Health care at home

After a booming decade, it’s understandable that the home health care part of the Medicare system would be in need of some fine-tuning. Leave it to the federal government to turn necessary adjustments into crisis.

The good idea behind home-based care for the ill elderly is simple and logical: better care, more efficiently delivered. Since 1990, home health care has been one of the fastest-growing benefits under Medicare, exploding from $3.7 billion then to $17.8 billion in 1997. And, as is the case whenever federal billions start getting tossed around, greed followed. A 1995 federal investigation of home care in five states (not Maine) uncovered massive fraud and abuse. With a budget to balance, reform-minded Congress sought to trim Medicare’s waste.

But where a scalpel was called for, Congress used a cleaver. It’s hard to fathom, but the essential result of the reform was to reward excess and to punish frugality. Under an interim system now in place, Medicare payments to providing agencies are based primarily upon how much each agency received for an average Medicare beneficiary in 1994 — before the investigation, before fraud and abuse were uncovered and, it is hoped, rooted out. The large, for-profit agencies, mostly in the Southern states, that padded the books with unnecessary visits for questionable reasons started this trimming down well padded with fat. The small, community-based, nonprofit agencies — the rule in the Northeast — began the process with bare bones.

And it’s really starting to hurt. Sen. Susan Collins led her Subcommittee on Investigations on an exploration of this issue last week and the findings were alarming. Maine nonprofits have lost millions in Medicare reimbursements in the last two years and the agencies are being gutted: Saco’s Visiting Nurse Service has eliminated 120 of its 420 jobs over the last year, dropped retirement benefits and plans to close one of three branch offices; the Visiting Nurses of Aroostook County cut 37 jobs, froze salaries, halved pension benefits and still operates at a loss; in Bangor, the Visiting Nurse Service has laid off 10 employees.

Fewer nurses, fewer visits, more ambulance calls, eventually more nursing homes. In the name of saving money, Congress has devised a plan that inevitably will cost more while providing worse care. If it’s not yet a crisis, a planned 15-percent cut in home care scheduled for next year will make it one. Backers of this giant step backwards, largely influential members of Congress from the aforementioned Southern states, proudly point to the $2.9 billion decrease in home-care Medicare spending last year. They’d prefer not to talk about the coming increase in acute care costs. They certainly don’t want to talk about the human cost.