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Private duty providers struggling with implementation
Despite the protests of many Medicare-certified private duty providers, the Health Care Financing Administration’s (HCFA) Outcomes Assessment and Information Set (OASIS) is here.
On Jan. 25, HCFA issued final regulations for the data collection effort that will be used in the home care prospective payment system and the outcomes-based quality improvement of all Medicare-certified agencies. After a testing period, the regulations obligated providers to routinely collect and submit data to HCFA by April 26.
Medicare-certified providers must complete OASIS assessments upon admission and at other specified times on all patients, with a few exceptions. Excluded are those under 18, or those receiving maternal-child, housekeeping, and chore-type services. Those receiving nutrition and medical social work services may also be excluded. The National Association for Home Care (NAHC) is awaiting clarification on this apparent super-regulation policy decision from HCFA, according to Chandra Branham, associate director of regulatory affairs at NAHC.
HCFA argues it needs data on all patients to substantiate that Medicare patients receive the same level of care as others and ensure it pays consistent rates across the country.
Most providers laud OASIS’ long-term potential for establishing a Medicare prospective payment system and substantiating the benefit of home care through statistically significant clinical outcomes. However, those operating Medicare-certified private duty services in one entity have serious quarrels with the project. The requirement to perform OASIS assessments on sometimes significantly higher numbers of private duty rather than Medicare patients is onerous at best. It adds costs and layers of administration to slim-margined operations radically different from those involving Medicare patients, they contend.
Consider the case of Delray Beach, FL-based LifeCare Home Health Services. More than 80% of the Medicare-certified provider’s patients are private pay, according to Barbara Little, RN, MPPA, CHCE, director of compliance.
The company primarily provides personal care services through its branch offices in Connecticut, Illinois, Indiana, Maryland, and Arizona. One office has only 30 Medicare patients out of 125. Yet, because the private duty and Medicare operations are one entity, LifeCare must perform OASIS assessments on all patients.
Sacramento, CA-based Chicken Soup Plus is in a similar situation. Medicare pays for the care of only about 10% of its patients, according to Mary Baker, RNC, MSN, MHS, FNP, president and chief executive officer. The remainder of its skilled and personal care cases have both managed care and private funding.
OASIS requires additional resource expenditures. Direct expenses include such items as additional staff for increased data entry and new information technology. Productivity decreases also indirectly increase expenses. Despite industry calls to do so, HCFA has not agreed to any additional compensation for the OASIS implementation.
Of even more concern to some is the personal information the OASIS assessment involves, such as a patient’s experience with alcohol and drug dependency, depression, and thoughts of suicide. Obtaining and transmitting such data to HCFA violates the privacy rights of all patients, particularly those whose care is not reimbursed by Medicare, they argue.
When asked by NAHC what providers should do if a patient refused to answer OASIS questions, HCFA initially stated that agencies should document the patient’s refusal in the chart but continue providing services, Branham reports.
About a week later, HCFA reversed itself and said that under such circumstances, providers could not continue providing services. Recently, it has indicated that it needs to research the subject and develop a definitive answer. At Private Duty Homecare press time, NAHC was awaiting this response.
The OASIS-related privacy concerns sparked a controversy. NAHC members who visited congressional offices while attending the association’s mid-March policy conference reported that legislators expressed surprise and concern about the requirement.
In addition to home care industry associations, the American Psychiatric Association and the Health Privacy Project at Georgetown University have communicated concerns to HCFA, as has the federal Small Business Administration (SBA). The subject has also received major press coverage, including the front page of The Washington Post.
"I’m pretty amazed that out of all the things that have happened to home care in the past year, this is the issue that has attracted attention. Legally and ethically, though, it’s a quandary [that] I don’t know how it will be resolved," says Elizabeth Hogue, a health care attorney in Burtonsville, MD.
With increased costs not recognized by HCFA and a potential loss of business from patients who refuse the OASIS assessment, some private duty providers are considering if they should decertify themselves from the Medicare program.
Eliminating one problem may create others. Depending on the state(s) they do business in and their long-term strategies, Medicare disenrollment may inhibit rather than support organizational growth.
"It’s a real quandary. To provide services to Medicare + Choice or even some regular managed care patients, you must be Medicare-certified," says Hogue. Many state Medicaid programs require Medicare certification, as do numerous third-party payers.
"So many private pay sources want you to be Medicare-certified because they want you up to a certain level of services," explains Pat Stalica, RN, BSN, director of private services for Outreach Health Services in Austin, TX.
A provider bowing out of the Medicare program may in turn close the doors to other payer sources.
It may not be much of a consolation, but payers also caught in the dilemma of meeting Medicare regulations and trying to achieve financial objectives have opted out of the program.
"The Medicare managed care companies have to abide by Medicare regulations," Hogue explains. "That’s why so many are fleeing the market because they want to get out from under the burdensome regulatory requirements and what they regard as too little reimbursement."
Unless HCFA moderates its positions, Medicare-certified private duty providers have little choice but to comply with the requirement. (See related article on easing the OASIS implementation burden, on right.)
In the meantime, Branham encourages pursuing all avenues of objection — including contacting members of Congress, the SBA, and the HCFA Office of Clinical Standards and Quality — which oversee OASIS implementation.
Don’t miss opportunities to educate patients and the public, Baker advises. In recent presentations to Sacramento, CA, business groups, she found people were fairly ignorant about the subject, despite some national media coverage. Once informed, they expressed outrage at the government’s intrusiveness, she reports.
Focusing on the long-term benefits of OASIS may also help plow through the immediate morass.
"We’re looking at what OASIS will mean in 18 months. We hope the benefits will far outweigh the temporary inconvenience and costs," explains William Deary, chief financial officer of Great Lakes Home Health Services in Jackson, MI.
"OASIS could be enormously favorable for home care providers," Hogue says. "It may demonstrate value in a way they’ve never done before."
"It is at least an opportunity to validate home care," agrees Catherine Mallard, MEd, RN, director of clinical system design for the New York City-based Visiting Nurse Service of New York. "There is a lot of debate about its value. Now we have a way to tell, through reliable and valid tools, the improvement we made with patients."