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Since When is a Co-Pay the Cure for Fraud?

Medicare coverage for home care visits has a checkered history. The original rationale for including home care in Medicare was straightforward and compelling: it’s much cheaper, healthier and pleasant for a patient to be at home receiving skilled care than to stay in a hospital for lack of enough support in the home environment.

That logic remains solid.

Unfortunately it doesn’t mean Medicare spending has dropped with home care coverage in place. That’s because operators of home care agencies don’t see it as their job to reduce Medicare spending and neither do hospitals. Both want to make as much money as possible under the fee-for-service system. Home care ended up being an additional cost to the system, not a cheaper substitute for the hospital.

There have been various attempts to control home care spending. The latest is a 13-1 recommendation by the Medicare Payment Advisory Commission to impose co-payments to discourage unneeded use of home care services. From the AP (Seniors may have to pay for Medicare home health):

Part of the problem appears to be rampant fraud. In some counties home health admissions exceed the number of residents on Medicare.

Several commissioners said they worried about the impact of a new charge on seniors with modest incomes. Numerous studies have shown that even small copayments can discourage patients from getting medical services…

The recommendation exempts low-income patients, whose copayments would be covered by Medicaid, as well as those just discharged from the hospital. More than 30 million beneficiaries in traditional Medicare would be directly subject to the fee. Repercussions for seniors in private Medicare Advantage plans are uncertain.

Specific co-payment levels have not been set, but according to the article they are likely to be about $150 for a series of visits.

Maybe this recommendation will reduce overall costs to Medicare, but I kind of doubt it, because:

  • There are plenty of ways those bent on fraud can continue to exploit the system. I don’t see how a co-pay provision for a portion of Medicare recipients will slow fraudsters down for more than a minute
  • Co-pay’s are a blunt instrument and will discourage some needed care while still providing a subsidized bargain to others

I’m not saying co-pay’s for home care absolutely shouldn’t  be introduced. After all, Medicare has co-pays for other services. Still, if the problems we want to tackle are excessive costs and fraud there are a couple of better approaches:

  • Global payments so that hospital systems are responsible for the overall cost of a patient’s episode of care. That’s likely to get hospitals to substitute home care for hospital care when possible
  • Introduce more sophisticated fraud-detection tools in the market. These violations are not that difficult to ferret out with modern approaches
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