Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Medicare Beneficiary Access 
to Home Health Agencies: 2000 
JUNE GIBBS BROWN 
Inspector General 
SEPTEMBER 2000 
OEI-02-00-00320  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

Ellen Vinkey, Project Leader
 Tricia Davis, Program Specialist

Jodi Nudelman
 Brian Ritchie, Director, Technical Support Staff 
Danielle Fletcher
 Linda Moscoe, Technical Support 
Judy Lin
 Scott Horning, Technical Support 
Betti Weimersheimer, intern
 Barbara Tedesco, Mathematical Statistician 
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 interim payment system on access to home health agencies for 
Medicare beneficiaries discharged from the hospital. 
BACKGROUND 
The Health Care Financing Administration asked the Office of Inspector General to assess 
the effects of the interim payment system for home health services on beneficiaries access 
to care.  The interim payment system changed the method and level of payment to home 
health agencies and is intended to control home health spending until a prospective 
payment system is developed.  Concerns have been raised that the payment limits under 
the interim payment system may adversely affect beneficiary access to home health care. 
As the implementation of the prospective payment system proceeds, continued monitoring 
of agencies responses to these changes is important to ensure that beneficiary access is 
not compromised. 
This inspection follows an earlier study completed by the Office of Inspector General in 
October 1999 entitled, Medicare Beneficiary Access to Home Health Agencies OEI-02-
99-00530.  In that study,  most hospital discharge planners report generally being able to 
place Medicare beneficiaries with home health agencies; however, some volunteer concern 
that not all beneficiaries may be getting adequate care.  This study follows up on those 
concerns and is part of a series of inspections that the Office of Inspector General has 
conducted on home health care. 
For this study we interviewed a random sample of 202 hospital discharge planners, as well 
as analyzed data from the Health Care Financing Administration related to discharges to 
home health agencies and hospital lengths of stay. 
FINDINGS 
Almost All Medicare Beneficiaries Can be Placed With Home Health Care 
Most Medicare beneficiaries can be placed.  Eighty-seven percent of discharge planners 
report they can place all of their patients.  Another 6 percent estimate between 1 and 5 
percent of patients cannot be placed, while the remaining discharge planners put the 
estimate above 5 percent.  Patients who cannot be placed reportedly remain in the 
i 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  hospital, go to a nursing facility, or are cared for by family or friends at home. 
Among those Medicare patients whom discharge planners say they cannot place are some 
who are no longer eligible due to recent changes in eligibility.  When discharge planners 
responded to our question on the percentage they could not place, some may have 
included beneficiaries whose need for venipuncture alone no longer qualifies them for 
home care. 
In a separate effort to assess patient access to home health care under the interim payment 
system, we compared pre- and post-interim payment system data for patients in the 12 
diagnosis related groups most commonly discharged to home health agencies.  With the 
exception of one diagnosis related group (106- coronary bypass), we found no substantial 
decreases.  This seems to indicate that, in general, patients with these medical conditions 
are not being denied access to home health care. 
Some experience delays.  Seventy-eight percent of discharge planners report that they 
rarely or never experience delays in placing Medicare patients.  Nineteen percent report 
they sometimes do. When we asked discharge planners whether delays are more common 
now than before the interim payment system, 74 percent report there has been no change, 
while 20 percent report that they are more common under the interim payment system. 
However, in a separate analysis based on data from the Health Care Financing 
Administration, we found that for the 12 diagnosis related groups most commonly 
discharged to a home health agency, there were no substantial increases in the average 
hospital length of stay.  In fact, for all but one diagnosis related group, there was a 
decrease. 
Changes in The Medicare Home Care Environment Have Affected The Placement 
Process 
Stricter enforcement.  Discharge planners report that during the placement process, 
home health agencies are now looking more carefully at whether patients meet Medicare 
homebound and skilled need eligibility requirements.  This may be a result of recent 
enforcement activities by the Health Care Financing Administration and the Office of 
Inspector General. 
Focus on medical conditions.  Some discharge planners suggest agencies are using 
information on medical condition and service needs to screen certain patients.  On the 
occasions when there are placement delays, discharge planners most commonly cite 
problems with patients needing IV antibiotics or expensive drugs.  They also cite delays in 
placing patients who have decubitus ulcers or who need other wound care, as well as 
those who need rehabilitation.  On average, about a third who cite delays due to medical 
conditions attribute these delays directly to the interim payment system. 
ii 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  Fewer home health agencies.  Forty-two percent of discharge planners report that the 
availability of home care for Medicare patients in their area has decreased since the 
implementation of the interim payment system.  Analysis of data from the Health Care 
Financing Administration show a 25 percent decrease in home health agencies from 1997 
to 1999.  A small number of discharge planners we spoke with volunteered that home 
health agency closures in their area were making the process of placement more difficult. 
Some of them attribute these closures to the interim payment system. 
Staffing shortages.  There appears to be a drop in home health care staffing in some 
areas.  About one quarter of discharge planners report home health staffing shortages in 
their area have contributed to delays in placement.  Those who volunteered this 
information most commonly attribute the shortage to payments under the interim payment 
system. 
CONCLUSION 
The findings of this follow-up study are consistent with those in original study Medicare 
Beneficiary Access to Home Health Agencies, OEI-02-99-00530.  There appear to be no 
major disruptions in placing Medicare hospital patients with home health agencies.  To the 
extent that there are some disruptions, they appear to be localized. 
Agency Comments 
The Health Care Financing Administration provided comments on this and two related 
draft reports.  They concur with our conclusion that qualified Medicare beneficiaries are 
receiving the home health care they need.  They also note that on October 1, 2000, the 
new prospective payment system for home health care will go into effect.  They, like we, 
will monitor that new system to assure that beneficiaries continue to have access to home 
care.  The Health Care Financing Administration comments are in Appendix E. 
iii 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  T A B L E   O F   C O N T E N T S  
PAGE

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

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

FINDINGS

Almost All Beneficiaries Can be Placed With Home Health Care  . . . . . . . . . . . . . . . . . . 6

Changes in Home Care Environment Have Affected Placement Process . . . . . . . . . . . . .  7

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

AGENCY COMMENTS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10

APPENDICES

A:  Selected List of Other Recent OIG Home Health Inspections . . . . . . . . . . . . . . . . .  11

B:  Point Estimates and Confidence Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

C:  Proportion of Discharges to HHAs by Top DRGs  . . . . . . . . . . . . . . . . . . . . . . . . . 13

D:  Average Hospital Length of Stay by Top DRGs  . . . . . . . . . . . . . . . . . . . . . . . . . . 14

E:  HCFA Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

iv 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  I N T R O D U C T I O N  
PURPOSE 
To assess the effects of the interim payment system (IPS) on access to home health 
agencies for Medicare beneficiaries discharged from the hospital. 
BACKGROUND 
The Health Care Financing Administration (HCFA) asked the Office of Inspector General 
(OIG) to assess the effects of the interim payment system (IPS) for home health services 
on beneficiaries access to care.  The IPS changed the method and level of payment to 
home health agencies (HHAs) and is intended to control home health spending until a 
prospective payment system is developed.  Concerns have been raised that the payment 
limits under IPS may adversely affect beneficiary access to home health care.  As the 
implementation of the prospective payment system proceeds, continued monitoring of 
agencies responses to these changes is important to ensure that beneficiary access is not 
compromised. 
This inspection follows an earlier study completed by the OIG in October 1999 entitled, 
Medicare Beneficiary Access to Home Health Agencies OEI-02-99-00530.  In that study, 
most hospital discharge planners report generally being able to place Medicare 
beneficiaries with home health agencies; however, some volunteer concern that not all 
beneficiaries may be getting adequate care.  Most discharge planners further note that 
patients with chronic health care needs, and those who need IV care, high cost care, or 
intensive care have become more difficult to place in home health care and that home 
health agencies have changed their admissions practices.  This study follows up on those 
concerns and is part of a series of inspections that the OIG has conducted on home health 
care.  (See Appendix A.) 
Medicare Home Health Care 
Home health care services consist of skilled nursing; therapy (physical, occupational and 
speech), and certain related services, including 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 with a HHA.  These agencies can be 
free-standing or provider-based and be 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, be under the care of a physician who has established a 
1 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  plan of care, and need physical therapy, speech therapy, continued occupational therapy, 
or skilled nursing on an intermittent basis.  There are no limits on the number of visits or 
length of coverage and no co-payments or deductibles apply. 
During much of the 1990s, Medicare spending for home health services increased 
substantially.  From 1990 to 1997, expenditures rose from $3.7 billion to $17.8 billion. 
This resulted from both an increase in the number of beneficiaries who received home 
health services and an increase in the number of visits they received.  In 1999, Medicare 
spending for home health services was about $9.5 billion. 
Several initiatives were implemented in response to concerns about Medicare home health 
spending and fraud and abuse.  An anti-fraud campaign known as Operation Restore Trust 
employed a number of approaches and is at least partially responsible for helping to slow 
Medicare home health spending.  The Health Insurance Portability and Accountability Act 
also included measures to control fraud and abuse by HHAs. Changes to Medicare 
participation rules designed to screen out problem providers as well as payment limits 
which are discussed below were also initiated. 
Two recent coverage rule changes are noteworthy.  The first relates to IV antibiotic 
therapy. The HCFA issued a rule, effective September 1, 1996, that there was insufficient 
evidence to support the necessity of an external infusion pump to administer vancomycin, 
a popular broad spectrum antibiotic.  Medicare covers IV drugs only when there is a 
medical necessity for them to be administered by an infusion pump.  Therefore, Medicare 
no longer covers vancomycin for home care patients as it does not require a pump.  The 
second change that is generally thought to have had a measurable impact on the number of 
Medicare beneficiaries eligible for home care relates to the provision of venipuncture 
services as a qualifying skilled need.  Beginning on February 5, 1998, a patient's need for 
venipuncture no longer constitutes a qualifying skilled need.  Prior to this change, some 
patients, for whom this was their only skilled need, qualified for home care. 
The Balanced Budget Act of 1997 
The Balanced Budget Act (BBA) of 1997 changed the way Medicare pays for home 
health care.  The BBA required that the existing cost-based payment system be replaced 
with a prospective payment system (PPS) of fixed, predetermined rates for home health 
services.  To allow time for HCFA to develop this prospective payment system, the BBA 
mandated an interim payment system (IPS) to limit payments.  The IPS became effective 
for cost-reporting periods beginning October 1, 1997, and will continue until PPS begins 
on October 1, 2000. 
The IPS is intended to control the aggregate costs of services provided to beneficiaries in 
two ways.  First, it subjects Medicare HHAs to a new payment limit that is based on an 
aggregate per-beneficiary amount. This limit is based on a blend of historical per-user 
costs for the agency and agencies in the region.  It is applied to an agencys total Medicare 
payments and not to specific beneficiaries.  Second, it decreases the per-visit 
2 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  limits from 112 percent of the national mean cost per visit to 105 percent of the national 
median.  Medicare then pays HHAs the lower of their actual costs, the aggregate per-
beneficiary limit, or the aggregate per-visit limit. 
The Omnibus Consolidated and Emergency Supplemental Appropriations Act of 1999 
moderated the restrictiveness of IPS.  This legislation made several changes to the 
payment limits, including increasing the per-visit limits for all agencies and increasing the 
aggregate beneficiary limit for certain agencies.  In that same year, Congress enacted the 
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, which delayed 
a 15 percent payment reduction to be imposed with the implementation of PPS and 
increased payments under IPS to certain agencies.  The changes stemmed from a concern 
that access to care was being adversely affected and that providers were overburdened. 
Under IPS, agencies can use several methods to keep costs below their payment limits, 
including balancing their mix of low and high cost patients, reducing their costs overall, 
and increasing their proportion of low-cost patients. 
Prior Work on Access to Home Health Care 
Several past studies have examined access to home health care for Medicare beneficiaries. 
A recent report by the General Accounting Office found that although about 14 percent of 
HHAs have closed since 1997, there is little evidence that appropriate access to care has 
been impaired.  The study found that closures occurred most frequently in areas that had 
experienced considerable growth.  Additionally, interviews with 130 stakeholders in 34 
counties that had significant closures indicated few access problems.  The interviews 
suggested, however, that as HHAs change their operations in response to IPS, 
beneficiaries who are likely to be costlier than average to treat may have increased 
difficulty obtaining home health care. 
A two-part study released by George Washington University (GWU) entitled, An 
Examination of Medicare Home Health Services: A Descriptive Study of the Effects of 
the Balanced Budget Act Interim Payment System on Access to and Quality of Care, 
found that the majority of HHAs participating in the study in eight States altered their case 
mix and/or practice patterns to conform utilization to IPS reimbursement.  It also found 
that diabetics and other beneficiaries with more intensive care needs as well as chronically 
ill beneficiaries appeared to be most affected by IPS. 
The second phase of the GWU study focused on the experiences of discharge planners in 
eight States.  It found that most hospital discharge planners reported increased difficulty in 
obtaining home health services for Medicare beneficiaries.  Most attributed these increases 
to changes in admitting and practice patterns by HHAs, changes in staffing patterns, or the 
effects of agency closures in their service area.  Additionally, respondents reported that 
beneficiaries most affected by these changes were those with short-term high intensity 
needs or chronic diseases, and those needing complex wound care or two 
3 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  visits per day. 
Similarly, a recent study sponsored by the Medicare Payment Advisory Commission that 
surveyed HHAs and held a panel discussion with individuals familiar with access problems 
found that many HHAs have adopted new admission and discharge practices since IPS 
was implemented.  Agencies reported that they are avoiding high-cost patients and most 
frequently identified long-term or chronic care patients as those they no longer admitted or 
have discharged as a result of IPS. 
Finally, two reports based on early data from HCFAs Per-Episode Home Health 
Prospective Payment Demonstration suggest that prospective payment can lower 
Medicare home health costs without harming quality of care.  Specifically, the first report 
found no evidence that quality of care as measured by patient outcomes was adversely 
affected.  A second report found that although the per-episode prospective payment 
demonstration substantially reduced home visits, it did not affect the use of or 
reimbursement for other Medicare-covered services, suggesting that prospective payment 
does not adversely affect quality of care.  Case studies conducted early in the 
demonstration found that agencies did not change their behavior in ways that threatened 
access or quality of care.  Specifically, there was no evidence that agencies changed their 
referral or admission practices to avoid costly patients or recruit lower-care ones as a 
result of per-episode PPS. 
METHODOLOGY 
Discharge Planner Interviews 
We used a combination of methods to analyze information for this inspection.  We chose a 
random sample of 225 acute care hospitals with 30 beds or more.  The sample was drawn 
from the 50 states in addition to the District of Columbia.  We conducted interviews with 
202 directors of discharge planning or their designees within a three week period from 
May 22 until June 23, 2000.  Twelve of the remaining 23 hospitals did not discharge 
Medicare patients to HHAs.  We were unable to reach a discharge planner to schedule an 
interview at the other 11 hospitals. 
Analysis of Medicare Data 
Secondly, we analyzed Medicare data.  Using HCFAs National Claims History data, we 
identified all Medicare beneficiaries who:  1) were discharged from a hospital between 
January 1, 1996, and March 31, 1996; and, 2)  had a home health episode that started 
within 30 days of their hospital discharge.  We then identified patients who met this 
criteria for an analogous period in 1997, 1998, 1999, and 2000.  We analyzed beneficiaries 
in the diagnosis related groups (DRGs) that are most commonly discharged to HHAs for 
these five time periods.  As part of this analysis we assessed whether HHAs are admitting 
different types of beneficiaries since the implementation of IPS.  We also 
4 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  analyzed hospital length of stay for beneficiaries discharged to home health care by these 
DRGs to examine whether certain patients are experiencing longer delays before being 
admitted to HHAs since IPS.  Lastly, using HCFA's Provider of Services File, we analyzed 
trends in the number of HHAs. 
This inspection was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and Efficiency. 
5 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  F I N D I N G S  
Almost all Medicare beneficiaries can be placed with home 
health care 
Most Medicare beneficiaries can be placed 
Eighty-seven percent of discharge planners report they can place all of their patients. 
Another 6 percent estimate between 1 and 5 percent of patients cannot be placed, while 
the remaining discharge planners put the estimate above 5 percent.  Patients who cannot 
be placed reportedly remain in the hospital, go to a nursing facility, or are cared for by 
family or friends at home. 
Additionally, when we asked whether the number of patients they are never able to place 
with home care has increased, decreased, or stayed the same since the implementation of 
the interim payment system (IPS), 79 percent say it has remained the same. 
It should be noted that recent changes in eligibility have had an impact on discharge 
planners' ability to place Medicare beneficiaries.  As indicated in the background of this 
report, a patients need for venipuncture alone no longer constitutes a qualifying skilled 
need.  Prior to HCFA's rule change, a significant number of patients who required 
venipuncture qualified for home care.  When discharge planners responded to our question 
on the percentage they could not place, some may have included beneficiaries who are no 
longer eligible. 
In another effort to assess patient access to home health care under IPS, we compared pre-
and post-IPS data for patients in the 12 diagnosis related groups (DRGs) most commonly 
discharged to HHAs.  We did this in order to evaluate whether certain patient types were 
experiencing a reduction in access to HHAs.  With the exception of one diagnosis related 
group (DRG 106 coronary bypass), we found no substantial decreases. (See Appendix C.) 
Some experience delays 
Seventy-eight percent of discharge planners report that they rarely or never experience 
delays in placing Medicare patients.  Nineteen percent report they sometimes experience 
delays.  When we asked discharge planners whether delays are more common now than 
before IPS, 74 percent report there has been no change, while 20 percent report that they 
are more common under IPS. 
In an effort to determine whether patients with certain diagnoses are being delayed to the 
point that their hospital stays are longer, we compared pre- and post-IPS hospital lengths 
of stay for patients in the 12 DRGs most commonly discharged to HHAs.  Overall, we 
6 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  found no substantial increases in the average hospital length of stay prior to discharge to 
an HHA.  In fact, for all but one DRG, there was a decrease.  (See Appendix D.) 
Finally, we asked discharge planners if the number of HHAs they need to contact in order to 
place a Medicare patient increased, decreased, or remained the same since the 
implementation of IPS.  Eighty-one percent say the number of HHAs they need to contact 
has remained the same since the implementation of IPS.  They contact, on average, between 
one and two agencies both before and since the implementation of IPS.  Twelve percent say 
they had to contact fewer agencies before IPS.  Four percent say they had to contact more 
agencies before IPS.  The remaining 4 percent say they do not know. 
Changes in the Medicare home care environment have 
affected the placement process 
Although most discharge planners do not attribute any significant increases in access 
problems to IPS, just over 40 percent indicate they have noticed changes in the placement 
process.  These changes reflect recent changes within the Medicare home care environment. 
Stricter enforcement 
Discharge planners report that during the placement process, home health agencies are 
now looking more carefully at whether patients meet Medicare homebound and skilled need 
eligibility requirements.  This may be a result of recent HCFA and OIG enforcement 
activities.1 
Focus on medical conditions 
Some discharge planners observe that the admissions process is taking longer because 
agencies are asking for more medical information from prospective patients.  They 
suggest agencies are using information on medical condition and service needs to screen 
certain patients. 
On the occasions when there are placement delays, discharge planners most commonly 
cite problems with patients needing IV antibiotics or expensive drugs.  As mentioned in 
the background, vancomycin, a broad spectrum antibiotic, is no longer covered under 
Medicare.  Discharge planners report that some patients tend to stay in the hospital longer 
to continue receiving IV antibiotics or are placed instead into skilled nursing facilities where 
IV antibiotic coverage is still available.  Additionally, we have heard of incidents 
1 
1995 legislation established Operation Restore Trust which allocated funds to reduce fraud, waste, and abuse in the Medicare 
program. The home health benefit was one of the primary areas of focus. In addition, the Health Insurance Portability and 
Accountability Act of 1996 included measures to control fraud and abuse by HHAs. 
7 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  where discharge planners have asked hospitals to pay for IV antibiotics in order for the 
patient to receive home health care. 
Discharge planners also cite delays in placing patients who have decubitus ulcers or who 
need other wound care, as well as those needing rehabilitation.  It appears that it takes 
longer to place these patients primarily because of staffing issues.  Wound care patients 
often require frequent dressing changes, which may entail multiple visits per day. 
Rehabilitation patients require the assistance of physical, speech, or occupational 
therapists that some discharge planners tell us are in short supply. 
On average, only about a third of the discharge planners who cite delays in getting home 
care for patients with the previously mentioned medical conditions attribute these delays 
directly to IPS.  The majority of discharge planners who say delays are associated with 
certain medical conditions or service needs attribute these delays to a wide range of 
factors.  These include: HHAs not able to afford enough qualified staff to care for certain 
medical conditions; finding family members capable of providing enough care at home; 
and, rural area travel distances. 
Fewer home health agencies 
Forty-two percent of discharge planners report that the availability of home care for 
Medicare patients in their area has decreased since the implementation of IPS.  Analysis 
of HCFA data shows a 25 percent decrease in HHAs from 1997 to 1999.  A small number 
of discharge planners we spoke with volunteered that HHA closures in their area were 
making the process of placement more difficult.  Some of them attribute these closures to 
IPS. 
Staffing shortages 
In addition, there appears to be a drop in home health care staffing in some areas.  About 
one quarter of discharge planners report home health staffing shortages in their area have 
contributed to delays in placement.  Discharge planners who volunteered this information 
most commonly attribute the shortage to IPS.  They explain that because of  low 
reimbursement, they believe that HHAs have cut back on staffing or have closed.  These 
discharge planners say that the remaining staff have been unable to provide care for 
everyone who needs home care in their area.  Other discharge planners cite labor market 
forces when asked about the cause of staff shortages.  These discharge planners say that, 
in some areas, nurses and home health aides are simply in short supply. 
8 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  C O N C L U S I O N  
The findings of this follow-up study are consistent with those in original study Medicare 
Beneficiary Access to Home Health Agencies, OEI-02-99-00530.  There appear to be no 
major disruptions in placing Medicare hospital patients with home health agencies.  To 
the extent that there are some disruptions, they appear to be localized. 
9 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  A G E N C Y  C O M M E N T S  
The Health Care Financing Administration provided comments on this and two related draft 
reports.  They concur with our conclusion that qualified Medicare beneficiaries are 
receiving the home health care they need.  They also note that on October 1, 2000, the 
new prospective payment system for home health care will go into effect.  They, like we, 
will monitor that new system to assure that beneficiaries continue to have access to home 
care.  The Health Care Financing Administration comments are in Appendix E. 
10 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  APPENDIX A 
Selected List of Other Recent Office of Inspector General 
Home Health Inspections 
Office of Inspector General, US Department of Health and Human Services, Medicare 
Beneficiary Access to Home Health Agencies, OEI-02-99-00530, October 1999. 
Office of Inspector General, US 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, US Department of Health and Human Services,  Medicare 
Home Health Agency Survey and Certification Deficiencies, OEI-02-99-00532, September 
2000. 
11 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  APPENDIX B 
Confidence Intervals for Key Findings 

We calculated confidence intervals for key findings for discharge planners.  The point 
estimate and 95% confidence interval are given for each of the following: 
KEY FINDINGS  POINT  CONFIDENCE 
ESTIMATE  INTERVAL 
Eighty-seven percent of discharge planners report they can 
87%  +/- 4.6 
place all of their patients. 
Seventy-nine percent of discharge planners say the number 
79%  +/- 7.3 
of Medicare patients they cannot place with home care has 
remained the same since IPS. 
Seventy-eight percent of discharge planners report that 
78%  +/- 5.7 
they rarely or never experience delays in placing Medicare 
patients. 
Seventy-four percent report no change in the percentage 
74%  +/- 6.1 
of Medicare patients who experience a delay since IPS. 
Nineteen percent of discharge planners report they 
19%  +/- 5.4 
sometimes experience delays in placing Medicare patients. 
Eighty-one percent of discharge planners report that the 
81%  +/- 5.5 
number of HHAs they need to contact has remained the 
same since IPS. 
Just over 40 percent indicate they have noticed changes in 
44%  +/- 6.9 
the placement process. 
On the occasions when there are placement delays, 
47%  +/- 11.0 
discharge planners most commonly cite problems with 
patients needing IV antibiotics or expensive drugs. 
Forty-two percent of discharge planners report that the 
42%  +/- 6.8 
availability of home care for Medicare patients in their 
area has decreased since IPS. 
12 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  APPENDIX C 
Proportion of Discharges to HHAs 

by Top Diagnosis Related Groups (DRGs)

Percent  Percent  Percent  Percent  Percent  Difference 
Initial Hospital DRG  1996  1997  1998  1999  2000  1996-2000 
DRG 106- Coronary bypass 
2.2  2.2  2.1  0.1  0.1  -2.1 
with PTCA 
DRG 014- Specific 
4.0  3.9  3.4  3.3  3.1  -0.9 
cerebrovascular disorders 
DRG 079- Respiratory 
1.6  1.7  1.3  1.2  1.1  -0.5 
infections and inflammations 
DRG 209- Major joint and limb 
8.1  8.0  8.3  8.0  7.7  -0.4 
reattachment 
DRG 148- Major small and 
2.1  2.0  1.9  1.8  1.7  -0.3 
large bowel procedures 
DRG 127- Heart failure and 
6.2  6.0  6.1  5.9  6.0  -0.3 
shock 
DRG 121- Circulatory 
disorders w/acute myocardial  1.7  1.6  1.6  1.7  1.7  0.0 
infarction 
DRG 174- GI hemorrhage 
1.2  1.2  1.2  1.2  1.2  0.0 
w/CC 
DRG 296- Nutritional and 
1.5  1.5  1.5  1.6  1.6  +0.2 
misc. metabolic disorders 
DRG 088- Chronic obstructive 
3.2  3.7  4.3  4.5  4.1  +0.9 
pulmonary disease 
DRG 462- Rehabilitation  5.2  5.3  5.1  5.7  6.1  +0.9 
DRG 089- Simple pneumonia 
3.9  4.6  5.7  6.0  5.9  +2.0 
and pleurisy 
Source: National Claims History File 
13 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  APPENDIX D 
Average Hospital Lengths of Stay For Top 

Diagnosis Related Groups (DRGs) Discharged to HHAs

Days  Days  Days  Days  Days  Difference 
Initial Hospital DRG  1996  1997  1998  1999  2000  1996-2000 
DRG 462- Rehabilitation  16.5  15.5  14.2  14.3  14.0  -2.5 
DRG 079- Respiratory 
10.0  9.9  9.8  9.9  7.9  -2.1 
infections and inflammations 
DRG 014- Specific 
8.8  8.1  7.6  7.5  7.5  -1.3 
cerebrovascular disorders 
DRG 210- Hip and femur 
7.5  6.8  6.5  6.4  6.4  -1.1 
procedures except major joint 
DRG 209- Major joint and limb 
5.7  5.2  4.8  4.8  4.7  -1.0 
reattachment 
DRG 121- Circulatory disorders 
9.2  8.7  8.5  8.4  8.3  -0.9
w/acute myocardial infarction 
DRG 296- Nutritional and misc. 
6.7  6.3  6.0  6.1  5.9  -0.8
metabolic disorders 
DRG 148- Major small and 
13.8  13.5  12.9  13.2  13.1  -0.7
large bowel procedures 
DRG 127- Heart failure and 
7.2  6.8  6.6  6.6  6.5  -0.7
shock 
DRG 089- Simple pneumonia 
7.9  7.6  7.3  7.2  7.2  -0.7
and pleurisy 
DRG 088- Chronic obstructive 
7.4  7.1  6.7  6.8  7.0  -0.4
pulmonary disease 
DRG 106- Coronary bypass 
11.9  11.3  10.9  11.7  12.0  +0.1
with PTCA 
Source: National Claims History File 
14 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  APPENDIX E 
Agency Comments

In this appendix, we present the comments from the Health Care Financing 
Administration. 
15 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  16 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  17 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320  18 
Medicare Beneficiary Access to HHAs: 2000  OEI-02-00-00320