News Release

Length of stay in medicare home care programs declines after passage of Balanced Budget Act

Peer-Reviewed Publication

Beth Israel Deaconess Medical Center

BOSTON – The median length of stay for Medicare patients in home health care programs dropped sharply after passage of the 1997 federal Balanced Budget Act, particularly among people receiving care from for-profit agencies, Beth Israel Deaconess Medical Center researchers report in the June 4 issue of the Journal of the American Medical Association, urging more study on the effect of shortened length of stay on quality of care and patient outcomes.

“We found that after the Balanced Budget Act, length of stay in home care decreased among Medicare patients, particularly among those in for-profit agencies,” says Rachel Murkofsky, M.D., M.P.H., the study’s lead author, a staff physician in the Gerontology Division at Beth Israel Deaconess Medical Center (BIDMC) and an instructor of medicine at Harvard Medical School. “However, we don’t know what effect the shortened length of stay had on quality of care or patient outcomes.”

Medicare beneficiaries are eligible for home health care if they are homebound, under a physician’s care and require medically necessary part-time or intermittent skilled nursing or therapy services.

Prior to the Balanced Budget Act, home care reimbursements were made primarily on a fee-for-service basis. With mounting concerns about potential fraud and abuse, in 1997 Congress mandated a new home health payment system to control Medicare spending on what was, prior to passage of the act, the fastest-growing segment of the health care industry.

Using data provided by the National Home and Hospice Care Surveys from 1996 and 1998 – and focusing on patients with diagnoses associated with chronic home health care needs such as congestive heart failure, chronic obstructive pulmonary disease, diabetes and cancer – researchers compared length of stay in home care for Medicare beneficiaries before and after the 1997 Balanced Budget Act.

Most patients receiving home care were older than 65 years. Some needed support with one or more activities of daily living (ADLs), such as bathing, dressing or eating. Others needed help with instrumental activities of daily living (IADLs) such as shopping, preparing meals or managing money. After passage of the act, patients in home care were less likely to be younger than 65 years and more likely to need help with ADLs.

Before the act, median length of stay in home care ranged from 46 days in non-profit agencies to 111 days in the for-profit sector. After passage, the reimbursement change trimmed the median stay to 36 days in non-profit agencies and 55 days in the for-profit sector, a 22 percent and 51 percent reduction respectively.

“Some of the shortened length of stay was probably appropriate, given evidence of fraud and abuse in the system,” Murkofsky notes, adding some of the decrease of Medicare disabled home care patients may have been the result of enforcement of eligibility criteria for home care services that took place during that time.

“However, in addition to eliminating unnecessary services in home care, the Balanced Budget Act may have reduced access to necessary services, resulting in unintended adverse consequences for beneficiaries.”

The study urges additional research into the status of patients after their discharge from home health care. “While patients who are discharged from the hospital have the safety net of home health care and skilled nursing facilities, patients who are discharged from home health care have no comparable protection,” says Murkofsky.

“We were unable to determine quality of care or appropriateness of care with our study. Given the large number of Medicare beneficiaries that use home health care and the aging of the population, future studies are needed to assess the effect of shortened length of stay on quality of care and patient outcomes.”

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The study’s co-authors include Russell S. Phillips, M.D., Ellen P. McCarthy, Ph.D., M.P.H., Roger B. Davis, Sc.D., and Mary Beth Hamel, M.D., M.P.H., all of the Division of General Medicine and Primary Care at BIDMC. Funding was provided in part by The National Institute of Aging, the Harvard/Hartford Center of Excellence Advanced Research Fellowship, and the Paul Beeson Physician Faculty Scholars in Aging program.

Beth Israel Deaconess Medical Center is a major patient care, teaching and research affiliate of Harvard Medical School, ranking third in National Institutes of Health funding among independent hospitals nationwide. The medical center is clinically affiliated with the Joslin Diabetes Center and is a founding member of the Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox.


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