The provision of home health care services through health maintenance organizations.
The vast majority of the HMOs responding to the survey in this study use home health care as a substitute for acute inpatient hospitalization, contract out for services with community-based home health agencies, reimburse on a discounted fee-for-service basis, and use prior authorization and concurrent review as the primary methods to control the use of home health care. These findings suggest that HMO home health care services mirror the inadequacies of Medicare home health care in that they are acute care-focused and not intended to fill the supportive and maintenance care needs of the chronically ill elderly. HMOs, however, are typically more flexible in their service provision than is Medicare. Need for home health care is determined primarily on prospective, case-by-case evaluations of cost effectiveness, not on retrospective determinations based on strict, and sometimes arbitrary, guidelines and limitations. This, however, does raise some important issues for access and quality and for the relationship between HMOs and home health agencies. Is cost containment the only legitimate reason for providing home health care? Should home health care be used solely as a substitute for acute inpatient hospitalization? Where does the locus of authority lie for deciding coverage of home health care services? This study uncovered several issues related to the provision of home health care in HMOs that created conflict and uncertainty for all parties. These issues included: conflicting roles for HMOs, whether to provide services internally or externally, contracting between HMOs and home health agencies, the locus of authority for utilization review, the role of physicians, quality assurance, and perceived problems with the Health Care Financing Administration. HMOs are often perceived as failing to do an adequate job of providing home health care services because of the difficulty in satisfying conflicting considerations in three key areas: whether home health care should be focused on cost containment or meeting unmet needs, whether home health care should be focused on acute or long term care, and the unrealistic expectations patients and providers have of HMOs. HMOs primarily provide home health care in an effort to contain costs, particularly by using home health care to substitute for inpatient hospitalization. While HMO representatives acknowledge the importance of home health care in improving the patient's and family's quality of life by providing supportive or chronic maintenance care, the use of home health care for this purpose is generally not allowed by HMOs.(ABSTRACT TRUNCATED AT 400 WORDS)
D000208:Acute Disease; D000368:Aged; D002908:Chronic Disease; D003625:Data Collection; D005069:Evaluation Studies as Topic; D006279:Health Maintenance Organizations / Q000458:organization & administration*; D006699:Home Care Services / Q000191:economics*; D006801:Humans; D006278:Medicare / Q000458:organization & administration*; D008962:Models, Theoretical; D013223:Statistics as Topic; D014481:United States