With the home-care industry facing financial crises and some agencies unexpectedly shutting their doors, one organization's efforts to ensure that patients will not be abandoned have left other agencies with a bad taste in their mouths.
Earlier this month, the Dallas-based Visiting Nurse Association of Texas sent letters to home-care agencies, urging those thinking about closing their business to discuss "possibilities of a smooth transition of your patients to VNA."
Smaller home-care agencies were confused and offended by the letter, which was sent to companies in VNA's service region. "I felt like they were trying to muscle the small guy instead of trying to help," said Phillipa Anuwe, administrator of Dallas-based CLEST Nurses Home Health. VNA is "indirectly soliciting patients and asking us for referrals," she said.
VNA of Texas is a community-based not-for-profit home-care agency with six offices in north-central and west Texas. VNA said it faced financial difficulties itself and was forced to close its office in Brownwood, Texas. The association is a member of Visiting Nurse Associations of America, a national organization with about 200 member organizations.
Executives at VNA of Texas said they did not intend to undermine smaller agencies or solicit their patients. Rather, they wanted to "address community needs for patient care," said Emily Tripp, vice president for home care and hospice. "We do not want any patients to be left without needed home care because the agency that was taking care of them decided to go out of business."
Tripp said she was prompted to write the letter when an agency closed and left a friend's grandmother with no one to change her catheter. "She needed continued care but didn't know what to do or where to go." VNA of Texas wanted agencies to "know that we're a resource for their patients if they make that decision (to close)," she added.
Still, small agencies said VNA's intention to help patients did not come across in the letter. "If they really cared, they'd issue help to keep us going," said Peninnah Ihemelu, administrator of Supreme Home Health Services in Dallas. "We didn't come into home health for the money; we are in it because we care for our patients. We intend to survive. I know we'll make it by God's grace," Ihemelu said.
VNA of Texas sent clarification letters March 10 to all companies that received the initial March 2 letter. The follow-up letter stated the association's intention and reiterated its desire to discuss opportunities for patients.
The fact that Mary Suther, president and chief executive officer of VNA of Texas is also chairman of the board for the National Association for Home Care deepened the wound felt by small agencies, said Carmen Johnston, administrator of the Jacksonville, Fla.-based Home Care Association of America, which represents freestanding home health agencies -- those not affiliated with hospitals or large chains.
The Washington-based NAHC represents more than 6,000 home-care organizations of all sizes including VNA of Texas.
"How can (the NAHC) represent (small agencies) if you've already determined their death?" Johnston asked.
Suther denied that VNA acted out of self-interest. "There's no way I would do anything that wasn't fair and didn't represent agencies," she said. "I have to represent all providers that are members of the national association, not just VNAs. I've been diligently working to keep people in business, not to drive people out of business. I spend every waking moment trying to help agencies combat (legislation). I'm trying to figure out how all of us are going to survive."
The NAHC is currently lobbying to amend some provisions in the 1997 balanced-budget law that it believes may force smaller home-care agencies to close or sell to larger companies like VNA. Troublesome provisions deal with the interim payment system, surety bonds and elimination of coverage for venipuncture.
The requirement that agencies secure surety bonds -- the greater of $50,000 or 15% of annual Medicare revenues -- affects smaller home-care agencies the most. Many small home-care companies have trouble obtaining bonds because they lack capital and assets. The NAHC is among several groups that appealed to HCFA to delay implementation of this requirement.
A recent decision by HCFA is a small victory for home health agencies. The surety bond requirement was scheduled to take effect Feb. 27, but the day before the effective date HCFA decided to delay implementation for 60 days. HCFA regulations issued late last month limit a surety bond's coverage to the term during which HCFA determines that funds owed to Medicare or Medicaid were unpaid, extend surety liability to two years after a home health agency leaves the Medicare or Medicaid program, and allow bond companies to appeal overpayments, civil money penalties and assessments.
But the regulations do not change balanced-budget law requirements regarding the extent of surety bond coverage, the posting of bonds every year and nonreimbursement for the cost of the bonds.
Even though HCFA did not change the extent of surety bond coverage required, it said the "15% is open to reconsideration."
Connie Cenac, founder of Americans for Responsible Medicare Spending, said, "Our goal is to change the law so that no one goes under." She added that the letter sent by VNA of Texas was "not in the best interest of the patient. Patients never win when big business gets involved in their patient care. When small home health agencies go away, the elderly can kiss home healthcare goodbye."
Suther said home health agencies should stop fighting with one another and buckle down to the real issues. "At a time when the industry is in trouble, we don't need to spend time fighting," she said. "We need to help everyone. We're all angels with only one wing. Only when we embrace each other, can we fly."