Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

MEDICARE BENEFICIARY SATISFACTION


WITH AND UNDERSTANDING OF


HOME HEALTH SERVICES


SERWCE$ p,t+ J+ ~iq 

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JUNE GIBBS BROWN 

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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 OIG’S 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. 

OEI’S 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


#J SERVJC[$ 

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JUNE GIBBS BROWN ~v 

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


PAGE


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


SURVEY RESULT’S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...2


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


� About Half Don’t 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 President’s Council on Integrity and Efficiency.


1

SURVEY RESULTS


Most M&are Benejiciati Are Sati#iedWtihHome Health Care 

b	 91 percent of beneficiaries said home health agency personnel did an adequate 

job. 

b	 86 percent of the beneficiaries said they received the number of home health 

visits they thought they needed. 

b	 76 percent of the beneficiaries reported that a physician or home health agency 

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%em Do Not UntkmtandW4atMedicarePaidFor 

k	 As illustrated below, only 53 percent of beneficiaries thought it was clear what 

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 didn’t. 

BENEFICIARY UNDERSTANDING OF WHAT MEDICARE PAID FOR 

DON’T KN Ow 

CLEAR 53% 

b	 Beneficiaries in our survey had a better understanding of what hospital services 

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 HCFA’S 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 

b	 Stressing the requirement that HHAs explain the benefit as well as the patient’s 

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: 

b	 Providing an Explanation of Medicare Benefits to home health beneficiaries, 

and 

b	 Issuing a description of the home health benefit directly to Medicare 

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 HCFA’S 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 don’t know what Medicare paid for. 

2. Thinking back to when you received home care from a home health agency, 

a.	 Did the caregiver(s) 

~ YES 

~ NO 

b.	 Did the caregiver(s) 

~ YEs 

~ NO 

stay long enough to do his or her job? 

do his or her job adequately? 

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 don’t recall. 

B-2

APPENDIX C 

AGENCY COMh4E~ 

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FROM: 

SUBJECT: 

we reviewed 

Healttl Care Financirlg Administr 

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1 tl? Adr]](llis~rator 

Wijstlingtor], D.C. 20201 

OCT -6 IW 

June Gibbs }Irown 

Inspectc]r CrlleraI 

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Bruce C. Vladeck c~ 

Administrator ——-— 

O~Ce of Inspector GcneraI Draft Report: “Meticae Deneficiq 

Satisfaction With and UnderstaI]di[lg of IIome Health Services,” 

(OEI-04-93-00143) 

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 

HCFA’S home health initiative, It was reviewed by several beneficiary advocacy groups 

and provider organizations, i.ncuding the ]lome }Iealthassociations. It was alSO tested 

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 Medicare’s 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 patient’s 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.