Rising need for home health care puts pressure on medicare. Critics say US has not set fair payment criteria

One of the lesser-known parts of the sprawling US medicare system is also the fastest growing and the subject of rising controversy. It is the home health care program, designed for people who are ``homebound,'' and need ``intermittent'' skilled care from nurses and nurses aides.

At issue is fairness to taxpayers and private organizations which provide services, and equity to older Americans in need of physical assistance. The issue involves the question: Are these Americans obtaining the care at government expense for which many are eligible?

The Department of Health and Human Services (HHS) has begun a reorganization of one aspect of the program which it says should end some criticisms. However, it is uncertain whether the move will blunt all criticism by certain members of Congress and other organizations.

A study recently released by the American Association of Retired Persons, for instance, says that despite growing demand for home health care, the government is seriously restricting older Americans' access to benefits.

Critics charge that criteria are too vague for determining when the federal government will pay for the skilled nursing care in the home of older Americans, and that the HHS administration is informally telling agencies that they must refuse more claims for such payment - a charge denied by the government.

In 1983 the federal government began a major effort to hold down costs of the medicare system, which was then facing the prospect of bankruptcy within a decade. A significant portion of that effort was to see that hospitals did not keep patients overly long; persons who could be aided as well in nursing facilities, or their own homes, were to be sent there rather than retained in the hospital.

In large part as a result, agencies that provide nursing services to people in their own homes report a 37 percent increase in the number of medicare patients they have aided since 1983.

The way this home care system works, agencies provide the medical services to medicare patients. The agencies then ask designated institutions, such as insurance agencies under contract to the federal government, to provide payment with medicare funds.

If the request is approved, Uncle Sam provides the money; if it is turned down, the agencies are likely out of pocket, although for a modest number of cases the federal government will provide funding anyway. The number of these denials of payment have tripled since early 1983, although only a very small percent of claims are refused.

A report of the Senate Special Committee on Aging this summer charged that HHS ``uses unwritten and unpublished guidelines to limit the medicare home health benefit.'' The implication is that the judgment is based on financial or arbitrary reasons, and irrespective of the medical validity of the claim.

HHS strongly denies the charge. ``We want the people that are homebound and need home health care to get it,'' says a spokesman. ``But those that can get out to doctors and clinics should do so.''

This response leads to the subject of the controversy: the vagueness of two principal eligibility requirements - that persons must be ``homebound,'' and must require ``intermittent'' care.

Critics charge that an increasing number of patients in very difficult physical straits are effectively homebound yet adjudged ineligible because, with considerable assistance from family and friends, they are able to be taken to a physician once a month.

Further, critics say a ruling on eligibility often depends on which financial agency passes on the claim. In an effort to make the judgments more uniform, HHS last month began reducing the number of these agencies from 52 to 10.