Home Health Prior-Authorization: Unfortunately, this analogy, is no joke.


You have probably heard the joke about the guy who walks into a bar and asks the bartender for a drink.

Well, here is one that you probably have not heard:  A mother walks into a grocery story to buy food for her family for the week. She selects everything she will need to feed her husband and children for seven days.  She pays the cashier by credit card and signs the charge slip.  What happens next?  She should go home to unload her grocery bags into her refrigerator and pantry and then prepare dinner for her family.

Instead, the mother is sent home.  Without any food for her family.

Before she is permitted to provide the food she selected to feed her children, she is required to complete a series for documents for the cashier, explaining calorie-count, nutritional-value-content detail, why she needs to purchase the food and why her children need to eat.  Then, the grocery store manager decides if she really needs the food to feed her family. The mother is told she can expect to hear back from the store manager in 10 days as to whether or not she has been authorized to bring the food home and feed her family…tonight, tomorrow and for the rest of the week.

No, you didn’t read that wrong. There is no punchline here. And unfortunately, this is not a joke.

This process is exactly what the Centers for Medicare & Medicaid Services (CMS) is essentially proposing through a process called “Prior Authorization” for Medicare home health services. To translate the analogy: The mother is the “doctor.” The food is the prescribed “health care in the home.” The signed credit card charge slip is the “doctor’s signed plan of care for home health services.” Her family is the “patient.” And, the store manager is the “government bureaucrat” making decisions about the need for health care.

CMS’ surprising proposed rule for Prior Authorization of Medicare home health care services will mean that patients will have to wait for the health care prescribed by their doctor, while government Medicare officials review the doctor’s recommended course of health care to determine if it is necessary or not. Again, this is not a joke.

While the role of a middleman is suggested to be a fraud deterrent, it places a government bureaucrat between the doctor and their patient. And to continue the analogy, the Prior Authorization proposal does not stop fraud at the grocery store. The shop-lifter is still stealing food, while the mother is waiting to learn if she can feed her family.

Prior Authorization only stands to have a negative and disruptive impact on necessary health care and the patient’s clinical outcomes. Medicare home health beneficiaries are already documented as being older, poorer, sicker, more likely to be female, a minority and disabled than all other Medicare beneficiaries combined. Adding a bureaucratic layer to the process will impede the delivery of timely, necessary health care to a very vulnerable and frail patient population. These delays in the provision of health care put our seniors at risk for medical crises during the “review” period that could result in the patient returning, unnecessarily to the hospital, because the health care they needed, that was ordered by their doctor, was not provided.

Keep in mind, other health care sectors have experience with Prior Authorization and have documented wait-time delays. Durable Medical Equipment (DME) providers have noted delays of up to 10 days to receive authorization to deliver medical equipment, but key differentiators exist. For example, in a DME scenario, a patient is in a wheel chair, but may be better served by a power wheel chair. But the patient still has a wheel chair while they wait.

The 89-year-old gentleman, living alone after his surgery waiting for a nurse to change his wound care dressing, reconcile his medications to ensure there is not a harmful medication interaction between his old pills and new pills, and teach him about what to do to accelerate his recovery, does not have 10 days to wait for the health care his doctor has already ordered. Ten days provides a long time for medical emergencies, missed medication, infection and various other adverse events to occur, while a frail patient waits for the government bureaucrat to review his or her need for home health care.

Important to note, one of the primary goals of home health care is monitoring the patient who is sent home from the hospital, to prevent medical emergencies that needlessly send the patient back to the emergency room or the hospital, which then unnecessarily increases costs to the Medicare program.  If unable to provide these home-based health care services for up to 10 days after a hospital discharge or a doctor’s office visit, we are jeopardizing patients’ health during the very window when they are most at risk.  Medicare’s Prior Authorization policy is setting the patient up for an unnecessary admission or readmission to the hospital, inherent in what is a flawed design that will do absolutely nothing to decrease fraud.

The bottom line, not the punchline, is that if finalized and implemented, this Prior Authorization proposal needlessly and recklessly will prolong the wait  time for delivery of the patient’s health care, jeopardize the health of frail seniors, drive up unnecessary hospital readmission rates and increase both Medicare spending and taxpayer costs.

Instead, Medicare should continue their efforts to promote policies that reward and encourage effective health care coordination to the benefit of home health patients as well as the Medicare program, while simultaneously reducing costs, by keeping patients who do not need hospital-based care, out of the hospital.

Prior Authorization is a bad joke, which does not need repeating.

William Deary is Chief Executive Officer of Great Lakes Caring Home Health and Hospice, a leading provider of a post-acute continuum of in-home health care.  

Morning Consult