Pre-Existing Inequality: The Impact of COVID-19 on Medicare Home Health Beneficiaries.

There is significant data on the adverse impact of COVID-19 on persons who were poor, minorities, had compromised physical or mental health, or other vulnerabilities prior to the COVID-19 pandemic. A significant portion of the overall Medicare population has such vulnerabilities. The Medicare home health beneficiary population is even more vulnerable than the overall Medicare population based on gender, race, income level, living alone status, and number of chronic conditions. A literature review indicates there is only 1 study on the impact of COVID-19 in Medicare home health on home care workers and none on the impact on home health beneficiaries. The current study is a qualitative study based on interviews of a convenience sample of 48 home care nurses from 9 different home health agencies in New York City between April 1 and August 31, 2020. Six major themes emerged: need for social service supports increased; loneliness and depression increased among patients; physical and mental health conditions became exacerbated; substance use and abuse increased; evidence of domestic violence against patients increased; and there was a limited amount of staff and equipment to care for patients.

In the Realm of Haunting Ghosts: Denying the Existence of Substance Abuse in Medicare Home Health.

Purpose: There is extensive literature on the significance of substance use, misuse, and abuse among the elderly in the United States. A literature review indicates no studies on the nature, significance, or impacts of the lack of substance use and abuse coverage in Medicare home health.Method: The current study is an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 37 home care nurses between January 2013 and May 2014 in the New York City metropolitan area.Results: Nurses believe substance use and abuse occurs frequently among Medicare home health patients; substance use and abuse is not assessed and treated professionally in Medicare home health; the lack of coverage in Medicare home health results in exacerbation of existing patient physical and mental health conditions, which, in turn, worsen substance use and abuse conditions; the homebound requirement and lack of coverage of transportation and personal care assistants limits home care patients ability to obtain outpatient substance use and abuse treatment; and lack of home-based assessment and treatment contributes to increased home care readmissions, re-hospitalizations, and increased caregiver burden.Discussion: The new PDGM system, which begins January 2020, provides an ideal opportunity for representatives of the home care, social work, and substance use professional associations to assert the need to change coverage and reimbursement requirements to allow for a more evidence-based approach to assess and treat Medicare home health patients with substance use challenges.

Medicare constrains social workers' and nurses' home care for clients with Alzheimer's disease.

The Medicare home health prospective payment system (PPS) has existed for 13 years, yielding significant profits to providers. However, studies indicate many unresolved questions about whether PPS improves patient quality of care, is cost-effective, and reduces patient levels of unmet need. In addition, PPS has undermined the provision of social work home health services. The article presents the views of 29 home health care nurses regarding the impact ofPPS on their care decisions for people with Alzheimer's disease and their caregivers. The nurses identify Alzheimer's disease symptom management and psychosocial needs as phantoms, omnipresent below the surface but not attended to by home care clinicians. The interviews support the greater involvement of social workers to more adequately address the psychosocial needs of Medicare home health patients. The article contends that the current failure to simultaneously address the cost, needs, and quality-of-life issues of people with Alzheimer's disease who are cared for at home is analogous to the end-of-life care situation before passage of the Medicare Hospice Benefit. A collaborative demonstration project--social work and nursing--is proposed to determine how PPS might better address quality of life and costs of home-based people with Alzheimer's disease and their caregivers.

For-profit medicare home health agencies' costs appear higher and quality appears lower compared to nonprofit agencies.

For-profit, or proprietary, home health agencies were banned from Medicare until 1980 but now account for a majority of the agencies that provide such services. Medicare home health costs have grown rapidly since the implementation of a risk-based prospective payment system in 2000. We analyzed recent national cost and case-mix-adjusted quality outcomes to assess the performance of for-profit and nonprofit home health agencies. For-profit agencies scored slightly but significantly worse on overall quality indicators compared to nonprofits (77.18 percent and 78.71 percent, respectively). Notably, for-profit agencies scored lower than nonprofits on the clinically important outcome "avoidance of hospitalization" (71.64 percent versus 73.53 percent). Scores on quality measures were lowest in the South, where for-profits predominate. Compared to nonprofits, proprietary agencies also had higher costs per patient ($4,827 versus $4,075), were more profitable, and had higher administrative costs. Our findings raise concerns about whether for-profit agencies should continue to be eligible for Medicare payments and about the efficiency of Medicare's market-oriented, risk-based home care payment system.

Moving toward Medicare home health coverage for persons with Alzheimer's disease.

Medicare home health care policy does not incorporate research evidence of effective palliative home care interventions for Alzheimer's disease and dementia patients and caregivers. This article examines the dissonance between the needs and burdens of Alzheimer's disease patients and caregivers, research results on medical and palliative care interventions, and medicalized public policy in the Medicare home health benefit. The article asserts existing research establishes a prima facie case exists for the federal government to fund a Medicare Palliative Home Care for Alzheimer's disease demonstration project. The article cites the success of the Medicare Hospice Demonstration project and Hospice Medicare Benefit in reducing costs and improving client quality of life as precedent and a model for Alzheimer's disease. Other research implications are identified.

Phantoms of home care: regulatory constraints on home care nurse care management of persons with Alzheimer's disease.

Early indications are that the Medicare home health prospective payment system has controlled Medicare home health expenditures. However, studies indicate many unresolved questions about whether the prospective payment system improves patient quality of care and is cost-effective. The question persists as to whether the prospective payment system has intensified the Medicare home health benefit's historic focus on acute medical care, ignoring the needs of persons with chronic diseases. The article reviews effective home-based palliative care interventions and presents the views of 7 home health care nurses regarding the impact of Medicare requirements on their care decisions for one chronic disease population, patients with Alzheimer's disease. The nurses identify Alzheimer's disease symptom management and psychosocial needs as phantoms, omnipresent below the surface but not attended to by home care clinicians. Nurse coping strategies are discussed. The article asserts that the current failure to simultaneously address the cost and quality-of-life issues of persons with Alzheimer's disease who are cared for at home is analogous to the end-of-life care situation Medicare confronted in the 1970s prior to the Medicare hospice demonstration program, which preceded the Hospice Medicare Benefit. The article asserts that a similar demonstration is appropriate to determine how the prospective payment system might better address quality of life and costs of persons with Alzheimer's disease who are cared for at home.