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Sheila Guither: Illinois as Medicare's home health testing ground

Published by The State Journal-Register
Sheila Guither
September 11, 2016

Deciding what's best for a patient's health is most often, and most appropriately, addressed within the trusted relationship between a doctor and patient. But for nearly 200,000 seniors across Illinois, as of Aug. 3, important choices now require another decision maker: The U.S. government.

As the first state in the U.S. to be subject to a novel Medicare demonstration project, physicians across Illinois, who know best that Medicare home health would clinically benefit their patients, no longer have the final say in prescribing post-acute and chronic care management services that they have deemed medically necessary for their patients. Instead, a government Medicare Administrative Contractor (MAC) makes the final call. It's a move that Medicare claims will save money by reducing health care fraud, but that compliant providers, patients and advocates justifiably consider a frightening, slippery slope with potential national application.

Health care providers, and the elderly patients they serve, have come to depend greatly on the availability of skilled home health care services. This type of care, offered in seniors' own homes by licensed practitioners, allows patients to recover from serious illness, injury, surgery or recent hospitalization comfortably and at lower cost to payers than facility-based care. In fact, a day of home health costs Medicare less than half the cost of a day of skilled nursing home care. Many doctors prescribe skilled home health as a condition for hospital discharge, since the days following a hospitalization can be some of the most critical for patients, when costly complications and readmissions are most likely to occur.

But Medicare's so-called "Pre-Claim Review Demonstration Project" for home health is a game changer. With burdensome and time consuming paperwork requirements prior to a third party contractor approving a claim for home health, the result will be poor care transitions, and still further complications involved with maintaining seamless care at home. More patients will find themselves in institutional (and more expensive) skilled nursing facilities as the path of least resistance following inpatient hospital care.

In fact, providers in Illinois have reported that physical therapy, and in some cases, nursing care for knee replacement patients has been denied. Despite physician orders, the MAC responded by saying the documentation did not show medical necessity. If skilled care ordered by a physician after hospitalization from knee replacement surgery is now deemed medically unnecessary, the patients will suffer first followed by a rise in the cost of care due to higher institutional costs.

Pre-claim review simply isn't the answer to reduce costs, and it's certainly not what patients want. A recent national poll of nearly 2,000 registered voters over age 65 found that 83 percent of U.S. seniors agree that a doctor should be able to prescribe medications and services they choose for their patients without the government interfering. Three quarters most trust health care professionals (primary care physicians and nurses) to handle issues related to their health care compared to just 6 percent who trust government officials.

Lawmakers similarly object: A bipartisan group of federal lawmakers including Illinois Representatives Tammy Duckworth, Bob Dold and Rodney Davis in the U.S. House and Senators Dick Durbin and Mark Kirk in the US Senate asked Medicare to scrap a similar policy altogether.

Care provided to seniors in their homes is without question a key element of the health care delivery system for older adults, and one that we must encourage and protect. The Medicare patients we serve are older, sicker, poorer and are more likely to be female, a minority, and disabled than all other beneficiaries in the Medicare program combined. Coast to coast, 3.5 million homebound Medicare beneficiaries depend on the Medicare home health benefit and stand to be negatively impacted if pre-claim review becomes the standard.

Providers are committed to working with CMS to find a better way one that stands a realistic chance of reducing fraudulent expenditures without also reversing progress in patient care, savings and outcomes.

Before this policy is expanded to other parts of the country, I urge federal regulators and lawmakers to closely examine how this demonstration is impacting our state's home health community.

Sheila Guither is president of the Illinois HomeCare and Hospice Council.

Click here to see the original article on The State Journal-Register website.

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