Blog#40- 8/24/20

By Richard Davis

The literal meaning of the Yiddish word bupkis is nothing. But as is the case with many Yiddish words, bupkis can add richness and nuance to the description of situations. For example: I got bupkis for presents from my friends on my 70th birthday. Bupkis implies disappointment and some degree of anger, as well as an expectation of a specific kind of behavior from friends.

As the current pandemic unfolded in this country it became clear that the American health care non-system is not meeting the needs of a large segment of the population. It was not exactly a revelation, but it should have been a wakeup call.

Politicians offered their usual meaningless rhetoric and there was no legislation put forward to address the sickness of the health care system. In fact, the pandemic legislation that passed became a financial windfall for obscenely rich Americans while the rest of us were thrown a few crumbs: political bupkis.

This country still has an opportunity to create meaningful health care reform without having to have the big battle over single payer, Medicare For All or any other major systemic change. Politicians could pick out a few areas where comprehensive legislative changes could spark policy changes that would improve the quality of health that Americans receive.

One area that is ripe for change is home health care. I worked as a home health care nurse for 15 years and it was a time when the reimbursement of that kind of care was subjected to major changes that resulted in care that became less available.

Medicare accounts for the lion’s share of home health reimbursement. Medicaid and private insurance are smaller players in the overall scheme of things but they are still critical to agency reimbursement. When I first worked in home health, agencies were reimbursed by Medicare by the visit and we operated within a tangled web of federal regulations and policies.

But even with all of the regulatory burden, we were still able to provide a lot of preventive care. I was able to visit patients with heart failure, COPD and a variety of chronic conditions on a regular basis over a period of years. We followed the rules that forced an insane paperwork burden upon us, but we knew that doing the paperwork meant our patients’ health was being maximized. If chronic diseases are monitored carefully the quality of people’s lives improves and the health care system saves a lot of money.

In 1999 congress started to implement a prospective payment system for the reimbursement of home health care by Medicare. It meant that home health agencies would receive a pre-determined amount of money for each patient based on diagnosis and that patients could only receive care within a 60 day window. Exceptions were allowed.

Part of the reason that this new system was created was because politicians felt that there was too much fraud and abuse in the old system. There were a number of cases where home health agencies in Florida and other states were able to defraud Medicare of millions of dollars. Politicians felt the system was too vulnerable to fraud.

The resulting changes pushed home health care more towards the acute side and it became more difficult to provide chronic care without losing a lot of money. Nurses were turned into bean counters and meetings that previously focused on care planning became financial sessions where nurses had to figure out how many visits a patient could have before the agency started losing money. Nurses were forced into a position of having to be guardians of the bottom line, relinquishing some of their role as case managers while becoming money managers.

Then in January 2020 the Patient Driven Groupings Model (PDGM)was introduced. Commenting on this new model the Center for Medicare Advocacy stated, “PDGM will worsen concerns regarding inequities in available care. Consideration of social determinants of health will be more meaningful when CMS develops a payment system that does not discriminate on the basis of illness or injury and when CMS does not allow agencies to cherry-pick beneficiaries to serve based on inequitable policies.”

The new PDGM model made a bad system even worse. They go on to note that, “Medicare beneficiaries who were not recent inpatients and/or need more than 30 days of home health care will experience even greater problems accessing care than currently. Beneficiaries with longer-term and chronic conditions who are unlikely to improve will continue to experience a decline in the availability of Medicare home care services. Beneficiaries with hospital observation, outpatient, or emergency stays will experience a decline in access to home health care, since PDGM treats them as admissions from “the community” and attaches lower reimbursement rates. Beneficiaries who need and qualify for Medicare-covered therapy will receive less therapy.”

My suggestion is to dismantle the current reimbursement system and to pass legislation to create a home health reimbursement model that is based on the delivery of chronic care so that people can remain at home longer. The prospective payment system did not serve the needs of enough people who want to stay in their own homes and be cared for in the least restrictive setting as possible. The PDGM only makes matters worse.

So far, what we have in the way of health care reform is worse than bupkis.

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