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CMS has published the second quarterly 2003 home health consolidated billing updates. The update adds a single nonroutine supply code (A6440 “Zinc Paste>=”<5″ w/roll”) to the list of codes subject to consolidated billing. CMS identified the code too late to include it in the Medicare system changes for the January quarter.

Ensuring access to expensive new drug therapies for persons with HIV disease is important because access to these therapies is related to morbidity and mortality (Palella et al. 1998). Over the past decade, the proportion of costs attributable to drugs has risen from 10 percent to more than 40 percent among persons with HIV disease, and the cost of drug therapy is now between $10,000 and $15,000 per year (Hellinger 1993a; Bozzette et al. 1998, 2001).

The importance of drug therapy is evidenced by the drop in the number of HIV deaths in the United States after the diffusion of drug therapies that include a protease inhibitor or a nonnucleoside reverse transcriptase inhibitor and at least one nucleoside reverse transcriptase inhibitor (referred hereinafter as highly active antiretroviral therapy or HAART)(Aldridge, Davis, and Doyle 2002). In December 1995, the first protease inhibitor was approved and several other protease inhibitors were approved in early 1996 (Moore and Chaisson 1997). In June 1996, the first nonnucleoside reverse transcriptase inhibitor was approved. In 1995, there were 51,117 persons in the United States who died from AIDS, and, after the diffusion of protease inhibitors and nonnucleoside reverse transcriptase inhibitors in 1996, the number of persons who died from AIDS fell to 22,245 in 1997 (Centers for Disease Control and Prevention 2001).

Over the past several years the rate of increase in the number of women with HIV disease has exceeded that of men. And, it is likely that this phenomenon will endure because 21 percent of persons living with HIV disease in the United States were women in 2001 yet more than 32 percent of those newly infected with HIV in 2001 were women (Centers for Disease Control and Prevention 2002).

Existing studies of gender-based differences among persons with HIV disease have been conducted before the diffusion of protease inhibitors and nonnucleoside reverse transcriptase inhibitors or immediately thereafter. This study examines gender-based differences in access to new and costly drug therapies four years after the introduction of proteases inhibitors and nonnucleoside reverse transcriptase inhibitors.

To insure that patients are prescribed appropriate combinations of antiretroviral drugs it is important that patients be closely monitored and that patients receive immune panel tests to measure their level of CD4+ cells and the quantity of virus in their bloodstream (i.e., viral load). It is also important that patients have access to a variety of outpatient and inpatient services in order to mitigate the occurrence of opportunistic infections and adverse drug reactions. Consequently, this study examines variations in the utilization and cost of all health care services by women and men with HIV disease.

This study is based on administrative data, not on patient recall, and it is the first claims-based study of the privately insured population of persons with HIV disease. Problems related to patient recall are likely to be greatest among the population of patients who received many health services and among patients who have cognitive problems. And, HIV patients receive many health care services and are more likely than other patients to suffer cognitive impairments (Belkin et al. 1992).

BACKGROUND

Identifying Patients with HIV Disease

Explicit codes for HIV-related illness (codes 042 to 044) were put into practice in October 1986 (Green and Arno 1990). After October 1994, the International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9-CM) system included only one code (042) for HIV disease and AIDS (Fasciano et al. 1998).

In the most comprehensive study of the accuracy of diagnostic coding for persons with HIV disease, it was determined that 97 percent of persons with an HIV diagnosis on their hospital discharge abstract were infected with HIV (Rosenblum et al. 1993). In that study more than 7,000 hospital records of persons in six states with diagnostic codes indicative of HIV disease were examined, and it was determined whether or not an individual was infected using AIDS surveillance data from state health departments and a review of the medical charts. The predictive accuracy of using codes for AIDS-related illnesses was poor. For example, it was determined that only 38 percent of patients with the diagnostic code for Pneumocystis carinii pneumonia (136.3) were infected with HIV.

Access to Antiretroviral Drugs

The first drug approved to treat HIV disease was zidovudine (also referred to as AZT and by its brand name Retrovir). It was approved in March 1987 for persons with CD4+ cell counts of less than 200 or persons with a documented case of Pneumocystis carinii pneumonia (PCP). In March 1990, the Food and Drug Administration expanded the recommended use of zidovudine to persons with CD4+ counts of less than 500.

The AIDS Cost and Service Utilization (ACSUS) was the first large survey of persons with HIV disease that examined the utilization of healthcare services (Fleishman, Hsia, and Hellinger 1994). ACSUS conducted surveys of almost 2,000 persons with HIV disease from 26 sites (hospitals, clinics, and physician offices) in 10 cities in 1991 and in 1992. In his study of ACSUS, Hellinger concluded that, “This study shows that, even after being diagnosed and after having accessed the medical care system, women with AIDS receive fewer services than men with AIDS” (Hellinger 1993b, p. 543). In particular, Hellinger found that women with HIV disease were less likely to receive zidovudine than men with HIV disease.

The “Catholic” in Catholic health care is set to become a brand name. Catholic hospitals are to be marketed as a large but special niche within the sprawling $1.54 trillion U.S. health care industry.

That was the word–and steady drum-beat–from Catholic health care leaders at the 88th Catholic Health Assembly here June 8-11.

U.S. Catholic health care faces an increasingly complex existence complicated by mounting financial pressures. At the same time, the Catholic ministry refuses to back down from fresh public undertakings. In its day-to-day operations, Catholic health care must maintain state-of-the-art facilities catering to the broad U.S. public while simultaneously keeping its doors open to the poorest people in the society.

All of which means that some 600 Catholic Health Association members gathered here, willingly or hesitantly as administrators and local leaders, added their weight to two new central CHA goals: to achieve health coverage for all Americans by the end of the 110th Congress (calendar year 2008), and to reacquaint all Americans with Catholic health care’s vital role and commitment as the country’s largest nationwide nonprofit health services provider present in all 50 states.

The theme spelled out the intent: “Advocacy, uniting our voice for change.”

The means had much to do with the marketing plan.

Task forces, speakers and panelists took on the underlying issues: health care reform, and the need to “brand name” Catholic care.

On the first point, health care coverage for all isn’t the end social goal–full-fledged health care reform is, explained Carol Bayley of Catholic Healthcare West.

“Health care reform isn’t just crowding more people under the leaky umbrella,” she said. “Even if everyone is covered, would we have a good health care system? No. We’d still have a cobbled-together system with more people in it.

“But how to change it?” she asked, rhetorically. “We [Catholics] don’t have a lot of good theory or good models of practice. And remember how deeply we are embedded in the existing system. We have a lot of reasons not to change the fundamental system.”

Essentially, she said, a nation’s health care system that requires the person to be employed in order to be covered is flawed in “an economic system, a capitalistic system, that runs on an engine that requires between 4 and 6 percent unemployment to function.”

“So we have an economic system predicated on unemployment,” she said, “and yet we give health coverage only to people who are employed. How much sense does that make if we want to take care of people’s health the way we take care of their literacy–by guaranteeing education for all?”

Continued Bayley, “Our mission is to keep hospital doors open so the poor have somewhere to go. That is convincing, and in the short term that’s what the strategies have to be aimed at. In the long term we have to get to a more equitable system.”

Commitments to increase coverage and develop the Catholic brand name are being made, said CHA president Fr. Michael Place, while Catholic health care is “balancing ethical principles [such as those raised by providing tubal ligations] post-Brackenridge” with staff shortages, rising salary, pharmaceutical and technology and Medicaid cutbacks, the increasing numbers of Americans uninsured, and relationships with the marketplace.” (”Brackenridge” refers to the manner in which an Austin, Texas, Catholic-owned hospital dealt with the question of providing tubal ligations. See NCR, July 4.)

Balancing ethical principals with practical demands, said new Catholic Health Association chair Richard Statuto, president and CEO of St. Joseph Health System, Orange, Calif., means that Catholic health care has to recognize “the power we have in our unified commitment”–meaning the three quarters of a million Catholic health care employees, and the millions more Americans annually served by Catholic hospitals.

Scarcely surprising, given the Catholic systems’ overall size and internal changes, even the Vatican is somewhat bewildered.

For decades, because they were run by religious orders, Catholic hospitals came under the Congregation for Institutes of Consecrated Life and Societies of Apostolic Life. But with the switch to lay trustees, some Vatican officials weigh changing oversight to, perhaps, the Pontifical Council for the Laity.

During his walkabout address at his “president’s lunch,” Place explained to the assembly that the Vatican is concerned that it may not be able to supply the managerial expertise to assess or place in perspective multibillion dollar operations with a Catholic mission.

Back at home, said Place, what has never been mobilized on Catholic health care’s behalf is the interest and support of the overall numbers, neither the wider Catholic sentiment, nor the internal employees.

There is already a New Covenant initiative (see Peter Feuerherd’s upcoming account, NCR, Aug. which is an attempt to meld Catholic interests together at the local and regional levels. In the meantime, the challenge now is to organize, in the words of. CHA chair Statuto “all these internal stakeholders–staff, the sponsoring religious communities, physicians, management, trustees, employees–into true advocates for Catholic health care ministry wherever they are. Every facility, every person, has a role.”

USDA is providing $1 million in grants to promote the establishment of rural home health care cooperatives. Deadline for applying for the grants, provided under the Rural Community Development Initiative (RCDI), is Feb. 13, 2004. The grants are to be used for pre-development work or revolving loans.

“Creating a strong network of rural health care services is critical to improving the quality of life of families living in rural areas,” says Agriculture Secretary Ann M. Veneman. “These grants will support community-based efforts to establish home-based health care cooperatives that will help meet local health care needs.”

Pre-development grants to assist cooperatives with providing outreach to home-based health mare providers, assessing local-level human service provider needs and assisting with the organizing and implementation of a successful cooperative structure are available to qualified public bodies or nonprofit-based community development organizations.

Grants to assist in the funding and administering of a revolving loan program to provide start-up and operating funds to newly created home-based health care cooperatives are available to qualified public or nonprofit intermediary organizations (including tribal organizations).

For revolving loan fund grants, recipients are required to obtain matching funds equal to the amount of the USDA grant. Eligible applicants must be located in rural areas with populations of 50,000 or less. Funding of selected applicants will be contingent upon meeting the conditions of the grant agreement.

This paper by Janet Furniaux and Theresa Mitchell reports on the findings of a one year project in Gloucestershire that piloted a community mental health nurse (CMHN) initiative to liaise with care homes for older people, offering support, advice and education to senior carers and nurses. The key aims of this primary/secondary care initiative were to increase the knowledge and thereby confidence of staff working in care homes for older people in relation to the assessment, treatment and care of older people with depression and dementia. Although this pilot study is based on a small sample, the findings suggest that specific mental health nursing/carer qualifications are held by very few care home staff (6.4% n=5). It suggests that training tailored to identified educational needs has a positive effect on the knowledge and confidence levels of staff working in care homes. This pilot study was funded by Barnwood House Trust Challenge Fund and focused upon a small sample of 25 care homes. The findings may be used to inform future service development within the area Dementia and depression are significant but neglected causes of disability amongst older people. This constitutes a challenge to health and social care provision in the United Kingdom and is particularly pertinent to staff working in care homes for older people (Pritchard and Dewing, 1999).

The pilot study reported here aimed to explore the educational needs of staff from identified care homes in order to devise and deliver a teaching package relating to dementia and depression in older people. The impetus for the pilot study came principally from the National Audit Report - Forget Me Not (The Audit Commission, 2000) and the National Service Framework (NSF) for Older People (Department of Health (DoH, 2001a). The National Audit Report found significant variations in admission rates to psychiatric wards from care homes for older people. It was suggested that some admissions to psychiatric wards may be avoided if community mental health teams (CMHTs) provide support and training to care home staff in relation to these mental health disorders.

The role of the CMHTs in providing advice and support to care homes for older people was reinforced by the NSF for Older People (DoH, 2001a) that suggests an outreach service should be offered to those providing residential/nursing care for older people. The NSF for Older People (DoH, 2001a) and the Essence of Care (DoH, 2001b) aim to establish new standards for care of older people (Aoki and Davies, 2002). This process of benchmarking will directly affect staff working in care homes as they will be expected to update their knowledge in relation to different areas of practice, including mental health.

Since April 2002, all care homes for older people have been subject to National Minimum Standards for staff training (Department of Health, 2001c) which aim to address variable standards between care homes. In relation to mental health, it is suggested by the NSF for Older People (2001a) and the Health Promotion report, Making it Happen (DoH, 2001d), that within care home environments, training is necessary to address care requirements for patients with depression and dementia. It is suggested that an improvement in training and education will have a positive effect on patient care and staff attitudes (Skog et al, 1999; Ballard et al, 2002).

For the purpose of this study, care home staff were asked to identify their knowledge and confidence levels in relation to caring for older people with dementia and depression both before and after receiving the content of the teaching package developed in response to the needs of care home staff.

The aims of the study were to:

* Identify the educational needs of care home staff, in relation to the care of older people with dementia and depression.

* Design and deliver a teaching package to care homes to meet identified educational needs.

* Increase the knowledge and confidence of staff working in identified care homes, in j relation to the care of older people with dementia and depression.

An approach similar to action research was adopted for the study which involved the systematic collection and analysis of data to identify the changes required in practice, and in addition, an evaluation of the changes after they had been implemented (Coghlan and Casey, 2001; Le May and Lathlean, 2001; Moyer et al, 1999). The cyclical process of action research involves

a) defining the problem

b) taking action

c) evaluating the action

d) further planning (Coghlan and Casey 2001)

This approach was chosen for the pilot study for several reasons; there is evidence to suggest that more traditional forms of research may not impact as effectively on practice (Sackett et al, 1997; Le May and Lathlean, 2001). It is anticipated that the outcomes of this pilot study may influence the nature and context of CMHN service delivery.

The researcher’s involvement in caring for older people and the desire to work collaboratively with nurses at the interface of mental health care provision was congruent with an action research approach. The research provided an opportunity for the researcher to liaise between secondary mental health services and care homes for older people. The intention of initial meetings with care home managers was to discuss the potential outcome of the research and also to engage them in the process of the action research cycle. Care home managers were particularly interested in the needs of their staff during the assessment phase, the development of the teaching package in the development phase and the evaluation of progress. The researcher had a responsibility to collaborate with the care home managers and was seen as a facilitator, researcher and practitioner.

CALENDAR

Level   Seminar                          10/27-30   11/17-20   12/8-11
Atlanta    Phoenix    Chicago

Financial Management/
Reimbursement

2       Using Activity-Based
Information to Enhance
Operational Decision Making      10/29-30   11/19-20

2       Cost Accounting Applications
for Management Decision Making   10/28      11/18

2       Cost Control and Six Sigma:
Using Process Redesign to
Reduce Operating Costs           10/27-28

1       Fundamentals of Healthcare
Financial Management             10/27-28   11/17-18   12/8-9

2       Turning Data into Useful
Information: How to
Effectively Collect, Analyze,
and Report Financial and
Clinical Data to Enhance
Decision Making in Health Care   10/29-30   11/19-20   12/10-11

2       Charting Your Course through
Hospital Medicare Cost
Reporting                        10/27-28   11/19-20   12/8-9

2       Emergency Department: APCs,
Compliance, and EMTALA *                               12/10-11

Revenue Cycle

2       Charge Master Strategies to
Enhance and Maintain Your
Billing Process                  10/29-30              12/8-9

2       Denials Management: Improving
Revenue through Effective
Registration, Coding, Billing,
and Compliance ([dagger])        10/29-30              12/8-9

2,3     Revenue Cycle Management
Strategies                       10/29-30              12/10-11

3       Implementing the Ultimate
Revenue Cycle Model:
Strategies for Success                      11/19-20   12/8-9

2,3     Managing Denials to Capture
Lost Revenue ([dagger])                     11/19-20

3       APC Changes for 2004:
Financial Implications and
Evolving Management
Strategies *                                11/19-20   12/10-11

2,3     Revenue Cycle and Supply Chain
Management-Gaining Insight and
Improving Key Hospital
Processes *                                 11/17-18

2       Revenue Cycle Impacts of
HIPAA: An Operational Focus
([dagger])                       10/29-30   11/17-18

Managed Care Operations and
Processes

1       Fundamentals of Managed Care     10/27-28

2       Understanding and Evaluating
Managed Care Contracts                      11/17-18   12/8-9

2,3     HFMA/AAHP’s Health Plans and
Providers: Working Together to
Improve the Claims Process,
Part 3! ([dagger])                          11/18

3       Breakthrough Negotiation
Strategies                                  11/19-20

2,3     Reimbursement Methodologies in
the Changing Managed Care
Environment *                               11/17      12/10

Long-Term Care/Home Health
Care

2       Prospective Payment System,
Consolidated Billing, Cost
Reporting, Coverage, and
Compliance for SNFs and
Subacute Providers               10/27-28              12/8-9

3       Compliance, Coverage, and Cost
Reporting for Home Health
Agencies under the Prospective
Payment System                   10/29-30

* New

([dagger]) Cosponsored with the American Association of Health Plans

(1) Core courses providing, essential knowledge upon which to build
further skills. (2) Operational courses providing nuts-and-bolts
information about solving problems to improve the bottom line.
(3) Strategic courses for healthcare leaders seeking to advance their
organization through long-term planning and best practices.

With a policy of zero tolerance of healthcare fraud and abuse, the Federal government has redoubled its efforts to investigate questionable financial behavior of healthcare organizations. Congress has encouraged efforts to recover healthcare payments secured through fraudulent or abusive means, and coming into this election year, it likely will increase the legislative anti financial support for such efforts. According to the Office of Inspector General (OIG), the FBI dedicated more than 600,000 hours to fraud and abuse investigations in 1995, and OIG staffing, which increased 20 percent in 1997, is expected to double by 2002.

A number of circumstances can trigger an investigation, including audit findings, patient or employee complaints, and clinical reviews. Having an effective compliance program in place, however, can help healthcare organizations reduce their legal and regulatory, exposure and may help mitigate damages should a government investigation uncover evidence of fraudulent or abusive behavior.

Government Antifraud Initiatives

The Federal government has several weapons in its antifraud arsenal. Operation Restore Trust (ORT), a program established in 1995 to investigate overpayments to nursing homes and home health agencies, has become an effective initiative for the recovery of overpayments. As a pilot project limited to five states, ORT investigations resulted in $188 million in recoveries. ORT now has been expanded to 17 states and eventually will operate in all 50 states. In addition, the program will be expanded to include different types of providers and services.

The Federal government also has used broad application of provisions of the False Claims Act to crack down on suspected cases of fraud and abuse. While some charges brought against providers under the False Claims Act have been refuted successfully, the Department of Justice and the OIG continue to resist setting enforcement limits so as to be able to apply the act as broadly as possible.

In addition, healthcare organizations must be prepared to defend themselves against lawsuits filed under qui tam, or whistle-blower, statutes. Whistle-blowers whose actions lead to a successful qui tam lawsuit against a healthcare organization can receive as much as 30 percent of any judgment awarded. Because of the attractiveness of this financial incentive and perhaps as a result of a heightened awareness among individuals, particularly those working for healthcare organizations, of the nature of fraudulent activities, qui tam lawsuits have increased from 33 cases in 1987 to approximately 530 cases during 1997. The financial judgments resulting from these cases have increased from $355,000 in 1988 to more than $625 million during 1997, with an average recovery of approximately $7.2 million.(a)

The IRS also has been investigating both for-profit and not-for-profit healthcare organizations aggressively. Some not-for-profit healthcare organizations may have their tax-exempt status reviewed clue to violations of rules and regulations governing tax-exempt entities as set forth in Sections 501-530 of the Internal Revenue Code (IRC).

Congress’s passage in 1996 of the Taxpayer Bill of Rights 2 gave the IRS additional power to assess penalties called intermediate tax sanctions on disqualified persons involved in excess benefit transactions.

The Next Targets

The home health and long-term care segments of the healthcare industry have been targeted as the next major focus of fraud and abuse investigations, largely because oversight of these segments has been relatively lax to date. These two industry segments also represent the most rapidly growing share of Medicare expenditures.

The OIG currently is conducting and preparing to conduct several studies that could greatly affect provider organizations, particularly with regard to home health and long-term care, in the years to come. These nationwide studies (except where indicated) include the following:

Hospital ownership of home health agencies. This study will determine more precisely how and to what extent hospital ownership of home health agencies affects referrals to these agencies.

General and administrative costs. This study will comprise a series of reviews to determine whether general and administrative costs incurred in chain organizations should be eligible for Medicare payment.

Home health agency cost reports. This limited-scope retrospective review of Medicare cost reports will determine if home health agencies in selected states properly documented the reasonableness of costs (eg, salaries and miscellaneous and accrued costs) for which payment was claimed.

Home health eligibility reviews. This study, currently under way, is being conducted to determine whether home health visits claimed by various home health providers meet Medicare payment guidelines. Thus far, OIG reviews of home health agency claims in California, Illinois, New York, and Texas have found that 40 percent of the services billed did not qualify, for Medicare payment.

ABSTRACT. Background: Home enterai nutrition (HEN) is most frequently prescribed for older adults. Medicare reimbursement policy limits in-home nursing visits, and in-home professional nutrition services are restricted to those patients with diabetes or predialysis kidney disease. Most older adults receiving HEN rely on informal (family) caregivers to provide HEN care. The purpose of this study was to apply care process theory to identify and investigate variables related to health care outcomes of HEN in a sample of older adults dependent on informal caregivers. We assessed relationships among patient characteristics, the HEN regimen prescription and adherence, formal provider involvement, and health care outcomes. Methods: In-home interviews were conducted with a multiethnic (14 white, 8 Hispanic, 7 African American, 1 Asian) sample of 30 older adults (mean = 68.4 years) during their first 3 months of HEN (mean = 1.83 months). Results: Daily enterai intake averaged 1596 ± 553 kcal. Gastrointestinal complications, occurring in up to 63.3% of patients, interrupted daily infusions. Further, one-third reported tube clogging or leaking, and one-third had tube displacement. Water intake was half of calculated need and associated with decreased urination (p = .001). Average weight change was -4.35 pounds (p = .001), and 17 patients had body mass indexes (BMIs)

Older adults comprise the majority of home enteral nutrition (HEN) patients. The main indications for HEN are diseases that often occur in later years (eg, neoplasms of the head, neck, and upper gastrointestinal tract; neuromuscular swallowing disorders; and a variety of bowel disorders, including malabsorption syndromes and anorexia associated with illnesses).1 Medicare payments for HEN are estimated at over $600 million annually.1 In Florida, for example, Medicare paid more than $9 million for HEN during fiscal year 1998.2

However, Medicare reimbursement policy restricts home and community-based professional nutrition services to those patients with diabetes or predialysis kidney disease. Further, in-home nursing services are typically limited to 3 visits after hospital discharge.3 This gap in care delivery is felt by HEN patients who report dissatisfaction with continuity and quality of care, specifically from inadequate interactions with professionals knowledgeable of nutrition and infusionrelated issues.4,5 The lack of adequate formal home health services also means that >75% of older adults rely on informal caregivers (ie, unpaid family/relatives, friends, or neighbors) to manage their HEN.6

The current state of postacute health care delivery raises concerns as to whether the goal of providing HEN to older adults (ie, to improve health, functionality, and quality of life by reversing malnutrition in a safe and cost-effective manner) is being met.7,8 Conceptual models of the care delivery process offer insight into the variety of factors that may influence HEN outcomes. In Smith’s model,9 developed with home parenteral nutrition patients, quality of care is linked to patient physical condition, technology-related side effects, and quality of life. The model of Pearlin et al10 suggests that the background and context of care delivery (eg, caregiver and care recipient characteristics, knowledge, responsibilities) and factors that mediate the care process (eg, coping and adaptation skills, support networks, resources) influence outcomes.

In this dual-phase integrated study, we used care process theory to identify and investigate several factors that may be associated with the efficacy of HEN in a sample of older adults dependent on family caregivers for daily HEN care (Fig. 1). The full methods and findings from the first phase have been reported previously.11 To summarize, in-home structured interviews were conducted with 30 family caregivers (24 women, 6 men) who were primarily responsible for managing an older adult’s daily HEN for an average of 1.8 ± 0.7 months after hospital discharge. Caregivers were 52.3 ± 14.9 years old (range, 21 to 76 years). They performed an average of 20 functional, care management, technical, and nutrition-related tasks daily for an average of 62 caregiving hours weekly. Half received training for these tasks in the hospital before patient discharge. Nine were trained in the patient’s home, 4 in the outpatient clinic, and 2 never received any training. Overall, their reported need for training exceeded the number of tasks for which they reported receiving training. They were generally unprepared for caregiving, lacked competence and confidence, and felt anxious, sad, tense, overwhelmed, and frustrated.

In the second phase of this study, reported here, we conducted in-home structured interviews with the patients to further investigate factors identified in Smith’s model of caregiving9 that may be related to outcomes of HEN in older adults. Thus, the relationships we assessed for the background and context of care delivery were patient characteristics and the enteral regimen, for mediators of care we assessed adherence to the enteral regimen and health care provider involvement/follow-up care, and for patient-related health care outcomes we assessed physical and technical complications, patient condition, quality of life, and health care use.

SONYA Dakar was treating acne, scarring, discoloration and irritation at her home before setting up her skin care business on Beverly Boulevard, where she operated for 14 years and developed a celebrity clientele that she says includes Gwyneth Paltrow, Debra Messing and Cameron Diaz. Born in Israel, where she attended aesthetician school, she is about to open a five-level clinic in Beverly Hills, with a location in New York to follow. Her products are also sold in about 100 spas and are being introduced in hotels. Dakar, who works closely with her husband and four kids, envisions clinics popping up across the country.

Answer: Anti-aging today is the most screaming thing, maybe even more than acne. The people in their 20s are worried about the first few lines. I have a 20-year-old musician, huge, famous. He said Sonya, “I don’t like the frown here.” They are concerned today. They see the moms who used to be sitting on the beach with a reflector and baby oil. It used to be the St. Tropez look, Bridget Bardot–to look tan is wealthy, beautiful. Today, it is the opposite.

Q: So what’s it like to get a treatment from Sonya Dakar?

A: You come to me, and you fill a form just like you are going into a doctor’s office. What products you are using, what kind of medication. I am very, very detail oriented. I will do a skin analysis. I will get you the products you need and give you a regimen. That is my partnership with you. I will take photos. I document all the skin conditions before you start the treatment.

Q: Doesn’t sound like the pampering approach normally associated with Beverly Hills,

A: I am not going to be sweet with you because you are going to love me. No, I will tell you everything. The treatment is basically a boot camp.

Q: Yet you’ve managed to attract several celebrity clients.

A: My celebrity clients look for what all my other clients come to me for–results. They do not mind the boot camp approach because it works. They do not come to me for pampering. They come for good skin.

Q: Who was your first celebrity client?

A: Cameron Diaz. She wasn’t very famous at the time. We kind of grew together. It was like Cameron is getting here, and I am getting there and all these things are happening.

Q: The fashion and skin care world thrives on celebrity endorsements. What do you think of them?

A: Celebrities are pushing certain brands even though they are not necessarily using them. Everything is about money. It’s business and that is why they endorse a product, not necessarily that they use them or believe in them.

Q: Still, wouldn’t you want your own?

A: I have actually had celebrities offer this to me many times. I always told them that when the time is right and budgets allow, I will take them up on it.

Q: Don’t you think we’re too obsessed with looks and beauty?

A: I have mixed feelings. Los Angeles may be known for being obsessed with beauty because the entertainment industry is based here and their face is their business card. Celebrities have no choice but to look good. That is part of their job. It spills into society because we read and watch these people all day long and feel inspired to look like them. My business is not about covering up your natural beauty, it is about being a natural beauty.

Q: You’re not cheap.

A: $220, $225 (a session). The first time takes an hour and a half. The rest of the treatments would be like 30 minutes.

Q: Do people wince at the cost of your treatments/products?

A: My products are an upscale solution to corrective skin care. They deliver results and everybody wants results. People everywhere want good skin, no matter where they live.

Q: Did Botox take away some of your business?

A: Not at all. Botox can do anything for your forehead, but the whole face is not just a forehead. We have a lot more. When we age, the pores become enlarged, the texture is not the same. Botox is really a small part of the whole need.

Q: Why aren’t you selling widely in stores?

A: My product really is about everything customized. I couldn’t visualize a saleswoman analyzing someone’s skin.

Q: How did you raise your profile?

A: In the last six or eight years, the company got a lot of media. The more they started writing, people started calling. People started flying to me from all over, from South Africa, from Australia–”Make a vacation to Sonya Dakar.” I had people flying from New York for 24 hours.

Q: Do you actually develop your own products?

A: It takes a year, up to two years. My husband is like the controller. We have three chemists working all the time. I get all the information, I research it, I judge it, I dissect it, I analyze it. I give a sample to my clients. We keep a log on it. I want to see how is the elasticity of the skin or how is the discoloration coming. We want to see it long term.

Q: What about your skin care products?

A: One of the most well known is the drying potion. Men know about it for in-grown hair, and teen-agers know about it for breakouts. That sells for $25 for the small bottle, $45 for the big one.

Over the past decade, Medicare spending on HHC has expanded faster than any other expenditure component. From 1990 to 1995, Medicare home health costs grew more than 30 percent per year (Health Care Financing Administration, 1996). Much of this growth is the result of a liberalization and standardization of coverage that occurred in the late 1980s (Welch, Wennberg, and Welch, 1996). As a result, the number of home health agencies increased by more than 50 percent from 1989 to 1995 (Welch, Wennberg, and Welch, 1996). Patterns of use among the aged have been well documented. However, the impact of this rapidly expanding HHC industry on vulnerable patient populations is still an understudied area. This study uses a national claims-based data set to examine HHC use by a special group of Medicare beneficiaries, ESRD patients. The results from the analysis are compared with the existing literature on HHC use by Medicare beneficiaries overall. The implications of recent changes to the HHC benefit resulting from the Balanced Budget Act of 1997 (BBA) are also discussed.

Since its inception in 1973, Medicare’s ESRD program has provided full Medicare Parts A and B coverage to most individuals diagnosed with ESRD, including most of the cost of dialysis treatment and renal transplantation. Certain prescription medications are also covered, mainly, erythropoietin for the anemia of renal failure and immunosuppressant drugs (for a period of 3 years following transplantation). Eligibility for the ESRD program is based on confirmed diagnosis of the disease, regardless of the patient’s age. This is an important distinction between elderly Medicare beneficiaries and those in the ESRD program. The distribution of sex and race among ESRD beneficiaries is much less skewed than for Medicare enrollees overall, probably due in large part to the younger age of the group, on average.

Because of the chronic and debilitating nature of the disease, ESRD patients are much more costly than their elderly Medicare counterparts. The high cost associated with the treatment of kidney failure–either kidney transplantation or life-long dialysis–represents a potentially catastrophic cost to patients and their families. ESRD patients were included in the Medicare program to preserve their treatment options and prevent the devastating financial effects of the disease.

In 1997, Medicare covered approximately 75 percent of total ESRD costs, estimated at $15.64 billion (United States Renal Data System, 1999). Medicare spending per patient-year during the period 1993-97 was $43,000. Program expenses vary by dialysis modality and underlying disease state. ESRD patients receiving hemodialysis, the vast majority of program enrollees, cost Medicare an average of $52,000 per patient-year during this time period, $7,000 more per patient-year than patients on peritoneal dialysis and $35,000 more per patient-year than those who had received transplants (United States Renal Data System, 1999). Across modalities and age groups, diabetic ESRD patients represent the greatest proportion of ESRD enrollees and the greatest cost per patient-year. On average, diabetic patients (one-third of ESRD enrollees) cost about $51,000 per patient-year for the period 1993-97, compared with $39,000 per patient-year for non-diabetic patients (United States Renal Data System, 1999). Thus, high-risk subgroups exist in this population that is already much more costly than other Medicare beneficiaries.

Both the cost and the incidence of ESRD have been increasing over the past decade, with ESRD beneficiaries generating more than seven times the expenditures of aged Medicare beneficiaries (Health Care Financing Administration, 1996). Even though the ESRD program remains a small percentage of total Medicare spending at 5.6 percent, policymakers have been increasingly concerned about cost containment and quality of care for this population. Reimbursement and coverage decisions made on the basis of existing literature may have serious consequences for this group if its patterns of use differ from those of Medicare enrollees overall. Thus, it is important to examine utilization for this distinct patient population.

HOME HEALTH CARE

HHC was originally used by hospitals in response to the prospective payment system as a way to shorten lengths of stay. Following hospitalization, patients were discharged earlier and received home health services in lieu of increased inpatient days. Research in this area has documented the impact of HHC in reducing hospital days and costs (Hughes et al., 1997; Feldman, Latimer, and Davidson, 1996). Prior to 1980, Medicare coverage of HHC was contingent upon prior hospitalization (Welch, Wennberg, and Welch, 1996). This requirement was eliminated in 1980, and subsequent changes to Medicare further expanded the scope of coverage. In 1994, nearly 8 percent of Medicare beneficiaries used HHC; the average number of visits per user increased from 52 visits in 1992 to 65 in 1994 (Mauser, 1997). The distribution of visits is highly skewed, with 14 percent of users receiving more than 150 visits yearly (Mauser, 1997).