Department of Health and Human Servces 
OFFICE OF 
INSPECTOR GENERAL 
HOME HEALTH SERVICES 
Medicare Beneficiary Satisfaction And 
Understanding In 1995 
SERVICE 
JU 
GffBS BROWN 
Inspector General 
'0 
Apri 199 
""d:m 
OEI-093-O153  OFFCE OF INSPECfOR GENERA 
The mission of the Offce of Inspector General (OIG), as mandated by Public Law 
95-452, is to protect the integrty of the Department of Health and Human Servces 
programs as well as the health and welfare of beneficiaries seIVed by them. Ths 
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. 
Offce of Evaluation and Inpetions 
The Offce of Evaluation and Inspections (OEI) is one of several components of the 
Offce 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 effciency, vulnerabilty, and effectiveness of departmental 
programs. 
The OEI's Atlanta Regional Offce prepared this report under the direction of Jesse J. 
Flowers, Regional Inspector General, and Christopher Koehler, Deputy Regional
Inspector General. Principal OEI staff included: 
Rel!on  Headquaers 
Paula Bowker, Project Leader 
Jennfer Antico, Program Specialist
Betty Apt, Team Leader  Brian Ritchie, Technical Support
Tammy Hipple, Statistician  Barbara Tedesco, Statistician
James Green, Contractor 
To obtai a copy of this report, caU the Atlanta Regional Offce at 404-
331-4108.  Department of Health and Human Servces 
OFFICE OF 
INSPECTOR GENERAL. 
HOME HEALTH SERVICES 
Medicare Beneficiary Satisfaction And 
Understanding In 1995 
SERVICls. 
JU 
GffBS BROWN 
Inspector General 
Apri 199
'lO'd3'O 
OEI-093-O153  EXECUTIVE 
SUMMAR Y

PUROSE
To determe beneficiar satisfaction with and understanding of home health servces. 
BACKGROUN
Medicare is a Federal health insurance program for individuals age 65 and older
, and
for certain categories of disabled people. One Medicare benefit is home health 
servces. To receive such care, beneficiares must need skied servces such as nursing,
physica therapy, and speech therapy on an intermittent or part-tie basis. A 
physician must cert in a Plan of Care that such care is necessary. Once qua1ed, a
beneficiary may also receive servces such as home health aide servces and on-
going
occupational therapy.
As part of a 1995 sUIVey to determne beneficiary satisfaction with Medicare, we asked
beneficiaries about their experiences with home health servces. 
Of the 942 
respondents to the 
sUIVey, 139 beneficiaries said they had received home health 
servces. Some of the questions used in the 1995 sUIVey were also used in a 1994 
sUIVey. We made comparisons whenever possible
, and tested for statisticaUy
signcant differences using the t-test.
FIINGS
Medcae Beneficiares Contiued to be Satified With Home Heath Cae
Ninety-five percent said home health agency personnel did an adequate job.
Ths is about the same as in 1994, when 91 percent said so.
Ninety-six percent of the beneficiaries said they received the number of home 
health visits they thought they needed. This is an increase from 1994
, when 86
percent said the same thing. 
percent confThds eis an sctatiesti callly seigvnficeanlt in.cr ease at the 90
Ninety-two percent of the beneficiaries said that a 
physiCian or home health
agency employee had explained how their medical condition should improve as 
a result of care. Ths is an increase from 1994, when 76 percent reported that 
an explanation had been provided. In both years
, most beneficiaries believed 
their condition improved as expected.
Eighty-seven percent of the beneficiaries said a medical person (doctor
, hospital
employee, etc.) referred them to the home health agency they selected for care.
Ths is about the same as in 1994
, when 79 percent responded similarly.  Two percent of the beneficiaries said that they were contacted by a home 
health agency, and that was how they selected the one they used. Ths is not a 
statistically signficant difference from the 6 percent who said the same thing in 
the 1994 sUIVey.

Most Beneficiares Understoo What Medcae Paid For 
Seventy-seven percent of beneficiaries said it was clear what Medicare paid for. 
In the prior year s sUIVey, 53 percent said it was clear. However, our 1994 
sUIVey contained a response option we did not offer in 1995. Therefore, we 
could not statistically compare these results. 
Few Beneficies Were Awae Of State Hot Unes 
Only 25 percent of the beneficiaries said they were aware of the hot lines run 
by the State for reporting complaints and fraud. This question was not asked in 
the previous year.

RECOMMNDATION 
Based on our prior 1994 sUIVey, we recommended that 
the Health Care Financing 
Admistration (HCFA) consider ways to improve existing explanations of the home 
health benefit to beneficiaries and pursue new methods to increase understanding of 
the benefit. Since our report was issued, HCFA published a beneficiar pamphlet and 
a video tape presentation which explain hpme health benefits in simple terms. 
Additionally, the pamphlet contais phone numbers and information on fraud, quality
of care complaints, and counselig servces. 
In addition to the palIphlet and video tape presentation, HCFA has developed a 
home health equivalent of an Exlanation of Medicare Benefits, called a Notice of 
Utition. Ths is intended to inorm beneficiaries of what home health servces 
Medicare has paid for on their behalf. 
Our 1995 sUIVey indicates that such HCFA activities are working. OveralI, beneficiary
satisfaction with home health care continued to be high and their understanding of 
home health benefits improved since 1994. However, almost 25 percent of Medicare
beneficiaries stil do not understand what home health care is paid for by Medicare. 
Further, about 75 percent of Medicare beneficiaries are not aware of State hot lines 
for registering complaints about care received, and reporting possible fraud. 
We recommend that HCFA continue efforts to educate beneficiaries on Medicare-
funded home health servces. HCFA should make every effort to insure the broadest 
possible distribution of the pamphlet and video tape presentation. Such information 
material could be distributed. to beneficiaries through home health agencies
, hospital
discharge planning units, and other institutional sources of referrals for home health 
care. HCFA should also plan to evaluate the Notice of Utilition after it has been in  use for six to twelve months to determe its 
impact on beneficiar understanding and
on the Regional Home Health 
"Intermediaries. 
COMM 
AGENCY 
HCFA concurred with our recommendation. They pointed out that implementation of 
the Notice of Uti1tion
, started in October of 1996, wi be phased in over the next
few months  In FY 1997, HCFA plans to evaluate the effectiveness of the Notice of
Uti1tion 
process. Further, they wi require 
intermediaries to conduct beneficiary
outreach activities to improve quality of care and reduce fraud. 
iii  ..........................
. . . . . . . . . . " 
. . . ."  ..  ...   ...   ...   ...  . .. .  . .. .  . ..  . .. .  . .. .  . .. .  . .. .  . .. .  . ...    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ...   ...   ...   ...   ..  . . . . 
TABLE OF CONTENTS
EX 
PAGE
SUMY 
INODUCTON . . 
FIINGS. . 
. . . . . . . . . . . . . . . . . 3 
Contiued Satisfaction 
........................ .................. 3 
Understanding Of What Medicare Paid For 
State "Hot ties  . . . . . . . . . . . . . 4 
RECOMMATION. . 
. . . . . . . . 5 
COMM ............................................ 
AGENCY 
APPENIX 
SUIVey Questions And 
-A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .sesnopseR
Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. B- INTRODUCTION
PUROSE
To determe beneficiary satisfaction with and understanding of home health servces.
BACKGROUN
Progr
The Medcae 
Medicae is a Federal health inurance program for individuals 
cert  age 65 and older, and for
!;tegories of disabled people. Medicare 
was authoried in 1965 by title XVII of
the Social Security Act. In Fisca Year 1995, Medicae seIVed approxiately 37.6 miion
beneficiaries, and paid benefits totallng over $159 billion. 
The Home Heath Benefit
One Medicare benefit is home health servces. Home health agencies (HH) 
who
provide such servce to Medicare beneficiaries must be certified as a Medicare provider.
To receive such care, beneficiaries must need skiled servces such as nursing, 
physical
therapy, and speech therapy on an intermittent or part-
time basis in their homes. A
physician must certif in a Plan of Care that such care is 
necessary. Once qualified, a
beneficiary may receive other servces such as home health aide servces and on-
going
occupational therapy. The number of visits a beneficiary 
may receive is not limited.
MEODS
In September 1995, wesuIVeyed 1244 randomly selected Medicare beneficiaries on their
satisfaction with the Medicare program. Of the 942 
beneficiaries who returned
hcompeleteda quelstitonhnaire s,s 914e saidr thevy hacd ore hads not .rec eived home health servces in
the past year. .Of the 914 beneficiares, 139 (15 percent) said they did receive home
Ths report is based on responses from those 139 beneficiaries. Our analyses are based
on the number of beneficiaries who answered each question. Based on the number of
respondents, estimates are generally within 8 percentage points of the true value at the
95 percent confdence level. Appendix A contains our 
questionnaire and beneficiary
responses to each question.
HeaIth Care Financig Administration, United States Department of Health and Human Servce,
HCFA Statistics. September 1995. ------------
Comparion to Prevus Sureys 
In 1994 we conducted a simlar national 
sUIVey of Medicare beneficiaries 
to assess their
satisfaction with and understanding of Medicare home health servces.2 Seven of our ten 
sUIVey questions in 1995 were the same as those used in 1994. Therefore
, we compared
our sUIVey results for the two years where applicable. 
In makig comparisons of 
sUIVey
results for the two years, we tested for statistically signcat diferences using the t-test. 
We conducted this inspection in accordance with the 

Quality Standards for Inspections

issued by the President's Council on Integrty and Effciency. 
0ffce of Inpeor 
General, United States Department of Health and Human Servce 
Medicare
Beneficiarv Satisfaction With And Understandin2 Of Home Health Servce. 
OEI-093-O143  FINDINGS 
BENCI 
CONT 
/MJEIC A  SATIFI WI 
TO BE  HOME
HETH CAR
Ade 
Heo Agen Di 
Sa Home  An  Job 
The percent of Medicare beneficiaries who said home health personnel did an adequate 
job was about the same in 1995 and 1994. In 1995, 95 percent of the 
beneficiaries said 
home health agency personnel did an adequate job. 
In 1994, 91 percent said so. Ths is 
not a statisticay signcant increase. 
The number of beneficiaries who said they received the number of home health visits
they thought they needed increased from 1994 to 1995. In 1995, 96 percent of the
beneficiaries said so, as compared to 86 percent in 1994. Ths is a statistically signcant
increase at the 90 percent confdence level. 
In 1995, 80 percent of the beneficiaries said home health agency caregivers provided 
servce every tie they were supposed to do so. Likewise, 99 percent of the beneficiaries 
said the caregivers were courteous and respectfl. We did not ask these questions in our 
1994 sUIVey, therefore we cannot make a comparison. 
Be 
Pote 
of Home Heall Cae Were Exlain to Medare 
The number of beneficiaries who said a physician or home health agency employee 
explained how their medical condition should improve increased from 1994 to 1995. In 
1995, 92 percent of the beneficiaries reported that a physician or home health agency 
employee had explaied how their medical condition should improve as a result of home 
health care. In 1994, 76 percent said such. The increase from 1994 to 1995 is 
statistically signcant at the 95 percent confdence level. In both years, most of the
beneficiaries said their condition improved as explained. 
Be 
Gen 
Med 
Peronn 
Refered  To Home Heall Agen 
Sources of referral to a home health agency were about the same for most beneficiaries 
in 1994 and 1995. In 1995 87 percent of the beneficiaries said that a medical person 
(doctor, hospital employee, or other provider) had referred them to the home health 
agency they selected for care. In 1994, 79 percent responded sinariy. Ths does not 
reflect a statistical1y signcant change from 1994 to 1995. 
In 1995 2 percent of the beneficiaries said that they were contacted by a home health 
agency employee, as compared to 6 percent in 1994. Ths is not a signcant decrease 
from 1994 to 1995.  BENCI 
UNEROOD WHT MEICAR PAI 
MOST  FOR
In 1995, 77 percent of beneficiaries said it was clear what home health servces Medicare 
paid for. In 1994, only 53 percent said it was clear what Medicare paid for. However
because our 1994 sUIVey contained a response option that we did not offer in 1995, we
cannot statistically compare these results.
BENCI WE  LI 
FEW  AWAR OF STATE HOT  FOR REORTIG
COMPI. AN 
FRUD
States operate hot lines that beneficiaries can use to register complaints about care
, and
to report possible fraudulent practices. Health Care Financing Administration staff 
asked us to determe whether or not Medicae beneficiares were aware of State hot
lies. Our sUIVey showed that only about 25 percent of the beneficiaries said they were
aware of the hot lies. We have no basis for determning whether or not beneficiary
awareness of hot lies is increasing or decreasing since we did not ask this question in
our prior sUIVeys. RECOMMENDATION
Based on our prior 1994 sUIVey, we recommended that HCFA consider ways to improve
existing explanations of the home health benefit to beneficiares and pursue new methods
to increase understanding of the benefit. Since our report was issued, HCFA published a
beneficiar pamphlet and a video tape presentation 
which explai home health benefits
in simple terms. Additionally, the pamphlet contains phone numbers and inormation on
fraud, qualty of care complaints, and counselig servces.
In addition to the pamphlet and video tape presentation
, HCFA has developed a home
health equivalent of an Exlanation of Medicare Benefits, called a Notice of Utilition.
Ths is intended to inorm 
beneficiaries of what home health servces Medicare has paid
for on their behalf.

Our 1995 sUIVey indicates that such HCFA activities 
are workig. OveralI, beneficiary
satisfaction with home health care continued to be high and their understanding of home
health benefits improved since 1994. However, almost 25 percent of Medicare
beneficiaries stil do not understand what home health care is paid for by Medicare.
Further, about 75 percent of Medicare beneficiaries are not aware of State hot lines for
registerig complaints about care received, and reporting possible fraud.
We recommend that HCFA continue efforts to educate beneficiares on Medicare-
funded
home health servces. HCFA should make every effort to insure the broadest possible
distribution of the pamphlet and video tape presentation. Such information material
could be distributed to beneficiaries through home health agencies
, hospital discharge
plamIg unts, and other institutional sources of referrals for home health care. HCFA
should also plan to evaluate the Notice of Utilition after 
it has been in use for six to
twelve months to determine its impact on beneficiary understanding and on the Regional
Home Health Intermediaries. AGENCY COMMENTS 
HCFA concurred with our recommendation. They pointed out that the Notice of
Utiltion
, implemented in October of 1996, wil be phased in over the next few months. 
In FY 1997, HCFA plans to evaluate the effectiveness of the Notice of Utilzation 
process. Furter, they wi requie 
intermediares to conduct beneficiary outreach 
activities related to the home health benefit to improve quality of care and reduce fraud. 
Appendi B shows the full text of the comments provided by HCFA  APPENDIX A
SURVEY QUEONS AN REPONSES 
Have you recived servce  in your home from a  home heath al!en  in the past
yea? 
139  Yes 
775
Th 
about the lat tie you recived servce  in vour home from a  home heath 
Was it clea to you what Medca pad for? 
aner. 
one 
(Check 
103  Yes, it was clear what Medicare paid for. 
not clear what Medicare paid for. 
, it was 
I do not remember if it was clear what Medicare paid for. 
Medicare has not yet paid for the home health servces. 
Thinking back to when you recived home cae from a home heath 
agency, 
Did the caegier(s) stay 
long enough to do hi or her job? 
128  Yes 
Did the caegier(s) do hi or her 
job adequately? 
123  Yes 
agency? 
How would you describe the number of viits you 
reived from the home
123(cid:1) I received the number of visits I needed. 
I received fewer visits than I needed. 
I received more visits than I needed.  suppo 
How many ties did the caegier(s) come when he or she wa  to?
tie
106  Every 
Most of the time
tie
Some of the 
Seldom
Never
re?
Was the caegier(s) frm the home heath agency courus and 
130  Yes
Some caregivers were courteous and some were not.
as!i
Took food and drik and Tvleno  hout 
(Please explai): 
Did your docor or home heath agency exla how your medca condition should 
improe as a result of the ca you recived frm a home heath agency? 
116  Yes
Did your condition improve as much as you were told it would?
Yes
No one explained how much I should improve. 
us? 
How did you selec the home heath agency you 
115  A doctor; hospital, or other medical person or facilty referred me to the 
home health agency. . 
Friends or famiy referred me to the home health agency.

The home health agency contacted me fist.
I don t recall.
10.(cid:1) Before toy, were you awae that your State has a "hot lie" to regiter
complaits about home heath cae? 
Yes
A- 2
 APPENDIX B 
AGENCY COMMNT  : ..
('., 
DEPARTMENT OF HEALTH &, HUMAN SERVICES 
Health Care Financing Administration 
5'! 
The Administrator 
Washington. D.C. 20201

'k~ 
DATE: 
FEB I 31997 

TO:  Bruce C. Vladec
Admstrator \: 
FROM:  June Gibbs Brown 
Inpector General

SUBJECT:  Offce of Inspector Genera (OIG) Draf Report: "Home Health Servces-
Medicare BeneficiBI Satisfaction and Understadig in 
1995" - Operation 
Restore Trust 
We reviewed the above-referenced report concerng home health servces to Medicare 
beneficiares. Our comments are attched for your considemtion. Than you for the 
opportty to 
review and comment on ths report. 
Attchment 
- ( :J 
fTrqC  ; co 
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EAO c 0

SAO 
PDI0
DI!JAS
DI!JEC
DI!JEI
DI!JI
DIO. 
AlO. 
OOCIO 
Execec 
Date Scnt 
 e F' 
HCF A should contiue its effort to educate beneficiares on Medicare-fuded home 
health servces. It should make every effort to ensure the broadest possible distrbution 
the pamphlet and video tape presentation. HCFA should also plan to evaluate the Notice 
of Utition (NOD) afer it has been in use for six to twelve month to determe its 
impact on beneficiar understadig and the regional home health intermediares. 
We concur, HCFA is actively involved in effort to increase and improve beneficiar 
understadig of home health benefits. In October 1996, HCFA implemented the 
requiement that intermediares send an NOU to Medicare beneficiares receivig home 
heath servces. The NOD process wi be phased-in on a national level over the next 
several months. HCFA plans to evaluate the NOD process afer July 1997. In addition, 
HCF A wil requie al intermediares to conduct beneficiar outreach activities related to 
home health benefit coverage issues such as qualty of care, fraud and counelig 
servces.