September 11, 1974
Page 30774
DEVELOPING A NATIONAL HOME HEALTH POLICY
Mr. MUSKIE. Mr. President, yesterday the Senate passed S. 3280, the Health Services Act of 1974, which included authorization of home health services startup funds. Support for this provision was based on the work of the Senate Special Committee on Aging's Subcommittee on Health of the Elderly, which I chair.
I am pleased to announce that on the same day HEW's Health Insurance Benefits Advisory Council adopted a report from its Committee on Home Care which also drew upon the work of the Subcommittee.
The committee found:
Properly utilized, in-home health services can provide a preferred means of restoring and maintaining the health of individuals and families, as well as reduce or prevent hospitalization or long-term institutional care.
Yet the committee concluded:
Despite the demonstrated value of home health services, priority continues to be given by third party payers and current legislation to the present institutionally-oriented system of health care. Reversing this priority would make it possible for home health care to emerge as a major national health resource and to take its rightful place in any comprehensive health insurance program that may be enacted.
Mr. President, passage of the Health Services Act is a significant step forward in making home health care a major national health resource. However, improvements in medicare are still needed. The committee's recommendations are:
First, change the requirement for "skilled nursing care" to nursing care or nursing services. As the committee noted:
The "skilled" nursing requirement has been one of the main barriers to the provision of needed home care to the elderly since it has limited benefits to those who are acutely ill and need rehabilitation, while denying needed benefits to patients whose condition has stabilized or who require a somewhat lower level of care than that defined as "skilled".
Second, need for any one of the covered services in the law should qualify the beneficiary for medicare home health benefits rather than the need for skilled nursing care or physical or speech therapy.
These two recommendations of the committee are included in S. 2690, my home health medicare amendments. I heartily concur with these recommendations as well as the administrative recommendations and urge the Secretary of Health, Education, and Welfare to give them serious consideration. Adoption of these proposals would certainly help to strengthen home health coverage for aged and disabled Americans.
Mr. President, I ask unanimous consent that the report of the committee be printed in the RECORD.
'There being no objection, the report was ordered to be printed in the RECORD, as follows:
REPORT FROM COMMITTEE ON HOME HEALTH CARE TO HEALTH INSURANCE BENEFITS ADVISORY COUNCIL
SEPTEMBER 10, 1974.
BACKGROUND
The recommendations in this report are made in the belief that home health care is a basic component of any comprehensive health program. Properly utilized, in-home health services can provide a preferred means of restoring and maintaining the health of individuals and families, as well as reduce or prevent hospitalization or longterm institutional care. Furthermore, studies indicate that the majority of older persons prefer to remain in their own homes. The familiar intimacy of the home setting meets a unique and vital health need: convalescence is faster, more complete.
The home health care benefits currently available under the Medicare and Medicaid programs as well as from other third party payers are far from meeting the full range of patients' health care needs. Home health care currently accounts for less than 1 % of Medicare expenditures and an estimated .4% of Federal/State expenditures under Medicaid. Increased utilization may follow the recent elimination of beneficiary coinsurance payment for home health care under the medical insurance portion of Medicare; however, further changes are needed before home health care can reach its full potential as an important contributor to the Nation's health care delivery system.
The present low utilization of home health care benefits can be attributed to a variety of factors.
These include the Medicare statutory requirement for "skilled nursing care;" the absence of coverage under the Medicare law for homemaker services; the lack of recognition on the part of physicians, other providers and patients of the available benefits or of the services of local agencies; the reluctance of some physicians to prescribe home care; and the absence of home health care services in rural or remote areas. From the consumer standpoint, home health services of quality are not a valid resource in terms of availability and accessibility. About half of all the counties in the Nation had no home health agencies as of July 1973.
The Report of the Special Senate Committee on Aging, "Home Health Services in the United States" (April, 1972), identifies convincingly the problems which home health agencies are encountering in their endeavor to provide vitally needed services to home bound patients under Medicare or Medicaid programs. The Special Committee on Aging feels that the legislative instrument materially limits the delivery of home health care. In addition, participants in the hearings before the Special Senate Committee on Aging identified restrictive administrative policies, complex reimbursement procedures, narrow interpretation of the law, and limited coverage as serious roadblocks to the development of additional home health services.
This is reinforced by the GAO Report of July 9, 1974 Home Health Care Benefits Under Medicare and Medicaid, which emphasizes the same problems and makes specific recommendations to improve utilization and assure more effective and uniform interpretation of existing benefits.
While home care can normally be provided at a fraction of the cost of inpatient care, there are no definitive national cost figures. The GAO report cites the fact that several studies have pointed out that home health care can be considerably less expensive than care in a hospital or skilled nursing facility. The Committee believes that it will prove to be more cost effective to utilize home health care services instead of institutions for the long term care patient. It urges the Secretary to continue the special studies authorized by Section 222 of P. L. 92-603 in order to broaden the existing base of knowledge about home health care.
There is ample documentary evidence that home health services represent a logical, humane, and economical means of maintaining a quality of life and of forestalling or shortening institutional care. The restrictive laws now in effect do not recognize the value of preventive, supportive, and counseling services in health maintenance. The chronic diseases to which the aging are prone demand sustained attention to prevent health care crises requiring institutionalization.
Home health care is also preferred for those who require only part-time or intermittent health services. A home health aide can frequently make it possible for an ailing person who lives alone, or with a spouse too frail to provide care, to remain at home.
Despite the demonstrated value of home health services, priority continues to be given by third party payers and current legislation to the present institutionally oriented system of health care. Reversing this priority would make it possible for home health care to emerge as a major national health resource and to take its rightful place in any comprehensive health insurance program that may be enacted.
There is broad consensus and increasing activity regarding the need to expand the breadth, scope, and reimbursement of home health services, subject to appropriate utilization safeguards. Such expansion could be accomplished by revising or eliminating restrictive administrative and statutory requirements; embarking on a program to develop an affirmative attitude toward home health services by third-party payers, physicians and others in the health care community, and consumers; and providing strong Federal support for the development of comprehensive home health services throughout the Nation.
RECOMMENDATIONS RELATING TO MEDICARE
Although the Committee believes that a number of administrative and legislative changes would be desirable in the Medicare home health benefit, it has agreed that the recommendations below should be given highest priority. The administrative recommendations are considered by the Committee as having potential for immediate implementation. The legislative recommendations have longer range implications and should be considered essential to any development of new health legislation or modification of existing benefits defined by statute.
A. Administrative actions
1. The term "home health aide", should identify an individual who could render a broad range of services addressed to health and health-related needs. Under current interpretive practice, the services of a home health aide are narrowly defined as primarily personal care services, greatly limiting services such as cleaning or shopping which are needed to protect the health and safety of the patient. Without these supportive services, aged persons who live alone may be forced to remain in a hospital longer than necessary or forced from their own homes into an institution earlier than necessary. Since these supportive services are so often essential to the care and continued independence of the ailing elderly it is recommended that the guidelines clearly define these supportive services as an integral part of the overall services.
2. The adequate utilization of home health services requires knowledge and understanding by both the consumer and the health professional. It is recommended that the Department embark on a strong public information program to fully acquaint families, patients, physicians, hospitals, home health agencies and other health organizations with home health services currently available in the community.
B. Legislative actions
1. The words "skilled nursing care" in the physician certification requirements of the statute, and the words "skilled nursing services" in the conditions of participation for home health agencies, should be replaced by the words "nursing care", or "nursing services", omitting the word "skilled". The "skilled" nursing requirement has been one of the main barriers to the provision of needed home care to the elderly since it has limited benefits to those who are acutely ill and need rehabilitation, while denying needed benefits to patients whose condition has stabilized or who require a somewhat lower level of care than that defined as "skilled".
2. The physician certification requirement in the statute for home health services should be changed to provide that the need for any one of the covered services would qualify the person for home health benefits, provided the services are based on medical need and rendered as part of a written care plan approved by a physician. (At present, in order for a beneficiary to be eligible for any home health benefits, a physician must certify that the beneficiary needs either skilled nursing care or physical or speech therapy.)
RECOMMENDATIONS RELATING TO MEDICAID
With regard to the Medicaid program, the Home Health Committee endorses the GAO recommendations to improve the administration of the Medicaid home health care benefits program by:
1. Impressing upon the States that home health care is generally a less expensive alternative to institutional care and is therefore intended to be used when home health care would meet the patient's needs and reduce costs.
2. Clarifying for the States the specific home health services which are eligible for Federal financial participation and define these services.
3. Encouraging the States to establish payment rates for home health care at a level that will stimulate greater utilization of home health care.
4. Encouraging and assisting home health agencies in their efforts to increase the awareness and support of the health field regarding Medicaid home health care benefits as an alternative to institutional care.
CONCLUSION
The Home Health Care Committee urges that the Council approve the recommendations herein because of their contribution to sound patient care in the home and their potential for reducing unnecessary institutionalization.