October 29, 2014

To safeguard seniors, repeal cuts to home health

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The Hill Congress Blog

Every day, about one in every 25 Americans – an estimated 12 million in all – receive healthcare in a place where it was once only rarely available: at home. Clinical services brought to your front door are increasingly in demand and, as our population ages, will be required in the decades ahead vastly more than ever before.

Yet on January 1 this year the Centers for Medicare and Medicaid Services (CMS), under the Affordable Care Act (ACA), slashed funding for home health by 3.5 percent a year for four years. That decision directly affects the 3.5 million Medicare patients nationwide who currently depend on home health. It also defies common sense, flying in the face of everything I ever learned as a family physician.

Certainly I understand the big push to lower healthcare costs, whether with accountable care organizations, patient-centered medical homes or bundled payment programs, and applaud any and all efforts along those lines. Healthcare in the U.S. is still much too expensive, and even though costs are now rising at a slower rate, we can do better, and we should.
Still, the across-the-board 14 percent Medicare cut for home health is fraught with the most glaring of ironies. Healthcare delivered at home often costs demonstrably less than – while providing clinical attention equally effective as – services rendered either in a hospital, a nursing home or an assisted-living facility.

Hence, the cuts will achieve the opposite of the effects intended. Chronically ill elderly patients, the absolute sickest of our sick and thus by far the most vulnerable, will be placed at even greater risk. As a consequence, hospital admissions and readmissions, despite initiatives underway to lower the rate of both, will rise. With patients institutionalized rather than at home, the costs of care will soar.

Ultimately, the ACA, based on the premise of improving access to care for all, especially the disadvantaged, will hamper such access, with our poorest suffering the worst. Indeed, independent analysis of CMS data shows that the cuts will put 1.3 million Medicare patients at risk of losing access to home healthcare.

As it happens, two lawmakers have proposed a solution. Reps. Tom Price (R-Ga.) and Greg Walden (R-Ore.) last month introduced the Securing Access Via Excellence (SAVE) Medicare Home Health Act. The bill calls for repeal of the home health Medicare cuts for 2015, 2016 and 2017. The reform would establish a purchasing program based more on value than volume. It would create incentives for home health agencies to provide beneficiaries with high-quality care and lower readmission rates, all along rewarding positive patient outcomes.

Even with such economic efficiencies in place, I favor this pending legislation largely on clinical grounds. Without the funds that grant access to home health, physicians will face a difficult choice about patients. Seniors and those with disabilities may have to return to a hospital or enter a long-term care facility, much costlier settings that drive Medicare spending higher. The home health benefit is long proven to shorten hospital length of stay, lower hospital readmissions and stays in long-term facilities, and improve patient outcomes.

Evidently most Americans agree. According to a survey of registered voters just last month, sponsored by the Partnership for Quality Home Healthcare, 81.5 percent of respondents believe Congress should act to prevent harm to American seniors that could result from the current cuts to Medicare home health services. Such skilled health care is needed desperately. Twenty years ago, every person over 80 in the U.S. could get support from seven caregivers, the AARP estimates. Over the next 20 years, that ratio is expected to drop to one in three.

In my role as chief medical officer for the nation’s largest healthcare at home provider, I know full well how much home health means to patients and caregivers. Every day, we dispatch thousands of nurses, therapists, social workers and others to deliver deeply intimate attention on a one-to-one basis. Those professionals routinely help patients and family caregivers manage chronic diseases such as diabetes and heart failure, monitor prescription medications, handle necessary tests, and administer essential therapy.

Our average patient is 81 years old, suffering at least one chronic disease and taking no fewer than 12 different medications. But thanks to such services, they eventually move better, eat better, breathe better, and suffer less pain. Those unable to walk can once again climb to the top of the stairs. A man who has lost the power of speech can once again tell his wife he loves her.

Years ago, as a family physician in Louisiana, I made house calls. Certain patients were too sick or too hurt to get to my office. Sometimes a condition or injury had worsened, requiring my evaluation bedside. I would visit patients at home because home was where they needed care.

We should keep making those house calls. After all, the house call is true healthcare reform in action.

Fleming is former president of the American Academy Of Family Physicians and chief medical officer of Amedisys Home Health & Hospice Care.

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