Chronically ill patients soak up lots of a doctor&s time. Home care offers an economical alternative.
Chronically ill patients soak up lots of a doctor's time. Home care offers an economical alternative.
No matter what he tried, FP George Taler couldn't stabilize 56-year-old Jamie, a morbidly obese woman with osteoarthritis, congestive heart failure, and diabetes. Jamie's cardiovascular status was deteriorating, she had chronic unhealed wounds, and the monthly visits to Taler's Washington, DC, office were taxing her more and more. Concerned and frustrated, Taler turned to a home care agency and ordered a nursing assessment for Jamie.
The results were startling. The nurse found potato chips and other forbidden foods throughout Jamie's house. Worse, Jamie's abusive, alcoholic son capriciously withheld her medications. The nurse and Taler collaborated with local social and governmental agencies to place Jamie in an assisted-living facility, where she was better able to take care of herself. Her wounds have since healed and her CHF is under control. "Without that home nursing visit, I never would have learned the extent of Jamie's problems, and her condition would have worsened," says Taler.
Having nurses and other health providers, such as physical and occupational therapists, visit chronically ill patients at home is both an efficient and cost-effective way to manage care. But when Taler, who is the immediate past president of the American Academy of Home Care Physicians (AAHCP), mentions home care to other doctors, he hears more grumbling than enthusiasm. The common perception is that home care requires a lot of unreimbursed physician time, is prone to Medicare audits, is fraught with paperwork, and seldom provides doctors with timely feedback about their patients.
In Taler's view, home care is more beneficial than detrimental to physicians. For starters, seeing chronically ill patients in the office costs doctors money. Although upper-level office visits garner greater reimbursement, physicians earn less per minute than when they see patients with less complex problems. And the extra time a physician spends with chronically ill patients can throw him off schedule or force him to see fewer patients each day, says Taler.
"When a CHF patient comes to the office and you haven't seen him in a while, there's a long list of symptoms you have to discuss," he explains. "You're counting on the patient's veracity, but often he will tell you what he thinks you want to hear. You can make significant mistakes by assuming your regimen isn't working when actually it isn't being adhered to."
Taler, for example, kept trying to fine-tune Jamie's medications, not realizing she wasn't doing her part and was being hindered by her son. Taler relies on home care nurses to monitor his patients' compliance and provide him with ongoing assessments of their functional status. Armed with objective information, he can focus on the most critical problems first.
Geriatrician Cheryl E. Woodson of Woodson Center for Adult Health Care in Chicago Heights, IL, depends on home care nurses to catch complications early on. "Nurses are our eyes and ears in the field, and their observations are critical," she says. "A nursing problem today will be a physician emergency in three days if it's not addressed."
Clinical studies prove Woodson's point. A 1997 study published in the American Journal of Cardiology found that within six months of being enrolled in a home-based monitoring system, CHF patients made 23 percent fewer general medical visits to doctors' offices, their emergency room visits for heart failure were down 67 percent, and hospitalization rates declined 74 percent. And a 1991 study that appeared in the medical journal Chest showed that providing comprehensive home care services to severe COPD patients reduced the monthly cost of care per patient by $328.
Home care also spares physicians and their office staffs the task of providing the extensive education that chronically ill patients often need. "I would spend twice as much timemaybe moreanswering patient and family-member questions if home care nurses didn't visit my patients," says geriatrician James Powers, director of Vanderbilt Senior Care, a three-doctor practice affiliated with Vanderbilt University in Nashville.
Some patients are obvious candidates for home care: the post-stroke patient who needs ongoing physical therapy, or the CHF patient having difficulty complying with dietary and medication regimens. But there are many more who, with home care, can improve their functional status and use fewer medical resources. "Those patients who are ambulatory but moderately dysfunctional are disasters waiting to happen," says FP Lawrence Bernstein of Longmeadow, MA. An elderly patient with mild gait instability, for example, is at risk for falling and breaking a hip. A home assessment can identify strategies to make the patient safer with simple, often low-cost home modifications and, perhaps, in-home physical therapy.
Few insurers, however, will pay for home care if the patient is ambulatory. Medicare reimburses home health services only for patients who can leave their homes for medical appointments but little else. Other insurers don't necessarily insist that a patient be homebound before he or she qualifies for home care, but according to geriatrician Peter Boling, professor of medicine at Virginia Commonwealth University and past president of the AAHCP, "generally Medicare is one of the most flexible if not the most flexible payer. Most private payers approve far fewer visits."
To keep their loved ones out of a nursing facility for as long as possible, some families might be willing to foot the bill for home care, even if insurance doesn't cover it, Bernstein says.
Despite the cost savings of home care, payers seldom recognize the time physicians spend managing it. In fact, Medicare is the only major payer to reimburse doctors for care plan oversight. And to qualify for Medicare reimbursement, physicians must document 30 minutes per patient in a calendar month spent doing such things as developing and revising care plans, reviewing diagnostic tests and lab results, and communicating with home care professionals.
But attempting to get paid for overseeing home care isn't on most primary care doctors' to-do list. According to a 1998 survey of Massachusetts Medical Society members, nearly 90 percent of the more than 1,300 respondents didn't submit claims for care plan oversight to Medicare. More than half said they didn't know they could. Others said the time involved wasn't worth the payment, they weren't paid when they did submit claims, or they didn't spend enough time each month overseeing care. "It's such a headache," complains family practitioner Alan Weaver of Sturgeon, MO. "It's just one more thing in a busy practice." James Powers estimates that he files claims for overseeing home care for fewer than 10 of his 200 Medicare patients. The reason: He can't meet Medicare's 30-minutes-per-month requirement for most of them.
That's a shortsighted attitude, counters George Taler. Reimbursement is around $80 per patient per month, and, according to his experience, primary care physicians should be able to qualify for payment for about a quarter of their patients who receive home care. Doctors who are organized and systematize their interactions with home care staff may be able to justify reimbursement for as many as one-third of all homebound patients. "It's all in capturing the small moments," Taler says. "If you discuss a patient in two home care team meetings and have two other conversations with the nurse, then you've hit the 30-minute target."
Another reason physicians don't bill for care-plan oversight is that they don't understand the rules, maintains Peter Boling. "But if they would spend a little more time looking over forms as they are signing them, calling the home care agencies with questions, and reviewing patients' charts, all those activities count as oversight, qualifying them for reimbursement."
Then there is the issue of audits. When HCFA first authorized separate payment for care plan oversight in 1995, it projected a $310 million expenditure that year for the code, but paid only about $45 million in claims. The number of claims paid went up the following year, but by 1998 reimbursements had dropped to $25 million. With so few claims being filed, it's possible that physicians with large geriatric populations who submit care plan oversight claims may show up as statistical outliers. Whether they are actually audited may depend on how the private insurance companies that process Medicare claims view home care, Taler believes.
Concerns about being auditedthough realmay be overstated, especially for those who meet all the care plan oversight requirements, says Boling. "You hear the horror stories about audits, but I wonder how many people who tell them are squeaky clean. Were they really meeting the 30-minute requirement, or did they just automatically do the billing? Those who have good documentation and follow the rules will be all right."
Audits aside, if something goes wrong, are you likely to be sued? No, says Bernstein. "There have been almost no home care suits brought against physicians," he maintains. "Patients and families are so darned grateful for your involvement, suing you is the last thing on their mind. The axiom 'happy patients don't sue' is germane to home care." Vanderbilt's Powers agrees: "Liability is low with home care. Families are very satisfied and outcomes are enhanced."
There are several things you can do to ensure that a home care situation runs smoothly and that you'll be reimbursed for overseeing it.
If you're using a home care agency, Taler recommends a weekly meeting with the agency's nurse case manager. Those meetings apply toward the 30-minute requirement, they'll cut down on daily phone calls, and they afford doctors an opportunity to indicate the type of care they want delivered. "You have to give very specific orders as to what the nurses should call you about, what you want them to monitor, and what to teach patients," advises geriatrician Woodson. "That requires you to do a functional assessment of the patientevaluating, say, gait stability or cognitive status."
Likewise, you want to hear from the caregiver. Nurses know this. But if the caregiver is a family member, or somebody hired privately, you may have to encourage her to be forthcoming. "Caregivers can be intimidated by you. Even home care nurses, sometimes," Woodson says. If face-to-face meetings aren't possible, then schedule "phone rounds" at certain times of the day, she suggests.
There's no best way to track time spent on care plan oversight. Powers files all phone calls with home nurses in the patient's chart and tallies the calls at the end of the month, with four calls equaling the requisite 30 minutes. Susan Callaway-Stradley, a coding consultant in North Augusta, SC, recommends using a bright log sheet opposite the progress notes page in the patient's chart to record any home-care-related activities. "You have to track time in a way that's as effortless and automatic as possible," she says. "This way, the doctor makes a note in the chart to document the continuity of care and, with a few strokes of the pen, also records care plan oversight activities on the log sheet." (The AAHCP publication Making Home Care Work in Your Practice includes a sample form for recording care plan oversight activities.)
Recent rule changes will likely affect how doctors work with home care agencies. Last October, Medicare instituted a prospective payment system (PPS) for home health agencies. Paid a fixed rate for 60-day episodes of care, the agencies now have incentive to make care more efficient and to achieve the same outcomes with fewer resources and visits.
"Doctors will have to be more involved in setting care goals and determining rather quickly whether desired outcomes are being achieved," says geriatrician Joanne Schwartzberg, director of aging and community health at the American Medical Association. "The good news is that with PPS, doctors will probably be eligible for reimbursement for care plan oversight in most instances." But that will be largely because of the extra time they'll have to spend collaborating with the home care agencies. The bad news is that patients may get fewer home care visits, which may ultimately drive them into a nursing home or the hospital. The unprecedented clout of aging baby boomers may eventually be needed to ensure the continued availability of home care services.
Indeed, the elderly, who are the primary users of home care, account for about 13 percent of the current US population, but by 2030, when all of the surviving boomers are in their golden years, one of every five Americans will be elderly.
And many of these seniors will need some type of assistance. If not living with a long-term illness, seniors typically have other infirmities that affect their quality of life and ability to live independentlyproblems that occur more frequently with increasing age. About 14 percent have difficulty carrying out activities of daily living such as bathing and dressing; 21 percent need help completing instrumental ADLs like managing money, doing housework, and taking medications. Such challenges are almost twice as prevalent among seniors 80 and older: An estimated 27 percent have difficulty with ADLs; 40 percent with instrumental ADLs.
In tackling these problems, home care can be a bargain in comparison with other care venues, such as nursing homes, which cost an average of about $150 per day, or some $4,500 per month (although costs vary widely by regionfrom $90 per day in Hibbing, MN, to $295 per day in Manhattan). A MetLife Mature Market Institute study puts the cost of home health care at $12 to $24 per hour. That does mean round-the-clock home care can be even more expensive than nursing home care. However, all but the most fragile seniors usually can be maintained in their own homes with far less than 24-hour assistance.
Val J. Halamandaris, president of the National Association of Home Care, points out that an even more important advantage of home care is that it allows seniors to remain in their own homes and to function as viable members of society. "A hospital is, of necessity, a regulated, regimented environment. The same is true of a nursing home," Halamandaris says. "Upon admission to either, an individual is required to surrender a significant portion of his rights in the name of the common good. Such sacrifices are not required at home."