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OEI-02-94-00170  OFFICE  OF  INSPECIOR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Services, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE  OF  AUDIT  SERVICES 
The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout  the Department. 
OFFICE  OF  INVESTIGATIONS 
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE  OF  EVALUATION  AND  INSPECTIONS 
The OIGSOffice of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
This report was prepared  in the New York Regional Office under the direction of the then 
Regional Inspector General Thomas F. Tully and Alan S. Meyer, Ph.D. the present Acting 
Regional Inspector General, Office of Evaluations and Inspections.  Participating in this 
project were the following personnel: 
New York Region  Headquarters 
Renee Dunn, P.T. (Project Leader)  Jennifer Antico 
Lucille M. Cop, R.N.  Barbara R. Tedesco 
Nancy Harrison  Brian P. Ritchie 
Linda M. Moscoe 
To obtain a copy of this report, contact the New York Regional Office at (212) 264-1998  Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
THE  PHYSICIANS  ROLE  IN  HOME 
HEALTH CARE  EXECUTIVE  SUMMARY

PURPOSE 
To  describe  the  current  role  of the  physician  in Medicare  home  health  care. 
BACKGROUND 
Medicare  defines  home  health  care  as certain  services  provided  under  a physicians

plan  ofcarein  theresidence  ofa  homebound  patient.  Care  can consist  of services

such as skilled  nursing  services,  home  health  aide  services,  physical  and  occupational

therapy,  and  medical  services.  Typically,  the  care  is provided  by home  health

agencies,  home  care  aide  organizations  or hospices.

Little  data  exist about  the  current  nature  of physician  involvement  in home  health

care.  Services  a physician  may provide  include:  managing  medical  problems,

preparing  and  reassessing  the  treatment  plan,  and  documenting  medical  records.

Concerns  have  been  raised  based  on audits  of certain  home  health  agencies  and

anecdotal  information  that  physicians  are  not  appropriately  involved  in planning  and

coordinating  home  health  services.

Medicare  covers  home  visits by a physician  the  same  as any other  physician  visit.

Until  recently,  it did not  separately  cover  the  services  of physicians  for managing  the

home  health  care  of their  patients.  In the  December  8, 1994 Federal  Register,  HCFA

issued  anew  regulation  providing  separate  payment  for physician  care  plan  oversight

services.

The  HCFA  administrator  has asked  the  Inspector  General  to assist HCFA  in its effort

to examine  the  physician  role  in home  health  care.  In conducting  this inspection  we

sent  a questionnaire  to a random  sample  of 1000 agencies  stratified  by census  regions.

The  agencies  were  asked  about  their  relationship  with their  patients  physicians  and

the  physician  role  in home  health  care.  We  received  700 completed  surveys.

Subsamples  of 96 agencies  and  85 physicians  were  interviewed  by telephone  to  obtain

more  in-depth  answers  about  the  present  physician  role,  Also, we reviewed  1992

beneficiary  histories  for  191 beneficiaries  to determine  whether  the  physician  who

signed  the  plan  of care  billed  for visits to the  beneficiary  and,  if so, how often.  All of

our  data  collection  occurred  prior  to the  regulation  providing  separate  payment  for

physician  plan  care  oversight  services.

FINDINGS 
Physicians Are Most Involved in Refemng Patienfi, Approving Plans of Care, and 
Monitotig  the fiogress  of Complex Patients 
.  Physicians  are  usually  involved  in initiating  referrals  to home  health  agencies. 
i  .	 Most  of thesample  physicians  hadarelationship  with thepatient  for whom 
they  signed  a plan  of care. 
.  Physicians  review  and  sign the  plans  of care. 
.  Physicians  are  most  involved  when  caring  for complex  patients. 
Physicians are Less Involved in Coordinating Semces, Viiiting Patients At Home  and 
Participating in Interdkciplinary Conferences 
  Physicians  feel  they  coordinate  their  patients  home  care;  agencies  disagree. 
.	 Physicians  do not  usually take  part  in interdisciplinary  conferences  or make 
home  visits. 
Both Agencies  and Physicians Identifi some  Obstaclm and Issues Related to the 
Physician Role 
	 Communication.  Most  agencies  and  physicians  believe  they  communicate  well 
with each  other.  However,  physicians  feel  the  agencies  could  improve 
communication  by calling  at scheduled  times  and  having  one  nurse  responsible 
for contacting  the  physician.  Agencies  say having  a medical  director  would 
improve  communication. 
	 Plans of Care.  Physicians  and  agencies  generally  agree  that  physicians  should 
continue  to sign plans  of care;  agencies  feel  it is not  always necessary  for 
recertification  or for  chronic  patients.  Three-quarters  of the  physicians  consider 
their  arrangement  for completing  and  signing the  plans  of care  satisfactory. 
	 Burdensome  Paperwork.  Sixty-five percent  of agencies  and  51 percent  of 
physician  respondents  find the  process  of reviewing  and  signing plans  of care 
burdensome.  Physicians  indicate  that  there  is too  much  paperwork  and  find it 
difficult  to find  the  information  on the  plan  of care  that  they  consider 
important. 
	 Physician Awareness  and Education.  Some  agencies  feel  that  physicians 
awareness  and  education  in home  health  care  is inadequate,  that  some 
physicians  lack  an understanding  of the  home  health  benefit. 
RECOMMENDATIONS 
We  support  the  work  of HCFAS home  health  work  group  in reviewing  and 
restructuring  the  home  health  benefit.  As home  health  care  continues  to expand, 
there  will be  ongoing  discussions  about  the  physician  role.  The  HCFA  will be  pressed 
ii  to continue  its leadership  role  to undertake  appropriate  activity  and  better  define  and 
tell what  the  physician  role  should  be.  Therefore,  we recommend: 
	 The  HCFA  should  continue  its efforts  to change  the  plan  of care  to ensure  it 
conveys  critical  information  to caregivers  and  relieves  unnecessary  burden  from 
physicians. 
.	 The  HCFA  should  strengthen  its efforts  to educate  both  agencies  and 
physicians  about  its policies  regarding  the  physicians  role  in home  health  care. 
Issues for Further Study 
Based  on our  findings  and  on comments  received  on our  draft  report,  there  are  a 
number  of issues  about  the  role  of physicians  which  require  further  study. 
	 Should  other  professionals  such as the  patient  care  coordinator,  home  health 
nurse,  physical  therapist,  occupational  therapist,  speech  therapist  or social 
worker  take  on more  responsibility  for certain  aspects  of home  health  care?  If 
so, how does  this impact  the  physicians  role? 
	 Should  the  complexity  of the  case  determine  physician  involvement?  If so, 
should  the  physician  be  more  involved  in complex  cases  and  less involved  in 
chronic  cases? 
	 Should  home  health  reimbursement  be  different  for  different  levels  of care?  If 
so, should  chronic  care  cases  be  reimbursed  a lower  level  than  those  more 
complex  cases? 
	 Does  payment  to physicians  for care  plan  oversight  lead  to greater  physician 
involvement  ? 
COMMENTS

Comments  on the  draft  report  were  received  from  HCFA,  ASPE  and  the  Acting 
Assistant  Secretary  for Management  and  Budget  (ASMB.)  Suggestions  for additional 
information  and  clarifications  of the  text have  for the  most  part  been  incorporated 
into  the  final report.  The  actual  comments  received  are  included  in Appendix  A. 
The  HCFA  defers  action  on our  recommendations  at this time.  Nevertheless,  we 
appreciate  their  recognition  of the  importance  of our  recommendations  and  support 
their  efforts  towards  developing  a Core  Standard  Assessment  Instrument  which would 
significantly  impact  on the  requirements  for the  plans  of care.  We  look  forward  to 
their  decisions  on our  recommendations  after  issuance  of the  final report. 
The  HCFA,  ASPE,  and  ASMB  all commented  on physician  payment  for care  plan 
oversight.  We  recognize  that  HCFA  is now reimbursing  physicians  for  care  plan 
... 
111  oversight.  We plan  a follow-up  study  to  see  whether  this has lead  to greater  physician 
involvement  and  prudent  utilization  of the  home  health  benefit  as HCFAS  comments 
suggest. 
The  ASPE  suggests  that  further  study is needed  to examine  the  actual  behavior  of 
physicians  and  other  providers.  We  support  further  study of physicians  in home  health 
care  that  could  contribute  useful  information.  We  added  a new section  to our  report 
on issues for further  study 
Both  HCFA  and  ASPE  expressed  concerns  about  specific  evaluative  issues  that  fall 
outside  the  scope  of this study.  This  report  provides  descriptive  rather  than  evaluative 
information.  We  modified  the  report  to make  this clearer. 
The  ASPE  raised  concerns  about  bias in self-reported  information.  This is always a 
problem  in these  kinds  of studies.  We  had  addressed  it in our  original  design  by 
obtaining  information  from  many  diverse  sources.  We  obtained  information  from  both 
home  health  agencies  and  physicians.  We  also obtained  patient  payment  records  to 
establish  whether  a relationship  existed  between  patients  and  the  physicians  who 
signed  the  plans  of care.  We  provide  a methodology  section  for the  reader  to draw 
his/her  own conclusions. 
The  ASPE  requested  that  we include  study instruments  in our  reports.  We  usually  do 
not  do this, but  they  are  available  upon  request. 
iv  TABLE  OF  CONTENTS 
PAGE 
EXECuT~  S~Y 
moWcTmN  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 
I

F~INGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...6

  Physicians&e  Most  Involved  in Initiating  Care  . . . . . . . . . . . . . . . .

. . . . . . .m.  6

.  Physicians  Are  Less  Involved  in Coordinating  Services  . . . . . . . . . . . . . . . .

. . . .  8

  Agencies  and  Physicians  Identify  Some  Obstacles  . . . . . . . . . . . . . . . .

. . . . . . .  9

~COMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  II

APPENDIX 
A  Comments  . . . . . . . . . . . . . .

. . . . ..$  .OO. . . . . . . . . . . . . . . . . . . ..  OOOO
.  A-1

v  INTRODUCTION 
PURPOSE 
To  describe  the  current  role  of the  physician  in Medicare  home  health  care. 
BACKGROUND 
Home  health  care  allows people  with limited  independence  to remain  in their  homes. 
The  American  Medical  Association  (AMA)  defines  it as the  provision  of equipment 
and  services  to the  patient  in the  home  for the  purpose  of restoring  and  maintaining 
his or her  maximal  level  of comfort,  function  and  health.  Medicare  defines  it as 
certain  services  provided  under  a physicians  plan  of care  in the  residence  of a 
homebound  patient.  Patients  may require  home  care  because  of acute  illness,  long-
term  health  conditions,  permanent  disability  or terminal  illness. 
Home  care  is one  of the  nations  fastest  growing  segments  of health  care.  Patients  are 
living longer,  are  being  discharged  from  the  hospital  earlier  and  receiving  more 
complex  care  in the  home.  This  care  can  consist  of a variety  of services  such as skilled 
nursing  care,  home  health  aide  services,  speech-language  therapy,  physical  and 
occupational  therapy,  medical  services,  medical  supplies  and  durable  medical 
equipment. 
Typically,  home  health  care  is provided  by home  health  agencies,  home  care  aide 
organizations  or hospices.  The  National  Association  for Home  Care  (NAHC) 
identified  a total  of 13,951 home  care  agencies  in the  United  States  as of February 
1993.  Of this total,  more  than  half are  certified  Medicare  home  health  agencies  or 
hospices.  Approximately  6 million  individuals  received  home  care  services  in 1993. 
Skilled  nursing  and  aide  services  were  the  most  frequently  offered  services  by all types 
of providers,  followed  by physical  therapy  and  speech  therapy. 
Physiciim-3role 
Little  data  exist about  the  current  nature  of physician  involvement  in home  health 
care.  Literature  indicates  that  they  are  seen  as the  gatekeepers  of service, 
responsible  for planning  and  supervising  most  home  health  care.  Concerns  have  been 
raised  based  on audits  of certain  home  health  agencies  and  anecdotal  information  that 
physicians  are  not  appropriately  involved  in planning  and  coordinating  home  health 
services.  Some  say physicians  simply sign the  plan  of care  without  reviewing  it or 
without  knowing  the  patient. 
Services  a physician  may provide  include:  making  the  medical  diagnosis  and  managing 
medical  problems;  preparing  a treatment  plan  with short  and  long term  goals;  ordering 
ancillary  personal  care;  prescribing  equipment  and  supplies;  reassessing  the  treatment 
plan;  documenting  medical  records,  and  providing  for 24-hour  physician  coverage.  The  AMA  formed  a Home  Care  Advisory  Panel  in  1987 to consider  educational 
efforts  to assist physicians  in better  understanding  their  role  in the  delivery  of medical 
care  in the  home.  To  increase  such physician  participation,  the  panel  developed 
guidelines  which  outline  how the  physician  should  relate  to the  home  care  patient. 
They  describe  the  role  of the  physician  as including  medical  management,  such  as 
evaluation  and  assessments,  and  communication  and  coordination  of the  services  with 
the  interdisciplinary  team. 
Medicare  home  health  agency  regulations  require  physicians  to sign a plan  of care 
specifying  all services  the  patient  is to receive.  This certification  must  be  updated, 
according  to the  regulations,  every  60 days, but  the  doctor  is not  required  to see the 
patient.  To be  certified  as a Medicare  provider,  each  agency  must  have  a medical 
advisory  board  that  meets  periodically,  and  each  board  must  have  a medical  director. 
The  role  of a physician  is also discussed  in the  Medicare  Hospice  regulations  which 
require  hospices  to have  a physician  medical  director.  As one  of his/her 
responsibilities  this physician  must  be  a member  of the  interdisciplinary  team  who 
discusses  the  plan  of care  with all involved  disciplines,  either  in person  or by 
teleconference. 
Medicare Coverage 
Title  XVIII  of the  Social  Security  Act, Section  1861, authorizes  Medicare  payments  for

home  health  services  under  certain  conditions.  The  care  must  be  provided  by certified

home  health  agencies,  which may be  either  freestanding  or facility-based.  They  can be

voluntary  not-for-profit,  proprietary  or governmental  in nature.

For  Medicare  to reimburse  the  agencies,  beneficiaries  must  be  considered  homebound,

get  services  under  a plan  of care  established  and  periodically  reviewed  by a physician,

and  receive  skilled  care.  For  purposes  of qualifying  for  coverage,  skilled  care  includes:

intermittent  skilled  nursing  services,  physical  therapy  or speech  therapy  services.  Only

if the  patient  requires  one  of these  qualifying  services  may the  patient  then  get  the

services  of an occupational  therapist,  a medical  social worker  or a home  health  aide.

If the  patient  no longer  needs  intermittent  skilled  nursing  care,  physical  therapy  or

speech  therapy,  but  continues  to need  occupational  therapy,  the  beneficiary  remains

eligible  for Medicare  coverage  of home  health  services  for the  duration  of the  need

for occupational  therapy.  However,  a beneficiary  whose  sole need  is for custodial  care

does  not  qualify.

Beneficiaries  pay no coinsurance  or deductibles  for home  health  care  other  than  for

durable  medical  equipment.  Their  claims  are  submitted  to one  of nine  fiscal

intermediaries  known  as Regional  Home  Health  Intermediaries.

Medicare  covers  home  visits by a physician  the  same  as any other  physician  visit.

Until  recently,  it did not  separately  cover  the  services  of physicians  for managing  the

home  health  care  of their  patients,  such as interfacing  with the  home  health  agency  by

2  telephone,  reviewing  medical  records  or signing plans  of care.  These  services  were 
considered  part  of the  physicians  work  involved  in other  services,  such as visits or 
procedures.  In the  December  8, 1994 Federal  Register,  HCFA  issued  a new 
regulation  providing  separate  payment  for physician  care  plan  oversight  services. 
HCFA Activities 
The  HCFA  Administrator  has formed  an internal  task  force  to evaluate  the  home 
health  benefit.  With  more  home  and  community-based  care,  he sees  the  need  to 
improve  and  redesign  the  home  health  benefit  to assure  that  Medicare  beneficiaries 
receive  high quality  and  affordable  home  health  care. 
This  task  force  is expected  to recommend  both  short-term  and  long-term 
improvements  in all aspects  of the  benefit.  It has  discussed  restructuring  the  benefit 
to better  accommodate  the  differing  needs  of the  patients  with  complex,  post-acute 
care  or long-term  custodial  needs,  and  has also discussed  the  role  of the  physician  in 
home  care. 
Other  HCFA  activities  include  ongoing  research  efforts  to improve  the  measurement 
of quality  in home  health  care,  focusing  on outcomes;  revisions  to the  current  plan  of 
care  form;  planned  improvements  to the  survey and  certification  process;  and  studies 
related  to prospective  payment  in home  health  care. 
Q@ce  of Impector  General (OIG)  Home  Health EfforLs 
The  HCFA  administrator  has  asked  the  Inspector  General  to join  in HCFAS efforts 
to examine  home  health  care.  The  OIG  has  developed  a strategic  plan  in response  to 
issues raised  by the  HCFA  administrator.  It focuses  on management,  costs  and 
payments,  compliance  with statutes,  regulations  and  policies,  utilization,  and  outcomes 
of home  health  services. 
The  OIG  has  conducted  an audit  of home  health  agency visits in Florida  to determine 
whether  payments  to these  agencies  met  Medicare  reimbursement  requirements.  The 
preliminary  results  show that  too  often  the  physicians  involvement  is limited  to signing 
the  plan  of care  prepared  by the  agencies  without  proper  evaluation  by the  physician 
of the  patients  medical  needs.  This resulted  in the  agencies  making  their  own 
determinations  about  the  types  and  frequency  of services  the  patients  should  receive 
without  the  guidance  of the  physician. 
Other Surveys 
Aetna  in Florida  surveyed  beneficiaries  who had  received  home  health  care,  primarily 
in the  Southeast,  and  the  physicians  who signed  their  plan  of care.  Their  study 
reported  aggressive  marketing  by some  agencies  to maximize  visits, overutilization  and 
a concern  about  the  quality  of care  rendered.  The  physicians  also indicated  that  many 
beneficiaries  did not  need  skilled  care.  Aetna  is piloting  another  survey which  will  send  an explanation  of benefits  to the  certifying  physicians,  along with  a questionnaire

asking  if the  services  the  agency  billed  for were  appropriate  for that  patient.

In 1990, the  AMA  surveyed  and  interviewed  1,161 family practice  and  internal

medicine  physicians  about  their  involvement  in home  care.  It found  that  physicians

who refer  approximately  three  patients  a month  to a home  health  agency  spend

substantial  amounts  of time  coordinating  the  care  provided  by the  agency.  Rural

physicians  reported  more  involvement  than  their  non-rural  counterparts,  Seventy-five

percent  of the  physicians  interviewed  regarded  a home  visit as important,  but  only half

reported  making  one  or more  home  visits a year.  The  physicians  considered  the

current  payment  level for such visits inadequate;  45 percent  indicated  that  they would

do more  of them  if reimbursements  were  higher.  Eighty  percent  felt  that  home  care

agencies  should  be  used  more  frequently  than  they  currently  are.

METHODOLOGY 
We  identified  the  universe  of 4,461 home  health  agencies  (agencies)  from  the  certified 
agencies  listed  in the  Online  Survey  Certification  and  Reporting  System  (OSCAR)  that 
also, according  to  1992 National  Claims  History,  filed  Medicare  claims  during  1992 for 
a  1 percent  sample  of Medicare  beneficiaries.  From  these,  we selected  a stratified 
random  sample  of 1000 agencies.  The  agencies  were  stratified  by census  regions 
(Northeast,  Midwest,  South  and  West)  with 250 in each  region.  A questionnaire  was 
sent  to the  sample  agencies  asking  about  the  agencys relationship  with  its patients 
physicians,  its satisfaction  with the  physician  role  in home  health  care,  and  how the 
physician  role  may be  strengthened.  The  questions  divided  patient  care  into  three 
categories  defined  as follows: complex  - requiring  intensive  care,  using new 
technologies  (such  as infusion  therapy  or ventilators);  acule  - requiring  skilled  care 
(such  as post  hospital  care  or the  exacerbation  of a chronic  condition);  and  chronic  -
requiring  long term  care  (less intensive  than  acute  care.)  Basic descriptive  information 
on home  health  agencies  was accessed  from  the  OSCAR  file as well as from  the 
agencies. 
We  received  700 completed  surveys within  approximately  one  month  which we 
analyzed.  There  was no response  bias with regard  to region  or ownership,  The 
responses  from  the  agencies  were  tabulated  and  cross-tabulated  by agency  size, region, 
rural/urban  location,  ownership,  facility type  and  complexity  of the  patients  they  serve. 
Few statistically  significant  differences  were  found.  Where  differences  were  found, 
they  are  identified  in the  findings. 
A subsample  of 100 agencies  (25 within  each  region)  was selected  for interviews  by 
telephone  to obtain  more  in-depth  answers  about  the  present  physician  role  in home 
health  care  and  how it can be  strengthened.  All together,  96 representatives  of these 
agencies  were  interviewed.  Unless  otherwise  noted,  when  agency  information  is 
reported,  it is a result  of analysis  of the  700 mail  surveys.  The  information  from 
analysis  of the  agency  subsample  is noted  as such. 
4
 From  claims  filed by the  1000 sample  agencies,  we identified  unique  beneficiary 
physician  combinations.  These  physicians  are  the  ones  who signed  the  plans  of care. 
We  picked  a random  sample  of 200 physicians  from  these  combinations  to interview 
by telephone.  We  asked  them  about  their  current  role  in home  health  care,  their 
current  interaction  with home  care  agencies  and  their  views on how their  role  could  be 
strengthened.  We  interviewed  85 physicians.  We were  unable  to obtain  the  names  of 
10 physicians  from  carrier  or agency  data  and were  unable  to locate  18.  This  left us 
with  a universe  of 172 physicians.  Of the  remaining  non-responding  physicians,  25 
refused  to be  interviewed,  saying they  do not  do interviews  or were  too busy and  62 
did not  return  our  calls, even  after  repeated  contact.  This is a response  rate  of 49 
percent.  While  there  are  no significant  differences  between  the  physician  respondents 
and  non-respondents  relative  to region  or specialty,  we recognize  that  the  low 
physician  response  rate  is a limitation. 
From  the  random  sample  of the  200 physicians,  we identified  the  200 beneficiaries  for 
whom  they  signed  plans  of care.  Due  to the  way the  sample  was selected,  we cannot 
determine  whether  the  plans  were  initial  or recertification.  We  obtained  1992 
beneficiary  histories  for these  beneficiaries.  We  reviewed  them  to determine  whether 
the  physician  who signed  the  plan  of care  billed  for visits to the  beneficiary  and,  if so, 
how often.  Of the  beneficiary  histories,  nine  contained  unusable  data;  thus  we 
reviewed  histories  for  191.  Some  of these  191 histories  appeared  to have  missing  data. 
In those  cases we contacted  the  appropriate  carriers  for additional  information. 
The  confidence  interval  for the  responses  to the  physician  survey using the  lowest 
possible  respondent  number  (79) is plus  or minus  11 percentage  points  at  the  95 
percent  confidence  level.  The  confidence  intervals  for the  agency  survey  at the  95 
percent  confidence  level  are  much  smaller,  always within  5 percentage  points. 
It should  be  noted  that  all of our  data  collection  occurred  prior  to the  regulation 
providing  separate  payment  for physician  care  plan  oversight  services.  We  conducted 
our  review  in accordance  with the  Standards for Inspections  issued  by the  Presidents 
Council  on  Integrity  and  Efficiency. 
.J  FINDINGS

PHYSICIANS  ARE  MOST INVOLVED  IN REFERRING  PATIENTS, 
APPROVING  PLANS  OF CARE, AND  MONITORING  THE  PROGRESS  OF 
COMPLEX  PATIENTS 
Re$ewals to home  health agencti  are usually initiated by physicians either alone or in 
collaboration  with someone  etie 
Agencies  and  physicians  agree  that  physicians  are  involved  in referrals.  Virtually  all 
agencies  (99 percent)  report  that  physicians  participate  in patient  referrals,  often  in 
collaboration  with hospital  discharge  planners. 
Almost  all physicians  say it is usually their  idea,  or a combination  of their  idea  and 
someone  elses, to refer  patients  for home  health  care.  Half  of them  say the  hospital 
discharge  planner  or the  patients  family assists in the  decision. 
The  number  of patients  physicians  refer  varies.  Thirty-eight  percent  of physicians  we 
interviewed  refer  from  one  to five; 32 percent  refer  six to ten,  and  31 percent  refer  11 
to 60 patients  per  month.  Those  physicians  that  refer  the  most  patients  are  more 
likely to be  specialists  in internal  medicine  and  orthopedic  surgery. 
Most of the sample physicians have a reikztionshipwith their home  health pahena 
A review  of 1992 beneficiary  histories  reveals  that  at least  91 percent  of the  physicians 
who signed  the  plan  of care  (either  initial  or recertification)  had  a relationship  with 
the  patient.  Some  of the  remaining  patients  may have  also had  such visits, but  this 
information  was not  available  in the  histories.  For  example,  the  patient  may not  have 
had  Medicare  Part  B or may have  been  in a Medicare  HMO. 
Of the  91 percent  with  a relationship,  more  than  three-quarters  had  four  or more 
visits in 1992.  See table  below. 
Visit Frequency  Percent  of Physicians 
10 or more  visits  29 percent 
7-9 visits  21 percent 
4-6 visits  29 percent 
1-3 visits  21 percent 
6
 Physicians review and sign the plans of care 
Eighteen  percent  ofphysicians  report  preparing  the  plans  of care  themselves.  Ninety-
three  percent  of the  physicians  who  do not  prepare  them  saythey  review  the  plans  of 
care  before  signing them.  Usually  the  agency  or discharge  planner  fills them  out 
according  to the  physicians  orders  or instructions  and  sends  them  to the  physician  for 
signature.  Almost  half  of the  physicians  who review  plans  of care  report  sometimes 
making  changes  before  signing them.  Many  of those  who do not  make  changes 
attribute  it to the  fact  the  plans  of care  have  been  filled  out  exactly  as ordered. 
Virtually  all of the  agencies  (99 percent)  indicate  it is the  patients  personal  physician 
who signs the  plan  of care.  Seventy-seven  percent  of the  agencies  believe  only a 
physician  who  has personally  seen  the  patient  should  sign it. 
Seventy-eight  percent  (66) of the  physicians  state  they  usually  determine  the  types  of 
visit the  patient  gets.  Of the  remaining  19 physicians  who  do not  make  that 
determination,  17 say they  let  the  agency  nurse  or other  professional  make  it.  A lesser 
number  of physicians,  56 percent,  say they  determine  the  number  of visits the  patient 
gets.  For  those  who do not,  89 percent  allow the  agency  nurse  or other  professional 
to make  that  determination. 
Eighty-five  percent  (72) of the  physicians  believe  a physician  should  see  the  patient 
before  signing the  initial  plan  of care.  Only 28 percent  (24), however,  believe  the 
physician  needs  to see  the  patient  before  recerti~ing  the  plan  of care.  Physicians 
report  they  are  more  likely to see  a patient  for recertification  if the  patients  condition 
changes,  rather  than  just  for routine  recertification. 
Some  physicians,  especially  orthopedists  and  surgeons,  say that  their  patients  rarely 
have  home  health  care  long enough  to require  recertification  and  are  usually 
discharged  within  60 days.  Both  physicians  and  agencies  say some  of these  patients 
have  unrelated  medical  problems  requiring  home  care.  Some  physicians  and  agencies 
are  concerned  because  although  the  specialist  has referred  the  patient  to home  care, 
there  are  other  problems  that  should  be managed  by a different  physician,  usually  the 
patients  primary  physician.  One  agency  administrator  says, Specialists  only want  to 
address  one  aspect  of medical  management  and  often  leave  the  patient  without  a 
central  physician  addressing  overall  medical  issues. 
Physicians are most involved when caringfor complex patients 
Both  agencies  and  physicians  have  greater  involvement  with the  complex  patient. 
Seventy-nine  percent  of physicians  say their  complex  patients  require  more  physician 
involvement  than  their  chronic  patients.  The  agencies  agree:  81 percent  say they  are 
in contact  with the  patients  physician  5 or more  times  a month  for complex  patients. 
Communication  is more  frequent  in these  cases  because  it is imperative  the  physician 
knows the  status  of the  case  in order  to prevent  problems.  Most  frequently,  the 
7
 agency  nurse  communicates  with the  physician,  but  other  professionals  may 
communicate  once  or twice  a month. 
PHYSICIANS  ARE  LESS INVOLVED  IN COORDINATING  SERVICES, 
VISITING PATIENTS  AT HOME  AND  PARTICIPATING  IN 
INTERDISCIPLINARY  CONFERENCES 
Physicians feel  they coordinate their patienti  home  care; agencies disagree 
Eighty-three  percent  of physicians  believe  that  they  serve  the  coordinating  role. 
Several  feel  that  they  provide  continuity  of care, just  like in the  hospital. 
In contrast,  a majority  of agencies  (61 percent)  do not  attribute  the  role  of 
coordination  to the  physician.  The  Visiting Nurse  Associations  are  more  likely than 
others  to say the  physician  does  not  coordinate  care.  More  than  half  of all agencies 
say the  nurse  is usually  responsible  for coordinating  the  patients  care.  An 
administrator,  when  discussing  the  physicians  relationship  with other  members  of the 
team,  says, I would  like to see  more  of a partnership,  more  directly  related  to patient 
care. 
Interviews  with the  agencies  and  the  physicians  suggest  these  differing  opinions  are 
due  to the  two groups  different  perspectives.  The  agencies  view the  coordinating  role 
as actively  managing  the  interdisciplinary  team,  including  the  physician.  The 
physicians  see the  coordinating  role  as overseeing  the  case,  being  involved  in the 
medical  management  of their  patient,  and  determining  the  number  and  type  of visits. 
Seventy-two  percent  of the  agencies  are  satisfied  with physician  involvement  in the 
medical  management  of the  patient.  An agency  administrator  says, the physician  is 
the  key member  in the  delivery  of care.  Agencies  agree  that  the  physician  determines 
the  number  of visits for medical  management,  but  say other  professionals  make  that 
determination  for each  discipline.  One  agency  administrator  says, the home  care 
nurse  should  be  responsible  for coordination  of all home  care  services.  Another 
says, I hope  you are  not  reducing  the  role  of the  physician  because  they  are 
responsible  for medical  management  always. 
Physicians do not u.wQllytake part in interdisciplimnyconferences  or make home  vikifi 
Forty-three  percent  of agencies  report  that  some  of their  patients  personal  physicians 
participate  in agency  patient  conferences.  Although  these  conferences  are  not 
frequent,  they  are  more  likely to occur  when  patients  experience  problems. 
Seventy-nine  percent  of physicians  say they  have  not  participated  in such  conferences. 
Both  agencies  and  physicians  agree  that  physicians  participating  in patient  conferences, 
either  in person  or by telephone,  would  be  ideal,  but  many  say that  physicians  busy 
schedules  makes  it impossible  and  unrealistic. 
8
 Fourteen  percent  ofphysicians  report  making  home  visits; most  of them  say these 
visits are  infrequent  and  only when  absolutely  necessary.  They  add  that  since 
Medicare  pays so little  for a home  visit it is not  affordable  for them  to see  patients  in 
their  home.  They visit only when  the  patient  cannot  get to the  office.  Some 
physicians  feel  that  physicians  should  visit patients  at home  more  frequently.  Some 
subsample  agencies  feel  that  physicians  should  make  home  visits to their  patients 
occasionally.  Perhaps,  at times,  with the  home  health  nurse. 
BOTH  AGENCIES  AND  PHYSICIANS  IDENTIFY  SOME  OBSTACLES  AND 
ISSUES RELATED  TO THE  PHYSICIAN  ROLE 
Communication 
While  all agree  that  good  communication  is extremely  important  for  quality  patient 
care,  some  obstacles  are  identified.  Agencies  say they  continually  work  to improve 
communication  with physicians.  Ideas  they  have  tried  include  newsletters,  lunch  or 
breakfast  meetings  to get  the  physician  involved,  simplifying  requirements,  setting  a 
special  time  for phone  calls, hand  carrying  orders  to the  physician,  providing  cellular 
phones  to the  visiting  nurses,  and  having  a physician  from  the  medical  advisory 
committee  communicate  with the  patients  personal  physician,  especially  in problem 
cases. 
Ninety-two  percent  of physicians  are  satisfied  with  their  communication  with  agencies 
and  seventy-three  percent  of agencies  are  satisfied  with  physician  communication  with 
them.  Agency  satisfaction  is somewhat  lower with physician  communication  with other 
home  health  professionals,  such as the  primary  care  nurse  or therapists,  with only 
sixty-three  percent  of agencies  satisfied. 
However,  three-quarters  of the  agency  subsample  mention  obstacles  which  get  in the 
way of good  communication  between  the  agency  and  the  patients  physician.  They 
include  physicians  being  too busy to do all the  paperwork  and  answer  all the  agencys 
phone  calls; physicians  not  getting  paid  for their  time;  the  physicians  office  staff 
making  it difficult  to reach  him/her;  the  visiting nurse  and  the  physician  having 
difficulty  finding  convenient  times  to get together  on the  phone.  Agencies  consider  it 
critical  that  nurses  have  access  to physicians  for medical  direction  and  support. 
Physicians  feel  the  agencies  could  improve  communication  by calling  at scheduled 
times  and  leaving  clearer  messages,  or having  one  nurse  responsible  for contacting  the 
physician  so that  many  different  people  do not  call about  the  same  thing.  Paying  the 
physician  for the  time  he/she  spends  on the  phone  and  doing  paper  work  and  reducing 
the  amount  of such paperwork  are  also suggestions  made  by physicians. 
Medical Directom 
Agencies  say having  a medical  director  would  improve  communications.  Eighty-six 
percent  of the  agencies  in the  subsample  think  home  health  agencies  should  have  a 
9  medical  director.  They  feel  this physician  would be  a good  liaison  with the  patients 
personal  physician.  Physician  to physician  communication  is valuable,  especially  if 
there  are  problems  and  the  medical  director  would  be  helpful  in educating  other 
physicians.  Sixty-eight  percent  of agencies  report  currently  having  a medical  director, 
although  in some  cases  he/she  is actually  the  medical  director  of the  advisory  board  or 
the  hospice  program  and  not  functioning  as a full time  medical  director  for the  home 
health  agency.  Thirty-five  percent  of physicians  feel  that  agencies  should  employ 
physicians,  usually in a medical  director  role. 
Plans of Care 
Physicians  and  agencies  generally  agree  that  physicians  should  continue  to sign initial 
plans  of care;  however,  most  subsample  agencies  feel  that  qualified  staff other  than 
the  physician  can  sign the  plan  of care  for recertification  or for chronic  patients 
Almost  all (97 percent)  agencies  indicate  that  physicians  should  sign the  plan  of care 
for complex  patients;  ninety-two  percent  say physicians  should  sign for acute  patients; 
and  sixty-four  percent  for chronic  patients.  Sixty-three  percent  of physicians  feel  that 
they  should  sign all plans  of care,  regardless  of the  complexity  of the  patients 
condition. 
Three-quarters  of the  physicians  consider  their  arrangements  with the  agencies  for 
completing  and  signing the  plans  of care  satisfactory,  although  almost  half  of them  find 
it burdensome.  Physicians  frequently  complained  about  the  amount  of paperwork 
required  for home  care.  Three-quarters  of the  physicians  believe  that  when  they  sign 
the  plan  of care  they  are  liable  for the  home  health  services  their  patients  receive. 
Some  volunteer  that  there  are  agencies  that  try to add  too  many  services,  especially 
home  health  aide  services.  They  say they  stop  referring  patients  to these  agencies. 
Regardless  of the  condition  of the  patient,  fifty-three  percent  of the  subsample 
agencies  feel  that  the  physician  should  always sign the  initial  plan  of care;  but  a 
majority  (57 percent),  think  the  physician  does  not  need  to sign the  recertification. 
These  agencies  and  some  physicians  say that  a qualified  person  other  than  the 
physician  should  be  allowed  to sign the  plan  of care,  such as the  prima~  care  nurse  or 
nurse  practitioner  or the  treating  therapist.  They  consider  it especially  appropriate  for 
services  to chronic,  stable  patients,  such as those  only needing  a catheter  change  once 
a month,  or for the  therapist,  dietitian  or social worker  services  they  have  evaluated. 
Most  agencies  and  some  physicians  suggest  support  services,  such as home  health  aide 
or personal  care  services,  may be signed  for by a nurse.  One  agency  administrator 
voices  the  opinion  of others  when  she says, Under  Medicare  we are  tied  to the 
medical  model  which is expensive.  We  should  look  to use other  professionals  to fill 
some  needs. 
10
 Burdensome Paperwork 
Sixty-five percent  of agencies  and51  percent  ofphysician  respondents  find the  process 
of reviewing  and  signing plans  of care  burdensome,  The  large  agencies  and  the 
Visiting  Nurse  Associations  are  most  likely to feel  burdened.  Agencies  feel  paperwork 
is too  complex  and  burdensome  for them.  An administrator  agrees  and  says that 
having  too  many  orders  for doctors  to sign strains  the  agency  - physician  relationship. 
One  suggestion  is to accept  telephone  orders  for changes  in the  frequency  of visits so 
that  the  agency  does  not  have  to generate  a piece  of paper  for such minor  changes. 
Physicians  indicate  that  there  is too  much  paperwork  and  find it difficult  to find the 
information  on the  plan  of care  that  they  consider  important.  They  suggest  paring 
down  the  amount  of required  information  and  highlighting  the  medical  care.  An 
agency  respondent  says, The plan  of care  as it is today  is a compilation  of physician, 
nursing,  therapy  and  social  service  practices,  each  of which  is specific  unto  itself, but 
the  physician  is expected  to sign for all of it.  Several  respondents  suggested  the  plan 
be  simplified. 
Physician Awareness and Education 
Some  agencies  feel  that  the  physicians  awareness  and  education  in home  health  care 
is inadequate.  They  say medical  schools  usually  do not  include  home  health  care  in 
their  curriculum.  Agencies  also mention  that  some  physicians  lack  understanding  of 
the  Medicare  home  health  benefit. 
Overall Role of Physicians 
Forty-six  percent  of agencies  feel  the  physician  role  should  be  stronger  than  it 
presently  is; thirteen  percent  feel  it should  be weaker;  and  forty-one  percent  feel  it 
should  stay the  same.  Eighty-eight  percent  of the  agencies  believe  if the  physicians 
were  paid  for their  home  care  case  management  role,  they would  get  more  involved; 
seventy-one  percent  of the  physicians  agree.  As noted,  this data  were  collected 
before  physicians  were  paid  for care  plan  oversight. 
RECOMMENDATIONS 
We  support  the  work  of HCFAS home  health  work  group  in reviewing  and 
restructuring  the  home  health  benefit.  As home  health  care  continues  to expand, 
there  will be  ongoing  discussions  about  the  physician  role.  The  HCFA  will be  pressed 
to continue  its leadership  role  to undertake  appropriate  activity  and  better  define  and 
tell what  the  physician  role  should  be.  Therefore,  we recommend: 
	 The  HCFA  should  continue  its efforts  to change  the  plan  of care  to ensure  it 
conveys  critical  information  to caregivers  and  relieves  unnecessary  burden  from 
physicians, 
	 The  HCFA  should  strengthen  its efforts  to educate  both  agencies  and 
physicians  about  its policies  regarding  the  physicians  role  in home  health  care. 
Issues for Further Su.dy 
Based  on our  findings  and  on comments  received  on our  draft  report,  there  are  a 
number  of issues  about  the  role  of physicians  which  require  further  study. 
Should  other  professionals  such as the  patient  care  coordinator,  home  health 
nurse,  physical  therapist,  occupational  therapist,  speech  therapist  or social 
worker  take  on more  responsibility  for certain  aspects  of home  health  care?  If 
so, how does  this impact  the  physicians  role? 
Should  the  complexity  of the  case  determine  physician  involvement?  If so, 
should  the  physician  be  more  involved  in complex  cases  and  less involved  in 
chronic  cases? 
Should  home  health  reimbursement  be  different  for  different  levels  of care?  If 
so, should  chronic  care  cases  be  reimbursed  a lower  level than  those  more 
complex  cases? 
Does  payment  to physicians  for care  plan  oversight  lead  to greater  physician 
involvement ? 
COMMENTS

Comments  on the  draft  report  were  received  from  HCFA,  ASPE  and  the  Acting 
Assistant  Secretary  for Management  and  Budget  (ASMB.)  Suggestions  for additional 
information  and  clarifications  of the  text  have  for the  most  part  been  incorporated 
into  the  final  report.  The  actual  comments  received  are  included  in Appendix  A. 
The  HCFA  defers  action  on our  recommendations  at this time.  Nevertheless,  we 
appreciate  their  recognition  of the  importance  of our  recommendations  and  support 
their  efforts  towards  developing  a Core  Standard  Assessment  Instrument  which would 
significantly  impact  on the  requirements  for the  plans  of care.  We  look forward  to 
their  decisions  on our  recommendations  after  issuance  of the  final report. 
The  HCFA,  ASPE,  and  ASMB  all commented  on physician  payment  for care  plan 
oversight.  We  recognize  that  HCFA  is now reimbursing  physicians  for care  plan 
oversight.  We  plan  a follow-up  study to see whether  this has lead  to greater  physician 
12  involvement  and  prudent  utilization  of the  home  health  benefit  as HCFAS comments 
suggest. 
The  ASPE  suggests  that  further  study is needed  to examine  the  actual  behavior  of 
physicians  and  other  providers.  We  support  further  study  of physicians  in home  health 
care  that  could  contribute  useful  information.  We  added  a new section  to report  on 
issues for further  study. 
Both  HCFA  and  ASPE  expressed  concerns  about  specific  evaluative  issues that  fall 
outside  the  scope  of this study.  This report  provides  descriptive  rather  than  evaluative 
information.  We modified  the  report  to make  this clearer. 
The  ASPE  raised  concerns  about  bias  in self-reported  information.  This is always a 
problem  in these  kinds  of studies.  We had  addressed  it in our  original  design  by 
obtaining  information  from  many  diverse  sources  of data.  We  obtained  information 
from  both  home  health  agencies  and  physicians.  We  also  obtained  patient  payment 
records  to establish  whether  a relationship  existed  between  patients  and  the  physicians 
who signed  the  plans  of care.  We  provide  a methodology  section  for the  reader  to 
draw his/her  own conclusions. 
The  ASPE  requested  that  we include  study instruments  in our  reports.  We  usually do 
not  do this, but  they  are  available  upon  request. 
  APPENDIX  A 
COMMENTS 
A-1  ,*
 ,mw,, 
.+  %,  Health Care 
  DEPARTMENT  OF HEALTH&  HUMAN  SERVICES 
5g   Financing Administration
/ / 
Memorandum 
1 
twi?
DATE  271995  M 
FROM	 Bruce  C. Wade 
Administrator  w  -
SUBJECT	 Office  of Inspector  General  Draft  Reports:  The Physicians  Role  in Home 
Health  Care,  (OEI-02-94-O0170)  and  Home  Health  Agencies:  Alternative 
Coverage  and  Payment  Policies,  (OEI-12-94-00180) 
TO	 June  Gibbs  Brown 
Inspector  General 
We reviewed  the subject draft reports  which  examine  home  health  care  provided  under 
the  Medicare  program.  Our  comments  are  attached  for your  consideration. 
Thank  you for the  opportunity  to review  and  comment  on these  reports.  Please  advise 
us if you would  like to discuss our  position  on the  recommendations. 
Attachment 
, 
.._.  - Comments  of the Health  Care Financin~ Administration  (HCFAj 
on Office  of Inspector General  (OIGl  Draft Reports: 
The Phvsicians Role  in Home  Health  Care, (OEI-02-94-00170~ 
and Home Health  Agencies:  Alternative  Coverage  and Pavmen~ 
policies, (OEI-12-94-00180\ 
OIG  Recommendations  on The Phvsicians Role  in Home  Health  Care 
1.	 The  HCFA  should continue  its efforts to change the plan of care to ensure it 
conveys critical information  to caregivers and relieves  unnecessary  burden from 
physicians. 
2.	 The  IICFA  should further communicate  its expectations  about physician 
involvement  and take steps to assure that it is more clearly understood  by home 
health  agencies  and physicians. 
HCFA  Response

HCFA  defers  action on the above recommendations  at this time.  We are in the process

of examining  issues related  to plans of care and the physicians role  and recognize  the

importance  of both recommendations.  However,  we believe  it would  be premature  to

make immediate  changes.

Clearly one  of the most important problems facing the Medicare  home  health benefit  is

utilization.  OIG  is commended  for its attempts to better understand the appropriate

role of the physician in monitoring utilization  and appropriateness  and duration of care.

HCFA  has  addressed  the  issue of physician involvement  through regulations.  In the

December  8, 1994 Federal  Register,  HCFA  issued a new regulation  providing separate

payment for physiciancare plan oversightservices.  Reimbursing  physicians for care

oversightservices should lead to greater physician involvement  and prudent utilization  of

the home  health benefit.

HCFA  has also established  a Medicare  Home  Healfh  C .re Work Group which is

currently drafting revised Home  Health  Agency  Conditions  of Participation.  HCFA  is

also developing  a Core Standard Assessment  Instrument.  Requirements  for the

assessment  instrument could significantly impact the information  requirements  on the

plan of care. The work group expects to develop  recommendations  after it completes  its

research.  Until  then our operational  plans are to continue  using HCFA  Forms 485 and

486 (Medicare  Collection  of Medical  Information on Home  Health  Services).

We note  that the report recommendations  do not address the two main questions  listed

on page 3:  Are physicians effectively  fulfilling their gatekeeper  role  in initiating and

monitoring  theplan of care?  Do physicians rubber stamp the plan of care?  While the

report recognizes  that there  are discrepancies  in how physicians and agencies  view the
 Page 2 
physicians role  in coordinating  care, it does not address whether  physicians are an 
effective  gatekeeper.  Perhaps the study might more effectively  address Does greater 
physician involvement  result in a more cost-effective  utilization  of the home  health 
benefit? 
Additionally,  we would be interested  in any specific suggestions  OIG  may be able to 
offer on the following: 
o	 After  interviewing both agencies  and physicians, does  OIG  have any 
specific  suggestions  of ways the plan of care can be changed? 
o	 Does  OIG have specific suggestions on how the role  of physicians should 
be better communicated? 
o	 Does  OIG feel  that  after talking to agencies  and physicians,  there is a 
consensus  on what the physician role ought to be? 
Comments  on Home Health  Agencies:  Alternative  Coverape  and Pavment  Policies 
The report appears to assume that other agencies  are more  effective  than Medicare  in 
controlling  costs.  However,  there are no data in the report comparing  the average 
number of visits or expenditures  per beneficiary.  While the report identifies  other plans 
limits on utilization,  there may be other factors, such as age, health  status, and income, 
that could  explain  differences  in utilization,  if they exist. 
We are in the process  of developing  our approach to revitalizing  the coverage  and 
payment policies  for home  health agencies.  The roints  of Further Analysis  in this report 
raise interesting  alternatives  that will be considered by HCFA  as it formulates  its plan to 
revitalize  the home  health benefits.  .
.
:
a+>4. .,, 
L  DEPARTMENT  OF HEALTH  & HUMAN  SERVICES  Officeof the Secre[arY
2   
2 
-0 
** 
+,,,, ,d 
Washington,  D.C.  20201 
MAY i. .W5

TO:	 June Gibbs Brown 
Inspector General 
FROM:	 Assistant Secretary  for 
Planning  and  Evaluation 
SUBJECI:  OIG  Draft  Reports  on Home  Health  Care  -- COMMENTS 
The  following  are our comments  on the draft  inspection  report,  The Physicians  Role  in Home 
Health  Care,  OEI-02-94-00  170.  There  ~e  no Cements  on  the second  report,  Home  Health 
Agencies:  Alternative  Coverage  and Payment  policies,  OEI-12-94-00  180. 
GENERAL  COMMENTS 
.  The  purpose  of the report  needs c~~rification, The pur-poseis stated  as to describe  the 
current  role ... and obtain  suggestions  as  can be strengthened.  J?e agree 
tO  ho~v  this  role 
that  this  report  describes  the current  role of physicians,  based  on physician  and pro~ider 
perceptions.  However,  since  the effectiveness  of the physicians  role  is not evalua[cd  in 
this  StUdy,  the  physicians  role. 
\VC  recommend  C]imindting  references  to  strengthening 
.  1IIc  studys  limitations  S]IOU]d  be  sf~te~.  The  repofl describes  what conclusions  can be 
drawn  from  the study  but does  not  define  what  inferences  are outside  the  studys  scope. 
For  example,  since  the  study  does  not  include  a comparison  of  the  perceived  role  to 
current  reglllatory  requirements,  intewretations  related to current ]a\v are outside  the SCOp~ 
of this  study.  Furthermore,  because  the measwements  of physician involvement  may be 
biased  due to self-report,  the findings  should bc interpreted  with caution.  Finalljr,  the 
10\\f 
physician  response  rate to the telephone  interview  (43%)  should  be noted  as a limitation. 
  llcfcrcuccs  to g~te]<ccping should  bc rr-~iscd. Since the effcctivcncss  of the physicians 
~a(ckccper  is not c~~aluatcd in this study,  rcfcrcnccs  as part of the studys 
rOIC  as  a  [O  this 
purpose  should  bc climinstcd  (see p.3  paragraph  4). Instead,  the reports  findings  should 
further  study  of  this  issu~  b~c2us~ they  indica[~  {hat other  professionals  (e.g. 
SUiJ~CS[ 
l]~irsi[}g,tl~crapy, sociol  \vork)  dctcrnlinc  the ~nloun[ and [\Pc  of c;lrc, (i~i~]l r:]rc chm~cs 
b> [1~~pl}ysici~n) and [hat [hc physician  do~s not rolllincly  .&  [Ilc pa[icn[ to rcccrtify  care.  Page 2- June  Gibbs  Brown 
  Revisions to the recommendations are needed.  Since the study is based on perceptions 
versus actual behavior,a further study fiat examines the actual behavior of physicians and 
other providers should be recommended.  Additionally, the report should recommend that 
HCFA consider revising its expectations about physician involvement to reflect  current 
practice.  For  example,  the report  states that physicians are most involved  in  complex 
medical  cases.  Since  c~ent  law  allows reimbursement  to  physicians  for  care  plan 
oversight  in all cases, this should be considered a highly relevant finding. 
.  The  report  should  include  the study instruments.  It is difficult  to  interpret  these 
findings  without  knowing  the actual questions that were asked.  We recommend  you 
include the questionnaires  in an appendix. 
Prepared by: HP:Susan Manfredi 690-7862/DALTCP:Ruth Irwin 260-0370 
  *. >, Jg,   
.  DEPARTMENT  OF HEALTH  & HUMAN  SERVICES 
z.   office of the Secretary
~ 
z 
%3+ 
.78,.10  Washington,  D.C.  20201 
6i3s 
MAR 
To:	 Inspector  General 
Attn:  George  Grob 
From:	 Elizabeth  M.  James 
Acting  Assistant  Se  et 
Subject  :  Draft  OIG  Report--Ph&ci.ans  Ro  e  n Home Health Care 
(OEI-12-94-00170)  --Concur  with  c u  ent 
~~-qll-~?~ 
We recommend  that the final report acknowledges that, effective 
this calendar year, Medicare now makes separate payments  to 
physicians  for their work in providing home health care plan 
oversight.  Because the draft report finds that lack of payment 
was one obstacle  to  improving  physician  involvement  i-n  the 
ongoing  care  of  home  health  patients,  we  believe  it  is 
appropriate  that  the  new  payment  policy  be  discussed  in  the  final 
report  . 
We appreciate  the opportunity  to review the draft report.