TOPICS > Health

Paying for Health

May 15, 1997 at 12:00 AM EDT


JIM LEHRER: Now another in our continuing series of reports on health care. Tonight: Paying for home health care. Tom Bearden reports from Louisiana.

TOM BEARDEN: Virtually every day a nurse or nurse’s aide comes to visit the Gills’ residence just outside Baton Rouge, Louisiana. Charles Gills has diabetes, Alzheimer’s, and Parkinson’s Disease.

HEALTH CARE WORKER: Let’s check your vital signs before we get started.

TOM BEARDEN: The nurses check his blood pressure and breathing, clean the wounds on his feet, and make sure he’s been taking the proper medication.

HEALTH CARE WORKER: You forgot to take your pill with your lunch.

TOM BEARDEN: Daughter Mona says she doesn’t know what she would do without the help.

MONA GILLS COLLINS: Instead of trying to take care of him, you know, himself, and juggle his medications and everything, someone is there to give him that medications when he has to take ’em and everything. It was hit and miss when he was doing it himself, but, no, someone’s there to do it for him. He’s gotten much better, much stronger.

HEALTH CARE WORKER: (talking to patient) Hello. Morning. How are you doing?

PATIENT: All right.

TOM BEARDEN: Scenes like these are repeated hundreds of thousands of times each day across the country, courtesy of the federal government’s home health care program. It’s designed to bring medical services to Medicaid and Medicare recipients recently discharged from the hospital, or to provide treatments that will prevent hospitalization. The goal is better health care at a lower cost. The patients love it. Shirley Falsetta has received two visits a day from a home health care nurse ever since surgery a month ago to remove a blood clot in her leg.

SHIRLEY FALSETTA: They took me out of the hospital. I was in the hospital for three weeks doing nothing really. And I was able to come home and be in my own home and still have the same thing done.

TOM BEARDEN: Is that important to you, the fact that you can be at home?

SHIRLEY FALSETTA: Of course. Of course. Well, everybody wants to be at home. No one likes to look at four walls in a hospital.

TOM BEARDEN: The government pays about $80 for each home care visit, far less than a day in the hospital.

HEALTH CARE WORKER: (talking to patient) No pain up here?

TOM BEARDEN: But Medicare’s spending for home health care has risen at an average of 30 percent every year for the last five years, far exceeding expectations. In 1995, Medicare paid out $16 billion to home care agencies. Bill Dombi is a vice president for the National Association for Home Care. He says costs are growing because the need is growing.

BILL DOMBI, National Association for Home Care: The fastest growing segment of our population is over 80, and invariably, they’re afflicted with some kind of chronic illness or disease, which is going to require some support, so we have that growth in need, accompanied by growth in service. Over the last few years the Medicare home health expenditures have grown significantly, but in looking at where that growth is we see more than double the number of people receiving care. And I think that has to be viewed quite positively. People are going to home care, rather than in a nursing home. That rapid growth in home visits has become a major concern for officials at the Health Care Finance Administration, the agency that pays the bills. Judy Berek says the growth has been accompanied by massive fraud.

JUDY BEREK, Health Care Financing Administration: We’ve had a major effort inside HCFA to look at what we call provider enrollment to make sure that we are doing a better job of only allowing into the program providers who are coming into the program for the purpose of providing services to beneficiaries and not people who look at the Medicare program as a program they can rip off.

TOM BEARDEN: Ripping off the program was apparently what Jack and Margie Mills had in mind. Last year in Georgia they were convicted of defrauding Medicare of more than a million dollars, billing the government for services that were never rendered. Several agencies in Louisiana are also getting special scrutiny from Washington. There are some 550 home health care agencies in the state, while neighboring Mississippi has just 75. And billings per patient are higher in Louisiana than anywhere else.

BOBBY JINDAL, Louisiana Secretary of Health & Hospitals: They’re asking for a lot more money than I think we want to give ’em.

TOM BEARDEN: Bobby Jindal is Louisiana’s Secretary of Health & Hospitals. In the year he’s been on the job, the Department has found widespread abuse and conflict of interest.

BOBBY JINDAL: We have certain cases where physicians are referring patients to their own home health agencies, which is not allowed by the law. We’ve got other home health agencies where they go and they perform shopping, or house cleaning, or they just do other types of services for individuals that are not medically covered, services you and I might like to have, but we don’t ask the state to pay for them. We’ve got over-billing. We’ve got billing for patients that don’t exist. We’ve been billed for patients that have been long dead. Those are the kinds of abuses we seek throughout the entire program.

TOM BEARDEN: Investigators found that 40 percent of the billing in just 25 targeted agencies in Louisiana was improper.

BOBBY JINDAL: Part of the attraction of the home help is also its danger. Part of the attraction of allowing someone to live at home means that it’s also unsupervised. It’s obviously easier to supervise or check on an institution. It’s much harder for the state to be in everybody’s home, to watch over their shoulders, to know what’s really going on.

HEALTH CARE WORKER: (talking to patient) Just relax your arm down.

TOM BEARDEN: No one really knows how widespread fraud and abuse is, either in Louisiana or nationwide. When Jindal took office last year, home health agencies were growing so rapidly that his department didn’t have enough people to keep up with inspecting them. The legislature passed a moratorium on new agencies, and Jindal is asking it be extended to the year 2000. That has stirred some debate.

RODNEY ALEXANDER, State Representative: If you’ve been keeping up with the news, if you know anything about what’s happening in the state of Louisiana, you know that home health agencies, for instance, have skyrocketed in the numbers. This bill will again place a moratorium on those agencies and stop that–give the department some latitude in trying to get a handle on this.

RAYMOND JETSON, State Representative: The home health agencies are little folks. They are persons who–who display the entrepreneurial spirit and start small businesses and go into business. And I believe that there’s a fundamental problem with saying to folks that you can’t start a business; you can’t go into a particular business, not because you aren’t capable of it, not because you don’t have the expertise necessary to be successful, but simply because government says you shouldn’t go into that business.

TOM BEARDEN: Not surprisingly, current owners of home care agencies support a continued moratorium.

BECKY LINGUITI, Home Care Agency Owner: We’re not dealing with a fruit stand or a grocery store, or just a private business, so to speak. We’re dealing with people’s lives. We’re dealing with state and federal funds, and there are some problems.

TOM BEARDEN: Becky Linguiti was a nurse for eighteen years before starting her own home care agency six years ago. She also heads the Louisiana chapter of the Home Care Association of America.

BECKY LINGUITI: We need to figure out what’s going wrong, what do we need to do differently, how can we improve to really focus on patient care and the intent of the program. There’s going to be people that entered into this program that aren’t going to want to be in it anymore.

TOM BEARDEN: One of the reforms being talked about both in Louisiana and in Washington is whether to move home care agencies toward a payment plan called “capitation” that puts a limit on the amount paid out for various health problems.

JUDY BEREK: We want to set rates of payment on an episodic basis that says, you know, if you’ve been in a hospital and you come out and you need home health care, odds are this is how much home health care you need. And that’s what we’ll pay the agency for.

TOM BEARDEN: Members of the National Association for Home Care aren’t opposed to that but warn that if care is limited too much, it can be more costly in the long run. They point to a government study of people in managed care plans whose home care was limited.

BILL DOMBI: What they have found there where the patients are significantly under-served with negative outcomes–negative outcomes mean they go back into the hospital, they get sicker for a longer–stay sick for a longer period of time, or they’re not rehabilitated appropriately. So what we’d have to do on the payment reform side is make sure the quality of care is maintained, the patient outcomes are appropriately achieved, and that resources be developed to focus in on that.

TOM BEARDEN: Benny Lanoix is watching all this with some anxiety. He suffers from emphysema and receives three home care visits a week.

BENNY LANOIX: I couldn’t do without it because my wife, she couldn’t–she couldn’t take care of me because she done had a heart operation and broke her hip, so she couldn’t take care of me, so I need somebody.

TOM BEARDEN: Lanoix hopes he will continue to get help while the government tries to figure out how to deal with fraud and rising demand for the service, without defeating the whole purpose of the program, reducing costs by keeping people out of hospitals and in their homes, where studies show they clearly stay healthier and happier.

JIM LEHRER: Still to come on the NewsHour tonight the new opening to Vietnam and a David Gergen dialogue.