Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
The Physicians Role 
in Medicare Home Health 
2001 
JANET REHNQUIST 
Inspector General 
December 2001 
OEI-02-00-00620  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
 
Judy Kellis, Lead Analyst
  Brian Ritchie, Technical Support
 
Christi Macrina
  Scott Horning
 
Thomas Zimmermann
  Linda Moscoe
 
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 describe physicians practices in prescribing, certifying, and monitoring Medicare home 
health services within the context of the Centers for Medicare and Medicaid Services 
expectations. 
BACKGROUND 
The home health care environment has undergone a great deal of change within the last 
few years.  This inspection is part of a larger body of work that the Office of Inspector 
General is conducting on Medicare home health services.  For this study, we mailed 
questionnaires to 600 physicians who signed Medicare home health plans of care in the 
last 6 months of 2000.  We supplemented these data with survey data from Medicare 
beneficiaries and home health agencies, as well as the Centers for Medicare and Medicaid 
Services (CMS) claims data. 
FINDINGS 
Physicians Play a Key Role in Medicares Home Health Benefit 
Virtually all physicians (97 percent) report that they have some familiarity with most 
patients for whom they sign a home health plan of care.  Most physicians also say they are 
involved in identifying the specific home health services their patients need, with over half 
reporting that they work jointly with home health agencies or hospital staff to make these 
determinations.  Eighty-six percent of physicians report that they see their patients at least 
once a month while they are receiving home health services. 
Physicians Report a Lack of Knowledge of Medicare Home Health Rules 
Physicians report that they are not clear on key Medicare rules.  For example, 38 percent 
of physicians report that they are unclear on the Medicare criteria for homebound.  Half 
say that they are not clear on the definition to apply when certifying medical necessity. 
Physicians Believe Not All Medicare Expectations of Them Can be Met 
We found that most physicians know what CMS expects of them but many believe they 
are not able to provide this level of oversight of Medicare home health patients.  For 
example, while 83 percent of physicians believe that Medicare expects them to ensure that 
only medically necessary services are on the plan of care, only 48 percent say they are able 
to ensure that this is the case.  There is also a large difference between the percentage of 
physicians that believe Medicare expects them to ensure that home health 
i 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  patients are homebound, and the number that believe they are able to do this (59 versus 26 
percent).  In addition to reporting concerns about their ability to meet CMS oversight 
expectations, some physicians report being confused about the degree to which they can 
be held liable for inappropriate home health certifications. 
Over Half of Medicare Physicians Are Unaware of New Home Health Prospective 
Payment System 
About 60 percent of physicians report they have never heard of the Medicare home health 
prospective payment system, which went into effect October 1, 2000. 
Effectiveness of Physician Payments is Questionable 
Beginning in 1995, physicians were permitted to bill for care plan oversight in an effort to 
encourage additional physician involvement.  Recent claims data indicate that physicians 
bill for care plan oversight at a rate of less than three percent of total home health claims. 
Regarding newly available payments for certification and re-certification of the plan of 
care, data for the first quarter of 2001 reveal that physicians billed for these payments at a 
rate of less than five percent. These low billing rates indicate that, at present, there is little 
willingness on the part of physicians to pursue these payments.  Physicians report that 
there is too much paperwork involved in submitting these claims, and the payment amount 
is not high enough to make it worthwhile. 
RECOMMENDATIONS 
Physicians are currently playing an important role in initiating, certifying and monitoring 
the care for Medicare home health beneficiaries.  However, they are doing so despite 
limited knowledge of key Medicare rules as well as discomfort with CMS expectations. 
At present, the availability of reimbursement for their oversight role does not seem to be 
having a significant impact on physicians who care for Medicare home health patients. 
In order to address physician concerns and improve the Medicare home health services, 
we recommend the following. 
<	  The Centers for Medicare & Medicaid Services should review relevant 
informational materials available to Medicare physicians to determine areas where 
improvements and clarifications can be made. 
<	  The Centers for Medicare & Medicaid Services should establish a workgroup 
composed of physicians, home health representatives, and departmental designees, 
or utilize an existing workgroup such as the Practicing Physicians Advisory 
Council or the Physician Regulatory Issues Team to discuss issues related to 
Medicare home health care.  We offer the following issues for consideration by the 
workgroup. 
ii 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620   -	  The need for more effective and widespread home health education for 
physicians; 
-	  Further clarification of payment and coverage policies, including the home 
health definitions for homebound and medically necessary; 
- The simplification of home health certification forms; 
-	  An analysis of the costs and benefits associated with the promotion of 
physician home visits; 
-	  The possibility of requiring home health agencies to employ medical 
directors; 
-	  The consideration of whether CMS oversight expectations of physicians can 
be realistically met; and, 
-	  The creation of a system enabling patients to appeal if they feel they are 
receiving inadequate care. 
COMMENTS 
We received comments on our draft report from several physician and home health 
organizations: The American Academy of Home Care Physicians, The American College 
of Physicians-American Society of Internal Medicine, The American Medical Association, 
and The National Association for Home Care.  These organizations generally agreed with 
our findings and recommendations.  They also provided specific suggestions on how to 
increase physician understanding of the Medicare home health benefit and to promote 
further physician involvement with their home care patients.  (We include these 
organizations' comments in full in Appendix E.) 
We also received comments on our draft report from the Centers for Medicare & 
Medicaid Services (CMS).  The CMS concurred with our findings and also made a 
number of technical comments that we incorporated into the report when appropriate.  In 
addition, CMS had two methodological concerns.  First, they expressed concern that our 
sampling time frame did not include a long enough period of time when the prospective 
payment system (PPS) was in effect.  We acknowledge that our work occurred in the early 
stages of PPS implementation.  However, it is important to note that physician knowledge 
of PPS is only one issue among several that we sought to address.  Second, CMS stated 
that our sample may be biased against respondents who have had enough experience 
signing plans of care.  We were also concerned about this.  Therefore, in our 
methodology we included only physicians who signed two or more home health plans of 
care during the 6 month sampling time frame. 
iii 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  T A B L E   O F   C O N T E N T S
PAGE
 
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  i
 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 
FINDINGS 
Physicians Play a Key Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10
 
Physicians Report a Lack of Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11
 
Physicians Believe Not All Expectations Can be Met  . . . . . . . . . . . . . . . . . . . . . . . . . . 13
 
Over Half of Medicare Physicians Are Unaware of PPS  . . . . . . . . . . . . . . . . . . . . . . . . 15
 
Effectiveness of Physician Payments is Questionable  . . . . . . . . . . . . . . . . . . . . . . . . . . 15
 
RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17
 
APPENDICES 

A: Selected List of Recent OIG Home Health Inspections  . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
 
B: Chi-Square Test For Urban/Rural Differences  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
 
C: Confidence Intervals For Key Findings  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
 
D: Physician Non-Respondent Analysis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
 
E: Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24
 
iv 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  I N T R O D U C T I O N  
PURPOSE 
To describe physicians practices in prescribing, certifying, and monitoring Medicare home 
health services within the context of the Centers for Medicare and Medicaid Services 
expectations. 
BACKGROUND 
The home health care environment has undergone a great deal of change within the last 
few years.  This inspection is part of a current series of four Office of Inspector General 
(OIG) inspections about Medicare home health care.  Medicare Beneficiary Experiences 
With Home Health Care OEI-02-00-00560, looks at the experiences of Medicare 
beneficiaries in accessing and receiving home health care.  Access to Home Health Care 
After Hospital Discharge 2001 OEI-02-01-00180, assesses the effects of the prospective 
payment system on access to home health care for Medicare beneficiaries who are 
discharged from the hospital.  Medicare Home Health Care- Beneficiaries From The 
Community OEI-02-01-00070, looks at access to home health for beneficiaries who have 
not recently been in the hospital.  See Appendix A for a list of other recent OIG reports 
relating to home health care. 
This inspection also follows up on a June 1995 study on the physician role in providing 
home health care.  In that earlier report, the OIG found that physicians were most 
involved in referring patients, approving plans of care, and monitoring the progress of 
complex patients.  However, both home health agencies and physicians identified obstacles 
to effective physician involvement. 
Medicare Home Health Care 
Home health services consist of skilled nursing, therapy (physical, occupational and 
speech), and certain related services, including social work and 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 
(HHA).  These agencies can be free-standing 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, be 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 
1 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  services: skilled nursing care, physical therapy, speech therapy, and 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.)  Home health aide visits are covered to 
the extent that the aide services support the skilled need of the beneficiary. There are no 
specific limits on the number of visits or length of coverage and no co-payments or 
deductibles apply. 
Trends in Medicare Home Health Care 
After a history of increases, Medicare home health expenditures have dropped since 1998. 
Between Fiscal Years 1991 and 1997, Medicare home health care annual expenditures 
rose from $4.7 billion to $17.6 billion.  This was due to an increase in both the 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 about $8.7 billion.  Furthermore, the average home health length of stay has declined 
from 98 days in 1997 to 58 days in 1999, and the number of beneficiaries served has 
decreased by 22 percent1. 
A number of factors have contributed to the recent decrease in Medicare home health 
spending.  These include interim 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. 
The Physicians Role in Home Health Care 
Physician as the Gatekeeper 
The Centers for Medicare and Medicaid Services (CMS) require that a physician sign 
every patients individual plan of care certifying that the patient is homebound and the 
planned services are medically necessary in order for the home health agency to be 
reimbursed for Medicare covered services.2  This role that CMS is relying on physicians to 
fulfill is sometimes thought of as a gatekeeper.  Historically, many physicians have 
focused their attention on the determination of their patients medical needs and have been 
less comfortable with the gatekeeper role. 
Physician liability fraud alert 
In January 1999, the OIG released a special fraud alert directed to the physician 
community that addressed their role in certifying Medicare home health services for their 
patients.  The Fraud Alert was issued because physicians may not appreciate the legal 
1
Comparisons are between the first 2 months of 1997 and the analogous period in 1999. 
2
Medicare home health regulations, 42 CFR 484.18, require physicians to establish, sign, and periodically review a 
plan of care specifying all services the patient is to receive. The plan of care must be re-certified every 60 days. 
2 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  and programmatic significance of certifications they make in connection with the ordering 
of home health care for Medicare beneficiaries.  It stresses the significance of their 
responsibility as the party who certifies the medical necessity for home health care, signs 
off on the level of services needed, and certifies that the patient is homebound.  The Fraud 
Alert also emphasizes the need for the certifying physician to have firsthand knowledge of 
the relevant patient. 
The Fraud Alert notes that a physician is not personally liable for erroneous claims due to 
mistakes, inadvertence, or simple negligence, but that knowingly signing a false or 
misleading certification or signing with reckless disregard for the truth can lead to serious 
criminal, civil, and administrative penalties.  However, in our pre-inspection discussions 
with physicians, it was apparent that there is a significant amount of confusion surrounding 
the physician liability issue.  Many physicians were aware of the fraud alert and mistakenly 
thought that it held them personally liable in all cases.  Some physician groups and home 
health agencies indicate that physicians have become less willing to sign off on Medicare 
plans of care as a result of the Fraud Alert.  The OIG recently issued the final version of 
the Compliance Program Guidance for Individual and Small Group Physician Practices.  A 
major focus of  this guidance is on the difference between erroneous claims and 
fraudulent claims. 
The physicians role under the prospective payment system 
Recent changes in the way Medicare reimburses home health agencies have affected the 
physician role in home health care envisioned by CMS.  The Balanced Budget Act of 1997 
required that the existing cost-based home health payment system be replaced with a 
prospective payment system (PPS) of fixed, predetermined rates.  Prior to the 
implementation of PPS on October 1, 2000, home health agencies were reimbursed based 
on what it costs to provide services to Medicare beneficiaries.  As a result, there was a 
financial incentive for HHAs to provide more services than might be necessary.  As 
indicated earlier, under this system the physician was seen as the gatekeeper, responsible 
for ensuring that patients only received services that were medically necessary.  Under the 
new prospective payment system, financial incentives have changed somewhat, and 
physicians are now being asked to fulfill a dual role.  The CMS is still relying on physicians 
to ensure that Medicare beneficiaries are homebound and have a need for medical services. 
However, because agencies are now paid fixed, pre-determined rates, there may be an 
incentive for some home health agencies to limit the services provided within a given 
episode of care.  As a result, physicians are now also being called upon to ensure that 
patients get appropriate care, as well as a sufficient amount of care. 
In a recent directive sent to Medicare Carriers, CMS provided guidance on this new 
physician role and directed the Carriers to alert physicians about their new responsibilities 
under the prospective payment system.  This program memorandum indicated that 
physician responsibility in the PPS environment is to be the determiner of the patients 
health care needs and advocate for the services required to meet those needs.  The 
physicians role is no longer simply that of a gatekeeper for the duration of home care 
3 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  services.  Instead, under PPS the physician role has become one of  gatekeeper at the 
onset, ensuring that the patient is eligible for Medicare home health services, then, 
subsequent to the start of home health, physicians are expected to ensure that the patient is 
not short-changed with regard to the services that Medicare is paying the agency to 
provide.  It is worth noting that there are no specific guidelines as to what level of service 
a given type of Medicare beneficiary should receive.  The physician is expected to make 
this determination as the patients advocate. 
Prospective Payment System Reimbursement 
Under the new prospective payment system, reimbursement is based on each 60-day 
episode of care.  For initial episodes, the home health agency receives 60 percent of its 
estimated payment for services up front when it submits a Request for Anticipated 
Payment.  Although a physician signed plan of care is not required prior to the submission 
of the Request for Anticipated Payment, home health agencies must receive and 
substantiate a physician order before this request can be made.  This can be done through 
one of three alternative processes set out in recently revised CMS regulations.  One 
alternative is for agencies to record the physicians verbal order in the patients plan of 
care, including a physician description of the patients condition and the services to be 
provided.  This verbal order must be signed and dated by the agencys registered nurse or 
therapist and a copy of the plan of care must be immediately submitted to the physician.  A 
second alternative is for the physician to write out a prescription for services, again 
including the patients condition and the services to be provided.  Finally, agencies can 
follow the previously established procedure and have the physician sign the plan of care 
prior to submitting the Request for Anticipated Payment. Under the new procedure, a 
signed plan of care is required by the end of the 60-day episode in order for the HHA to 
receive the remaining 40 percent payment. 
Physician Payments for Oversight and Certification of the Plan of Care 
Payment for care plan oversight 
In an effort to encourage additional physician involvement, beginning in 1995, CMS 
regulations have provided for physician reimbursement for care plan oversight.  Physicians 
(as well as nurse practitioners, physician assistants, and clinical nurse specialists) may bill 
Medicare for this under CPT code 99375.3  On January 1, 2001, the national average 
payment rose from $99 to $122. 
3 
Since 1995, the code used to bill for home health care plan oversight has changed a number of times for a variety of 
reasons. As of January 1, 2001, the code is temporary HCPCS code G0181. 
4 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  In order to bill for care plan oversight, the following conditions must be met: 
1.	  the beneficiary must require complex or multi-disciplinary care modalities requiring 
ongoing physician involvement in the patient's plan of care; 
2.	  the care plan oversight services should be furnished during the period in which the 
beneficiary is receiving Medicare covered home health care services; 
3.	  the physician who bills for care plan oversight must be the same physician who 
signed the home health plan of care; 
4.	  the physician must furnish at least 30 minutes of care plan oversight within the 
calendar month for which payment is claimed; and, 
5.	  no other physician can be paid for care plan oversight for the same patient during 
the relevant month. 
The CMS representatives indicate that the number of physicians claiming care plan 
oversight reimbursement has been below projections.  Some believe this indicates that the 
availability of this reimbursement has not increased physician involvement in the way it 
was hoped.  This has led to ongoing discussions about other approaches that might be 
effective in increasing physician involvement. 
New payment for certification of plan of care 
Another change related to physicians with home health patients involves new payments for 
physician certification and re-certification of patients plans of care.  As of January 1, 
2001, physicians are able to bill for these services under HCPCS code G0180, for 
certification, and HCPCS code G0179, for re-certification.  The final rule establishing 
these payments indicates that the certification (and re-certification) services being paid 
for include creation and review of a plan of care for a patient and verification that the 
home health agency initially complies with the physicians plan of care.  In addition, these 
payments include the physicians work in reviewing data collected in the home health 
agencys patient assessment, including Outcome and Assessment Information Set (OASIS) 
data.  CMS does not require physicians to review the OASIS, but if they do, this work is 
included in the payment for certification or re-certification. 
The CMS introduced these new payments in hopes of increasing physician involvement, 
particularly given the implementation of the prospective payment system.  Physicians will 
be able to claim these payments in addition to reimbursement claimed for care plan 
oversight.  Unlike care plan oversight, nurse practitioners, physician assistants and clinical 
nurse specialists cannot bill for certification or re-certification of the home health plan of 
care.  Physician payments for these services will be, on average, $73 and $61, respectively. 
5 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  Physician Group Established by the Centers for Medicare and Medicaid Services 
The Physician Regulatory Issues Team was created by CMS in 1998 to help make 
Medicare rules clear and reasonable for physicians.  The Team provides physicians with a 
forum to discuss how Medicare regulations and other program rules and guidelines affect 
their practices and their patients.  One of its main goals is to reduce the regulatory burden 
on physicians. 
Prior OIG Work on Physician Involvement in Home Health Care 
Two previous OIG studies have examined physician involvement in Medicare home health 
care.  As indicated earlier, The Physicians Role in Home Health Care, OEI-02-94-00170, 
surveyed both home health agencies and the physicians who referred patients to them. 
The study provided a description of physicians involvement in home health at the time.  It 
found that physicians were most involved in referring patients, approving plans of care, 
and monitoring the progress of complex patients.  They appear to have been less involved 
in coordinating services, visiting patients at home, and participating in interdisciplinary 
conferences.  Physicians and agencies both cited problems in communicating with each 
other and difficulties in getting the plan of care signed.  Some agencies felt physicians 
lacked adequate education in home health care and an understanding of the home health 
benefit. 
Another OIG report issued in 1996, Results of the Operation Restore Trust Audit of 
Medicare Home Health Services in California, Illinois, New York, and Texas, A-04-96-
02121, found that 40 percent of services in a sub-sample of the home health claims 
reviewed did not meet Medicare reimbursement requirements.  These inappropriate claims 
included services not reasonable and necessary, services to beneficiaries who were not 
homebound, services that did not have a valid physicians order, and services that did not 
have supporting documentation.  The study found the majority of physicians relied on 
home health agencies to assess their patients needs and to make the homebound 
determination.  The audit report suggested that inadequate physician involvement was a 
leading cause of the unallowable services identified in the audit.  In a follow-up audit 
conducted in 1998, Review of Medicare Home Health Services in California, Illinois, 
New York, and Texas, A-04-99-01194, the OIG found that the error rate for inappropriate 
home health services dropped to 19 percent; however, the error rate associated with 
payments for these services was higher at 30 percent. 
Related Work 
The American Medical Association (AMA) released a report in 1993 discussing two 
potential conflicts of interest physicians may come across in referring patients to home 
health care.  In some instances, home health agencies may offer payment to physicians for 
their services or referrals.  The AMA advises physicians not to accept these payments, as 
they may compromise physician objectivity in choosing the most appropriate home health 
agency for their patients needs.  Physicians may also come across situations where they 
may want to refer patients to agencies in which they have an ownership interest.  The 
6 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  AMA advises against this practice of self-referral unless the physician provides direct care 
under the agency or there is a community need for the agency and no alternative financing 
is available.  In 1998, the AMA published a report entitled Medical Management of the 
Home Care Patient: Guidelines for Physicians.  It provides an overview of the 
physicians role in home health care and discusses related Medicare policies and fraudulent 
practices. 
A 1998 report released by the Massachusetts Medical Society, entitled Physicians 
Practice Patterns, Attitudes Towards, and Perceptions of Home Health Care, found that 
physicians in their sample were less than moderately involved in the selection of the home 
health agency.  These physicians also reported a low level of knowledge of home care 
payments and regulations.  At the same time, the physicians acknowledged the importance 
of improving physician education in these areas.  Very few physicians reported submitting 
care plan oversight charges.  The majority were not aware they could charge for oversight 
services.  Only 39 percent of sample respondents reported making home visits.  The study 
suggested that while respondents are not satisfied with their current level of oversight, 
and would like to see a greater level of control, they dont wish to undertake this 
themselves. 
METHODOLOGY 
We obtained data for this study from a number of different sources.  These included the 
following: a physician mail survey; a mail survey of home health care beneficiaries; a 
telephone survey of home health agencies; and, CMS claims data. 
We conducted our mail surveys subsequent to the implementation of the home health 
prospective payment system which went into effect on October 1, 2000.  In addition, our 
physician survey was conducted after the implementation of the calendar year 2001 
physician payment fee schedule, which authorizes payments for certification and re-
certification of the home health plan of care. 
Sample Selection 
Using the CMS National Claims History File, we identified all Medicare beneficiary HHA 
claims for services begun during the last 6 months of calendar year 20004.  Based on CMS 
data, we identified all physicians who signed the home health plan of care associated with 
the claim.  To assure we had physicians that refer beneficiaries to home health with some 
frequency, we eliminated physicians who signed home health plans of care for only one 
beneficiary during the six month period.  After eliminating duplicate physicians and invalid 
provider numbers, we then selected a simple random sample of 600 physicians. 
4This sample was pulled during the third week of February 2001. 
7 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  Physician Mail Survey 
A self-administered mail questionnaire was sent to all 600 sample physicians.  Our 
questions focused primarily on the experiences of physicians when ordering and 
overseeing Medicare home health services; obstacles they face in performing this function; 
whether the availability of additional Medicare payments provides sufficient incentive for 
physicians to be more involved in the provision of home health services to their patients; 
and, how, if at all, the physician role has changed since the implementation of the home 
health prospective payment system.  In order to maximize our response rate, we sent a 
letter prior to the questionnaire, reminder postcards after the questionnaire, and a second 
mailing of questionnaires to non-respondents.  We received responses back from 349 
physicians, giving us an overall response rate of 58 percent. 
Beneficiary Mail Survey 
For this study, we included a limited number of questions as part of a larger self-
administered mail questionnaire being sent by the OIG to a separate sample of Medicare 
home health beneficiaries.  This questionnaire was sent to 700 beneficiaries with a usable 
address.  Our questions focused primarily on beneficiary experiences with their physicians 
at the time home health care was ordered, as well as during their home health episode. 
The overall response rate for that survey was 74 percent. 
Home Health Agency Survey 
We conducted telephone interviews with a random sample of 30 home health agencies. 
Our questions focused on their perception of the physicians role in home health care. 
Due to the small sample size we consider these data descriptive in nature and do not 
project to the universe based on this data. 
Analysis of Claims 
We used the five percent sample of Part B claims from CMS National Claims History File 
to determine how often physicians bill for care plan oversight.  Our analysis involved 
looking at the percentage of HHA claims that had a physician care plan oversight bill 
associated with them in 1999 (as a proportion of all home health claims in that year).  We 
also analyzed data from prior years to identify whether this percentage is increasing, 
decreasing, or remaining constant.  Similarly, we identified the percentage of physicians 
who submitted claims for the certification or re-certification of care plans in the first few 
months of 2001, the year these payments became available. 
In addition, we used National Claims Data to determine how familiar physicians are with 
their patients prior to signing their plans of care, as well as how much they remain 
involved with patients after they start receiving home health care.  To do this, we 
identified all beneficiaries who started home health services in the last 6 months of 2000. 
We analyzed the number of patient visits billed to Medicare by the physician who signed 
the plan of care in the 12 month period preceding their signature on the care plan. 
8 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  Similarly, we analyzed physicians involvement once home health services began by 
looking at the number of patient visits billed by the physician for the duration of the 
patients stay in home health, up to 3 months5. 
Limitations 
Our sample selection methodology focused on physicians who signed multiple plans of 
care in an effort to ensure that respondents had sufficient experience to answer our 
questions.  Therefore, our results are projectable to physicians who sign more than one 
plan of care in a given 6 month period. 
In addition, for all analyses where CMS claims data are utilized, data for more recent 
periods will be somewhat less complete than prior period data. 
5Please note that not all beneficiaries included in this analysis received home health care for the entire 3 
month period. 
9 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  F I N D I N G S  
Physicians play a key role in Medicares home health benefit 
A majority of physicians have had contact with patients prior to signing the plan 
of care 
Virtually all physicians in our sample (97 percent) report that they have some familiarity 
with most of the patients for whom they sign a home health plan of care.  A majority of 
Medicare patients (82 percent) concur with physicians, reporting that they know the 
doctor who ordered their home health.  Recent claims data are consistent with the 
reported experiences of physicians and patients.  These data show that 85 percent of all 
beneficiaries saw the physician who signed their plan of care at least once in the 12 months 
prior to the start of their home health care.6  At present, there is no requirement that 
physicians see patients before signing their care plan. 
Physicians help determine and initiate home health services 
Most physicians are involved in identifying the specific home health services their patients 
need.  Over half report working jointly with home health agencies or hospital staff to 
determine the services their patients will receive.  Another quarter say they do this 
themselves, while 15 percent leave the determination of what a patient needs to the home 
health agency. 
Many physicians are also involved in finalizing the initial plan of care.  Just under a third 
report they sometimes make changes to the plan of care.  The majority of those who make 
changes do so when the home health agencies include different services than they think are 
appropriate.  They also make changes to plans of care when they believe there are too 
many or too few services listed, or when a change in medication or patient needs occurs. 
Recent changes in Medicare guidelines allow home health agencies to begin services 
immediately after receiving a physician verbal order or a signed prescription.  Previously, 
agencies were required to wait for physicians to sign the plan of care to commence 
services.  About half of physicians report they currently initiate services by providing a 
verbal order describing the services needed with just under a quarter saying they are 
providing a prescription.  Only 21 percent say they sign the plan of care to initiate 
services7.  The 30 home health agencies we spoke with also report that most physicians 
are now providing a verbal order to initiate home health services.  It should be noted that 
all physicians are still required to sign the finalized care plans for their Medicare patients. 
6Note that any additional claims that were submitted by physicians after 2/28/01 are not reflected in this 
analysis, possibly understating this percentage. 
7Nine percent report that they initiate services in some other way. 
10 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  Physicians remain involved with their home health patients 
Almost all physicians (86 percent) report that they see their patients at least once a month 
while they are receiving home health services.  These visits include both office and home 
visits.  Claims data generally support the reported experiences of physicians.  Claims data 
indicate that during the 3 month period following the start of home health care, at least 60 
percent of beneficiaries received services from the physician who signed their plan of 
care.8 
Additionally, physicians report they spend some time communicating with home health 
agencies and reviewing their patients records.  About a third say they spend at least half 
an hour a month doing this for each patient, while 60 percent spend less than half an hour. 
Only 7 percent report that they do not spend any time communicating with home health 
agencies or reviewing their patients records. 
Overall, physicians are satisfied with the home health care their patients are receiving. 
Fifty-four percent report they are somewhat satisfied with their patients care, while 
another 37 percent report they are very satisfied. 
Few urban and rural differences 
Because there is some concern that the experiences of home health patients differ by 
geographical region, we looked for differences in opinions and reported practices of the 
physicians in our sample that practice in rural versus urban areas.  We found only two 
statistically significant differences in our key findings.  First, more rural physicians report 
making the initial determination that Medicare home health services are needed, while 
more urban physicians report that someone other than the physician makes this 
determination.  Secondly, more rural physicians report they would prefer that the 
oversight of home health patients be done by physicians, while more urban physicians 
report they would prefer the oversight role be performed by someone else.  (See Appendix 
B for more information.) 
Physicians report a lack of knowledge of Medicare home 
health rules 
As indicated earlier, the Centers for Medicare and Medicaid Services require that all 
Medicare home health patients be certified by a physician as homebound to be eligible for 
home health services.  However, as indicated in the chart on the next page, 38 percent of 
physicians report that they are unclear on the Medicare criteria for homebound.  In 
addition, just under half of all Medicare physicians report that they are not clear on the 
8Note that additional claims that were submitted by physicians after 2/28/01 are not reflected in this 
analysis possibly understating this percentage and not all beneficiaries received home health services for the entire 
3 month period. 
11 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  definition they are expected to apply when certifying that planned home health services are 
medically necessary.  Although Medicare does not explicitly require physicians to certify 
that a given patient has a skilled need or that a given medical service is, in fact, covered 
by Medicare, in practice there is a need for physicians to have knowledge of Medicare 
rules in these areas.  However, a full 80 percent report that they are unclear on what 
services are covered by Medicare and 50 percent do not know what Medicare considers a 
skilled need. 
* Note: percentages do not total 100 in each case due to non-response  Source: OEI physician survey, 2001. 
Physicians rely on several sources for home health information 
We asked physicians what guidance on home health, if any, had been most helpful to them. 
It is worth noting that the majority of physicians do not obtain their information from 
CMS.  The top three answers they gave were: guidance from hospital staff such as 
discharge planners (76 percent), guidance provided by home health agencies (55 percent), 
and guidance from physician publications that cover home health issues periodically (16 
percent).  At present, only 11 percent of physicians report relying on program memoranda 
issued to physicians by Medicare Carriers.  The number of doctors that report getting 
information from the Medicare website or Medicare conferences is also low, 1 percent and 
5 percent respectively.  When we asked physicians what suggestions they have for future 
initiatives to provide them with guidance about Medicare home health rules, just over 20 
percent volunteered that they would like simplified information and more concise 
literature. 
12 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  Physicians believe not all Medicare expectations of them can 
be met 
Under the home health prospective payment system, the Centers for Medicare and 
Medicaid Services are relying on physicians to fulfill two distinct expectations.  First, 
physicians are required to certify that Medicare beneficiaries are homebound and have a 
medical need for services.  Secondly, because agencies are now paid fixed rates, possibly 
providing an incentive for some home health agencies to limit services, physicians are 
being relied upon to help ensure that patients get all of the care for which they are eligible. 
A recent CMS program memorandum indicated that physician responsibility in the PPS 
environment is to be the determiner of the patients health care needs and advocate for the 
services required to meet those needs. 
Most physicians know what CMS expects of them but many believe they are not 
able to provide this oversight 
We asked physicians a number of questions about the functions Medicare expects them to 
perform with regard to home health patients.  In addition, we asked them whether they 
believe they are able to perform these functions.  There is wide discrepancy between what 
physicians believe they are expected to do and what they believe they are able to do.  For 
example, while 83 percent of physicians believe that Medicare expects them to ensure that 
only medically necessary services are on the plan of care, only 48 percent believe they are 
able to ensure that this is the case.  There is also a large difference between the percentage 
of physicians that believe Medicare expects them to ensure that home health patients are 
homebound and the number that believe that they are able to ensure this (59 versus 26 
percent).  Chart B, below, provides additional information on the differences that exist 
between what physicians believe Medicare expects them to do and what they believe they 
are able to do. 
Source: OEI physician survey, 2001 
13 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620 Interestingly, the 30 home health agencies we spoke with were more likely to say that 
physicians can fulfill CMS expectations than physicians were.  Returning to the issue of 
whether physicians are able to ensure that only medically necessary services are on the 
plan of care, 24 of the 30 home health agencies we spoke to say yes.  As indicated 
above, only 48 percent of physicians say they are able to do this.  Sixteen of the home 
health agencies report that physicians can ensure patients are homebound, while only 26 
percent of physicians report that this is the case. 
Concerns over physician liability 
In addition to reporting concerns about their ability to meet CMS oversight expectations, 
some physicians are confused about the degree to which they can be held liable for 
inappropriate certifications.  One quarter of physicians report that they have heard about 
the 1999 Fraud Alert issued by the Office of Inspector General that addresses physician 
liability for home health certification.  Of physicians aware of this directive, 24 percent 
volunteer concerns about being held personally liable for well intentioned certifications of 
their patients home health care.  Another 10 percent report that they have been made 
nervous by the Fraud Alert. 
In addition to finding concerns among physicians who are aware of the Fraud Alert, we 
found a large degree of misunderstanding on the part of all physicians.  Only 25 percent 
correctly report that physicians can be held liable for inappropriate certifications only 
when they knowingly sign false or misleading certifications.  The balance of physicians 
report incorrectly that they can be held liable for any inappropriate certifications they sign 
(41 percent) or that they have no clear understanding of what their liability may be (27 
percent). 
Physicians divided on who should perform the oversight role 
Despite the fact that physicians report reservations about their ability to fulfill the role 
Medicare expects of them, there is no consensus on the issue of who should perform this 
function.  Forty-one percent of physicians report that they would like to see independent 
case managers, an unspecified person, home health agency medical directors, or 
independent ombudsman perform this function9.  However, 56 percent report that the 
oversight of home health patients should not be done by someone other than the physician. 
9Three percent of physicians did not respond to this question on the survey instrument. 
14 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  Over half of Medicare physicians are unaware of new home 
health prospective payment system 
As indicated earlier, under the prospective payment system, physicians are being relied 
upon to ensure that patients get all the care for which they are eligible.  We asked 
physicians whether or not they were aware of the new prospective payment system. 
About 60 percent of physicians report they have never heard of the Medicare home health 
prospective payment system (PPS), which went into effect October 1, 2000.  Physicians 
who have heard of it, report having learned about it through physician publications, home 
health agencies, and hospital staff. 
We asked physicians who are aware of PPS if the implementation of the prospective 
payment system has changed their interactions with home health agencies or Medicare 
beneficiaries.  Seventy-three percent report that it has not affected their interactions with 
agencies or beneficiaries. 
Effectiveness of physician payments is questionable 
Beginning in 1995, physicians were permitted to bill for care plan oversight.  Reasons for 
the implementation of this payment include a desire on the part of the Centers for 
Medicare and Medicaid Services to recognize work physicians were performing, as well as 
to encourage additional physician involvement.  Recent claims data indicate that physicians 
bill for care plan oversight at a rate of less than 3 percent of total home health claims. 
This low billing rate indicates that, at present, there is little willingness on the part of 
physicians to pursue these payments.  Historic data show that these billings have been 
consistently low since they became available in 1995. 
Over two-thirds of all physicians report that they either do not know what constitutes 
home health care plan oversight or are not aware that they can bill for it.  Of those 
physicians that report being aware that they can submit these bills, 82 percent say they 
choose not to.  Physicians report that there is too much paperwork involved in submitting 
these claims and the payment amount is not high enough to make it worthwhile.  In 
addition, many claim that it is unclear what Medicare requirements physicians must meet 
in order to qualify for reimbursement.  In fact, a full one-third of the small number of 
physicians who are submitting bills to Medicare for home health care plan oversight report 
being unclear about requirements. 
A similar story is unfolding with regard to newly available payments for certification and 
re-certification of the plan of care.  We analyzed early data on physician billings for these 
payments.  Data for the first quarter of 2001 reveal that physicians billed for these 
payments at a rate of less than 3 percent each.10  Ninety percent of physicians report being 
10Based on physician claims received by April 30, 2001.  Denominator is total number of Medicare home 
health claims submitted for the same period. 
15 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  unclear on the requirements associated with certification/re-certification payments at the 
present time.  Interestingly, despite a low initial billing rate and confusion about billing 
requirements, one-third of physicians report that they plan to submit bills to Medicare for 
these payments in the future. 
We asked home health agencies if they believe the amount of time physicians spend with 
their home health patients has increased, decreased or remained the same since CMS 
1995 implementation of the care plan oversight payment.  Fifteen agencies say it has 
remained the same; nine say the amount of time physicians spend with their home health 
patients has increased; one agency reports that the amount of time has decreased; and, five 
say they dont know. 
Physicians report desire for simplified rules and cite obstacles to more effective 
physician involvement 
As indicated earlier, just over 20 percent of physicians volunteered that they would like  to 
see simplified Medicare rules related to their role in certifying home health and more 
concise guidance on the subject. When asked what obstacles they see to increased 
physician involvement in monitoring Medicare home health patients, physicians cite 
burdensome paperwork, a lack of time, and limited Medicare reimbursement. 
16 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  R E C O M M E N D A T I O N S  
Physicians are currently playing an important role in initiating, certifying and monitoring 
the care for Medicare home health beneficiaries.  However, they are doing so despite 
limited knowledge of key Medicare rules as well as discomfort with CMS expectations. 
At present, the availability of reimbursement for their oversight role does not seem to be 
having a significant impact on physicians who care for Medicare home health patients. 
In order to address physician concerns and improve the Medicare home health services, 
we recommend the following. 
<	  The Centers for Medicare & Medicaid Services should review relevant 
informational materials available to Medicare physicians to determine areas where 
improvements and clarifications can be made. 
<	  The Centers for Medicare & Medicaid Services should establish a workgroup 
composed of physicians, home health representatives, and departmental designees, 
or utilize an existing workgroup such as the Practicing Physicians Advisory 
Council or the Physician Regulatory Issues Team to discuss issues related to 
Medicare home health care.  We offer the following issues for consideration by the 
workgroup. 
-	  The need for more effective and widespread home health education for 
physicians; 
-	  Further clarification of payment and coverage policies, including the home 
health definitions for homebound and medically necessary; 
- The simplification of home health certification forms; 
-	  An analysis of the costs and benefits associated with the promotion of 
physician home visits; 
-	  The possibility of requiring home health agencies to employ medical 
directors; 
-	  The consideration of whether CMS oversight expectations of physicians can 
be realistically met; and, 
-	  The creation of a system enabling patients to appeal if they feel they are 
receiving inadequate care. 
17 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  COMMENTS 
We received comments on our draft report from several physician and home health 
organizations: The American Academy of Home Care Physicians, The American College 
of Physicians-American Society of Internal Medicine, The American Medical Association, 
and The National Association for Home Care.  These organizations generally agreed with 
our findings and recommendations.  They also provided specific suggestions on how to 
increase physician understanding of the Medicare home health benefit and to promote 
further physician involvement with their home care patients.  (We include these 
organizations' comments in full in Appendix E.) 
We also received comments on our draft report from the Centers for Medicare & 
Medicaid Services (CMS).  The CMS concurred with our findings and also made a 
number of technical comments that we incorporated into the report when appropriate. In 
addition, CMS had two methodological concerns.  First, they expressed concern that our 
sampling time frame did not include a long enough period of time when the prospective 
payment system (PPS) was in effect.  We acknowledge that our work occurred in the early 
stages of PPS implementation.  However, it is important to note that physician knowledge 
of PPS is only one issue among several that we sought to address.  Second, CMS stated 
that our sample may be biased against respondents who have had enough experience 
signing plans of care.  We were also concerned about this.  Therefore, in our 
methodology we included only physicians who signed two or more home health plans of 
care during the 6 month sampling time frame. 
18 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  APPENDIX A 
Selected List of Recent Office of Inspector General 
Home Health Inspections 
Office of Inspector General, US Department of Health and Human Services, The Physicians 
Role in Home Health Care, OEI-02-94-00170, June 1995. 
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, Medicare 
Beneficiary Access to Home Health Agencies 2000, OEI-02-00-00320, September 2000. 
Office of Inspector General, US Department of Health and Human Services, Adequacy of Home 
Health Services: Hospital Re-Admissions and Emergency Room Visits, OEI-02-99-00531, 
September 2000. 
Office of Inspector General, US Department of Health and Human Services,  Medicare Home 
Health Services: Survey and Certification Deficiencies, OEI-02-99-00532, September 2000. 
19 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  APPENDIX B 
Chi-Square Test for Urban/Rural Differences 
We computed Chi-square values for differences in physicians geographical place of work.  All 
variables were analyzed at the 95 percent confidence level.  As shown in the table below, only two 
variables showed statistically significant differences. 
Chi-Square Values for Testing Significance 
of Geographic Place of Work 
Degrees of 
Variable  Percents  Freedom  Chi-Square  Probability  Significant? 
Determination that patient  Rural Urban 
needs home health:  1*  4.45  .03  Y 
Physician  71%  57% 
Non-physician  29%  43% 
Preference of person  Rural Urban 
responsible for oversight:  1*  4.00  .05  Y 
Physician  68%  55% 
Non-physician  32%  46% 
Familiarity with patients  3  1.65  .65  N 
prior to home health 
Time spent each month  1*  2.48  .12  N 
with a typical home health 
patient 
Awareness of care plan  3  0.35  .95  N 
oversight payment 
Knowledge of home health  1*  1.97  .06  N 
PPS 
Ability to ensure patient is  3  5.56  .13  N 
homebound 
* When testing for urban rural differences, response categories were combined in some 
instances in order to better understand any differences. 
20 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  APPENDIX C 
Confidence Intervals For Key Findings * 
We calculated confidence intervals for key findings for physicians.  The point estimate and 95 
percent confidence interval are given for each of the following: 
Point 
Key Findings  N  Estimate 
Virtually all physicians report that they have some 
familiarity with the patients for whom they sign a home  343  97%  +/- 1.8 
health plan of care. 
Over half report working jointly with home health  343  55%  +/- 5.3 
agencies or hospital staff to determine services for their 
patients. 
Almost all physicians see their patients at least once a  343  86%  +/- 3.7 
month while they are receiving home health services. 
Thirty-eight percent of physicians report that they are  343  38%  +/- 5.1 
unclear on the Medicare criteria for "homebound." 
Eighty-three percent of physicians believe that Medicare 
expects them to ensure that only medically necessary  343  83%  +/- 4.0 
services are on the plan of care. 
Only 48 percent of physicians believe they are able to  343  48%  +/- 5.3 
ensure that only medically necessary services are on the 
plan of care. 
Fifty-nine percent of physicians believe Medicare expects  343  59%  +/- 5.2 
them to ensure that home health patients are homebound. 
Twenty-six percent of physicians believe they are able to  343  26%  +/- 4.6 
ensure that home health patients are homebound. 
Of the physicians who are aware of the Fraud Alert, 24 
percent volunteer concerns about being held personally  84  24%  +/- 9.1 
liable for well intentioned certifications of their patients 
home health care. 
Twenty-five percent of physicians correctly report that 
physicians can be held liable for inappropriate  343  25%  +/- 4.6 
certifications only when they knowingly sign false or 
misleading certifications. 
* Note: The N values above include item non-respondents. Item non-respondents were included in the denominator 
used to calculate point estimates. These item non-respondents do not include those survey respondents who were 
instructed to skip the question at issue. In the majority of the findings above, item non-respondents numbered less 
than 10. 
21 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  APPENDIX D 
Physician Non-Respondent Analysis 
We tested for the presence of any non-response bias in our sample.  For this analysis, a physician 
who did not complete and return the survey is a non-respondent.  We dropped six physicians from 
the overall sample who told us they did not sign plans of care. 
To test for non-response bias in our sample, we analyzed two variables which might influence 
whether an individual would respond to the survey or that might affect his or her responses: 
geographical place of work and the number of home health plans of care signed by the physicians 
within a given 6 month period. 
For the purpose of this analysis, geographical place of work was divided into urban and rural.  For 
the number of home health plans of care signed within a given 6 month period, we divided the 
physicians into three categories: 
1.  Physicians with an average of less than one plan of care signed a month, 
2.  Physicians with an average of one but less than two plans of care signed a month, and 
3.  Physicians with an average of two or more plans of care signed a month. 
These categorical variables were tested using Chi-square with the appropriate degrees of freedom. 
In order for the results to be statistically significant at the 95 percent confidence interval, the Chi-
square value must be higher than 3.84 with 1 degree of freedom. 
The results of this analysis are presented in Tables A and B.  The Chi-square values given in the 
tables provide a test of difference between the distribution of respondents and of non-respondents 
for the variable of interest.  Also provided in the tables are the response rates by the different 
values of the variables. 
Tables A and B show no statistically significant differences between respondents and non-
respondents for either geographical place of work or the number of home health plans of care 
signed by the physicians. 
22 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  Table A 
Geographical Place of Work* 
Respondents  Non-Respondents  Total  Percent 
Urban  252 (46%)  193 (35%)  445  81% 
Rural  70 (13%)  37  (7%)  107  19% 
Total  322  230  552  58% 
Chi-square= 2.74 
Degrees of freedom= 1 
*
 The overall sample size is only 552 because there were no matches on the urban/rural indicator for 42 
physicians. 
Table B 
Average Home Health Plans of Care Signed a Month 
Respondents  Non-Respondents  Total 
< 1 /month  206 (35%)  139 (23%)  345  58% 
1-2 /month  83 (14%)  66  (11%)  149  25% 
> 2 /month  54 (9%)  46  (8%)  100  17% 
Total  343  251  594  58% 
Chi-square= 1.38 
Degrees of freedom= 2 
23 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620  APPENDIX E 
Comments 
In this appendix, we present in full the comments from the Centers for Medicare and Medicaid 
Services, the American Academy of Home Care Physicians, the American College of 
Physicians-American Society of Internal Medicine, the American Medical Association, and the 
National Association for Home Care. 
24 
The Physicians Role in Medicare Home Health 2001  OEI-02-00-00620