Medicare is the largest single payer of home health services. Home health agencies may be Medicare-certified (eligible for Medicare reimbursement) or non-Medicare-certified (reimbursed by insurers, private payment or other sources). Close to one-fourth of all home health care is still funded through private payment by clients.
Much of the home care of clients receiving occupational therapy is coordinated by home health agencies. Medicare defines a home health agency as a public or private organization primarily engaged in providing skilled nursing care or other therapeutic services (Humphrey & Milone-Nuzzo, 1996). To qualify under Medicare certification regulations, an agency must do the following: firstly, provide at least one therapeutic service besides skilled nursing. Secondly, have policies developed by at least one physician and one registered nurse. Thirdly, maintain records for all clients seen. Fourthly, employ professional personnel who meet established qualifications. Lastly, provide for regular review of policies. Under Medicare guidelines, any client services provided by a home health agency must be ordered by a physician.
On the other hand, for a home health agency to receive Medicare or Medicaid reimbursement, it must first be surveyed and certified by a state agency as complying with the conditions of participation set forth in the federal regulations developed by the Health Care Financing Administration (HCFA) (Kavaler & Spiegel, 2003). If a national accrediting body, such as the Joint Commission, provides HCFA with reasonable assurance that a home health agency it accredits meets the federal meets the federal conditions of participation, HCFA may deem that the home health agency meets certification requirements. This recognition is known as deemed status.
The Joint Commission first submitted its application to achieve such recognition for its home care accreditation program to HCFA in 1998. This application included a comprehensive comparison of the conditions of participation with the Joint Commission’s home care standards as well as a detailed analysis of the accreditation decision-making process. As part of its review, HCFA also evaluated surveyor selection, training, and supervision; survey process methods; and the Joint Commission’s general administrative policies and procedures. A final rule regarding deemed status for Joint Commission-accredited home health agencies was published in the Federal Register on June 30, 1993 and made effective September 28, 1993 (Medicare and Medicaid Program, 1993).
To ensure comparability between the federal certification and the Joint Commission evaluation processes, the Joint Commission agreed to several changes in its process for those home health agencies wishing to use accreditation for Medicare certification. Some changes are reflected in the standards and scoring guidelines of the CAMHC (Joint Commission, 1996). In addition, the Joint Commission agreed to use the HCFA functional assessment instrument and certain sampling procedures for those home health agencies that wish to elect the deemed status option.
Last, as required by law, any survey used for home health agency certification must be unannounced. Therefore, for those agencies interested in having the Joint Commission’s evaluation serve in lieu of the state survey, the organization must elect the deemed status option, allowing the Joint Commission to conduct an unannounced survey. During an initial or regular triennial survey in which the organization takes the deemed status option, all applicable Joint Commission standards as well as the Medicare conditions of participation are surveyed. If a Joint Commission surveyor surveys the organization during the interim years of the triennial accreditation cycle, only those standards that are comparable with the Medicare conditions of participation are evaluated.
The alterations to the standards, scoring guidelines, and survey process do not change the fundamental intent of the Joint Commission accreditation approach but rather are designed to provide congruency with the related regulatory requirements and procedures. Accreditation is, and will remain, voluntary. Seeking deemed status is an option available to interested home health agencies, not a requirement. Agencies desiring Medicare approval may choose to be surveyed by an accrediting body, such as the Joint Commission, or by state surveyors. The Joint Commission award letters, decision reports, and decision grids make the distinction that an agency has elected the deemed st6atus option and has undergone an annual unannounced survey for the purposes of satisfying certification requirements.
Meanwhile, in some cases, where reimbursement formulas are inadequate to support the costs of the services rendered, certification for program participation may be a mixed blessing, if not the kiss of death. Medicare certification for hospitals provides a useful example. In another separate analysis, survivor model estimates for the Bay Area suggest that hospitals that are certified to serve Medicare patients were three times more likely to exit the population than those that were not certified.
I do not think, however, that this result implies that Medicare approval does not involve direct certification by a federal agency but rather accreditation by the JCAHO. When they control for this legitimating effect (which is positively associated with hospital survival), the remaining negative impact of Medicare certification appears to result from the fact that some of these hospitals are serving patient markets that present very burdensome demands on the care system, such that the costs of providing necessary services are greater than those covered by the reimbursement formulas.
Funding for Medicare certification activities comes from the Medicare trust funds. Historically, although states have submitted estimated budgets each year to their regional offices, they have received Medicare allocations incrementally larger than their previous year’s budget. In 1981 the Medicare certification budget was cut from $30 million to $25 million and, in 1982 it was cut to less than $14 million. When Congress restored the funding in 1983, the HCFA tried to reallocate the funding among states more in accordance with workload. The costs of average long-term care and other health facility surveys are estimated on the basis of 1980 expenditures, and are updated annually with an inflation factor.
The Federal Government collects many different kinds of information in connection with the certification of home health agencies for Medicare and the payment of Medicare home health claims. Thus, much more is known about Medicare-certified home health agencies than about non-Medicare-certified home health agencies.
The proportion of home health agencies that are Medicare-certified varies among States. In 1987, for example, 85 percent of the 194 home health agencies in Arkansas were Medicare-certified, compared to only 21 percent of the 921 home health agencies in New York.
Home health agencies are licensed by some States and territories, but not by others. OTA’s tabulation of the results of a survey by the National Association for Home Care (NAHC, 1989) shows that, as of March 1989, 35 States and territories licensed Medicare-certified home health agencies, and 30 States and territories licensed non-Medicare-certified home health agencies.
It has been estimated that people who receive Medicare-funded in home services constitute 60 to 100 percent of the clients of individual Medicare-certified home health agencies (Minnesota Task Force, 1985). If that estimate is correct, then up to 40 percent of the clients of some Medicare-certified home health agencies receive in-home services that are not Medicare-funded. Very little information is available about those people or about people who receive in-home services from non-Medicare-certified home health agencies.
Medicare is the largest third-party payer for home health care. As noted earlier, Medicare pays only for in-home services that are provided or contracted for by Medicare-certified home health agencies. Medicare expenditures for in-home services for 1989 were estimated to be $2.9 billion. Data for fiscal year 1984 show that Medicare payments accounted for almost three-quarter of the revenues of Medicare-certified home health agencies in that year (Foundation for Hospice and Homecare, 1988), but anecdotal evidence suggests that proportion may have decreased since then.
Foundation for Hospice and Homecare (1988). Basic Home Care Statistics: The Industry.
Joint Commission on Accreditation of Healthcare Organizations. (1996). Comprehensive
Accreditation Manual for Home Care. Oakbrook Terrace, II; Joint Commission.
Humphrey, C., Milone-Nuzzo, P. (1996). Orientation to Home Care Nursing.
Gaithersburg, Md.: Aspen Publishers, Inc.
Kavaler, F., Spiegel, A. (2003). Risk Management in Health Care Institutions: A
Strategic Approach. Sunbury, Mass: Jones & Bartlett Publishers.
Medicare and Medicaid program. (1993). Recognition of the Joint Commission on
Accreditation of Healthcare Organizations standards for home care organizations.
Federal Register 58:35007-35017.
Minnesota Task Force on the Needs of Persons with Brain Impairment (1985). Final
Report of the Minnesota Task Force on the Needs of Person with Brain
Impairment. Submitted to the Commissioner of the Minnesota Department of
Human Services, MN: St. Paul.
National Association for Home Care (1989). State License and Certificate of Need
Survey. Washington, DC.