Crisis in care: Budget cuts are bad medicine
Steamboat Springs — Born more than a month premature, tiny Jack Strotbeck needs regular medical attention. His parents are thankful that means visits at home from trained nurses rather than trips to a doctor’s office.
“Jack is supposed to stay away from other children right now and if we had to take him to a doctor’s office three times a week, he’d be exposed to other children,” his mother, Mary Beth, explained. “The other option is keeping him in a hospital and we don’t want that because he’s fine except for the monitoring.”
Six-week-old Jack needs to have the oxygen level in his blood monitored while he’s awake, asleep and feeding things easier done in a home than in an office.
But the leader of the Visiting Nurse Association in northwest Colorado fears that her ability to provide those kinds of home health care services will be reduced significantly if the federal government continues to cut funding.
The VNA’s money problems started with the Balanced Budget Act of 1997, which reduced home health spending with the intention of saving $16 billion over five years. Estimates now indicate that home health spending will be reduced by $69 billion more than four times the targeted reduction.
That means the Visiting Nurse Association in Routt and Moffat counties can’t employ as many nurses or accept as many patients because Medicare and Medicaid payments aren’t being reimbursed at the same level.
“We’ve cut our budget, reduced programs and we’ve become more selective about which patients we take,” VNA Executive Director Sue Birch said.
Jack’s father, Erich, believes his baby son is getting better care by having nurses come to him.
“The home visits allow for a more accurate assessment,” he said.
The Strotbecks are among a minority, about 25 percent, of VNA clients who pay for services with private insurance. The rest of the 250 home-bound or frail people in Routt and Moffat counties who count on the VNA use Medicaid or Medicare to pay for their home health needs.
Medicare money is portioned out to people when they retire. Medicaid assistance is given to disabled people who can’t work.
The government is supposed to reimburse the VNA for the cost of home health services, but Birch said the paybacks don’t cover all her expenses.
While local governments aren’t mandated to pick up the difference, Routt County has doubled its funding to VNA from $81,500 in 1997 to $165,000 this year. County Commissioner Dan Ellison said the county is anticipating setting aside $181,500 in next year’s budget.
Meanwhile, home health agencies are dropping like flies, especially in rural areas. Almost half of all home health providers in Colorado have shut down in recent years, from 210 to 120. Nationally, one-third of all agencies have closed in the last few years.
TLC, a for-profit home health company in Moffat County, got out of the business last year, adding more patients to VNA’s load. They are patients like Chrissy, an 11-year-old comatose girl, who is cared for during the day by her grandparents in Craig. At night, Medicaid pays for a visiting nurse to care for her. If those payments weren’t secured and a nurse couldn’t continue to visit Chrissy, she would have to be taken to a facility that provides round-the-clock care.
The cheapest way to care for those who need nursing supervision is in the home. It costs about $100 a day. Assisted living or a group home can cost about $130 a day. A stay at a hospital, which varies in price, goes up from there.
“It makes much more sense if we can care for these people at home,” Ellison said. “No. 1 they’re happier, and No. 2 your pocketbook is happier.”
Home health care is more expensive in rural areas for several reasons, but the factor that stands out is economy of scale. Instead of seeing 10 patients a day in a smaller urban neighborhood, local visiting nurses drive from the Little Snake River in north Routt to Maybell and from Yampa to Steamboat.
A nurse here can visit five patients in south Routt County and log 100 miles in one day, said VNA nursing manager Susan Fowler.
“In an inner city where you travel 10 miles, you might see 10 patients, but on a dirt road covered in snow and ice it takes longer to see each patient,” Fowler said.
On a day when a nurse only sees two patients, she spends the rest of her day with paperwork. Enrollment forms for nursing care can be up to 18 pages long, according to Ellison.
“The nurse has to sit with the patient and fill it out and then fill out a different one 60 days later. If the program changes, they have to fill out another form,” he said.
One of the questions asks the patient who takes out his or her garbage, an important detail to ensure environmental health, but the kind of detail that adds frustration to a time-consuming effort.
“VNA’s financial situation is severe and we need help from the state,” Ellison said. “It’s a serious issue and an underfunded area.”
A staff of less than 30 people cares for VNA’s 250 clients. It’s a staff that has been cut and might continue to be reduced as nurses find higher wages in urban areas.
New VNA offices
In the midst of the funding crisis, VNA is planning to move into the medical office building under construction at the Yampa Valley Medical Center. It’s a costly proposition, but one Birch defends.
In Craig, the VNA office is physically connected to The Memorial Hospital. Birch said she wants to do the same in Steamboat to provide easy access to shared services.
VNA has $900,000 secured for the move from Sixth Street to the new medical office building. Of that, $600,000 is coming from a grant. The county will buy the Sixth Street building for about $300,000 and tear it down to build a new court facility.
Birch said VNA plans to hold fund-raisers closer to the time the medical office building is completed to help pay for the move into the new offices.
In addition to home health, the Visiting Nurse Association provides hospice care for terminally ill people and health care for the general public, such as immunizations. Those services need to be in the hospital complex for easier access, Birch said.
The restrictions on home health care, however, are dragging down VNA’s other services, Birch said.
“The agency has increased its requests to local funding sources to include funding for home health services, but this takes away from funding for public health services which are facing an equally challenging funding situation,” reads a Feb. 15 draft statement from the VNA.
VNA’s only hope is that Medicare will start reimbursing the agency at its actual cost of service, the report states.
Northwest Colorado’s Visiting Nurse Association is not alone in its struggle to make ends meet for home health care. Counties across Colorado are experiencing similar challenges. Ellison said Routt and Moffat counties have joined forces with Clear Creek, Gilpin, Fremont, La Plata, Teller and Weld counties to look for a long-term solution.
“These counties cover the spectrum of urban, rural, resort and non-resort and they show it’s a state-wide problem,” Ellison said.
Ellison and Birch testified in favor a bill, sponsored by state Rep. Jack Taylor of Steamboat Springs, to study how Medicaid reimburses home health providers. Taylor said it makes sense to him to keep people out of nursing homes if they can be cared for at home for less money.
“I approached it from my business background because it seems logical to save money where it can be saved,” Taylor said.
Taylor’s bill died last week in the Appropriations Committee but he said he’ll try something different next session.
“So we don’t have any immediate solutions,” Ellison said. “But we’ve asked legislators to study the funding allocation.”
Not to be put off, Birch said U.S. Sen.Wayne Allard is willing to support a bill to hold off on more federal budget cuts. Instead of a 15-percent cut each year in the amount reimbursed to providers, the amount would freeze where it is.
“The feds have acknowledged they put the rural areas at risk. They told us to hang on for two years,” Birch said.
Allard’s press secretary, Sean Conway, said he thinks relief may come sooner than that. Allard is co-sponsoring two bills dealing with payments to home health care providers that could be voted on this year.
The Medicare Home Health Equity Act would adjust the cost limits on payments. The Home Health Care Payment Fairness Act would eliminate the 15 percent reduction in payment rates under the reimbursement system.
“Senator Allard is fighting in Congress with these two bills and he’s confident he can get them enacted this session. We’re cautiously optimistic that these two bills can address the crisis and provide some instant relief,” Conway said.
Until then, Birch said residents need to speak up to politicians in particular, because they are in a position to effect changes at the state and federal levels.
“It’s a measure of what our community values. If we aren’t willing to take care of our frail people and young children, it’s concerning to me,” Birch said. “This can’t continue. We need people to voice their opinions if they think quality services are critical.”
To reach Michelle Bales call 871-4208 or e-mail email@example.com
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