Abstract
To the Editor: Our firm conducted a study of home health agency costs and utilization in the Medicaid program of a rural western state that confirms the variability in visit length and frequency discussed by Christine Bishop and colleagues in their DataWatch, "The Home Health Visit: An Appropriate Unit for Medicare Payment?" Among Medicaid beneficiaries in the state who used home health care, a small number (8 percent) received a skilled nursing visit every day, one-third had a visit every two to three days, and another third had a visit every four to seven days.1 The remaining patients were di- vided between those whose average frequency of visits was less than once per week and those whose home health care episode consisted of only a single visit. "1 Realizing that counts of visits are an uncertain proxy for resource use, the Health Care Financing Administration is supporting research to measure home health visit content, that is, time spent and tasks performed, as well as a number of visits for cases of various types.2 We certainly agree with Feldman and Murtaugh that a payment system based on tasks and time would be cumbersome to administer. Capitation payment to Medicare risk contract plans, the only widespread bundled payment encompassing home health care, appears to result in significantly less service to patients.3 A recent survey of Medicare health maintenance organization (HMO) members found that 17 percent of those receiving home health care felt that they did not receive enough such care, and 70 percent of these beneficiaries reported adverse consequences, including worsened conditions, delayed recovery, out-of-pocket payments, and family burdens.4 Use of the episode as the unit of service in a fee-for-service system would provide incentives for a similar reduction in care inputs and for increases in the number of episodes supplied.