Home health programs have the best intentions but are often plagued with fraud

 

 

On Friday, the owner of a Miami home healthcare company pleaded guilty to Medicare fraud that totaled $32 million in stolen funds. According to the FBI release, Felix Gonzalez admitted that he and his partners operated the company in order to bill Medicare for expensive physical therapy and home health services that were never provided. Gonzalez also admitted to paying recruiters kickbacks for patient referrals, prescriptions, plans of care and certifications for medically unnecessary care.

Although names and locations change, this type of scheme has become all too familiar to those who deal in fraud prevention. Just last month, a rash of cases shed some light on the prevalence of home health fraud across the country. One involved an ex-mayor in Minnesota. Another Texas scheme totaled more than $100 million. An infamous District of Columbia fraudster was indicted on six more charges related to a home health scheme she was arrested for in February. All this at a time when Medicare spending on home-visit services has increased 40 percent between 2006 and 2012.

That's the dark side of home healthcare. A sunnier perspective paints the industry as a much-needed option beneficial to both patients and payers. Home healthcare, after all, is much less expensive than nursing home alternatives. For elderly patients, especially, it offers choice and comfort--two words that aren't associated with healthcare enough.

As a result, state-based programs increasingly aim to make home health more accessible. At first glance, these programs exude notable benefits. In California, for example, the In-Home Supportive Services Program (IHSS) is a $7.3 billion state-funded program that pays for home health services for elderly disabled patients. In 73 percent of cases, the caregiver assigned to the patient is a family member, according to Kaiser Health News. Since 2000, the patient case load has nearly doubled, and the budget has more than tripled.

As a result, more lower-income patients receive care in the comfort of their own home; in many cases, this provides life-altering benefits to patients who may have otherwise been relegated to nursing homes. But the program also has glaring weaknesses. Caregivers undergo virtually no training and are not required to submit a background check; oversight has become woefully inadequate as the program has grown, and hiring is left up to the patient.

Here's where things get dicey. This arrangement brings forth particularly egregious cases--inadequate care at best, elder abuse at worse. Kaiser Health News recounts an incident in which one patient's previously homeless daughter was paid $900 a month by the program to care for her mother. The 85-year-old woman eventually died from septic shock related to severe bed sores--a sign of longstanding neglect.

Set aside the unsettling patient safety violations, at least for a moment. If this happened in any regulated healthcare facility, it would be considered fraud. Although it's certainly not as cut and dry as billing Medicare for unnecessary services, as outlined in the Gonzalez case, caregivers are being paid for services that aren't provided. Although IHSS inspectors do focus on fraud prevention, some caseworkers average more than 500 patients. That leads to the obvious question: How much fraud and poor care is really out there?

Of course, this isn't a problem unique to California. The Columbus Dispatch recently reported on the "home care crisis" throughout Ohio. Home health spending in Michigan equals that of 42 other states combined, a good indication that fraud schemes are at play, while Minnesota is woefully inadequate at recouping money from home health fraud. So it's no surprise that the Office of Inspector General openly criticized home health fraud oversight, two years after the agency released a report calling for similar improvements.

To be clear, home healthcare is a good option and a laudable industry. Programs like the one in California, which make that option more accessible to patients, are often implemented with the best intentions. But more often than not, these programs also unwittingly fling open the door to an unprecedented amount of fraud and abuse, not to mention horrifying instances of poor patient care and elder abuse. We see the unsavory impact of that now.

That's where the home health Catch-22 comes in. It seems like every effort to make home health more accessible is met by those who are willing to seize every available opportunity to commit fraud. As the aging population grows, the home health industry and state governments face the following conundrum: Provide affordable and accessible high quality care to patients in need of home health options without making it easy to rob the system blind. How do you offer patients more flexibility with their care while also protecting the financial source that makes that possible?

It's a convoluted problem, with a solution that has been more elusive than we'd like to admit. Personally, I'd like to see state-based programs that make home healthcare more accessible continuing growing--but only if the good outweighs the harm. - Evan (@HealthPayer)

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