Pharmacists and other providers who fear that the shift to a Medicare nursing facility prospective payment system will have a major detrimental impact on patient care won't find any comfort in a new report on early experience with capped payments for Medicare home health services.
The report, based on a national study by the Lewin Group, a policy research firm based in Washington, D.C., cites the potential for major access problems and inappropriate patient transfers stemming from tight caps on home care payments under an interim payment system (IPS) implemented last October. As mandated by the Balanced Budget Act of 1997, the IPS pays home care companies the lower of actual allowable costs, newly reduced cost limits, or strict per-beneficiary limits based on companies'1993-94 Medicare cost data.
According to the Lewin Group report, tight IPS payment limits and resultant cost control pressures create strong "disincentives" for home care companies to accept the sickest and most fragile patients; others will likely respond by reducing service levels. These pressures are especially pronounced on small companies serving large numbers of high-need patients, companies in rural areas where alternative sources of care are often not available, and agencies that have experienced an increase in the acuity of their case mix since 1994, the report says.
Val Halamandaris, president of the National Association for Home Care (NAHC), said the new report "confirms our fears that the IPS poses a very serious threat to both the beneficiary and home care [provider] communities."
Halamandaris said the six-month lag between IPS implementation and publication of per-capita payment limits on April 1 has forced home care providers to "fly blind," continuing to provide services without knowing exactly how much of the costs they incur will be reimbursed. He also cited basic "inequities" in the way per-capita limits are determined. "The system is so flawed in this regard that in one city, one agency has a limit of approximately $2,500 while another has a limit of $13,000. The fact that the IPS adversely affects the vast majority of patients and providers sends a clear message that something is fundamentally wrong with this system."
NAHC says the only way to correct these flaws and institute a payment system that is fair to both patients and providers is for federal officials to proceed as quickly as possible with development of an episodic home care prospective payment system.
The report, "Implications of the Medicare Home Health Interim Payment System of the 1997 Balanced Budget Act," can be obtained from NAHC at 202-547-7424 (www.nahc.org ).
Health care workers reporting suspected illegal activities by their employers would have strong federal guarantees of job security and freedom from harassment under a new bill working its way through Congress.
Introduced by Reps. Mark Foley (R-Fla.) and Ron Klink (D-Penn.), the bill would prohibit any employer in any health care setting from dismissing, demoting, or browbeating workers who participate in "qui tam" (whistle-blower) actions.
"Fear of firing has a chilling effect on workers who would otherwise blow the whistle on abuses," said Foley, who contends that uniform protections are needed because current federal protections are not strong enough and state protections vary widely. During a press conference to announce introduction of the new bill, Foley pointed to the case of an Ohio nurse who was allegedly fired without cause from her job at a blood bank after refusing to lie about quality control violations and fiscal improprieties she had reported to company management.
Qui tam lawsuits have been an increasingly prominent fixture on the health care landscape since 1986, when Congress amended the federal False Claims Act to encourage employee reporting of suspected corporate wrongdoing. Pharmacies and other health care operations are a frequent target of qui tam actions. According to Department of Justice statistics, health care organizations were named in roughly 40% of the 360 corporate qui tam actions filed over a recent 12-month period. Whistle-blowers stand to come away with 15%-30% of any recovered moneys; in major cases, that can translate into millions of dollars.