Medicare program puts government between doctor, patient
Published by Orlando Sentinel
March 7, 2017
In its ongoing effort to reduce health-care costs and improve program integrity, the Centers for Medicare and Medicaid Services launched a mandatory demonstration program last year that alters how Medicare approves and pays for skilled home health-care services for elderly Americans. Medicare picked five states in which to try out this program — including Florida.
CMS’s “Pre-Claim Review” demonstration project is currently underway in Illinois, and Florida is scheduled next. The demonstration requires government contractors to decide whether physician-prescribed home health care is “medically necessary” before reimbursing providers for services.
Medicare was wise to roll out this project slowly, since its debut in Illinois has been a bumpy road, to put it mildly. But while major changes, like this one, are rarely without glitches, sometimes those glitches serve as huge red flags to pump the brakes because we’re on the wrong path.
When it comes to the health of our nation’s seniors, it behooves us to proceed cautiously. And with Pre-Claim Review scheduled to launch roll out in Florida on or after April 1, our responsibility is to the nearly 350,000 seniors who stand to be impacted.
Last year in Illinois, patient care was undermined by a program fraught with problems. The Pre-Claim Review process was designed to reduce fraudulent health-care expenditures by requiring a third party to ensure claims were valid; however, no evidence supports that the program is achieving these goals.
Lack of resources and education by Medicare to home-health agencies led to delays in care and outright refusals for services deemed not medically necessary. Licensed health-care providers, who were best equipped to make health-care decisions for their patients — found themselves caught up in considerable bureaucratic red tape when Medicare administrative contractors overrode their orders. And patients, in the most critical phases of their recovery, were delayed in receiving essential care.
Nationwide, health-care providers and more than 3.5 million patients depend greatly on the availability of home health. Often prescribed by physicians before a patient is considered safe for hospital discharge, this type of care sends licensed practitioners to the home — allowing patients to recover from serious illness, injury, or surgery comfortably and more cost effectively. A day of home health, in fact, costs Medicare less than half the cost of a day of skilled nursing home care.
Delays and refusals in care — like those in Illinois — can prove disastrous since the days immediately following an injury or hospitalization can be precarious. Research shows that without this readily available “medically necessary care” prescribed by a provider, complications are more likely to occur often due to unintended side effects from a new medication, an easily treatable infection that progresses to something far more serious, or even a dangerous fall because of decreased mobility. It’s these types of situations that home health care has always helped to prevent –– and that help avoid costly hospital readmissions.
Safeguarding the health of our seniors and providing care that controls costs should remain our overriding purpose. That’s why it’s crucial that lawmakers act immediately and ask CMS to revoke their plans to implement Pre-Claim Review in Florida. Failing to do so could result in a repeat performance of what has occurred in Illinois.
This is not a partisan issue. Bipartisan lawmakers from Florida in both the U.S. Senate and House have expressed concern over Pre-Claim Review, asking Medicare to rethink this program in Florida, and other states. It’s time for others in the Florida congressional delegation to do the same. Pre-Claim Review is a perfect example of a government rule that goes too far in interfering with the delivery of health care.
Home-health providers fully support program integrity improvements to strengthen care delivery for our patients, but putting a government contractor in between a patient and his or her physician is not the right approach. We welcome the opportunity to work collaboratively with Congress and Medicare to develop targeted reforms that do not result in patient-care delays and higher costs to Medicare and taxpayers.
Medicare should be commended for its efforts to keep costs down for the future of the program — but doing so simply cannot be done haphazardly, and at the expense of our nation’s vulnerable seniors. Florida’s home-health patients should not be the next victims of a program we know isn’t working.
Bobby Lolley is executive director of the Home Care Association of Florida.
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