Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
MEDICARE  BENEFICIARY  SATISFACTION

WITH  AND  UNDERSTANDING  OF

HOME  HEALTH  SERVICES

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> 0EI-04-93-O0143  OFFICE  OF INSPECTOR  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 
car~ng  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  OIGS  Office 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. 
OEIS Atlanta  Regional  Office staff prepared  this report  under  the direction  of Jesse  J. 
Flowers,  Regional  Inspector  General,  and Christopher  Koehler,  Deputy  Regional  Inspector 
General. 
Atlanta Region  Headquarters 
Paula  Bowker,  Project  Leader  Jennifer  Antico,  Program  Specialist

Ron  Kalil, Team  Leader

Peggy Daniel,  Program  Analyst

Betty  Apt,  Program  Analyst

To obtain  a copy of this report,  call the Atlanta  Regional  Office at 404-331-4108.
 I 
Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERA 
MEDICARE  BENEFICIARY  SATISFACTION

WITH  AND  UNDERSTANDING  OF

HOME  HEALTH  SERVICES

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JUNE 
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%>d~~  OEI-04-93-O0143  TABLE  OF  CONTENTS

PAGE

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

SURVEY  RESULTS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...2

Most  Beneficiaries  Are  Satisfied  With  Home  Health  Care  . . . . . . . . . . . . . . . .  2

 
About  Half  Dont  Understand  What  Medicare  Paid  For  . . . . . . . . . . . . . . . . . .  2

 
RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

APPENDICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A  Methodology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  A-1

B:  Survey  Questions  And  Responses  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  B-1

C  Agency  Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  c-1
 INTRODUCTION

PURPOSE

To  determine  Medicare  beneficiary  satisfaction  with  and  understanding  of home  health

services  they  received.

BACKGROUND

The  Office  of Inspector  General  entered  into  a partnership  with  the  Health  Care

Financing  Administration  (HCFA)  in 1994 to examine  home  health  services  paid  for

by Medicare.  Inpart,  weagreed  topefiorm  asumeyof  Medicare  beneficiaries  to

determine  their  satisfaction  with and  understanding  of home  health  services.

Beneficiary  satisfaction  has been  one  of the  concerns  faced  by the  HCFA  Task  Force

on Home  Health  in its efforts  to revise  home  health  services.  As part  of a recurring

nationwide  Medicare  beneficia~  satisfaction  survey, we included  questions,  in 1994,

about  satisfaction  with  and  understanding  of home  health  services.

We  mailed  a survey questionnaire  to over  1200 randomly  selected  Medicare

beneficiaries  for whom  Part  B claims  had  been  filed in calendar  year  1993.  Of the

1002 beneficiaries  who returned  a completed  questionnaire,  200 said they  had  received

home  health  services.  This report  is based  on questions  and  answers  about  home

health  services  from  the  200 respondents.  Details  of the  methodology  are  contained  in

Appendix  A.

We  conducted  this inspection  in accordance  with Quality Standards for Inspections

issued  by the  Presidents  Council  on Integrity  and  Efficiency.

1
 SURVEY  RESULTS

Most M&are  Benejiciati  Are Sati#iedWtihHome HealthCare 
91 percent  of beneficiaries  said home  health  agency  personnel  did an adequate 
b	
job. 
86 percent  of the  beneficiaries  said they received  the  number  of home  health 
b	
visits they  thought  they  needed. 
76 percent  of the  beneficiaries  reported  that  a physician  or home  health  agency 
b	
employee  had  explained  how their  medical  condition  should  improve  as a result 
of care  received  from  a home  health  agency.  Most  of them  believed  their 
condition  improved  accordingly. 
HoweverAbout Ha~ Of l%emDo Not UntkmtandW4atMedicarePaidFor 
As illustrated  below,  only 53 percent  of beneficiaries  thought  it was clear  what 
k	
Medicare  paid  for.  Given  the  confidence  interval  of our  estimate,  there  is 
virtually  no difference  between  the  number  of beneficiaries  who  understood 
what  Medicare  paid  for and  those  who didnt. 
BENEFICIARY  UNDERSTANDING  OF  WHAT  MEDICARE  PAID  FOR 
Ow 
DONT  KN 
CLEAR  53% 
Beneficiaries  in our  survey had  a better  understanding  of what  hospital  services 
b	
were  covered  under  Medicare  than  they  did for what  home  health  services  were 
2  covered.  Sixty-two percent  understood  what  hospital  services  Medicare 
covered,  as compared  to the  53 percent  who understood  what  home  health 
services  were  covered  by Medicare.  Home  health  beneficiaries  do not  receive 
an Explanation  of Medicare  Benefits,  as do hospital  beneficiaries. 
The  survey  instrument  and  responses  are  shown in Appendix  B. 
3
 RECOMMENDATIONS

We  strongly  support  HCFAS ongoing  activities  to improve  beneficiary  understanding 
of the  home  health  benefit.  To this end,  HCFA  should  consider  ways to improve 
upon  existing  opportunities  to explain  the  home  health  benefit  to beneficiaries.  This 
might  include  the  following: 
	 Developing  a plan  to increase  understanding  of the  home  health  benefit  by 
physicians  and  discharge  planners,  and  encouraging  them  to explain  the  benefit 
to patients  receiving  home  health  services,  and 
Stressing  the  requirement  that  HHAs  explain  the  benefit  as well as the  patients 
b	
rights  to beneficiaries  when  they  start  home  health  services. 
In addition  to existing  opportunities,  HCFA  should  pursue  new methods  to increase 
beneficiary  understanding  of what  home  health  services  Medicare  pays for.  This  might 
include  the  following: 
Providing  an Explanation  of Medicare  Benefits  to home  health  beneficiaries, 
b	
and 
Issuing  a description  of the  home  health  benefit  directly  to Medicare 
b	
beneficiaries. 
HCFA  is currently  testing  (1) an Explanation  of Medicare  Benefits  for home  health 
services,  and  (2) a pamphlet  on the  home  health  benefit  that  they plan  to distribute  to 
home  health  beneficiaries. 
AGENCY  COMMENTS 
We  received  comments  on the  report  from  HCFA.  The  HCFA  concurred  with  our 
recommendations  and  provided  more  detail  on their  activities  in this area.  The  full 
text  of HCFAS comments  is in Appendix  C. 
4
 APPENDIX  A

METHODOLOGY 
In July  1994, wemailed  asurvey  questionnaire  to  1279 randomly  selected  Medicare 
beneficiaries  for whom  Part  B claims had  been  filed in calendar  year  1993.  Based  on 
previous  experience  with  similar  beneficiary  surveys, we calculated  our  sample  size to 
produce  an estimate  within  3.5 percent  of the  true  value  at the  95 percent  confidence 
level.  Weusedstandard  equations  forestimating  sample  size with a binary  response 
variable. 
Beneficiary  participation  inoursurvey  was voluntary.  A total  of 1002 beneficiaries 
returned  completed  questionnaires,  for a response  rate  of 78 percent  for the  entire 
survey.  Of those  1002 respondents,  200 had  received  home  health  services  (20 
percent)  and  responded  to our  questions  pertaining  to home  health  services.  This 
response  rate  produced  an estimate  within  ~  7 percent  of the  true  value  at the  95 
percent  confidence  level. 
A-1
 APPENDIX  B

SURVEY  QUESTIONS  MID  RESPONSES 
Following are the questions regarding home health services that were included in the 
broader Medicare  beneficial  sat&faction survey.  l%e numbers preceding  each answer 
indicate how many respondents selected  that answer. 
1.	 Thinking  about  the  most  recent  time  you received  services  in vour  home  from  a 
home  health  a~encv, was it clear  to you what  Medicare  paid  for? 
(Check  one  answer.) 
I have  not  received  services  from  a home  health  agency  since  I 
have  had  Medicare.  (Skip to page  21) 
Yes,  it was clear  what  Medicare  paid  for. 
No, it was NOT  clear  what  Medicare  paid  for. 
I do not  remember  if it was clear  what  Medicare  paid  for. 
Medicare  has not  yet paid  for the  home  health  services. 
I dont know what  Medicare  paid  for. 
2.  Thinking  back  to when  you received  home  care  from  a home  health  agency, 
a.	 Did  the  caregiver(s)  stay long enough  to do his or her job? 
~  YES 
~  NO 
b.	 Did  the  caregiver(s)  do his or her job  adequately? 
~  YEs 
~  NO 
B-1
 3.	 How would  you characterize  the  number  of visits nurses  and  nurse  aides  from 
the  home  health  agency  made  to your  home? 
~  I received  the  number  of visits I needed. 
_NJ  I received  less visits than  I needed. 
7   I received  more  visits than  I needed.
4.	 Did your  physician  or home  health  agency  explain  how your  medical  condition 
should  improve  as a result  of the  care  you received  from  the  home  health 
agency? 
5.	 Did your  condition  improve  as much  as you were  led to believe  you would 
improve? 
y-J)  YEs 
J&  No one  explained  how much  I should  improve. 
6.  How  did you select  the  home  health  agency you used? 
~	 A doctor,  hospital  or other  medical  person  or facility referred  me 
to the  home  health  agency. 
~  Friends  or family referred  me  to the  home  health  agency. 
Jl_  The  home  health  agency  contacted  me  first. 
~  I dont recall. 
B-2
 APPENDIX  C 
AGENCY  COMh4E~ 
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1 tl?  Adr]](llis~rator 
Wijstlingtor],  D.C.  20201 
DATE: 
OCT -6  IW 
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June  Gibbs }Irown 
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FROM:  Bruce  C. Vladeck 
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Administrator  - 
SUBJECT:  O~Ce  of Inspector  GcneraI Draft Report: Meticae  Deneficiq 
Satisfaction  With and UnderstaI]di[lg of IIome Health  Services, 
(OEI-04-93-00143) 
we  reviewed  the above-referenced  repoti  on Medicare beneficiq  satisfaction  with home 
health services.  Attached  are our comments on the report recommei]dations. 
Thank  YOUfor  the  opportu[]ity  to review and commc])t on this draft report. 
Attachment  Comments  of the Health  Care  F@ncinq  Administration  (HCFA) 
on OffIce of Inspector General (OIG) 
Draft Report, Medicare  Beneficiary  Satisfaction  with
. 
and  Understanding  of Home Health Services,: 
QEI-04-93-00143j 
OIG Recommendations 
o	 IICFA should  consider  ways to improve upon existing oppoi tunities  to explain the 
home health  benefit  to beneficiaries. 
0	 HCFA should pursue new methods to increase beneficiary  understanding  of what 
home health  services  Medic,are pays for. 
HCFA Response 
We concur  and are pleased  that (JIG llas acknowledged  our ongoing activities  to improve 
beneficiary  understanding  of the home health benefit. 
Tle  benefit  of providing  ranExplanation  of Medicare  Benefits  (notice  of utilization)  to 
beneficiaries  is being pilot tested  in Flofida and Alabama.  Similar infot-matio~  in survey 
form, is being sent to ordering  physicians  in Georgia and Mississippi.  A final report 
including  our  plan  of action  will be available  in Decemhcr  1995. 
A pamphlet  explaining  the Medicare  home hea,ith betlefit was developed  through 
HCFAS home health  initiative,  It was reviewed by several beneficiary  advocacy  groups 
and provider  organizations,  i.ncuding the ]lome }Iealthassociations.  It was  tested 
alSO 
with stnall  groups  of Medicare  beneficiaries  in three  states.  The  pamphlet  will  be ready 
for distribution  in November  1995.  We will  publicize  the existence  of the home health 
pamphlet  through  the Medicare  hotline  and other sources, such as the Senior Advocacy 
News Service. 
The pamphlet  will be distributed  to groups aMdorganizations  that provide  counseling  and 
assistance  services  to beneficiaries  SIIChas the [formation  Counseling  and Assistance 
(lCA) state grantees,  the Retired  Seniors volunteer  Program, state and area Agencies  On 
Aging,  and  others.  It wil] also  be distributed  to hospitals  to be shared  with  the std% 
(hospital  discharge  planners  anti social workers) who assist  beneficiaries  with  their 
posthospital  health  care  needs.  Hnrd  and  canlera-re~dy  copies of fhe pamphlet  will be 
sent to a variety  of provider  organizations.  Page  2 
We hope to produce  a short video describing  Medicares  home  health benefit.  The video 
will be distributed  to hospitals,  senior centels,  and ICA grantees.  We expect to release 
the video in early  1996. 
We recently  published  a final rule to strengthen  our hospital discharge  planning 
requirements.  In that rule, we require hospitals  to provide a discharge  planning 
evaluation  to patients  and to discuss the results of the evaluation  with the patient  or 
individual  acting on his or l~erbehalf  We filso plan to propose a general revision of the 
hospital  conditions  and, in this context,  t~lli consider any comments  we receive  on how 
hospitals  could  be encouraged  to voluntarily  ed~]cate their  physicians,  discharge  planners, 
and  Medicare  patients  ou the home health benefit.  However, a major goal of the planned 
revision  is to reduce  the number and scope of prescri ptive, process-oriented  requirements 
that hospitals  must meet, and any changes in the conditions  would have to be evaluated 
relative  to this objective. 
Currently,  home health  agencies  (IIHAs}  responsibilities  in this  area  are more specific. 
~  the current  patients  rights condition  of p[uticipation  at section 42 CFR 484. 10(e), 
HHAs are required  to inform patients,  orally  and in wl-iting, of the following:  (1) the 
extent to which payment  may  lX expected  from  Medicare,  Medicaid,  or any other 
Federally-fi.mded  or aided program known to dle 13}IA;(2) the charges for services  that 
will not be covered  by ?vfedica.re;and (3) the charges that the individual  may have to pay. 
In addition,  the HHA must inform patien~s {}faIIy changes in the inf nnation,  orally and 
in writing,  as soon as possible,  but IIOlater tha,n30 calendar days from the date the HHA 
becomes  aware of the change.