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Homecare Industry Rallying Support to Kill Reconciliation Act

Senate bill going back to House for final vote freezes pay rate at 2005 level

Jan. 22, 2006 – Among the most active in fighting to kill the Budget Reconciliation Act is the American Association for Homecare, the industry group for home health care providers and those who use this service. Despite home health care being a popular option with senior citizens and studies showing it can be the least costly way to care for the elderly, the bill has several provisions that negatively impact the service. The most critical is a freeze on their pay rate for services from the Centers for Medicare and Medicaid Services.

The pay rate was scheduled to increase 2.8 percent for 2006, but will be frozen at 2005 levels by the bill, which is expected to be considered by February 1. Since the bill has not been approved, the rate increase did take effect on Jan. 1, 2006, and CMS says until the bill is final, they do not know if this money will have to be repaid.

"Homecare is the preferred by seniors, and homecare is by far the most cost-effective setting for healthcare in America, as HHS Secretary Leavitt has argued," says AAH on their Website. 

"A cut to home health agencies is clinically and fiscally unwise given its tremendous value to both patients and to taxpayers."

This is just is the most important but only one of the reasons, however, that AAH is opposing the bill (S. 1931), when it returns to the House for a final vote. A compromise bill approved earlier by the House was also approved by the Senate but due to technical points raised by Senate Democrats, it has to be voted on again in the House.

Another key objection is that the bill eliminates the beneficiaries' option to continue to rent home medical equipment, eliminating the capped-rental category, transferring title of the equipment to the beneficiary after 13 months, and eliminating the maintenance fee.

The bill also makes home oxygen equipment a rent-to-purchase item, forcing transfer of ownership to beneficiaries after 36 months, which AAH opposes.

"Beneficiaries choose to rent rather than purchase this medical equipment because renting allows worry-free, professional maintenance of complex medical equipment and lowers costs to seniors," says a message from AAH to members.

"Forcing seniors to take title of complex medical equipment after a capped rental period is unfair and dangerous."

The association also says, "Oxygen equipment in particular is critical to approximately one million Americans who suffer from respiratory illnesses such chronic obstructive pulmonary disease (COPD) and who require oxygen therapy.  Oxygen is a federal legend drug and the devices are prescription only. Transferring the burden of maintenance and repair of sophisticated oxygen technologies to the beneficiary presents a serious risk to patient safety and care."

The association says many state homecare associations and homecare providers report that – when asked – homecare beneficiaries are turning out in force to voice opposition to the budget bill, S. 1932.

One example of beneficiary action AAH cites is from Shawn M. Steffey of Respiratory Care Associates in Winchester, VA. He reports that "they sent more than 400 letters to their beneficiaries regarding the changes to oxygen policy in S. 1932."

As a result - “We are receiving three to five calls per hour from patients either asking for more information about what to say to their congressman or to tell us that they have called.

"For the most part, every patient we have heard from is extremely opposed to the O2 cap. Several patients have told us that the congressman’s office asked how they were getting this information and that they were ‘unaware’ of this provision being in the bill," reported Steffey.

"I am estimating that at least 50 to 75 of our patients have called their congressman in the past three days. Imagine the result if every member did the same thing. I truly believe that if we can defeat this bill, it will only be through the voices of our patients."

At the AAHomecare’s Website, www.aahomecare.org are provided two sample letters that can be sent to beneficiaries.

"While a number of Republicans in the House voted against the bill the first time it was considered, it is vital to convince additional Republicans to vote NO in the final up or down vote," says the AAH message to members.

There is some benefit to the home health industry in the bill. Despite proposing a freeze on the primary rates, it does re-instate the rural add-on of 5 percent for 2006. The rural add-on expired last April 1.

The Oxygen Proposal

An alarming provision in the bill for many seniors is a new rent-to-purchase payment policy for home oxygen equipment after 36 months. Based on language in the bill, after a maximum 36 month rental period, all home oxygen stationary and portable technologies will be considered “purchased” and the title of the equipment and responsibilities for the maintenance, service, and repair of the devices transferred to the Medicare beneficiary.

"This is a drastic, unprecedented and inappropriate shift," according to AAHomecare.

Oxygen cylinders and liquid vessels are the drug’s container/closure. Oxygen concentrators and oxygen concentrators with add-on compressor units are devices that - when properly serviced and maintained - are used for the safe administration of medical oxygen, says the association.

The list below identifies some of the key FDA regulatory, patient, and public-safety issues that could result from the forced conversion of medical oxygen administration devices to private ownership.

Currently, medical oxygen can only be prescribed by a physician specifically for individual patient use because it is a drug. While oxygen has many therapeutic benefits, it can be dangerous if not properly administered or used.

  ● With the transfer of ownership of the medical device to the patient, the control over the dosage levels becomes the patient’s responsibility and the opportunity of self medication to their own detriment is increased significantly.

  ● Today many of the home oxygen patients are prescribed liquid and/or high pressure oxygen to assist and enhance their rehabilitation and mobility. Under the proposed legislation, the use of liquid oxygen and high pressure cylinder oxygen may be greatly diminished as viable modalities, and patients could be forced to accept stationary systems as their only source.

  ● There is a potential for patients who may, based on cost and/or ease of procurement, shift to industrial oxygen to meet their needs.

Many Safety Issues Arise

  ● Ongoing patient education and monitoring regarding oxygen usage and safety will no longer be performed, creating the potential for unsafe use of oxygen (e.g., smoking while using oxygen).

  ● The use of life enhancing medical oxygen equipment is imperative to the overall well being of patients on oxygen therapy.  Homecare companies currently provide 24-hour on-call service to assist patients with trouble shooting equipment malfunctions or improper use. Lack of 24-hour on-call support will undoubtedly increase patient visits to emergency rooms and the need for readmissions to hospitals.

  ● Homecare companies would no longer perform routine maintenance on concentrators and liquid oxygen systems after 36 months with potential detrimental effects to the patients (e.g. equipment malfunction, low O2 percentage delivery, etc.).  In addition, once ownership of medical oxygen equipment is transferred to the patient, homecare companies will no longer be able to assist the equipment manufacturer with potential recalls.

  ● Once ownership has converted to the patient and the patient expires, relatives may decide to dispose of cylinders containing hazardous oxidizing material into the trash leading to potentially unsafe conditions for the general public.  These cylinders may also be used by inexperienced, untrained, and unqualified individuals in ways that are inappropriate and dangerous.

  ● Discarded medical equipment may find its way back into service.

  ● Typical cylinder filling is currently performed using a multi-cylinder manifold following cGMPs.  Filling only one or a few cylinders based on an individual patient request is not practical.  When patients take ownership of high pressure cylinders, the potential exists for them to attempt to fill their own cylinders using one-to-one cylinder filling.  The supply cylinder may be industrial product.  In addition, the potential exists for non-compliant companies to arrive at a patient’s doorstep and offer to fill his or her cylinder curbside without following cGMPs (e.g., proper pre-fill inspections, evacuation, testing, labeling, etc.).

  ● Additional concerns include hydrostatic testing, product traceability, drug product labeling with the potential for misbranding, chain of custody and control issues, and other hazardous material concerns.

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