[Congressional Record Volume 144, Number 84 (Wednesday, June 24, 1998)]
[House]
[Pages H5275-H5287]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
ON MEDICARE CUTS TO HOME HEALTH SERVICES
The SPEAKER pro tempore. Under the Speaker's announced policy of
January 7, 1997, the gentleman from Massachusetts (Mr. McGovern) is
recognized for 60 minutes as the designee of the minority leader.
Mr. McGOVERN. Mr. Speaker, tonight I join my House colleagues to
discuss the home health care cuts contained in last year's Balanced
Budget Act. While I have pushed this issue in Congress, and with the
Clinton administration since November, time is running out.
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If Congress is going to find the will to fix this problem, all sides
are going to need to act quickly and move this issue forward and move
it forward now.
Mr. Speaker, a hastily conceived and ill-considered provision in last
year's Balanced Budget Act mandated deep cuts in the Federal
Government's commitment to home health care. My colleagues and I take
to the floor tonight to shed some light on this national crisis.
When the Balanced Budget Act of 1997 was passed into law, it cut
Medicare by $115 billion over five years. Between $16 and $17 billion
of the Medicare cuts came out of home health care through the
institution of a per-beneficiary cap under an interim payment system.
The new formula for home health care in the act will cap Medicare
payments to home health care
[[Page H5276]]
agencies based on costs from four or five years ago, regardless of how
efficient or wasteful an agency was at that time.
Now, try going to your local car dealer and telling them that you are
only willing to pay 1993 prices for your new car. Rightly so, they
would laugh you off the lot. But that is exactly what the Balanced
Budget Act does to home health care providers throughout this country
in order to save money.
Further, agencies are caught in a Catch-22 under this act. They are
forced to cut agency costs back to 1993 levels, but Federal law
prevents them from cutting back on the care they provide today.
In addition, eligibility requirements for people to receive home care
services have not changed at all. Those who qualified for home health
care before the Balanced Budget Act qualify for home health care today,
and under law, they must be treated.
How do agencies cut back their costs some 20 percent without cutting
back care? Well, in Massachusetts they have been closing their doors to
everyone and getting out of the home health care business altogether.
The rationale for the cuts in the Balanced Budget Act was that costs in
home health care were spiraling out of control because of waste, fraud
and abuse. And while we are all against waste, fraud and abuse, the
Balanced Budget Act that passed this Congress made no distinction
between wasteful providers and efficient ones.
The fact that my home State of Massachusetts has been nationally
recognized as a leader in providing efficient home health care was
apparently lost on the budget negotiators. The Balanced Budget Act cut
wasteful agencies and efficient agencies at nearly identical rates. In
Massachusetts and many other States where there is very little fat to
trim, these cuts are going right to the bone. And even in traditionally
inefficient States, the providers that did the right thing and kept
costs down are being punished for that action. It is as if this
Congress is saying to these agencies, these efficient agencies, shame
on you for being efficient. Shame on you for being cost-effective.
Shame on you for putting patients first. It is crazy.
Waste was rewarded in the Balanced Budget Act, and fraud and waste
and abuse were not attacked. In fact, HCFA's own statistical data for
1994 shows that Massachusetts has the fourth lowest cost per home
health care visit of any State. Further, Massachusetts passed a State
initiative to encourage the use of home health care, avoiding the more
costly alternative of moving seniors to a nursing home and, thus,
saving tax dollars. But under the Balanced Budget Act, we are being
punished for our forethought.
I strongly support balancing the budget. I recognize the need to
crack down on waste, fraud and abuse. But the version of the Balanced
Budget Act that passed was an example of what happens when legislation
is negotiated in back rooms and pushed through Congress without
appropriate hearings, without committee oversight and without the
opportunity for Members to examine closely the bill that they are about
to vote on.
We are now beginning to see the effects of that provision, both in my
home State of Massachusetts and across this Nation. Just a few months
ago the Massachusetts legislature and the Governor of my home State
worked together to investigate the impact of the Balanced Budget Act on
the State.
In May the Commissioner of the Division of Health Care Finance and
Policy in Massachusetts issued a report which stated that the Balanced
Budget Act may result in, and I quote, ``a large number of chronically
ill patients being admitted to long-term care facilities at
significantly greater cost to both the Medicare and Medicaid
programs.''
In essence, Congress passed an unfunded mandate on the States last
year. By cutting home health care, seniors and the disabled will be
placed in nursing homes. While the exact dollar cost to Massachusetts
taxpayers is still unclear, I would like to commend my State's leaders
for their efforts to shed more light on this issue and bring concrete
information to the debate.
Attorneys General from across the Nation have also recognized the
depth of the problem in home health care. Nineteen of them have
endorsed H.R. 3205, a bill that I have introduced to fix the home
health care crisis. At least three independent studies have assessed
the impact of the interim payment system enacted in the Balanced Budget
Act. The results are chilling. All the studies show that the interim
payment system will most deeply harm patients with chronic, complex and
incurable illnesses. The studies also show that the agencies that
provide these services will be hurt.
According to the report by the Massachusetts Division of Health Care
Finance and Policy, the Balanced Budget Act will result in a $111
million cut to Massachusetts citizens needing home health care, and
some have estimated that the Balanced Budget Act is threatening 1.5
million doctor-prescribed home health care visits in Massachusetts this
year alone.
While only one in 10 Medicare beneficiaries use home health care
services, those who do are poorer, sicker, more often female, more
likely to live alone and have more mobility problems than the Medicare
population generally.
Approximately 25 percent of these, quote, frail elderly in
Massachusetts are over the age of 85. These are the people who are
currently at risk for premature institutionalization since the
enactment of the Balanced Budget Act.
There is also an economic component to this issue. Last year the home
health care industry employed 18,000 people and was one of the major
employers in Massachusetts. This year the numbers will be far less. To
date, in Massachusetts the home health care community has laid off well
over 600 staff and these reductions in staffing levels, particularly
direct care staff, dramatically decrease patient access to quality
care. Many of the people losing jobs are women who are trying to stay
off of welfare or who were on welfare at one time. This is a
particularly hard time to turn these workers out, given Federal changes
under welfare reform.
According to a survey by the Home & Health Care Association of
Massachusetts, 60 percent of their member agencies anticipate staff
reductions over the next fiscal year. But numbers, of course, do not
tell the whole story. And there is an enormous human cost to this
crisis.
There is the story of Massachusetts Easter Seals. Massachusetts
Easter Seals provides critical assistance to some of my State's most
frail residents, and they do a tremendous job. But because of what
Congress passed, they are being forced to eliminate their home health
care program which served patients suffering from multiple sclerosis,
Alzheimers, cancer, as well as those who are disabled or suffer from
serious medical problems.
Mr. Speaker, over 500 patients will now be thrust into a shrinking
home health care industry. Because of the Balanced Budget Act, very few
agencies are looking for new patients, especially those with chronic
and severe illnesses or disabilities. And 120 employees are being laid
off as a result of Massachusetts's Easter Seals home health care agency
closing its doors.
Now we have another victim in Massachusetts. The Assabet Valley Home
Health Care Association in Marlborough, Massachusetts was trying to
merge with a local hospital because they could not survive under the
Balanced Budget Act as a freestanding agency. Two and a half months ago
they asked the Health Care Finance Administration for a determination
of what their reimbursement level will be under the new formulas in the
act.
Until the gentleman from Massachusetts (Mr. Meehan) and I intervened
last week, they had not received an answer and the prospect of a merger
was terminated. One hundred thirty people have lost their jobs. Over
400 people will have to find a new provider of home health care
services. The same scenario is occurring all over this Nation, and the
efficient nonprofits are repeatedly the first to go.
Mr. Speaker, many of my House colleagues have recognized and are
responding to how these costly errors in the Balanced Budget Act are
affecting home health care. Over 100 Members of the House from both
parties have cosponsored legislation, sent letters to the
administration or stood up for home health care in their communities.
Several Members of the other body have also begun looking for a
solution to this issue.
[[Page H5277]]
And this pressure is having an effect here in Congress. Many Members
who were most opposed to changing the Balanced Budget Act and who
believed that these cuts were necessary are now beginning to change.
In the House, we have seen motion on this issue. I want to commend my
colleagues from both sides of the aisle who have pushed this issue
forward.
At a Senate Finance Committee meeting in Washington on March, 12,
Senators gathered to review the mistakes caused in the Balanced Budget
Act as it relates to home health care. After months of pressure, I am
pleased to tell you that at a meeting earlier this month, Christopher
Jennings, Deputy Assistant to President Clinton for Health Policy,
promised me that the White House will work with Congress to solve this
crisis and will help move a bill through this Congress for passage.
I want to especially commend the grass roots efforts to solve this
crisis for all they have done so far. Every day Members of Congress are
hearing from senior citizens or patients in their district, from the
medical community and from home health care providers. As an example,
just today I received a letter from 22 national organizations that are
members of the Consortium for Citizens with Disabilities, which I will
enter in the Congressional Record.
They endorse my bill and they have asked Congress to change the home
health care provisions of the Balanced Budget Act this year.
Clearly people across the Nation are becoming educated on this issue.
Home health care is in critical condition. Time is running out. Our
most vulnerable citizens are at risk. Congress must act now, if we are
to keep people at home with their families.
I believe home health patients should be comfortable, at home, and
should stay with their loved ones for as long as possible, not
institutionalized in more expensive nursing homes. I believe that those
are the family values that this Congress should stand for.
Mr. Speaker, Congress must act to resolve this crisis before we
adjourn this year. People are being hurt now, and we cannot afford to
wait. I call upon my colleagues and the leadership of this House, and I
call upon Speaker Gingrich to move quickly on this issue to allow us
the opportunity to debate this issue on the floor, to bring this issue
up so we can correct the mistakes that were made a year ago in this
Congress.
Mr. Speaker, I yield to the gentlewoman from Michigan, (Ms.
Stabenow), a leader in trying to correct the mistakes in the Balanced
Budget Act, who has been very outspoken on behalf of home health care
agencies in her district and across this country and somebody who has
put patients first.
Ms. STABENOW. Mr. Speaker, I thank the gentleman from Massachusetts
(Mr. McGovern) for yielding to me.
I first want to thank him for very quickly moving, when this was
brought to our attention, to put in his bill, H.R. 3205.
I was very pleased to be an original cosponsor with him to delay the
interim payments system, as he has indicated there are other bills as
well that change the formula.
The gentleman from New Jersey (Mr. Pappas) has a bill that also would
right many of the wrongs, and there are certainly a number of options
for us.
I rise also, coming from a State that is extremely efficient. We
have, as a State, been serving people in their homes for a little over
$3800 per user, which is less than the national average of a little
over $4600, $3800 versus $4600. And we know that there are providers
that are using as much as $9000 per user, per patient.
One of the difficulties with the way that the Health Care Finance
Administration has begun to implement the changes in the balanced
budget agreement is by doing it across the board, as opposed to looking
at the high-user States or the high-user providers and addressing them.
Instead they are penalizing everyone. In States like Michigan, where
we have very dedicated small businesses, nonprofits, visiting nurses
associations, Easter Seals, that have been working very diligently to
keep costs down and yet provide very high quality care, they are being
penalized. We are going to see a reduction of some 27 percent, and we
are looking at possibly as high as 80,000 people in my home State over
the next 2 years that will not be able to receive service.
This is a critical issue. As you have indicated, this is one that
needs to be addressed now. It needs to be addressed tomorrow. As soon
as possible. We have changes taking place July 1 that will greatly
impact these home health care providers, and we need to make this a top
priority.
I want to speak for a moment, if I might, about the kinds of
responses and the kinds of conversations I have had with families in my
district, not just now around home health care but over the last 2
years representing the people of the 8th district.
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When I first was campaigning 2 years ago, I was amazed at the number
of homes as you walk down the street that had ramps on the front of
their homes. The number of people that were asking me about home health
care for their mother, their father, their husband, their wife, another
loved one, this is one of the top issues on the minds of the people
that I represent.
We all know of loved ones who need care. It is not only better for
them and for the family to support them at home, but we know it saves
tax dollars. So it is really amazing to me that we would be looking at
these kinds of drastic cuts in something that saves money as well as
providing quality care for families, for individuals. This just makes
no sense at all.
I supported the balanced budget agreement. I want to have the budget
balanced. I support going after fraud and abuse, but I can tell my
colleagues, in Michigan, with my home care providers, they are not the
folks that we ought to be focusing the attention on, because they are
providing quality care at very low cost.
I did want to mention one other issue as well, and that is the whole
issue of surety bonds. This is something that HCFA can address
themselves right now if they choose to do that tomorrow morning. I
would call on the administration of HCFA to do this.
We put in place a requirement to protect, for new home health
agencies that were opening, requiring a surety bond of $50,000 or 15
percent. The maker of that amendment indicated that she meant whichever
was less.
Instead, we are seeing efforts that have gone into place that are
requiring people to go for a higher amount, whichever is more, 50,000
or 15 percent, whichever is more rather than whichever is less.
What does that mean? Right now, only 41 percent of the home health
care agencies across our country have been able to get a surety bond.
The rule regarding having to have a surety bond takes effect July 1.
Time is running out. We have got to see some kind of a response that
is reasonable to those that are on the frontlines providing home health
care. We have got to make sure that it is done in a timely manner.
So I join with the gentleman from Massachusetts (Mr. McGovern)
calling on the Speaker of the House. There are vehicles. We have the
gentleman's bill. We have other bills. We do not care if it is a
Republican bill. We do not care if it is a Democratic bill. We just
need action now because the people at home are going to be feeling the
effects. We are going to see businesses closing, home health care not
provided. And this is one of the most critical issues facing our
families.
So I am pleased to join with my colleagues tonight, calling for
action.
Mr. McGOVERN. Mr. Speaker, I thank the gentlewoman for her comments,
and she raises two points that I think deserve to be emphasized again;
and that is that if we are truly trying to save money, and that is what
one of the goals of the balanced budget act was about, this is not the
way to do it.
You do not need to be a mathematician or an expert in health care to
know that it is a lot cheaper to provide somebody good quality care at
home than to have that person in a long-term nursing care facility or a
nursing home.
The other thing that my colleague raises, which I think is very
important, and that is this whole issue of how do you encourage
efficiency and cost effectiveness. Massachusetts has some
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great home health care agencies, visiting nurse associations who have
been very good, who have been very efficient.
But the way this whole thing has been put together, in essence, we
are punishing those who have been good. It is almost as if we are
saying to these people you should have been bad. You should have padded
the books. You should not have been cost efficient and effective;
because if you violated all of the things that we asked you to do, you
would be okay right now, because you would only be trimming the fat.
It is the good agencies that are being put out of business. I think
that is sad, and it goes against and it contradicts what this Congress
is supposed to be all about. It contradicts what this administration
says its goal is in health care.
So I commend the gentlewoman for her comments. We are going to make
sure we work together; that something happens. We are all dedicated in
this here. We need to convince our leadership in this Congress that
this issue is important enough to have a vote now.
I sent a letter to Speaker Gingrich, which I would like to enter into
the record now, saying maybe we can bring this up during the technical
corrections billion. We need to do this quickly. Clearly, this issue is
of such importance that I think it takes precedence even over some of
the things we have been doing in this Congress. So I thank the
gentlewoman for her comments.
Mr. Chairman, I yield to the gentleman from Rhode Island (Mr.
Weygand) who has been an effective leader in this issue. I was with him
at Warwick, Rhode Island in a health care agency, and it was a great
rally with over 200 people all protesting these cutbacks and demanding
that Congress fix it.
I yield to my colleague the gentleman from Rhode Island (Mr.
Weygand).
Mr. WEYGAND. Mr. Speaker, I want to thank the gentleman from
Massachusetts (Mr. McGovern) for yielding me this time.
Mr. Speaker, the discussion we are embarking on is very important for
a lot of reasons. Home health care is, indeed, without a question, a
kind of health care system right now in deep peril.
A lot of times, people will look at the home health care system and
think about just the numbers and the dollars and the cents. Something
that we fail to recognize often unless you had a family member or
friend who has been receiving home health care is that home health care
providers provide a lot more than just simply the medical services.
They come into our homes, they come into our families, and they
provide a friendship and a warmth and the kind of camaraderie that goes
along with the health care system and the provisions that they are
giving to our seniors, to our disabled.
They reduce the cost of health care tremendously, as we have heard
from the gentlewoman from Michigan (Ms. Stabenow) and from the
gentleman from Massachusetts (Mr. McGovern).
The average cost throughout the country is only approximately $4,600
per year. Many States like the gentleman's State and my State have
tremendously cut those costs. My State, in 1996, had a cost of
approximately $4,000 per year per patient for home health care.
The wonderful thing about home health care is that it prevents many
people from going into acute care facilities and long-term care
facilities. But if we want to talk about dollars and cents, let us talk
about them. Talk about what it costs for an average per patient cost
per year; $4,600. In Massachusetts, it is $3,800 per year. In Rhode
Island, it is $4,000. In Michigan, I think it is around $3,900 per
year.
If that same person is forced into acute care facility or even a
long-term care facility, the average cost on a national basis is around
$40,000 per year for a Medicaid recipient. That is shared about 50
percent by the State government and 50 percent on the Federal
Government. That means, on the Federal side, we would be spending
$20,000 out of the Federal budget per year per patient.
It does not take much to determine that home health care is the far
better bargain for the taxpayers and the Federal Government. We want to
make sure that they stay in home health care versus a far more
expensive acute care or nursing home facility. Granted, we have great
facilities like that; and where they are needed, they are there for our
patients. But it is far better to have someone at home.
At home, they get more assistance from home health care, but they
also get assistance from family and friends. The unique thing about it
is we are giving them a life of dignity and independence.
A lot of times, we talk about numbers and providers without seeing
the faces of these people. The gentleman from Massachusetts (Mr.
McGovern), the gentlewoman from Michigan (Ms. Stabenow), and the
gentleman from Maine (Mr. Allen) and I have all visited, as well as
other people on the other side of the aisle, many different people in
many different places to try and find out the real problem.
Let me tell you about a young lady that I visited with about a month
and a half ago. Her name is Genevieve Weeser. Genevieve lives in
Warwick, Rhode Island in the middle of the second congressional
district in Rhode Island.
I went over and met with her. Genevieve is 98 years young. She is at
home. She is in an apartment that she has, a Federally subsidized
apartment unit, and she has friends who assist her. She is 98. She
receives one nurse who comes in once a week to try to take care of her
medications and monitor her various vital signs to be sure she is okay.
On top of that, she gets some small homemaker service. She has
friends who come in and help her. She has family who comes in and helps
her. But without that kind of activity, without that kind of home care,
she would be, without a doubt, in a far more expensive acute care
setting or nursing home.
Her care has been cut nearly in half now because of the IPS system.
She is going to be receiving half the number of visits and half the
care. Eventually what will happen is she will end up in the nursing
home some place, costing the taxpayers of Rhode Island and the Federal
Government far more money than what we would have had with home health
care.
Last year, when we made that revision in the budget and we put in a
system that we thought would, indeed, try to give us a transition into
a new prospective payment system from home health care, it did a lot of
things that we were not familiar with, and that is why we need to
change it.
First of all, home health care only represents 9 percent of the
entire Medicare budget. Yet, it was targeted for over 14 percent of the
cuts. It took a large hit. On top of that, it was the manner in which,
as we have all heard tonight, that home health care agencies were
targeted. It was one swoop across the top.
We had in Rhode Island one VNA already go out of business. It had
been in business for 87 years, a nonprofit agency providing quality
home health care at a cost of less than $3,600 per year per patient. It
had to close its door. Kent County VNA had to lay off 11 people. It cut
most of its visits in half.
Do my colleagues know what? All of these good quality, very cost
effective agencies have been driven to virtually close their doors, cut
down on their employees. Yet, there is a unique part of the IPS system
that many people do not know about, that if the gentleman or I started
a new agency last year, and only had a 1-year track record and had
costs of around $5,000 or $6,000 per year per patient, and we bought up
those other agencies, those great cost effective agencies, acquire them
somehow, we would now get, not the old rate that they are now required
to keep, the 1993 rates or 1994 rates, but if I were a new agency
buying up these older agencies, I would get a brand-new rate.
We are, in fact, saying to these new companies, gobble up the most
cost effective companies and become fat and wasteful; but to the cost
effective nonprofits and the ones that have been providing services for
decades, we are closing the door on them. But more importantly, we are
closing the door on patients.
Patients come first. It is not about jobs. It is not about agencies.
It is about people. What we have done here is drastically wrong.
We have a bill, the McGovern-Weygand bill. We have other bills, the
Pappas bill. There are a lot of bills out there that will help correct
it. Just last month, in the Committee on the
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Budget hearing on the resolution on the budget, I was able to put in
amendment to the budget, one of only two amendments that were allowed
as a sense of Congress that said the following.
First, the interim payment system for home health care services was
adversely affected and has adversely affected home health care agencies
and particularly Medicare beneficiaries.
Second, if home health care is threatened and further reduced, the
overall health care costs of our people are going to rise. As we push
down on home health, the cost of acute care facilities and long-term
care facilities is going to go up. It is only a matter of time when the
cost for HCFA and Medicare are going to rise if we allow this system to
stay in place.
Third, we have asked all the committees of jurisdiction, particularly
the Committee on Ways and Means, to come up with a revision on the
interim payment system this year in this Congress before we go home so
that we can make revisions that are appropriate to take care of the
people at home.
Lastly, on the overall picture, we must have in place a prospective
payment system no later than October 1 of 1999.
It is going to take the requirements of both parties and particularly
the leadership on the Republican side to make this occur. In the
Committee on Ways and Means, we need to have the chairman and the
subcommittee chairman work with us on both sides of the aisle to come
up with a revision.
It is not for us as Democrats or for them as Republicans. This is for
people at home that need quality care at a cost effective way. We need
to do it now.
I want to thank the gentleman from Massachusetts for having us this
evening for this discussion. I particularly want to thank our friends
on the other side of the aisle who have done a tremendous job to bring
this to the forefront. We cannot let this go. We must provide the kind
of dignity and independence that our people deserve.
Mr. McGOVERN. Mr. Speaker, I thank the gentleman for his comments and
his leadership and for reminding this Congress that patients do come
first and should come first.
The gentleman gave an example of somebody that he had visited. I had
a similar situation. I went on a home health care visit with an agency
in my district and visited a gentleman in Hopkinton, a retired fire
chief in Hopkinton named Arthur Stewart.
This was in January, and it was a cold wintry day, and he was sitting
by his fireplace. He said to me, ``You know, a lot of things I want to
do in life are right here, even if it is just poking this darn fire. I
would be totally wiped out financially if I had to be in a nursing home
or rehab. And I cannot say enough about what the visiting nurses are
doing for me. And I just cannot see how shortsighted Congress can be.''
It is people like Arthur Stewart, and there are hundreds, if not
thousands, of Arthur Stewarts in Massachusetts and throughout the
country who should compel this Congress to fix this mistake.
The gentlewoman from Michigan said it and the gentleman from Rhode
Island said it that we need to act now. I mean, this needs to be done
now. We cannot put this off until next year. If we do not do something
now, the cuts are going to adversely impact these home health care
agencies to the point where people are going to lose their care. They
are going to be forced into nursing homes. Families are going to be
devastated. I mean, this is just not right.
Mr. WEYGAND. Mr. Speaker, if the gentleman will yield just a minute,
I know my friend, the gentleman from Maine, wants to speak on this
subject as well. One of the things we have just seen come out of HCFA
is that the rate of reimbursement that we have right now with this cut,
HCFA and the people have acknowledged within Medicare that they are
receiving far less, 93 percent actually is what they are receiving in
terms of what they should be receiving. They are only receiving 93
cents on the dollar minimum. In many cases, they are cutting more.
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The other matter is that the amount of surplus that we have seen
generated from these massive cuts far exceeds what was estimated by CBO
and everybody else. We are in fact cutting a system so drastically so
that we can provide tax cuts to other people. That is the terrible
shame that we have before us. We are taking people that are in dire
need and we are cutting them to provide tax cuts to other people.
Mr. McGOVERN. The other irony is that in this Chamber, not a day goes
by when someone does not rise and talk about unfunded mandates on
States. Ironically, this provision in the Balanced Budget Act is the
biggest unfunded mandate on States that we have ever seen. This will be
devastating to States if they have to pick up an increased cost of
Medicaid to provide for long-term care. Every single governor has an
interest in making sure this Congress acts on this issue and acts on it
now.
Mr. Speaker, I yield to the gentleman from Maine Mr. Allen) who has
been a leader on campaign finance reform, who has been a leader on this
issue as well.
Mr. ALLEN. I thank the gentleman for yielding. I just want to say to
the gentleman from Massachusetts Mr. McGovern), the gentleman from
Rhode Island Mr. Weygand), the gentlewoman from Michigan Ms. Stabenow)
and the gentlewoman from Texas Ms. Jackson-Lee) that what you are all
doing in terms of home health care is very important, not just for the
people in your district, for people all around the country. The
gentleman from Rhode Island was right. This is at the end of the day
not just about a few agencies and not just about the Federal
Government. This is about some of our most vulnerable citizens.
I have been thinking about this issue a little bit and thinking of so
many people that I run into in Maine. I have to say that of the people
who come through my office, probably 25 percent of them are concerned
in one way or another with health care. When I go out to seniors events
or senior centers or talk to senior groups throughout the State of
Maine, health care is always right at the top of their agenda. For most
people that I talk to who are on that borderline, where the question
is, can I continue to stay and live at home, or do I need to move into
some sort of facility, almost all of them want to stay at home as long
as they can. That seems to be an almost universal desire. The service
that allows them to stay at home is some form of home health care. So I
find, I believe, that not only is home health care critically important
to how well we manage costs at the Federal budget level, but it is also
critically important to all of those people, unlike us, for whom this
is a real issue in terms of their health, their quality of life and
their future.
Last year we took aggressive action to balance the Federal budget and
through the Balanced Budget Act deal with the rapid growth and
perceived fraud and abuse in Medicare's home health benefit.
I wanted to say a few words about some of the conversation that is
going on. If we look back at the Balanced Budget Act, we were trying to
get control of runaway costs in part of our health care system. It was
not irrational to do that. We have to control fraud and abuse. We have
to control the explosion of costs in our health care system. I want to
go back and just look at what was going on. I think all of us have seen
some figures about the growth of home health care in different States
around the country. In every State, it has been significant. There has
been significant growth. But the growth has varied dramatically from
State to State. You can think about that growth in several ways.
First in terms of the number of home health care agencies. In just
the last 4 years, in some States there has been a 20 percent increase
or a 40 percent increase. But in some States, the increase has been
several hundred percent in just 4 years, an explosion in the number of
health care agencies. Second, you can look at the number of visits to
an individual patient. In some States it is a fairly modest increase
and in some States it is a very rapid increase. Third, you can look at
the cost per visit. Again in some States it is fairly modest and in
other States it is a dramatic increase in the cost of visits. So what
the Congress did was to say, ``Wait a minute, put the brakes on, let's
try to deal with this, because if we can't get control of home health
[[Page H5280]]
care costs, we are in big trouble in terms of what is happening to the
Federal budget.''
So we took some action. But that action has included unintended
consequences for people who are receiving home health care benefits and
for the agencies that provide that service. We have to weed out fraud
and abuse in this system. We have to find ways to cut costs in the
Medicare system. But it is wrong to make cuts at the expense of our
most vulnerable citizens, our homebound seniors who are relying for
health care services provided in their home.
I want to talk about three of those services right now, or three of
the changes we made. First, the removal of blood drawing as a Medicare
covered service, what is called venipuncture. That is one. Second,
there is a requirement of surety bonds. The gentlewoman from Michigan
referred to that. That is an added cost for home health care agencies.
Sometimes it may be appropriate, but other times it is simply an added
expense which is not covered. And, third, the new interim payment
system. Those three, I believe, are changes we have made where we have
really gone too far and we need to fine-tune those changes. That is
really what the McGovern bill does and why I am a cosponsor.
I want you to think about Maine for a moment, not just because it is
the State I represent but because it highlights some of the issues that
we have here. If you are in Portland, Maine, you are closer to New York
City than you are to the northern communities in Maine. If you drive an
hour north to Augusta, the capital city, you are still closer to New
York City than you are to the northern Maine towns of Mattawamkeag and
Fort Kent. It is a very big State. It is a rural State, like so many in
this country, and you cannot have a hospital on every corner. So what
you have is home health care agencies across the State which have
sprung up to provide services to seniors, many of them in rural areas,
and for many of whom a trip to the hospital is quite a hike. So I think
it is unreasonable to require seniors to take a one-hour or two-hour
trip to a hospital just to have blood drawn once a week when you can
have a home health care nurse moving through a community providing this
kind of service to many people who need it. And for many people, the
drawing of blood, the testing of that blood is essential to monitoring
their medications. Really it is a very important health care service.
It is too expensive for them. It is too inconvenient for them. I
believe we need to support the restoration of venipuncture as a
Medicare covered home health benefit.
The second issue, the gentleman from Rhode Island referred to it in
particular, the new Interim Payment System, IPS, bases Medicare
reimbursement rates on agency and regional costs in 1993. Let us look
at that for a moment. We have, in Maine especially, nonprofit agencies
which have been around for a long period of time which, of necessity,
have had to hold their costs down. You look at the cost per visit or
the number of visits of those agencies, and then compare them to some
of the newer, for-profit agencies around the country, and there is a
dramatic contrast. That dramatic contrast is one that represents a case
where we should say to the nonprofit, well-established, low-cost
agency, ``You are doing a great job. Keep it up.'' But what have we
said? No. We have said in 1998 through this IPS system, ``You've got to
go back to the cost you had in 1993 or 1994 and we're going to base
what you get paid now on what your costs were then, not on what the
costs are across the region, but on what your individual costs were
back then.'' There is a problem there. Because if you have inflated
costs, if you are a new agency, a for-profit agency or an agency which
for whatever reason has inflated costs, you are going to get
compensated for your current costs. If we are going to be cost-
effective, what we need is a formula that will reward cost-efficient
agencies, those agencies that provide quality care at an appropriate
price. We need a formula that does that. That is why I support the
McGovern bill, the Medicare Home Health Equity Act of 1998. It provides
a fairer formula for reimbursement to efficient home health agencies.
I really believe that the bottom line is this. We have got to root
out fraud and abuse in this system. We have got to contain costs, but
we have to be smart about it. When it comes time, as it has, to look
back at what we did last year and fine-tune that product and make it
work better for home health care agencies and for seniors who are
homebound, we need to do it. We have no business penalizing reputable
providers and the seniors that their programs serve. That is why I am
very glad to be here tonight with all my colleagues and to urge the
Republican leadership in this House to bring this issue up, because
time is a-wasting, our home health care agencies are hurting, our
seniors need the assistance, there is no time to waste, we can do it
now, we have got the time, and we should move ahead.
Ms. STABENOW. If the gentleman will yield, I just wanted to emphasize
one point that the gentleman from Maine said so eloquently again, and
that is the fact that we are talking about States and areas that have
long-established, well-run home health providers who it does not make
sense in my mind to be asking them to do a surety bond when they have a
record of what they have been providing and what they have been
receiving and billing for and so on, and it does not make sense when
there has been an explosion in some areas, and certainly we need to be
concerned about those explosions of areas as it relates to costs and
number of visits and so on. Why do we not just focus on those? Let us
focus on the problem areas and not in turn require everyone to have to
take a cut when we know that some are doing an outstanding job
operating well below the national average. I think it is just a point
that we need to reemphasize over and over again. We want to go after
waste, fraud and abuse, of course we want to do that, but let us do it
in a way that makes sense. I am sure that in Texas as well, we are
talking about a situation where we need to be focusing on those, in
fact, who are abusing the system and not focusing on those who have
been providing quality service at low cost.
Mr. McGOVERN. I could not agree with the gentlewoman more. In fact
this, what we are talking about today, is not fraud, waste and abuse,
because we all are in agreement that we need to crack down on these
agencies that are engaged in fraud, waste and abuse. I do not think
anybody in this Chamber is in favor of fraud, waste and abuse. Those
agencies that abuse the system deserve to be held accountable. But as
the gentlewoman points out in Michigan and the gentleman from Maine
points out in Maine and in Massachusetts, we have some agencies that
are models, that are cost effective, that put patients first, that are
good. These agencies are being punished in essence for being good. That
is not fair and that is not right, and a lot of people are going to
suffer if we do not do something about it.
Mr. Speaker, I yield to the gentlewoman from Texas (Ms. Jackson-Lee)
who has been a passionate spokesperson for so many issues impacting
working families and senior citizens. I am delighted that she is here
tonight.
Ms. JACKSON-LEE of Texas. I thank the gentleman from Massachusetts
very much for yielding and for his leadership on this issue,
recognizing the extreme importance of confronting the issue of health
care in general and the home health care agencies.
Frankly I would like to speak on behalf of our neighbors, because
that is what we are speaking about. We are speaking about the American
people, but we are speaking about our neighbors that are in our
neighborhoods, that own these home health care agencies in particular.
It is extremely important that we recognize that we are doing damage to
those people that we know, the small businesses, the people who take
care of our neighbors. It is extremely important that your legislation
comes quickly to the floor of the House.
We realize that Congress, as we all have stated, needed to take care
of fraud, waste and abuse. When we began about the first Congress that
I was here, the 104th Congress, we were talking about Medicare.
Everyone was talking about fraud, waste and abuse. Those who wanted to
completely overhaul Medicare wanted to do extremist type cutting to the
Medicare system, when in fact the fraud, waste and abuse
[[Page H5281]]
was a mere, or a simple $89 billion that we could have handled easily
without totally remodeling the Medicare system. The same thing happens
with the home health care agencies. We know that we have to take care
of those issues. But does it mean that because there are rising costs,
does it mean that the system is broken? Or does it mean that more
people are availing themselves of home health services in an effort to
stay in better health and remain with their families? That is the
philosophical question that we should ask. If we are trying to make
sure that we keep the good home health care agencies, so many of whom
have come to my office, I have met with them, we visited at the Beale
Senior Citizen Village when I gathered, home health care agencies from
around the southern region where my district is located, people as far
to the south as different areas and then well into Houston came to meet
with me to talk about how they were being mistreated, if you will, and
not being able to take care of their patients.
{time} 2130
And they asked a real question:
Is the rising cost a basis of abuse or fraud, or is it because we
have been doing such a good job that in fact we have been having rising
costs because so many people are using it?
I do believe there are certain issues that we need to emphasize, and
that is, as you have said, I say to the gentleman from Massachusetts
(Mr. McGovern), there are effective, safe and caring home health care
agencies, and my concern is what do we do when we lose those facilities
in our neighborhood, what about the teacher who comes home during the
lunch hour, who comes home at dinner time, who stays up all night to
take care of her elderly parent? What is going to happen to that person
who at some point in time has been able to access a home health care
professional? What happens when that working single parent with that
elderly parent in their home has no resources, no sort of assistance
from a home health care agency because the resources, the Medicare
process, has totally torpedoed, if you will, those particular neighbors
and small business out of the system?
You are very right that the poor, sicker and certainly those with
less, the less ability to be mobile, are the ones that use the home
health care system, and again I would like to emphasize these are our
friends.
One of the issues that has been discussed with me, of course, is in
whole question of the interim payment system, and I would like to just
briefly explain what the difficulty is, as my other colleagues have
already mentioned.
Prior to the Balanced Budget Amendment, the home health care agencies
were reimbursed after services were provided. Beginning in October 1,
1999, the agencies will be paid before services are rendered and at a
level significantly lower than that in place before the Balanced Budget
Amendment.
The prospective payment system is a monumental change for the
Medicare system. Setting aside temporarily the merits of the new
payment system, a very logistical problem has developed. Congress
enacted a 2-year interim payment system for home care that will be
effective until the prospective payment system is implemented in
October 1999.
Under the IPS, home health care agencies are reimbursed according to
a new beneficiary limit. The problem is, as my colleague from Maine has
already said, that home health care agencies have been provided with
little or no guidance as to what this per beneficiary limit is. What
the agencies do know is that the new limits do not accurately reflect
the amount agencies spend to provide services.
In fact, as they have said to me, they are flying in the blind, and
when you fly in the blind, you are apt to make mistakes. When you are
apt to make mistakes, what happens? The regulatory agencies come down
on you, our neighbors, the small business.
So, in fact we are in a catch 22. It is extremely important that we
recognize that the new per beneficiary limits will reduce per-visit and
per-patient costs, however patients' health may be compromised. We
cannot establish unrealistic arbitrary cost-cutting measures without
experiencing reduced quality and quantity in the home health system. At
the same time again we are asking our friends, our neighbors, the small
businesses, people who take care of our family members, we are asking
them to make decisions and to make guesstimates and not do their work
well.
Another point that I would like to mention that was a very strong
point of discussion amongst my many agencies that visited with me on
this issue, and that is why I am so grateful for this opportunity and
your leadership, and that is the venipuncture, the removing of blood.
Many people do not think of that as a serious element, if you will.
Well, the recovering of blood gives all kinds of data to the physician,
and the home bound person is in need of the ability for blood to be
taken so that diagnosis can be made on whether their blood sugar level
is up or down, what is going on with hypertension, what kind of
infection they may be having, and necessarily that person is home bound
and is in need of that service. The venipuncture service that was
mentioned by my colleague is another one that was excluded from the
availability of the home health agency.
And I received a call from a constituent whose mother is in her
nineties, lives with him in Houston. She is home bound but happy that,
thanks to her doctor's ability to monitor certain medication and blood
levels through venipuncture she is able to remain at home with her son.
She is not, if you will, incarcerated in the hospital. My good friends
who run hospitals, you know that I respect you a great deal. But how
many of our senior citizens say I want to be at home, I am well enough,
I want to be at home?
Well, Mr. Speaker, this home bound, elderly person, their son called
me and said because of the changes made by the Balanced Budget
Amendment her venipuncture coverage was drastically reduced and her
ability to remain at home may be compromised. We should do all that we
can to encourage our seniors to stay at home, and if their families are
capable of taking care of them with assistance from home health care
agencies, removing this coverage, it just skews the whole system, takes
away the independence that these senior citizens are enjoying, the
comfort of their home and the low cost.
Another constituent called and said I am desperate, I will even pay
for the service in order for them to be able to utilize it at home, and
of course we know that when you interfere with the Medicare system and
offer to pay, that will not work because these home health care
agencies are related very closely to the Medicare structure and system.
So my concern is that we do move H.R. 3205, but more importantly that
we emphasize how much home health care saves us as compared to the
$40,000 a year we pay if you were home bound, not at home but in a
nursing home.
I think the important as well is we care for our friends in the
nursing homes, we respect them, but I cannot tell you how valuable the
home health care professionals have been to our communities, how
important it is to make sure that these agencies continue, and that
they exist and that they continue to service in our neighborhoods.
I would hope that Speaker Gingrich listens to the letter that you
have sent and that we all join in pressing forward on both this
legislation, the venipuncture legislation that we tried to reform the
interim payment system that will be moving to the October 1, 1999,
where we will be asking our home health care agencies to guess at what
they will need and to take moneys ahead of time, which necessarily cuts
down on the kind of treatment that the recipients need to get.
We need to thank those who brought health care costs down, and I do
not think we are thanking them right now. We are putting a lot of
burdens on them. In fact, they are frightened, they are fearful of
closing their doors, they are fearful of having to lay off their
employees, they are fearful of no longer being the kind of citizens
that they have been by contributing to the community as businesses that
are active at the partnerships and chambers. They are just plain
fearful, and I, for one, want to see us do something about it.
And so I thank the gentleman from Massachusetts for his leadership on
this, and hopefully we can push this
[[Page H5282]]
after the district work recess that we will be venturing onto. I would
like to see this done before we leave here in August, and hopefully we
will have that opportunity.
Mr. McGOVERN. Mr. Speaker, I appreciate the comments of my colleague
from Texas. As always, they are right on target, and again I hope that
we can press this issue to a vote shortly after the July 4th recess.
This is and should be a bipartisan issue. One of my chief cosponsors
on this bill is the gentleman from Utah (Mr. Cook) a Republican who has
been very helpful in advocating passage of this bill. This should not
be a partisan issue, and I hope we can move on it very quickly.
Let me summarize my remarks today and what everybody has so patiently
and so importantly said here today by saying that I think that this
issue comes down to three important points:
One, we need to find ways to provide incentives for high quality and
good quality home care. The fact of the matter is that the way the
Balanced Budget Act was constructed and the way the provisions with
regard to home health care have been constructed the opposite is true.
We actually provide incentives for home health care agencies and
visiting nurse associations to be bad, to not be cost efficient, to not
be effective, to not put patients first. Well, that is wrong. I mean
that goes against everything that all of us believe.
So we need to fix the Balanced Budget Act so that we turn that
around, so that we reward and recognize the good agencies and we do not
reward the bad agencies.
Secondly, I think the issue here is that we need to prevent another
unfunded mandate on States. I mean, as I said before, every Governor in
this country should be up in arms over what is about to be thrust on
them. If we do not do something, then more and more patients in States
all across this country, who right now enjoy good quality home health
care, are going to be thrust prematurely into long-term nursing care.
Nothing wrong with nursing homes and nursing care in this country, but
it is much better, it is much better for the patient, it is much more
cost effective for the taxpayers if we can keep them at home, if we can
keep them with their families.
If we do not do something, there is going to be a greater cost that
Medicaid is going to have to bear, and that means that States are going
to have to contribute more, and again I would encourage all those
Governors out there and all the State legislators to weigh in with
their respective Members of Congress so we can get this bill passed
quickly.
Thirdly, I think that this issue is about family values. I mean every
time I turn on C-Span or every time I am on the floor, someone is
getting up and talking about family values, how we have to put families
first and how important it is to provide families with opportunities
and security. Well, this is about family values, allowing a loved one
to stay at home, you know, with their son or daughter. Allowing family
units to stay together is important and is something we should try to
preserve.
So, you know, this issue that we are talking about today is about
saving money for taxpayers, it is about family values, it is about
putting patients first, it is about what this Congress should stand
for, and I hope that we can convince Speaker Gingrich to make this one
of his priorities. I hope that we can convince Speaker Gingrich to put
this on the schedule to direct the appropriate committees to act on
this now. I mean I hope that we can convince Speaker Gingrich and the
Republican leadership in this Congress that this is not a partisan
issue, that it is in their interests that we fix this mistake and we
fix it now before anybody else in this country has to suffer.
And so I thank the gentlewoman from Texas for her comments, and I
will yield to her.
Ms. JACKSON-LEE of Texas. Your passion has captured the real key.
There is a massive constituency for this legislation, and it goes
across party lines. It is to keep families together, it is to keep
senior citizens and the disabled at home in a loving environment, and
it is, of course, to applaud and respect the many small businesses like
home health care agencies who go into neighborhoods knowing their
neighbors, providing the service, providing the warmth, and the
nurture, and good health care at a reasonable cost.
What more can we ask for? I think it is extremely important.
I appreciate the gentleman and his concepts of trying to get this to
the floor very quickly.
Mr. McGOVERN. Mr. Speaker, I thank again my colleague from Texas for
her remarks, and I would just conclude by saying that I am going to do
everything I can, and I hope all those watching will do everything they
can to urge this Congress to move quickly on this legislation. We
cannot afford to let this year go by, this session go by without
acting. If we do, then people are going to suffer, more and more home
health care agencies and visiting nurse associations are going to
close.
That is not what we want, that is not what we should stand for, and
we need to redouble our efforts in the coming months to make sure that
this legislation gets to the floor for a vote.
And again I would urge the Speaker, if he is listening, to please
listen to what we are saying here today, to do the right thing and to
move this issue and move it quickly.
I thank my colleague from Texas.
Mr. DELAHUNT. Mr. Speaker, I am pleased to join with my friend, Mr.
McGovern, and our other colleagues in this special order on the home
health care crisis.
The Balanced Budget Act has had a devastating effect on home health
care programs in many parts of the country. But the impact has been
especially severe in Massachusetts and other New England states, which
already provide more visits, at a lower cost per visit, than agencies
in other states.
In Massachusetts, the new per beneficiary limit means a loss this
year alone of $100 million. That translates into 1.5 million fewer home
visits for the elderly and disabled.
On April 30, the South Shore Visiting Nurses Association was forced
to eliminate 50 positions as a direct result of the $4 million in cuts
it was forced to absorb. Home care providers across our state are
facing cuts this year of 25 percent.
What does all this mean for the people who need these services?
Listen to some of the letters I have received:
From a woman in Quincy:
I take care of my elderly mother. She has Alzheimer's
Disease and has had several minor strokes. At the present
time I am fortunate enough to have home health care for her
three mornings a week through Quincy Visiting Nurses. Without
this assistance, my mother would probably be in a nursing
home. I cannot praise the nurses and aides that I have dealt
with enough. My mother is unable to dress herself, take a
shower by herself, or make her own breakfast. This is what
her home health aide does three mornings a week. I do the
same on the other four mornings. The release that I feel
having three mornings of not having to do these deeds helps
me keep my sanity. I am a full-time teacher in Quincy and I
also work two other part-time jobs.
From a man in Harwich:
My wife is 78 and has Alzheimer's Disease. I am also 78
years of age and have spinal stenosis. I am her care giver
and wish to continue to care for her at home and not in a
nursing home. . . . Presently we have the assistance of two
[home health] aides, two hours in the morning and one hour in
the afternoon which is covered by Medicare. . . . With over
100,000 Massachusetts residents with Alzheimer's Disease or
related neurological disorders and other related elderly
problems, we are not alone, but it feels that way with no
future long term home health care.
From a husband and wife in Whitman:
We read with dismay of the federal cuts affecting home
health care. For those of us in our older years, being able
to stay in our own home is the only bright light on the
horizon. Anything else is unthinkable.
From a woman in Weymouth:
I take care of my mother and have for the past eight years.
The last four years have been 24 hours a day, seven days a
week. We have [a home health care aide who] comes in twice a
day for a total of four hours. . . . My mother has
Progressive Supranuclear Palsy which is a devastating
neurological disease. It takes everything but your mind. She
is literally a prisoner in her own body. The rest of the
family has chosen to give up on my mother, thinking the way a
lot of people do, that she should be put in a nursing home.
Congressman Delahunt, would you want to be put in a nursing
home if the only people that understood your needs were the
aide and your daughter? . . . My mother still wants to be
alive and if she was to go into a nursing home she would die.
She communicates with us sometimes by blinking . . . or
breathing a certain way. Sometimes it takes a long time to
figure out what she wants. In a nursing home they wouldn't do
that. I promised her I would never put her in one, and I vow
to keep that promise no matter what. I'm not well myself and
these cut-
[[Page H5283]]
backs might kill us both. . . . I appreciate you taking the
time to read this letter and know you will do all you can to
stop these cut-backs, for all those in need of home-care, for
someday we may all need to depend on this system for love,
care, and support because we have no one else to turn to or
that cares.
And finally, Mr. Speaker, one of the letters I have received from
nurses and physicians. This one comes from an emergency physician from
Hingham:
As an emergency physician . . . I deal with the human side
of health care financing decisions on a daily basis. . . .
Most medical problems, recognized early enough, can be
treated effectively in an outpatient setting. . . . At the
present time . . . I am able to safely send elderly patients
home with close nursing follow up rather than to admit to the
hospital. I am afraid the proposed Medicare cuts will
severely jeopardize this sensible medical option. There is
also a human side to this issue. Frail, elderly patients do
better in their own familiar home surroundings. I can attest
by my own personal experience with my mother that her medical
health and quality of life were markedly enhanced by having
her medical care at home. Although she had multiple medical
problems, she did not require a single hospital visit or
admission in the last eight months of her life.
These are but a few of the letters I have received from my
constituents about this situation. In addition, I ask unanimous
consent, Mr. Speaker, to place in the Record a series of articles that
appeared recently in the Mariner Community Newspapers based in
Marshfield, Massachusetts, and a transcript of the calls from readers
that were recorded on their response line.
Mr. Speaker, this testimony speaks far more eloquently than I can
about the plight of those affected by this situation. But what is to be
done about it?
I know that a number of bills have been introduced to try to fix this
problem. I have cosponsored H.R. 3205, which was introduced by the
gentleman from Massachusetts (Mr. McGovern) and the gentleman from Utah
(Mr. Cook), which would delay implementation of the per beneficiary
limit for one year. The extra time would enable home health agencies to
minimize disruptions in services by gradually reducing costs.
Mr. Speaker, I voted against the Balanced Budget Act, largely because
of the cuts it inflicted on the Medicare program. I continue to believe
that those cuts were a terrible mistake. The least we can do now is
help cushion the blow.
[From the Weymouth (MA) News, June 10, 1998]
Losing Patients Over Home Health Care Cuts
(By Alison Cohen)
Millie and Mattie B. started their life-long love affair
when she asked her aunt to see if Mattie would take her to
the high school prom.
``I didn't have a date and there were four boys living
across the street,'' Millie said. (The couple did not want
their identities revealed.)
She watched from her front windows while her aunt dutifully
went across the street.
``I could see him come to the window--he'd been shaving--
and then I saw him nod his head yes, so I knew I was set,''
Millie said.
Mattie smiles and gives his take on the request.
``I had the only car on the street, a '34 Lafayette.'' he
said. ``That's why she asked me.
That was more than 50 years ago and their dancing days are
behind them now. Mattie, who turned 77 last week, spends his
days in a wheelchair, the result of 12 years battling
Parkinson's disease.
Someone once said growing old isn't for sissies. Mattie and
Millie are living proof. As Parkinson's progressively
immobilizes Mattie's once-powerful body, it takes all his
strength to get through what used to be the simplest tasks.
It's only one of many medical problems that leave him weak
and vulnerable.
Millie, 75, wears a weight-lifter's truss around her waist.
The weight she lifts is Mattie.
More than once she's been forced to pick him up off the
floor after he's fallen. Once she suffered a slipped disc in
the process and permanently weakened her back. Every night
she transfers him from his wheelchair to the bed. Now her
spine curves and the discs along her lower back project out
like ragged mountain peaks.
``I got this taking care of him,'' she says, as she shows
the nurse her ravaged back.
Worse yet, Mattie's voice dwindled to a mere whisper about
six months ago. By the end of the day, he's exhausted from
trying to communicate and she's exhausted from trying to hear
what he's saying.
``It's frustrating,'' he says.
Parkinson's is a chronic, progressive disease. Millie
doesn't want to think what the future holds if she becomes
too frail to help her husband get in and out of his
wheelchair.
``I hate to think about it,'' she says. ``I don't think
about it.''
Another challenge lurks in Mattie's near future. After four
years serving his country in time of war and 37 years toiling
to maintain Boston's schools. Mattie has discovered the
federal government wants to balance Medicare's budget by
imposing a cap on the amount of money home health care
providers can receive for taking care of him and other
patients.
The cost-containment method chosen by the Health Care
Financing Administration (HCFA), a division of the U.S.
Department of Health and Human Services, caps reimbursement
for each patient at a percentage of the agency's 1993-94
budget. Although South Shore agencies have yet to receive
official notification of their maximum reimbursement level
per patient, similar agencies in other parts of the country
have been told they must serve even the most challenging
patients for no more than $1,500 to $4,000. (See related
story.)
According to Meg Doherty, executive director of Norwell
Visiting Nurse Association, some of the patients on her
roster cost as much as $50,000 a year to maintain at home.
And the fallout is already happening. On May 7, Easter Seals
of Massachusetts announced it could not afford to provide
home health care services with such unreasonable cuts.
Life, for Mattie, already has dwindled to the size of the
small summer cottage on the South Shore they winterized and
moved to four years ago when it become impossible for him to
maneuver the stairs in their South Boston home. Getting
outside is a production--Mattie must move from his wheelchair
to a walker to traverse the step separating the dining room
from the back entry and a shallow flight of stairs leading
outdoors.
Getting to bed is an even greater challenge. Together they
position his wheelchair near his bed. Millie struggles to
push him up out of the chair as best she can.
``I fall right in,'' he says. ``She straightens my legs out
and covers me with the blankets.''
Most of his days are spent watching television and talking
with Millie. On weekends, he looks forward to spending time
with the two of their six children who live nearby.
The man who once prided himself on his ability to ``fix
anything,'' now relies on a cadre of home health aides who
come five days a week to assist him with the activities he
once took for granted, things like showering, shaving and
getting dressed. On the weekends, he must ask his son to
handle that duty. A visiting nurse comes once a week to check
his blood pressure and monitor his health.
It's hard to put a price tag on continuity of care.
Sometimes symptoms are subtle. An older patient doesn't
experience the crushing chest pain that alerts middle-aged
men they are having a heart attack.
``I start to lose my breath,'' explains Adolph Wacker, 84,
a home health care patient.
A visiting nurse checks Wacker once a week, looking for
clues that would show whether trouble is looming.
Wacker had five heart attacks, including a cardiac arrest,
within a 15-month span. He also has a pace maker to regulate
his heart rhythm. The hands that once deftly wielded
butcher's knives tremble uncontrollably from Parkinson's
disease. Wacker also suffers from diabetes. He's tethered to
an oxygen pump because of chronic obstructive lung disease
that leaves him vulnerable to pneumonia.
His rapid decline made it necessary for Wacker and his now-
deceased wife, Stephanie, to leave his Connecticut home and
move in with their daughter, Barbara Steiglitz.
``It was obvious he couldn't go home and care for my mother
any more,'' Steiglitz says.
Steiglitz couldn't do it alone, either. A registered nurse,
Steiglitz works three days a week for a long-term care
facility in Dorchester. Although her mother, who suffered
from advanced Parkinson's disease, could be left alone for
short periods of time at first, it didn't last long.
``She wandered,'' she said. ``She would get to the end of
the driveway and wouldn't know how to get back to the house--
and there's a swamp across the street and conservation land
goes almost to Norwell.''
At the end, both Stephanie's mind and body failed badly.
``She needed total care,'' Steiglitz said. ``She was in
diapers, she was senile and she could barely walk.''
Steiglitz put together a patchwork of family care, home
health services and what Wacker himself calls ``my private
baby-sitter'' to keep the two of them safe and healthy.
Stephanie Wacker died Sept. 27, just a week shy of their
59th wedding anniversary.
Wacker says they met when a fire alarm went off.
``She asked me what happened,'' he recollected. ``We got to
talking, I walked her home. We started dating and a year
later we got married.''
The two were very close, he says. It remains a marvel to
him, perhaps because his father died when he was two, his
mother when he was seven.
``My brothers and sisters took care of me until I was 16.
Then I was on my own,'' he explains. ``We got married when I
was 24.''
Wacker is a favorite with his caregivers.
Home Health Aide Anne Marie Foley comes two mornings a
week. She helps Wacker get up and dressed, brings him
downstairs and makes his breakfast. The two of them swap
recipe tips.
``He's an incredible cook,'' Foley says. ``His soups are
wonderful. I'm trying to get him to write a cook book.''
[[Page H5284]]
A male home health aide, Frank Serra, comes once a week to
help Wacker shower. Although Wacker would like to have a
shower more frequently, especially in the hot, humid season,
Medicare won't cover the costs because he isn't incontinent.
The combination of lung disease and Parkinson's makes him
increasingly frail.
``I try to walk up to the end of the driveway and back for
exercise,'' he says. ``I have to stop twice on the way up.
And I can't talk and walk at the same time or I run out of
breath.''
Falling is an ever-present risk because Parkinson's disease
affects both balance and gait.
``He fell in February and cracked his sternum,'' says his
daughter. ``I really have to hire someone to be here when I'm
not home.''
Wacker is philosophical about his own failing health.
``As long as you know your own capabilities, you get along
pretty good. You have to accept the idea you can't do what
you used to do. If you don't you go nuts and you end up in
the hospital any way.''
As Wacker's health inevitably deteriorates, his daughter
promises to advocate for the services he needs, and as long
as there is a Medicare certified home health care agency
providing services in * * *, he'll continue to get what he
needs.
That's the kicker.
Home health agencies aren't run on volunteer power. Without
a realistic reimbursement schedule to pay the nurses,
therapists and home health aides for services delivered those
agencies say they cannot continue in business.
The U.S. Congressional delegation from Massachusetts hopes
to derail the new system before it drives any more home
health care agencies out of the business. Rep. James P.
McGovern, D-Worcester, and Sen. Edward M. Kennedy have filed
companion bills in the House and Senate to address the
problem.
The bills will delay the effective date of the caps until
Oct. 1, 1998, to allow time for agencies to adjust to the
system. Additionally, the bills change the base year for
calculating benefit limits from 1994 to 1995.
``This change means that payments will more accurately
reflect the type of home care that is currently delivered,''
explains Kennedy.
In testifying about his bill, McGovern has said that the
one in 10 Medicare beneficiaries who use home health care
services are ``poorer, sicker, more often female, more likely
to live alone, and have more mobility problems than the
Medicare population generally. Approximately 25 percent of
these ``frail elderly'' in Massachusetts are over age 83.''
____
[From the Scituate (MA) Mariner, June 18, 1998]
Paying the Price for Mismanagement
(By Alison Cohen)
According to many home health care providers and advocates,
Medicare officials created a classic example of the law of
unintended consequences when they embarked on their campaign
to root out fraud, waste and overutilization in the home
health care system.
The federal government decided large increases in home
health care were caused by waste and fraud following a two-
year investigation, known as Operation Restore Trust. That
study focused on the five states that account for 40 percent
of Medicare payments; California, New York, Florida, Texas
and Illinois.
The subsequent report by the Office of the Inspector
General of the U.S. Department of Health and Human Services
said that one-fourth of home health agencies in those states
received nearly half the Medicare payments for home health
care. The report placed the blame on for-profit, closely held
corporations where owners engaged in a web of interlocking
companies that referred patients among themselves. Texas was
cited as the biggest offender.
A similar study conducted in Massachusetts and Connecticut
in 1997 uncovered no such pattern of fraud.
According to Julie Deschenes, legislative and public
affairs coordinator for the Home & Health Care Association of
Massachusetts, ``No fraud was uncovered in the 20
Massachusetts agencies that were audited.''
Deschenes said the worst that federal auditors could find
were examples of technical billing errors, mostly stemming
from failure of an attending physician to update medical
records to reflect the need for the higher level of services
patients were receiving and for which Medicare had been
billed.
Rather than conducting audits to identify and penalize
agencies guilty of intentional fraud or overutilization,
Congress believed the solution to spiraling costs nationwide
and wildly disparate costs among the states should be a
standardized, flat rate according to diagnosis. This system,
known as the ``prospective payment system,'' is similar to
the system Medicare uses in paying for hospital care.
When the federal Health Care Financing Administration
(HCFA) said it couldn't develop the complex formula necessary
to reward efficiency by providers as quickly as Congress
wanted, the interim payment system based on per patient caps
was set in motion. This payment plan--set to run through Oct.
1, 1999--basically freezes spending at 1993-94 levels, before
Operation Restore Trust began.
The projected caps fall hardest on frugal, non-profit
agencies and rewards those that spent lavishly at taxpayers'
expense. Home health care agencies in Massachusetts
consistently deliver care cheaper than the national average
both in terms of Medicare's cost per visit and per patient.
Relying on data provided by HCFA itself, The Wall Street
Journal reported earlier this year that Massachusetts' home
health care providers served 119,000 patients in 1995 at an
average cost of $50 per visit, which was 19 percent below the
national average of $62. The average annual cost per patient
worked out to $4,730, or less than six percent above the
national average of $4,473.
Across New England, the regional cost per visit undercut
the national average by 15 percent and the annual average
cost per patient was only $4,400.
Donna (who didn't want her last name used) has been a home
health care worker for more than 20 years and says she can't
understand with those kind of figures why Massachusetts
people have to suffer. She says she's outraged by what's
happening.
``We're the ones on the front lines and we're the ones who
have to deal with the patients,'' she said. ``Do you know
what it's like when you have to tell them this is you're last
day with them. Some of these people have been my clients for
a long time.''
Donna spoke of a 50-year-old patient she has been
assisting. The man, a father of two young children, is
primarily bed-ridden, he has to be fed and has come to rely
on home health care workers to maintain some semi-balance of
a normal life.
``I was overcome on my last day with him,'' she said. ``I
felt awful. It was so hard to tell him it would be my last
day helping him. You feel so much guilt. What am I supposed
to say, `gee, good luck?' How could this be happening?''
If there is fraud and over-spending, Donna says she is all
for fixing it. But if Massachusetts and several other states
have been spending reasonably, she can't see why others can't
pay the price.
HCFA identified the big spenders among the states as
Louisiana, Oklahoma, Texas, Tennessee, Utah and Mississippi.
On average, home health care providers in these states spent
$5,488 per patient in 1995, or almost 23 percent more than
the national average. The biggest offender was Louisiana with
an average cost per patient of $7,867, almost 76 percent more
than the national average.
Officials at the Texas Association of Home Care have
justified their higher costs, saying they have a high rate of
poor elderly who have never had proper health care.
Costs are driven up by the increasing number of Americans
considered ``frail'' or the ``old old''--those aged 85 or
older. Additionally, medical technology has improved survival
rates for individuals who survive head and spinal chord
injuries and degenerative diseases such as Alzheimer's,
Multiple Sclerosis, heart failure and severe diabetes.
The resulting ``per beneficiary limit'' guarantees, in
HCFA's own words, that 90 percent of all home health agencies
will be reimbursed at a rate below the cost of
delivering services. Providers say it will put them on the
road to financial ruin. How quickly they arrive at that
destination depends on the number of high-cost patients an
agency serves. These are the patients with degenerative,
progressive diseases such as Multiple Sclerosis, Muscular
Dystrophy, Parkinson's Disease, Alzheimer's Disease,
advanced diabetes and other conditions that require
intensive levels of care.
Apparently loathe to slash services to America's most
vulnerable citizens, the frail elderly and persons with
disabilities, Congress and HCFA announced to recipients of
home health services and their advocates that no patient was
to be denied services, terminated from care or have the level
of care reduced unless medically justified. That puts home
health care providers in a Catch-22 bind: they cannot reduce
costs through reductions in services or cutbacks in direct
care staff. Already several home health providers have chosen
to abandon ship rather than risk bankruptcy.
Cynics might find this governmental ``solution'' to
spiraling costs reminiscent of the village pacification
campaign of the Vietnam War years. That official ``solution''
led to an American officer explaining. ``It became necessary
to destroy the town in order to save it.''
According to Deschenes, home health care is being asked
``to assume an unfair proportion of Medicare cuts.'' While
home health care consumes only 9 percent of total Medicare
expenditures, it is targeted to assume 14 percent of the
total five-year cut and close to 18 percent of the provider
cost enacted in the Balanced Budget Act of 1997. A recent
HCFA forecast has increased the home health ``savings'' to
$20 million, or 25 percent more than the original estimate by
the Congressional Budget Office at the same time that the
population of older Americans continues to grow.
Home health care providers and people who receive the care
aren't buying this theory that no one will lose benefits. It
just doesn't add up, they say.
Community Newspaper Company's Reader Response line was
flooded with calls last week regarding the potential cuts in
home care. More than half the calls came for people who were
losing some form of care, or family members of those who were
expected to lose their care.
A Marshfield resident told the story of her grandmother who
has already been denied additional care. Her grandmother has
been cut back to one visit per day from a home
[[Page H5285]]
health aide and now the family is forced to provide care that
was once handled by professionals. It is now up to
grandchildren to come at night and put their grandmother to
bed, change her and put her in diapers.
``It is devastating to her,'' the woman said in her call.
``She cries every night when she sees us coming. She's so
humiliated her grandchildren have to do this. It's a disgrace
to see what these poor old people have to go through. These
people have worked all their lives and this is what it has
come down to. It's just ridiculous.''
Experts say saving money in home health care may even be
counter-productive. If home health services dry up, patients
will be forced into more expensive nursing home placements or
extended hospital stays. The pocket may change, but taxpayers
will still be paying the bill.
While home health care isn't cheap, it certainly provides a
cost-savings when compared to a year's stay in a nursing home
which Deschenes estimates at $60,000 per year. More
importantly, it allows older American and disabled citizens
to remain linked to their families and their communities.
The importance of that connection to home, family and
community can't be quantified, but it is of immeasurable
value to all of us in determining our quality of life. That
message came through loud and clear in the messages on the
Reader Response line during the past week.
A number of callers said they feared they might be forced
to put their mother, father or elderly relative in a nursing
home. And they held out little hope for their ``golden
years,'' as one caller put it.
How can this be?'' questioned a Weymouth resident. ``I
won't be able to care for my husband if we can't maintain the
current level of care, that would be devastating to us, both
financially and emotionally. We have been together for 55
years. I can't bear the thought of being separated like that.
We are getting along fine at home right now, but that could
all change. Please don't let it.''
Edward J. Flynn, executive director of South Shore Elder
Services, Inc., says if the current policy remains unchanged,
its primary victims will be the nation's elders. In a recent
newsletter, Flynn urged Congress and HCFA to reconsider the
cuts and clarify eligibility criteria.
____
Calls from CNC Reader Response Line
1. John Murphy, Weymouth. Why isn't Sen. Kerry speaking out
loudly on what government is doing to cut reimbursement to
health care providers? Where is the senator on this issue? He
should be at the forefront of the battle to protect Medicare.
2. Louise Cipriano, Weymouth. I was informed by my
healthcare, I have a home health aide now and my insurance
pays for it, in September, I will be 65 and I'll be on
Medicare and Medex and they said they wouldn't cover me
because I'm a chronic patient. I'm unable to walk or stand, I
have severe rheumatoid arthritis and osteoporosis. I can't
even wash my face. I need a complete sponge bath. I can't get
in the shower and my husband also is disabled with his hip.
He had a serious operation and hip replacement. He would have
to take care of me and they would not send anyone to give me
personal care with this new Medicare thing. I am a chronic
case they said and unless I need a nurse they cannot send me
Medicare help. Please don't let this happen to us. It would
be devastating. I don't think we could take it.
3. Nancy W. Clapp, Marshfield. I am adamantly opposed to
the Medicare cuts and I would like to see the congressmen if
necessary establish a fraud squad to sort out Medicare's
problems which would quickly pay for itself and look for some
other way to balance the budget and not on the backs of those
who need help most.
4. Karen Ruginski, So. Weymouth. I work for ZNA Associates
in the office and I see (health care) cuts on these patients
and I also have a father-in-law who is very ill with lung
cancer and can barely do anything on his own. I have a
handicapped child and I need to go out and help my father in
law, because he's so ill and no one else can who's home. So
it's very difficult for us and if the home health care
agencies could provide more care and get more benefits from
Medicare and the other insurance carriers, this burden
wouldn't be so difficult. I'm hoping they'll make changes to
this. Home health care is definitely needed. They're
discharged early from the hospital and they need care at
home.
5. June Sutcliff, Weymouth. I'd like to add my voice saying
Congress needs to find other ways to reduce expenses. Home
care should be the last place they cut. Some of the pork
barrel projects we read about should be eliminated first.
6. Thomas F. and Elaine Cahill, Pembroke. We totally object
to cuts in home health care. Our own family has suffered on
account of that and we are totally against it.
7. Lynn White, Hanover. My brief comment is that even if
people get worse and deteriorate under this plan, the
Medicare has made it that it will make no difference. The
amount of money spent will be the same. So what this says is
that the federal government doesn't care whether people
deteriorate or not, because they've set their budget and
locked in their cuts. Visiting nurses all these years have
kept people stable, and now without them people will be
unstable but it will make no difference as far as cost to the
government.
8. Ann Martin, Braintree. I'm calling to protest Congress's
attempt to cut Medicare's health care program. Please tell
them not to do this. Because most of us can't afford
outrageous home health care. 843-7325.
9. Joan Golden, Hanover. I'm calling with regard to the
Healthcare cuts. My grandmother is 92 years old living in a
nursing home and because of healthcare cuts she may be in
jeopardy of being taken out of the nursing home, and they're
saying she can be put into the community or in a lesser
scaled facility. It's just disgraceful because she spent her
whole life putting money into this system and now everthing
she had is gone and we're depending on the system. I'm
scared. I'm her granddaughter, I don't know what I'm going to
do if she doesn't have that facility to depend on. It's a
very scary thing, and like you said it's the people who need
it the most. Thanks and I hope we can do something for the
number of people who I'm sure are in the same predicament.
10. Mary S. McElroy, N. Weymouth. I would like to say to my
congressmen--Have the courage to stop sending billions of
dollars to the Middle East for Israel and Egypt. Spend the
money on our senior citizens who have paid taxes in this
country and deserve decent health care. We get nothing back
from Egypt or Israel, take care of our own before we keep
throwing our money away. Have some courage.
11. Lorraine McGrath, East Weymouth. I am a former
supervisor of home health care services. My comment is
briefly that the entire purpose of home care is to keep
patients out of hospitals and nursing homes and at home as
long as possible and to cut down on trips to emergency rooms
etc. I wonder if the government has done any study on the
cost of these patients being hospitalized and re-hospitalized
numerous times or placed in nursing homes. The cost of
hospitalization and nursing home placement is far more than
home care has ever been. I think they're putting the cart
before the horse because while they think they're going to
save money here, they're really going to pay more in the long
run with more frequent hospitalizations and long term care
placement.
12. Joan Kyler, Marshfield. I want to comment I have two
elderly parents who are in a nursing home and it seems
ridiculous to me that because of Medicare and Medicare cuts,
and because they didn't have enough money to afford to stay
in their home, the state is willing to pay $5,000 to $6,000 a
month per person as opposed to keeping them in their own
home, with home health care. I don't care how good a nursing
home is, it's not a place I really want my parents to be.
It's our future as well, and in another quarter century you
and I may be in a nursing home. That's something I shudder to
think of.
13. Sandra Sweetzer, Duxbury. In regard to cutting home
health care aid to the elderly, I take care of my mother,
she's a diabetic. She's had a heart attack. She's almost
wheelchair bound now. She's on a walker, I have to learn now
to give insulin shots and mix insulins. I'm not a nurse. I
don't know how to take a blood pressure. I do the best I
can and pretty soon the home health aid nurse who comes
once a week said she won't be coming anymore and I think
this is a crime. It'll force people into nursing homes who
should still be at home. It's terrible.
14. Mary O'Neil, Scituate. I just read your article in the
Scituate Mariner about the cutbacks and I think it's
disgusting. I know of some people who have been hurt by it. I
just wanted to let you know.
15. Ann Tarallo. My husband Joseph and I are really
appalled at any cuts that are being made to home care and
Medicare. I firmly believe there are other things that can be
cut, so that these don't have to be.
16. Annabelle Burlinback. I'm replying to the response line
against the ill-advised cuts in home health care.
17. Tina Degust, Marshfield. I read your article in the
paper and I just wanted to let you know it's affecting two
people I know. My grandmother who has the home health care
and also my father-in-law. It's absolutely terrible what's
happening, to see just the horrible things that are going on.
My grandfather now only receives one aide during the day and
in turn all the kids and grand-kids have to come at night to
put my grandmother to bed. She actually cries every night to
see us coming in because she has no legs and we have to
change her. She's in diapers, and she's so humiliated by
this. Not to mention my father-in-law who now has two home
health aides coming in also, who's cut back to absolutely
nothing, will have nothing during the week and his wife (my
mother-in-law) has only one kidney. Right now she needs a
serious operation on the one kidney that she has because it's
not functioning right, and they expect her to put him to bed.
He's had a stroke and he's paralyzed on one side. It's
absolutely devastating to see what these poor old people have
to go through. It's affecting two sides of my family.
Something really has to be done, these people shouldn't have
to go through this, they've worked all their lives. My
grandfather's a veteran. It's just ridiculous.
I guess what I'm trying to say is that these people
shouldn't have to go to nursing homes, they should be able to
live in their houses until whenever the time comes for them
to go and they should be able to live in comfort and not have
to worry about who's coming to change them and take care of
them. They should be able to have the help they need and not
have to worry about it
[[Page H5286]]
every day who's going to be able to put them into bed and
who's going to have to change them and the embarrassment.
They should be able to leave the world with a little bit of
dignity. They just worked too hard for their houses and
everything they have. I think it's just absolutely
devastating. I can't imagine how this is going to affect my
family alone. I have my father-in-law and my grandmother. And
my grandfather who has a colostomy and is 78 years old, he
has to help lift my grandmother to put her into bed. It's
just a matter of time before it takes its toll on him and
then what's going to happen to my grandmother. It's just
really sad and not fair.
19. Rev. Steve Harvester, Church Hill United Methodist
Church, Norwell. I'm calling to say the elderly and frail
members of my congregation would, in most cases, rather die
than be put in a nursing home. Home health care is their
spiritual survival line and I hope and I pray that our
congressmen will do everything in their power to keep home
health care alive and well.
20. Louise Penny, Rockland. I think it's very necessary
that they do not cut home health care.
21. Beverly Thomas, Marshfield. My husband is receiving a
home health aide two times a day, seven days a week. It's
about the only way we can manage and I certainly would
encourage the legislators to do what they can to help people
who need to receive this kind of assistance.
22. Jacqueline Harrington, Scituate. I am begging our
congressmen to do something about these Medicare cuts to our
most fragile people who need the care the most. I'm in the
field so I know what I'm talking about. They can't be left
out on the limb, there's got to be some other way to do it.
Please find a way.
23. Mary Anne Spilache, Abington. I work for Home Health
and Childcare in Brockton as a home health aide and I don't
think it's right that they're making all these cuts on these
poor elderly. They need so much of our help. That's all I've
got to say.
24. Jo Duvall, Hingham. I'm calling in response to the
article in the Hingham Journal yesterday and I wanted to
definitely join you in speaking out against the ill-advised
cuts in home health care. As a health care worker I'm finding
this devastating to my patients and I certainly hope that
something can be done about this as soon as possible because
it's going to be very detrimental to our whole society.
25. Pat Peters, Abington. I'd like to express my opinion on
the way the government is treating the elderly by cutting
back on their services. I'm a home health aide and I don't
understand if you leave elderly people who are sick and need
services by themselves, and you don't provide them,
ultimately they're going to fall or end up in nursing home
and that's going to cost the government more. I think this is
a real tragedy.
26. Joseph McCue, Hingham. How are senators acting on this
question? Is it a feat a complete or do we send the
information to the lady that has one the cutting?
27. Eunice and George Pope. We are now receiving home
health care services that will be cut off shortly due to the
Medicare cutback. I would like to speak to someone and
complain further if someone would return my call. xxxxxxxxxx
xxxx.
28. Gus Duffy, Scituate. I want to lend my support to
people trying to get home health care and keep it from being
cut, and express the opinion that without a Democratic
congress, you're not going to have any luck, because they're
going to balance the budget on the backs of the poor and
serve the wealthy. Get the Republicans out and you'll be
in good shape.
29. Dolores Murphy, Rockland. I read your article and I
guess I could sum it up with ``There but for the grace of God
go I.'' And hopefully make an impact.
30. Bill Parr, Weymouth. I think cuts for home health care
are despicable since there's so much government waste. They
should look at their own inefficiencies to be cut versus home
health care that's serving a wonderful service.
31. Elizabeth Greenwald-Centani, Hingham. The reason why I
am especially interested in this article is that I am a home
health worker, a nurse, and I also have an elderly mother who
suffers from Alzheimer's. I've been impacted in both ways.
And I was very pleased that your article brought up both
situations, both scapegoating of home health agencies and the
plight of the elderly.
32. Ralph and Polly Gosnick, Marshfield. We want to be
recorded in favor of efforts you are putting forward, and
want our congressmen to know that we are opposed to the cuts.
33. Mary Alice Flynn, Scituate. I think that the plan they
have on cutting the budget back on the helpless people who
are citizens and who have served our country so well over the
years is reprehensible, and I feel it's imperative that it be
turned around. I thank you for your efforts on this behalf.
34. Sophia Jackson, Weymouth. I think they should stop
spending so much money on investigating sex scandals that
make no difference to us and put the money where it belongs,
for the elderly.
35. Christine Whitehouse, Marshfield. I have been affected
by the Medicare cuts and I would be interested in what you
hope to offer. I would like to write a letter as well, so any
information you could be of assistance for I'd appreciate.
36. Suzanne Naustilius, Marshfield. I wanted to call after
reading the article in the newspaper to say that I am very
much opposed to cutting federal spending in the area of
Medicare home health, and I would like you to add my name to
any kind of letter or whatever kind of program you're going
to undertake, to try to give this message to our congressmen
and senators.
37. Dolores L. Johnson, Hanover. I've been a volunteer for
the South Shore Visiting Nurses Association for several
years. They've been forced to move to Braintree from Hanover.
The whole thing disgusts me. I am writing today to my
senators and representatives.
38. Dorothy R. Field, Kingston. Our seniors should come
first. I work in a nursing home and some of our clients are
devastated, having to leave their homes when all they need is
a home health care worker to come by and see to their needs.
39. Alice and David Katema, Holbrook. We're very concerned
about the possibility of cutting the budget by cutting
Medicare home health programs. We feel that if you don't need
them today you may need them tomorrow. Everybody's getting
older and we're all so concerned that they may not be there
when we need them. We also want to have the legislature think
about the fact that if they don't spend at that level, they
may need to spend more at another level which is hospital
care.
40. Mary McDonald, Hingham. Thank you for the opportunity
of leaving a message for the congressmen. I'm an RN who
provides infusion therapy in the home. In have come across
and my company has had to deny providing antibiotic therapy,
just basic therapy, for these patients in their home because
Medicare doesn't cover that cost. I just don't understand
where the cost cutting comes in. We are hurting our most
fragile population in that to send a nurse out to them to
teach them how to do procedures themselves, a lot of times
we can get them independent. To me that's a bigger cost-
cutting measure than keeping them in the hospital and
having them take up a bed. So, send that message to the
congressmen. I appreciate that you afford us this
opportunity. I would just like someone to explain how this
is cutting costs by denying people benefits.
41. Marilyn Keegan, Holbrook. I am calling in response to
Congress's attempt to balance the federal budget by cutting
Medicare's home health care program. This is positively
absurd. We pay taxes all our lives and then if we end up in
the position where we need help, you are suggesting we are
not able to receive it. My brother-in-law just died. He was
bedridden with cancer of the legs along with other cancers.
His wife died years ago, he had no children. He positively
needed help with home health care and it was minimal. Along
with anything friends and neighbors could do, this helped him
to live as normal a life as he could. Would it have made more
sense to put him in a nursing home and the government would
have had to pay that expense rather than the much lesser
expense of home health care. What Congress is proposing in
the face of making these kinds of cuts is both inhumane and
unnecessary. Many of these infirm and elderly have fought for
their country and served their fellow man in many capacities.
How can we turn our backs on them when they are in need.
Please do not stop Medicare's home health care program. It is
a real necessity.
42. Ruth Spiegel, Holbrook. My mother lives with me, she is
87 years old and handicapped. She's diabetic, she can't do
anything for herself and for several years through Medicare
the home health agency was taking care of her. They
terminated her March 19 of this year and I would appreciate
it if something could be done for her. Her name is Sally
Barman.
43. Pam Bernard, Kingston. I'm very concerned about this. I
have three elderly people who need this service. One is 95,
one is 91. They've been cut back to five days, then to three
days, then no days. Some of these people can't afford to have
private duty care come in. Very concerned about it.
44. Mrs. Robert C. Wright, Hingham. I think it's
unconscionable what Congress has done to cut Medicare to the
bone. They just cut $17 billion more out, gave millions of
dollars more than was asked for the road and bridge
construction bill and they're balancing the budget on the
backs of the poor and elderly and people who really need
help. They will take care of other countries in all
directions but don't take care of their own. I think
something has got to be done about this because people are
suffering.
Mr. MENENDEZ. Mr. Speaker, I want to thank Congressman McGovern for
reserving time this evening to afford us an opportunity to discuss a
critical situation for many of our states' home health agencies.
As we all know, last year's Balanced Budget Amendment contained
language which would move Medicare home health payments to a
prospective payment system, effective October 1, 1999. Until that date
an Interim Payment System (IPS) for the home health agencies was to be
put into place.
Unfortunately, the formula which has been approved to implement this
IPS has unfairly penalized those states, like New Jersey, who have been
prudent with their funds. New Jersey ranks fourth nationwide in terms
of visits per beneficiary, averaging just 43 visits per person,
compared to the national average of 73.9 visits per person.
New Jersey's home health agencies provide support services for over
50,000 patients and
[[Page H5287]]
families each year. The new iPS implemented by HCFA will cut Medicare
reimbursement to most agencies in New Jersey anywhere from $500,000 to
several million dollars per agency in 1998 alone. Cumulatively,
Medicare home health payments to New Jersey's agencies in 1998 will be
over $25 million less than in 1997. For patients in New Jersey, cuts of
this magnitude will mean they will receive fewer visits.
Mr. Speaker, who are these patients who will suffer because of this
formula? According to the Institute for Health Care Research and Policy
at Georgetown University, home health patients are more likely to
report fair or poor health. Twenty-five percent of users are 85 years
of age or older, and 69% of all users of home health services have
incomes below $15,000. These people are the among the neediest of our
neighbors for whom a home health visit may well mean the difference
between life and death.
The problem with the current IPS is that it singles out the most
efficient providers and subjects them to the deepest cuts. This is
neither fair nor prudent. Where is the equity in asking responsible
agencies to accept deeper cuts than those states whose home health
agencies have billed Medicare for more dollars? What is the sense in
driving fiscally responsible home health agencies out of the provider
market because of these inequitable cuts?
There are several bills which have been introduced to correct the IPS
formula. I am a co-sponsor of H.R. 3657, introduced by my colleague
from New Jersey. The Medicare Home Health Equity Act of 1998 would
level the playing field and recognize--not penalize--those home health
agencies which have been prudent in their use of Medicare dollars.
We need to address this problem now. Many of our home health agencies
are in critical condition while they wait and hope that Congress will
treat them fairly. The agencies in my state are not asking for
preferential treatment; they are merely asking for fairness.
Again, I thank the gentleman from Massachusetts for taking time
tonight to focus attention on this very important issue.
Mr. FROST. Mr. Speaker, I rise to express my strong concern with the
current situation of home health care agencies across the country, and
particularly of those in the State of Texas. Last summer Congress
passed the Balanced Budget Act of 1997 and in doing so reduced Medicare
payments to home health agencies. While the intent was to curb waste
and abuse within the home health industry, it has now become quite
clear that the BBA is negatively affecting thousands of home health
agencies and those who use their services.
I have serious concerns that these provisions affecting payment to
home health agencies will force hundreds of agencies in the State of
Texas out of business and thereby forcing patients into nursing homes
and hospitals. It was reported in the Forth Worth Star Telegram on June
23, 1998 that half of Texas' home health care agencies will soon being
filing bankruptcy. It is imperative that Congress fix the problem with
the home health care payment system, before this story in a newspaper
becomes a reality.
H.R. 3205, a bill introduced by my colleague from Massachusetts, Mr.
McGovern, will fix part of the problem by delaying the implementation
of the interim payment system for home health agencies. I support this
bill, and urge my colleagues to work for its passage.
The Texas Association for Home Care informed my office that in one
day alone, twenty agencies reported to them that they were going out of
business. This needs to stop. Congress needs to find solutions to the
problems it created for this industry and for the thousands of people
it serves.
Mr. MANTON. Mr. Speaker, I rise to voice my support for improving the
already high quality home health care services for Medicare
beneficiaries. I thank my colleague, Congressman McGovern, for
organizing this important and timely Special Order to address the need
to fix a major formula issue for the home health care industry and
those who rely on its services.
The Balanced Budget Act of 1997, signed into law last year, moved
Medicare's home health benefit package payment system to a prospective
payment system (PPS). Although this system has worked well in the past
for hospitals, it has not yet been implemented into the home health
care industry, in turn, an interim payment system (IPS) was put into
play until the PPS was ready. The IPS formula has since created
problems for home health care providers and patients by unfairly
burdening and penalizing home health businesses who are most cost
effective.
The impact this situation will have on home health in New York is
astounding. Because providers in New York are currently having their
1998 reimbursements based on 1993 experience, it will be a tremendous
blow to the services the New York home health care industry has
delivered so well to its patients in the past. Should the IPS continue,
New York home care providers would see a $130 million reduction in 1998
reimbursements.
To remedy this unfortunate situation, a number of pieces of
legislation have been introduced, including H.R. 3651 and H.R. 3567.
Introduced by my good friend and colleague, Congressman Engel, H.R.
3651, The Medicare Home Health Agency Efficiency Act of 1998 proposes
to change the existing formula and make adjustments to the IPS which
would treat efficient ag4ncies more fairly. In addition, H.R. 3567, The
Medicare Home Health Equity Act of 1998, introduced by congressman
McGovern, would help reinstate equitable reimbursements and allow home
care agencies to make a less rocky transition the PPS.
Mr. Speaker, the Balanced Budget Act of 1997 did a fantastic job
addressing the waste and abuse within the home health care industry. I
encourage my colleagues in joining me by taking one more step in
improving the quality services the home health care industry has
provided for so many Medicare beneficiaries by cosponsoring these vital
pieces of legislation.
Too many individuals rely on home health care for their livelihood.
It would be devastating to both the home health care industry, the
patients they serve, if the number of home care businesses continue to
be unfairly burdened through the Interim Payment System contained in
the Balanced Budget Act of 1997.
Once again, I would like to thank Congressman McGovern and my other
colleagues who have gone to great lengths to guarantee the Medicare
beneficiaries of our nation receive the quality, affordable home health
care services they deserve.
Mr. McGOVERN. Mr. Speaker, I submit the following letter:
U.S. House of Representatives,
Congress of the United States,
Washington, DC, May 20, 1998.
Hon. Newt Gingrich,
Speaker of the House, U.S. House of Representatives,
Washington, DC.
Dear Speaker Gingrich: With the support of the
administration, Congress worked to pass the Balanced Budget
Act of 1997 (BBA) last summer and in doing so reduced
Medicare payments to home health providers across the nation
by over $16 billion. The expressed intent of these cuts was
to curb waste and abuse within the home health industry.
Sadly, it is now clear that the provisions in the Balanced
Budget Act do not end such abuse, and actually punish non-
wasteful home health providers across the nation. Because of
a funding formula buried in the BBA, previously efficient and
waste-free providers have been given a Medicare spending
``cap'' that is below financially manageable levels, and, as
a result, many agencies in Massachusetts are facing
insolvency.
One of the many examples of this phenomenon is
Massachusetts Easter Seals, which has provided quality home
health care to disabled citizens in my state for over fifteen
years. In Massachusetts, Easter Seals is an acknowledged
leader in devising and efficiently implementing coordinated
treatment plans for people with disabilities and complex
medical conditions. In fact, when audited by Operation Trust
in 1997, Easter Seals, like most home health providers in
Massachusetts, passed with flying colors.
Massachusetts Easter Seals will no longer offer home health
services because of the Balanced Budget Act of 1997. Faced
with a projected deficit in excess of one million dollars,
the Board of Directors has chosen to exit home health care as
of August 31, 1998. This means that over 500 individuals, the
majority of whom have disabilities or chronic medical
conditions, will be forced to seek care elsewhere in the
Massachusetts home health market--which is already downsizing
dramatically. In the future, individuals with disabilities or
chronic conditions may well be unable to access appropriate
home health services. The net result will be that many
Massachusetts citizens will be institutionalized at high
personal cost and greater expenditure of public funds.
Pressure to correct these unintended consequences is
growing in Congress. At a recent Senate hearing, twelve
Senators from both parties gathered to discuss the problems
this law created for home health care. They agreed that a
``mistake'' had been made in the Balanced Budget Act and were
prepared to look at ways to solve the crisis. I have called
for a hearing in the House of Representatives, and on
February 12, 1998, I introduced a bipartisan bill, H.R. 3205,
``The IPS Technical Correction Act of 1998.'' This bill,
which would ease the crisis in home health, currently has
over 40 cosponsors from both parties. Senators Kennedy and
Jeffords introduced the Senate companion, S. 1643, and
support is growing in the Senate as well.
I would like to request that you include H.R. 3205 for the
House Calendar on technical corrections day. Seniors, the
disabled, and the medically complex individuals in our nation
are paying for this poorly-drafted provision to cut waste and
abuse in the home care industry. I support ending abuse and
pledge to work with you toward this goal, but patients should
never be the ones to suffer from such attempts. I look
forward to working with you to provide needed and efficient
home health care to our nation, and I thank you in advance
for your attention to my request.
Sincerely,
James P. McGovern,
Member of Congress.
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