Political Perspectives on Uncertified Home Care Agencies
Silberberg, Mina, Estes, Carroll L., Harrington, Charlene, Health Care Financing Review
Home care (the provision of a broad range of health and social services to individuals and their families in the home) is a booming component of health care (Neu and Harrison, 1987; U.S. General Accounting Office, 1988; Van Gelder and Bernstein, 1986). It is, therefore, increasingly important to examine the policies and policy debates which shape in-home services. In particular, little is known about the large segment of home care agencies which is not certified by the Federal Government. This article examines the political agendas of public sector and organized private sector interests concerned with uncertified home care policy in three metropolitan areas: San Francisco, Houston, and Philadelphia. We discuss the relative prominence of quality, cost, and access-related policies on the political agendas of these groups and agencies and describe the nature of their policy concerns. Finally, the article examines two issues in light of this research: (1) the characteristics of home care politics, and (2) the potential contribution of the different perspectives of government, home care providers, consumers, and others for policy analysis.
Home care services are defined in this article as assistance provided in the home which enables a person with an illness or disability to remain in his/her residence. These services include what are often referred to as home health services (nursing, administration of medications by a home health aide, etc.) and home care support (chores, assistance with dressing, etc.). Home care is the fastest-growing component of personal health care expenditures Letsch et al., 1992). According to one estimate, the home care market grew 10 percent annually between 1986 and 1991 (National Association for Health Care, 1993). Home care was a $12 billion industry in 1991 (Letsch et al., 1992) and is expected to reach $40 billion in 2018 (Wiener and Illston, 1994). A number of factors have contributed to the increased demand for this type of assistance. These include the aging of the population, the implementation of policies shortening hospital stays, and the advent of technologies which make such care feasible for an increasing variety of consumers (Estes et al., 1992; U.S. House of Representatives, 1987; Stark, 1987; U.S. Department of Commerce, 1990). The enormous growth of the home care industry, along with spiraling long-term care costs, has focused attention on cost, access, and quality issues for in-home services (Estes et al., 1992).
The variety of home care providers can be roughly grouped into three categories: agencies certified by the Federal Government, uncertified agencies, and independent providers, i.e., individuals providing in-home services.(1) Most attention has been focused on the services provided by those agencies which are certified and paid for by the Medicare or Medicaid programs. Very little is known about uncertified providers of home care services to the elderly and disabled (Harrington and Grant, 1990).
Yet, uncertified agencies--the focus of this article--are both conceptually and numerically a major part of the home care market. Recent studies have found that approximately one-half of all home care agencies are uncertified (U.S. Department of Commerce, 1990; National Association for Home Care, 1993; Estes et al., 1993). These agencies offer a broad range of services. Only those home care agencies which provide nursing services and at least one other therapeutic service can be federally certified. Furthermore, agencies close to meeting certification standards may choose not to certify.
Current research shows that the four most common barriers to certification in the eyes of uncertified agencies are the paperwork, costs, and bureaucracy associated with the process, followed by a perception that Medicare and Medicaid reimbursement levels are inadequate.(2) Home care agencies need not certify to survive, as they have alternative funding sources available to them, including Government programs and out-of-pocket payments. …