Medicare Constrains Home Health Murses' and Social Workers' Care for Persons with Alzheimer's and their Caregivers

Medicare home health is a $19 billion annual business, generating a 19.4% profit margin, the highest profit margin among major Medicare provider types. The profitability has been generated due to a managed care model prospective payment system (PPS) implemented in October 2000. The intent of PPS was to decrease costs and increase quality. However, now nearly 15 years later, profits have soared, costs have increased, quality has been relatively stagnant-to-modest in improvement. No studies have qualitatively analyzed the impact of these trends on meeting patient and informal caregiver needs. The present study focuses on needs of Medicare home health patients with Alzheimer’s disease and their caregivers. It is based on interviews of 29 home care nurses in the New York City metropolitan area from October 2013-January 2015. The findings indicate: Medicare policy, moderated by agency policies, constrains the ability to meet patient and caregiver needs; Medicare does not cover evidence-based practice that can more effectively meet care needs; and the failure to effectively meet care needs exacerbates patient and caregiver needs and increases re-hospitalization rates. Policy and practice implications are discussed.