TennCare trims on the table

Video: Families seek to keep home health-care benefits

Hixson resident Sherry Campbell relies on private-duty nursing services to help care for her 30-year-old son Chad.

Mr. Campbell, who suffered brain injuries in a car accident at 10 months old, has an at-home nurse for 40 hours a week. He also undergoes physical and speech therapy at Orange Grove Center, which serves people with developmental disabilities. TennCare pays for both.

“What keeps Chad at home instead of being in an institution is the fact that I have help,” said Mrs. Campbell, 55, who cared for her son without any outside assistance for the first 20 years of his life.

But ballooning expenditures on home health and private-duty nursing, often in the form of 24-hour-a-day care, are forcing TennCare officials to propose coverage limits.

Spending on these services increased 1,250 percent from 2000 to 2007 — from $18 million to $234 million, TennCare figures show.

“Today, home health and private-duty nursing services are not bankrupting the state. If we don’t manage it now, it will,” TennCare spokeswoman Marilyn Wilson said.

TennCare’s 2009 budget proposes to cap the home health benefit at the amount for the enrollee to be institutionalized. Children and ventilator-dependent adults are exempt.

If the federal Centers for Medicare and Medicaid Services approves the cap, it will go into effect this summer, saving TennCare $87.8 million in state and federal dollars in fiscal year 2009.

State legislation also is on the table to make cost-effective and home-based care options more accessible to the elderly and disabled. Under the current system they have easier access to nursing homes and expensive at-home care.

Gordon Bonnyman, executive director of the Tennessee Justice Center, a TennCare advocacy agency, said the legislation to open up timely access to the home and community-based waiver services must pass before TennCare’s caps go into effect.

“You have to sequence this properly or people are going to be left high and dry,” he said. “We don’t have services available to substitute for care being provided by home health agencies. You don’t want to burn the bridge that you’re standing on until you have something else to move to.”

GROWTH IN THE BENEFIT

Of the 6,579 adults using the home health and private-duty nursing benefit in fiscal year 2007, almost 900 exceeded the average annual cost of intermediate-level nursing home care, which is more than $50,000, said Patti Killingsworth, TennCare’s chief of long-term care.

More than half of those 900 are costing in excess of $100,000 a year, and some individual enrollees have costs of $1 million in a year, she said.

“In this population there are people with very legitimate nursing needs, (but) I do think there are situations in which physicians have ordered and people are receiving services beyond their needs,” Ms. Killingsworth said.

The state’s fragmented and inefficient long-term care system encourages the overuse of the most expensive benefits, TennCare Bureau Director Darin Gordon said.

“The services that are the most costly are the easiest to get in to, the way the system is designed, and that’s something we’re trying to address,” he said.

Compared to other states, Tennessee’s benefit for home health and private-duty nursing is wide open, state officials said.

The benefit is overutilized “and in some cases, exploited,” Mr. Gordon said. “It looks as if people are using this very high-costing service as an alternative to ... home and community-based services,” which are less costly.

For enrollees with extensive medical needs such as Mr. Campbell, the combination of at-home and community-based services is the approach TennCare officials envision for cost-effective long-term care arrangements.

Yet the cost Mr. Campbell’s private nursing care — six hours on the weekday evenings and 10 hours on Saturday — most likely will exceed the cap that the bureau has proposed.

“I think what we have is pretty minimal, but it’s very necessary for me to have that. If they’re talking about cutting those nursing hours, it will make it harder for me, especially as I age,” Mrs. Campbell said.

SPEND LESS, SERVE MORE

By freeing up millions of dollars that may be spent unnecessarily on some patients, far more people will ultimately be able to remain at home, Ms. Killingsworth said.

Tennessee Association of Home Care executive director Gayla Sasser said the changes to how long-term care is paid for will result in more choices for patients.

“I think our industry recognizes the significant expense of maintaining someone at home with nurses in 12-hour, 24-hour shifts. It is very expensive and so having the state propose a cap was not a surprise,” she said.

This month Gov. Bredesen outlined legislation, the Long-Term Care Community Choices Act, that would streamline and centralize the state’s long-term care system.

The legislation would provide a single entry point for all long-term care services, through the state’s nine Area Agencies on Aging and Disability, and speed up the approval process to get on the home and community-based care waiver.

For Medicaid-eligible people in the long-term care system, the legislation would require an enrollee’s assigned managed-care organization, such as BlueCross BlueShield of Tennessee, to coordinate the most cost-effective and health appropriate arrangement of long-term care, Ms. Wilson of TennCare said.

For Medicaid-eligible people in the long-term care system, the legislation would require an enrollee’s assigned managed care organization, such as BlueCross BlueShield of Tennessee, to coordinate the most cost-effective and health appropriate arrangement of long-term care, using the least intensive and most home-based options possible, Ms. Wilson of TennCare said.

State Rep. Dennis Ferguson, D-Midtown, chairman of the joint committee on long-term care, is one of the sponsors of the legislation, which he said should be heard by the end of the month. He said support for the bill is widespread.

“I think this is going to be the biggest thing that’s ever happened to our state in a long time when it comes to health care and helping people,” he said. “This affects everybody.”

Mr. Bonnyman said if the new legislation passes, MCO-directed coordination of care will wipe out the bulk of the unnecessary care driving costs in the home health benefit, making TennCare’s proposed caps on those services unnecessary.

“The whole concept of managed care is you require the managed care organization to work out the most cost-effective mix of services,” he said. “You don’t need to impose some arbitrary cap.”

TENNCARE’S LONG-TERM CARE SERVICES

* Home health and private-duty nursing benefit: Provides at-home care for recipients requiring continuous skilled nursing care, such as for wound care, ventilator services or medication administration.

TennCare spending on this benefit has increased from $18 million in 2000 to $243 million in fiscal year 2007.

* Home and community-based care waiver: Provides a community-based, cost-effective alternative to institutional nursing facility care for people who are eligible for Level 1 nursing home care and are financially eligible for Medicaid. Services include homemaker services, home-delivered meals and assistance with bathing, feeding, dressing, etc.

TennCare’s proposed fiscal year 2009 budget adds 2,300 slots to the 3,700 currently available on the waiver. Call the Southeast Tennessee Area Agency on Aging and Disability at (866) 836-6678 for information on how to apply.

SOURCE: TennCare Bureau; Tennessee Commission on Aging and Disability