http://www.nytimes.com/2009/12/05/health/policy/05home.html
By ROBERT PEAR
Published: December 4, 2009
CARIBOU, Me. — Dozing in a big lift chair, propped up by pillows in the living room of her modest home here, Bertha G. Milliard greeted the nurse who had come to check her condition and review the medications she takes for chronic pain, heart failure, stroke and dementia.
Ms. Milliard, 94, said those visits had been highly effective in keeping her out of the hospital. But the home care she receives could be altered under legislation passed by the House and pending on the Senate floor as Congress returned to work this week.
As they are across the nation, Medicare patients and nurses in this town in northern Maine are anxiously following the Congressional debate because its outcome could affect Medicare’s popular home health benefit in a big way. The legislation would reduce Medicare spending on home health services, a lifeline for homebound Medicare beneficiaries, which keeps them out of hospitals and nursing homes.
Under the bills, more than 30 million Americans would gain health coverage. The cost would be offset by new taxes and fees and by cutbacks in Medicare payments to health care providers.
The impact of the legislation on Medicare beneficiaries has been a pervasive theme in the first week of Senate debate, which is scheduled to continue through the weekend.
Home care shows, in microcosm, a conundrum at the heart of the health care debate. Lawmakers have decided that most of the money to cover the uninsured should come from the health care system itself. This raises the question: Can health care providers reduce costs without slashing services?
Under the legislation, home care would absorb a disproportionate share of the cuts. It currently accounts for 3.7 percent of the Medicare budget, but would absorb 10.2 percent of the savings squeezed from Medicare by the House bill and 9.4 percent of savings in the Senate bill, the Congressional Budget Office says.
The House bill would slice $55 billion over 10 years from projected Medicare spending on home health services, while the Senate bill would take $43 billion.
Democratic leaders in the House and Senate justify the proposed cuts in nearly identical terms. “These payment reductions will not adversely affect access to care,” but will bring payments in line with costs, the House Ways and Means Committee said. The Senate Finance Committee said the changes would encourage home care workers to be more productive.
The proposed cuts appear to be at odds with other provisions of the giant health care bills. A major goal of those bills is to reduce the readmission of Medicare patients to hospitals. Medicare patients say that is exactly what home care does.
“It helps me be independent,” said Mildred A. Carkin, 77, of Patten, Me., as a visiting nurse changed the dressing on a gaping wound in her right leg, a complication of knee replacement surgery. “It’s cheaper to care for us at home than to stick us in a nursing home or even a hospital.”
Delmer A. Wilcox, 89, of Caribou, lives alone, is losing his vision, uses a walker and has chronic diseases of the lungs, heart and kidneys. He said his condition would deteriorate quickly without the regular visits he received from Visiting Nurses of Aroostook, a unit of Eastern Maine Home Care.
The Aroostook County home care agency, which lost $190,000 on total revenues of $1.9 million in the year that ended Sept. 30, estimates that it would lose an additional $313,000 in the first year of the House bill and $237,000 under the Senate bill.
The prospect of such cuts has alarmed patients and home care workers. “We would have to consider shrinking the area we serve or discontinuing some services,” said Lisa Harvey-McPherson, who supervises the Aroostook agency as president of Eastern Maine Home Care.
“Our staff are scared,” Ms. Harvey-McPherson said, “but it’s our patients who will pay the price if Congress makes the cuts in home care.”
The four agencies under the umbrella of Eastern Maine Home Care cover a huge geographic area. Its nurses aim to see five patients a day, and they drive an average of 25 miles between patients, traversing potato fields and forests of spruce, birch and maple trees — and a few bear, moose and lynx. In winter, they may need a snowmobile, or even cross-country skis, to reach patients in remote areas.
President Obama has said that the savings in Medicare would be achieved by eliminating “waste and inefficiency” and that “nobody is talking about reducing Medicare benefits.” Moreover, he said, health care providers stand to benefit because they would gain tens of millions of new paying customers.
Home care executives question the arithmetic.
“No family or individual should ever go without health care coverage,” Ms. Harvey-McPherson said, as she drove up to a patient’s home here. “But an increase in the number of people with insurance would not necessarily help our agency because we depend so heavily on caring for seniors, with 80 to 90 percent of our home care revenue coming from Medicare.”
The impact on Medicare is a major concern for Maine’s senators, Susan Collins and Olympia J. Snowe, both Republicans being courted by the White House. Ms. Collins, a longtime champion of home care, has indicated she will resist the proposed cuts.
“Deep cuts to home health care would be completely counterproductive to our efforts to control overall health care costs,” Ms. Collins said. “Home care and hospice have consistently proven to be cost-effective and compassionate alternatives to institutional care.”
Private insurance companies often follow Medicare’s lead. So cuts in home-care payments could also jeopardize home care for privately insured patients like Christopher M. Hayes, a 35-year-old police officer in Presque Isle, Me. His left leg was crushed when he was struck by a car while jogging. He is learning to walk again with the help of a physical therapist.
In trying to slow the growth of Medicare, Democrats in Congress assume that health care providers can increase their productivity at the same pace as the overall economy.
But Saundra Scott-Adams, executive vice president of Eastern Maine Home Care, said: “That’s a joke for home health care. We provide one-on-one care.”
Her doubts are shared by Richard S. Foster, chief actuary of the federal Centers for Medicare and Medicaid Services. Mr. Foster said the health care industry was “very labor-intensive” and could probably not match the productivity gains of the overall economy.
While nurses can monitor some patients with electronic telecommunications devices, they said they still needed to provide hands-on care to many.
Phillip H. Moran, a 65-year-old diabetic in Houlton, Me., lost his right leg several years ago. His kidneys are failing. Without regular visits from a home health nurse, Mr. Moran said, he would be in danger of losing his other leg because of complications from diabetes. As a double amputee, he would be more likely to go into a nursing home.
“The nurses’ visits are really important,” Mr. Moran said. “If they are cut, it could cost people their lives.”
