Home Care


Vol. 16 •Issue 17 • Page 29
Home Care

Length of stay in programs declines after passage of BBA in 1997

The median length of stay for Medicare patients in home health care programs dropped sharply after passage of the 1997 federal Balanced Budget Act (BBA), particularly among people receiving care from for-profit agencies, researchers report (Journal of the American Medical Association, June 4, 2003).

“We don’t know what effect the shortened length of stay had on quality of care or patient outcomes,” said lead author Rachel Murkofsky, MD, MPH, a staff physician in the Gerontology Division at Beth Israel Deaconess Medical Center, in Boston, Mass., and an instructor of medicine at Harvard Medical School. The researchers urged more study on the effect of shortened length of stay on quality of care and patient outcomes.

Medicare beneficiaries are eligible for home health care if they are homebound, are under a physician’s care, and require medically necessary part-time or intermittent skilled nursing or therapy services. Prior to BBA, home care reimbursements were made primarily on a fee-for-service basis. With mounting concerns about potential fraud and abuse, Congress mandated a new home health payment system in 1997 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 BBA.

Most patients receiving home care were over 65. 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 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, 22 percent and 51 percent reductions, respectively.

“Some of the shortened length of stay was probably appropriate, given evidence of fraud and abuse in the system,” Murkofsky noted.

Some of the decrease of Medicare home care patients with disabilities may have been the result of enforcement of eligibility criteria for home care services that took place during that time, she added. “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 researchers urged 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,” Murkofsky said. “We were unable to determine quality of care or appropriateness of care with our study. Given the large number of Medicare beneficiaries who 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.”

Co-authors of the study were Russell Phillips, MD; Ellen McCarthy, PhD, MPH; Roger Davis, ScD; and Mary Beth Hamel, MD, MPH, all of the Division of General Medicine and Primary Care at Beth Israel.

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.

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