Medicare:

Home Health Utilization Expands While Program Controls Deteriorate

HEHS-96-16: Published: Mar 27, 1996. Publicly Released: Apr 3, 1996.

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Pursuant to a congressional request, GAO examined the growth in the use of Medicare home health benefits, focusing on the: (1) changes in the home health industry; (2) composition of Medicare home health users; (3) differences in utilization of home health benefits across geographic areas; (4) incentives to overuse Medicare home health benefits; and (5) effectiveness of payment controls in preventing payment for services not covered by Medicare.

GAO noted that: (1) the growth in Medicare's home health benefits resulted from less restrictive Health Care Financing Administration (HCFA) guidelines issued in 1989; (2) 2.8 million Medicare beneficiaries received home health services in 1993, up from 1.7 million in 1989; (3) during the same period, the average number of home health care visits doubled from 26 visits per year in 1989 to 57 visits per year in 1993; (4) more than 25 percent of home health beneficiaries received at least 60 visits per year; (5) between 1989 and 1994, the number of Medicare-certified home health agencies grew from 5,692 to 7,864; (6) proprietary home health agencies provided beneficiaries with 78 visits per year, while voluntary and government agencies provided beneficiaries with 46 visits per year; (7) home health beneficiaries with the same diagnosis received more visits from proprietary agencies than from non-profit agencies; and (8) Medicare's home health services can be improved by subjecting claims to medical review and audit, requiring visits from intermediaries and physicians to beneficiaries, and determining whether beneficiaries are qualified for such service, and actually need or receive the service billed to Medicare.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Matters for Congressional Consideration

    Matter: Congress may wish to consider whether the Medicare home health benefit should continue to become more of a long-term care benefit or if it should be limited primarily to a posthospital acute care benefit.

    Status: Closed - Implemented

    Comments: The Balanced Budget Act of 1997 included a number of provisions designed to control Medicare home health expenditures, including a requirement that HCFA study the criteria that should be applied in the determination of whether a beneficiary is homebound. The HCFA report did not yield any new options for clarifying the homebound determinations.

    Matter: Congress may wish to consider providing additional resources so that controls against abuse of the home health benefit can be better enforced.

    Status: Closed - Implemented

    Comments: The Health Insurance Portability and Accountability Act of 1996 increased funding for Medicare program integrity activities beginning in fiscal year 1997. Since HIPAA, additional funding has been allotted to home health care. Therefore, the intent of this recommendation is being met.

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