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Quality of care issues raised by Medicare cuts

EDITOR'S NOTE -- Congress was applauded when it passed the Balanced Budget Act of 1997 as a way to trim spending and cut the deficit. The act also cut billions from Medicare, the nation's health care program for disabled and older Americans.

The Associated Press spent three months reviewing the act's effects and found that for rural West Virginia, which has the nation's oldest population, the Medicare cuts have resulted in diminished access, sicker patients -- and even deaths.

Today is the second day of a four-part series on how efforts to trim federal spending have changed the quality of health care in the Mountain State.

by Malia Rulon

THE ASSOCIATED PRESS

BIM -- Frances Bishop's world rarely stretches beyond her Boone County home. For her, bathing, dressing and feeding her 78-year-old mother is a full-time job.

"These big officials and stuff, they don't realize. They don't understand what we go through out here," says Bishop, whose tired face tells her story.

Less than 50 miles away, Joan Stegge sits at the kitchen table of her St. Albans home, reviewing lists of medications, feeding tables and blood pressure readings.

The 54-year-old woman can't remember the last time she slept, shopped or did anything for longer than four hours at a stretch.

"He needs to be fed every four hours," she says looking across the room at her 73-year-old husband, Charles, who sleeps in a hospital bed in the living room. "I work around his schedule."

Both women live each day to care for their loved ones. They are always tired and frequently lonely. Bishop, who is terrified to leave the house, talks to her birds for company. Stegge takes medication to help with depression.

The Associated Press spent three months reviewing health care in West Virginia and found hundreds of families such as Bishop's and Stegge's picking up the slack for a system struggling under Medicare cuts imposed by the Balanced Budget Act of 1997.

Health care providers in West Virginia say patients are getting caught in the middle. They leave hospitals too soon, then can't receive the home health services they need to recover.

Meanwhile, back in Washington, officials pore over reports and surveys that say all is well.

"None of those has found any access or quality problems resulting from the Balanced Budget Act," says Chris Peacock, spokesman for the federal Health Care Financing Administration, which oversees the Medicare and Medicaid programs.

n n n

Since the first wave of Medicare cuts hit in 1997, more than 5,000 patients in West Virginia have become ineligible for home health and 432 others have been denied home health services for a variety of reasons, including the cost of providing services.

"They did have the option to purchase home care on a private pay basis, but, you know, many of these people can't afford to do that," says Suzan Sayres, who directs Davis Home Care.

Home health care providers in West Virginia used to receive dollar-for-dollar reimbursements from Medicare but now collect an average cap of $2,800 per patient per year. The change, Medicare officials say, is one of many new incentives adopted to make local agencies provide care more efficiently.

Home health administrators say efficiencies are achieved by deciding some people are just too expensive to treat.

"Agencies are looking very carefully at what patients will require," says state Sen. Jon Blair Hunter, executive director of the West Virginia Council of Home Health Care Agencies.

Hunter, D-Monongalia, says home health agencies throughout the state are re-evaluating their caseloads based on Medicare's new payment schedule. The result, he says, isn't positive.

"Patients who are more costly to care for are falling through the cracks on this," says David Lyon, administrator at Beckley Appalachian Regional Hospital.

Bedridden patients like Charles Stegge and Bishop's mother, Delphia Vance -- both of whom depend on feeding tubes and have histories of diabetes and strokes, require constant care and can use up the $2,800 in two months.

"That's the type of patient that home health companies at this point don't want," says Renee Hull, clinical supervisor at Elite HealthCare Inc.

But Elite continues to treat Stegge, even though it is losing money.

Nursing homes also face a reimbursement cap, but it is rarely enough to cover all the patient's needs.

"That money runs out real quickly and then these people have to be taken care of," says John Vance, administrator of SunBridge Care & Rehabilitation for Dunbar.

The nursing home chain, which has seven homes serving about 820 patients in West Virginia, has filed for Chapter 11 bankruptcy protection.

"It has been devastating. I do not know a better way to put it," he says.

Because of the Medicare cuts, it's hard to find nursing homes that will accept patients with complex medical conditions.

"If we get a referral for someone with a debilitating need, we have to look very carefully at whether we will be able to meet our costs," Vance says.

Last year, Michael Hash, HCFA's deputy administrator, told a congressional committee that such business decisions stem from a misunderstanding or efforts to "cherry pick" low-cost patients and take advantage of the system.

n n n

In West Virginia, where families pride themselves on taking care of their own, daughters, sons and spouses often sacrifice their own lives to care for their loved ones.

"My mother never turned her back on me and I'm not going to turn my back on my mother," Bishop says. "I will take care of her in my home until God calls her back to Him."

But without home health care, that is becoming more difficult.

"Families can do a lot, but we can't do everything," says Ann Blevins, who along with her brother, Jack Thomas, cared for her mother until she died on New Year's Day.

Patients without family help end up depending on state programs or heading back to the hospital.

"We're starting to see readmissions of these patients increase," says Robert L. Hammer, executive director of Davis Memorial Hospital in Elkins. "They are getting into health trouble because they don't have the services they need, and that is a trend statewide and nationwide."

Robin Wagner, a physician's assistant at Davis Memorial's clinic in Parsons, sees this every day.

"We're definitely seeing sicker patients," she says. "They are sicker because they're not being monitored."

It's a downward spiral many in the health care industry fear.

"If I discharge a patient a day earlier, then I save the hospital money," says Dr. David Eells, a primary care surgeon at Welch Emergency Hospital. "But there is a risk in that. I may be sending patients home too early."

Eells says doctors are routinely pressured to discharge patients earlier to cut costs. It's a liability risk, but for doctors who rely on hospitals for their practice, helping the hospital is often the only way to help themselves.

"If that building is not there, that will impact me directly and trust me, you will see doctors respond to that," he says.

However, because 20 home health agencies have closed since 1997 and others are financially unstable, releasing patients into the care of a home health agency is often not an option.

"The federal government has taken the money out of home health agencies," Eells says, "so now when you discharge that patient, where is the home health service that used to be watching them for you?"

n n n

It's a circular problem that becomes a crisis as different parts of the health care system start to cave in.

Air and land ambulance companies are next. Cuts to these services are expected next year, when a new payment system goes into effect.

"One thing you gotta keep in mind about ambulances is nobody wants to think about us until you need us, but when you need us, we better darn well be there for you," says A.G. Lucas, executive director of the Weirton Area Ambulance and Rescue Squad.

Lucas, who is also vice president of the Ambulance Association of West Virginia, says when home health decreased, transportation calls to the Weirton squad increased from five a month to 30. But these trips aren't reimbursed, he says.

George "Chip" Sovick III, president and CEO of HealthNet, says helicopter ambulance flights increased 7 percent between 1998 and 1999.

"We've anticipated this as rural hospitals do away with services," he says. "If they cut back, we've got to get the patients out."

Ambulance crews are becoming the first-line providers of health care in West Virginia, says Roger Bryant, executive director of Logan Emergency Ambulance Services and president of the state Emergency Medical Services Coalition.

"A lot of areas don't have hospitals, so their local EMS provider is their local hospital. If those services disappear, certainly, those folks aren't going to have health care.

"It's not only going to result in higher health care costs; it could also cost someone their life."

n n n

That's a day Bishop and Joan Stegge fear.

"Every time he goes into the hospital," Stegge says of her husband, "I'm afraid he won't come back."

Bishop breaks up at the thought of something happening to her mother.

"She's all the love that I've ever had in my life," Bishop says. "But she's old, and I don't believe people want to take care of the old people anymore.

"It's not right because we are all going to get old someday. What's it going to be like when we get old?"

TOMORROW: The political debate surrounding health care

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