Home Health Programs Face New Hurdles

It’s a common story, with a twist.
Statistics show that the population of Massachusetts — and the United States, for that matter — is simultaneously increasing and aging. And as Baby Boomers edge closer to their retirement years and the average age of Americans continues to rise, medicine has advanced to the point where people are living longer with sometimes serious medical conditions.

And, increasingly, they want to live at home, not in a nursing home, making the need for home health care services a growing one. But here’s the twist — despite this need, the trend is actually toward closing home-care agencies, not establishing new ones, due partly to the insufficient reimbursement that home-care programs are receiving from public and private insurance payers.

And that, obviously, poses a problem for the agencies that remain, who are saddled with the burden of caring for the growing number of patients who are able to live outside the nursing home setting but still require some outside care.

Put simply, the shrinking number of agencies, coupled with the continuing financial stress, is making it more difficult to meet the needs of everyone who needs home care.

“Our own agencies’ contracts were cut by $200,000 this year, and our vendor rate increases were $200,000, so we expect to have a $400,000 loss this year,” said Doug Stiles, executive director of Greater Springfield Senior Services Inc. (GSSS). Meanwhile, “we’ve been asked to create waiting lists because we simply don’t have the funds to take on new clients. That is the impact on the client.”

The Healthcare News takes a look this month at growing concerns in the home-health field — and the growing need for these suddenly troubled programs.

A Growing Need

It would be difficult to argue that home health care hasn’t become a crucial segment of health care in the Commonwealth and across the nation. The field has grown to become a $750 million industry in Massachusetts, employing more than 15,000 people at more than 125 certified agencies, according to the Home and Health Care Assoc. of Mass. Inc.

Breaking that down further, more than 25,000 home health visits are made in the Bay State every day — a figure larger than the number of people receiving care at hospitals. One in every 10 homes benefited from home health care services last year — or 200,000 patients in all.

Simply put, home health is the fastest-growing segment of the health care industry nationwide, according to statistics from the U.S. Bureau of Labor. And as the population ages and people live longer with conditions that might have killed them a decade or two ago, the need for home care — which is usually less expensive to provide than nursing home care — will only increase.

And that’s why it’s not a good sign that 40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of all agencies that provided home care nationwide four years ago have closed since then, with that figure reaching 27{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} in Massachusetts, said Carla Braveman, director of the VNA /Hospice Alliance in Northampton.

Some agencies have been frustrated at not being able to offer as many services as in the past, she said. Since Medicare changed the payment structure several years ago from per-visit payments to one disbursement for a 60-day ‘episode of care,’ agencies have simply been forced to cut back on services they cannot afford.

“We have been through many, many client service plan reductions, cutting out hours of service for existing clients to help us survive,” Stiles added. “It definitely has an impact on clients when service plans are being reduced out of necessity.”

Federal lawmakers are also talking about a 15{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} across-the-board cut in Medicare, said Joseph Larkin, director of Mercy Home Care. “That would hurt a lot of agencies,” he said. “It’s certainly not definite, but if we see the 15{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} cut, I think you’ll see agencies close across the country.”

And Medicaid has been equally troublesome, said Julie Deschenes, legislative and public affairs coordinator for the Mass. Home Health Assoc., a home-care trade association. She explained that the rates are set every two years by the Division of Health Care Finances and Policy of the Mass. Department of Health. The latest rates were set in September.

“Were they enough?” Deschenes asked. “One could argue that the nursing rate was sufficient, but the home health aide and therapist rates were low; they average between 25 and 30{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of what it costs to provide care.”

For visiting nurse agencies that operate as non-profits, serving patients means operating under a mission, regardless of what the funding situation is, she added. But it’s getting more difficult to meet that mission.

“The agencies generally find ways to survive through private fund-raising or, if they’re lucky enough, through an endowment,” she added. “But we have often asked the question, should agencies be using fund-raising money to subsidize the state?”

Comforts of Home

Although the aging of the population shines a brighter light on the need for home-care services, home health spans a much wider range of patients, including disabled adults and children with special needs who are able to receive care at home.

In fact, home health agencies provide health and supportive services throughout all stages of life, from prenatal care through hospice and bereavement counseling. These services might include skilled nursing; social services; physical, occupational, and speech therapy; emergency response; nutrition counseling; and case management, just to name a few, Larkin said.

In addition, advancing technology is opening new horizons in home care, from chemotherapy, ventilator care, and infusion therapy to apnea monitoring and photo therapy for infants. And for individuals who simply need assistance with the activities of daily living, such as bathing, dressing, grooming, and getting into and out of bed, home health agencies can provide home health aides or personal care homemakers.

“Our agencies provide these skilled services to mothers and their newborn children, chronically ill children, disabled adults, as well as the elderly population. We provide services for a broad spectrum,” Deschenes said, as opposed to the home-care program offered through the state’s Office of Elder Affairs, which provides household assistance to the senior population only.

The ideal home health service, she said, is delivered under the guidance of a patient’s physician, in close collaboration with hospitals, nursing homes, and other health care providers so that patients may move seamlessly from one setting to the next as their needs change.

Considering the benefits offered by home health entities for those who can remain at home — and keeping in mind that it is less expensive to provide care in a home setting than in a nursing home — it’s disappointing that Massachusetts spends 23 times more for nursing home care than for home care, noted Karen Martin, director of Community Services for GSSS. She added that every patient who can receive care at home instead of at a nursing home creates a savings of between $28,000 and $40,000 per year on average.

“In a lot of cases, home care is the cost-effective option,” Larkin said, referring partly to patients who leave an acute-care setting and require four to eight weeks of intermittent help at home to recover.

“If a patient can be at home and doesn’t require the amount of help given at a nursing home, there’s nothing cheaper than staying at home,” he said. “It saves insurance companies money, and it saves the health care system money.”

Getting On with Life

It also can be a great comfort to people who know they can get by at home with a little outside help.

“I believe in it,” Larkin said. “There are so many things you can do with so fewer dollars — and people want to be at home. Nobody likes to go to the hospital; nobody likes to go to a nursing home.”

Virtually everyone, however, likes knowing that their health needs can be met in a setting in which they are comfortable. Even as they face an uncertain future, home health providers and proponents know that, even if the money to pay for such services can be elusive, the need isn’t going to go away quite as easily.