Health Insurance for the Aged: Participating Home Health Agencies

Transcription

1 Health nsurance for the Aged Partcpatng Home Health Agences by DAVD ALLEN* THE 965 AMENDMENTS to the Socal Securty Act establshed a comprehensve program of health nsurance for the aged (Medcare). Rembursement for home health servces rendered under the auspces of organzed home health agences s one of the covered benefts. The program helps meet the cost of parttme or ntermttent nursng care and related servces furnshed by vstng nurse agences, hosptalbased home health programs, and smlar agences. Ths beneft provdes an mportant and less costly alternatve to nsttutonalzaton, whether n a hospt,al or extendedcare faclty, for persons who requre medcal care but could be taken care of at home. Home health servces are offered under both the hosptal nsurance and supplementary medcal nsurance part of the program. The legslaton establshng health nsurance for the aged under the Socal Securty Act stmulated consderable growth n the number of home health agences throughout the country. The Publc Health Servce estmates that n 963 only about 25 agences would have met the defnton of a home health agency n the Socal Securty Act,. As of March 3, 967, close to,8 home health agences had been certfed for partcpaton under the Medcare program. What knds of agences are these? Where are they located! What knds of servces do they provde? Ths artcle descrbes the home health care servces covered under Medcare and presents some data on the number and characterstcs of agences certfed for partcpaton under the program. HOME HEALTH AGENCY DEFNED A home health agency s a publc agency or prvate organzaton, or a subdvson of such an * Dvson of Health nsurance Studes, Offre of Research and Statstcs. agency or organzaton, that s prmarly engaged n provdng sklled nursng and other therapeutc servces. To be approved for partcpaton under the program as a home health agency, each faclty must meet specal requrements, ncludng provson of both sklled nursng care and at least one other therapeutc servce rendered drectly to patents. Each agency must also have polces establshed by an advsory group of professonal personnel, ncludng at least one physcan and one regstered nurse, and must be supervsed by.. a physcan or regstered nurse. n addton, each partcpatng agency must be lcensed n accordance wth State or local law where applcable. Prvate proftmakng organzatons cannot partcpate n the program unless they are lcensed under State law. Under the hosptal nsurance program, an agency prmarly provdng care and treatment of patents wth mental dseases cannot be defned as a home health agency.* Servces avalable from the partcpatng agency need not be rendered by staff members (full tme or part tme). Contractual arrangement for provson of servces by nonstaff members s permtted under the law. BENEFTS PROVDED Home health servces are offered under both t,he hosptal nsurance and supplementary medcal nsurance programs of Medcare. Under the.former a patent s enttled to as many as vsts n a lyear perod followng hs most recent. dscharge from a stay of at least 3 consecutve For a detaled detnton of a home health agency, see secton 86 () of the Socal Securty Act as amended July 3, 965. For a detaled and complete descrpton of the condtons of partcpaton, see Wealth nsurawe for the Aged Condtons of Partcpaton for Home Health. Agences (HM2), Socal Swurty Admnstraton, SOCAL SECURTY

2 days n a hosptal or extendedcare faclty. n a calendar year wthout the requrements for Under the supplementary medcal nsurance pro prevous nsttutonalzaton. gram, a patent s enttled to as many as vsts Gnder both programs, a vst s defned as a TABLE l.number and percentage dstrbuton of partcpatng home health agences, by type of agency, geographc dvson, and State, as of March 967 Geographc dvson and State Total Unted States, Z New England Mane.. New Hampshre 29 Vermont 5 Massachusetts. 67 Rhode sland. Connectcut G Mddle Atlantc _. New York New Jersey. 55 Pennsylvana. 9 East North Central 29 Oho.. 9% ndsna... 2 llnos Mchgan E Wsconsn 5 West North Central 7 Mnnesota 35 owa 7 Mssour. North Dakota 7 South Dakota 4 Nebraska. KJlnS&S~. 2 South Atlantc 86 Delaware Maryland 2 Dstrct of Columba Vrgna West Vrgna North Carolna. South Carolna es Georga... Florda. 56 East South Central. Kentucky Tennessee Alabama 3 Msssspp. 2 West South Central Arkansas Z4 Lousana 37 Oklahoma Texas... g Mountan 5 Montana f daho Wyomng. Colorado.~~~.~~~~~~.~~~~~~~ l! New Mexco Arzona f Utah Nevada Pactc... 4 J?ashngton 2 orego*... 2 Calforna 8 Alaska Hawa stng nnrse ssocaton t 9 8 a 5 A c 4 ; 3; 3 ombston of overnlent and duntarg _ Guam Puerto Rco Vrgn lslsnds ( 8 26 Number of agences Percentage dstrbuton H ospta based P rogmm Subunts of State Health Departments certfed on a statewde bass counted separately. BULLETN, SEPTEMBER 967,, Other 39 Total loo.. loo.... loo.. loo. loo... w.. loo loo loo. loo.. loo loo. a w. a loo. lw.. loo. loo. m E!.. ( loq.( loo.( loo.( loq.( Jstng * T? kxocaton x2 2.5 _. _. 3.7 A _ _ ; Comb laton f governn oent an< V oluntar Y agency 5.3 _ !E t.! 5.._ _ _._ 66. _... (.. loo.( 7.6 _ FE loo Q ma o.a! o.c 5l.C 63.C Hosptal. based program _ _ _ zo 7.,

3 personal contact n t,he place of resdence of a patent made for the purpose of provdng a covered servce by a health worker on the staff of the home health agency, or by others under contract or arrnqenlent ; or a vst by a patent on an outpatent bass to a partcpatng hosptal, extencledcare faclty, or rebabltat on center. The followng servces, when provded by a partcpatng home health agency, are covered under both programs Parttme or ntermttent nursng care Physcal, occupatonal, and speech therapy Medcal socal servces Parttme or ntermttent servces of a home health ade Medcal supples (except for drugs and bologcals) and the use of medcal applances Servces of nterns and resdentsntranng Outpatent servces. All home health servces must be provded under a plan establshed and supervsed by a physcan and specfyng the nature and frequency of servces to be furnshed. The plan must be establshed wthn 4 days after dscharge from a hosptal or extendedcare faclty. nder the hosptal nsurance program, the patent does not need to meet. any deductble or consurance requrements for home health servces. The cost of the maxmum of vsts to whch a patent may be enttled s covered n full. The home health agency receves payment for covered servces based on reasonable costs. Under the supplementary medcal nsurance program, the home health agency s rembursed for 8 percent of the reasonable cost of covered servces, after the patent has frst ncurred s&cent expenses to meet the $5 deductble requrement. The $5 deductble can be met by the patent by ncurrng expenses for any servces covered under ths program, not just those for home health servces. As of March 3, 967,,753 home health agences had been certfed to partcpate n Medcare. Certfcatons are made to the Department of Healt,h, Educaton, and Welfare on the recom Socal Securty Admnstraton, Home Health Agency Manual (HM), page 8. mendaton of State agences that the provders meet the condtons for partcpaton promulgated by the Secretary of Health, Educaton, and Welfare.,L partcpatng provder s a certfed nsttuton that has entered nto an agreement wth the Socal Securty Admnstraton not to make charges for covered tems and servces except deductble and consurance amomlts where applcable and to provde servces on a nondscrmnatory bass n complance wth ttle V of the Cvl Rghts Act of 964. TYPE AND. GEOGRAPHC OF FACLTES DSTRBUTON The overwhelmng majorty of partcpatng home health agences are ether agences admnstered by State or local health departments or vstng nurse assocatons (table ). Offcal health agences accounted for 54 percent of the,753 agences, and vstng nurse assocatons rel)reseutecl an ~ddton~l 3 percent of the total. These two tyl)es of agences hare tradtonally provded the bulk of home health servces. Hosptnlhsed programs, whch represented only 8 percent of all partcpatng agences, are a com )aratvely recent development u the feld of home health care. There are regonal dfferences by type of part &pat ng agency. Vstng nurse assocatons account for 73 percent of all home health agences n Kew EGglad, compared wth 3 percent, n the South Central States. n contrast, only out of every 5 agences n Bew England s an offcal lealtl agency, and almost 95 percent of the agences n the South Central States are admnstered by State or local departments of health. n only three geographc dvsons, hosptalbased programs represent more than percent of the partcpatng agences n the programthe &fddle Atlantc States wth 9 percent, the West Nortb Central Slates wth 6 percent, and the Mountan States wth 4 percent. n seven States, the State Department of Health has elected to partcpate as a sngle state. wde agency. Techncally, each of these health departments consttutes one home health agency. To determne the avalablty of servces wth greater geographc precson, each ndvdual 4 SOCAL SECURTY

4 local unt n these States has been dentfed and counted separately. The number of subunts of statewde agences counted n ths way are Alabama, 34 countes; Arkansas, 66 countes; Lousana, 34 parshes ; Oklahoma, 4 countes ; Pennsylvana, 44 countes ; South Carolna, 22 countes; and Vrgna, 28 dstrcts. n the frst report of partcpatng home health agences, each statewde agency was consdered one agency because the subunts could not be dentfed and counted separately. Thus, more than half the ncrease n the number of agencesfrom,675 as of October 5, 966, to,753 as of March 3, 967reflects ths dtference n countng procedures. TABLE P.Xumber and percentage dstrbuton of persons enrolled n the hosptal nsurance program and of partcpatng home health agences, by geographc dvson Persons enrolled n hosptal Partcpatng home wursnce program L health agences 2 Oeographc dvsm Unted States ,7 /.224 3,765 3,672,848 2,47,77, ,5Y. A lr.6 Y ,753 loo Yo tt. 5 O7 6. ll6. t Y Y.6 5Y x.2 Other areas R 3l.2 As of July.~66. 2 As of March 3, ly6. J Excludes enrollees n foregn countres and those wth place of resdence unknown. Comparng the dstrbutons of Facltes and of persons enrolled n the hosptal nsurance program provdes one measure of the geographc tlterences n the avalablty of servces of home health agences (table 2). t s recognzed that the agences vary consderably n the range of servces provded aud the number of patents served. Even wthout consderaton of these factors, t seems clear that there are wde varatons n the avalablty of home health agences n the Saton. Oneffth of the agences but only 6 percent of the hosptal nsurance enrollees are Howard West, Health nsurarwe for the Aged The statstcal Program, Socul Securty llrclt?u, January 967, page 2. located n Sew England. n the Pacfc regon, llowever, only 8 percent of the agences are servng percent of the enrollees. HOME HEALTH SERVCES AVALABLE The lack of homogenety n the entre group of home health agences s a noteworthy characterstc of all home health agences, whether they l)lrtclx\te the )rogrn or not.,gences vary greatly, for esanlple, n sze and extent of servces otered. Each makes ts unque contrbuton to the care of the sck at home. At one end of the spectrum are agences prmarly provdng ntermttent or parttme nursng servce and one more other therapeutc servces to the homebound. At the other end are agences provdng comprellensve home care programs that coordnate under a central admnstraton the provson of medcal, nursng, socal, and other servces n t le home for tle )ateut wth multple medcal and yartmetlcal needs. Soule of these )rograms lmt admsson to very ll or serously hatdcapped persons ; others admt less serously ll persons who need only one or more types of servce. To partcl~te n the health surance program each of the,753 home health agences must oter sklled nursng care and at least one other servce. There are dentfable types of servce avalable from home health agences, of whch sklled uursng care s one. Over twotllrds of the partcpatng agences (69 percent) offer physcal t lerapy ; t thrd (;$4 percent) offer the servces of home health ades (table 3). Servces offered by oneffth or more of the partcpatng agences are nutrton al gudance, applances and equpment, medcal socal servce, and speech therapy. There s also large amount of varaton n the type of servces avalable n ndvdual States. For example, physcal therapy servces, avalable n almost 7 percent of the partcpatng agences natonally, are offered n each of the four agences n Nebrnska but by none of the eght agences n Wyomng. C om arable dterences n the avalablty of servces other than nursng care may be found for all of the other 9 types of servces. BULLETN, SEPTEMBER 967 5

5 Table 4 shows the dstrbuton of the 53 States ng to the relatve avalablty of specfed servces. and Terrtores wt,h at least one partcpatng Thus, there are t,hree Stat.es where physcal home health agency (nether Alaska nor Amer therapy s avalable n less than 2 percent, of the can Samoa have a partcpatng agency) accord partcpatng agences. n 22 States, n contrast, TABLE 3.Number of partcpatng home health aeences and percent) offerng selected servces, by geographc dvson and State, as of March 3, 967 Geographc dvson and State Total Unted States.753 NC! England... Mane... New Hampshre. Vermont.... Massachusetts.. Rhode sland Connectcut Mddle Atlantc _.. New York... New Jersey... Pennsylvana. East North Central. Oho... ndana llnos. Mchgan. Wsconsn. West North Central. Mnnesota... owa Mssour... North Dakota.. South Dakota Nebraska... Kansas South Atlantc.... Delaware.~..~~~~~~~ Maryland Dstrct of Colomba Vrgna. West Vrgna... North Carolna. South Carolna * Georga Florda.. East South Central Kentucky.. Tennessee. Alabama... Msssspp. E % 29 F z c West South Central 66 Arkansas. 6f Lousana. 3; Oklahoma. 4 Texaco. 2z Mountan. Montana... daho..._ Wyomng Colorado... New Mexco Arzona Utah.. Nevada.. PscfC... Washngton Oregon. Calforna. Alaska. Hawa... 5f f f 4 f 4 2 sl _ Other BTess.. Amercan Samoa. Guam... Puerto Rca... Vrgn slands.. lursng care loo. hyscal,kx3py ,;; o ES ; % l. 85. oo.c f.C C f f El 5. loo. c 2.; f3.t 55.t c 55. 9O.t loo. ( c ( W.l loo. ( OO.l k.cupatonal hcrapy S tl u [edcal racal s ervce loo S 2.C C 9. 5.C ~ 2O.C 37.! l 5.f 8. 4.t ! 8... Xl. 33. GU.f Subunts of State health departments on a statewde bass counted separately ; 2t ~s c f f C 66.2 oo.c J.c xl loo. ma nterm and &dents F hsrmac eutcal servce Applances and 2% R ! C!.f O.C 2. f; 3.! Zft loo. a , , 29. a, , ma BJ , , ?; loo. loo., c 6.. y 2o.C 7.f ; O.C 27.f ;. loo. c 2. 3.! C C 33.2 _. c.c VOCRtonal udance fl z SOCAL SECURTY

6 TABLE 4.Number and percentage dstrbuton of 53 States, by percent of agences offerng specfed servces, as of March 3, 967 Percent of agences Number of States Percentage dstrbuton of States Under loo. 2X Z! s ~~.~~~~~~~~~~~~~~ ,ormore ncludes 49 States (Alaska omtted), the Dstrct of Columba, Guam, Puerto Rco, and the Vrgn slands 8 percent or more of the agences ofler ths serv States each of the home health servces specfed s ce. Except for physcal therapy, home health avalable n less than twoffths of the agences ades, and nutrtonal gudance, n nearly all the partcpatng. Recent Publcatons* SOCAL SECURTY ADMNSTRATON BUREAU OF D~ABLTY NSUHANCE AND PU~.C HEALT SERVCE OCCUPATON HEALTH PROCHAM. Occupa tonuz Characterstcs of Dsabled Workera, by Dsablng Condton Dsablty?zsurance Hencft Swards Uade n to Men Under dye 65. Washngton U.S. Govt. Prnt. Off., pp, $.75 Jont study by the Socal Securty Admnstraton and the U.S. Publc Health Servce presents tabular data on the number of dsablty nsurance benefts awarded to men under the Socal Securty Act for each occupatonal group, by age and dsablng condton. GENERAL ABBOTT, CARLES C., ed. Bad Research n Fnance Xccds and Prospects. Charlottesvlle Unversty of Vrgna, Graduate School of Busness Admnstraton, pp. $5. BARTELS, ROBERT. Credt Uanagement. New York Ronald Press, pp. $9. Credt vewed n ts elemental and collectve aspects both as a socal and a techncal phenomenon. * Prepared n the Lbrary, Department of Health, Educaton, and Welfare. Orders for tems lsted should be drected to publshers and booksellers ; Federal publcatons for whch prces are lsted should be ordered from the Superntendent of Documents, U.S. Government Prntng Offce, Washngton, D.C BEGHERS, JAMES M. Populaton Processes n Socal Q&ems. Sew Pork Free Press, pp. $6.95. GROSS, BERTRAND &., ed. Acton Un.der Plannng The Gudance of EcorLomc Deelopmest. McGrawHll Book Company, pp. $2. Deals drectly wth mplementaton of plans for economc development. HARRS& C. LOWELL. Haur7bool of State and Local Government Fnance pp. $.5. Sew York Tax Foundaton, nc., Hoes, RA R. Zctauny the H ork Force An Analyss of Current h xpcrencc. Berkeley Unversty of Calforna Press,!%7. 28 l,p. $6. Descrbes the knds of tranng programs n exstence, the reason for ther establshment, ther sponsors, and ther results. SELSON, RCHARD R., and others.!z ecl&nozoyy, Economc Growth and Publc polcy. Washngton, Brookngs nsttuton, pp. $t. Relaton of research and nnovaton to economc growth. POWELL, F. ENOCH. Hazjnys n a Free Socety. (2d ed.) London nsttute of Economc Affars, 9t6. 4 pp. $5.85. U.S. CONGREBS. HOUSE. COMMTTEE ON GOVERNMENT OPERATONS. The Use of Socal Research >L F&era Domestc Programs. Washngton U.S. Govt. Prnt. Off., vol. (Commttee Prnt. 9th Cong. st sess.) (Contcued on page 46) BULLETN, SEPTEMBER 967 7