1972
1973
1974
Year
The Medicare beneficiary population in Washington State is
characterized by consistent unmet need for home health
services.
Need estimates assume that 6.6 percent of the beneficiary
population is institutionalized each year.
Utilization data taken from home health agency Medicare cost
reports.
27
B. Use of Services by Persons Under Age 65
The following table shows the number of under-65 persons served
by home health agencies in the region since 1970. (These
persons are all Whatcom County residents.)
Under-65 Persons Served, Region
Year
Regional Total
9
1970
96
1971
111
1972
134
1973
97
1974
117
As with the elderly, we find that the 117 persons served in 1974
meets only a small fraction of the estimated need of 1,500 to
3,100 persons that year, about 4 to 8 percent of the need.
Although 1974 saw 22 percent more people served than in 1970,
use of the services by the under-65 population has been erratic
and not characterized by steady growth -- despite the size of
the unmet need.
In contrast with the region's elderly population, the region's
under-65 population has grown less between 1970 and 1974, and the
group's use of hospital services has increased nearly in
proportion to increases in size of the group itself.
10
Year
Number of Persons Under 65
11
Under-65 Hospital Admissions
1970
145,966
18,404
1971
148,610
18,620
1972
149,780
19,439
1973
149,660
20,107
1974
149,770
19,241
Percent Increase,
1970-74
2.6%
4.5%
Comparable data on use of services by the under-65 population are
not available for the state as a whole.
28
References
1. Data source: Medicare cost reports from home health agencies within
the region.
2. Source: Attachment 6.
3. Data sources:
1970-1973
Comprehensive Health Planning Council of
Whatcom, Skagit, Island, and San Juan
Counties, Health Indicators Report, 1968-1973.
Mount Vernon, Washington, August 1975,
Table 26.
1974
State of Washington, Office of Planning and
Health Facilities, Hospital Utilization
Report. Olympia, Washington, 1974.
4. Comprehensive Health Planning Council of Whatcom, Skagit, Island,
and San Juan Counties, A Study of the Title XIX Program, Whatcom,
Skagit, Island, and San Juan Counties, and the State of
Washington, 1968-1973. Mount Vernon, Washington, February 1975,
Table 7.
5. Maximum need is defined as 16.4 percent of the noninstitutional
beneficiary population plus 25 percent of the institutional
beneficiary population. The institutional population is assumed
to include 6.6 percent of the total beneficiary population each
year. Beneficiary population figures are taken from Medicare
enrollment figures shown in Attachment 8.
6. Minimum need is defined as 3.2 percent of the noninstitutional
beneficiary population. The noninstitutional population includes
93.4 percent of the total beneficiary population each year.
Beneficiary population figures are taken from Medicare enrollment
figures shown in Attachment 8.
7. These figures are derived from Medicare cost reports from home
health agencies across the state. Exact figures on persons
receiving services are not available because several agencies
reported no data. Estimates were generated for these agencies
from other data provided by them on numbers of Medicare visits
and amounts of Medicare reimbursement. The methodology is shown
below for 1974.
Total visits, agencies not reporting number of patients: 33,675
Visits per patient, agencies reporting number of patients: 8.9
Estimated patients: 33,675 ÷ 8.9 = 3,784
Reported patients: 3,924
Total patients: 3,784 + 3,924 = 7,708
29
Total reimbursement, agencies not reporting number of
patients: $732,887
Reimbursement per patient, agencies reporting numbers
of patients: $218.91
Estimated patients: $732,887 ÷ $218.91 = 3,348
Reported patients: 3,924
Total patients: 3,348 + 3,924 = 7,272
Persons receiving services: 7,300 to 7,700
8. Figures were calculated by dividing high estimate of persons
receiving services by minimum number of persons estimated to
need services. For 1974, 7,700 ÷ 10,371 = 74%.
9. Data supplied by the Visiting Nurse Association, Bellingham,
Washington.
10. Source: Attachment 9.
11. Data sources:
1970-73
Comprehensive Health Planning Council of
Whatcom, Skagit, Island, and San Juan
Counties, Health Indicators Report,
1968-1973. Mount Vernon, Washington,
August 1975, Tables 23 and 26.
1974
State of Washington, Office of Planning and
Health Facilities, Hospital Utilization
Report. Olympia, Washington, 1974.
30
System: A Useful Planning Tool
Recent federal legislation (Public Law 93-641) created "health systems
agencies" to develop plans for the "health system.' The law did not,
however, define "health system. This Development Guide has used a
functional definition of "system" as a way of identifying problems
(analysis) and as a way of grouping solutions to the problems
(synthesis). As an analytical tool, the model was used to identify
problems connected with Medicare and Medicaid. As a synthetic
tool, the model was used to organize regional, state, and national.
recommendations into an understandable and rational arrangement.
The model was not used at the regional level to identify problems
because (1) the Task Force used a goal-related planning process
and (2) the development of the model occurred too late in the
planning process to be used as an analytical tool. The model is,
however, compatible with a goal-related planning process, provided
that the goals used correspond to the system's major components.
As used in this document, "system" has been defined to have four
functional components. These four components appear to be the
minimum set of attributes that can be used to characterize a system
comprehensively. The four components are administration, resources,
service delivery, and inter-coordination
The first component, administation, encompasses such functions as
management and supervision, planning and policy development,
definition and interpretation of performance data, organization of
resources, and internal coordination.
Resources are, of course, the raw materials out of which services
are provided: personnel, money, time, buildings, equipment. The
resources component of a system performs such functions as
acquiring, maintaining, improving, or providing resources.
Service delivery, the third component, is the productive part
of the system, the part that involves the using of resources to
conduct activities or provide services. Performance data, costs,
and health benefits are some by-products generated by this component
of the system.
The fourth component of a system, inter-coordination, encompasses
those activities which link the system to other systems. In the
field of health care, the biomedical delivery "system" links or
coordinates itself with individual and collective human systems
(patients and communities), political systems, religious systems,
labor systems, etc. Inter-coordination involves such things as
public information, public relations, public accountability and
responsiveness, planning coordination, and activity coordination with
other systems.
There are a number of reasons to use this model as a health
planning tool. Its major asset is its simplicity. Its key
31
characteristics can be described in just a few paragraphs. The
model is also comprehensive. Unlike many other planning models,
for example, this model immediately suggests that such things as
policy development and public accountability are legitimate
considerations for planners. The model is rational. It identifies
key functions that must be performed by a system if it is to be
or remain a system. The model is versatile. It can be applied to
virtually any identifiable system. For all these reasons, the
model system described and used in this Guide appears to be a
useful tool as the art of health planning moves into its second
decade.
Findings and. Recommendations
The bulk of the remaining portion of the Development Guide contains.
findings and recommendations made by the Task Force. The findings and
recommendations are divided into three groups according to geographic
area: regional, state, or national. In each of these groups,
the findings are listed first and are followed by relevant
recommendations. At the regional level, findings are based on a
research tied to a set of "indicators" developed by the Task Force
as a means of applying the Health Planning Council's overall goals
for health services to a particular health service, i.e., home
health services. Regional findings are displayed opposite appropriate
indicators from pp. 32 to 57. Regional recommendations have been
grouped according to elements of the system model discussed on pp. 30
to 31. At state and national levels both findings and recommendations
are directly related to elements of the system model. At the national
level both findings and recommendations are also separated according
to type of national program.
Regional Level: Findings
This section shows health services goals and associated indicators used by the Task Force to study home
health services in the region. The indicators are found at the left side of the pages that follow.
Findings related to specific indicators are listed in either the column labeled "Areas of Strength" or
the column labeled "Areas for Improvement." Following this listing of goals, indicators, and findings
is a section showing regional recommendations.
Goal l.a. The need for acceptable services: Clients need services that are comfortable, punctual,
non-discriminatory, understandable, personalized, responsive to individual and special
needs, courteous, and confidential.
Indicators
Areas of Strength
Areas for Improvement
1. Whether supervisory visits
1. Supervisory visits are
are made to access care
made by home health agency
received.
personnel to assess care
32
provided to patients.
2. Whether patient care
2. Patient care methods
methods are understand-
appear to be understand-
able to the patient and/or
able to the patient and/or
the patient's family.
the patient's family.
3. Whether access to home care
3. Physician access to exist-
services for physicians is
ing home health services
as easy as possible.
appears to be generally
satisfactory.
4. Whether the patient meets
4. Two out of three patients
home care personnel prior
do not meet health agency
to being discharged from
personnel prior to
an institution.
receiving home health
services.
5. Whether the home care
program evaluates the char-
acteristics mentioned in
the goal (1.a.).
Goal l.a. (continued)
Indicators
Areas of Strength
Areas for Improvement
6. Whether care is provided
by someone the patient
already knows, or whether
the provider of care already
knows the patient.
7. Whether care is personal-
ized through the use of
managing physician's
personnel at home.
8. Whether patients can report
8. Patients. are able to
33
adverse experiences in a
report adverse experiences
non-face-to-face manner.
through the use of anonymous
letters or telephone calls.
Patients are well-satis-
fied with home health
services they have received.
9. Whether the services use
9. Home health agencies have
several different methods
developed and currently
to evaluate their success
use a number of methods to
in meeting each of the
monitor the acceptability
client needs listed.
of care provided to patients.
10. Whether utilization review
respects individual patient
needs that mitigate for or
against rapid discharge.
Goal l.b. The need for alternatives: Citizens need to be able to choose from among places and
methods of care.
Indicators
Areas of Strength
Areas for Improvement
1. Extent to which patients
1. Home health services are
can choose home care prior
seldom discussed by
to admission or prior to
physicians and patients
discharge.
prior to non-emergent
hospitalizations.
2. Whether a patient can
2, The patient's choice of
choose to receive home care
3, home care as an option is
instead of or in addition
4. limited for a number of
to institutional care or
reasons: home health
outpatient care.
services are not adequately
34
available in three of the
3. Whether the patient has the
region's four counties;
choice to stay at home if
many patients are unfamiliar
is at all medically
with their insurance policies'
feasible.
provisions for home health
services or unaware of home
health services available
4. Whether the patient has a
voice in deciding the kinds
in the community; a signi-
of services to be provided
ficant proportion (about
and where they are to be
half) of patients have
received.
little or no input into
medical care decision-
making processes.
Goal 1.b. (continued)
Indicators
Areas of Strength
Areas for Improvement
5. Whether boarding homes or
5. Boarding homes, halfway
halfway houses are avail-
houses, congregate care
able for the elderly who
facilities, low income
need minimal care or super-
housing, and similar
vision (less care than that
residential facilities
in a hospital or nursing
appear to be inadequately
home).
available as "alternatives"
in the region. Intermediate
care facilities and adult
foster homes may also be
inadequately available.
6. Whether a patient can
6. The absence of "alternative"
choose from among a number
residential facilities
35
of alternative living
limits consumer choice in
arrangements.
living arrangements.
7. Whether physicians can
7. Physicians believe "places"
choose (for their patients)
(facilities) for continuing,
from among places and
post-acute patient care
methods of care.
are adequately available.
8. Whether the service has
developed methods of enabling
a patient who lives alone
to go home anyway.
9. Whether a variety of service
choices are available.
Goal 1.c. The need for competence and appropriateness: Clients need services that are medically
and technically competent and appropriate.
Indicators
Areas of Strength
Areas for Improvement
1. Extent to which providers
1. Consistent under-use of
of care are adequately
home health services in
qualified and trained.
the region raises questions
about physician knowledge
of the kinds of circumstances
in which home care should be
used.
2. Whether patients already in
2. Medical assistance nursing
nursing homes are period-
home patients are period-
ically identified on the
ically reviewed relative
36
basis of their suitability
to their suitability for
for home care.
home care.
3. Whether nurse and physician
education in this region
and State provides. for
training regarding home
care.
4. Whether home care personnel,
including physicians, receive
adequate continuing education.
5. Extent to which patients
who need skilled nursing
care are correctly placed
in a skilled nursing facility
or in a home care program.
6. Extent to which Medicare or
other administrative require-
ments promote appropriate
patient placement.
Goal 1.c. (continued)
Indicators
Areas of Strength
Areas for Improvement
7. Extent to which services are
appropriately provided in
the home.
8. Extent to which utilization
8, Utilization review committees
review committees have
9. have not developed and do
developed and use criteria
not use systematic criteria
to identify patients
or procedures to identify
eligible for home care.
patients eligible for home
care. Such identification
9. Extent to which patients
is not performed because the
with diagnoses appropriate
utilization review committee
for home health care do
functions only to identify
not remain in the hospital
patients who no longer need
37
unnecessarily long.
institutional care. Identi-
fication of potential home
care patients in hospitals
appears to be spotty in
quality and generally not
systematic or routine.
10. Whether services are
10. Home health services are
provided in the home
not always provided when
when desired by the
desired by the patient
patient.
because (a) the services
are not available, or (b)
the services must be
ordered by a physician, or
(c) the patient's insurance
will not pay for the services
needed and the patient can't
afford to pay for them out-
of-pocket.
Goal 1.c. (continued)
Indicators
Areas of Strength
Areas for Improvement
11. Whether the appropriate
level of skill provides the
requested services.
12. Whether patients who do not
need to go into a nursing
home are identified prior
to admission.
38
Goal l.d. The need for comprehensiveness: Clients need care that provides a full range of services,
orients toward the whole person, and provides for coordination and continuity.
Indicators
Areas of Strength
Areas for Improvement
1. Whether the following
1. With the exception of
1. A reasonably adequate
services are adequately
age- and residence-related
set of home health services
available for use in the
service availability
is available only in Whatcom
home:
problems previously mentioned,
County. Home health services
the following home health
are available only to Medicare
a. /olunteer home visitors.
services appear to be
patients in Skagit and Island
b.
Homemakers.
adequately available for
Counties. No home health
C. Health aides.
use in the home: nursing,
services are available in
d. Speech therapy.
physical and speech therapy,
San Juan County except through
e. Physical therapy.
medical supplies/equipment,
public health nurses.
f. Occupational therapy.
oxygen, and laboratory services.
Goal l.d. (continued)
Indicators
Areas of Strength
Areas for Improvement
g. Meal services.
Services that appear
h. Inhalation therapy.
to be inadequately
i. Medical supplies.
available across the
j. Equipment transportation.
region for use in the
k. Child birth services.
home include occupational
1. Public health nursing.
therapy, homemaker/health
m. Skilled nursing.
aide services, chore
n. Caseworker or medical
services, meal delivery
social services.
services, and medical
0. Equipment loan.
social services. Health
p. Medications.
aide services appear to
q. Oxygen.
be the most needed type
39
r. Intravenous therapies.
of service not adequately
S. Laboratory services.
available. Live-in
t. Patient transportation.
housekeepers or companions
U. Home maintenance
also appear to be needed
services.
but not adequately available.
2. Extent to which continuing
2. Medicare patients generally
or maintenance-type care
do not receive needed
is provided in the home.
health maintenance or
homemaker/health aide
services at home because
Medicare will not pay
for the services or will
not pay for the services
in the kinds of situations
in which they are most
needed by patients.
3. Whether the patient is
3. Patients generally receive
trained in self-care.
training in self-care.
The training is provided by
Goal 1.d. (continued)
Indicators
Areas of Strength
Areas for Improvement
physicians, hospital
personnel, and home health
agency personnel.
4. Whether home care services
4. Home health services
are available to people of
are not available to
all ages.
people of all ages.
Only Whatcom County
has home health services
available to people of
all ages.
40
5. Whether standards exist for
5. Uniform standards have
referral to home care from
not been developed in
the hospital.
any community in the
region for the referral
of hospital patients to
home health services.
6. Whether continuity between
6. Continuity between patients
the patient and hospital
and hospital therapy or
therapy or rehabilitation
rehabilitation personnel
personnel is achieved.
is achieved for only about
half the patients who
continue to receive such
services after discharge
from the hospital.
7. Whether continuity between
GERALD
the patient and the managing
physician is maintained.
FORD
Goal 1.d. (continued)
Indicators
Areas of Strength
Areas for Improvement
8. Whether physicians have
8. Physicians generally
access to a full range
do not have access to
of home care services.
a full range of home
health services for
their patients because
some types of needed
services, such as health
aide services, are not
adequately available.
9. Whether referrals to home
9. Referrals to home health
9. Referrals to home health
care are made on an
services are made mostly
services are made mostly
41
individual basis (because
on a case-to-case basis.
on a case-to-case basis.
of complexities involved).
This mode of referral
This mode of referral
provides considerable
provides considerable
flexibility for both
potential for the non-
patients and providers
identification of possible
of care.
home care patients.
10. Whether citizen information
and referral services for
one's vocational, recre-
ational, social, and
physical needs are available.
11. Whether an adequate number
of professional and non-
professional referral
sources are available.
Goal l.e. The need for convenience and accessibility: Clients need services that are not too
far away in either time or distance.
Indicators
Areas of Strength
Areas for Improvement
1. Whether home health services
1. Home health services
are available in one's
are not conveniently
county of residence.
available to persons
under age 65 in three
of the region's four
counties.
2. Whether physician access
2. Physicians generally
to home health services
have convenient access
is convenient in both
to the home health services
time and distance.
that currently exist.
42
3. Whether home health personnel
3. Home health personnel
are available in isolated
are generally not
areas.
available in isolated
areas within the region.
Goal l.f. The need for economy: Clients need services that are affordable and need to be protected
from financial disaster resulting from the costs of services.
Indicators
Areas of Strength
Areas for Improvement
1. Whether home care fees are
competitive with those of
an extended care facility.
2. Whether long-term care
services to maintain patients
in their homes are affordable
to the patients.
Goal l.f. (continued)
Indicators
Areas of Strength
Areas for Improvement
3. Whether charges for
3. Home health services
3. Charges for services
services are low enough
included under Medicare's
are generally not low
to permit use of services
benefit package are quite
enough to permit the
by all people regardless
affordable to patients who
use of services by all
of income.
receive services.
people reagrdless of
income.
4. Whether home care fees are
4. Charges for services
low enough to induce
are generally not low
physician support for the
enough to induce physician
services.
support for the services.
This finding may be due
43
to the fact that home
health agency charges are
based on numbers of visits
provided instead of numbers
of days of care provided.
Use of visits as the mode
of charge has a concentration
effect on charges. As a
result, charges appear high.
On a cost-per-day basis,
however, home health
services are considerably
less expensive than care
in a health facility.
5. Whether costs are low enough
to permit home care services
to be offered through
Skagit County Hospitals.
Goal l.f. (continued)
Indicators
Areas of Strength
Areas for Improvement
6. Whether transportation of
the patient to a source of
care is available when the
total cost of such service
is less than that of a visit
in the home.
Goal 1. g. The need for maintenance of health: Citizens need services that emphasize maintenance
of good health, including information, education, and prevention services.
44
Indicators
Areas of Strength
Areas for Improvement
1. Whether preventive services
are adequately available
in the community to prevent
unnecessary use of
institutions or therapeutic
home care services.
2. Whether there is early
2. Early patient and family
patient and family involve-
involvement in preparations
ment in preparations for
for continued care after
continued patient care prior
hospitalization appears
to discharge from an
to occur for about 3 out
institution.
of 4 Medicare hospital
patients.
Goal l.g. (continued)
Indicators
Areas of Strength
Areas for Improvement
3. Whether community and
3. Community and intra-
intra-institutional
institutional information
information and education
services appear to be
services are adequately
inadequate. The extent
available.
of consumer knowledge
about home health services
is generally very low.
The home health services
survey found that two
out of five former home
health patients learned of
the existence of home
45
health services only
after they left the hospital.
4. Whether a full range of
preventive health services
are available for persons
of high risk. Such services
should include nutrition,
well-clinics, dental care,
immunization services, eye
and ear examinations.
5. Whether adequate liaison is
available between providers
and lay caretakers.
6. Whether there are reasonable
6. Medicare's home health
restrictions on the provision
services benefit package
of continuing or mainte-
contains unreasonable
nance-type care.
restrictions on the provision
Goal 1.g. (continued)
Indicators
Areas of Strength
Areas for Improvement
of continuing or
maintenance-type
home health care.
Maintenance-type
home care is generally
not provided to
Medicare patients.
7. Whether physicians receive
adequate information or
education on home care
services.
46
8. Whether maintenance-type
a
care is provided in the
home.
9. Whether home care services
9. The kinds of home health
are available for prevention
services needed to prevent
of dependency, such as the
dependency and admissions
dependency that forces some
to health facilities are
people into nursing homes.
generally not adequately
available.
Goal 1.h. The need to know: Citizens need to know what services are available, what is occurring
during the process of care (including procedures, risks, diagnoses, and alternatives),
what costs are involved, and what is being done with their tax dollars for health.
Indicators
Areas of Strength
Areas for Improvement
1. Whether patients understand
1. Prior to hospitalization,
the extent of their insurance
between 50 and 85 percent
coverage in relation to home
of the patients are not
care services upon entering
familiar with the extent
an institution.
to which their insurance
provides home health
services benefits.
2. Whether citizens have
2. Two out of three home
2. About 9 patients in 10
access to information on
health agencies publish
have never seen information
47
how much tax money is spent
annual reports containing
on the extent to which
for the provision of home
information on tax funds
tax money is spent for the
care services.
spent to provide home
provision of home health
health services.
services.
3. Whether all medical procedures,
including risks, diagnoses,
and procedures, are explained
to the patient and his or her
family before treatment begins.
4. Whether patients are adequately
4, Prior to hospitalization,
informed about home care
5. about 4 patients in 5
services available prior to
are not familiar with
entering an institution.
the extent to which home
health services are
available in their community,
including costs and
financing methods.
Goal 1.h. (continued)
Indicators
Areas of Strength
Areas for Improvement
5. Whether citizens are
4, Prior to hospitalization,
generally well informed
5. about 4 patients in 5
about the availability of
are not familiar with
home care services,
the extent to which home
including financing and
health services are
costs of the service.
available in their
community, including
costs and financing methods.
Goal l.i. The need for participation: Citizens and clients need to be able to affect, via their
48
participation in decision-making processes, the nature and distribution of health services
and the definition of quality of care.
Indicators
Areas of Strength
Areas for Improvement
1. Whether both physicians
1. Physicians serve on home
1. Former home health patients
and former home care
health agency governing
do not serve on committees
patients are represented
boards as either official
or governing boards of any
on home care boards and
board members or as ex
of the home health agencies.
committees.
officio members.
Physicians serve on
committees maintained
by home health agencies.
2. Whether the patient
2, About half the Medicare
is given a choice between
3. patients participating
home care services and
in the home health services
alternative types of
survey reported that they
services.
had little or no involvement
in medical care decision-making
Goal l.i. (continued)
Indicators
Areas of Strength
Areas for Improvement
3. Whether the patient
processes. As a result,
participates in the
these non-participating
decision on the place
patients have little
of further care.
choice between home health
services and other methods
of treatment. Their non-
participation, coupled
with their ignorance about
home health services,
makes them very dependent
on providers of care, such
as physicians, for the
ordering of the services.
49
Goal 1.j. The need for person-centered and family-centered services: Citizens need services that
consider the whole person, not just the complaint or problem at hand.
Indicators
Areas of Strength
Areas for Improvement
1. Whether an adequately
No indicators were studied under this goal.
comprehensive evaluation
of all relevant factors
that affect the patient's
health or ability to
regain health is made
prior to the patient's
entrance into a home
care program.
2. Whether the pre-home
care evaluation provides
information on the needs
that will be generated
Goal l.j. (continued)
Indicators
Areas of Strength
Areas for Improvement
within the family
while the patient
receives home care.
3. Whether the home
care program acts
upon the pre-home care
patient evaluation in
order to minimize all
factors detrimental to
the patient's health.
50
Goal 1.k. The need for responsiveness: Citizens need individual and organizational providers willing
to modify their methods to respond to individual and community needs.
Indicators
Areas of Strength
Areas for Improvement
1. Whether providers modify
Responsiveness of providers cannot be determined until after
their methods in accordance
the Home Health Services Development Guide is published.
with Task Force or Council
recommendations.
2. Whether home health services
have become more readily
available or more extensively
used.
Goal 2. Resources of sufficient quantity and quality should be available to meet health needs.
Resources include personnel, funds, facilities, equipment, and finances.
Indicators
Areas of Strength
Areas for Improvement
1. Whether adequate private and
1. Adequate private and
public reimbursement
public mechanisms for
mechanisms are available
reimbursement of home
for preventive and health
health services, including
maintenance home care
services provided for
services.
prevention or health
maintenance are not
available. See Attachments
11 and 12. Also see
p. 8.
51
2. Extent to which reimburse-
2. Home health agencies
ment regulations are
believe insurance-related
reasonable and applied
reimbursement regulations
fairly and consistently.
are generally applied
fairly and consistently.
3. Whether there is an
3. The adequacy of
adequate number of social
availability of social
worker-type personnel for
worker-type personnel
needed counseling, planning,
in health care institutions
and supportive services to
is questionable.
patients in institutions.
4. Whether services are provided
4. Home health services
and reimbursed despite a
are provided and reimbursed
patient's inability to pay.
despite a patient's ability
to pay only in Whatcom
County. Such reimbursement
occurs there through the
Comprehensive Employment
Training Act, United Way
Goal 2 (continued)
Indicators
Areas of Strength
Areas for Improvement
Funds, or revenue sharing
obtained from local govern-
ment. Home health services
in Skagit and Island
Counties are provided only
to persons who can afford
to pay, i.e., Medicare
patients.
5. Whether the methods of
5. Current methods of reimbursement
financing home care services
based on cost per visit create
create incentives for the
disincentives for appropriate
52
appropriate use of services
use of services because of the
by both consumers and
concentration effect such a
providers of care.
payment method has on charges.
6. Whether an adequate number
of physicians refer patients
to home care programs.
7. Whether there is an adequate
7. There is an adequate
7. Homemakers and health aides
number of personnel (such as
number of nurses, speech
are not adequately avail-
health aides, homemakers,
therapists, and physical
able to patients who require
therapists, nurses, etc.)
therapists available to
such home health services.
available to patients who
patients who have access
While there is large consumer
require home care services.
to home health services.
demand for these services,
The number of personnel
there is little provider
employed can be readily
demand for the services.
expanded to meet demand.
Consumer demand for the
services that do exist in
Whatcom County surpasses supply
by a factor of two or three.
Goal 3. Providers of health services should function with coordination, flexibility, and foresight.
Indicators
Areas of Strength
Areas for Improvement
1. Whether the hospital develops
1. Some hospitals have not
and maintains an effective
developed effective
mechanism for the identifi-
mechanisms for the identi-
cation of patients
fication and prompt
potentially suitable for
referral of patients
home care and for their
potentially suitable for
prompt referral to the
home care.
program.
2. Whether there is orderly,
2. Some hospitals have not
systematic, and coordinated
developed adequate
planning for patient
procedures for orderly,
53
discharge between the
systematic, and coordinated
hospital, the family, home
planning for patient
health care services, and
discharge. Only 60 percent
other post-hospital
of the Medicare patients
resources.
participating in the home
health services survey
thought that they received
both adequate advance
preparations for discharge
and satisfactory arrangements.
3. Whether home health care is
3. Some home health services
available and used as
are available for use as
preventive care prior to
preventive services, but
hospitalization and is not
they are seldom used for
restricted just to those
this purpose, mainly because
who are discharged from
third party payors will not
acute care.
pay for such care.
Goal 4. Health services provided by programs and organizations should be evaluated by both consumers
and providers.
Indicators
Areas of Strength
Areas for Improvement
1. Whether the home care program
1, Home health agencies use
adequately uses such methods
2
patient interviews, super-
as patient interviews, patient-
visory visits, utilization
completed evaluation checklists
review committees, case
or utilization review
review or team conferences,
committees to evaluate its
and professional advisory
services.
committees as methods of
evaluating services or
2. Whether home care programs
determining the quality
use utilization committees
of program functioning.
or medical advisory committees
In addition, agencies are
54
to determine the quality of
periodically audited and
program functioning.
recertified by other
organizations, such as
Blue Cross. Physicians
participate on the
utilization review
committee of one agency
and on the professional
advisory committee of
two agencies.
3. Whether committees which
3. Former patients do not
determine quality of
serve on any of the home
program functioning are
health agency committees
Goal 4 (continued)
Indicators
Areas of Strength
Areas for Improvement
partly composed of former
responsible for evaluating
users of home care services,
the quality of program
including physicians.
functioning.
4. Whether committees which
4. Home health agencies
determine quality of program
hardly ever report the
functioning provide physicians
results of evaluations
with the results of their
of home health agency
assessments.
functioning to physicians
in the agency's service
area.
55
Goal 5. Programs and organizations providing health services should provide the public with
information about achievements and associated costs, services offered, and the charges for
services offered.
Indicators
Areas of Strength
Areas for Improvement
1. Whether both patients and
1. The consuming public is
physicians know the kinds
largely ignorant of most
of health conditions for
aspects of home health
which home care services
services: what services
are available and most
are available and for
appropriate, and the costs
whom, what their own
of such services.
health insurance benefits
are relative to home health
services, what costs and
charges are connected with
home health services, how
tax funds are spent for home
health services.
Goal 5 (continued)
Indicators
Areas of Strength
Areas for Improvement
None of the eight board--
certified and board-eligible
physicians interviewed in
the home health services
survey estimated "last year's"
home health agency charges
accurately. Collectively,
the eight physicians
identified many of the kinds
of health problems that can
be successfully treated via
home health services, but,
56
individually, physicians
mentioned few kinds of
problems that are generally
appropriate for home health
services. As discussed in
the "Home Health Services
Survey," physicians also
appear to be less informed
about the intricacies of
Medicare reimbursement
regulations than home health
agencies. These findings all
create the impression that
physicians are not adequately
informed about some aspects of
home health services.
Goal 5 (continued)
Indicators
Areas of Strength
Areas for Improvement
2. Whether home care programs
2. Two agencies make periodic
make periodic reports to
reports to the general
service and civic groups
public on program achieve-
and the general public
ments, program charges, and
regarding home care program
services offered. The third
achievements and costs,
agency publishes an annual
services offered, and
report which is distributed.
charges for services
to mayors, city councils, and
offered.
county commissioners in its
service area.
57
58
Regional Level: Recommendations
A. Administrative Recommendations
Introduction
Home health services should generally be organized within the
region as hospital-based services. The development of shared
hospital-based services is recommended because of the kinds of
benefits that would be likely to occur under such an arrangement:
a. Improved convenience for physicians.
b. Improved acceptance of home health services by
physicians because of the existence of hospital-
based quality control procedures.
C. Improved efficiency of operation because of the
existence of support services within the hospital
and because of the likelihood that utilization will
increase.
d. Increased visibility and availability of services
within the community.
e. Improved continuity of care because:
- Physician-home health agency interactions and
communications will be made more convenient.
- Patients are more likely to meet home health
personnel prior to discharge from the hospital.
- Hospital personnel from whom the patient received
care in the hospital may be able to continue to
provide care to the patient at home.
- Patient medical records will be concentrated at a
single facility.
- The development of an adequate range of home health
services by the hospitals will assure that patients
continue to receive needed care, whether hospitalized
or not, in a setting most appropriate to their
medical condition and social situation.
f. Improved ability to conduct research or develop
innovative programs, such as rotation of hospital
nursing personnel through the home health department.
g. Improved joint planning activities by hospitals.
59
h. Improved acceptance of home health services as a
legitimate method of treatment by insurance carriers.
Such acceptance should lead to increased availability
of insurance benefits for home health services.
i. Improved opportunities for staff education.
1. Organization of Resources
Whatcom County
Home health services in Whatcom County should be organized
as hospital-based services. To accomplish this recommendation,
the two Bellingham hospitals should:
a. Contract with existing home health agencies or programs
to provide home health services for the hospital. (Similar
arrangements already are used by the hospitals for the
provision of medical services and alcohol detoxification
services.) As with other contractees, these agencies
should be provided with adequate facility space to conduct
their activities. The two hospitals' contracts should
be as similar as possible in order to assure uniformity
of services and procedures at both hospitals.
OR
b. In the event existing agencies decline to contract with
the hospitals, the hospitals should each develop a
home health service department and operate the two
departments as a single shared service in competition
with other home health services agencies that may be
present in the community. As part of the procedures
used to develop such a shared service, the hospitals
should discuss and agree upon such things as common
organizational structures, operational variables
(departmental policies and procedures), accounting
and data-keeping methods, services to be provided,
and public relations programs.
This recommendation should be accomplished by November 1977.
Skagit and Island Counties
Home health services in Skagit County should be organized as
hospital-based services. To accomplish this recommendation,
the following activities should be undertaken:
a. United General Hospital and Skagit Valley Hospital should
each develop a home health service department and operate
the departments as a single shared service. As part of the
procedures used to develop such a shared service, the
60
hospitals should discuss and agree upon such things as
common organizational structures, operational variables
(departmental policies and procedures), accounting and
data-keeping methods, services to be provided, and public
relations programs. This recommendation should be
accomplished by November 1977.
b. Island Hospital and Whidbey General Hospital should each
develop a home health service department and operate
the departments as a single shared service. As part
of the procedures used to develop such a shared service,
the hospitals should discuss and agree upon such things
as common organizational structures, operational variables
(departmental policies and procedures), accounting and
data-keeping methods, services to be provided, and public
relations programs. This recommendation should be
accomplished by November 1977.
C. In designing their programs, the hospitals of Skagit
and Island Counties should draw upon the knowledge and
experience of employees currently affiliated with County
Health Department home health programs. In addition,
the hospitals should advise the Health Departments of
progress being made in the development of the hospital-
based home health services.
d. With the initiation of hospital-based home health services
in Island and Skagit Counties, the respective Health
Departments should terminate their home health programs.
San Juan County
Because of their geographic proximity to San Juan County,
hospitals in Bellingham and Anacortes should discuss ways
in which their home health services programs could be
organized to assure the availability of services to
residents of San Juan County.
Health Systems Agency
Health systems agencies across the State of Washington are
urged to take actions to encourage the state to place a
high priority on improving home health services.
2. Patient Care Decision-Making Process
Role of the Physician
a. Physicians should increase the extent to which they
involve patients in medical care decision-making. When
medically possible and practical, patients should be
61
encouraged and invited to discuss treatment alternatives,
such as home health services.
b. To help remedy consumer ignorance about home health
services, physicians should discuss home health services
as a treatment alternative with their patients or their
kin before hospitalization or during hospitalization.
Role of the Hospital
C. Hospitals, via representatives of the medical and nursing
staffs and other appropriate personnel, should develop
acceptable and systematic procedures and criteria for
the timely identification and referral of patients who
should receive home health services following hospitalization.
Similar criteria should be developed for the screening
of non-hospital patients for whom home health services
have been ordered. Ideally, the procedures and criteria
developed should be uniform within the four county region.
If this uniformity is not possible, procedures and
criteria should be uniform for each pair of hospitals.
offering shared home health services. See Attachment 13
for an example of a patient identification protocol
already in use.
d. To the extent possible, the patient identification
procedures described in the preceding paragraph should
be designed to serve, too, as a means by which systematic
discharge planning activities can be assured. See
Attachment 13 for an example of such a patient identification
protocol.
e. Hospitals should consider developing small, specialized,
multi-disciplinary discharge planning committees to
conduct the patient identification and discharge planning
activities described in the preceding two paragraphs.
Such committees would help upgrade the quality and
effectiveness of such activities, provide an expanded
supply of personnel within the hospital knowledgeable
about discharge planning activities, and provide
opportunities for in-service training for various types
of hospital personnel via a system of rotating committee
membership. (Such rotating membership now occurs among
physicians who serve on the hospital's utilization review
committee.)
f. The hospitals should generate data from their discharge
planning activities on the success with which patients
receive appropriate kinds of care after hospitalization.
The data should be used by the hospital, the community,
and/or the health systems agency to identify problems
62
(such as the inability to place some patients appropriately
because a needed facility is not available) and to
develop, subsequently, plans and initiatives to solve
the problems.
3. Consumer Participation in the Evaluation of Home Health Services
Where appropriate and feasible, non-professional personnel
and former home health services patients should participate
in methods used by the hospital to monitor or assess the
performance of the home health services program.
4. Definition and Interpretation of Performance Data
Hospitals should develop uniform data sets as part of the
development of their home health services programs. These
data sets should be designed to monitor quality of care
and program performance as well as to generate epidemiological
data for purposes of research. The health systems agency
should assist hospitals in the development of these data sets.
5. Coordination of Activities
The hospitals should consider hiring a qualified consultant(s)
to assist them develop their home health services programs,
their request(s for federal funds, or their proposal (s) to the
Social Security Administration for the funding of a demonstration
project.
B. Recommendations on Research
1. Funding of Home Health Services
a. To support hospital-based home health services recommended
for development in Skagit and Island Counties, the Skagit
County Medical Bureau should offer insurance packages
providing reimbursement for the use of such services. Home
health services should be an automatically and explicitly
insured hospital service, as automatically insured by the
Bureau's hospital insurance plans as inpatient
medical/surgical services. The development of these
benefits should be coordinated with the hospitals' efforts
to develop and offer home health services by November 1977.
The reimbursement of the services should occur via a
prospective payment method based on a flat rate per home
care admission or a flat rate per period of home care.
The managing physician's prerogatives in ordering types of
home health services for patients should not be restricted
by a payment method based on types of services covered;
such a method will prevent the development and use of
those home health services for which payment is not
available. Utilization review activities, the hospoital's
63
systematic patient identification protocol, and the
built-in financial limits of the prospective payment
method should, in combination, adequately serve to
prevent excessive utilization of home health services.
b. The Whatcom County Physicians Service, which now offers
coverage of certain types of home health services,
should also move toward prospective payment methods as
outlined in the preceding paragraph. Consumers'
copies of their insurance plans should contain explicit
information relative to the extent to which their
policies provide coverage of home health services.
These changes should be coordinated with the Bellingham
hospitals' efforts to develop and offer home health
services by November 1977.
C. In the event local insurers find. it impossible to
develop prospective payment methods for the reimbursement
of home health services, reimbursement should be linked
to charges for service.
d. Hospitals, in developing charge structures for their
services, should develop sliding scale charge structures
based on the patient's ability to pay. Such a charge
structure will help assure that access to care is
based more on need for care than ability to pay.
e. In no case should payment for home health services be
linked to the number of type of visits received by a
patient. Charges should be linked to admission to
the home care program or length of stay in the program.
But because patients may differ in their needs for
service, it may be appropriate to develop two or three
charge structures to reflect the intensity or complexity
of services being received (see p. 5).
f. Because of the rural nature of the region, the number
of elderly persons living here, the relatively high
rate of use of nursing homes by Title XIX patients,
the lack of needed home health services, and the absence
of Medicare reimbursement for needed homemaker services,
providers in the four county region should develop,
with the assistance of the health systems agency, a
demonstration project under Section 222 of Public
Law 92-603, the Social Security Amendments of 1972,
which would explore alternative methods of funding home
health services under Titles V, XVIII, or XIX of the
Social Security Act and/or seek reimbursement of
homemaker services.
g.
The assurance of adequate funding and delivery of home
health services is increasingly becoming a national and
state priority. But until these priorities are translated
64
into dollars and cents, some funding problems are
likely to occur. To help assure that hospital-based
home health services maintain financial solvency,
each hospital offering home health services should
have a hospital guild for home health services. These
guilds should not only help raise funds for the home
health program, but also help provide information to
the public about home health services available in
the community.
h. Hospitals, in developing their home health programs,
should attempt to acquire federal funds available for
the development of such programs under Section 602
of Public Law 94-63. * The health systems agency should
assist hospitals in their attempts to acquire such
funds.
i. One or more of the region's State Legislators serving
on the Legislature's Social and Health Services
Committee should introduce a bill in the next session
of the Legislature that would require health insurance
carriers in Washington to offer a minimum set of home
health services insurance benefits for sale to the
public as part of the carriers' hospital insurance
plans. The region's Legislators should review similar
legislation now in effect in Connecticut, New York,
and Arizona prior to submitting such a bill.
j. Between 1976 and 1978 the health systems agency should
use a reasonable portion of its health services development
funds to assist hospitals in their home health services'
development and implementation activities.
k. Elected officials in the four county region should
contribute toward the development and initiation of
hospital-based home health services by responding to
requests for revenue sharing funds by hospitals
developing the home health services programs recommended
in this Guide.
2. Home Health Services Personnel
a. To assure the availability of competent and adequately
trained personnel for home health services programs that
will be developed by hospitals in the region over the
next two years, Whatcom Community College and Skagit
Valley College should develop curricula for the training
of homemaker/home health aides. Because distinctions
*
The Nurse Training and Health Revenue Sharing and Health Services
Act of 1975.
65
made between "homemakers" and "health aides" are not
valid, community college curricula should be geared
toward the training of a hybrid paraprofessional: the
homemaker/home health aide. To the extent possible the
colleges' homemaker/home health aide curricula should
be integrated with other nursing education programs
in order to promote career advancement of the
homemaker/home health aides. The development of these
training programs will assure a supply of needed trained
personnel in the region to perform tasks now performed
by homemakers, health aides, chore service workers,
and live-in housekeepers or companions.
b. To reduce travel times of home health agency personnel,
hospitals should explore the possibility of using on a
part-time or intermittent basis indigenous health
personnel living in relatively isolated areas to provide
home health services to patients in those areas * If
appropriate, hospitals should draw upon listings of
health personnel maintained by the health systems agency
as a means of recruiting needed personnel in these outlying
areas.
C. Other personnel deficiencies noted in this Development
Guide are likely to be solved with the advent of
adequate funding mechanisms and increased utilization
of services.
3. Facilities
a. As part of its future planning activities relative to
long term care, the health systems agency should
plan for the development of residential and patient
care facilities that appear to be inadequately available
in the region: adult foster homes, boarding homes,
congregate care facilities, halfway houses, intermediate
care facilities, and low income housing.
b. Agencies in the region that may have roles to play in the
development of the facilities listed in the preceding
paragraph should begin to quantify the need for these
facilities in their service areas and begin taking action
to eliminate identified deficiencies. Included in this
recommendation are such agencies as the Department of
Social and Health Services, county governments, city
or county housing authorities, county mental health or
mental retardation programs, and county senior services
programs. The development of these kinds of facilities
*
This kind of approach would probably be the best method of
providing home health services to patients in San Juan County.
66
will promote consumer choice in and satisfaction with
living arrangements, improve the range of treatment
choices available to providers of care, and reduce
unnecessary and inappropriate institutionalization
of patients.
C. Service Delivery
1. Availability of Services
a. In the organization of their home health services
programs, hospitals should prepare to deliver a
variety of different kinds of home health services,
particularly if insurers are able to develop
prospective payment methods which permit flexibility
in the kinds of services that can be provided.
Hospitals should assure that all home health services
eligible for reimbursement under Medicare will be
available through their programs. Homemaker services
should be made available via homemaker/home health aide
personnel. All these services should be available to
persons of all ages and source-of-payment categories
in the hospitals' service areas. This recommendation
will assure that an adequate set of services will be
available to persons of all ages and sources of payment
in at least three of the region's four counties.
b. In reviewing the adequacy with which hospitals implement
the recommendations in this Guide, the health systems
agency should permit hospitals to establish reasonable
limits on the size of the service areas established for
their home health services programs. The service radius,
however, should not be less than 15 miles for each
hospital. See map, Attachment 14.
D. Inter-Coordination
1. Public Information
a. Hospitals should periodically advertise the availability
of home health services through their facilities.
Because the lack of consumer information is a serious
problem preventing the appropriate use of home health
services, and because similar advertising costs by
proprietary nursing homes are currently reimbursable
by Medicaid and Medicare, reasonable hospital home
health service advertising expenses should be reimbursed
by Medicare, Medicaid, and other third party payers.
b. Hospitals should release periodic reports to the public
on quantities of home health services provided, types
of patients served, amounts of tax funds spent, benefits
67
derived from the program, etc. to assure public
accountability of the programs and to help inform the
public of activities occurring. The news media have a
responsibility to the public to disseminate these
reports in a timely and accurate manner.
C. The news media should publish periodic reports or feature
stories on the success with which home health services
are developed by hospitals within the region. Such
reporting will promote the public accountability of the
region's hospitals and serve to provide the public with
needed information on home health services.
d. The news media should prepare and disseminate a series
of reports on the status of long term care in the
region. Such reporting will improve the public's
awareness of problems that exist and thereby improve
chances that the problems will be more readily solved.
e.
The availability of home health services should be
discussed in the patient information brochures distributed
by the hospitals to incoming patients.
f. In their publicity efforts, hospitals and home health
services hospital guilds should pay particular attention
to potential patient referral sources, such as employees
of the Social Security Administration, Department of
Social and Health Services, county health departments,
or county senior services programs. For their part,
these agencies should cooperate to the maximum extent
possible with the hospitals' efforts to publicize
their new programs.
2. Physician Information
As part of their home health services development activities,
hospitals should take appropriate measures to assure that
their medical staffs are kept informed of progress being
made. Leadership of the hospitals' medical staffs should
develop and implement methods to assure that members of the
medical staffs are familiar with (a) procedures that will be
used to identify or screen potential home health patients,
(b) the kinds of medical conditions for which home health
services are appropriate, and (c) insurance-related
restrictions on the provision of home health services. With
the initiation of services, physicians should be kept informed
of the results of evaluative and/or epidemiological studies
of the hospital's home health services program.
3. The Role of Organized Labor
Organized labor in the four county region should consider
developing home health services insurance benefits for
68
their memberships. This recommendation is made because of
the demonstrated effectiveness of home health services in
reducing the overall costs of hospitalization.
4. The Health Systems Agency
In addition to the health systems agency roles previously
mentioned in these recommendations, the agency should also
perform other planning assistance activities, such as
consultation to hospitals on the development of adequate
data systems or support for funding requests, that may be
required by the region's hospitals as they develop their
home health programs.
5. Planning Coordination
Hospitals, in developing their home care programs, should
actively involve other health care providers in developmental
activities to assure the future coordination of activities,
to improve cooperative efforts among providers, to assure
that relevant providers are kept informed of progress made
in program development, and to elicit worthwhile suggestions
and ideas.
69
State Level
The findings and recommendations listed in this section have
taken from the Health Planning Council's study entitled Home
Services Under Medicare and Medicaid: A Critical Analysis.
reader should consult the study for more detailed descriptions and
documentation of the findings that follow.
Findings
Problems in Administration
1. Lack of Policy
The State of Washington has not developed policies on the relative
emphasis to be placed on the development, provision, or use of
various kinds of long-term care services. through tax-supported
health care programs. Likewise, no explicit policy or policies
have been developed on the relative societal value or importance
of maintaining people, particularly the elderly, at an acceptable
level of functional independence in their own homes. The lack
of policy interferes with decision-making, problem definition
and problem-solving, modifications of programs and spending
priorities, and program evaluations.
2. Lack of Planning
The state has over-emphasized regulatory processes and under-
emphasized planning/policy development processes as means by
which to improve health and health spending problems. Health
planning at the state level has been given such low priority
that the state's Comprehensive Health Planning office has been
staffed by only three planners the past few years.
3. Lack of Competent Administration
The State's Medicaid program has not been adequately administered.
Needed analytical data are not published or are not available.
There appears to be little effort taken to identify Medicaid
service delivery problems topically or geographically. The
public has not been informed of studies undertaken (if any)
of program effectiveness. Although the Medicaid program is
characterized by significant levels of spending and spending
increases for institutional care, there has been no expansion
in the kinds of home health services eligible for reimbursement.
Furthermore, no effort has been made to develop home health
services in areas deficient in such services, such as this region.
Few, if any, experimental projects in the field of long-term
care have been designed or implemented by the state despite
permissive state and federal law. No systematic procedures
have been developed to monitor and analyze problems associated
with patient placement - despite the fact that many patients are
70
placed in inappropriate facilities. Finally, the state
continues to pay millions each year for unnecessary and
excessive institutional care but only a few thousand for needed
but unavailable or under-used home health services.
These problems have existed for roughly five years, despite the
responsibility of certain legislative bodies to assure proper
administration of the program.
Problems in Resources
1. Gross Under-Spending for Home Health Services
In 1972 the state's Medicaid program should have spent between
$1 and $10 million for home health services under Medicaid.
Actual spending was less than $200 thousand, about one-fifth the
minimum needed. Such under-spending occurred despite the ability
of home health services to substitute for inappropriate
institutional care at considerable savings to both the state
and patients.
2. Reimbursement by Fee Schedule
The state reimburses home health agencies participating in Medicaid
via a fee schedule that is not routinely revised (see Attachment 11).
The use of such a uniform fee schedule discriminates against home
health agencies because payments to hospitals and nursing homes
are based on each facility's costs. All home health agencies,
however, receive the same amount of money (via the fee schedule)
regardless of their individual costs. Although the uniform fee
schedule has helped control spending increases for home health
services, no attempt has been made to use such a uniform schedule
to reimburse hospitals or nursing homes, despite steady annual
increases in payments to these types of facilities. The state has
not waived or amended the fee schedule method of payment (though
it could have done so) in areas of the state, such as Skagit
County, where the unrealistic reimbursement level offered by
the schedule has been the sole factor preventing the development
of home health services for the Medicaid population.
3. No Reimbursement for Needed Services
Very few types of home health services are reimbursed by the
state's Medicaid program. No expansion in the kinds of
services eligible for reimbursement has occurred despite
the amount and rate of increase of spending for institutional
care by the program.
4. Payment Keyed to Number of Visits
Health facilities are reimbursed primarily on the basis of a
daily service charge. As a result, it is possible to determine
GERALD LIBRARY
71
the cost per day of care. Home health agencies, however, are paid
by Medicaid a flat rate per visit. Such a payment method, coupled
with Medicaid's failure to collect length-of-stay data,
prevents the establishment of cost per day figures that could
be used to compare the efficiency of home care relative to other
forms of care. As a result of the absence of such data, it is
difficult to make needed administrative assessments of efficiencies,
trade-offs, opportunity costs, and benefit package adequacy for
home care VS. other (institutional) forms of care.
Furthermore, keying payments to visits has a concentration effect
on the agency's charge structure with the result that the service
appears more expensive than it really is. The concentration effect
enables careless or biased individuals to make inaccurate and
misleading comparisons of home care charges per visit to institutional
charges per day. This type of erroneous comparison is then used
to argue that home care is too expensive or too inefficient to
be considered as a serious alternative to other modes of care.
Problems in Service Delivery
1. Excess Use of Nursing Homes
Use of nursing homes in this region by Medicaid beneficiaries
has been consistently and significantly higher than state averages
for at least five years. Use of nursing homes by elderly Medicaid
beneficiaries was 20 percent higher than the state average in
1973. Use of nursing homes by all Medicaid beneficiaries was
76 percent higher than the state average in 1973. In addition,
rate of use of nursing homes by the state's elderly Medicaid
beneficiary population has been increasing. In 1969, 24 percent
of the Medicaid elderly were in nursing homes (8,672 patients).
Four years later, 34 percent were in nursing homes (10,890 patients).
Recent efforts by the state to reclassify and transfer patients
to more appropriate levels of care have often been thwarted by
the absence of needed services (see Attachment 15). Locally,
there is no evidence that the state has attempted to develop
needed home health services.
2. Lack of Home Health Services
Only one of the four counties in this region has a home care
program that will serve Medicaid beneficiaries. In light of
the problems already described, the absence of services is
understandable. The absence of services constitutes de facto
discrimination against beneficiaries here and illustrates the
inability of current state funding mechanisms to stimulate the
development of obviously needed services.
72
3. Fragmentation of Services
Although professionals in the field of home care refer to the
activities performed by homemakers and health aides by the
combined title "homemaker/home health aide", the state uses three
different personnel classification and payment methods for these
personnel. The state pays for home nursing and health aide
services via a fee schedule. It provides homemaker services
directly. It supplements cash grants of clients to enable the
clients themselves to pay for chore (housekeeping) services.
This mosaic of payment and service delivery methods fragments
demand for and delivery of very similar services. By providing
homemaker services directly, for example, the state removes part
of the potential market from a non-governmental community agency
that might otherwise be able to serve both Medicaid clients and
the general community. By removing part of the community
agency's market, the state contributes to and participates
itself in reduced agency operating efficiency.
Problems in Inter-Coordination
1. Lack of Public Information
The general public receives little information about spending and
utilization patterns generated by Medicaid and even less reporting
of the few intelligent analyses or studies that have been made of
the program. Officials have, furthermore, made little attempt to
familiarize the public with important problems and issues
surrounding the state's Medicaid program, such as those discussed
in this document (see Attachment 16). Denied information about
problems and issues, the electorate is unable to assess the
quality of program functioning and unable to contribute toward
the solution of the problems and issues.
2. Lack of Public Accountability
Hidden behind screens of mis-information and non-information,
incompetent appointed and elected officials have been able to
let significant, correctable human and economic problems fester
and intensify for years with little more than a barely discernible
whimper from cheated consumers and taxpayers. The accountability
of the program to. the public has been and continues to be highly
questionable, particularly in view of the size of the program's
tax-supported budget and the program's impact on thousands of
beneficiaries across the state.
73
Recommendations: State Level
Recommendations on Administration
1. With the advent of new federal health planning legislation, the
State of Washington should develop an integrated health
planning/policy development office and provide enough financial
resources to enable the office to function effectively. The
State should review planning/policy development structure-function
models used in other states and utilize policy analysis resources
at the University of Washington before establishing its
planning/policy development office. These actions should be
undertaken by the Executive branch of government with assistance
and advice from the Legislative branch.
Coupled with this activity should be a shift in priorities by
both Legislative and Executive branches of government away from
regulation toward policy development and implementation as a
means of improving the delivery of health services in the state.
2. The state should work in conjunction with health systems agencies
to improve the availability of Title XIX data. Data on
enrollment, utilization of services, and expenditures for services
should be readily available and aggregated by health systems
agency planning areas. Annual summaries should also be published.
3. To improve the quality of program administration, the Legislature
should require the Department of Social and Health Services to
prepare and provide annual reports to relevant Legislative
committees on patterns of enrollment, utilization, and expenditures
by the State's Title XIX program. These reports should be required
to identify areas of the State showing significantly higher per
capita services' utilization rates and/or expenditures' rates.
In addition, the annual reports should explicitly define problems
existing with the Title XIX program and actions the Department
intends to take over the year to eliminate the problems. The
reports should also review actions taken during the preceding
year to correct problems identified in the Department's previous
annual report. The Legislature should confer with a variety
of consumers, providers, and health planners to help define the
kinds of information that should be provided by these annual
reports. The reports should, of course, be made available to the
public, particularly the press.
4. The Department of Social and Health Services should develop
and implement statewide methods to monitor and evaluate
statistically the appropriateness with which Title XIX patients
are placed into long-term care facilities. The data generated
by this monitoring system should be used by DSHS and the
Legislature to effect needed changes in Title XIX regulations,
benefits, or administration.
74
Recommendations on Resources
1. Forthcoming budgets for the Title XIX program should reflect
shifts needed in the state's currently inappropriate spending
patterns. In particular, much more money should be allocated to
home health services. These spending shifts should be proposed
by the Executive branch.
2. DSHS should largely abolish its fee schedule method of payment
of home health services and adopt a prospective payment system
similar to that outlined under the Medicare program (see p. 88).
Reimbursement for home health services should generally not be
linked to the number of visits provided by an agency to a patient.
3. Reimbursement should be extended to additional types of home
health services. At a minimum, the same services eligible for
reimbursement under Medicare should be eligible for reimbursement
under Medicaid. Well-adult services provided by home health
agency personnel to beneficiaries living in group quarters or
multi-unit housing facilities should also be reimbursed. The
Department of Social and Health Services should initiate
these modifications.
Recommendations on Service Delivery
1. DSHS should initiate experimental or innovative or research-
oriented projects related to the development of needed long-term
care services, particularly home care. This region, because of
the problems shown in this study, should be given priority for
inclusion in such projects.
2. DSHS should continue to pursue and even augment its belated
efforts to reduce the unnecessary and inappropriate institutional-
ization of Medicaid beneficiaries in long-term care facilities.
Part of these efforts should be devoted toward the development
of additional intermediate care facilities and the reduction of
skilled nursing facilities.
3. DSHS should take the initiative to help local areas develop
needed home health services. Since additional personnel will be
needed for these efforts, the Department's budget should respond
to this need. The savings generated by stronger home health
programs will help pay for these new personnel.
4. DSHS should cease the provison of homemaker services directly
and switch to contractual arrangements with community agencies to
provide these and similar services. The funding of homemaker,
health aide and chore services should be unified and consolidated.
DSHS should revise its homemaker/health aide/chore services
personnel classifications and categorizations toward the recognition
of a single category of worker, the homemaker/home health aide.
75
Recommendations on Inter-Coordination
1. The press and the media should expand their coverage of the
performance of the Medicaid program in order to improve the
public's awareness of Medicaid's benefits and problems. In
their reporting, the press and the media should interview
consumers, providers, administrators, and planners relative to
their viewpoints and concerns about Medicaid. The reporting
should, among other things, (1) address the question of
whether the program is improving or getting worse, and (2)
help define and clarify the problems and issues raised by
interviewees.
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76
National Level
The findings and recommendations on Medicare and Medicaid in this
section have been taken from the Health Planning Council's study
entitled Home Health Services Under Medicare and Medicaid: A
Critical Analysis. The reader should consult the study for more
detailed descriptions and documentation of the Medicare/Medicaid-related
findings that follow.
Findings
A. Medicare
Problems in Administration
1. Inadequate Administrative Data
Data needed for program analysis and program evaluation are
not adequately available:
- Data on utilization and expenditures by type of
service are not available at the county level after
1969.
- Other county data on enrollment take three years
to return to the local level.
- Data appear uncoordinated; it is difficult or
impossible to link enrollment, utilization, and
expenditures data together at the state or county
level, particularly for home health services.
These data problems, in addition to interfering with program
evaluation nationally, will also interfere with some of the
statutory obligations of health systems agencies under
Section 1513 (a) and (b) of Public Law 93-641.
The absence of adequate data raises serious questions about
the overall quality of administration of the $10 billion
Medicare program.
2. Discriminatory Conditions of Participation
Unlike any other provider participating in Medicare, home
health agencies are required to perform an "overall evaluation
of the agency's total program at least once a year. This
requirement is made of home health agencies despite their
receipt of less than 1 percent of Medicare expenditures each
year. Institutional providers under Medicare are not
required to perform such annual evaluations despite their
receipt of over 70 percent of Medicare's expenditures each
year. The existence of such program evaluation requirements
only for home health agencies clearly discriminates against them.
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3. Excess'ive "Red Tape"
The amount of paperwork required- of providers participating
in Medicare is frequently criticized in the region. This
paperwork confuses both beneficiaries and providers and has
led at least one provider in this region to drop out of the
program (see Attachment 17).
Problems in Resources
1. Amount and Rate of Spending for Institutional Care
National spending patterns under Medicare have been characterized
by (1) large proportions spent for institutional care and
(2) steady increases in the amount of money spent for such
care. Spending for home health services, however, has not
only consistently fallen far short of levels necessary to
meet minimum need for services, but has been characterized by
virtually no increase in spending between 1968 and 1972,
despite a growing elderly population, despite large unmet need
for the services, and despite steady annual increases in
spending for institutional care.
Coupled with the demonstrated effectiveness of home health
services in reducing hospitalization and resultant expenditures,
historical Medicare spending patterns imply the existence of
considerable over-spending for institutional care, spending
that could have been reduced by better use of the home care
benefit of the program.
2. Inadequate Spending for Home Health Services
Spending for home health services under Medicare declined
from 1.2 percent of total spending in 1968 to 0.8 percent
in 1972. Estimates of need for services in combination with
estimates of likely spending per home health patient lead
to the finding that Medicare should have spent between
2 and 11 percent of its total expenditures for home health
services in 1972. Actual spending for the services,
0.8 percent of all spending, was only half the estimated
spending needed to meet the minimum need for services
among beneficiaries.
3. Payment on the Basis of the "Lesser of Costs or Charges"
Section 233 of Public Law 92-603 amended Medicare law to
the effect that reimbursement to hospitals, skilled nursing
facilities, and home health agencies would be the lesser of
(a) the reasonable cost of the services of (b) the customary
charge for the service.
This amendment has several adverse consequences. First,
if an agency's charges generate fewer revenues than the
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agency's costs, the agency is forced to take a financial
loss. Second, to protect against potential financial
losses caused by the lesser of costs or charges policy,
agencies must charge a fee high enough to compensate for
predicted operating expenses as well as to provide a
safety factor for inflation. As a result, patients may
pay artificially high charges, and Medicare stands to benefit
from agency charge structure maladjustments at the expense
of the agency providing service. Since the size of the
charge definitely decreases the willingness with which
physicians will order home care, the lesser of costs or
charges policy, but increasing agencies' charges, also
serves to reduce the delivery of services to persons who
would otherwise need or be able to use home care services.
Thus, the policy results in the potential for (a) agency
financial difficulty and (b) under-utilization of
services by beneficiaries.
4. Payment on the Basis of Fee for Service
Home health services provided under Medicare are generally
paid on the basis of fee for service, usually by average cost
per visit. This payment method creates no incentives for
increased efficiency of operation by providers of service
since all reasonable costs are reimbursed (within the constraints
of the lesser of costs or charges policy).
5. Payment Keyed to Number of Visits
Health facilities are reimbursed primarily on the basis of a
daily service charge. As a result, it is possible to
determine cost per day of care. Home health agencies,
however, are paid by Medicare on the basis of average cost
or charge per visit. Such a payment method, coupled with
Medicare's failure to collect length-of-stay data, prevents
the establishment of cost per day figures that could be
used to compare the efficiency of home care relative to
other forms of care. As a result of the absence of such data,
it is difficult to make needed administrative assessments
of efficiencies, trade-offs, opportunity costs, and benefit
package adequacy for home care VS. other (institutional)
forms of care.
Furthermore, keying payments to visits has a concentration
effect on the agency's charge structure with the result
that the service appears more expensive than it really is.
The concentration effect enables careless or biased individuals
to make inaccurate and misleading comparisons of home care
charges per visit to institutional charges per day. This
type of erroneous comparison is then used to argue that home
care is too expensive or too inefficient to be considered as
a serious alternative to other modes of care.
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6. Co-Insurance Required for Visits to Skilled Nursing Facility
Patients
Under Medicare's Supplementary Medical Insurance program the
patient was formerly required to pay a portion of the charges
for home health services: "co-insurance." The requirement
for co-insurance was eliminated in 1972 for all patients
except those SMI beneficiaries who receive home health services
as patients in skilled nursing facilities. Requiring the
institutional patient to pay co-insurance for services that
would be free if provided at home discriminates against
the institutional patient, particularly since the receipt
of such services is probably necessitated by the absence
of the services in the skilled nursing facility itself.
Any savings to Medicare as a result of this unique
co-insurance requirement are probably largely neutralized
by the administrative costs generated by the requirement.
7. No Payment for Assessment Visits
Despite paying for consumer-initiated visits to physicians
and hospital outpatient departments for the assessment of
possible health problems, consumer-initiated requests
for a single assessment visit at home are not reimbursed
by Medicare. Confronted by a request for an assessment
visit by a homebound beneficiary or the beneficiary's
friend or relative, the home health agency must refuse to
make the visit, make the visit at its own expense, or
charge the person requesting the visit. If the beneficiary
were able to visit a physician or outpatient department,
however; Medicare would pay for the assessment, regardless
of the beneficiary's actual need for care. Thus, Medicare
discriminates against home health agencies by paying for
all consumer-initiated requests for health assessments
except those performed by a home health agency.
Problems in Service Delivery
1. Inappropriate Statutory Orientation Toward Acute Illness
Despite the prevalence of chronic conditions among the elderly,
Medicare is oriented primarily toward acute illness or acute
episodes associated with chronic illness. This orientation
mainly toward acute conditions represents an unbalanced approach
toward the health needs of the elderly. The orientation is
reflected in a number of ways relative to Medicare's home
health benefits.
a. Under Medicare's Health Insurance program beneficiaries
must be hospitalized at least three days to establish
eligibility for home health services. Thus, home health
services are accessible to HI beneficiaries only after an
episode of hospitalization.
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b. Patients who no longer require the more skilled types of
home health services are no longer eligible to receive the
less skilled types of home health services even though
such services may be needed to consolidate or maintain the
patient's revocery from an acute episode. As a result of
the failure to receive the less skilled (and less expensive)
home health services, many patients regress to various states
of incapacity and become patients in hospitals or nursing
homes. Purchase of the needed services is out of the
question for at least 25 percent of the elderly in this
region because of their poverty status.
C. Medicare provides no benefits for homemaker services
despite the need for such services among beneficiaries and
the ability of the services to prevent or postpone
institutionalization. The elderly beneficiary living alone
and afflicted by arthritis or other crippling diseases
would be the kind of person who would be likely to need
homemaker services, particularly during an acute illness,
such as influenza.
Medicare's orientation toward acute illness to the exclusion
of relatively inexpensive maintenance-of-health services results
in unnecessary human misery and unnecessary expenditures for
expensive institutional care.
2. Arbitrary Determination of Eligibility
The Medical Malpractice Commission found evidence that fiscal
intermediaries frequently make arbitrary findings relative
to the beneficiary's eligibility for services. Arbitrariness
in decisions involving eligibility, aside from being discriminatory,
irritates providers of care, confuses beneficiaries, and creates
disincentives for the ordering of services for persons in need.
3. Under-Use of Home Health Services
Analysis of national expenditures patterns reveals that spending
for home health services is considerably lower than levels that
would be necessary to meet even the most minimum estimates of
need for services.
4. Inadequate Mechanisms to Monitor Receipt of Care
Despite spending ever larger amounts of Medicare funds for
institutional care each year and despite manifest under-use of
home health services by beneficiaries, Medicare administration
has developed no method of monitoring the extent to which
beneficiaries who need home health services actually receive
them. Claims review procedures have been oriented in the past
toward preventing over-use of services by beneficiaries receiving
services, but no attempts have been made to identify the much
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larger number of beneficiaries who needed services but never
received them. As a result, the Medicare beneficiary population
has been able to remain medically under-served (relative to
home care) for years (see pp. 24-26).
5. Reduced Availability of Services
Nationally, the number of home health agencies participating
in Medicare has declined from 2,346 in 1970 to 2,217 in 1972.
Problems in Inter-Coordination
1. Lack of Public Information
The public is poorly informed about home health services benefits
under Medicare and even less informed about program performance
problems.
2. Lack of Responsiveness
Medicare has been characterized in the past by unresponsiveness
to large unmet home health services needs among the elderly.
Although some minor changes have begun to be made in Medicare's
home health services benefits, Medicare must continue to be
seen as unresponsive to these needs until significant increases
in the availability, use, and funding of home health services
occur.
3. Lack of Public Accountability
The existence of such problems as poor administration, unbalanced
spending patterns, restrictive benefits for chronic health
conditions and subsequent health care needs, lack of public
information, and lack of program responsiveness for at least a
five year period suggest that both the Department of Health,
Education, and Welfare and the Congressional bodies charged with
overseeing the performance of the Medicare program have failed
to be adequately accountable to the public for their actions.
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B. Medicaid
Problems in Administration
1. Lack of Policy
The federal government has failed to develop explicit guiding
policies on the relative emphasis to be placed on the
development, provision, or use of various kinds of long-term
care services through tax-supported programs. Likewise,
no policies have been developed on the relative societal
value or importance of maintaining people, particularly the
elderly, at an acceptable level of independence in their
own homes. In addition to the absence of policy, manifest
or de facto policies are inappropriate and detrimental to
the interests of both taxpayers and health care consumers.
Manifest policies, evidenced by national spending patterns,
are obviously oriented toward the promotion and support of
institutional forms of care at the expense of home health
services.
The absence of policy hinders program evaluation and
modification, resource allocation and re-allocation,
administrative evaluations of trade-off decisions, the
definition and solution of problems, and the consistency
and rationality of decision-making.
Problems in Resources
1. Gross Under-Spending for Home Health Services
Despite substantial need for home health services among the
Medicaid beneficiary population, particularly the elderly,
national Medicaid spending patterns. indicate that only a
small fraction of the need for services is met each year by
the program.
Problems in Service Delivery
1. Inadequate Federal Regulations
Existing federal regulations are oriented toward assuring
that state Medicaid programs "provide" required home health
services "sufficient in amount, duration and scope to
reasonably achieve their purposes, but little guidance
exists in either the regulations or case law to help define
"amount", "duration", "scope", or "purpose". Without
definition of these key terms it is virtually impossible
to assess the adequacy of home health services "provided"
by state programs.
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Several federal regulations require state programs to have
uniform eligibility standards and service benefits across
all categories of beneficiaries, but loopholes in the
regulations permit their circumvention. Even though
beneficiaries may be entitled to receive home health services,
the unavailability of services in many areas of the state
and country results in many beneficiaries being deprived of
access to the services. By offering to pay for home health
services uniformly, state programs technically conform to
the regulations even though thousands of beneficiaries
may have no access to services.
Other federal regulations require home health agencies to
qualify for Medicare certification. While it is laudable
to have high standards for providers participating in the
Medicaid program, the requirement for qualification as a
Medicare provider prevents the reimbursement of small or
newly-developed home health agencies that could provide
services. As a result, the development of needed services
is further hindered.
2. Excess Use of Nursing Homes
Excess use of nursing homes by Medicaid beneficiaries has
been repeatedly documented. (See, for example, "Final
Report, Survey of Title XIX Long Term Care Facilities and
Patients", Social and Rehabilitation Contract 72-68, a
study conducted across 15 states.)
Problems in Inter-Coordination
1. Lack of Public Information
One would think that a multi-million dollar, tax-supported,
public insurance program such as Medicaid would be subject
to considerable review, consideration, and discussion by
the people who ultimately have to foot the bill. Such is
not the case. The general public receives little information
about spending and utilization patterns generated by Medicaid
and even less reporting of the few intelligent analyses
or studies that have been made of the program. The public
is, of course, acutely aware of inflation in health care
costs and progressively higher taxes, but their frustration
and annoyance are usually directed toward "welfare bums"
instead of the policies, procedures, agencies, and officials
really responsible for misspending and overspending.
The public's ignorance of the real issues involving Medicaid
is all the more remarkable in light of the amount of spending
and the human and economic waste that currently characterize
the program. Without timely, accurate, and relevant
information, the public is prevented from making or influencing
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or contributing to the informed decision-making that should
characterize our society's democratic processes. Individual
curiosity is successfully and easily thwarted by the confusing
and increasingly complex bureaucratic machinery surrounding
the administration and implementation of the program.
2. Lack of Public Accountability
The existence of the problems identified in this document
for at least a five year period suggests that both the
Department of Health, Education, and Welfare and the
Congressional bodies charged with overseeing the performance
of the Medicaid program have failed to be adequately
accountable to the public for their actions.
C. CHAMPUS (Civilian Health and Medical Program of the Uniformed
Services)
Problems in Administration
1. Inadequate Administrative Data
Attachment 18 shows correspondence that attempted to elicit
basic administrative data from the CHAMPUS program. The
correspondence shows that many kinds of data are simply
not available from the program, particularly at a sub-national
level. National data do show that spending under the
program jumped 124 percent from FY 1969 to FY 1973 (about
30 percent per year) despite an increase in the beneficiary
population of only 10 percent in the same period.
Problems in Inter-Coordination
1. Lack of Public Accountability
The lack of basic administrative data, coupled with the
program's $478 million price tag in FY 1973 and the high
rate of spending increase, raises serious questions about
the adequacy with which the CHAMPUS program has administered
several billions in tax funds over the past few years.
2. Lack of Planning Coordination
The absence of data at sub-national levels interferes with
health planning activities in those regions, such as this
region, which contain significant numbers of CHAMPUS
beneficiaries. CHAMPUS, like most other federal programs,
has made no attempt to coordinate its obviously limited
data activities with health planning agencies, most of which
are also federally funded.
85
3. Lack of Public Information
The CHAMPUS beneficiary's benefit booklet, confusing and
complicated, is mute evidence of the complexity of the
CHAMPUS program. The reader is challenged to determine
from the booklet the kinds of home health services eligible
for reimbursement, the conditions under which the services
may be provided, and the extent to which the program will
pay for the services. See Attachment 19.
D. Indian Health Service
Problems in Administration
1. Inadequate Administrative Data
An attempt to secure data on the use of home health services
(and other services) under the Indian Health Services failed
because data are neither adequately nor readily available
(see Attachment 20). Only some of the relatively
routine data that were requested were provided -- at
"the diversion of considerable effort". Are data monitoring
activities of the Indian Health Services adequate in light
of their $32 million budget in fiscal 1973?
E. Federally-Funded Health and Insurance Programs
The consistent finding of data deficiencies in the Medicare,
Medicaid, CHAMPUS, and Indian Health Services programs warrants
a short but separate discussion in light of recent Congressional
initiatives and data mandates relative to an expanded nationwide
program of health planning, the likelihood of passage of national
health insurance legislation in the near future, the multi-billion
dollar magnitude of federal health spending, and the rapid rate
of increase in federal health spending in recent years. The
existing deficiencies in rather routine and ordinary administrative
data and the lack of congruence and coordination of data collection
and distribution activities among federal health spending programs
are very serious shortcomings that were uncovered as a by-product
of this project.
There are at least three fundamental kinds of data needed for
purposes of management and analysis of health programs: the
number of people enrolled or eligible or "targeted" for care,
the patterns of health services utilization generated by these
people, and the expenditures generated by use of the services.
The absence of any one of these three fundamental pieces of
information will prevent intelligent management and analysis
of a program. The availability of these data permits the
identification of trends and problems and helps pinpoint the
causes of changes in program expenditures.
Since patterns of health care very consideraly from area
to area, it is important that enrollment, utilization, and
86
expenditure data be available for relatively small geo-political
areas. In rural areas such as this, data by county are usually
sufficient. The availability of enrollment, utilization, and
expenditure data by county for various kinds of health care
programs enables health planners to identify and analyze
patterns and pinpoint problems.
Without these data, planners at the local level are immediately
and severaly restricted in their ability to generate accurate
analyses and projections. Gaps in data availability also
introduce the possibility, if not probability, that incredibly
expensive programs are not adequately administered. The public,
perforce uninformed of key patterns and trends in tax spending
for health, is subsequently prevented from making informed
choices.
Thus, data problems serve both internally and externally to
prevent intelligent program evaluation and modification. As
a result, large programs appear monolithic and, in their inexorable
inertia, unresponsive or unaware of real but often inarticulately
expressed unment needs. And so in the inflationary present
day, 10 years after the beginning of Medicare and Medicaid, it's
not too surprising to find that home care is struggling harder
than ever simply to survive, let alone flourish, because the
program evaluations that would lead to the conclusion that home
care must be strengthened have obviously not been done: the
data needed for such evaluations are just barely available.
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Recommendations: National Level
A. Medicare
Recommendations on Administration
1. Significant efforts should be made by the Social Security
Administration to upgrade the quality and timeliness of
its planning and administrative data. For example, annual
cost reports for home health agencies should require provision
of length of stay data. In-the-field health planners should
be called upon to assist Social Security in these efforts.
See also Recommendation E. p. 94.
2. Discriminatory Conditions of Participation that apply only
to home health agencies, i.e., the requirement for annual
program evaluation, should be eliminated or else uniformly
applied to all providers participating in Medicare. DHEW
should initiate this revision.
3. The Social Security Administration should undertake a
thorough review of the numerous administrative forms
used in the Medicare program with a view toward eliminating
unnecessary forms and/or data requirements and simplifying
or shortening remaining forms, particularly those forms
used by consumers. The advice of consumers and providers
outside the Social Security Administration should be
used in conducting this review.
4. Because the 1973 "Survey of Title XIX Long-Term Care Facilities
and Patients" (SRS Contract 72-68) found that there is
virtually no difference between Medicare and Medicaid patients
in long-term care facilities, DHEW should perform a study of
the feasibility of integrating skilled nursing benefits
under either Medicare or Medicaid. Such integration would
greatly reduce the red tape and inefficiencies now present
in the dual but overlapping benefit structures.
5. The Health Insurance Benefits Advisory Council should monitor
indicators of the availability, use, and funding of home
health services under Medicare. After a reasonable period
of time, the Advisory Council should adopt additional
recommendations on home health services benefits under
Medicare in the event the indicators reveal that improvements
are not occurring.
The Advisory Council should consider augmenting its September 1974
recommendations on home health services in the event the Council
finds the problems discussed in this Guide to be valid,
significant, and uncorrected.
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6. To improve administrative ability to make appropriate
modifications in Medicare, action should be taken by each
(multi-state) regional office of the Social Security
Administration to publicize the experimental reimbursement
and serve delivery projects authorized by Public Law 92-603,
particularly in DHEW Region X. If necessary, quotas should
be established for each regional office relative to the
generation of experimental projects. Increased personnel
and financial resources should be allocated to this
initiative, particularly for the purpose of provision of
technical and financial assistance to potential grantees.
Financial assistance could be used by potential grantees to
hire grant writers and pay for other project development
costs. These projects could provide a wealth of useful
information on alternative methods of reimbursing or
providing health services under Medicare.
7. Because of the manifest under-utilization of home health
services under Medicare at the present time, the Social
Security Administration should establish methods of monitoring
the adequacy of delivery of home health services. Each
multi-state regional Social Security office should file an
annual report describing problems identified by the
monitoring methods and actions taken to eliminate the
problems. These reports will help identify common
problems across the nation and thereby serve to improve
administrative efforts to modify the program appropriately.
Recommendations on Resources
1. Medicare should change its method of payment of home care
services to a prospective system with retrospective, fee
for service, payment methods used only as an exception.
The prospective system should certify the need for home
care for a set minimum period, say 30 days, and pay a
flat rate per period of care. The prospective payment
system should not be linked to numbers of visits provided
to patients. Intermediaries should provide or deny
certification of need for care prior to delivery of care.
In the event certification is denied, both patients and home
health agencies should be furnished with a written
justification. The patient's copy should describe actions
that can be taken to appeal the decision.
The payment method should be subject to flexibility from
area to area in order to respond to unique characteristics
or problems present. For example, if an agency provides a
sufficient volume of care such that patients are categorized
by level of intensity of care, the payment system should pay
different rates according to level of care provided. Such a
payment system is routine for the reimbursement of inpatient
hospital services.
89
2. The Health Insurance Benefits Advisory Council should review
the impact of Section 233 of Public Law 92-603 on the
availability and use of home health services. If the
positive impacts of the section appear to be outweighed
by the negative impacts, the Advisory Council should make
recommendations that will correct the problems identified.
3. Co-insurance requirements for home health agency visits to
patients in skilled nursing facilities should be eliminated.
The Department of Health, Education, and Welfare should
initiate the actions necessary to accomplish this change.
4. Assessment visits by home health agencies should be reimbursable,
just as they are reimbursable now for other providers of
care. The Department of Health, Education, and Welfare
should initiate the actions necessary to accomplish this
change.
Recommendations on Service Delivery
1. Under the HI Program, the three-day prior hospital stay
required to establish eligibility for home health services
should be eliminated or modified in such a way that if
prior hospital stay is still required, there is no minimum
set on the duration of hospitalization needed for establishment
of eligibility for home care. These actions should be taken
by Congress.
2. Federal law and relevant regulations should be changed to
permit the provision of homemaker/home health aide services
to beneficiaries without the requirement that skilled
services also be needed on an intermittent basis.
To rectify the mis-orientation of Medicare toward only the
acute recovering patient, home health services, particularly
those provided by the homemaker/home health aide, should be
made eligible for reimbursement when provided to stabilized
patients who need assistance with personal care and the
activities of daily living.
These changes should be initiated by Congress.
3. The Department of Health, Education, and Welfare should continue
its recent efforts to assure that beneficiaries will not be
subject to arbitrary decisions by fiscal intermediaries
relative to their eligibility for home health services.
4. In order to improve the extent to which hospital patients
are screened for eligibility for home care services, DHEW
should develop regulations as part of the Conditions. of
Participation for hospitals and skilled nursing facilities
to require that:
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a.
Each participating facility will develop procedures
and criteria for the screening of Medicare patients
relative to their suitability to receive home health
services or care in a skilled nursing facility following
discharge. The criteria should be uniform within each
PSRO review area or within each area served by a Health
Systems Agency. All Medicare patients should be screened.
b.
Each participating facility will define in writing
the procedures and criteria to be used to screen
Medicare patients for their suitability to receive home
health services.
C.
Each participating facility will use a multi-disciplinary
team of health professionals to screen patient need
for home health services.
Additional personnel costs incurred by the facility as
a result of these requirements should be reimbursable as
legitimate Medicare-related costs.
Attachment 13 shows a sample screening protocol developed.
by the Kaiser-Rermanente program in Portland, Oregon.
6. With the advent of prospective payment methods for home health
serivces, mechanisms should be developed by the Social
Security Administration to assure that too few services are
not provided to beneficiaries who receive services.
Recommendations on Inter-Coordination
1. The Health Insurance Benefits Advisory Council should play
more of a watchdog role in monitoring the quality of
administration of Medicare. If such a role is not appropriate
for the Advisory Council, the Council should review other
methods of improving the public accountability of the
program and recommend accordingly.
2. The DHEW should make annual, layman-oriented reports on the
functioning of the Medicare program. These reports should
analyze program performance in terms the general public can
understand. The reports should show changes in the use of
services, particularly home health services, and spending
patterns. The reports should provide some interpretation
of the data presented, including a description of manifest
problems. These reports should be available, free of charge,
at local Social Security offices.
3. The press and the media should expand their coverage of
the performance of the Medicare program in order to improve
the public's awareness of Medicare's benefits and problems.
In their reporting, the press and the media should interview
91
consumers, providers, administrators, and planners relative
to their viewpoints and concerns about Medicare. The
reporting should, among other things, (1) address the question
of whether the program is improving or getting worse, and
(2) help define and clarify the problems and issues raised by
interviewees.
B. Medicaid
Recommendations on Administration
1. Because of the manifest under-use of the home health service
benefit under Medicaid across the country, the Health
Insurance Benefits Advisory Council should monitor indicators
of the availability, use, and funding of home health services
under Medicaid. After a reasonable length of time, the
Advisory Council should adopt additional recommendations
on home health services benefits under Medicaid in the event
the indicators reveal that improvements are not occurring.
The Advisory Council should consider augmenting its
September 1974 recommendations on home health services in.
the event the Council finds the problems discussed in this
Guide valid, significant, and uncorrected.
2. To improve administrative ability to make appropriate
modifications in Medicaid, action should be taken by each
(multi-state) regional office of the Social and Rehabilitation
Service to publicize the experimental reimbursement and
service delivery projects authorized by Public Law 92-603,
particularly in DHEW Region X. If necessary, quotas should
be established for each regional office relative to the
generation of experimental projects. Increased personnel
and financial resources should be allocated to this
initiative, particularly for the purpose of provision of
technical and financial assistance to potential grantees.
Financial assistance could be used by potential grantees
to hire grant writers and pay for other project development
costs. These projects could provide a wealth of useful
information on alternative methods of reimbursing or providing
health services under Medicaid.
3. Because of the manifest under-utilization of home health
services under Medicaid at the present time, the Social
and Rehabilitation Service should establish methods of
monitoring the adequacy of delivery of home health services.
Each multi-state regional SRS office should file an annual
report describing problems identified by the monitoring
methods and actions taken to eliminate the problems. These
reports will help identify common problems across the nation
and thereby serve to improve administrative efforts to modify
the program appropriately.
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Recommendations on Resources
1. In light of national spending patterns under Medicaid,
federal regulations should be amended to require states to
reimburse a broader range of home health services under
Medicaid. At a minimum, states should reimburse the same
kinds of home health services under Medicaid as Medicare.
These modifications should be initiated by the Congress.
Recommendations on Service Delivery
1. Federal regulations and associated deficiencies discussed in
this Guide (pp. 82-83) should be reviewed and amended, to
the extent possible, to eliminate the deficiencies. This
review and modification should be initiated by DHEW.
Regulations which require home health agencies to qualify for
Medicare certification in order to participate in Medicaid
should be eliminated. This modification should also be
proposed by DHEW.
2. In order to improve the extent to which hospital patients
are screened for eligibility for home care services, DHEW
should develop regulations for hospitals and skilled
nursing facilities to require that:
a. Each participating facility will develop procedures
and criteria for the screening of Medicaid patients
relative to their suitability to receive home health
services or care in a skilled nursing facility following
discharge. The criteria should be uniform within each
PSRO review area or within each area served by a Health
Systems Agency. All Medicaid patient should be screened.
b. Each participating facility will define in writing the
procedures and criteria to be used to screen Medicaid
patients for their suitability to receive home health
services.
C. Each participating facility will use a multi-disciplinary
team of health professionals to screen patient need for
home health services.
Additional personnel costs incurred by the hospital as a result
of these requirements should be reimbursable as legitimate
Medicaid-related costs.
Attachment 13 shows a sample screening protocol developed
by the Kaiser-Permanente program in Portland, Oregon.
Recommendations on Inter-Coordination
1. The Health Insurance Benefits Advisory Council should play
more of a watchdog role in monitoring the quality of
93
administration of Medicaid. If such a role is not appropriate
for the Advisory Council, the Council should review other
methods of improving the public accountability of the program
and recommend accordingly.
2. The DHEW should make annual, layman-oriented reports on
the functioning of the Medicaid program. These reports
should analyze program performance in terms the general public
can understand. The reports should show changes in the use
of services, particularly home health services, and spending
patterns. The reports should provide some interpretation of
the data presented, including a description of manifest
problems. These reports should be available, free of
charge, at local Social Security offices.
C. CHAMPUS (Civilian Health and Medical Program of the Uniformed
Services
Recommendations on Administration
1. See Recommendations p. 94.
2. An independent consultant should be hired by a federal
contractor other than the Department of Defense to evaluate
the CHAMPUS program and recommend changes that should be
made in the program over the next 10 years. The consultant
should review relevant laws and administrative practices,
payment methods and resource constraints, serve benefits
and eligibility requirements, and inter-coordination
activities currently in effect with a view toward identifying
changes needed to modernize and simplify the program in ways
appropriate to characteristics of the projected beneficiary
population of the future. Appropriate Congressional bodies
should review the findings of the study and assure that
necessary and appropriate program changes are made.
Recommendations on Inter-Coordination
1. Congressional bodies charged with overseeing the performance
of the CHAMPUS program should require the Department of Defense
to prepare annual reports on CHAMPUS program performance
similar to the reports discussed under Recommendation 2 on
p. 90. These reports should be available to the public on
request.
2. The beneficiary booklet distributed by the Washington
Physicians Service should be reviewed by a panel composed in
part of CHAMPUS beneficiaries with a view toward clarifying
and simplifying the booklet's descriptions of benefits.
Since problems of clarity and intelligibility that currently
94
detract from the effectiveness of the booklet are largely
due to structural/functional problems of the CHAMPUS
program itself, the review panel should also identify the
most troublesome structure/fuction program problems that
prevent needed simplification and clarification of descriptions
of benefits and provedures in the booklet. Having identified
the most salient such problems, the review panel should make
recommendations on the program changes that should be made
to reduce the problems. This type of review should be
funded in this state and several other states by the
Department of Defense. The results of such reviews will
provide grassroots-based information that should be used to
supplement the findings of the national study recommended
on p. 93.
D. Indian Health Service
Recommendations on Administration
1. See Recommendation E.1. below.
E. Federally-Funded Health and Insurance Programs
Recommendations on Administration
1. The Department of Health, Education, and Welfare should
organize a task force to review national data systems of
Medicare, Medicaid, CHAMPUS, the Indian Health Service,
and other relevant programs. The review should focus on
identifying the actions needed to develop adequate, appropriate,
uniform, and coordinated data systems among the programs.
In light of the data and analytical requirements of
P.L. 93-641 and the obvious impact federal health and
insurance programs have on eligible populations at the
regional health planning level, the advice, assistance, and
participation of professional health planners should be
solicited by the task force in its review.
2. The Cooperative Health Statistics System should add a new
component on health expenditures. The continued absence of
this component from the currently proposed set of seven
components will seriously interfere with administrative
assessments of cost-effectiveness, benefit-cost ratios,
patterns of spending, and program efficiencies. Such an
expenditure component would not only assist future health
planning activities under Public Law 93-641 but also
promote the public accountability of federal programs.
95
F. Political Parties and Candidates for Elective Office
Because of the magnitude, diversity, and national prevalence of
the problems identifed in this Guide, political parties and
candidates for elective office should consider making the
improvement of home health services a priority health-related
campaign issue.
96
AL OF ONHSEM THE
ATTACHMENT 1
DANiEL J. EVANS
EMPLOYMENT DEVELOPMENT
SERVICES COUNCIL
GOVERNOR
THE
ROBERT L. BAILEY. CHAIRMAN
RICHARD W. HEMSTAD
LYLE M. TINKER. EXECUTIVE DIRECTOR
DIRECTOR
GENERAL ADMINISTRATION BUILDING
STATE OF WASHINGTON
OLYMPIA. WASHINGTON 08504
Office of the Governor
OFFICE OF COMMUNITY DEVELOPMENT
OLYMPIA, WASHINGTON 98504
206/753-2200
July 7, 1975
Ms. Sara F. Hackler, Coordinator
Home Health Aide Program
315 Halleck Street
Bellingham, Washington 98225
Dear Ms. Hackler:
Thank you for your letter and the information describing the Home Health Aide
Program. It is a program which is serving individuals who otherwise might be
forgotten.
One of our original goals when establishing CETA positions was to place them in
programs which would help individuals stay at home rather than having to be
placed in nursing facilities. Sadly, this objective has been met in only a few
areas of the state. The Home Health Aide Program is one that is working toward
this goal.
As you know, most Title II CETA positions have had to be either phased out or
moved to Title VI. The Home Health Aide Program positions have been moved to
Title VI. This should not make any difference in your operation of the pro-
gram. You have undoubtedly been informed by now that your positions will be
maintained until at least September 30. However, because of the need that
your program fills in the community and because of the quality of the service
provided, I can assure you that your positions will be funded through CETA un-
til the end of our grant, June 30, 1976. I hope that through this you can con-
tinue to provide the service to the many persons in need of it.
Sincerely,
Inker
Lyle M. Tinker
Administrator
LMT/bjb
cc: Eudora Peters
Dwight Wood
Cloyd Campbell
3
ATTACHMENT 1
97
May 5, 1975
CETA Program
Dear Mrs. Hackler:
This Program is a Godsend to the elderly. It supplies a great need.
It looked as if Mrs. B. W. who is just home from the hospital and
Mrs. M. H. who is blind might have to go to a rest home. Mrs. W's
savings were simply eaten up by her stay in the hospital.
Neither of these people could live alone but together with a little
help they can manage.
If possible it is far better for the elderly to remain in their own
homes where they are much happier. I think it is also much less
expensive and better management for the government than for paying
for two in a rest home.
With this girl coming twice a week and also being able to get a meal
three times a week from Lincoln Square, their need will be met. They
are two very happy people.
When I see the good that this Program is accomplishing I am very
grateful for it. It's one Government Program that I can whole
heartedly support and I fervently hope it will be continued.
These people are thrify and independent and wouldn't ask for help
unless it was vitally necessary.
Thank you with all my heart.
Sincerely,
/s/
Mrs. Phoebe B. Townley
98
ATTACHMENT 1
Bellingham, Washington
June 2, 1975
Dear Mrs. Hackler,
I just want you to know what it has meant to us that you were able to
send us help when you did through CETA.
I had been trying for over a year to hire a responsible person,
housekeeper or nurse, to help me care for my husband who has been
bedfast for over a year, but no help was to be had.
I was getting SO tired I was afraid I'd be unable to continue the rigid
routine and that he'd have to be placed in a nursing home.
Since Cheryl has been coming I've been able to do necessary shopping,
get jobs done that wouldn't wait any longer and most of all I'm getting
some rest.
I was scheduled for a series of x-rays when my husband became ill. Now
I hope to get these x-rays taken.
We both want you to know we are very pleased with Cheryl. Her attitude
and her work is most commendable.
Sincerely,
/s/
Judith Christofferson
GERALD
LIBRARY
ATTACHMENT 1
99
June 24, 1975
Dear Sara,
The Home Health Care Aide Program has truly been a blessing for all
involved. Already there have been many lives deeply touched in the
short two months that the program has existed.
There is a family in which the husband, who is 91 years old, has been
bedridden with heart congestion for the past year. His wife is
totally devoted to him and answers his every need. But after a year
of caring for him, she is worn out. Before this program started,
she had fears that she might have to send him to a nursing home. Now,
with help two times a week, she can leave the home and her husband
in the hands of another - she can relax and be with other people.
And she certainly does look and feel better now. She has said many
times that the program has been a real lifesaver for her and her
husband.
There is another family in which the wife is a paraplegic. She has
been bedridden for the past 18 years, and it had been several years
since she had seen a doctor. Since the program started, a doctor has
been to see her, she has been given a bed bath twice a week, her
pressure sores (one covered her entire left buttock) are starting to
heal, her hair has been shampooed weekly. She is now given the personal
care her husband is not able to give her. And they both enjoy an evening
meal which offers a change from the husband's quick, but not so nutritious
cooking.
There are two ladies who have lived together for the past 18 years.
One has been blind the last 20 years and the other is now suffering
from terminal cancer. The lady who is blind is 85 years old and a
very proud and determined woman. She loves her home and moving to a
nursing home would be detrimental to her fine spirit. The other lady
is 83 years old and is very much at peace when she's in her home.
This is where she wants to be during the last few months of her life.
These ladies are able to remain in their home with the help of a Home
Care Aide. Because of this program they can stay at home and yet be
assured of a clean home, clean clothes, clean hair and bodies, groceries
in their cupboards, food cooked up for their dinner - all the chores
they have done for years and years but now must rely on others to do
for them. How joyous it is that there is a program that gives them
that help.
And there is a lady who is an alcoholic. She is divorced and somewhat
abandoned from her family. She is a very lonely woman. Because of
this program, she is given at least two good meals a week, her laundry
is done, and her hair and body washed. In her case, maybe the most
important thing of all is that there is now someone she can play the
piano for. And how she does play!
100
ATTACHMENT 1
There are many others who have been helped. Sometimes older folks
are forgotten about in these times. No longer do they move in with
their children and become a part of their children's family. And
even though the children may visit and keep in touch, they are
oftentimes too busy with their own lives to care for their folks.
So where do the elderly turn when they find they can no longer do
the chores that need be done - to a nursing home - where everything
is new, strange and oddly institutionalized. At an older age, that
is quite an adjustment to make. An adjustment that might take a lot
of life out of them. With the Home Health Care Aide Program, they can
remain in their familiar setting, enjoying the peace and tranquility
that only their home can offer.
Sincerely,
/s/
Cheryl Kellerman
to
to
to
To
ATTACHMENT 1
101
Home Health Aide Program
Whatcom County Opportunity Council
Senior Citizens
Bellingham, WA 98225
I have been asked to record some of the experiences which I have had,
as well as some of the cases I have covered during the past two months
of this program. First of all, I would like to introduce myself. I
am one of four women working as an aide in this program, along with our
supervisor, Ms. Sara Hackler. I am the only one without some previous
medical training or experience. My training is in education and
particularly working with handicapped children.
We work with several families who have a handicapped child, cerebral
palsy being the main affliction. All of these families have other
children besides, and we were called in to give the mothers in these
situations a time to be away from the home and pursue business and.
social matters with the peace of mind in knowing they had left their
children in the care of a trained professional. These mothers have been
under particular strain in their various family situations, and could be
placed in the situation of venting their anger and frustrations upon their
children. By coming into the home and giving them some time to themselves,
helping with some household chores, and running errands for them, we have
taken much pressure from their shoulders and allowed them a breathing
space and some rejuvenation.
Specific situations include a woman with two children, one with cerebral
palsy, whose husband has left her with total responsibility for the
children as well as the property. She is scheduled for uterine surgery
soon and is trying to find foster care for her son (with cerebral palsy)
during her surgery and recuperation time. She is under much pressure
at this time and vitally needs some time to herself to take care of the
many business matters facing her right now. I visit her two afternoons
a week for four hours each, and during this time she has taken care of
personal and business matters. I take her son to therapy sessions and
have been taught some exercises to do with him by the therapist.
Another mother has a one and a half year old son with cerebral palsy
as well as two older sons. She is with the children constantly and
greatly needs some time to herself. I also visit her two afternoons
a week for four hours each, giving her some time to run errands and
take care of family business. I do some simple household chores for
her also, which gives her some respite from the daily grind. There are
other families in similar situations where the mother is given some
respite from family obligations. I have worked with the Occupational
Therapist with these children and do some therapy exercises with them
at home when I am there.
102
ATTACHMENT 1
Besides the children I take care of, I also visit several senior
citizens in the community. One woman has bone cancer and has been
taken care of by her husband for about a year. They are both in their
seventies and he was getting tired and somewhat bitter in his position
as full-time partner and nurse. I visit them two mornings a week
and help her with her bath and personal care, something her husband
would be very uncomfortable doing.
I see two different households where the residents are 90 years old
(and above) and still trying to maintain their own homes. They have
done (in both cases I'm connected with) very nice jobs of maintaining
their own apartments, but they are expending a maximum of energy merely
providing for their living necessities. With our visits, we are able
to help them do a more thorough job of keeping their living quarters
up to sanitary standards, and also take them out of the house for errands
and social calls. Our visits are keeping many of these people out of
costly nursing homes as well as preserving some sense of dignity
and self-sufficiency for our elderly citizens.
All four of us have been visiting one elderly lady who was seriously
ill but refused to stay in the hospital. We helped her through some
very critical stages and she is now recovering somewhat and becoming
self-sufficient again. If she had been forced to go to a nursing home,
she quite possibly may have given up and died, but she remained in her
own home and fought back to continue living.
One particular case bears mentioning here to point out the help we can
give persons who are temporarily afflicted with some disability. This
man had been injured in a ski accident and had broken both arms. He
was sent home from the hospital with both arms in a cast which covered
the entire trunk and made movement of arms and hands impossible. We
went in every morning and bathed him, fed him breakfast, and did his
immediate cleaning chores. He was quite helpless for three weeks and
would not have been able to afford private help. In fact, our services
are provided free-of-charge to all of our patients, who are from low-
income situations where private help is an impossibility. Without our
help, these people would have had to change their situations drastically.
A Home Health Aide Program can do these things I have mentioned and much
more. All of our patients were found in the community in only two months
of service of the program. There are most certainly many more cases like
them who have yet to be discovered or recommended to the program. These
people will suffer without the home health aide service, but certainly
not as much as those who have aTready been initiated into our service
and have now come to depend on us for help and relief.
A program such as this is a vital community service that Whatcom County
can be proud of. That it is possible that it will be discontinued
is almost unspeakable, but yet exists. I hope that this brief report
gives some idea of the type of thing we are doing for people in the
community and points out the basic service such a program can provide
to all kinds of people.
/s/
Diana L. Gay
103
ATTACHMENT 2
REPORTED SAVINGS ON HOSPITAL COSTS THROUGH HOME CARE
Selected Studies
This paper summarizes data on savings in hospital costs resulting
from early discharge to home health care as reported in selected studies
in New York State and elsewhere. Various other reports now available
could have been included, but the number has been restricted in the
interests of brevity.
Studies selected represent programs at three levels -- statewide,
metropolitan area, a single community hospital. Also included are two
studies related to a single disability -- 1) care at home of patients in
traction, and 2) home care of children with hemophilia.
Figures are given below which summarize savings in hospital days
and hospital costs reported in these studies. Later tables give source
references and additional breakdown data.
REPORTED HOME CARE SAVINGS
Hospital
Net
Days Saved
Savings
Study Report
Per Patient
Per Patient
1)
Visiting Nursing Service, Denver, 1971
15.6
$1,170
Hemophiliac Children, McGill Univ, 1972
70.2
4,477
Blue Cross, Philadelphia, 1963-71
12.9
330
St. Luke's Hospital, Denver, 1970
14.0
850
Blue Cross, Connecticut, 1970-72
21.6
2,175
Patients in Traction, Rochester, 1973
49.8
4,590
Blue Cross, Michigan, 1961-70
14.7
562
1)
Figures are net savings -- costs of home care de-
ducted from estimated savings in hospital costs.
A number of comments are in order with reference to the above figures
First, reported hospital days saved in the Philadelphia, Connecticut,
Denver VNA, and Michigan studies are based on estimates made by attending
physicians. Figures in 4 of the 5 studies fall within a relatively narrow
range of 12.9 to 15.6 days saved. Such a result involving hundreds of
physicians and thousands of patients in so many parts of the country
Prepared by Edward G. Lindsey, Director of Health Services, State
Communities Aid Association, New York, New York.
104
ATTACHMENT 2
strongly supports the validity of the data even though an element of
subjective judgment is involved. (See Table V for explanatory comment
on the higher Connecticut figures).
Second, data in the St. Luke's and McGill University reports are
based on carefully designed control studies. Savings reported are based
on objective data comparing selected groups receiving hospital care only,
and groups receiving hospital plus home health services.
Third, the substantial reductions in hospital stays reported in the
hemophiliac and traction case studies add an important dimension to the
cost effectiveness potential of home care. The number of such patients
in the population, of course; is relatively small. However, in view of
the very high dollar savings, there is strong indication that earlier
discharge to home care for these and other special disability groups ----
post-surgical, pediatric, coronary, pulmonary, to name a few -- could
add up to an impressive cost reduction.
Fourth, taken together these studies present a strong weight of
evidence that home care can make significant savings in hospital days.
Admittedly, there are limitations in the studies. But it would seem
imprudent to ignore the evidence of these reports while awaiting some
more comprehensive research project for which there is presently no
visible sponsor or source of funding.
Meanwhile, the explosion in health costs continues. Careful clini-
cal studies consistently report unnecessary hospital andnursing home
use, a portion of which could be reduced by home care. Over 42% of
Medicaid expenditures in the state in 1970 were for hospital care, and
more than 24% for nursing home care. Only a fraction goes for low-cost
care in the home.
The cost situation and the data in this report strongly suggest
the timeliness for action on home care.
For breakdown data on studies cited, see pages
3 through 9.
ATTACHMENT 2
105
ADDITIONAL DATA ON STUDIES
Tables I through VII which follow present additional data on the
home care studies cited on page 1. In some instances for convenience,
figures have rounded to the nearest dollar.
A. Denver Early Discharge Program
Table I below summarizes data reported by the Denver Visiting Nurse
Service on the 1971 Early Discharge Program. The study involves 620
patients referred to home care by 10 voluntary hospitals.
TABLE I
DENVER EARLY DISCHARGE PROGRAM - HOSPITAL DAYS SAVED
1)
Year 1971
Hospital Days
Home Care
Saved
Hospital Savings
Cost
Net
Per Patient
2)
Per Patient
2)
Per Patient
2)
Savings
15.6
$1,472
$302
$1,172
1) "Report of Early Discharge Program, " Visiting Nurse Association,
Denver, Colorado, 1972.
2)
Based on average hospital per diem of $95.
An additional 768 patients were referred to home care, but not
designated as "early discharge. 11 Data on these patients is not
included in Table II.
106
ATTACHMENT 2
B. Home Care of Hemophiliac Children
Table II below reports on a controlled study of 40 bleeding hemo-
philiac children carried out by McGill University and Montreal Children's
Hospital over a period of two years. One group of 20 children received
care at home and limited hospital care. The control group received care
for each bleeding episode only in the hospital.
TABLE II
HOME CARE VS. HOSPITAL CARE OF 40 HEMOPHILIAC CHILDREN 1)
Years 1970-72
Group A
Group B
Hospital Care
2)
Home Care 2)
Days Care
Cost
Days Care
Cost
Total
Hospital
Group
1,644
$164,400
-
-
$164,400
Home Care
Group
241
24,100
2,030
$50,750
74,850
Net Savings
$ 89,550
Savings Per Patient
$ 4,477
1) "Delivery of Care to Hemophiliac Children: Home Care
Versus Hospitalization, H Dr. Hanna Strawczyski, McGill
University, Department of Pediatrics, and Children's
Hospital, Montreal, Canada, November 1972.
2) Hospital costs estimated at $100 per day; home care costs
averaged approximately $25 per day during bleeding episodes.
Control Group B, through the addition of home care, used 85%
fewer hospital days than Group A. "School attendance in the home
care program was significantly better with an average of 2.5 school
days missed per bleeding episode, as compared to 6.2 days in the
hospital program."
ATTACHMENT 2
107
C. Philadelphia Blue Cross Study
Table III below summarizes data on hospital days saved as reported
in a home care study by Blue Cross of Greater Philadelphia. The study
covered a ten (10) year period -- 1961-70, and provides figures on
3,940 patients discharged to home care by four (4) hospitals during
that time.
TABLE III
HOSPITAL DAYS SAVED - PHILADELPHIA BLUE CROSS¹)
Years 1961 - 1970
Hospital
Home Care
Days Saved
Hospital Savings
Cost
Net Savings
Per Patient
Per Patient
Per Patient
Per Patient
12.9
$634
$304
$330 2)
1)
"Coordinated Home Care: An Effective Alternative, " Blue
Cross of Greater Philadelphia, February 1972.
2) A net savings of $473 per patient was later reported for
the year ending June 30, 1970.
Estimated hospital days saved on 3,940 cases totaled 50,800
days valued at $2,495,267. Net savings after deducting costs
of home health services and related administrative costs were
estimated at $1,298,381.
108
ATTACHMENT 2
D. St. Luke's Hospital Study, Denver
Table IV below summarizes data on hospital days saved as reported
in a controlled study by J. W. White at St. Luke's Hospital, Denver,
Colorado in 1970. The study involved one sample of 100 patients refer-
red by the Hospital Nurse Coordinator's Office to home care, and a
second sample of 100 patients selected on admission until "the same
number of cases for each diagnostic category was reached" as in the
home care sample.
TABLE IV
STUDY OF HOSPITAL DAYS SAVED THROUGH REFERRAL TO HOME CARE¹)
St. Luke's Hospital 1969
Hospital
Hospital
Home Care
Total
Days
Cost2)
Cost
Cost
Hospital
Group
2,554
$196,504
-
$196,504
Home Care
Group
1,155
88,935
$22,534
111,469
Net Savings
$ 85,035
1) "A Comparison of Referred and Non-Referred Cases to Home
Nursing Care, 11 unpublished Masters Thesis, J. W. White, M.A.
Hospital Administration, 1970.
2) Average per diem (St. Luke's, 1969)
$77.
Hospital days saved averaged 14.0 days per patient. Hospital costs
saved averaged $1,076 per patient. Home health services averaged 36.4
days per patient. Net savings were $850 per patient, a cost reduction
of over 43%.
ATTACHMENT 2
109
E. Connecticut Blue Cross Study
Table V below summarizes data on hospital days saved as reported
by Connecticut Blue Cross in a study of statewide home care coverage
which began in April 970 with one hospital participating. During the
two-year period the number participating hospitals increased to 16.
TABLE V
STUDY OF HOSPITAL DAYS SAVED CONNECTICUT BLUE CROSS¹)
August 1970 - September 1972
Hospital
Average
Home Care
Days Saved
Hospital Savings
Costs
Net Savings
Per Patient
Per Case 2)
Per Case
Per Case
21.6
$2,528
$353
$2,175
1)
"Coordinated Home Care - The Facts Speak for Themselves,"
Blue Cross of Connecticut, May 1972.
2) Total in-patient dollars saved were reported as $1,329,588,
based on "physician estimates of days saved multiplied by
an average per diem weighted cost of 16 hospitals."
A total of 526 patients were covered in the study. Blue Cross re-
ported in May 1973, eight months after completion of the study, that
there had been an increase of 100% over the total for the first two
years of coverage.
In reviewing the long-range Michigan and Philadelphia studies, it
is interesting to note that estimates of hospital days saved were
substantially higher in the early years of the program than in the later
years. This experience may relate to the relatively high estimates in
this study which covers a new program.
110
ATTACHMENT 2
F. Home Care of Patients in Traction
Table VI below summarizes data reported by the Home Care Association
of Rochester on care at home of six (6) patients in traction. Diagnoses
included: broken femur - 4; bilateral femoral fracture - 2. The data
assumes that without home care these patients would have continued to be
hospitalized for the full period in traction -- an average of 49.8 days
per patient.
TABLE VI
COSTS OF CARE AT HOME OF SIX (6) PATIENTS IN TRACTION 1)
Compared to Hospital Costs
Days at Home
Cost
Cost
Total
In Traction
Per Day
Per Patient
Cost
HOSPITAL
CARE
49.8
$110.00
$5,965
$35,794
HOME
CARE
49.8
27.60
1,375
8,250
Home Care Savings
$ 92.40
$4,590
$27,544
1)
"Home Care Tractions Cases - Six Patients, 11 Home Care
Association of Rochester, November 15, 1973.
Ages of patients in the study were 8, 15, 16, 17, 19, and 61
years. Some patients required limited home care services after
removal from traction, but this is not involved in the above data.
ATTACHMENT 2
111
G. Michigan Blue Cross Study
Table VII below summarizes hospital savings estimated in the Michigan
Blue Cross home care program for the year 1967. Included are 1,157 dis-
charges from coordinated home care. The data covers the last year of a
seven (7) year period of home care coverage -- 1960 through 1967.
TABLE VII
HOSPITAL DAYS SAVED - MICHIGAN BLUE CROSS1)
Year 1967
Hospital
Average
Home Care
Days Saved
Hospital Savings
Average Costs
Net Savings
Per Patient2)
Per Patient2)
Per Patient3)
Per Patient
14.7
$755
$193
$562
1)
"Blue Cross Home Care Benefits: The Michigan Experience, 11
Krause and Harmon, Michigan Hospital Service, 1969.
2) With estimated hospital savings of 17,008 patient days.
Average home care costs were $51.34 per diem.
3) Average home care days per case were 48.8 in 1967, and
totaled 52.8 over the 1960-67 period.
Estimates of hospital days saved averaged 17.9 days per patient
over the 1960-67 period: approximately 20 days for 1960-63; 17.2 for
1964-66, and 14.7 days for 1967.
112
ATTACHMENT 2
SUMMARY
This report has presented only a portion of available studies on
home care cost-effectiveness. Further, data presented has related only
to those hospital savings which result from early discharge to health
carein the home.
Additional hospital savings through home care could be documented:
the effectiveness of home health services in preventing
unnecessary or premature return to the hospital which
can occur for lack of proper follow-up care after
discharge;
the potential for care at home of chronic illness
patients during certain types of "flare-ups" which
would otherwise require hospitalization.
Further, home care has the potential to provide preventive and sup-
port services to infirm and elderly persons at home who would otherwise
require care in a nursing home or other institution.
These considerations are particularly important at this time in
of new provisions for "de-institutionalization" in the 1972 Social Sec
-Y
Amendments. States must take positive action to prevent costly over-use
of hospital and nursing home facilities by Medicare and Medicaid patients.
Home care çan provide a major asset in this "de-institutionalization,
but only if the home care services exist and can be made adequate for the
job. Certainly physicians are not going to send home cancer patients,
stroke patients, accident cases in traction, etc. unless they know that
home health agencies can give proper care. And, if there is insurance
or other coverage for more hospital days, and not for home care, it can
hardly be expected that physician, patient, or family will select home
care at more out-of-pocket costs.
ATTACHMENT 3
113
Chart B-15. Days of Restricted Activity and Disability Per Person Per Year, by Age and
Sex* (U.S.A., 1969).
40
Female
35
Male
30
Restricted
Activity Days
25
Days Per Person Per Year
20
15
Female
Bed Disability
Days
Male
10
5
10
20
30
40
50
60
65 and Over
Age Groups
*
Civilian, non-institutionalized population.
Source: U.S. National Center for Health Statistics, Current Estimates from the Health
Interview Survey: United States, 1969, Public Health Service Pub. No. 1000,
Series 10, No. 63 (Rockville, Maryland, June, 1971), Table 16, P. 20.
U-M Bur Publ Health Econ
-25-
II-B-1 (10) Rev 72
Chart taken from Medical Care Chart Book Fifth Edition, the University of
Michigan School of Public Health, 1972.
ATTACHMENT 4
114
Chart B-14. Percent of Persons with a Chronic Condition and with Specified
Limitations, by Sex and Age* (U.S.A., July 1965-June 1967).
100
Male
Female
90
80
70
Percent of Persons In Each Age Group
One or More
60
Chronic
Conditions
50
40
Some Limitation
30
of Activity
20
N
Unable to
Carry On
10
Major
Activity
10
20
30
40
50
60
65 and Over
Age Groups
NOTE: "Major activity" refers to ability to work, keep house, or engage in school
or pre-school activity.
*
Civilian, non-institutionalized population.
Source: U.S. National Center for Health Statistics, Chronic Conditions and Limitations
of Activity or Mobility: United States, July 1965-June 1967, Public Health
Service Pub. No. 1000, Series 10, No. 61 (Rockville, Maryland, January,
1971), Table 1, P. 19.
U-M Bur Publ Health Econ
-24-
II-B-1-d-3 (12) Rev 72
Chart taken from Medical Care Chart Book Fifth Edition, the University of
Michigan School of Public Health, 1972.
ATTACHMENT 5
115
Chart B-17. Percent of Persons with Chronic Conditions Causing Limitation in or
Inability to Carry on Major Activity, by Family Income and Age
(U.S.A., July 1965-June 1967).
50
Under $3,000
40
$ 3,000 - 4,999
$ 7,000 - 9,999
Percent of Persons in Each Age Group
(A)
30
$ 15,000 and over
20
(B)
10
(C)
(D)
0
10
20
30
40
50
60
65 and over
Age Groups
*
Civilian, non-institutionalized population.
Source: U.S. National Center for Health Statistics, Chronic Conditions and Limitations
of Activity and Mobility: United States, July 1965-June 1967, Public Health
Service Fub. No. 1000, Series 10, No. 61 (Rockville, Maryland, January,
1971), Table 15, P. 33.
U-M Bur Publ Health Econ
-27-
II-B-1-b (7)
Chart taken from Medical Care Chart Book Fifth Edition, The University of
Michigan School of Public Health, 1972.
116
ATTACHMENT 6
Population Age 65 and Over, Four County Region
and State of Washington, 1970-1975
yous
bib
Year
Whatcom
Skagit
Island
San Juan
TUG
nt
1970
9,564
6,469
2,465
767
1971
9,490
6,670
2,580
800
1972
9,610
6,670
2,810
830
975
1973
9,850
6,810
3,010
870
1974
10,090
6,980
3,070
890
903
1975
10,360
7,170
3,130
910
noticent
neds
Year
Region
State
Nation
70
1970
19,265
320,712
conuç?
1971
19,490
327,690
bns
1972
19,920
334,840
1973
20,540
342,920
Tsnotogy
1974
of
21,030
351,480
1975
21,570
360,870
Source: State of Washington, Office of Program Planning and Fiscal
Management, Population Studies Division, State of Washington
Population Trends 1975; July 1975, Table 9
1880
25
Projecting the Aged 1 Population to 1980,
Four County Region and State of Washington
Percent of State Aged
Range of
1980 Total Pop. Est.
Growth of Aged Pop. Method
Pop. Method
2 Methods
3
% factor
5
6
low
high
low
high
% factor
low
high
low
high
2
4
State
3,672,100
4,015,630
10.8
397,492
434,678
Region
179,849
194,585
13.1
23,524
25,547
6.00
23,860
26,092
23,524 - 26,092
2
3
Whatcom
90,110
94,100
13.1
11,802
12,324
2.982
11,853
12,962
11,802 - 12,962
2
3
Skagit
53,746
58,526
13.8
7,396
8,054
2.01
8,006
8,755
7,396 - 8,755
2
3
Island
29,800
35,000
10.6
3,139
3,687
0.768
3,052
3,338
3,052 - 3,687
3
3
7
7
117
San Juan
6,193
6,959
21.3
1,319
1,482
0.238
(948)
(1,036)
1,319 - 1,482
1. Over 65 years.
2.
State of Washington, Office of Program Planning and Fiscal Management, 1972.
3.
Whatcom County: Northwest Regional Council. Other Counties: County Planning Departments.
4. Obtained from summation of county projections to obtain regional projection. State projection
obtained by assuming region would retain the same fraction of state population as in the low
projection.
ATTACHMENT 7
5. The state's aged population (65+) is forecast by OPPFM as increasing from 9.4 percent of the total
in 1970 to 10.8 percent of the total in 1980. The regional and county fractions of aged population
have been estimated for 1980 to increase by the same 1.4 percent over the 1970 fraction shown in
Table 13. The 1.4 percent additional growth in aged population is based on the OPPFM projections
of total population for 1980.
6. Assumes the elderly constitute the same fraction of county and regional population in 1980 as
they did in 1970. Factor is that fraction.
7. Projections made in 1970 are already lower than current population due to unanticipated migration
to the San Juan Islands.
118
ATTACHMENT 8
Part A Medicare Enrollment, Four County Region,
State of Washington, and U.S., 1968-1973
Year
Whatcom
Skagit
Island
San Juan
1968
6,095
6,225
1,657
658
1969
9,581
6,351
1,758
680
1970
9,650
6,505
1,894
723
1971
9,563
6,640
2,003
751
1972
9,724
6,656
2,267
785
Year
Region
State
Nation
1968
14,635
313,002
19,457,518
1969
18,370
316,991
19,683,691
1970
18,772
322,986
20,014,667
1971
18,957
329,706
20,375,400
1972
19,432
336,379
20,731,382
1973
345,000
Data sources:
1968-1972
D.H.E.W., Social Security Administration, Office of
Research and Statistics, Medicare: Health Insurance
for the Aged, 19--, Section 2: Persons Enrolled in
the Health Insurance Program. 1968 through 1972.
1973
Social Security Administration, Social Security
Bulletin, Annual Statistical Supplement, 1973. U.S. Government
Printing Office, Washington, D.C., 1973. Table 131.
ATTACHMENT 9
119
Population Under Age 65, Four County Region
and State of Washington, 1970-1975
Year
Whatcom
Skagit
Island
San Juan
1970
72,419
45,912
24,546
3,089
1971
74,310
46,080
25,120
3,100
1972
75,390
46,230
25,090
3,070
1973
75,150
46,190
25,190
3,130
1974
75,110
46,020
25,530
3,110
1975
75,840
46,230
26,870
3,590
Year
Region
State
Nation
1970
145,966
3,092,538
1971
148,610
3,102,410
1972
149,780
3,083,960
1973
149,660
3,081,380
1974
149,770
3,096,620
1975
152,530
3,133,254
Source: State of Washington, Office of Program Planning and Fiscal
Management, Population Studies Division, State of Washington
Population Trends 1975, July 1975, Tables 1 and 9.
120
ATTACHMENT 10
Population Estimates, Four County Region
and State of Washington, 1980
All Persons
Whatcom
Skagit
Island
San Juan
Region
State
1
2
3
4
5
1980 low
90,110
53,746
29,800
6,193
179,849
3,672,100
6
7
8
9
10
1980 high
94,100
58,526
35,000
6,959
194,585
4,015,630
11
Persons Under Age 65
12
Whatcom
Skagit
Island
San Juan
Region
State
1980 low
78,308
46,350
26,748
4,874
156,325
3,274,608
1980 high
81,138
49,771
31,313
5,477
168,493
3,618,138
Notes
1. Source: Office of Program Planning and Fiscal Management; State
of Washington, "Interim Population Projections to Year
2000 by County," (mimeo), October 2, 1972.
2. Ibid.
3. Ibid.
4. Ibid.
5. Ibid.
6. Source: Whatcom County Council of Governments.
7. Estimates assumes 1.0 percent growth rate per year from 1973.
Estimate includes anticipated 1,134 person population increase
because of Skagit Nuclear Project.
8. Source: Island County Planning Department.
9. Estimate assumes 4.0 percent annual gorwth rate per year from 1974.
10. Source: Attachment 7.
11. Figures for region and counties obtained by subtracting population
figures shown in Attachment 7 from overall population figures shown
in Attachment 10.
12. Figures obtained by subtracting estimate of over-65 population in
1980 (397,492) from overall population figures shown in Attachment 10
Source of 1980 over-65 estimate: Office of Program Planning and
Fiscal Management, State of Washington, "Preliminary Population
by Sex and Age Groups, 1960-1980," (mimeo), 1972.
DEPARTMENT or SOCIAL AND HEALTH SERVICES
121
HEALTH SERVICES DIVISION
J. EVANS
P.O. BOX 1700. OLYMPIA. WASHINGTON 96504
VERNOR
December 11, 1973
JOHN A. BEARE. M.D.
ASSISTANT SEC TARY
ATTACHMENT 11
Robert M. Eastman, Assistant Director
Comprehensive Health Planning Council
of Whatcom, Skagit, Island & San Juan Counties
102 South Barker Street
Mount Vernon, Washington 98273
Dear Mr. Eastman:
Your letter dated November 26, 1973 to Doctor Robert Atwood
vas referred to this office for review and response. The
interest expressed by the Task Force in the development of
home health services should result in some improvement as well
as in more coordination of community service.
The following is an attempt to respond to the questions you pre-
sented which are identified by the numbers used in your communi-
cation.
2
Home health nursing service provided through Medical Assistance
funds for the years requested is as follows:
1967
$60,394.36
1968
95,302.87
1969
64,817.30
1970
169,087.85
1971
176,423.39
1972
173,603.00
The figure for 1972 is approximated because the accounting
source of the previous five years is not available at this
time.
2. The budgetary process in the Department is on a biennial basis.
In preparation the past history is reviewed and the projection
is developed, incorporating increments as legislative action
permits.
3. The present fee schedule is $13.55 reimbursement for home health
nursing visit, and $5.65 per hour for home health aide service.
Payment for these services is subject to approval by Nursing Care
Consultants assigned to local areas and directed from this office.
ATTACHMENT 11
122
The cost of care experience of certified home health agencies is
reviewed and verified by the Office of Standards within the Depart-
ment prior to submission to the Governor's committee on vendor rates.
This committee is charged with the function of recommending fees for
provider service to the Governor's office.
5.
The present fees were implemented in early 1973. There has not been
& routine revision of the fee schedule.
6:
The fees are paid on the basis of fee-for-service. At the present
time other methods of reimbursement are not utilized, and there are
no WAC's concerned with alternative methods.
7. A home health nursing visit for Medical Assistance purposes is &
professional public health nursing service provided to a Medical
Assistance client eligible for the service which has been determined
to be appropriate in meeting his health needs. Such nursing service
may be extended by home health aide service on an hourly basis under
the supervision of the certified home health agency nursing personnel.
8. Recommendations from your Task Force related to home health nursing
service for Medical Assistance clients may be sent to this office.
Should you wish to discuss such recommendations, a conference for that
purpose could be readily arranged.
If the recommended changes refer to the availability of home health
nursing services to the total population, they should be addressed to
Doctor Robert Atwood, Supervisor, Office of Community Support, Depart-
ment of Social and Health Services, P.O. Box 1788, Olympia, Washington,
98504, Mail Stop 1-2.
9. Chore services are provided eligible recipients through the direction
of the Office of Social Services, Department of Social and Health
Services, Capitol Center Building, Olympia, Washington, 98504, Mail
Stop 27-1, which is headed by William B. Pope.
If you desire an elaboration of any of the responses to the questions,
this office will attempt to secure as much information as is available.
Sincerely,
Robert P. Hall, M.D., Chief
Office of Personal Health Services
RPH:MAR:nh
cc: Robert Atwood, M.D., Supervisor,
Office of Community Support MS 1-2
ATTACHMENT 12
123
SKAGIT COUNTY MEDICAL BUREAU
A Member of Blue Shield
Second and Milwaukee
February 21, 1974
P.O. Box 699
Mount Vernon, Wash. 98273
Telephone 336-3101
Mr. Robert M. Eastman
Assistant Director
COMPREHENSIVE HEALTH
PLANNING COUNCIL
102 So. Baker Street
Mount Vernon, Wa 98273
Dear Mr. Eastman:
Thank you for your letter of February 5th, extending an
invitation to a representative of the Medical Bureau to speak at your
meeting of fiscal intermediaries and the Council's Task Forces on
Long-Term Care and Home Health Services on Thursday, February 21st.
I am also responding in this letter to the questions that were posed, and
I think you will see from the replies that the Bureau is really not in 2
position to speak with expertise on the subject matter, therefore, our
attendance at the meeting would be as a listener, not as a speaker,
and if this would be of benefit to your organization please advise me
so that arrangements can be made for a representative to attend.
Our answers to your six questions follow:
1. and 2. The Medical Bureau contracts have
historically provided its subscribers service
benefits of member physicians and have, in
general, excluded custodial or convalsecent
care. None of our contracts provide coverage
of non-physician home care services.
3. All of the Medical Bureau's contracts provide.
a core of benefits which include physicians
services, inpatient hospital care, and ambu-
lance service. These contracts incorporate
optional provisions to include prescription
drugs, appliances, etc. Non-physician home
care benefits are not a part of our benefit
core.
4. Individual and group policies provide the
same benefit structure, and as stated above,
PREPAID MEDICAL, SURGICAL and HOSPITAL CARE SPONSORED by PHYSICIANS of SKAGIT COUNTY
Page Two
124
ATTACHMENT 12
Mr. Robert M. Eastman
February 21, 1974
our contracts do not provide the option for
purchase of non-physician home care benefits.
5. To date, the Medical Bureau has not developed
experimental reimbursement methods for
hospital services. The Bureau would be
willing to participate in the development of
such experiments if the facts available gave
indication of sound fiscal management.
6. We do not have an opinion on how non-physician
home care services should be financed.
Should you wish further information concerning these answers
please advise.
Yours very truly,
Wm. Y. Duncan, M.D.
President
SKAGIT COUNTY
MEDICAL BUREAU
M/A
ATTACHMENT 13
125
14
ORGANIZATION AND IMPLEMENTATION OF THE PROJECT
HCS Home Care Service
All Potential Patients
OPD Outpatient Department
Degree of physician
High
Low
involvement
Hospital
Potential for rapid
High
Medium
Low
clinical deterioration
Hospital
Need for nursing and/or
Need
No Need
Need
No Need
other nonphysician therapies
ECF
Home, or
Custodial
Care
Degree of need for
High
Low
High
Low
registered nurse care
Hospital
ECF
Hospital
Degree of need for
Low,
High
multiple treatments
and/or non-RN care
ECF
Home environment
Appropriate Inappropriate
(physical)
ECF
Mental condition
Mental Problem
No Problem
of patient
Family and patient
Yes
No
Yes
No
willing and able to
accept home care
HCS
ECF
ECF
Mobility problem
None
Problem
HCS
Need for homebound
No
Yes
equipment only
OPD
HCS
Figure 3. Decision Grid for Evaluation of Need for Care in Home Care Service and
Extended Care Facility
8. Willingness and ability of patient and/or patient's family to accept home
care
9. Mobility of patient
10. Special equipment needed
This system was designed to provide independent sequential evaluations to place
the patient in the appropriate mode of care. Figure 4 (next page) shows how this
can be done. It illustrates, for example, that a patient with no need for high physi-
cian involvement, with a medium potential for rapid clinical deterioration, and
with a need for nursing and/or other nonphysician therapies and for intensive care
from a registered nurse, might be best cared for in a hospital. On the other hand, a
Source: Hurtado, Arnold V; Greenlick, Merwyn R.; Saward, Ernest W.,
Home Care and Extended Care in a Comprehensive Prepayment
Plan. Hospital Research and Educational Trust, Chicago,
Illinois, 1972, pp. 14-15.
126
ATTACHMENT 13
8
Appropriateness of Care 15
101 Papid
and Care
of
Appropriate Site
for Care
#
/
Mob. Mobility Problem
10, Only
High
Low
High
Hospital
Low
Medium
Need
High
Low
Low
Need
High
Home. or
Low
Custodial Care
Low
No Need
Low
Medium
No Need
Low
Medium
Need
Low
Extended Care
Low
Low
Need
Low
High
Facility
Low
Low
Need
Low
Low
Inapp
Low
Low
Need
Low
Low
Approp
Problem
No
Low
Low
Need
Low
Low
Approp
No Problem
No
Low
Low
Need
Low
Low
Approp
Problem
Yes
Home Care Service
Low
Low
Need
Low
Low
Approp
No Problem
Yes
Yes
Low
Low
Need
Low
LOW
Approp
No Problem
Yes
No
Yes
Outpatient Department
Low
Low
Need
Low
Low
Approp
No Problem
Yes
No
No
Figure 4. Specification of Decision Grid. for Determination of Appropriate Site for Care
patient without a need for intensive nursing care and with an appropriate home
environment, but with a negative patient and/or family attitude toward home care,
might best be served in an ECF. A patient whose only need is nursing therapy
might best be served by a home care service.
At the beginning of the project, these dimensions were specified only in a tenta-
tive manner. Much of the early discussion in this area was aimed at giving each
dimension a specific and objective meaning so that a reliable evaluation could be
provided for any given patient on any dimension. These efforts to refine the model
continued throughout the project.
REFERENCES
1. The extended care facility complies with the Social Security Administration's Con-
ditions of Participation for Extended Care Facilities, HIM-3, March 1966.
2. Griffith, J. R. McPherson Community Health Center home care program. Inquiry
4:5 Oct. 1967.
3. Ryder, C. F., and P. G. Stitt. Physician involvement in home care. Inquiry 4:41
Oct. 1967.
4. Mather, W. G., and R. J. Hobaugh. Physician and patient attitudes toward a hos-
pital home care program. Inquiry 4:47 Oct. 1967.
CANADA
BLAINE
0
SUMAS
LYNDEN
0
EVERSON
ATTACHMENT 14
FERNDALE
WHATCOM COUNTY
BELLINGHAM
FRIDAY
HARBOR
CONCRETE
ANACORTES
SEDRO WOOLLEY
BURLINGTON
SAN JUAN COUNTY
MOUNT VERNON
SKAGIT COUNTY
Home Health Services 15-Mile Radius
127
LA CONNER
OAK HARBOR
COUPEVILLE
ISLAND COUNTY
WASHINGTON
COMPREHENSIVE HEALTH PLANNING COUNCIL
LANGLEYO
of
WHATCOM, SKAGIT, ISL AND 8 SAN JUAN COUNTIES
128
ATTACHMENT 15
EPARTMENT OF SOCIAL AND HEALTH SERVICES
COMMUNITY SERVICES DIVISION
TO:
Neil Peterson
Dr. John Beare
Ralph Littlestone
Regional Administrators
Local Office Administrators
FROM:
Community Services Division
Gerald E. Thomas, Deputy Director
SUBJECT: DELAY OF ACTION ON RECLASSIFICATION AND TRANSFER
OF NURSING HOME PATIENTS
Due to the continuing shortage of ICF care on a statewide basis, and in order
to avoid hardship as a result of the geographic location of such care,
effective immediately and pending further study of the availability and
distribution of ICF beds, the following policy is to be observed:
It will not be necessary to attempt to transfer individuals
classified as not needing skilled care from SNF's to ICF's.
Any notices already sent to patients advising them that they
may be moving to another facility due to reclassification
downward shall be immediately retracted.
Any fair hearings on the issue of movement of patients will
be resolved in the patient's favor.
Voluntary relocations requested by patients and new admissions shall be made
to ICF care where such care is most appropriate and where ICF resources are
available. Good placement practices shall be followed in all instances,
which include pre-planning with the patient, family and facilities.
R
NIT
Inde
Bellingham, Wash., Herald, Friday, Nov. 22, 1974
11
ATTACHMENT 16
Inflation may force welfare cuts
to hospital, nurse home patients
OLYMPIA (AP) - Reeling under
cover Medicaid costs by economy
With nearly all of the predicted
the pressure of inflation. the Depart-
patients and that about 50.000 welfare
measures."
ment of Social and Health Services
deficit due to soaring costs in nursing
recipients get short-term hospital aid
If the department continues spend-
will have to cut back its aid to welfare
home and hospital care, some cut-
each year.
ing at its present rate - after the
backs in state aid might have to be
Although expressing concern for 129
patients in nursing homes and hospi-
initial cuts are counted - it will more
considered he said grimly
the deficit he said the overrun if it
Source: Bellingham Herald, Bellingham, Washington, November 22, 1974
100 much red rape
Medicare patients furned dively
By BETH ERICKSON
One problem in the past has been
admission to the nursing home.
remaining extended care facilities in
Herald Staff Writer
that nursing homes have accepted
-A patient is admitted for further
Bellingham.
patients in good faith on a doctor's
treatment of a condition for which he
Medicare patients may choose be-
Charging that he can no longer con-
recommendation only to find that the
was treated in the hospital.
tween St. Luke's Hospital, Highland
tend with time-consuming Health,
care they require is not covered
It helps pay for regular nursing
Convalescent Center, Alderwood,
Education and Welfare requirements
under Medicare.
services, drugs furnished by the
Shuksan and Bellingham Villa Care.
and "still make a buck," Gordon Den
Den Adel contends that persons are
skilled nursing facility, physical OC-
Den Adel is the first nursing home
Adel will no longer admit Medicare
given a "song and dance" concerning
cupational and speech therapy, me-
administrator in Whatcom County to
patients
to
his
Medicare patients. He
ork is be.
under a
et paid. I
le system
added.
130
81
ATTACHMENT 17
"There are more requirements for
documentation that medical treat-
Source: Bellingham Herald, Bellingham, Washington, April 4, 1974
ment is actually necessary," he
added
ATTACHMENT 18
131
P.O. Box 39
May 31, 1974
Lt. John G. Meyer, M.D., M.P.H.
Special Assistant to the Medical Advisor
Office for the Civilian Health and Medical
Program of the Uniformed Services
Department of Defense
Denver, CO 80240
Dear Lt. Meyer:
The Council is in the process of completing an inventory of hospital and other
health-related facilities prior to the development and publication of a
regional hospital plan by December. Concurrently, we are also developing
plans for nursing homes and home health services (see your previous correspond-
ence with Mrs. Mary Lou Shadle, Washington Physicians' Service, Seattle,
No. CHO2), and assembling a "health indicators" report.
One section of the health indicators report will deal with medical care utili-
zation and expenditures. Combined with enrollment figures, the utilization
and expenditures data, when analyzed, will permit identification of patterns
and trends across various insured groups. In one county in our region, for
example, Medicaid patients are hospitalized more than twice as often as persons
insured by the Blue Shield program. Analyses and comparisons enabled by
enrollment, utilization, and expenditure data will also be used, of course, to
improve our planning for hospitals, nursing homes, and home care services.
The complexity of planning for the health services mentioned is compounded in
this region by the existence of Whidbey Island Naval Air Station in Island
County and the presence there of a naval hospital. There may be as many as
10,000 people in this region, about 6 percent of the population, eligible for
C.H.A.H.P.U.S. coverage. I really don't know. Things are complicated even
more by the rumored eventual closure, or at least curtailment, of the naval
hospital. Clearly, our planning efforts for the western fringe of this region
are and will be effectively hampered without at least ballpark-level data on
the C.H.A.M.P.U.S. population here. With these thoughts in mind, and with
fears that I already know what your replies will be, I have several questions
for the C.H.A.M.P.U.S. program.
1. Approximately how many people are now eligible for C.H.A.M.P.U.S.
benefits or "enrolled" in the program in the following areas:
Whatcom, Skagit, Island, and San Juan Counties; the four-county
region; the state? How many people were eligible each calendar year
between 1968 and 1973 (same areas)? The easiest way of expressing
eligibility might be "persons eligible per month."
ATTACHMENT 18
132
2. For the same areas and calendar years in question 1, what were the
hospital and nursing home admission or discharge rates (admissions
or discharges per 1,000 enrollees) for the C.H.A.M.P.U.S. enrollees?
What were the home care utilization rates (home care starts per
1,000 enrollees) for the same areas and years?
3. For the same areas and years in question 1, how much hospital and
nursing home care was provided (days of care per 1,000 enrollees) ?
How much home care was provided (either visits per 1,000 enrollees
or days of home care per 1,000 enrollees) ?
4. For the same areas and years in question 1, how much money did the
C.H.A.M.P.U.S. program spend on hospital care? Nursing home care?
Home care? How much money did the program spend for physician
services? Dental services? How much money did the program spend
for all types of medical care for the areas and years in question 1?
5. Are figures on costs and utilization based on place of residence of
the enrollee regardless of the geographic site of care or on
geographic site of care regardless of place of residence of the
enrollee?
The enrollment, utilization, and expenditure data I have requested are
readily available for the state's federally-supported Medicaid program. The
data are also available, to a lesser extent, for the Medicare program. I
point out this federal insurance program data availability because I wish
to prevent the impression that the C.H.A.M.P.U.S. program is being singled
out for unreasonable requests. If it's any consolation, the Indian Health
Service is being asked the same questions.
Finally, I'd like to point out that this agency was established under Public
Law 89-749 and currently receives over $70,000 in federal funds annually to
conduct health planning activities. Please contact me if the data requests
are at all unclear.
Sincerely,
Robert M. Eastman, M.P.H.
Assistant Director
RME/cjs
133
ATTACHMENT 18
DEPARTMENT OF DEFENSE
OFFICE FOR THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES
DENVER, COLORADO 80240
J
14 June 1974
CIVILIAN PROGRAM FOR:
ARMY
IN REPLY REFER TO:
NAVY
CH.02
MARINE CORPS
AIR FORCE
COAST GUARD
U.S. PUBLIC HEALTH SERVICE
N.O. A. A.
Robert M. Eastman, M.P.H.
Assistant Director
Comprehensive Health Planning Council
102 South Baker Street
Mount Vernon, WA 98273
Dear Mr. Eastman:
Thank you for your very interesting and clearly written correspondence
of May 31, 1974. I readily appreciate what you are attempting to do,
and fully understand its implications. Unfortunately, I am afraid I will
have to confirm your fears by stating that no demographic statistics
are available for the CHAMPUS population. While this may seem incompre-
hensible to you (as it was to me), let me assure you that multiple people
have encouraged the development of such statistics, but with no success
to date. However, there is a very good chance that such data will be
available within the next couple of years. Unfortunately, that would be
a little late for your needs.
Inasmuch as the demographic data is unavailable, any of the "per thousand
enrollees" questions which you addressed are at this time unable to be
answered. Question four could be answered; however, it would require a
computer run, and such computer runs must be requested from the Assistant
Secretary of Defense (H&E), The Pentagon, Washington, D.C. Regarding
question five, what data is available is based on the cost and utilization
of care reported by the Fiscal Administrator or Hospital Contractor located
in the sponsor's geographic area. In other words, the sponsor's residence
is the geographic area where cost and utilization rates are based.
I am sorry I cannot help you more at this time. I strongly support the
work that Comprehensive Health Planning Councils are doing across the country,
and have numerous friends in the various CHP agencies.
One last thought. It has been my experience through the research I have
been conducting here, that the cost for acute medical and surgical services
are within the usual and customary in a given state. While I do not have
the utilization figures, I can assure you that if the State of Washington
is looked at out of the top ten diagnoses, five of them will encompass
psychiatric diagnoses. Might I also suggest that you contact the CHAMPUS
office at Washington Physicians' Service inasmuch as the individuals there
have a good understanding of costs for various services in the various
134
ATTACHMENT 18
CH.02
Robert M. Eastman, M.P.H.
geographical areas in Washington. In addition, you might be able to get
ballpark figures on how many claims come out of that area without going
through the Department of Defense.
Best regards,
Jol JOHN G. MEYER, M.D., M.P.H.
LCDR,
MC,
USN
Assistant to Medical Advisor
3:2013 JBSV
IDA3
CX
T808
CA
MAWBEN OR LO CIAIFIVM позытуга LES I'000
3:000
2
Directorate of Management Servicos
3 July 1974
NUMBER OF ADMISSIONS TO CIVILIAN HOSPITALS PER 1,000
POTENTIAL CHAMPUS BENEFICIARIES
CY 1968 THROUGH CY 1973
Dependents of Active Duty Personnel
CY 68
CY 69
CY 70
CY 71
CY 72
CY 73
Total Beneficiaries
3,719,000
3,573,000
3,462,000
3,415,000
2,996,000
3,136,000
Total Admissions
262,400
281,816
276,230
273,821
255,121
244,058
ATTACHMENT 18
No. Adm Per 1,000 Benef.
70.6
78,9
79.8
80.2
85.2
77.8
Retired Personnel
CY 68
CY 69
CY 70
CY 71
CY 72
CY 73
Total Beneficiaries
668,000
736,000
800,000
859,000
929,000
977,000
Total Admissions
16,700
21,951
27,825
36,230
43,657
48,404
No. Adm Per 1,000 Benef.
25.0
29.8
34.8
42.2
47.0
49.5
Dependents of Retired or Deceased Personnel
CY 68
CY 69
CY 70
CY 71
CY 72
CY 73
Total Bencficiaries
1,163,000
1,325,000
1,476,000
1,608,000
1,953,000
2,062,000
Total Admissions
55,200
71,731
87,407
108,638
126,764
137,948
No. Adm Per 1,000 Benef.
47.5
54.1
59.2
67.6
64.9
66.9
135
Total - All Eligible Beneficiaries
CY 68
CY 69
CY 70
CY 71
CY 72
CY 73
Total Beneficiaries
5,550,000
5,634,000
5,738,000
5,882,000
5,878,000
6,175,000
Total Admissions
334,300
375,498
391,462
418,689
425,542
430,410
No. Adm Per 1,000 Benef,
60.2
66.6
68.2
71.2
72.4
69.7
NOTE: Total beneficiaries shown for Dependents of Active Duty Personnel represent an
estimate of the number residing in the United States, Canada, Mexico and Puerto Rico.
Total beneficiaries shown for Retirees and Dependents of Retired or Deceased Personnel
represent estimates of the number of beneficiaries worldwide.
Total admissions represent admissions under CHAMPUS in the United States, Puerto Rico,
Canada and Mexico. Due to the lag in the submission of claims, total admissions shown
for CY 1973 are estimated to be approximately 96% complete.
Directorate or Management Services
3 July 1974
ESTIMATED NUMBER OF POTENTIAL CHAMPUS BENEFICIARIES.
CY 1968 THROUGH CY 1973
Category of
Beneficiary
CY 1968
CY 1969
CY 1970
CY 1971
CY 1972
CY 1973
Dependents of
Active Duty Personnel
3,719,000
3,573,000
3,462,000
3,415,000
2,996,000
3,136,000
Retired Personnel
668,000
736,000
800,000
859,000
929,000
977,000
Dependents of Retired
or Deceased Personnel
1,163,000
1,325,000
1,476,000
1,608,000
1,953,000
2,062,000
TOTAL - ALL
Categories of
5,550,000
5,634,000
5,738,000
5,882,000
5,878,000
6,175,000
Beneficiaries
136
NOTE: Dependents of Active Duty Personnel include only those dependents residing in
the United States, Canada, Mexico, and Puerto Rico. Source for this data was
Directorate of Information Operations, OSD, Report P14, as of 31 March for
each year.
Retired Personnel and Dependents of Retired or Deceased Personnel include
beneficiaries residing Worldwide since there are no data available which
show the number of these beneficiaries who reside only in the United States,
Canada, Mexico or Puerto Rico. Totals shown are based on estimates provided
by each uniformed service in its annual budget estimate.
ATTACHMENT 18
ATTACHMENT 18
137
ASSISTANT SECRETARY OF DEFENSE
WASHINGTON. D.C. 20301
HEALTH AND
ENVIRONMENT
17
JUL
1974
Honorable F. Edward Hebert
Chairman, Committee on Armed Services
House of Representatives
Washington, D.C. 20515
Dear Mr. Chairman:
This is in further reply to your letter of June 11, 1974 enclosing
correspondence from Mr. Robert M. Eastman, Assistant Director of the
Comprehensive Health Planning Council, Mount Vernon, Washington.
The ability to answer Mr. Eastman's questions is greatly hampered by
the nonavailability of demographic statistics on CHAMPUS beneficiaries.
Enclosed is a table which gives the estimated number of potential
CHAMPUS beneficiaries. These same individuals are eligible to use
military medical facilities as well. Therefore, while we have in-
cluded a chart which shows the number of admissions and hospital days/
thousand potential CHAMPUS beneficiaries, these numbers represent the
demand seen by CHAMPUS only, and are not a reflection of the demand
these people place on the total Department of Defense Health System.
The per thousand potential CHAMPUS beneficiary figure would vary
greatly if broken out by geographical area, and would depend to a
great extent on the availability of military facilities.
The CHAMPUS Data System records only inpatient care and does not isolate
nursing home care from hospital care. Home care is likewise not isolated.
The number of admissions and hospital days/thousand potential CHAMPUS
beneficiaries in the hospital setting are the only data we can present
in answering questions two and three of Mr. Eastman's letter at present.
The Total CHAMPUS Program Cost chart was prepared within the constraints
listed in the prior two paragraphs. An additional note regarding the
costs under professional services. These figures represent all pro-
fessional services (psychologists, speech therapists, physical thera-
pists, etc.) and not just physician (M.D. and D.O.) services.
I trust that this information will be helpful in replying to Mr. Eastman.
Sincerely,
Vernon McKenzie
Deputy Assistant Secretary of Defense
(Health Resources & Programs)
Enclosures
Directorate of Management Services
3 July 1974
TOTAL CHAMPUS PROGRAM COSTS*
CY 1968 THROUGH CY 1973
(Government Cost Only)
CALENDAR YEAR
Type of
Service
1968
1969
1970
1971
1972
1973
Hospital Services
$110,383,568
$142,347,736
$170,507,574
$202,841,161
$227,174,625
$242,259,035
Professional Services
Inpatient & Outpatient)
$ 70,895,348
$ 89,367,428
$105,565,607
$126,224,680
$141,823,539
$152,767,512
Excluding Dental
Dental Professional Services
(Inpatient & Outpatient)
$ 220,784
$ 440,748
$ 734,812
$ 1,728,107
$ 4,372,608
$ 5,289,807
Excluding Dental Handicapped
Outpatient
Prescription Drugs
$ 1,263,923
$ 2,605,245
$ 3,057,840
$ 3,927,547
$ 5,090,445
$ 5,898,581
138
Program for Handicapped
(Includes Physically
Handicapped, Mentally
$ 4,426,502
$ 8,654,929
$ 12,434,391
$ 20,983,980
$ 29,249,067
$ 23,437,655
Retarded and Dental
Handicapped)
TOTAL
$187,190,125
$243,416,086
$292,300,224
$355,705,475
$407,710,284
$429,652,590
* Excludes Administrative Costs. Based on all claims processed through 31 May 1974.
Total costs for CY 1973 are estimated to be approximately 96% complete.
ATTACHMENT 18
Directorate of Management Services
3 July 1974
NUMBER OF HOSPITAL DAYS IN CIVILIAN
HOSPITALS PER 1,000 POTENTIAL CHAMPUS BENEFICIARIES
CY 1968 THROUGH CY 1973
Dependents of Active Duty Personnel
CY 68
CY 69
CY 70
CY 71.
CY 72
CY 73
Total Beneficiaries
3,719,000
3,573,000
3,462,000
3,415,000
2,996,000
3,136,000
Total Hospital Days
1,633,958
1,819,952
1,855,966
1,886,550
1,909,388
1,828,466
No. Days Per 1,000 Benef.
439.4
509.4
536.1
552.4
637.3
583.1
Retired Personnel
CY 68
CY 69
CY 70
CY 71
CY 72
CY 73
Total Beneficlaries
668,000
736,000
800,000
859,000
929,000
977,000
Total Hospital Days
166,351
215,630
276,803
337,999
393,147
414,617
No. Days Per 1,000 Benef.
249.0
293.0
346.0
393.5
423.2
424.4
Dependents of Retired or Deceased Personnel
CY 68
CY 69
CY 70
CY 71
CY 72
CY 73
Total Beneficiaries
1,163,000
1,325,000
1,476,000
1,608,000
1,953,000
2,062,000
Total Hospital Days
548,528
762,349
937,319
1,199,145
1,455,151
1,500,311
No. Days Per 1,000 Benef.
471.6
575.4
635.0
745.7
745.1
727.6
139
Total - All Eligible Beneficiaries
CY 68
CY 69
CY 70
CY 71
CY 72
CY 73
Total Beneficiaries
5,550,000
5,634,000
5,738,000
5,882,000
5,878,000
6,175,000
Total Hospital Days
2,348,837
2,797,931
3,070,088
3,423,694
3,757,686
3,743,394
No. Days Per 1,000 Benef.
423.2
496.6
535.0
582.1
639.3
606.2
NOTE: Total beneficiaries shown for Dependents of Active Duty Personnel represent an
estimate of the number residing in the United States, Canada, Mexico and Puerto Rico.
Total beneficiaries shown for Retirees and Dependents of Retired or Deceased Personnel
represent estimates of the number of beneficiarics worldwide.
Total Hospital Days represent days under CHAMPUS in the United States, Puerto Rico,
Canada and Mexico. Due to the lag in the submission of claims, total hospital days
for CY 1973 are estimated to be approximately 96% complete.
ATTACHMENT 18
ATTACHMENT 19
140
WASHINGTON PHYSICIANS SERVICE
SPONSORED BY THE WASHINGTON STATE MEDICAL ASSOCIATION
220 WEST HARRISON
SEATTLE WASHINGTON 98119
261 3422 AREA CODE 200
COMPONENT COUNTY
MEDICAL BUREAUS
Benton Franklin Counties
Medic Service Division
of Medir Service Corp
of Spokane County
Kennewick
Chelan County
Medic Service Corp
Wereat bee
Clailam County
Physicians Service inc
Port Angeles
Clark County
Physicians Service Inc
Vancouver
To CHAMPUS and CHAMPVA Beneficiaries:
Commition Basin
Physic ... Service Corp
Moses Lake
Conside County
Media Service Corp
congriew
As the Fiscal Administrator for the State of Washington we wish to
Grays Harbor County
Medio Service Corp
serve the members of the CHAMPUS and CHAMPVA programs
Approped
Jetterson Countr
efficiently and expediently. In order to do this we will need your
Medical Service Bureau
Port Townsend
utmost cooperation. The following information will serve that
King County Medical
Blue Shield
Seattle
purpose.
Kitsap Physicians
Service
Bremerton
Kittitas County
Medical Service Corp
Very truly yours,
Ellensburg
Lews County
Medic Service Corp
Chehalis
County
WASHINGTON PHYSICIANS SERVICE
Medical Service Division
of Medical Service Corp
of Spokine County
Spokane
Pacific County
Medica Service Corp
Raymond
Pierce County
Medica Bureau Inc
Tacoma
Skagit County
Medic Bureau
Mount Vernon
Snohemish County
Physicians Corp
Everett
Medical Service Corp
of S: skane County
Spokane
Therston County
Medical Bureau
Olympia
Walla Walla Valley
Media at Service Corp
Walla Walla
Whatcum County
Physicians Service
Bellingham
Yakima Medical
Service Association
Yakima
Claims for services and supplies provided after January 1. 1974 must
be filed by the last day of the calendar year following the calendar
year in which the services and supplies were provided. EXAMPLE:
Services provided in January, 1974. must be submitted no later than
December 31, 1975. Claims for services and supplies provided before
January 1, 1974 will be processed according to past policies and
regulations.
141
ATTACHMENT 19
TABLE OF CONTENTS
Where to Submit Claims
1
Who is eligible for CHAMPUS
2
Who is eligible for CHAMPVA
3
Eligibility Determination
3
Authorized Providers of Care (CHAMPUS-CHAMPVA)
4
Authorized Benefits
4
Benefits Not Authorized
5
How to Obtain Care under CHAMPUS or CHAMPVA
5
What is Inpatient and Outpatient Care
6
Examples of Emergency Room Charges
6
The Deductible
7
Psychotherapeutic/Psychiatric Care
8
Cost Share - Active Duty
8
Cost Share - Retired or CHAMPVA
8
Certification
9
Medicare - Disability
10
Insurance Supplement to CHAMPUS
10
Dental
11
Dental Care for the Handicapped
13
Handicapped Programs
16
How to Complete DA 1863-2 Form-Direct Payment (CHAMPUS)
17
How to Complete DA 1863-2 Form-Reimbursement
19
How to Complete DA 1863-2 Form-Direct &
Reimbursement (CHAMPVA)
20
How to Complete DA 1863-4 Form for Direct Drug Payment
(CHAMPUS or CHAMPVA)
21
How to Submit Prescription Reimbursement
(CHAMPUS or CHAMPVA)
22
ATTACHMENT 19
142
Washington Physicians Service is the CHAMPUS and CHAMPVA fiscal admin-
istrator for the State of Washington; however, because of the volume of
claims and in order to continually improve the relationship between providers
of care, beneficiaries and CHAMPUS, we are sub-contracting to three addi-
tional medical bureaus, bringing the total to six. In most instances the divi-
sion is geographical which allows for closer contact between the afore-
mentioned three parties. This change in procedure is effective January 1,
1975. If your health services are provided in:
KING or YAKIMA COUNTIES - claims should be submitted to:
King County Medical Blue Shield
1800 Terry Avenue, Seattle, Washington 98101
464-3773
Attn: CHAMPUS Department, Telephone Number: (206) 624-4171
PIERCE, THURSTON, GRAYS HARBOR or LEWIS COUNTIES - claims
should be submitted to:
Pierce County Medical Bureau
1114 Broadway, Tacoma, Washington 98402
Attn: CHAMPUS Department, Telephone Number: (206) 627-7121
SPOKANE COUNTY (including Benton, Franklin, Okanogan, Ferry, Lincoln,
Pend Oreille, Whitman, Stevens, Asotin and Garfield), CHELAN and DOUG-
LAS COUNTIES, COLUMBIA BASIN (including Grant and Adams), KITTI-
TAS COUNTY and WALLA WALLA - claims should be submitted to:
Medical Service Corporation of Spokane County
Terminal Annex Box 3048, Spokane, Washington 99220
Attn: CHAMPUS Department, Telephone Number: (509) 455-5400
CLARK, COWLITZ and PACIFIC COUNTIES claims should be submitted to:
Clark County Physicians Service
3305 Main, Vancouver, Washington 99663
Attn: CHAMPUS Department, Telephone Number: (206) 693-2526
*KITSAP, MASON, CLALLAM and JEFFERSON COUNTIES - claims should
be submitted to:
Kitsap Physicians Service
820 Pacific, Bremerton, Washington 98310
Attn: CHAMPUS Department, Telephone Number: (206) 377-5576
SNOHOMISH, SKAGIT and WHATCOM COUNTIES - claims should be sub-
mitted to:
Snohomish County Physicians Corporation
2520 Colby Avenue, Everett, Washington 98201
Attn: CHAMPUS Department, Telephone Number: (206) 259-8181
New Claims processing locations
The Civilian Health and Medical Program of the Uniformed Services. better
known as CHAMPUS, applies to all of the United States Uniformed Services;
The Army, Navy, Air Force, Marine Corps, Coast Guard, Commissioned
Corps of the United States Public Health Service. and the Commissioned
Corps of the National Oceanic and Atmospheric Administration.
WHO IS ELIGIBLE FOR CHAMPUS?
1. The spouse and children of active duty members, as long as the member
is on active duty for a period of 30 or more.
NOTE: Dependents residing with their sponsor are required to obtain
INPATIENT treatment in military facilities when such facilities
are within 30 miles from their residence and are capable of
providing the needed care, except:
143
ATTACHMENT 19
A. When care is not available from the military facility and a
Statement of Non-Availability (DD Form 1251) is issued by
the military.
B. In an emergency, when certified as such by the attending
physician.
C. When the status of the dependent is changed from "residing
apart from sponsor" to "residing with sponsor" while he is
hospitalized in a civilian facility; or while a spouse is
obtaining maternity care and does not desire to change
physicians.
D. During a period of absence from the area of the sponsor's
household.
2. Retired members who are entitled to retired¹, retainer, or equivalent2
pay and their spouse and children.
NOTE: The retirees and/or spouse lose eligibility for CHAMPUS upon
reaching age 65 if they become eligible for hospital insurance
benefits (Part A) under the Social Security Medicare Program.*
They are still eligible for care in military facilities, however.
3. The unremarried widow and children of deceased members who, at the
time of sponsor's death, were active duty or retired members.
NOTE: The beneficiary's eligibility is terminated on the 65th birthday
if he becomes eligible for hospital insurance benefits (Part A)
under the Social Security Medicare program.* They are still
eligible for care in military facilities, however.
4. The spouse and children of North Atlantic Treaty Organization Military
Personnel who are on duty in, or traveling in, the United States in
connection with official orders.
NOTE: Parents and parents-in-law are not eligible for care in Civilian
facilities under the CHAMPUS.
5. Eligible dependents of active duty, retired, and deceased personnel are:
A. Wife
B. Unremarried widow
C. Husband, if dependent on service wife for more than one-half of his
support.
D. Unremarried widower, if he was dependent on service wife at the
time of her death for more than one-half of his support because of a
mental or physical incapacity.
E. Unmarried legitimate child, including an adopted child or stepchild,
in one of the following categories:
(1) Under 21 years of age, regardless of whether or not dependent
on the active duty or retired member.
(2) Twenty-one or over, but incapable of self-support because of a
mental or physical incapacity that existed before the age of 21,
and is (or was at the time of the member's death) dependent on
the member for more than one-half of his support.
(3) Under 23, enrolled in a full-time course of study in an approved
institution of higher learning, and is (or was at the time of the
member's death) dependent on the member for more than
one-half of his support.
1
"Retired pay" is pay from a uniformed service which the member was
entitled to at the time of retirement.
2
"Equivalent pay" is pay which the member elects to receive from. the
Veterans Administration in lieu of retired pay from the uniformed
service concerned at the time of retirement.
If not entitled to Part A (hospital portion) of Medicare, a copy of the
disallowance letter from Social Security must be submitted with the first
claim to CHAMPUS.
ATTACHMENT 19
144
F. Unmarried illegitimate child or illegitimate stepchild who is, or was
at the time of death of the active duty or retired member, dependent
on the member for more than one-half of his support; residing in the
member's household or in a dwelling place provided or maintained
by the member and -
(1) Under 21 years of age.
(2) and (3) - same as #2 and #3 listed for unmarried legitimate
child.
WHO IS ELIGIBLE FOR CHAMPVA?
The effective date for CHAMPVA is September 1, 1973.
Section 613 of the Veteran's Health Care Expansion Act of 1973 (PL93-82)
authorizes a CHAMPUS-like program for the spouse or child of a veteran
with a total permanent service-connected disability or the surviving spouse
or child of a veteran who dies from a service-connected disability. People
entitled to CHAMPUS benefits are excluded.
ELIGIBILITY DETERMINATION
Eligibility determination is the responsibility of the VA. Prospective benefici-
aries will make application to the nearest VA hospital or clinic for their ID.
card. A list of VA issuing stations is provided.
Washington
American Lake, Tacoma 98403
Seattle 98108 (4435 Beacon Ave., South)
Spokane 99208 (North 4815 Assembly St.)
Vancouver 98661
Walla Walla 99362 (77 Wainwright Drive)
1. The issuing station S number will appear on the ID card to identify the
"home station" where that beneficiary S case file will be kept. Once
eligibility has been determined and an appropriate VA identification
issued. these beneficiaries have complete freedom of choice in electing
their civilian health care providers. CHAMPUS non-availability statement
requirements do not apply to CHAMPVA beneficiaries.
The ID cards. when available, are the authority for providers to deliver
authorized services to these beneficiaries and bill for their services
through the CHAMPUS system using CHAMPUS contractor and
CHAMPUS deductible and cost sharing formulas. CHAMPVA bene-
ficiaries may pay for their care and seek reimbursement from fiscal ad-
ministrators and hopsital contractors.
2. CHAMPVA beneficiaries eligible for Part A Medicare at age 65 lose their
entitlement to CHAMPVA the same as CHAMPUS people. The
CHAMPUS relationship with Medicare, Medicaid, and FEHBP benefits
apply to CHAMPVA.
AUTHORIZED PROVIDERS OF CARE (CHAMPUS-CHAMPVA)
1. Doctors of medicine and osteopathy.
2. Doctors of dental surgery and dental medicine.
3. Optometrists, psychologists, podiatrists and pharmacists.
4. Specialists in sciences allied to the practice of medicine when ordered by
a physician. Such specialists include physical therapists, audiologists,
speech therapists, social workers, (MSW), pastoral counselors, consultants
and similar personnel.
5. Private duty nurses when ordered by a physician. (Check with fiscal
agent.)
6. Christian Science practitioners and nurses.
7. Civilian Hospitals.
8. Extended care facilities.
9. Ambulatory Surgical Centers.
10. Equipment rental agencies.
11. Medical and Surgical Supply Houses.
12. Civilian pharmacies.
145
ATTACHMENT 19
AUTHORIZED BENEFITS UNDER THE BASIC PROGRAM
Authorized benefits under CHAMPUS or CHAMPVA generally include medi-
cal care and surgical treatment including maternity, nervous, mental and
emotional disorders: chronic conditions; and contagious diseases. As a rule,
care which is furnished on either an inpatient or outpatient basis which is
generally accepted as good medical practice will be authorized as a
CHAMPUS or CHAMPVA benefit - except for certain benefits specifically
excluded by law. Benefits may not ordinarily be provided, however, in facili-
ties which discriminate on the basis of race, color or national origin. The
following are au thorized:
1. Professional services of all eligible practitioners providing authorized
treatment necessary to treat the patient's condition.
2. Semi-private hospital accommodation and all necessary services and
supplies furnished by the hospital. The charge for a private room is
allowable only when medically indicated, or when it is the only kind of
room available.
3. Drugs obtainable only by prescription and insulin.
4. Ambulance service when medically indicated.
5. Rental of durable equipment such as wheel chairs, respirators and
hospital beds. (These are not to be purchased under the basic program.)
6. Diagnostic examinations.
7. Dental care required as a direct result of injury or secondary to the
treatment of another medical or surgical condition or its aftermath.
8. Anesthetics and oxygen.
9. Blood transfusions, including the cost of blood and blood plasma, except
when donated or replaced.
10. Radiation therapy and physical therapy.
11. Orthopedic braces (except orthopedic shoes) and crutches.
12. Artificial limbs and eyes.
13. Immunizations when required as part of medical treatment. (Not routine
flu, DPT shots, etc.)
14. Family planning services including marital counseling (medically neces-
sary-referred by M.D.), vasectomies, tubaligations, and abortions if
legal in the state where you reside.
15. Home calls when medically indicated.
BENEFITS NOT AUTHORIZED (CHAMPUS-CHAMPVA)
-1. Routine physical examination and immunizations (except when required
because of overseas orders).
2. Outpatient routine well-baby care.
3. Routine eye examinations or glasses.
4. Prosthetic devices other than artificial limbs and eyes.
5. Routine dental care.
6. Domicillary or custodial care.
7. Chiropractic treatment.
8. Acupunture.
9. Human Chorionic Gonadotropin (HCG) injections.
HOW DOES ONE OBTAIN CARE UNDER CHAMPUS OR CHAMPVA?
CHAMPUS or CHAMPVA IS A voluntary program. The patient and the pro-
vider of care enter into a private contract. The contract states that the pro-
vider of care will perform a service and the patient will provide payment for
that service.
Under CHAMPUS or CHAMPVA the patient is responsible for finding a pro-
vider of care who participates in the program. A participating provider of care
agrees that in addition to the cost share* (20%/25% plus deductible, if
* Cost share later defined.
Deductible later defined.
ATTACHMENT 19
146
applicable) the provider will accept the usual, customary, and prevailing fee as
full payment for his services. Thus. when the provider signs the certification
(Block 20 of Form 1863-2) and receives an amount allowable which is less
than the charges he submitted, the patient has no moral obligation to pay the
difference. However, should the provider bill the patient for the difference,
the patient should furnish a copy of the additional billing to the fiscal agent
so that the agent can remind the provider of care of his agreement. If the
provider of care does not participate, the patient may still go to the non-
participating provider of care. but the patient or sponsor is responsible for
any difference between the provider's charges and the amount allowed by
CHAMPUS or CHAMPVA as a reimbursement to the beneficiary.
WHAT IS INPATIENT CARE AND OUTPATIENT CARE?
A. Inpatient care is treatment in a medical facility with formal admission to
the institution or to a bed in the institution. The 30-120 day inpatient
ruling no longer applies for any services after August 1, 1974. The care is
either inpatient (care provided on date of admission until date of dis-
charge) or the services are outpatient. At this time the two exceptions are
maternity and certain emergency room services.
B. Outpatient care is medical services performed by a provider of care which
do not involve admittance to a bed in a hospital and is not related to
hospitalization. Outpatient care is subject to the applicable deductible
and 20% or 25% cost share. Drugs obtained in civilian pharmacies are
always considered outpatient.
C. Emergency room treatment may be considered outpatient or inpatient
care depending on the following: The claim can be paid as inpatient care
if a surgical procedure is performed and/or if anesthesia is used. If there
is no surgical procedure or no anesthetic, it is considered an outpatient
benefit. This is important to remember since emergency room charges are
paid in whatever way is most advantageous to the beneficiary. For
example, if we pay a claim as inpatient care and the sponsor is active
duty, the beneficiary would be responsible for up to $25.00 of the
emergency room charge. The physician and other providers of care would
be paid at 100% of allowable charges for services provided in the emer-
gency room or related care on that date only. Follow-up care is out-
patient. In this case the beneficiary could not use the money paid to the
hospital as part of the outpatient deductible. Consequently, you as the
beneficiary must help us decide whether you want the charges to be paid
on an inpatient or outpatient basis. Retired personnel would pay 25% of
all related claims for services provided in the emergency room or related
care on that date only. Follow-up care is outpatient,
NOTE: Exception: Maternity care and treatment for conditions related to or
caused by the pregnancy are considered inpatient throughout the
entire pregnancy.
Emergency room charges could be paid either inpatient or outpatient if no
formal admission occurs. The following examples show how a claim
submitted for the dependent of an active duty serviceman could be
processed:
ACTIVE DUTY
Inpatient:
Total charges submitted
$65.00 - Emergency Room & Supplies
Inpatient Admission
Responsibility
-25.00 - Patient Pays
Total Payable
$40.00 - CHAMPUS Pays
Outpatient: (No deductible satisfied)
Total charges submitted
$65.00 - Emergency Room & Supplies
Deductible
-50.00 - Deductible
Co-Insurance
- 3.00 - Co-insurance -- 20%
Total Payable
$12.00 -- CHAMPUS Pays
147
ATTACHMENT 19
Outpatient: (Deductible met)
Total charges submitted
$65.00 - Emergency Room & Supplies
Co-Insurance
- 13.00 - Co-insurance -- 20%
Total Payable
$52.00 - CHAMPUS Pays
The following examples show how it could be processed for retired personnel
and dependents, eligible unremarried widows and dependents, and
CHAMPVA dependents.
Inpatient or Outpatient if deductible has been satisfied:
Total charges submitted
$65.00 - Emergency Room & Supplies
Co-Insurance
-16.25 - Co-insurance -- 25%
Total Payable
$48.75 - CHAMPUS Pays
Outpatient - No Deductible satisfied
Total charges submitted
$65.00 - Emergency Room & Supplies
Deductible
-50.00 - Deductible
Co-Insurance
- 3.75 - Co-insurance --- 25%
Total Payable
$11.25 - CHAMPUS Pays
HOW DOES THE BENEFICIARY ESTABLISH THE DEDUCTIBLE?
In the past, as the CHAMPUS Administrator for Washington, we have pro-
cessed claims toward the OUTPATIENT DEDUCTIBLE even though the
claims submitted did not total $50.00 on one person or $100.00 per family.
This policy has changed as of April 1, 1974. Any outpatient claims submitted
which are to establish the deductible must total $50.00 or more on one
person, or collectively, $100.00 per family. The maximum deductible taken
for one person is $50.00 per fiscal year.
Claims are being returned because the outpatient deductible has not been
established for the fiscal year. Providers of care who do not come into direct
contact with the patient and are therefore, unaware of the deductible status
may still submit their claims. However, if the deductible has not been met,
the claim will be returned and it will be the beneficiary's responsibility to pay
the charges.
The deductible applies only to the outpatient program. The beneficiary is
responsible for satisfying the deductible each fiscal year (July 1 to June 30),
that fiscal year. He pays the provider of
care for the authorized services he receives and obtains an itemized statement.
An itemized statement includes the patient's name, each date of care. the
amount charged, and the type of care, [i.e., office call or lab work] and
diagnosis (a complaint, symptom or reason for care). Itemizations from out
of state providers may also be used toward establishing the deductible.
As soon as the beneficiary accumulates itemized statements and/or drugs*
which total $50.00 on one person or $100.00 per family, he completes items
1-13 on the claim form (1863-2) for each member of his family who has
received care and submits this form and itemized statements to the Fiscal
Administrator. The Fiscal Administrator then processes the claims and estab-
lishes the deductible for the individual or family. The beneficiary will receive
from the Fiscal Administrator a deductible certificate showing that either the
$50.00 or the $100.00 deductible has been satisfied. The beneficiary should
carry this certificate and show it to all providers of care This tells the pro-
vider of care that the individual or family has established the deductible and
that CHAMPUS will pay 80% of the allowable charges for active duty depen-
dents or 75% for retirees, their dependents, eligible dependents of deceased
personnel and CHAMPVA dependents for the remainder of that fiscal year.
If the charges submitted for establishing the deductible exceed the required
amount, the fiscal administrator will reimburse the beneficiary the appro-
priate amount over the deductible and co-insurance (20% or 25%). Remem-
ber, if any information is missing from the claim, the itemized statement, or
ATTACHMENT 19
148
the drug reimbursement form, payment will bè delayed until the information
is furnished by the sponsor, patient, or provider of care. Children under 10
years use either parent's I.D. card, preferably the mother's. Be sure to use
effective date located in block 15b on the back of the card. Retirees be sure
to give the name, address. group # and effective date of your insurance
through employment. CHAMPUS co-ordinates with group insurance coverage.
List prescription drugs on a drug reimbursement form (198). This allows
you to keep the receipts for your records.
**If the deductible has been established in another state, be sure to send a
copy of the out-of-state deductible certificate with the first claim you submit
in Washington,
PSYCHOTHERAPEUTIC/PSYCHIATRIC CARE
Effective 6 September 1974, the 120 inpatient day and 60 outpatient visits/
days constraints on psychotherapeutic/psychiatrie care under CHAMPUS were
removed and a review system initiated based on medical necessity. Continued
coverage and extent of care after the 120th day/60th visit will be determined
by this review process. Questions should be referred to our office at the
address below as this benefit and its regulations are subject to change.
Washington Physicians Service
220 W. Harrison
Seattle, WA 98119
Area Code (206) 281-3422
COST SHARE - ACTIVE DUTY
A. Inpatient Care
The beneficiary pays the initial $25.00 or $3.70 per day, whichever is
greater, to the hospital. CHAMPUS will pay 100% of the balance of the
allowable charges to authorized providers of care or as a reimbursement
to the beneficiary. There is no deductible requirement for inpatient care.
B. Outpatient Care
There is the deductible of $50.00 for one person or $100.00 per family
each fiscal year, which runs from July 1 to June 30. Once the deductible
has been established, CHAMPUS will pay 80% of the allowable charges
and the beneficiary pays his deductible and 20% directly to the providers
of care - not to the fiscal administrator.
COST SHARE - RETIRED
Retired members, their dependents and dependents of deceased members
who were on active duty or retired at the time of their death and CHAMPVA
dependents:
A. Inpatient Care
The beneficiary is responsible for 25% to all authorized providers of care
and CHAMPUS will pay 75% of the allowable charges to all authorized
providers of care or as reimbursement to the beneficiary.
B. Outpatient Care
The annual deductible of $50.00 on one person or $100.00 per family
each fiscal year (July 1 to June 30) plus a cost share of 25% is to be paid
to the providers of care. CHAMPUS will pay 75% of the allowable
charges to authorized providers of care once the deductible has been
established or as reimbursement to the beneficiary.
CERTIFICATION
Certification (block 13) is to determine whether or not you have other
insurance coverage. If you are retired, the dependent of a retiree, the
unremarried widow of a deceased member who died while on active duty, or
during retirement, or CHAMPVA dependents, the following applies to you:
A. Individual (Personal Health Care Plan)
If you have individual coverage, (insurance not offered by employment)
you should check the first square in block 13 of the certification section
on the 1863:1 and/or 1863-2 form. CHAMPUS pays as the primary
149
ATTACHMENT 19
carrier when you have individual insurance coverage. We do not
coordinate unless the private insurance company will pay only the
provider of care. In this instance CHAMPUS will not duplicate payments
to the providers of care.
B. Insurance through employment
If you have insurance through employment (group coverage), it should
be established whether that plan or CHAMPUS is your primary carrier.*
It is considered group coverage if the employer contributes 10% or more
of the annual premium for coverage provided to the employee and/or his
family. If the employer contributes more than 10% of the premium and
if the insurance contract does not contain an exclusionary clause, your
group coverage is the primary carrier.
Basically, the exclusionary clause means that if you were entitled to
CHAMPUS benefits and had insurance through your employment prior to
October 1, 1966, CHAMPUS is considered the primary carrier (first-pay) and
your group coverage is the secondary carrier (last-pay). However, if you
obtain your insurance through employment or operation of law after October
1, 1966, the exclusionary clause no longer applies and your group coverage is
the primary carrier and CHAMPUS is the secondary carrier. This October 1,
1966, rule does not apply in the case of retirees, their dependents and
dependents of deceased personnel enrolled in a health plan under the Federal
Employees Health Benefits Program (FEHBP); in all such instances, such a
plan is "first-pay" and CHAMPUS is "last-pay". The other insurance provi-
sions of CHAMPUS also apply to CHAMPVA beneficiaries except the exclu-
sionary clause effective date is 1 September 1973 instead of 1 October 1966.
If you are in doubt as to which coverage is primary, you should furnish
CHAMPUS with the information requested below in Step 1, and we will assist
you in the determination. Once you have determined that your group plan is
the primary carrier, you should follow these four steps:
1. Furnish the CHAMPUS fiscal agent and/or CHAMPUS hospital contrac-
tor with the name of the insurance company, the address of the
insurance company, the group or policy number, the subscriber's Social
Security number, and if possible, the effective date of the policy or the
date of your employment.
2. Send all claims to the primary carrier first, and not to CHAMPUS.
3. When you receive either worksheets, payments, or disallowances from
your primary carrier, attach them to a completed DA 1863-2 form with
an itemized statement showing dates of service, amount charged and
diagnosis and submit them to our office. If the provider is to be paid
directly, please be sure he has completed Items 14 through 20, indicating
the amount (to be) paid by other insurance, and that he has signed the
claim form. We will then process and pay the balance as the secondary
carrier, if the deductible for outpatient care has been satisfied, and if the
primary plan has paid an amount equal to or greater than the amount
that would normally have to be paid by the beneficiary.
4. The payment procedure is the same for inpatient related charges except
there is no deductible taken, and the hospital room and board charges are
submitted to the hospital contractor (Blue Cross) on the completed
1863-1 form.
Please follow the above steps. It will expedite the processing of your claims.
If these steps are not followed, we will be unable to process your claims
because we lack necessary information.
MEDICARE - DISABILITY (UNDER AGE 65)
You can use either Medicare, CHAMPUS, or CHAMPVA. CHAMPUS and
CHAMPVA suggest that you submit your claims to Medicare first; then, as
with other insurance, submit an 1863-2 form, itemization and the Medicare
explanation of benefits to CHAMPUS: Medicare would become a first payor
and CHAMPUS or CHAMPVA would pay secondary and pay the balance
The primary carrier is the company which receives and processes all.
claims first.
ATTACHMENT 19
150
whenever possible. This offers more coverage than if you sumbit to either
CHAMPUS or CHAMPVA or Medicare.
Insurance Available to Supplement CHAMPUS
As the cost of medical care continues to rise. the 25 per cent share that many
beneficiaries have to pay takes a bigger and bigger chunk out of the family
budget. As a result, numerous organizations are now offering private health
insurance to cover the costs not covered by CHAMPUS.
Although the plans differ in detail, in general they offer similar coverage. As a
rule, the plans pay the 25 per cent that CHAMPUS does not cover for
inpatient and outpatient care. Some of the plans also cover the deductible.
There are, however, certain limitations in comparison with CHAMPUS. The
plans, for example, do not cover any injury or sickness resulting from an act
of war, or treatment for prevention or cure of alcoholism or drug addiction.
They also usually exclude coverage for pre-existing conditions during the
initial months the policy is in effect.
In addition to the CHAMPUS supplement, there are plans to supplement
Medicare coverage for members over 65 and their spouse, plus hospital
income plans which provide a cash income whenever the insured is hospitali-
zed.
Here is a listing of some organizations offering this type of insurance:
ASSOCIATION
ADDRESS
Air Force Sergeants
P.O. Box 9081
Association
Washington, D. C. 20003
Association of the
1529 18th Street, NW
United States Army
Washington, D. C. 20036
Defense Supply
1026 17th Street, NW
Association
Washington, D. C. 20036
Fleet Reserve
1303 New Hampshire Ave., NW
Association
Washington, D. C. 20036
National Association
956 North Monroe Street
for Uniformed Services
Arlington, Virginia 22201
Navy League of the
2100 M Street, NW
United States
Washington, D. C. 20037
Reserve Officers
1 Constitution Avenue, NE
Association of the U.S.
Washington, D. C. 20002
The Retired Officers
1625 Eye Street, NW
Association
Washington, D. C. 20006
North Carolina Blue Cross
P.O. Box 2291
and Blue Shield, Inc.
Durham, North Carolina 27702
Mutual of Omaha Insurance
Joseph E. Jones
Company
1666 Connecticut Avenue
Washington, D. C. 20009
DENTAL
I. GENERAL
A. Dental care under the CHAMPVA or CHAMPUS Basic program is
available on a limited basis to eligible beneficiaries.
II. DENTAL CARE AUTHORIZED UNDER THE CHAMPUS BASIC
PROGRAM
A. Eligibility - All categories of beneficiaries.
B. Dental care authorized.
1. Dental care required as the direct result of an accident.
2. Adjunctive dental care.
For dental care to be determined adjunctive, the patient must
have been under the care of a physician for a medical or surgical
151
ATTACHMENT 19
condition, OTHER THAN DENTAL, where proper treatment
required that the dental care given was necessary for the proper
treatment of that medical or surgical condition or its aftermath.
The primary diagnosis must be specific so that the relationship
between the primary condition and the requirement for dental
care in the treatment of the primary condition is clearly shown.
Treatment intended merely to improve the general health of the
patient is insufficient basis to support payment for dental care
under the CHAMPUS. Claims for adjunctive dental care must be
accompanied by a statement from the patient's physician giving
the medical diagnosis and attesting to the necessity for dental
care in the treatment of the primary medical condition.
3. Certain surgical procedures that come within the scope of the
dentist's license, such as reduction of fractures, removal of cysts
and tumors, the repair of clefts, etc. The surgical removal of
teeth is NOT an authorized program benefit unless said removal
falls under paragraph II B, 1 or 2.
4. Limited orthodontic care.
a. Orthodontics required in connection with the treatment of
a cleft palate.
b. Orthodontics required in connection with the treatment of
Scoliosis (wherein the wearing of a Milwaukee Brace is
required).
c. Orthodontics required following extensive surgery, such as
a bilateral sliding osteotomy of the mandible.
C. The beneficiary is also permitted to obtain a pre-authorization for
dental care, Obtaining a pre-authorization is recommended if it
appears the dental care is a questionable benefit. This will enable
both the beneficiary and the dentist to know whether or not it is an
authorized benefit before the work begins. Dentists should submit
requests for pre-authorization for the Basic Program to Colorado
Dental Service with a description of the work to be performed
accompanying-x-rays and an estimate of the charges.
D. Submission of Claims
1. Claims for authorized dental care provided under the Basic
Program must be submitted on a copy of DA form 1863-2.
Section I of this claim must be completed by the patient (or
sponsor): Section II by the dentist if he wishes direct payment.
If you wish reimbursement for authorized services, the benefici-
ary should complete Section I and attach an itemized statement
which shows the patient's name, dates of care, the exact nature
of the services provided and the cost. You must also submit
documentation verifying the adjunctive nature of the claims or
give the date and type of accident.
Dental claims under the Basic Program should be submitted
directly to:
Colorado Dental Service
1600 Downing Street
Denver, Colorado 80218
ATTN: CHAMPUS Dept.
Inquiries on claims previously submitted should also be directed
to Colorado Dental Service - CHAMPUS Department.
2. Claims for related hospital care should be completed in the same
manner as in D1., on a DA form 1863-1, and submitted directly
to the appropriate hospital contractor in the state where the
services were provided.
3. Claims for care other than the dental care should be submitted
on a copy of DA form 1863-2 directly to the appropriate fiscal
administrator for the state in which the services were provided.
E. Be sure to submit a copy of your deductible certificate with your
dental claim (if you have a certificate) to Colorado Dental Service. If
ATTACHMENT 19
152
your deductible is established by your dental claim, send a copy of
the deductible certificate to the fiscal administrator in the state
where you reside.
F. Exceptions, Outpatient Care
When outpatient care is DIRECTLY RELATED TO THE MEDICAL
CONDITION FOR WHICH A PATIENT IS HOSPITALIZED, it is
considered INPATIENT care in computing the patient's share of
charges in the following instances:
1. Pregnancy. That dental care required during a woman's pregnan-
cy, prescribed by her physician as being necessary to protect the
health of the mother and/or unborn child.
III. DENTAL CARE AUTHORIZED UNDER THE CHAMPUS PROGRAM
FOR THE HANDICAPPED.
A. Eligibility - LIMITED TO DEPENDENTS OF ACTIVE DUTY
MEMBERS ONLY.
B. Termination of Eligibility - A patient's eligibility for treatment
under the Program for the Handicapped ceases as of midnight of the
date of separation, retirement or death of the sponsor.
C. Effective Date of Program - 1 January 1967.
D. Dental Care Authorized --- CHAMPUS is authorized to share in the
cost of treatment of certain ORTHODONTIC conditions under the
CHAMPUS Program for the Handicapped which was established by
Public Law 89-164. Under this program, CHAMPUS may share in
the cost of orthodontic treatment which is needed to correct,
overcome or aid in adjustment to a handicapping condition.
However, the condition must be classified as a SERIOUS physical
handicap.
E. For the purpose of determining the severity of the malocclusion -
CHAMPUS Form 161 (Handicapping Labio-Lingual Deviations) has
been developed for the use of the orthodontist. CHAMPUS Form
161, which may be obtained from the fiscal administrator or the
address indicated below, must be completed by the orthodontist and
forwarded to:
Executive Director
OCHAMPUS
ATTN: MEDDC-D
Denver, Colorado 80240
All authorization for dental care under the Program for the Handi-
capped must go through Colorado Dental Service.
Upon receipt of CHAMPUS Form 161 by OCHAMPUS, the
orthodontist will be informed whether or not the case qualifies as a
serious physical handicapping condition for financial assistance
under the CHAMPUS Program for the Handicapped. If the case does
qualify, the doctor will also be provided with the applicable claim
form (DA Form 1863-3) and instructions for its use.
Only spouses and children of ACTIVE DUTY MEMBERS are eligible
for orthodontic care under the Program for the Handicapped. The
service member pays an initial share of the monthly cost of
orthodontic care according to his pay grade, as set forth below.
CHAMPUS pays the balance of the authorized charges up to a
maximum of $350 per month. A different payment procedure is
used where the orthodontist bills on a quarterly basis. (See Note on
Quarterly Billings.)
153
ATTACHMENT 19
MINIMUM MONTHLY COST
Pay Grade
Amount Per Month
E-1 through E-5
$25
E-6
30
E-7 and 0-1
35
E-8 and 0-2
40
E-9, 0-3, W-1 and W-2
45
W-3, W-4, and 0-4
50
0-5
65
0-6
75
0-7
100
0-8
150
0-9
200
0-10
250
The sponsor of a patient receiving orthodontic care under the Program for the
Handicapped has a monthly liability based on grade as reflected above.
Therefore, if the orthodontist bills a CHAMPUS beneficiary on a monthly
basis, CHAMPUS will generally only make a one-time payment for ortho-
dontic care, during the month in which the initial or banding services are
provided, as the subsequent monthly charges usually fall within the cost-
sharing liability of the sponsor. Payment for care cannot be made prior to the
time care was provided.
When claims for orthodontic care provided under the Program for the Handi-
capped are submitted on DA Form 1863-3, the patient, sponsor or other
responsible family member completes Section I, Items 1 through 11. The
source of care completes Section II, Items 12 through 16, and submits the
completed claim forms to:
Colorado Dental Service
1600 Downing Street
Denver, Colorado 80218
IV. FOR FURTHER INFORMATION CONCERNING DENTAL CARE
UNDER THE CHAMPUS
Inquiries pertaining to dental care under the Civilian Health and Medical
Program of the Uniformed Services should be directed to:
Colorado Dental Service
CHAMPUS Division
1600 Downing Street
Denver, Colorado 80218
Phone: (Area Code 303) 832-1111
NURSING CARE
Before placing an eligible CHAMPUS beneficiary in a nursing home or obtain-
ing a private duty nurse, contact the fiscal agent in your state. This benefit is
provided only under certain conditions and only in nursing homes accredited
by CHAMPUS or Medicare. Be sure to notify the CHAMPUS fiscal agent
before beginning care.
Claims for services and supplies provided after January 1, 1974
must be filed by the last day of the calendar year following
the calendar year in which the services and supplies were pro-
vided. EXAMPLE: Services provided in January, 1974, must
be submitted no later than December 31, 1975. Claims for
services and supplies provided before January 1, 1974 will be
processed according to current policies and regulations.
ATTACHMENT 19
154
HANDICAPPED PROGRAM
The CHAMPUS Program for the Handicapped provides benefits for the wife
and the children of Active Duty Members of the uniformed services and for
the dependents of military personnel of the NATO Nations.
To be eligible for care, the wife or child must
*Have a serious physical handicap
.or,
*Must be moderately or severely mentally retarded.
The authorized benefits include, but are not limited to.
*Diagnosis
*Inpatient Treatment
*Outpatient Treatment
*Home Treatment
*Training and Special Education
*Institutional Care
Dental Care, Including Orthodontics
*Prosthetic Devices
*Orthopedic Appliances
*Special Optical Devices
*Purchase of Durable Equipment
Rental of Durable Equipment
'Drugs and Medicine Obtainable only by Prescription
*Supplies Ordered by the Attending Practitioner
*Transportation
*Professional Services
Benefits are obtained by submission of an Application for Benefits and A
Plan for Management of the Handicapping Condition to:
The Executive Director
OCHAMPUS (Attn: MEDDC-PS)
Denver, CO 80240
who will review the plan and approve the plan. He may also suggest an
alternative method of obtaining the required care under the Basic Program
which would be more beneficial, from a financial standpoint, to the bene-
ficiary or his sponsor.
Retroactive approval may be granted; however, a retroactive approval may
not be granted for services performed prior to 1 January 1967, the effective
date of the entitlement.
If you are active duty and are in need of this type of assistance, please
contact Washington Physician Service.
155
ATTACHMENT 19
HOW TO COMPLETE DA 1863-2 CLAIM FORMS FOR DIRECT
PAYMENT TO SOURCE OF CARE - CHAMPUS Beneficiaries only
a) PATIENT'S PORTION
Submit DA 1863-2 (yellow) claim form completed one through 13
for patient, one for each member of the family. Indicate necessary
identification card numbers; effective and expiration dates for
eligibility. Children under ten may use their mother's or father's
identification card. Children ten years and over are required to have
an identification card of their own. A dependent child is not eligible
after age 21 unless a fulltime student; then they are eligible until
their 23rd birthday. Also indicate the sponsor's Social Security
number, Grade, Status, Branch of Service, Insurance Status if
retired, etc., on all claims. Each form must be signed by the patient,
sponsor, spouse, or guardian.
SECTION by patient family member Blease print of April
PATIENT DATA
DATA
NAME (last, first. middle initial)
NAME of SPONSOR clast. foral middle initial)
) ADDRESS (Include Zip Code)
** NUMBER
.
. SPACE
NUMBER
10 AND OUTY (Home Port for Ships (Address for Retired:
4 PATIENT (Check one)
" SPOUSE
121 DAUGHTER
31504
(4) RETIREE
B IDENTIF CATION CARD IDD Form 1173. DD Form 2 or PHS Form 1866 3) SPONSOR . OR RETIREE BRANCH - SERVICE
TM
CAY
YEAR
EFFECTIVE DATE
ILUSA
21 USAF
VEME
USN
(BLUSCE
(@) USPHS
ESSA
.
(Check one)
APART
SCONSOR
NOOR
FORM 1201 ATTACHED
(3)OUTPATIENT
12 STATUS
(Specify)
DUTY
12) RETIRED
'''
13.
to the best of my knowle Ige and belief the above information in Section is correct To the extent that I have authority
to
reby
auth
lize
the
release
of
medical
recor
is
in
this
case
to
both
the
contractor
and
the
Government
THE
ARED MI MBF R or de pendent of retured or deceased member, certify that to the best of my knowledge and belief. that
propriate box)
(Detete portion 11 parenthests not applicable)
patient is not) enrolled (neither is sponsor) in any other insurance. medical service, or health plan provided by
law
uployment.
(Lam)
enrolled (so is sponsor) in another insurance. medical service. or health plan provided by law or
throws
however the particular benefits claimed on this form are not payable under the other plan
Name
(pr
(Relationship to Patient)
Date
Signature
. TION CARD
JDD F orm 1173. DD / orm 2 or PHS t orm 1800-11
Dependent I.D. Card
ARONO
MONTH
DAY
YEAR
EU13,352A
EFFECTIVE
MAY
26
1960
MAY
25
1976
BASIS
RE
AC
DEPENDENTS ONL (Check One)
Only dependents
RESIDING WITH SPONSOR
(3) OUTPATIENT
00 FORM
of active duty
X
complete Item 6
EU
A
Yes May 60
29 May 70 25 May 76
ATTACHMENT 19
156
b) SOURCE OF CARE PORTION (MD, Ambulance, etc.)
The source of care for CHAMPUS or CHAMPVA must complete 14
through 20 of the DA 1863-2 claim form indicating the diagnosis,
the dates of service, services provided, and the charges, Please indi-
cate in Block 18 (dates) if the care is related to hospitalization.
Block 20 should be signed by the provider of service if direct pay-
ment is to be made.
SECTION = (To be completed by Source of Care)
14 NAME AND ADDRESS OF SOURCE OF CARE (Include Zip Code)
OF
CARE
LOCATION O
PROVIDER
or
SERVICES
CODE
PHYSICIAN
(Specify)
c. PATIENT STATUS
" INPATIENT
DISTRIBUTPATIENT
5 NAME AND TITLE OF INDIVIDUAL ORDERING CANE
16 INCLUSIVE DATES CARE
MONTH
DAY
YEAR
MONTH
YEAR
FROM
TO
17. DIAGNOSIS 11:00 standard nomenciature)
a. INTL STAT COOL
(Check when applicable)
services were necessary for treatment of a bunafide medical emergency
0.12 BREAK CODE
10 RELATED HOSPITALIZATION (If applicable)
FROM
TO
19
ENTER ESTIMATED OR ACTUAL DATE OF DELIVERY - CASES LIST BY DATE SURSICAL OPERATIONS AND/OR CARE FURNISHED INCLUDING
VISITS FOR WHICH SEPARATE CHARGES ARE CLAIMED (Type or print) (Attach additional sheets if required)
DATEIS) OF SERVICE
a. ITEM OR DESCRIPTION OF SERVICE
b CHARGES
c. PROCEDURE CODE
$
d. TOTAL CHARGES THIS STATEMENT FOR CARE AUTHORIZED
$
. IPAID and on IDUE FROM) PATIENT (Cross out one)
$
1. DUE FROM GOVERNMENT TO SOURCE OF CARE
$
#. DUE PATIENT OR SPONSOR. REIMBURSEMENT
S
20 CERTIFICATION BY SOURCE OF CARE
I certify that the services and / or supplies listed hereon were performed or authorized by the attending physician, dentist or other
professional personn. in charge. that payment due from the Government has not been received. and that, except for the amount pay able
by the patient in accordance with the terms of the Civilian Health and Medical Program of the Uniformed Services, the amount paid by
the Government will be accepted as ment in full for the authorized services and or supplies listed hereon
further certify that : am not an intern, resident or otherwise in training status for which am receiving compensation for services
listed on this claim.
Name (print or type)
Title
Date
Signature
The persons signing this form are of bed that the to illful making of a false or fraudulent statement herein
renders them Tuble to prosecu " under Federal Lows
DA FORM JUN 1863-2
REP. ACES DA FORM 1863-2. SEP
Form Approved
(Civilian Sources)
WHICH is CUSCLETE
Comptruller General, U.S., 22 Sep 67
157
ATTACHMENT 19
HOW TO COMPLETE DA 1863-2 CLAIM FORMS FOR REIMBURSE-
MENT
a) PATIENT'S PORTION
A DA 1863-2 claim form should be completed for each member of
the family. Please refer to Section I 'DIRECT PAYMENT-
PATIENT'S PORTION' for further instructions.
b) Submit itemized statements showing the name of the patient, dates
of service, services provided, amount, and the diagnosis and attach to
the DA 1863-2 claim forms. If any of this information is missing,
payment of your claim will be delayed.
THE ABC CLINIC
STATEMENT
OF ACCOUNT
L
John Doe
6 01 172
PATIENT
CLINIC NO
STATEMEN-DATE
****
MENT --
POSES CHANGE ..
Diagnosis: Diabetes
MADE
FOR "
CODES
CERTAIN ISSIONAL ...
AND OTHER CHARGES MAY
Doe, John
NOT D. WILLED UNTIL ***1
BILLTO
CONCLUSION OF TREATMENT
1234 6th St.
ORERAMINATION
Anywhere, Washington
HOSPITAL CHARGE ARE NOT
INCLUDED ... THE STATE
MENT AND - P. MILLED
SEPARATELY
PAYMENTS RECEIVED AFTER STATEMENT DATE
DO NOT APPEAR ON THIS STATEMENT
A
DATE
PHYSICAN/DEPT
Disc ACODE
AMOUNT
5.04.72 1 L.3
URINALYSIS-ROUTINE
2.50
5404-72 1 LEONARD
J
DIAGNOSTIC HISTORY-PHYSICAL
42.00
5-04-72 ) LAB
COMPLETE BLOOD COUNT
7.50
5.04-72 1 1/2
KETO ACID - URINE
1.00
5-04-72 1 LAB
CHEN SCREEN BATTERY
17.50
5.04.72
1
LAB
BLOOD SUGAR
4.50
5-04-72
ICDA 250,
5.08.72
REG OF DIABETES 05-08/05-12
5.06.72 1
14 DIABETIC MEALS
34.00
5-01-72 1
DAILY PHYS VISITS FOR
60.00
5-98-72
LAB
BLOOD SUGAR
4.50
5-10-72 1 LAB
KETO ACID - URINE
1.76
5..10-72 1 LA3
BLOOD SUGAR
4.50
5-10-72 1 LAB
SUGAR BY DIP STICK
N/C
0
PLACE or SERVICE
PLEASE PAY
$
178.00
1 OFFICE
THIS AMOUNT
2 IN HOSPITAL
3 EXT. CARE FACILITY
ATTACHMENT 19
158
CHAMPVA BENEFICIARIES
HOW TO COMPLETE 1-13 OF THE 1863-2 FORM FOR DIRECT
PAYMENT AND REIMBURSEMENT.
If direct payment, beneficiary completes 1-13 of an 1863-2 form and the
source of care completes 14-20 of the form and signs the bottom (exam-
ple, p. 18). If for reimbursement, beneficiary completes 1-13 of 1863-2
form and attaches an itemized statement (example, p. 19). Please read
carefully. Any omission delays payment.
SERVICES AND, OR SUPPLIES PROVIDED BY CIVILIAN SOURCES
SEE
EXCEPT HOSPITALS)
INSTRUCTIONS
CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES CHAMPUS
ON REVERSE
Form of this are the propossent agency is one Surgeon General
SECTION in completes paint or other responsible family member Ress print - (ype)
PATIENT DATA
CE MEMBER DATA
1. NAME ( - made
a DATE OF BIRTH
7. NAME OF SPONSOR will AND haddle indials
3. ADDRESS /Include Zip Code)
8. SERVICE NUMBER
8b SOCIAL SECURITY
9 GRADE
X
ACCOUNT NUMBER
X
10 ORGANIZATION AND DUTY STATION (Nome Part for Shippi (Address for Returnt,
. PATIENT /Check one)
(1) SPOUSE
(2) DAUGHTER
" SON
. IDENTIFICATION CARD CD/M 1173. DD Form or PHS From "
" SPONSORS OR RET BRANCH OF SERVICE
CARD NO.
MONTH
DAY
YEAR
USA
(2) USAF
USMC
(A) USN
EFFECTIVE DATE
EXPIRATION DATE
USCG
(6) USPHS
(7) ESSA
6 CARE ACTIVE DEPENDENTS ONLY
SING SPONSOR
(1)
OUTPATIENT
-
FROM SPONSOR
DECEASED
13. CERTIFICATION
I certify to the best of my knowledge and belief the above information in Section I is correct. To the extent that have authority
to hereby authorise the release of medical records in this cape to both the contractor and the Government
RETIRED MEMBER or dependent of retired or deceased member, certify that to the best of my knowledge and belief. that
(Cheal appropriate box) (Delete portion in parentheris not applicable)
(1 am not) (the patient 10 not) enroded (neither is sponsor) in any other Insurance. medical service, or health plan provided by
law or through employment
(1 am) the patient la) enrolled (#0 is sponsor) in another insurance, medical service. or health plan provided by law or
Grough employment, however the particular benefits claimed on this form are not payable under the other plan.
Name
(print or type)
(Relationship to Patient)
Date
Signature
CHAMPVA claims will be submitted to CHAMPUS contractors on forms
1863-1 (hospital) and 1863-2 (except hospital). The following informa-
tion is required:
Block 1: Patient name.
Block 2: Patient date of birth.
Block 3: Patient address.
Block 4: Check 1, 2, or 3 (4 does not apply, since sponsor is not
eligible).
Block 5: ID data will consist of the ID card number and the effec-
tive and expiration dates shown on the ID card. The ID
card number will be the veteran S VA file number with an
alpha suffix. The suffix will be different for each benefici-
ary of a sponsor.
Block 6: Not applicable.
Block 7: Veteran's name.
Block 8A: Leave blank.
Block 8B: Veteran's VA file number ( omit prefix or suffix). Do not
use any other former service numbers.
Block 9: Not applicable.
Block 10: Show the three-digit number of the VA station that issued
the ID card.
Block 11: Print VA in the Block.
Block 12: Not applicable.
Block 13: Other insurance blocks must be checked (see p. 8-9) and
the claim form signed. The same categories of people may
sign CHAMPVA claims as sign for CHAMPUS. The re-
mainder of each form applies as for CHAMPUS except
the emergency item (Block 33A of 1863-1) is not neces-
sary for CHAMPVA.
GERALD FORD VIBRARY
159
ATTACHMENT 19
HOW TO COMPLETE A DA 1863-4 FORM FOR DIRECT PAYMENT
OF DRUGS TO THE PHARMACIST.
Be sure to show your deductible certificate when requesting service. If
your pharmacy does not have the prescription Billing Forms DA Form
1863-4, they are available from the CHAMPUS Fiscal Administrator.
Pharmacies participating in the CHAMPUS or CHAMPVA Drug Program
will collect 20% or 25% directly from you. They in turn will submit a
claim to the CHAMPUS Fiscal Administrator for the remainder. You are
asked to fill out the top part of the DA Form 1863-4 and the pharmacist
completes the bottom portion and sends to the Fiscal Administrator.
Remember-Only those drugs requiring a prescription by law and Insulin
are covered.
OUTPATIENT
SERVICES
SERVICES
...
.
.
I
the
-
.
"
member
:
(1
sponsor)
plan
by
through
employment
in
!
-
I
and
:
listed
DA FORM -
ATTACHMENT 19
160
HOW TO SUBMIT CHAMPUS OR CHAMPVA CONSOLIDATED
PRESCRIPTION REIMBURSEMENT (FORM 198)
Complete blocks I through 8. Please list your drug charges according to
date of purchase including state tax on the Form 198. You must also
include the strength and quantity of the drug. Be sure to read item
number seven on the Form. Sign back of form.
Keep the drug receipts for your records and send only the completed 198
form. Complete one form for each member of the family and be sure to
sign the back of the claim form. If any information is missing the form
will be returned.
CHAMPUS CONSOLIDATED PRESCRIPTION REIMBURSEMENT
1 PATIENTS NAME & RELATIONSHIP TO SPONSOR
I D CARD #
6
INSURANCE THRO EMPLOY
MENT NO
if YES name and address of Insurance
EFFECTIVE DATE
Company Group #
2 SPONSOR NAME
EXPIRATION DATE
3 SPONSOR'S AND OR PATIENT'S ADDRESS
4 SPONSOR'S SOCIAL SECURITY NUMBER
ACTIVE
RETIRED
DECEASED
5 PATIENTS DIAGNOSIS
ATTENDING PHYSICIANS NAME
PATIENT'S BIRTHDATE
7. CHAMPUS ENEFICIARY
Reimbursement of your prescription claims will he expedited if you will itemize the prescription information from your
pharmacy receipts of statements in order of date filled Complete a 198 form for each eligible family member submitting
drugs. BE St RF THE QUANTITY. NAME AND STRENGTH of the drugs are included. otherwise the form will be returned.
Supporting pharmacy receipts or statements must be retained by you a minimum of twelve months for submission if
requested by the CHAMPUS Fiscal Administrator Be sure to sign back of form.
8 PHARMACY NAME AND ADDRESS
9 DATE
10 PRESCRIPTION
11 NAME ANDSTRENGTH OF DRUG
12. PRESCRIPTION
FILLED
NUMBER
CHARGE
QUANTITY
CHAMPUS FORM 198
(Over, please)
ATTACHMENT 20
161
P.O. Box 39
June 4, 1974
Director
Portland Area Indian Health Services
921 S.W. Washington
Portland, Oregon
Dear Colleague:
This Council is in the process of completing an inventory of hospital and
other health-related facilities prior to the development and publication of
a regional hospital plan by December. Concurrently, we are also developing
plans for nursing homes and home health services, and assembling a health
indicators report.
One section of the health indicators report will deal with medical care
utilization and expenditures. Combined with enrollment figures, the
utilization and expenditure data, when analyzed, will permit identification of
patterns and trends accoss various insured groups. Analyses and comparisons
enabled by enrollment, utilization, and expenditure data will also be used,
of course, to improve our planning for hospitals nursing homes, and home care
services.
The planning for these health services is complicated by the presence of three
Indian tribes (Lummi, Nooksack, Swinomish) in our region eligible for Indian
Health Service benefits. If you could answer any of the questions that
follow, our planning efforts will be improved. The questions refer strictly
to I.H.S. funds.
1. Mr. Marvin Wilbur, administrator of the Lummi Health Center, has
estimated that there are approximately 2,000 Indian people
eligible for Indian Health Service benefits in this region at
the present time. Another 500 Indians are not eligible. Could
you provide similar eligibility estimates for each of the calendar
years 1968 to 1973 for the following areas: Whatcom, Skagit,
Island, San Juan Counties; the four-county region; the state?
Eligibility could be expressed as average number of persons
eligible per month or per year.
2. For the same areas and calendar years in question 1, what were
the hospital and nursing home admission or discharge rates
(admissions or discharges per 1,000 persons eligible) for
Indians eligible for I.H.S. benefits? What were the home care
utilization rates (home care starts per 1,000 enrollees)?
ATTACHMENT 20
162
3: For the same areas and years in question 1, how much hospital
and nursing home care was provided (days of care per 1,000
beneficiaries) How much home care (either visits per 1,000
beneficiaries or days of home care per 1,000 beneficiaries)
4. For the same areas and years in question 1, how much money did
the I.H.S. spend for hospital care? Nursing home care? Home
care? How much money for physician services? Dental services?
How much for all types of medical care?
5. Are figures on costs and utilization based on place of residence
of the beneficiary regardless of the geographic site of care or
on geographic site of care regardless of place of residence of
the beneficiary?
The enrollment, utilization, and expenditure data I have requested are
readily available for the state's federally-supported Medicaid program. The
data are also available, to a lesser extent, for the Medicare program. I point
out this federal insurance data availability because I wish to prevent the
impression that the I.H.S. is being sincled out for unreasonable requests. If
it's any consolation, the C.H.A.M.P.U.S. program is being asked the same
questions.
Please contact me if these data requests are at all unclear.
Sincerely yours,
Robert M. Eastman, M.P.H.
Assistant Director
RME:afj
ATTACHMENT 20
163
Ref: OPP&S
14 June 1974
Robert M. Eastman, M.P.H.
Assistant Director
Comprehensive Health Planning Council
P.O.Box 39
Mount Vernon, Washington 98273
Dear Mr. Eastman:
This is in reply to your letter of the 4th of June. We have
assembled the information you requested insofar as we have
been able to do so.
The Northwest Washington Service Unit (Lummi) has been in
existence as a separate entity only since FY1971 and in many
cases it is quite impossible to separate the information for
that area from other parts of Western Washington. Our own
reporting system has undergone extensive change since its
inception. To retrieve information from 1968 would require,
at this time, more time and manpower than is presently
available and, in addition, we still could not obtain all the
information in the form you desire.
You will appreciate that this retrieval required the diversion
of considerable effort. We hope that the information provided
to you is sufficiently useful as to have warranted the effort.
In addition, we would like to request a copy of your health
indicators report as well as your regional hospital plans when
they are ready.
Very sincerely yours,
C.S.Stitt, Jr., D.D.S.
Director, Portland Area
Indian Health Service
AMBULATORY PATIENT CARE
ATTACHMENT 20
164
F.Y.71 F.Y.72 F. Y. 73 F.
No. of visits to Lummi Health Center
8,257
7,292
8,687
4,
CONTRACT HEALTH SERVICES
F. Y. 71 F.Y.72 F. Y. 73 F. Y. 74%
Outpatient Visits (MD Only)
1,417
1,559
2,508
1,347
Total Cost**
$ 24,826
$ 19,051
$ 33,599
$ 20,022
Average Cost Per Visit
$
18
$
12
$
13
$
15
GM&S Hospitalization
Discharges
134
95
299
108
Days
4,647
977
1,503
478
Total Cost**
$ 34,522
$ 24,568
$ 87,985
$ 33,077
Average Cost Per: Discharge
$
258
$
259
$
294
$
306
Day
$
7
$
25
$
59
$
69
Nursing Home Care
Discharges
14
10
8
Days
269
233
136
Total Cost**
-
$ 3,918
$ 3,523
$ 2,336
Average Cost Per: Discharge
$
$ 280
$
352
$
292
Day
-
$
15
$
15
$
17
AMBULATORY PATIENT CARE
F.Y.71 F. Y. 72 F.Y.73 F. Y. 74*
No. of visits to all IHS Clinics in
58,365
61,651
70,785
23,417
Washington State
ar.
CONTRACT HEALTH SERVICES (Wash. State)
F.Y.71
F.Y.72
F.Y.73
F.
Y.
74*
Outpatient Visits (M.D. & Optometrist)
No. of Visits
17,962
20,033
23,953
12,033
Total Cost**
$233,050
$258,260
$307,749
$170,852
Average Cost per Visit
$
13
$
13
$
13
$
14
GM&S Hospitalization
Discharges
2,212
2,168
3,683
994
Days
12,094
13,806
21,534
5,081
Total Cost**
$575,943
$820,577
$1221,219
$369,777
Average Cost per: Discharge
$ 260
$
378
$
332
$
372
Day
$
48
$
59
$
57
$
73
Nursing Home Care
Discharges
15
88
116
27
Days'
247
1,948
2,650
564
Total Cost**
$ 3,453
$ 27,960
$ 39,290
$ 8,151
Average Cost per: Discharge
$
230
$
318
$
339
$
302
Day
$
14
$
14
$
15
$
14
* First six (6) months of FY 74.
** Includes partial pay on some documents
SOURCE: APC & CHS Tabulations
BRIEFING INFORMATION ESPECIALLY PREPARED
FOR MR. SPENCER JOHNSON, THE DOMESTIC
COUNCIL February 10, 1976 1:45 p.m.
Old Executive Office Building
Washington, D.C.
CONTENTS
Statement
I. Facts
II. Analysis of Proposed Regulations
III. Comments and Recommendations
APPENDIX
a) Proposed regulations regarding Home Health Care (Federal Register,
Vol. 40, No. 163-Thursday, August 21, 1975)
b) Response of National Association of Home Health Agencies to pro-
posed regulations.
c) Statement of President of NAHHA at Congressional hearing (October 28,
1975)
DERINLO FORD LIBRARY
HOME HEALTH CARE
UNDER
THE MEDICAID PROGRAM
-
National Association of Home Health Agencies
February 10, 1976
FORD is LIBRARY
STATEMENT
The National Association of Home Health Agencies, comprising a
membership of approximatley 500 providers of home care in the
United States is deeply concerned with proposed regulations
related to provision of services under the Medicaid program
now under consideration by the Department of Health, Education
and Welfare.
In concert with other organizations that have an interest in
home care such as the National League for Nursing, National
Council for Homemakers-Home Health Aide Services, Inc., and
the American Hospital Association, N.A.H.H.A. is prepared to
commit its resources to constructive action which would
assure the highest quality in service to patients who re-
ceive home care and, expand the availability of service to
all those for whom it would be appropriate.
To achieve such action, N.A.H.H.A. herein submits a recapitu-
lation of analyses of the regulations and specific recommen-
dations related to the provision of home health care under
Medicare and Medicaid.
I. Facts
In the Federal Register of August 21, 1975, the Administrator of the Social
and Rehabilitation Service, with the approval of the Secretary of Health, Edu-
cation and Welfare, set forth tentative regulations with respect to Home Health
Services provided in State Medicaid programs (Title XIX, Social Security Act).
The purpose, according to S.R.S., "is to remove certain restrictions and
ambiguities in current regulations which have prevented full realization of the
benefits of home health services
11
The revisions, said S.R.S., were proposed "in light of the statutory
requirement under Title XIX to provide home health services, to all individuals
entitled to skilled nursing facility service under a State's Medicaid Plan,
the Department's efforts to develop alternatives to institutional care, and
Congressional interest in expanding the use of home health care
"
The revisions would permit certain types of qualified health service
agencies (those offering nursing or home health
aide services), in addition to those which meet
Medicare standards, to provide services under
State Medicaid programs.
=
"
"
prescribe standards
which parallel those for
Medicare but are appropriately adjusted for dif-
fering needs under Medicaid.
"
"
H
permit proprietary agencies to participate if
they meet standards whether or not the State
has a licensing law.
The revisions would clarify that States must make available
three
main types of services nursing, home health
aide, and supplies and equipment, and also, permit
them to provide various therapies
"
"
"
clarify Medicaid recipients to whom
services must
be available, specify requirements for a physicians
determination of medical needs in a plan of care
and clarify that Medicare requirements relating to
need for 'skilled' care on to post-hospitalization
do not apply under Medicaid.
In the 30 day period (extended to 47) allowed for comment, S.R.S. received
over 1,000 responses. On October 28, 1975, hearings on the proposed regulations
were held by the Subcommittee on Long-Term Care, Special Committee on Aging of
the U.S. Senate and the Subcommittee on Health and Long-Term Care, Select Com-
mittee on Aging of the House of Representatives.
In a letter on December 12, 1975, the chairmen of these committees, the
Honorable Frank E. Moss and the Honorable Claude Pepper wrote to Secretary
David Mathews, stating in part:
"
the regulations as proposed
are not in concert with Congressional
intent and would clearly have a deleterious effect on the quality of home
health care in the United States.
=
we ask that you intervene personally and examine the proposed
regulations and their likely effects. We ask that you eliminate
language facilitating the entry of for-profit agencies in the home
health field. We believe this to be critical. The result of this
decision, we believe, will determine whether home health care will
continue at a high level or whether a few years from now, we will
be confronted with the problems all too familiar from our nursing
home experience."
Final action on the proposed regulations has not been taken by the
Secretary of H.E.W. as of this date.
II. Analysis of Proposed Regulations
The following is a summary of comments from a variety of responsible
leaders engaged in or thoroughly familiar with the home care field.
Herbert Semmel, Center for Law and Social Policy (in behalf of
National Council of Senior Citizens and the Department of Public
Advocate, New Jersey)
"1. The regulations will deprive the states of the power
to control the provision of home health care services by
mandating the certification by the states of unlicensed
commercial enterprises as Medicaid home health care pro-
viders. Such an imposition on the states is contrary to
congressional action in four major legislative acts.
2. The regulations would undermine the development of
- 2 -
comprehensive home health service centers by requiring the
states to certify single service agencies as Medicaid home
health care providers.
3. The regulations will foster the same kind of uncontrolled
financial abuses in the delivery of home health services as has
occurred in the nursing home industry and will result in higher
costs without substantial improvement in the quality of care
being provided those in need."
Abraham Ribicoff, Chairman, Committee on Government Operations, U.S.
Senate
"
I must question whether policy to expand such services necessi-
tates the weakening of performance standards for the providers
"
agencies which qualify under the proposed Medicaid only option
would not have to prepare an overall plan and budget, providing
for an annual operating budget and a capital expenditure plan, nor
comply with existing requirements for certificate of need through
designated planning agencies. Neither would they have to comply
with existing requirements for coordination with related federal
programs.'
Ellen Winston, National Council of Homemaker-Home Health Aide Services
" regulations need to be held in abeyance until careful study
of their impact not only in quantity but in quality of home-
maker-home health service has been made."
Senator Charles Percy
"I am not certain that the real problem is the shortage of home
health agencies. The problem may be more one of the availability
of home health benefits for the elderly. Perhaps we should be
focusing our attention on ways to commit more dollars to home
health programs."
Honorable John B. Martin, American Association of Retired Persons
"Preliminary evidence evaluating proprietary home health agencies
indicates that profit may interfere with the provision of quality
care."
Eva Reese, Visiting Nurse Service of New York
"By definition, profit-making health care agencies do not make
quality patient care their primary concern. This point has been
made over and over again in the nursing home situation in New
York. Millions of tax dollars have been siphoned off for
marginal or non-existent services. Under these circumstances,
enabling profit-making enterprises to provide home health ser-
vices under tax-supported programs invites similar abuse."
Representative Claude Pepper
"...I am concerned that these regulations will deprive the States
- 3 -
of the power to control the provision of home health care ser-
vices by mandating the certification by the States of unlicensed
commercial enterprises
"
Representative Edward I. Koch
"
regulations establish a dangerous precedent whereby, regard-
less of whether a state has stricter legal requirements than federal
standards, the state cannot stop what are in its judgment poten-
tially abusive agencies from operating in the state."
Congressional Research Service
"The proposed regulations do not require Medicaid agencies to have
written policies. It is unclear as to how an agency's unwritten
policy would be evaluated. In addition, no mechanisms are required
to be established to collect data pertinent to evaluation (also a
Medicare requirement)
Homemakers-UpJohn
"The way to ensure quality of service is to establish a set of
workable controls for standards, accountability, organization,
and incentives for efficiency. These should then be applied
across the board to all providers with exclusions not based on
whether the providers are profit or not-profit organizations,
but whether they can live up to the standards. Participation
should be based on quality of service, availability, and rea-
sonable cost.
"We believe that all providers of home health care must be sub-
ject to thoughtful and productive government regulations, and
we welcome any effort to establish such uniform standards."
Nancy Tigar, National League for Nursing
"Currently, the standards by which home health agencies are cer-
tified to participate in the Medicare program are acknowledged
to be minimum, basic standards. The regulations, as set forth in
Section 249.150 of the Medical Assistance Program, will lower
even those minimum standards and set up a 'separate but not
equal' system of home health care for the Medicaid population.
Home health service needs of patients reimbursed under the
Medicaid program are not different from the needs of patients
reimbursed under Medicare. Agency standards cannot be lessened
for this group unless a two-class system of care, qualitatively
speaking, is acceptable as national policy.
"We have long believed that home health services must be made
available to all segments of the population and at the same
time assure maximum manpower utilization, provide quality assurance
and promote cost containment. While we appreciate the attempt by
the Social and Rehabilitation Service to increase the availability
of home health services through these regulations, we seriously doubt
that they will assure maximum manpower utilization, provide quality
assurance or promote cost containment. While the regulations may
- 4 -
increase the number of home health agencies, whether they will
increase the services available in rural and underserved areas
is questionable.
"In this time of fiscal crisis when we are urging smaller agencies to
merge their resources by establishing linkages, centralizing
administrative practice and policy, etc., to provide cost/benefit
effective management, we believe these regulations could con-
ceivably slow down or abort this process."
Senator Al Ullman
"I ask the Department to reconsider the home health regulations
in light of my comments, and those of the National Association
of Home Health Agencies."
A copy of N.A.H.H.A.'s response to the proposed regulations is contained
in the Appendix
III. Comment and Recommendations
Home health care, in existence for many years, has been "discovered" by
a great many people in the past few years legislators, health professionals,
health insurance companies, and profit-seeking organizations. Rightly or
wrongly, a substantial amount of the current interest stems from the costs of
home care when compared to those of acute-care or long-term care institutions.
The fact that qualified studies have confirmed that large numbers of persons,
particularly the elderly, have been needlessly placed in institutions at govern-
ment expense, has simply accelerated efforts to find alternatives.
It is also fact that restrictive regulations have not allowed the home
health care industry to grow as it should in order to accommodate people for
whom home care would be appropriate. Since substantial provision of Medicare
funding is contingent on hospitalization, there is an over-dependence on this
source of financing by most providers. Medicaid funds are spent on hospitaliza-
tion and nursing home care. Less than one percent of Medicare expenditures and
four-tenths of one percent of Medicaid expenditures have been for home health
care.
In its urgency to expand the use of home health care, the Social and
Rehabilitation Services has promulgated regulations that would open the door to
uncontrolled use of home care. No studies have been conducted to determine
the comparative quality of home health services rendered by either non-profit
or for-profit agencies. S.R.S. would propose to monitor possible abuse through
its regular fraud and abuse program but its present operations have been des-
cribed as undermanned and ineffective in respect to other H.E.W. programs.
The critical issue is one of standards that will apply equally to all pro-
viders-non-profit or proprietary. At least a dozen states have licensure laws
at present and a majority of the rest are considering their establishment.
For the states and the federal government, it is important to have both sound
national standards and others which are uniquely suitable to the operations of
each state and locality.
- 5 -
1
need for NR Stats for Home Health agencies
input need agencies, croumers, providers CMD. etc)
from
have agreement AHA, League NAHHA
to do something
(2200 againes - very small)
2.
no studies made before Aew made vogulation
3.
need amixion to get people together
is there a precedent ?
To move in haste will indeed confirm the fears of many that home health care
could be burdened with all of the concomitant scandals and problems that occurred
within an unregulated nursing home industry.
RECOMMENDATIONS
1. That the Department of Health, Education and Welfare withdraw its proposed
regulations related to home health care services under Medicaid.
2. That a national commission be established under the President's Domestic
Council for the purpose of establishing standards for home health care to
be applicable to both Medicare and Medicaid programs. This would include
examination of the appropriate role of home health services in the health
delivery system.
3. That the Secretary of H.E.W. authorize appropriate studies of the quality of
home care provided by all types of agencies.
DM:JPB:1ds
2/6/76
FORD STATE LIBRAR
- 6 -
APPENDIX
RECEIVED
AUG 29 A.M.
THURSDAY, AUGUST 21, 1975
Associated Home Health Service
ARCHIVES OF THE
NATIONAL UNITTD
THE 1934 STATES
PART II:
DEPARTMENT
OF HEALTH,
EDUCATION,
AND WELFARE
Social and Rehabilitation
Service
MEDICAL ASSISTANCE
PROGRAMS
Home Health Services
36702
PROPOSED RULES
DEPARTMENT OF HEALTH,
services which States must provide un-
jections thereto addressed to the Ad-
EDUCATION, AND WELFARE
der their State plans. It has been inter-
ministrator, Social and Rehabilitation
preted that the States are required to
Service, Department of Health, Educa-
Social and Rehabilitation Service
provide only one of the specified services
tion, and Welfare, P.O. Box 2366, Wash-
[ 45 CFR Part 249 ]
(nursing, home health aide, supplies and
ington, D.C. 20013, and received on or
equipment), when it fact it was intended
before September 22, 1975. Comments are
MEDICAL ASSISTANCE PROGRAM
that all of these were required to be
particularly solicited on the potential for
Home Health Services
available. The proposal now clarifies that
cost increases that might result from
Notice is hereby given that the regula-
States must make available, as deter-
adoption of the proposed regulations.
tione set forth in tentative form below
mined necessary by the recipient's phy-
Such comments will be available for
FEDERAL REGISTER, VOL. 40, No.
163-THUNSDAY,
AUGUST 21, 1975
252.2033
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from our highlights listing of
documents to be published in the
next day's issue of the FEDERAL
REGISTER.
AREA CODE 202
523.5022
NATIONAL ASSOCIATION OF HOME HEALTH AGENCIES
LEGISLATIVE COMMITTEE
1715 E. Burnside Street
Portland, Oregon 97214
(503) 233-5441
John A. Svahn
Acting Administrator
SRS / HEW
P.O. Box 2366
Washington, D.C. 20013
Re: "Medical Assistance 1838 Programs, Home Health Services,"
August 21, 1975, Federal Register
Dear Mr. Svahn:
The National Association of Home Health Agencies is
writing to respond to the Proposed Medicaid Regulations as
published in the August 21, 1975 Federal Register.
We strongly support the clarification of covered home
health services provided by the Title XIX program, however
we strongly oppose the development of two levels of care and
any dilution or weakening of the Medicare standards for Home
Health Agencies.
We would like to commend the department for clarifying
that Medicaid is not bound to the Medicare definitions of
"Skilled Nursing" and "Prior Hospitalization".
We support the proposed changes in S249.10 with five
exceptions. These are summarized as follows.
249.10 (b) (7) (B) Home health aide services provided by
a qualified agency be clearly defined in this section. The
definition should include the performance of simple procedures
such as an extension of therapy services, personal care, ambu-
lation and exercise, household services essential to health
care at home, assistance with medications that are ordinarily
self-administered, helping with meal preparation including
special diets and assisting in usual household duties such as
budgeting, marketing, housekeeping, laundry, etc.
249.10 (b) (7) Include item (D) as part of the required
services and add a new section (E) as the services which may be
provided at the State option. Section (E) should read as
CHAIRPERSON
MEMBERS
EX-OFFICIO
DONALD D. TRAUTMAN
MRS. GRACE M. BRADEN
MRS MILDRED HORN
JOHN P BYRNE
PORTLAND, OREGON
IRVINE, CALIFORNIA
LAKE FOREST, ILLINOIS
ST LOUIS, MISSOURI
NEAL D COLBY, JR
EDWARD G LINDSEY
MS MARTHA A MASEMAN
KANSAS CITY, MISSOURI
BUFFALO, NEW YORK
LINCOLN, NEBRASKA
MRS SHIRLEY C. DeMOTT
MRS MARIE MILLIKEN
HUGH ROHRER, M.D.
SCOTTSBLUFF NEBRASKA
LUBBOCK, TEXAS
PEORIA, ILLINOIS
AL G WAGNER, M.D
PHOENIX, ARIZONA
John Svahn
-2-
9/30/75
follows:
"(E) Nutritional counseling, therapeutic diets and medical
social service for patients with emotional problems."
249.10 (b) (7) (A) Add to this section a requirement that the
State Agency conduct a public hearing in the local area to
determine that there is no home health agency service available
before permitting the State Agency to reimburse for services
be provided by a licensed nurse.
249.10 (b) (7) (D) Add the following phraseology to this
section "when it is determined that these services are not
available through a qualified agency. "
249.10 (b) (7) (ii) Change this section to read "In
order to participate under a state Title XIX plan as an agency
qualified to provide home health services, such agency must be
certified under Title XVIII of the act to provide such services".
We believe each program should pay for the combinations
of services needed by their respective target populations.
The Medicaid covered services should include as a minimum
all Medicare covered services plus those additional services
needed to develop realistic alternatives to institutional
care and to encourage the use of home health services in
appropriate cases.
Therefore, we urge immediate adoption and publication
of the above recommendations and deletion of sections
249.150 and 249.151. in the final regulations.
The National Association of Home Health Agencies member--
ship includes public, voluntary, and profit making Home
Health Agencies. The question raised by sections 249.150 and
249.151 in the Proposed Regulations does not relate to
profit VS. non-profit - the question is "Do the regulations
establish verifiable quality services, reduce fragmentation
and focus upon the needs of the Medicaid population"?
After reviewing the Proposed Regulations, we are convinced
these regulations set up another level of care for the
indigent and dilute the quality of patient care.
REDUCE QUALITY
These regulations will lower the standards of care
which providers of home health care are currently required
to maintain. These Proposed Regulations change or eliminate
the following Medicare requirements.
- Under Medicare a proprietary organization must be
licensed as a home health agency pursuant to state law, and,
if no state law exists for the licensure of such type agency,
John Svahn
-3-
9/30/75
it cannot be certified for participation. The proposed
rules removes the prohibition.
- Changes the Medicare periodic review of patient
services from 60 days to 90 days.
- Deletes the existing Medicare requirement that a
proprietary agency provides all services directly, through
agency employees (405.1221 (a).
- Deletes the Medicare requirement that there is an
annual operating budget which includes all anticipated
income and expenses related to items which would, under
generally accepted accounting principles, be considered
income and expense.
- Deletes the medicare requirement that a capital
expenditure proposal must be submitted to the designated
planning agency for approval.
-Deletes the Medicare requirement that an overall plan
and budget is prepared under the direction of the governing
body, the administrative staff and the medical staff.
-Deletes the medicare requirement that the overall plan
and budget is reviewed and updated at least annually by the
governing board.
- Deletes the medicare requirement that services provided
under contract may not exceed an amount which would have
been reasonably paid if the services had been paid in an
employment relationship.
- Deletes the Medicare requirement that under contracted
services patients are only accepted for care by the primary
home health agency.
- Changes the medicare supervisory visit requirement
from once every two weeks to at least monthly.
Therefore, we must take issue with those statements in
the regulations which state that, " The standards are basically
those used under Medicare
and that proper enforcement of
standards and monitoring of performance will provide adequate
safeguards against abuse. "
FRAGMENTATION
For Home Health Care services to become a viable alter-
native to institutional care, these services must be provided
by an organization that is held accountable and is responsible
for delivering a comprehensive range of services but only
the amount and type of services needed by the individual.
No more. No less.
John Svahn
-4-
9/30/75
Under the Proposed Regulations, single service agencies
will proliferate, causing duplication of services, lack of
coordination and an increase in costs due to wasteful
inefficiencies.
Setting up standards which cater to those agencies
which are unwilling to expand the scope of services and
will ensure that those same agencies will continue to provide
only minimal services, thus penalizing those patients who
need and will benefit from comprehensive care at home.
When different standards are required for qualified
providers to participate for Title XIX than for Title XVIII,
the following will result. Different standards will fragment
services - providers - and payors; be difficult, and expensive
to monitor; be confusing for agencies attempting to meet
them; require different rules to be applied to each patient
dependent on the source of payment; prevent adequate fiscal
controls from developing; and encourage over-utilization of
services.
The issue of uniform standards for skilled nursing
facilities under Medicare and Medicaid was addressed by
Section 246 of PL 92-603 (The 1972 Social Security Amendments).
The Senate Finance Committee Report address the issues
raised in the foregoing paragraphs as follows:
"The Committee believes that it would be desirable to
apply a single set of requirements to skilled nursing facilities
under both Medicare and Medicaid.
The amendment would
provide that facilities which satisfy
the new definition of "skilled nursing facility" under one program
shall be eligible to participate in the other provided it agreed
to contract terms. The amendment would incorporate the present
Medicare definition and requirements for an extended care facility
A single consolidated survey would be performed
to determine
a facility's qualifications for both Medicare and Medicaid.
The committee's amendment is not intended to result in any dilution
or weakening of standards for skilled nursing facilities.
This amendment incorporates the general thrust of an amendment
previously developed by the committee and included in H.R. 17550. "
John Svahn
-5-
9/30/75
LOCAL CONTROL
The Proposed Regulations circumvent local controls.
The Federal Legislation, notably the Comprehensive Health
Planning Act and the 1972 amendments to the Social Security
Act has mandated and supported certificate of need, rate
review and consumer involvement. These regulations ignore
this legislation.
The lack of local review is self-defeating, expensive
and contrary to other public policies. State licensing,
certification of need, budget review, contract review and
other mechanisms are needed to provide for local review.
Without such monitoring, the government will be providing an
expensive Welfare Program for providers NOT services for
the sick and disabled.
We believe that local controls must be encouraged not
circumvented by Federal Regulations. Effective Home Health
Service programs require that local consumers, providers and
government officials share the responsibility of improving
local services to meet the unique needs of the individuals
in their community. Such controls as State Licensure,
certificate of need, rate review, contract review should be
supported by all Federal Agencies.
LACK OF ADEQUATE FUNDS FOR SURVEILLANCE
Without funds for staff at the federal, state or local
level to survey, certify, verify or monitor providers, a
bureaucratic "jungle" is created where patients become
secondary.
The survey agency of each individual state must monitor
the operation and performance of each provider of home
health services. Yet these regulations do not establish any
performance guidelines to assure that there will be adequate
surveillance.
This cannot be accomplished without budgeting funds for
the state survey agencies to gear up and provide adequate
surveillance. However this can be easily and economically
accomplished by using the Medicare certification.
We agree with congress that the existence of separate
requirements (which may differ only slightly) and separate
certification processes for determining provider eligibility
to participate in Medicaid is administratively cumberson and
unnecessarily expensive.
John Svahn
-6-
9/30/75
Therefore, we believe there should be a single uniform
federal standard for all Home Health Agencies which should
be based on the Medicare Certification. Such standard
should include a provision for local controls, including
state licensure and certificate of need, as a minimum.
Changes to improve Medicare Certification should be made by
legislation and not by each Federal Agency that reimburses
for home health services. For example, hospitals use a
single definition in all federal programs while nursing
homes were defined separately by various federal programs.
Many problems can be avoided by using a single uniform
definition for a Home Health Agency.
We will actively oppose any attempt to REDUCE QUALITY,
to establish different levels of care for the Medicaid
population, to circumvent local planning agencies and state
licensure laws because these activities have been developed
to prevent exploitation of various federal programs. Exploi-
tation of the Home Health sector must be prevented.
We trust that the Department will seriously consider
the points we have raised and include our recommendations in
the final regulations.
As we have stated on previous occasions we are willing
to assist HEW staff in any effort to improve the quality and
avaliability of a comprehensive renge of home health services
needed to make home health a viable alternative to insti-
tutional care.
Sincerely,
YES
Donald D. Trautman,
Chairman
to
NATIONAL ASSOCIATION OF HOME HEALTH AGENCIES
LEGISLATIVE COMMITTEE
1715 E. Burnside Street
Portland, Oregon 97214
(503) 233-5441
STATEMENT OF
JOHN BYRNE, PRESIDENT
NATIONAL ASSOCIATION OF HOME HEALTH AGENCIES
OCTOBER 28, 1975
ECEIVE
NOV 17 1975
V.N.A.
CHAIRPERSON
MEMBERS
EX-OFFICIO
DONALD D. TRAUTMAN
MRS. GRACE M. BRADEN
MRS. MILDRED HORN
JOHN P. BYRNE
PORTLAND, OREGON
IRVINE, CALIFORNIA
LAKE FOREST, ILLINOIS
ST. LOUIS, MISSOURI
NEAL D. COLBY, JR.
EDWARD G. LINDSEY
MS. MARTHA A. MASEMAN
KANSAS CITY, MISSOURI
BUFFALO, NEW YORK
LINCOLN, NEBRASKA
MRS. SHIRLEY C. DeMOTT
MRS. MARIE MILLIKEN
HUGH ROHRER, M.D.
SCOTTSBLUFF, NEBRASKA
LUBBOCK, TEXAS
PEORIA, ILLINOIS
AL G. WAGNER, M.D.
PHOENIX, ARIZONA
NAHHA Oral Statement, John Byrne 10/28/75
Chairman Moss, Chairman Pepper, and members of the
Senate and House Committees on Long-Term Care, I appreciate
the opportunity to appear before you today to discuss the
impact of the Proposed August 21, 1975 Medicaid Regulations
on the future quality of Home Health Services.
My name is John Byrne. I am Executive Director of The
Visiting Nurse Association of Greater St. Louis, President
of the National Association of Home Health Agencies and am
speaking on behalf of the National Association of Home
Health Agencies.
With me is Don Trautman, Chairman of the Legislative
Committee of our Association. Both Don and I will be happy
to answer any questions the committe may wish to ask following
our statement.
I ask permission to have our written statement with
attachments included for the record and proceed with our
oral statement.
The impact of the August 21, 1975 Proposed Medicaid
regulations is important. This set of regulations makes a
major policy change that lowers standards for Home Health
Service while Congress is developing changes designed to
maintain quality while increasing the use of Home Health
Services.
The prime purpose of the National Association of Home
Health Agencies is to support the delivery of high quality
cost effective services to those who would benefit from such
services. It is the policy of our association that no
-2-
distinction should be made between agencies on the basis of
sponsorship, ie between official, non-profit and for-profit
agencies.
It appears that home health agencies are facing the
same dilemma nursing homes faced in 1967. We want to avoid
the problems that developed in the nursing home field during
an accelerated growth period. These problems were the
result of an increase in quantity at the expense of quality
which took about eight years to identify. We cannot stand
by silently and permit a similar development in home health
services.
The Proposed Regulations include a provision to certify
single service agencies as home health agencies. This lowers
standards by catering to those who are not willing or
interested in being responsible and held accountable for the
delivery of a comprehensive range of services. Why change
one comprehensive service agency into seven different single
service agencies? This is diametrically opposed to the
concept of organized and coordinated home health services.
We should be raising the minimum requirements not lowering
them.
Quality is important. It must assure the user 1) that
he will receive services when he needs help, 2) that he will
be trained to help himself when he is able, and 3) that he
will be able to care for himself as long as possible.
Quality eliminates the costly dependency trap.
Quality must guarantee that the user's needs will be
routinely reviewed by a group of health workers. Subtle
changes need to be noted and the treatment modified to avoid
-3-
the development of serious problems.
Quality must be practical and include the user in
planning the home treatment program. The home treatment
program must put the recipient's needs above that of the
"budget" or the "profit and loss statement" of the organization.
Quality includes using the most appropriately qualified
person (not necessarily the cheapest) to treat the problem.
This includes efficient utilization of staff by matching the
task to the level of the worker. It takes Quality to make
the best use of staff, to match needs to level of worker, to
know when to seek consultation of another, or when to turn
the primary responsibility of treatment over to a more
qualified person.
We don't expect a carpenter to be a nuclear physicist
just because he helped build the physicist's office. By the
same token we should not expect a homemaker to know when the
patient's overall condition requires the skills of a registered
nurse to plan and supervise the services, just because she
is providing housekeeping services.
Quality home health service is all of these melted
together into a cohesive organization called a home health
agency, an organization that uses the best available to do
the job right.
Quality is important to home health because 1.) it can
help reduce the long-term cost of caring for a person, 2.)
it requires nursing and rehabilitation staff to work together,
side by side, in the home to help the patient, 3.) it stimulates
development of innovative solutions and encourages redesign
-4-
of the service systems, and 4.) it tells you when to stop
treating, start teaching self-care and finally when to let
go.
Our Association's specific recommendations on the
Medicaid regulations can be summarized in two groupings.
First, we urge immediate adoption and final publication
of the Medicaid regulations as recommended in our September
30 letter to the Commissioner of The Social Rehabilitation
Service. This involves deleting sections 249.150 and
249.151 and making the following changes to Section 249.10
(a) (4) and (b) 7.
- Home Health aide services provided by a qualified
agency must be clearly defined.
- Include all Medicare home health services as required
Medicaid services and add nutrition counseling,
therapeutic diets, and medical social services as
the services which may be provided at state option.
- Add a requirement that the State Agency conduct a
public hearing in the local area to determine that
there is no home health agency service available
before permitting the State Agency to reimburse
for services provided by other than a Medicare
Certified Home Health Agency.
- Require that in order to participate under a State
Title XIX plan as an agency qualified to provide
Home Health Services, such agency must be certified
under Title XVIII of the act to provide such services.
-5-
Second, we want a committment from both Congress and
H.E.W. to develop a single uniform Federal standard for all
home health agencies which uses the Medicare Certification
as the basis.
The real issue is what type of controls are needed to
maintain quality. This is not a question of profit versus
non-profit. Different committees in our Association have
been meeting with various groups gathering information
needed to formulate a policy that will have enough teeth to
apply equally across the board to everyone.
Since this is an industry problem as well as a public
policy issue, we would like to cooperate with the various
administrative agencies and legislative committees to develop
the solutions. We'would hope that we in the industry would
be permitted sufficient time to complete our work and develop
a solution that is fair.
We think a key role of the Congress and Administrative
Agencies should be to fully explore and carefully review the
issues which bear on the quality of service provided to
patients. We believe this will result in a public policy
that will include the safeguards needed to retain quality
while liberalizing payment and expanding the scope of services.
We firmly believe that now is the time to develop a
single uniform Federal standard for all Home Health Agencies
which should be based on the Medicare Certification. Such
standard should include a provision for local controls,
including state licensure, certificate of need, and require-
-6-
ments for full disclosure of information as a minimum.
Changes to improve Medicare Certification should be made by
legislation and not by each Federal Agency that reimburses
for home health services. Many problems can be avoided by
using a single uniform definition for a Home Health Agency.
The National Association of Home Health Agencies
actively supports efforts that assure the delivery of high
quality cost effective home health and vigorously opposes
attempts to REDUCE QUALITY, establish different levels
of care, or circumvent local planning agencies and state
licensure laws.
We need help. We cannot afford to expand the quantity
of Home Health Services at the expense of Quality. Please
help us.