By 1992, the importance of home health care as well as hospice care had become of great importance. By then, an estimate of 9.5 million individuals in the United States suffered from physical and mental condition and had difficulty in performing elementary activities in their lives. Such required long term care which could be given by home health care. Medicaid and Medicare played and increased actions to make these individuals have access to home health care. Kathleen Simione in her article; the Home Health Care Industry and Reimbursement issues: Current and Future. Explores the importance of home health care industry and how it is funded by Medicaid and Medicare.
Simione presents the profile and history of home health care industry. The methodology used in its reimbursement, payment system and alternative methods that can be used in the industry’s reimbursement. The paper presents the shortfalls of the home health care resources. This shortfall is due to the increase in competition and the crucial elements to examine efficient use of resources by maximization of reimbursement. The bottom line of home heath care is to provide costs effective means and of high quality to all those in need of the service (Simione, 1992, pp 25).
Research frame work
Home health care agencies operate within the given regulations given the state and federal health laws. These home care agencies are also businesses which operate under business law. The home care industry operators have to have certification and licenses for its operation. To participate in Medicaid and Medicare, the HHA has to be granted a license to meet the Medicare requirements of certification. Medicare Covers the medical needs of those 65 and over. This is a federal health program. Eligible patients to this program have to be under a physicians care. Medicaid program is funded by both the state and the federal government and meant for people with low income.
Certain parameters have to be followed by the Medicare and Medicaid program as they provide for the needs of patients. This includes aspects like HHA should employed skilled workers and nurses, maintain clinical records, budget and plan records. This gives and assurance that quality service is given to the clients.
Different methods are used to determine reimbursement as well as ceiling and guidelines. There is a fiscal intermediary that is appointed by the payer to determine and evaluate the requirements and guidelines that suits the requirements of the insurance. The study describes the differing and complex system of reimbursements that the payers use for home healthcare service purchase. The charges for these services are compared and inferences are drawn from the differences in payer’s payment levels.
The research utilizes data from home heath agencies surveys of hospices, the 1992 National Home and Hospice Care Survey and patients done by the NationalCenter for health statistics. The case mix system is also used to establish the history of average cost and budgeted cost. The current method of reimbursement had nothing to encourage management efficiency or discourage waste of resources. This old system only encourages home health care to be within the limits of Medicare. An accurate estimation is also not provided by the current methodology. This makes it hard to the home care agency as a business to operate without knowing its revenue.
Samples for the study consist of the home heath patients who benefit from the insurance payers. Analysis of each patient is studied in respect to the received services from the Medicare and Medicaid. Billing of information is however unavailable to the whole chosen sample. This affects the outcome of the data which affects the general outcome of the study. Additionally, patients who are the direct beneficiaries of the payments from the insurance providers are unknown.
NHHCS inquired the home health care agencies to offer information that deals with the number of visits done by patients and the last billing period. This information concerns medical supplies, drugs, and services charges. The difference on the payer reimbursement to HHA is presented by the use of various regression models. The five categories to be created as similar to those of Medicare discipline include; therapy service (audio logy, speech therapy, physical therapy, vocational/ occupational therapy). Home health aide services include medication and personal care assistance.
Medical services category include referrals services, counseling and social services. The fourth category of skilled nursing services includes high tech care, skilled care, and wound care and catheter maintenance. The last category is on physician services. The two categories of services that are not covered by Medicare are services like transportation, meals on wheels, nutritional and dietary services and the category under companion / homemaker services.
Selected PPS features have been selected to determine payment methods of HHAs. Alternative units of payment also have to be evaluated. The PPS models needs to test to minimize the risk in the finances of HHAs for them to participate. Case -mix adjustment method to be used to measure the HHA.
The significance of the research
The aim of the research is to monitor and measures HHA’s quality care among those sampled for the study. The different phases to be used clearly demonstrate the evaluation of quality care payment. The findings will show whether or not PPS affect the outcomes of the patients under study. Also reduced costs in the management of HHAs can be reduced without tampering with the quality and outcome of health care.
Evidence and Data analysis
The differentials to the mix of patients who visited the HHA could be estimated by the model. This is through the limitation of patient samples especially those who have received one type of service since the last recorded time. This is mainly applied to those patients in need of skilled nursing services. The characteristics of other agencies could however influence the differences in charge.
Therefore, it is important to specialize on those patients who benefit from the specified insurance source. This means that patients who benefit from Medicare will be analyzed differently from those financed by Medicaid. The agency cost structures are also measured in relation to the specification of the payor.
The estimated difference could reflect on the differences of these agencies and how the patients are affected differently. The two specifications are then measured to determine what or not the difference of the patient’s outcome is a result of the difference of payment from the two payors- Medicaid and Medicare.
Simione, K (1992) Home Health Care Industry and Reimbursement issues: Current and Future. pdf