Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Access to Home Health Care 
After Hospital Discharge 
2001 
JULY 2001 
OEI-02-01-00180  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them. This statutory mission is carried out through 
a nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General. It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public. 
The inspection reports provide findings and recommendations on the efficiency, vulnerability, 
and effectiveness of departmental programs. 
OEI's New York regional office prepared this report under the direction of John I. Molnar, 
Regional Inspector General, and Renee C. Dunn, Deputy Regional Inspector General. Principal 
OEI staff included: 
REGION  HEADQUARTERS 
Jodi Nudelman, Project Leader
 Tricia Davis, Program Specialist

Vincent Greiber, Lead Analyst
 Brian Richie, Director, Technical Support Staff

Danielle Fletcher
 Linda Moscoe, Technical Support

Nicole Gillette

Thomas Purvis, Region IX

Thomas Zimmermann

.

To obtain copies of this report, please call the New York Regional Office at (212) 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.hhs.gov/oig/oei  E X E C U T I V E  S U M M A R Y  
PURPOSE 
To assess the effects of the prospective payment system on access to home health care for 
Medicare beneficiaries who are discharged from the hospital. 
BACKGROUND 
The Balanced Budget Act of 1997 (BBA) changed the way Medicare pays for home 
health care. The law changed reimbursement for home health services from a cost-based 
method to a prospective payment system of fixed, predetermined rates. To allow time for 
the Centers for Medicare and Medicaid Services to develop this system, the law 
mandated an interim payment system. On October 1, 2000, the prospective payment 
system replaced the interim payment system. This is the first report that looks at access 
to care under the prospective payment system. 
This report is a follow-up to two previous Office of Inspector General inspections, 
Medicare Beneficiary Access to Home Health Agencies, OEI-02-99-00530 and Medicare 
Beneficiary Access to Home Health Agencies: 2000, OEI-02-00-00320.  Both reports 
found that hospital discharge planners can place most Medicare beneficiaries in home 
health care. In the most recent report, some discharge planners also noted that the 
placement process has changed and that some HHAs are asking for additional medical 
information about prospective patients. 
We used several methods to address the inspection issues. We conducted a survey of a 
random sample of 208 hospital discharge planners that focused on beneficiary access to 
home health care. We also analyzed the Provider of Services File and the National 
Claims History File. 
FINDINGS 
Medicare beneficiaries discharged from hospitals maintain access to 
home health care 
The prospective payment system does not appear to limit access to home health 
care. Eighty-nine percent of discharge planners report that under the prospective 
payment system they can place all of their Medicare patients who need care in home 
i 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  health agencies. Another 7 percent estimate they are able to place all but 1 to 5 percent 
of patients, and 4 percent put the estimate above 5 percent. Discharge planners gave 
similar responses last year. Discharge planners most commonly explain that patients 
whom they cannot place go to a nursing home, are sent home to be cared for by a family 
member, or stay in the hospital. 
Medicare data support discharge planners experiences. The data show that there are no 
large changes in the types of Medicare beneficiaries being discharged to HHAs in the last 
five years. Specifically, there are no substantial decreases in the 13 most common DRGs 
discharged to home health care between 1997 and 2001. 
Availability of home health services seems to be sufficient, even though the number 
of agencies has decreased. The majority of discharge planners (83 percent) report that 
there are sufficient home health services available in their area for Medicare patients. 
Medicare data show that the number of agencies dropped by 32 percent, from 10,556 in 
1997 to 7,175 in 2000. 
Some patients experience delays associated with certain service needs 
About one quarter of discharge planners reports that they experience delays at least 
sometimes when placing Medicare patients in home health agencies. Many discharge 
planners (61 percent) who report delays say that they are associated with medical 
conditions or service needs. Some explain that patients who need IV therapy may require 
expensive drugs that are not usually reimbursed under Medicare. These patients may 
also need frequent or continuous monitoring of their IV which may require multiple or 
long visits. Patients with wound care needs may also be delayed because they require 
many expensive supplies and frequent visits by home health staff. 
Medicare data, however, show no large increases in the average hospital length of stay 
for Medicare beneficiaries discharged to HHAs. In fact, the average length of stay 
decreased for all but 2 of the 13 most common DRGs between 1997 and 2001. 
CONCLUSION 
The results this year are similar to the findings in our prior two inspections on access to 
home health care. We continue to find that Medicare beneficiaries discharged from 
hospitals have access to home health care. In addition, we find little evidence that the 
new prospective payment system that replaced the interim payment system limits 
beneficiaries access to care. We encourage the Centers for Medicare and Medicaid 
Services to continue to monitor access to care and home health agencies responses to the 
payment system. 
ii 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY .................................................  i

INTRODUCTION  .......................................................... 1

FINDINGS

Medicare Beneficiaries Maintain Access to Home Health Care .................... 7

Some Patients Experience Delays Associated with Certain Service Needs  ........... 9

CONCLUSION  ..........................................................  11

APPENDICES

A:  Recent OIG Home Health Inspections ................................. 12

B:  Confidence Intervals for Key Findings  ................................ 13

C:  Proportion of Beneficiaries Discharged to HHAs by Top DRGs  ............ 14

D:  Average Hospital Length of Stay by Top DRGs ......................... 15

ii 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  I N T R O D U C T I O N  
PURPOSE 
To assess the effects of the prospective payment system on access to home health care for 
Medicare beneficiaries who are discharged from the hospital. 
BACKGROUND 
This inspection is part of the Office of Inspector Generals (OIG) continuing effort to 
monitor home health care. It examines the effects of the prospective payment system 
(PPS) on Medicare beneficiary access to care in response to concerns that changes to the 
payment system may affect the ability of home health agencies (HHAs) to serve 
Medicare beneficiaries. The OIG monitors HHAs implementation of these payment 
changes to ensure that beneficiary access is not compromised. This is the first report that 
looks at access to care under the prospective payment system. 
This report is a follow-up to two previous OIG inspections. In 1999, the Centers for 
Medicare and Medicaid Services (CMS) asked the OIG to assess the effects of the 
interim payment system (IPS) on access to home health care. In response, we completed 
two reports entitled, Medicare Beneficiary Access to Home Health Agencies, OEI-02-99-
00530 and Medicare Beneficiary Access to Home Health Agencies: 2000, OEI-02-00-
00320. Both reports found that hospital discharge planners can place most Medicare 
beneficiaries in home health care. In the most recent report, some discharge planners 
also noted that the placement process has changed and that some HHAs are asking for 
additional medical information about prospective patients. 
This inspection is part of a current series of four Office of Inspector General inspections 
about Medicare home health care. Medicare Home Health Care- Beneficiaries from the 
Community, OEI -02-01-00070, looks at access to home health care for Medicare 
beneficiaries who have not recently been in the hospital.  Medicare Beneficiary 
Experiences with Home Health Care, OEI-02-00-00560, describes the experiences of 
Medicare beneficiaries who obtain and receive home health care. We are also conducting 
a study that examines physician practices in prescribing, certifying, and monitoring 
Medicare home health services. See Appendix A for a list of recent OIG reports relating 
to home health care. 
1 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  Medicare Home Health Care 
Home health services consist of part-time or intermittent skilled nursing, physical, 
occupational, and speech therapy, and certain related services, including social work and 
home health aide services, all furnished in a patients home. Services are typically 
provided by registered nurses, therapists, social workers, or home health aides employed 
by or under contract to a home health agency. These agencies can be freestanding or 
hospital-based and are classified as not-for-profit, proprietary, or governmental. 
Medicare will pay for home health care only if it is reasonable and necessary for the 
treatment of the patients illness or injury. In order to be eligible for services, a 
beneficiary must be homebound, under the care of a physician who has established a plan 
of care, and need at least one of the following intermittent and not full time skilled 
services: skilled nursing care, physical therapy, speech language pathology or continued 
occupational therapy at the start of care. Occupational therapy alone does not constitute 
a skilled need. However, after care has begun and other skilled services are discontinued, 
continued occupational therapy is a skilled need. There are no specific limits on the 
number of visits or length of coverage and no co-payments or deductibles. 
The Prospective Payment System 
The Balanced Budget Act of 1997 (BBA) changed the way Medicare pays for home 
health care. The law changed reimbursement for home health services from a cost-based 
method to a prospective payment system of fixed, predetermined rates. 
To allow time for the CMS to develop PPS, the BBA mandated an interim payment 
system (IPS) that was in effect from October 1997 to October 2000. The IPS intended to 
control aggregate costs of services provided to beneficiaries. It decreased the per-visit 
limits and subjected HHAs to a new payment limit based on an aggregate per-beneficiary 
amount. Medicare then paid HHAs the lower of either their actual costs, the aggregate 
per-beneficiary limit, or the aggregate per-visit limit. 
Beginning October 1, 2000, PPS replaced IPS. Under PPS, home health agency 
payments are based on a 60-day episode, and are case-mix and wage adjusted. The case 
mix is based on data elements from a patients medical assessment that incorporates the 
Outcomes and Assessment Information Set (OASIS), and the projected number of 
therapy hours. Upon receiving a referral, the home health agency performs an initial 
assessment using OASIS that converts the patients condition into a numeric score for 
three areas: clinical severity, functional status, and service utilization. These scores are 
totaled and assigned a value, which correlates to a patients home health resource group 
(HHRG), which are used to determine payment rates. There are 80 HHRGs representing 
the range of complexity of a patients condition. 
2 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  In general, HHAs are paid for a full 60-day episode even if the actual services are 
provided during a fewer number of days.  HHAs typically receive two payments for each 
60-day episode. At the beginning of an episode, HHAs submit a Request for Advanced 
Payment (RAP) that includes the HHRG. Upon receipt of the RAP, the home health 
agency receives 60 percent of the estimated base payment for the initial 60-day episode. 
At the end of the episode, the agency submits a clean claim that accurately details the 
services provided and receives the residual 40 percent of the payment. If a beneficiary is 
still eligible for care at the end of the first episode, the agency can begin a second 60-day 
episode. There is no limit to number of episodes that an eligible beneficiary can receive. 
There are two types of outlier payments, a Partial Episode Payment and a Significant 
Change In Condition payment, that are made in addition to 60-day payments for episodes 
that incur unusually large costs. There is also a Low Utilization Payment Adjustment for 
episodes that include four or fewer visits. These are described in more detail below. 
The Partial Episode Payment (PEP). The PEP adjustment occurs when 1) a 
beneficiary elects to transfer to another HHA, or 2) a beneficiary is discharged and 
returns to the same HHA. The original episode payment is proportionally adjusted to 
reflect the length of time the beneficiary remains under the agency's care before the 
intervening event. 
Significant Change In Condition (SCIC).  The SCIC is the proportional payment 
adjustment that occurs when a patient experiences a significant change in condition that 
was not envisioned in the original plan of care. In order to receive a new case-mix 
assignment for purposes of SCIC payment, the HHA must complete an OASIS 
assessment and obtain the necessary physician orders reflecting the significant change in 
treatment approach. 
Low Utilization Payment Adjustment (LUPA). The HHAs receive less than the full 
60-day episode rate if they provide four or fewer visits to a beneficiary. For these 
episodes, HHAs are paid the standardized, service-specific per-visit amount multiplied by 
the number of visits actually provided during the episode. 
Trends in Medicare Home Health Care 
After a history of increases, Medicare home health expenditures have decreased since 
1998. Between Fiscal Years 1991 and 1997, home health care annual expenditures rose 
from $4.7 billion to $17.6 billion. This was due to an increase in both number of 
beneficiaries receiving home health services and the number of visits they received. In 
1998, however, spending for home health services began to drop and in Fiscal Year 1999 
was $8.7 billion. 
3 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  A number of factors have contributed to the recent decrease in Medicare home health 
spending. These include the prospective payment limits created by the Balanced Budget 
Act of 1997 as well as several initiatives that were implemented in response to concerns 
about fraud and abuse. Specifically, the Health Insurance Portability and Accountability 
Act substantially increased financial support to the OIGs fraud control efforts. 
Other Changes to Medicare Home Health Care 
Medicare home health care has experienced a number of other changes in recent years. 
One significant change is in the coverage rules for vancomycin and venipuncture. As of 
September 1996, Medicare discontinued payment for infusion pump delivery of 
vancomycin, a popular broad spectrum antibiotic used in IV therapy. Medicare covers 
IV drugs only when there is a medical necessity for them to be administered by an 
external infusion pump, and there was insufficient evidence to support the necessity of a 
pump to administer this antibiotic. Additionally, as of February 1998, a patient's need for 
venipuncture no longer constituted a qualifying skilled need. Prior to this change, 
patients whose only skilled need was venipuncture qualified for home care. 
The clarification of the definition of homebound is another recent change to Medicare 
home health rules. There were some concerns about the ambiguity of the definition and 
the potential to deny benefits to eligible beneficiaries who are able to leave their home 
occasionally.  In response, the Benefits Improvement and Protection Act of 2000 (BIPA) 
clarified the definition, stating that a person can leave his or her home for certain 
purposes such as attending adult day care activities or religious services and still qualify 
for Medicare home health services. 
Finally, a January 1999 special OIG fraud alert that addressed the role of physicians in 
certifying services also affected Medicare home health. Physicians were cautioned in the 
fraud alert not to: 1) prescribe services and items as a courtesy to a patient or service 
provider, nor prescribe medical equipment, without first making a determination of 
medical necessity; 2) knowingly or recklessly sign false or misleading medical 
certifications; and 3) accept kickbacks in return for their signature. 
Related Work 
Three recent reports focus on the effects of IPS on Medicare beneficiary access to home 
health care. In 1999, the GAO released a report entitled Medicare Home Health 
Agencies; Closures Continue, With Little Evidence Beneficiary Access is Impaired. The 
GAO found that although about 14 percent of HHAs closed since 1997, there is little 
evidence that appropriate access to care has been impaired. Additionally, interviews with 
stakeholders in counties that had significant closures indicate few access problems. The 
interviews suggested, however, that as HHAs change their operations in response to IPS, 
4 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  beneficiaries who are likely to be costlier than average to treat may have increased 
difficulty obtaining home health care. 
A two-phase study conducted by George Washington University Medical Center in 1999 
also examined the effects of IPS on access to care. The first phase found that the 
majority of HHAs participating in a study in eight States altered their case mix and/or 
practice based on IPS reimbursement. Diabetics, beneficiaries with intensive care needs, 
and chronically ill beneficiaries appeared to be most affected by IPS. 
The second phase of the study interviewed hospital discharge planners in eight States and 
found that most of them reported increased difficulty in obtaining home health services 
for Medicare beneficiaries. Most attributed these difficulties to changes in admitting 
patterns by HHAs, changes in staffing patterns, or the effects of agency closures in their 
service area. Respondents reported that beneficiaries most affected by these changes 
were those with short-term, high-intensity needs or chronic diseases, and/or those 
needing complex wound care or two visits a day. 
A third report, Access to Home Health Services conducted by the Medicare Payment 
Advisory Commission (MedPAC) analyzed health claims data, surveyed home health 
agencies, and convened a panel discussion with individuals familiar with access 
problems. The report found that many HHAs have adopted new admission and discharge 
practices since IPS was implemented. The HHAs reported that they are avoiding high-
cost patients. They most frequently identified long-term or chronic-care patients as those 
they no longer admit or have discharged as a result of IPS. 
In 2000, the GAO released two studies on PPS.  PPS Could Reverse Recent Declines in 
Spending found that program controls may be inadequate and lead to overpayments and 
increased program spending. The other, Medicare Home Health Care: Prospective 
Payment System Will Need Refinement as Data Become Available, found that although the 
CMSs research and demonstration projects have proven useful in designing PPS, 
information gaps remain that could lead Medicare to overpay for unnecessary services or 
underpay for required care. The report suggests that these consequences may result in 
beneficiaries facing access problems or receiving poor quality of care. 
METHODOLOGY 
We used several methods to address the inspection issues. These methods replicate the 
approach used in the prior two OIG inspections on access to home health. 
5 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  Discharge Planner Interviews 
We conducted a survey of hospital discharge planners that focused on beneficiary access 
to home health care. To do this, we selected a random sample of 225 acute care hospitals 
with 30 or more beds from the 50 States and the District of Columbia. We conducted 
interviews with 208 directors of discharge planning or their designees within a 3 week 
period between April 2, 2001 and April 20, 2001. We achieved a 92 percent response 
rate. This sample of hospitals is the same as the one used in the OIG inspection, Medicare 
Beneficiary Access to Skilled Nursing Facilities: 2001, OEI-02-01-00160. 
Analysis of Medicare Data 
We also conducted several analyses of Medicare data. First, we reviewed trends in the 
number of HHAs using the Provider of Services (POS) File. Second, we analyzed 
Medicare data for beneficiaries who were discharged from a hospital to home health care. 
Specifically, we analyzed the proportion of Medicare beneficiaries discharged to home 
health care by key diagnosis related group (DRG) to determine the extent to which HHAs 
are admitting different types of patients. We also analyzed the length of hospital stays by 
key DRGs to examine whether patients are experiencing longer delays before being 
admitted to HHAs. 
These analyses are based on data from the National Claims History File. We identified all 
beneficiaries who: 1) had a home health claim in the first quarter of 2001, and; 2) had a 
hospital discharge within 15 days prior to their home health claim. We then compared 
these data to the same data for beneficiaries who met these criteria for the first quarter of 
1997, 1998, 1999, and 2000. Note that this definition is the same as the one used in the 
inspection, Medicare Home Health Care - Beneficiaries from the Community, OEI-02-01-
00070.1  
Limitations 
The data for the most recent quarter, January to March 2001, are not as complete as the 
other quarters of data. Additional and adjusted claims will be collected for this quarter 
that may alter these data. 
This inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
1This definition differs from the one used in the prior two OIG inspections on access to home health. 
These studies were based on data for all beneficiaries who were discharged from a hospital in the first quarter of 
each year and who had a home health claim within 30 days of discharge. 
6 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  F I N D I N G S
Medicare beneficiaries discharged from hospitals maintain access to
home health care
PPS does not appear to limit access to home health care
Eighty-nine percent of discharge planners report that under PPS they can place all of their
Medicare patients who need care in home health agencies.  Another 7 percent estimate
they are able to place all but 1 to 5 percent of patients, and 4 percent put the estimate
above 5 percent.  (See Figure 1).  Most discharge planners (90 percent) also report no
change in the number of patients whom they cannot place since last October when PPS
was implemented.  Discharge planners most commonly explain that patients whom they
cannot place go to a nursing home, are sent home to be cared for by a family member, or
stay in the hospital.  
Figure 1
Proportion of Discharge Planners Placing Patients in HHAs
Source: Discharge Planner Survey, 2001
We looked at several factors that may affect access to care and found no large differences.
Specifically, discharge planners in urban and rural hospitals are able to place Medicare
beneficiaries in home health care at similar rates.  There are also no differences in the
proportion of discharge planners from hospitals with affiliated HHAs and those without
affiliations who can place all of their Medicare patients.   Further, discharge planners
ability to place Medicare beneficiaries under PPS is similar to that of discharge planners
last year under the interim payment system. 
7
Access to Home Health Care After Hospital Discharge 2001                           OEI 02-01-00180 Medicare data support discharge planners experiences. The data show that there are no 
large changes in the types of Medicare beneficiaries being discharged to HHAs in the last 
5 years. A decrease in a diagnosis related group (DRG) may indicate that patients with 
that condition are experiencing problems with access to care. With one exception, there 
are no substantial decreases in the 13 most common DRGs discharged to HHAs between 
1997 and 2001.2  These 13 DRGs represent about 43 percent of all beneficiaries 
discharged to home health care. (See Appendix C.) 
Medicare data also suggest that beneficiaries who are discharged from hospitals have 
access to care. The data show that beneficiaries receiving home health care are 
increasingly coming from the hospital as opposed to the community. In 2000, almost half 
of Medicare beneficiaries in home health care came from a hospital within 15 days of their 
discharge. Another 14 percent came from a SNF, while the remaining 38 percent came 
from the community. Between 1998 and 2000, the number of beneficiaries coming from 
the hospital increased by 3 percent, whereas those coming from the community decreased 
by 10 percent. 
Availability of home health services seems to be sufficient, even though the 
number of agencies has decreased 
The majority of discharge planners (83 percent) report that there are sufficient home 
health services available in their area for Medicare patients. About 63 percent note that 
the availability of services is about the same as last year under the interim payment 
system. Discharge planners also report that they need to contact an average of 1 to 2 
agencies to place a patient, about the same number discharge planners reported last year. 
At the same time, there continues to be a decline in the number of home health agencies in 
some areas. About one third of discharge planners say that there is a decrease in the 
availability of home health services since last year. Medicare data support these 
observations and show that the number of HHAs nationwide has decreased. As shown in 
Figure 2, the number of agencies dropped by 32 percent, from 10,556 in 1997 to 7,175 in 
2000. 
2 The proportion of beneficiaries in DRG 106 decreased by 2.4 percentage points due to a change in the 
definition of that DRG that occurred in 1998. 
8 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  Figure 2

Number of Home Health Agencies,

1997-2000

12,000 
10,000 
10,556 
9,398 
8,000 
7,924 
7,175 
6,000 
4,000 
2,000 
0 
1997  1998  1999  2000 
Source: Provider of Services File 
Some patients experience delays associated with certain service 
needs 
About one quarter of discharge planners report that they experience delays at least 
sometimes when placing Medicare patients in home health agencies.3  About 22 percent 
also note that the number of delays have increased since last October when PPS was 
implemented. These responses are similar to those given by discharge planners last year 
under the interim payment system. 
Many discharge planners (61 percent) who report delays say that they are associated with 
certain medical conditions or service needs. They most frequently note that patients who 
need IV antibiotics and/or expensive drugs and those who require wound care are 
delayed. Several also report that delays are associated with conditions requiring multiple 
visits per day. These are the same medical conditions and service needs discharge 
planners describe for beneficiaries who they cannot place. 
3A placement delay occurs when a patient is medically cleared by a doctor but no home health services 
have been arranged. 
9 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  Medicare data, however, show no large increases in the average hospital length of stay for 
Medicare beneficiaries discharged to HHAs. In fact, the average length of stay decreased 
for all but 2 of the 13 most common DRGs between 1997 and 2001.4  Specifically, the 
average length of stay decreased by 2.2 days and 1.1 days for rehabilitation and specific 
cerebrovascular disorders, respectively and by less than one day for all the other DRGs. 
(See Appendix D.) 
About half of discharge planners who report that delays are associated with medical 
conditions or service needs attribute these delays to PPS. Some explain that patients who 
need IV therapy may require expensive drugs that are not usually reimbursed under 
Medicare. These patients may also need frequent or continuous monitoring of their IV 
which may require multiple or long visits. Patients with wound care needs may also be 
delayed because they require many expensive supplies and frequent visits by home health 
staff. 
Some discharge planners also attribute delays to staffing issues. They observe that HHAs 
do not have enough skilled nurses or home health aides to provide necessary services. A 
few discharge planners note that staffing shortages are a problem in rural areas where staff 
have to travel long distances to reach beneficiaries. Additionally, a few explain that some 
patients experience delays because HHAs cannot afford to pay staff under PPS to provide 
care for patients with certain conditions. 
Finally, discharge planners mention several other factors that affect the placement process. 
About 40 percent report that HHAs have changed their admissions practices since PPS 
was implemented last October. Many explain that HHAs are requesting more information 
about patients and screening patients before making admission decisions. Some also note 
that HHAs are conducting more thorough evaluations in order to assess whether a patient 
has a skilled need and is eligible for Medicare. In addition, some discharge planners 
mention that HHAs are putting more emphasis on teaching family members and others to 
provide care and that finding individuals willing to be trained is often difficult. 
4 The average length of stay for beneficiaries in DRG 106 and 107 increased but this may be due to a 
change in the definition of these DRGs that occurred in 1998. 
10 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  C O N C L U S I O N  
The results this year are similar to the findings in our prior two inspections on access to 
home health care. We continue to find that Medicare beneficiaries discharged from 
hospitals have access to home health care. In addition, we find little evidence that the new 
prospective payment system that replaced the interim payment system limits beneficiaries 
access to care. We encourage the Centers for Medicare and Medicaid Services to continue 
to monitor access to care and home health agencies responses to the payment system. 
11 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  APPENDIX A 
Recent Office of Inspector General

Home Health Inspections

Office of Inspector General, U.S. Department of Health and Human Services, Medicare 
Beneficiary Experiences with Home Health Care, OEI-02-00-00560, July 2001. 
Office of Inspector General, U.S. Department of Health and Human Services, Medicare 
Beneficiary Access to Home Health Agencies: 2000, OEI-02-00-00320, September 2000. 
Office of Inspector General, U.S. Department of Health and Human Services, Adequacy of 
Home Health Services: Hospital Readmission and Emergency Room Visits, OEI-02-99-00531, 
September 2000. 
Office of Inspector General, U.S. Department of Health and Human Services, Medicare Home 
Health Agency Survey and Certification Deficiencies, OEI-02-99-00532, September 2000. 
Office of Inspector General, U.S. Department of Health and Human Services, Medicare 
Beneficiary Access to Home Health Agencies, OEI-02-99-00530, October 1999. 
APPENDIX B 
12 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  Confidence Intervals for Key Findings 
We calculated confidence intervals for key findings for discharge planners. The point 
estimate and 95% confidence intervals are given for each of the following: 
Point  Confidence 
Key Findings  n 
Estimate  Interval 
89 percent report they can place all of their 
Medicare patients with home health care under  208  89%  4.4% 
PPS. 
90 percent report no change in the number of 
patients whom they cannot place since last  206  90%  4.1% 
October when PPS was implemented. 
The majority of discharge planners (83 percent) 
report that there are sufficient home health 
208  83%  5.1% 
services available in their area for Medicare 
patients. 
About 63 percent note that the availability of 
services is about the same as last year under the  208  63%  6.6% 
interim payment system. 
About one quarter of discharge planners (23%) 
report that they experience delays at least 
208  23%  5.7% 
sometimes in placing Medicare patients in home 
health care. 
22 percent note that delays have increased since 
206  22%  5.7% 
last October when PPS was implemented. 
Many discharge planner (61 percent) who report 
delays say that they are associated with certain  135  61%  8.2% 
medical conditions or service needs. 
About half of discharge planners who report that 
delays are associated with service needs attribute  83  57%  10.7% 
these delays are because of PPS. 
About 40 percent of discharge planners report 
that HHAs have changed their admissions 
208  40%  6.6% 
practices since PPS was implemented last 
October. 
13 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  APPENDIX C 
Proportion of Beneficiaries Discharged to HHAs

by Top Diagnosis Related Groups (DRGs)**

1997-2001
1997  1998  1999  2000  2001 
Initial Hospital DRG  Difference 
DRG 106-Coronary bypass with 
2.5%  2.3%  0.1%  0.1%  0.1%  -2.4 
PTCA* 
DRG 079- Respiratory infections 
1.7  1.3  1.2  1.1  1.0  -0.8 
and inflammations 
DRG 014- Specific 
3.3  2.9  2.8  2.7  2.7  -0.6 
cerebrovascular disorders 
DRG 148- Major small and large 
2.1  2.0  1.8  1.8  1.8  -0.3 
bowel procedures 
DRG 088- Chronic obstructive 
4.2  4.9  5.1  4.6  4.1  -0.1 
pulmonary disease 
DRG 121- Circulatory disorders 
w/acute myocardial infarction &  1.8  1.7  1.8  1.7  1.7  -0.1 
major complications 
DRG 089- Simple pneumonia 
4.9  6.1  6.5  6.2  4.9  0.0 
and pleurisy 
DRG 127- Heart failure and 
6.7  6.9  6.8  6.7  6.8  0.1 
shock 
DRG 296- Nutritional and misc. 
1.5  1.5  1.6  1.7  1.6  0.1 
metabolic disorders 
DRG 107- Coronary bypass with 
1.6  1.5  2.1  2.1  2.1  0.5 
cardiac catheterization* 
DRG 209- Major joint and limb 
reattachment procedures of  4.5  4.5  4.4  4.4  5.2  0.7 
lower extremity 
DRG 116-Other permanent

cardiac pacemaker implant or 
0.8  1.6  1.6  1.7  1.7  1.0

PTCA with coronary artery stent

implant*

DRG 462- Rehabilitation  7.1  6.9  7.8  8.5  9.1  2.0 
Source: National Claims History File 
*Note: In 1998, the CMS reclassified DRG 107 as DRG 106, coronary bypass with cardiac catheterization. DRG 109 was 
classified as coronary bypass without catheterization, formerly DRG 107. DRG 106 was classified as coronary bypass with 
PTCA. Under DRG 116, PTCA with coronary artery stent implant replaced AICD lead or generator procedure. 
**Note: Differences may be due to rounding. 
14 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180  APPENDIX D 
Average Hospital Lengths of Stay for Beneficiaries Discharged to 
HHAs by Top Diagnosis Related Groups (DRGs)** 
1997  1998  1999  2000  2001  1997-2001 
Initial Hospital DRG  Days  Days  Days  Days  Days  Difference 
DRG 462- Rehabilitation  16.6  15.4  15.4  15.1  14.4  -2.2 
DRG 014- Specific 
10.3  9.6  9.4  9.5  9.1  -1.1 
cerebrovascular disorders 
DRG 209- Major joint and limb 
6.5  6.1  6.0  5.9  5.7  -0.8 
reattachment procedures 
DRG 121- Circulatory disorders 
w/acute myocardial infarction &  9.6  9.4  9.2  9.1  8.8  -0.8 
major complications 
DRG 148- Major small and large 
14.2  13.6  13.8  13.9  13.6  -0.6 
bowel procedures 
DRG 089- Simple pneumonia and 
8.6  8.3  8.2  8.2  8.1  -0.5 
pleurisy 
DRG 296- Nutritional and misc. 
7.3  7.1  7.1  7.0  7.0  -0.3 
metabolic disorders 
DRG 127- Heart failure and shock  7.8  7.6  7.6  7.5  7.5  -0.3 
DRG 088- Chronic obstructive 
8.3  7.8  7.9  8.0  8.0  -0.3 
pulmonary disease 
DRG 116-Other permanent 
cardiac pacemaker implant or 
7.6  7.4  7.4  7.4  7.4  -0.3 
PTCA w/coronary artery stent 
implant* 
DRG 079- Respiratory infections 
11.1  11.0  11.1  11.5  11.0  -0.1 
and inflammations 
DRG 106-Coronary bypass with 
11.7  11.4  12.2  12.1  12.2  0.4 
PTCA* 
DRG 107- Coronary bypass with 
9.1  8.6  11.2  11.1  11.2  2.1 
cardiac catheterization* 
Source: National Claims History File 
*Note: In 1998, the CMS reclassified DRG 107 as DRG 106, coronary bypass with cardiac catheterization. DRG 109 was 
classified as coronary bypass without catheterization, formerly DRG 107. DRG 106 was classified as coronary bypass with 
PTCA. Under DRG 116, PTCA with coronary artery stent implant replaced AICD lead or generator procedure. 
**Note: Differences may be due to rounding. 
15 
Access to Home Health Care After Hospital Discharge 2001  OEI 02-01-00180