The Science Journal of the American Association for Respiratory Care

1998 OPEN FORUM Abstracts

Any Changes in Homecare Reimbursement?

Patrick J. Dunne, MEd, RRT

The traditional indemnity-based, fee for service paradigm used to provide reimbursement for health care services is undergoing a rapid transformation. Following years at political center-stage where legislative initiatives failed to materialize, health care reform has evolved into a highly competitive, market-driven restructuring process, of which the keystone is the emergence of a new reimbursement concept. Known as capitation, this new approach to reimbursement is based on the twin precepts of pre-payment and provider risk-sharing, and it is drastically altering the entire health care delivery system.

Reimbursement for respiratory home care is steadily feeling the impact of this transformation. Medicare, the dominant payer for respiratory home care under the aforementioned fee for service model, is slowly but surely changing the manner in which it operates. The most significant change is the noticeable effort underway to encourage Medicare beneficiaries to join a Medicare-risk HMO. This translates to financial risk being shifted to the various participating private sector health plans authorized by HCFA to offer the Medicare-risk programs. Other efforts by HCFA to change the traditional Medicare approach to reimbursement includes the application of the concept of inherent reasonableness (most recently with the publication of illogical coverage criteria for non-invasive positive pressure ventilation) and the implementation of the oft-delayed and controversial Competitive Bidding Demonstration Project for DMEPOS.

Although the major challenges to respiratory home care reimbursement are indeed emanating from HCFA/Medicare, it is important to realize that private health plans are likewise moving away from traditional fee for service thinking. Increasingly, private health plans are expecting, and at times demanding, providers to share financial risk along the lines of Medicare-risk HMOs. Accordingly, respiratory therapists involved in home care must possess, in addition to traditional clinical and technical competencies, a clear understanding and appreciation of the necessity to link all care/service decisions with an analysis of resource utilization and resultant costs. An inability or unwillingness to view care/service decisions within the context of cost considerations will severely undermine ones success in an increasingly competitive health care delivery marketplace.

The 44th International Respiratory Congress Abstracts-On-DiskĀ®, November 7 - 10, 1998, Atlanta, Georgia.

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