Department of Health and Human Servces 

OFFICE OF 

INSPECTOR GENERAL 

HOME HEALTH SERVICES 

Medicare Beneficiary Satisfaction And 

Understanding In 1995 

SERVICE 

'0 

""d:m 

JU GffBS BROWN 

Inspector General 

Apri 199 

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. 

'lO'd3'O 

JU GffBS BROWN 

Inspector General 

Apri 199 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. Ths is a statistically signficant increase at the 90 percent confdence level. 

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 Medicarefunded 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. 

AGENCY COMM 

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 
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......................... . . . . . . . . . . 

TABLE OF CONTENTS€

PAGE EX SUMY 

INODUCTON . . 

FIINGS. . . . . . . . . . . . . . . . . . . 3 

Contiued Satisfaction ........................ .................. 3 

Understanding Of What Medicare Paid For 

State "Hot ties . . . . . . . . . . . . . 4 

RECOMMATION. . . . . . . . . . 5 

AGENCY COMM ............................................ 

APPENIX 

SUIVey Questions And € . . . . . . . . . . . . . . . . . . . . . . . . . . 

Responses

Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. B-
INTRODUCTION€

PUROSE€

To determe beneficiary satisfaction with and understanding of home health servces.€

BACKGROUN€

The Medcae Progr€

Medicae is a Federal health inurance program for individuals age 65 and older, and for€ cert !;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€

completed questionnaires, 914 said they had or had not received home health servces in€ health servces. € 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 

MEICA BENCI CONT TO BE SATIFI WI HOME HETH CAR /J Sa Home Heo Agen Di An Ade 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. 

Pote Be 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. 

Med Peronn Gen Refered Be 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. 
MOST BENCI UNEROOD WHT MEICAR PAI 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.€

FEW BENCI WE AWAR OF STATE HOT LI 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? 

(Check one aner. 

103 Yes, it was clear what Medicare paid for. 

, 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 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 

How would you describe the number of viits you reived from the home agency? 

123 I received the number of visits I needed. 

I received fewer visits than I needed. 

I received more visits than I needed. 
How many ties did the caegier(s) come when he or she wa suppo to?€

106 Every tie€

Most of the time€

Some of the tie€

Seldom€

Never€

Was the caegier(s) frm the home heath agency courus and re?€

130 Yes€

Some caregivers were courteous and some were not.€

(Please explai): Took food and drik and Tvleno hout as!i€

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. 

How did you selec the home heath agency you us? 

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. 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 
: ..

fTC; co 

(., 

DEPARTMENT OF HEALTH &, HUMAN SERVICES Health Care Financing Administration 

5'! The Administrator 

Washington. D.C. 20201


DATE: FEB I 31997 


TO: Bruce C. Vladec'k~ 

Admstrator \: 

FROM: June Gibbs Brown 

Inpector General


SUBJECT: Offce of Inspector Genera (OIG) Draf Report: "Home Health ServcesMedicare 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 

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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.