Medicare Home Health Services Research Articles

Reduced Awareness of Memory Deficit is Associated With Increased Medicare Home Health Care Use in Dementia

The objective of this study was to examine whether reduced awareness of memory deficits in individuals with dementia is associated with more frequent need for Medicare home health care services. Cross-sectional analyses were conducted in a multicenter, clinic-based cohort. In total, 192 participants diagnosed with dementia and their informants were independently asked whether or not the participant demonstrated cognitive symptoms of dementia related to memory and word-finding. Participant self-awareness was measured as the discrepancy between participant and caregiver report of these symptoms. Annual Medicare home health benefit use data was obtained from Medicare claims matched by year to the Predictors study visit. Participants that used home health services had lower awareness scores than those who did not. Awareness remained independently associated with home health use in a logistic regression adjusted for age, gender, education, caregiver relationship, global cognition, dementia subtype, and medical comorbidities. Reduced self-awareness of memory deficits in individuals with dementia is associated with more frequent use of Medicare home health services. The disproportionate use of in-home assistance as a function of awareness level may reflect dangers faced by patients, and challenges faced by caregivers, when patients have limited awareness of their memory deficits. Current results have implications for clinical care, caregiver education, and models of health care utilization.

Discharge home health services referral and 30-day all-cause readmission in older adults with heart failure.

IntroductionHeart failure (HF) is the leading cause of hospital readmission. Medicare home health services provide intermittent skilled nursing care to homebound Medicare beneficiaries. We examined whether discharge home health referral is associated with a lower risk of 30-day all-cause readmission in HF.Material and methodsOf the 8049 Medicare beneficiaries hospitalized for acute HF and discharged alive from 106 Alabama hospitals, 6406 (76%) patients were not admitted from nursing homes and were discharged home without discharge hospice referrals. Of these, 1369 (21%) received a discharge home health referral. Using propensity scores for home health referral, we assembled a matched cohort of 1253 pairs of patients receiving and not receiving home health referrals, balanced on 33 baseline characteristics.ResultsThe 2506 matched patients had a mean age of 78 years, 61% were women, and 27% were African American. Thirty-day all-cause readmission occurred in 28% and 19% of matched patients receiving and not receiving home health referrals, respectively (hazard ratio (HR) = 1.52; 95% confidence interval (CI): 1.29–1.80; p < 0.001). Home health referral was also associated with a higher risk of 30-day all-cause mortality (HR = 2.32; 95% CI: 1.58–3.41; p < 0.001) but not with 30-day HF readmission (HR = 1.28; 95% CI: 0.99–1.64; p = 0.056). HRs (95% CIs) for 1-year all-cause readmission, all-cause mortality, and HF readmission are 1.24 (1.13–1.36; p < 0.001), 1.37 (1.20–1.57; p < 0.001) and 1.09 (0.95–1.24; p = 0.216), respectively.ConclusionsHospitalized HF patients who received discharge home health services referral had a higher risk of 30-day and 1-year all-cause readmission and all-cause mortality, but not of HF readmission.

Factors Associated With Accelerated Hospitalization and Re-hospitalization Among Medicare Home Health Patients.

Preventing hospitalizations and re-hospitalizations of older adults receiving Medicare home health (HH) services is a key goal for patients and care providers. This study aimed to identify factors related to greater risk of and earlier hospitalizations from HH, a key step in targeting preventive efforts. Data come from Medicare mandated start-of-care assessments from 87,780 HH patients served by 132 agencies in 32 states, collected from January 2013 to March 2015. Using parametric accelerated failure time (AFT) survival models, we evaluated the association between key patient and environmental characteristics and the hazard of and time until hospitalization and re-hospitalization. In total, 15,030 hospitalizations, including 6,539 re-hospitalizations, occurred in the sample within 60 days of start of HH. Factors most strongly associated with substantially greater risk of and earlier hospitalization included male gender, history of hospitalization, polypharmacy, elevated depressive symptoms, greater functional disability, primary diagnoses of heart disease, chronic obstructive pulmonary disease, and urinary tract infection, and government-controlled agency care. In addition to these factors, black race and primary diagnosis of skin wounds were uniquely related to risk of earlier re-hospitalization. Results suggest that factors collected during routine HH patient assessments can provide important information to predict risk of earlier hospitalization and re-hospitalization among Medicare HH patients. Identified factors can help identify patients at greatest risk of early hospitalization and may be important targets for agencies and care providers to prevent avoidable hospitalizations.

A Theoretically Based Behavioral Nutrition Intervention for Community Elders at High Risk: The B-NICE Randomized Controlled Clinical Trial

We conducted a study designed to evaluate the efficacy and feasibility of a multilevel self-management intervention to improve nutritional intake in a group of older adults receiving Medicare home health services who were at especially high risk for experiencing undernutrition. The Behavioral Nutrition Intervention for Community Elders (B-NICE) trial used a prospective randomized controlled design to determine whether individually tailored counseling focused on social and behavioral aspects of eating resulted in increased caloric intake and improved nutrition-related health outcomes in a high-risk population of older adults. The study was guided by the theoretical approaches of the Ecological Model and Social Cognitive Theory. The development and implementation of the B-NICE protocol, including the theoretical framework, methodology, specific elements of the behavioral intervention, and assurances of the treatment fidelity, as well as the health policy implications of the trial results, are presented in this article.

Aging in Place Versus Nursing Home Care: Comparison of Costs to Medicare and Medicaid

The objective of this study was to compare the community-based, long-term care program called Aging in Place (AIP) and nursing home care, in terms of cost to the Medicare and Medicaid programs. A retrospective cohort design was used in this study of 39 nursing home residents in the Midwest who were matched with 39 AIP participants. The AIP program consisted of a combination of Medicare home health, Medicaid home and community-based services (HCBS), and intensive nurse care coordination. Controlling for high inpatient Medicare cost in the 6 months prior and the 10 most frequently occurring chronic conditions, multiple regression was used to estimate the relationship of the AIP program on Medicare and Medicaid costs. Total Medicare and Medicaid costs were $1,591.61 lower per month in the AIP group (p < 0.01) when compared with the nursing home group over a 12-month period. The findings suggest that the provision of nurse-coordinated HCBS and Medicare home health services has potential to provide savings in the total cost of health care to the Medicaid program while not increasing the cost of the Medicare program.

Undernutrition at Baseline and Health Services Utilization and Mortality Over a 1-Year Period in Older Adults Receiving Medicare Home Health Services

Older adults receiving Medicare home health services who experience undernutrition may be at increased risk of experiencing adverse outcomes. We sought to identify the association between baseline nutritional status and subsequent health service utilization and mortality over a 1-year period in older adults receiving Medicare home health services. This was a longitudinal study using questionnaires and anthropometric measures designed to assess nutritional status (Mini-Nutritional Assessment) at baseline and health services utilization and mortality status at 6-month and 1-year follow-ups. Participants were evaluated in their homes. A total of 198 older adults who were receiving Medicare home health services. Based on Mini-Nutritional Assessment, 12.0% of patients were malnourished, 51.0% were at risk for malnourishment, and 36.9% had normal nutritional status. Based on body mass index, 8.1% of participants were underweight, 37.9% were normal weight, 25.3% were overweight, and 28.8% were obese. Using multivariate binary logistic regression analyses, participants who were malnourished or at risk for malnourishment were more likely to experience subsequent hospitalization, emergency room visit, home health aide use, and mortality for the entire sample and hospitalization and nursing home stay for overweight and obese participants. Experiencing undernutrition at the time of receipt of Medicare home health services was associated with increased health services utilization and mortality for the entire sample, and with increased health services utilization only for the overweight and obese subsample. Opportunities exist to address risk of undernutrition in patients receiving home health services, including those who are overweight or obese, to prevent subsequent adverse health outcomes.

Depression Outcomes and Quality of Postdischarge Care of Elders Hospitalized for Major Depression

Depression Outcomes and Quality of Postdischarge Care of Elders Hospitalized for Major Depression

Nurse Care Coordination in Community‐Based Long‐Term Care

To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options (MCO). A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination (NCC) and 30 clients who received MCO services but no nurse care coordination. Nurse care coordination consists of the assignment of a registered nurse who provides home care services for both the MCO program and Medicare home health services. Two standardized datasets, the Minimum Data Set (MDS) for resident care and planning and the Outcome Assessment Instrument and Data Set (OASIS) were collected at baseline, 6 months, and 12 months on both groups. Cognition was measured with the MDS Cognitive Performance Scale (CPS), activities of daily living (ADL) as the sum of five MDS ADL items, depression with the MDS-Depression Rating Scale, and incontinence and pressure ulcers with specific MDS items. Three OASIS items were used to measure pain, dyspnea, and medication management. The Cochran-Mantel-Haenszel (CMH) method was used to test the association between the NCC intervention and clinical outcomes. At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain, dyspnea, and ADLs. No significant differences between groups were found in eight clinical outcome measures at 6 months. Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults.

Clinical Outcomes of Aging in Place

Programs such as Medicaid Home and Community-based Services (HCBS) have provided an alternative to institutionalization through community-based, long-term care services; however, there are limited studies on the clinical outcomes of participants in these programs as compared to nursing home (NH) residents. To compare clinical outcomes of individuals in a community-based, long-term care program to individuals of similar case mix in institutional-based, long-term care. A program called Aging in Place (AIP) was developed by the Sinclair School of Nursing in cooperation with the state of Missouri's HCBS program. The AIP intervention consisted of nurse coordination of the HCBS program and Medicare home health services. A total of 78 AIP participants were matched with 78 NH residents on admission period, activities of daily living (ADLs), cognitive status, and age. The Minimum Data Set (MDS) was collected on the AIP group at admission and every 6 months over a 30-month period. Cognition was measured by the MDS Cognitive Performance Scale (CPS), ADLs by the sum of 5 MDS ADL items, depression by the MDS-Depression Rating Scale, and incontinence by rating on 2 MDS items related to urinary continence. The Cochran-Mantel-Haenszel method was used to test the association between the AIP intervention and clinical outcomes. The AIP group clinical outcomes were better at a statistically significant level (less than .05) for the following outcomes: (a) cognition at 6, 12, and 18 months (p = .00); (b) depression at 6 and 12 months (p = .00); (c) ADL at 6 (p = .02), 12 (p = .04), and 24 (p = .00) months; and (d) incontinence at 24 (p = .02) months. In all 4 outcome measures, the AIP group stabilized or improved outcome scores whereas the NH group's outcome scores deteriorated. Study results suggest that community-based care with nurse coordination enhances clinical outcomes of long-term care participants.

Medicare and Medicaid Home Health and Medicaid Waiver Services for Dually Eligible Older Adults: Risk Factors for Use and Correlates of Expenditures

The purpose of this work was to, among frail dually eligible older adults, determine risk factors for the likelihood of using Medicare home health and Medicaid home health services and to, among service users, determine correlates of Medicare home health, Medicaid home health, and Medicaid waiver service expenditures. Dually eligible individuals enrolled in Connecticut's Medicaid home- and community-based services (HCBS) waiver program for the aged (N = 5,232) were identified from a statewide database containing person-level linked data from Medicare claims, Medicaid claims, and uniform clinical assessment forms. Expenditures, based on claims data, were observed from the month following clinical assessment over the period August 1995 to December 1997. In multivariate models controlling for medical conditions and sociodemographic variables, similar functional disability measures were strongly associated with the probability of the use of, and expenditures for, Medicare home health and Medicaid home health services; severe cognitive impairment was strongly associated with greater Medicaid waiver service expenditures. Given the similarity of factors associated with Medicare and Medicaid home health service use and expenditures, greater integration of Medicare and Medicaid financing, reimbursement, and delivery strategies for home health services may be feasible and warranted for dually eligible older adults enrolled in state Medicaid HCBS waiver programs.

How state-funded home care programs respond to changes in Medicare home health care: resource allocation decisions on the front line.

To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment. Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders. Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N = 2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices. Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients. Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels. Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics.

Seniors' Need for and Use of Medicare Home Health Services

ABSTRACT This study examined: (a) nature and extent of seniors' need for care both at time of admission to and discharge from Medicare home health services, and (b) relationships among admission need, service utilization, need at discharge, and discharge disposition for one episode of home care services. The sample of 195 was stratified by home health discharge disposition: (a) acute group, (b) chronic group, and (c) stable home group. Two classification systems were used to access the seniors' level of need, the mandated Medicare case-mix system (CMS) and a holistic intensity of need system. Findings show that there were no differences in services received by the three groups, that discharge did not mean seniors' need for home care services had been eliminated or reduced, and that caregiver support impacts seniors' need for home care.

How Do They Manage? Disabled Elderly Persons in the Community Who Are Not Receiving Medicaid Long-Term Care Services

ABSTRACT Objective: To expand our understanding of how low-income functionally impaired elderly persons are able to remain in the community. Data Sources and Study Setting: In-person and telephone interviews with 25 elderly individuals who applied for but did not enroll in Connecticut's Home Care Program for Elders (CHCPE). All met the state's nursing home level-of-care criteria. Study Design: In-depth discussions with a small, purposefully selected sample of functionally impaired elderly persons in the community. Principle Findings: Many sample members with very high levels of impairment and multiple chronic health conditions remained in the community without CHCPE services because of Medicare home health services combined with extensive levels of informal care. Some sample members, particularly those with more limited informal care networks, did not receive the level of care that they needed. Virtually all were at high risk for medical complications, hospitalizations for acute illnesses, falls, and further loss of functioning. Further, in many cases, informal care networks were overextended, stressed and vulnerable to breakdown. All but a few of those we interviewed were not receiving services through the waiver program for financial reasons. Most met Medicaid's income criteria but had assets that exceeded Medicaid's $2,000 limit. Several were not participating due to concerns about estate recovery. Conclusions: Additional formal help is needed to avoid eventual nursing home placement for many sample members. This could be achieved by expanding the availability of case management services and/or relaxing program financial requirements. Further, efforts to reduce Medicare home health expenditures must recognize the heightened vulnerability of many beneficiaries for potentially costly adverse outcomes.

Home care: what a physician needs to know.

When elderly patients might benefit from home care, a key question is whether Medicare will pay for it. We describe what physicians can do to avoid the pitfalls in qualifying appropriate patients for Medicare's Home Health Services and hospice programs, and the basic features of these two programs. We also describe the experience and methods used in prototype programs that provide home-based hospital-level care, and that revive a supposedly lost art: physician house calls.

An Examination of Medicare Home Health Services: A Descriptive Study of the Effects of the Balanced Budget Act Interim Payment System on Access to and Quality of Care

Between 1987 and 1993 sharp increases in Medicarefinanced home health care utilization occurred, peeking in 1990 at a growth rate of over 40%. Multiple factors contributed to this growth including an increasing number of beneficiaries, expanded coverage to include care for chronically ill beneficiaries as well as those seeking post-hospital care, and increased utilization per beneficiary. This rapid rise in home care spending led to inclusion in Balanced Budget Act of 1997 (BBA) of changes in payment methodology designed to substantially reduce payments for and utilization of home health services. This article examines specific responses made by home health agencies to BBA payment reforms. The ultimate goal of BBA home health provisions was to convert home care reimbursement to a case-mix adjusted prospective payment system (PPS) and end cost-based reimbursement considered to create incentives to increase utilization. The BBA mandated an interim payment system (IPS) to be in effect for two years to allow time for permanent risk-adjusted PPS to be developed and implemented (Smith, Rosenbaum, Schwartz, 1998). However, because of difficulties in developing PPS, IPS remained in place until October, 2000 (Nancy Ann Min De Parle, Administrator HCFA, personal communication to Honorable Bill Thomas, Chairman Health Subcommittee on Ways and Means, September 14, 1998). The IPS included a number of elements designed to constrain growth substantially in home care costs. Of primary concern, however, was payment formula known as the per beneficiary limit. This element of IPS imposed limits on aggregate payments to home health agencies that capped total payment an agency could receive based on an agency's average cost per beneficiary in 1994. In other words, an agency's maximum payment was its average per beneficiary cost in 1994 multiplied by number of beneficiaries admitted in current fiscal year, subject to other adjustments. (For a detailed analysis of home health payment reforms established by BBA, see Center for Health Services initial report on this issue, Medicare Home Health Services: An Analysis of Implications of Balanced Budged Act of 1997 for Access and Quality) (Report 1) (Smith, Rosenbaum, & Schwartz, 1998). The authors raised concern that this payment methodology would create incentives to deny care to sickest and frailest beneficiaries that could result in substantial regional variation in access to and in quality of care. METHODOLOGY This research was conducted as a descriptive study to explore and document effect of IPS on service delivery patterns of home health agencies; examine whether these effects led to a reduction in availability of services; and assess whether a reduction in services affected disproportionately sickest (i.e., high-cost) beneficiaries. The purpose of study was to examine changes, if any, in home health agency behavior and their potential effects on access to and quality of care. We hypothesized that agencies would avoid highcost patients because of lack of cost-based or riskadjusted payment. We also anticipated that sicker beneficiaries would experience access problems including difficulty being admitted to a home health agency, premature discharge from home health agency care, increased referrals to other sources of care and financing, and increased institutional care. This study was not designed to statistically quantify national changes in home health utilization or to serve as outcomes research. Quantification of changes is therefore used to illustrate changes in service delivery patterns and capacity of agencies studied. In order to explore behavior of home health agencies since implementation of BBA, authors solicited home health agency participation in study through state home health associations in nine states: California, Florida, Indiana, Iowa, Louisiana, Massachusetts, Mississippi, Pennsylvania, and Texas. …

Effects of the Home Health Care Interim Payment System on Access to Home Health Care for People on Medicare

In the Balanced Budget Act of 1997 (the BBA), Congress established an Interim Payment System (IPS), effective October 1, 1997, and directed the Health Care Financing Administration (HCFA) to promulgate a Prospective Payment System (PPS) to pay for home health care by October 1, 1999. Since the inception of IPS, the Medicare Rights Center,1 through our work with people on Medicare across the country, has seen a marked increase in the number of people who are eligible for the home health benefit, but who are unable to access it. In particular, we have found that the reduced reimbursement to home health agencies under IPS has meant that agencies have increasingly refused, reduced or terminated care to people with costly, complex or chronic illness. Because establishment of PPS has been delayed until October 2000, we recommend immediate reforms to constrain or reverse the pernicious effect of IPS on the frailest and sickest people on Medicare. MEDICARE HOME HEALTH CARE BENEFIT: BACKGROUND The Medicare home health benefit consists of skilled nursing, therapy, and related services provided by a Medicare-certified home health agency (HHA). To qualify for Medicare home health services, the patient must be homebound and require skilled nursing care or physical, speech or occupational therapy on a part-time or intermittent basis or need daily skilled services for a finite and predictable period of time.2 The services must be furnished under a plan of care prescribed and periodically reviewed by a doctor. If all of these criteria are met, Medicare will pay for home health visits provided by a registered nurse, a physical, occupational, or speech therapist, a social worker, and a home health aide. Medicare regulations do not impose limits on the length of time a patient may continue to receive home health benefits. Medicare will pay for home health care as long as the patient meets Medicare eligibility criteria (see Note 2) and home health care is reasonable and necessary for the treatment or management of a patient's illness or injury. There are no limits on the number of visits or length of coverage, and there are no copayments or deductibles for the benefit. Today, approximately 3 million acutely and chronically ill seniors and people with disabilities on Medicare depend on home health care as part of their medical care (Smith, 1999). Because patients must be homebound in order to qualify for the benefit, they are typically the sickest and the oldest people on Medicare. They are disproportionately female and 85 years of age or older. About 70 percent have incomes of $15,000 or less (Smith, 1999). Home health care has been one of Medicare's fastest growing benefits over the last 15 years. In 1990, the Medicare home health benefit was used by 57 out of every 1,000 people on Medicare. By 1997,109 out of every 1,000 were using the benefit. In the same time period, the average number of visits per user in Original Medicare, the government-run fee-for-service program, went from 36 to 73. Expenditures rose from 3.2 percent ($3.7 billion) of total Medicare spending in 1990 to 9 percent ($17.8 billion) in 1997. This translates to an average annual growth rate of 25.2 percent, compared with 8 percent for the Medicare program as a whole (GAO, May 1999). While some of this growth was attributable to fraud and abuse on the part of disreputable home health providers, much of it came as a result of improved access to the benefit by people who needed home health care and the shift in common health care practices toward an emphasis on outpatient care and managing serious illnesses at home. The United States General Accounting Office (GAO) and other researchers attribute the following factors to the rise in home health care costs over the past 10 years (GAO, May 1999, Komisar, 1998): 1. Change of home health care coverage guidelines to include patients with chronic healthcare needs as a result of a 1988 lawsuit. …

Understanding dual enrollees' use of Medicare home health services: the effects of differences in Medicaid home care programs.

Both the Medicare and Medicaid programs have experienced considerable growth in spending on home care in recent years. As policymakers adopt measures (such as those legislated in the Balanced Budget Act of 1997) to curb the rate of spending growth on home care services, it is important to understand interactions between the Medicare and Medicaid home care programs in serving the dually enrolled population. This study examines the potential effects of the Medicaid home care program on Medicare home health utilization using multivariate models. The study relied on data from the Health Care Financing Administration's Medicare Current Beneficiary Survey (MCBS), a longitudinal survey of Medicare enrollees. The primary MCBS file used was from Round 1 of the survey, which was fielded between September and December 1991. The unit of analysis was individuals. The authors used descriptive and multivariate methods to explore the relationship between Medicare coverage and state home care program characteristics. Included were variables that have been found to be significant determinants of Medicare home health utilization in other studies as well as variables to indicate the availability and generosity of Medicaid home care services in each state represented in the survey. The findings were consistent with those of previous studies, in that dual enrollees were disproportionate users of Medicare home health services, accounting for only 16% of enrollees but receiving 40% of all visits. In addition, lower levels of Medicare home health use were observed in states with relatively higher Medicaid spending on home health and personal care services, but this relationship appeared to be heavily dominated by the inclusion of enrollees living in New York State. When individuals from New York were excluded from the analysis, we found a negative but statistically significant relationship between Medicaid outlays on home health and personal care services and Medicare home health utilization. Because the Medicare and Medicaid programs are interconnected through the sizable dual enrollee population, changes in one program are likely to have ramifications for the other. This study presents another step in exploring how the two programs interact and emphasizes the fact that costs can be shifted between the two programs as policy changes are made to control the rate of home care spending growth.

National Health Policy Influence on Medicare Home Health

ABSTRACT National health policy regulates the delivery of Medicare home health services. These services have grown exponentially over the past several years. Current challenges to service delivery revolve around attempts to contain costs while ensuring quality of and access to care. To meet these challenges, providers must be aware of the societal and ideological influences on national health policies that impact service delivery. This article uses Wong's model of the progression of health care reform to address past health policy influences on Medicare home health delivery, investigate recent sociological trends for relevance to health policy, and propose changes based on current ideology.

The Medicare Home Health Benefit Implications of Recent Payment Changes

The interim payment system (IPS) for Medicare home health services, enacted in the Balanced Budget Act of 1997, was intended to slow the growth of home health expenses until HCFA could design a new prospective system. Instead, the IPS has acted like a per-case payment system without case-mix adjustment. Its impact on agencies, along with other policy pressures, has been first to slow and then to reverse the dramatic expansion of the home health sector. In this paper, we identify the impetus for payment changes in the recent history of the Medicare home health benefit. We then present emerging evidence about the effects of IPS and other recent policies on home health. Finally, we draw several lessons from this experience for the impending prospective payment system.

The home health visit: an appropriate unit for Medicare payment?

To contain costs and increase incentives for efficient provision of care, prospective payment methods are being proposed for Medicare home health services. Although a shift to per episode payment is much discussed, the methods rely on the home health visit as a fundamental building block in setting rates and ceilings. Some propose setting fixed per visit prices in the interim until episode payment can be developed. Findings from the evaluation of a Health Care Financing Administration (HCFA) demonstration of per visit payment suggest that this could shorten to the length of visits provided to Medicare beneficiaries. Because of home health agencies' discretion over visit length, we question whether the visit is the appropriate basic unit for developing prospectives payment methods for Medicare home health.