LONG-TERM SOLUTION NEEDED FOR MEDICARE; MORATORIUM ON CERTIFYING AGENCIES IS NOT FAIR TO LEGITIMATE PROVIDERS.

Byline: Joseph H. Hafkenschiel

PRESIDENT Clinton's announcement in September of a six-month moratorium on certifying additional home-health agencies for participation in Medicare was less a policy shift than it was a declaration of surrender.

Ostensibly to reduce fraud and abuse, the real message behind the moratorium was that Medicare's complex regulations and lack of oversight have pushed the program out of control at a time of unprecedented demand.

The moratorium is just a chance for the government to catch its breath and does not address the real need: a long-term solution that will make Medicare more efficient without denying care to those who need - and pay - for it.

It's hard to be optimistic that the federal government will develop effective new regulations in the next few months that will keep potentially abusive providers out of Medicare and not exclude legitimate agencies. After all, it was the government that certified the 10,000 agencies currently participating in the program, and it's unlikely a revolutionary new answer will emerge during the moratorium that hasn't been tried during the past 30 years.

The moratorium will limit the supply of home-health services and result in a huge backlog of applications to be processed if it is lifted within the six months. Arbitrarily suspending certification is also grossly unfair to credible providers who have spent thousands of dollars applying to Medicare, only to be put in limbo.

The president's call for re-enrolling providers in Medicare every three years and doubling the number of provider audits is really a backhanded way of acknowledging that existing mechanisms to address problems are either not used or misapplied. Last year, only 0.2 percent of claims were denied as being medically unnecessary, and the doubling of audits still will leave more than 80 percent of providers unaudited annually.

The basic weakness of the president's plan is that it does nothing to deal with the core problem, which is Medicare's antiquated and inherently flawed cost-reimbursed home health payment. The balanced-budget act of 1997 mandates that the Health Care Financing Administration substitute a new approach for home health called a Prospective Payment System by October 1999. PPS would simplify Medicare by paying a certain amount per health ``episode'' rather than for each individual service.

But HCFA has been under congressional mandate to develop such a system since 1987. And even though the industry has offered a plan that could be the foundation for change, don't expect PPS any time soon: HCFA succeeded in obtaining language in the balanced-budget act allowing it to delay implementing the system for up to four years.

When the federal government announced its initiative to control Medicare fraud and abuse in December 1995, the California Association for Health Services at Home identified the root problems and offered to work with the government to develop real solutions, including an effective PPS plan that would greatly eliminate waste, fraud and abuse. We have never been taken up on our offer.

The vast majority of home-care providers are hard-working people on the front line who dedicate their daily lives to helping the elderly and disabled remain in the homes they love. They know how Medicare has helped countless parents and grandparents avoid nursing homes and hospitals, and also how numbingly complex and bureaucratic the system can be. If the government is going to develop an effective PPS system that reduces costs without denying care, HCFA must call on the experience of the CAHSAH and the home-care industry.

It is in everyone's best interests - including the government, home-care providers, patients and taxpayers - to arrive at a long-term solution that incorporates real world experience. We're ready to come to the table to find real answers; all we need is the invitation.