When Congress passed the federal health care law, it included a provision designed to cut down on Medicare fraud and improve care for patients.
A congressional study found fraud is a significant problem in home health care in the Medicare program. Another investigation found some doctors had approved patients for home health with no personal knowledge of the patient they certified.
The federal health care law now requires traditional Medicare patients seeking home health care to meet with a physician or a nurse practitioner under a doctor's direction, at least 90 days before they receive the care or within 30 days after the care starts. Some doctors, however, may not be ready to comply with the change.
Doctors must certify that a patient is homebound and explain, in writing, why the patient needs the service.
The face-to-face requirement will help eliminate fraud and also be better for patients, said Dr. Ed Ratner, medical director of Heartland Home Health Care and Hospice in Roseville, Minn.
"Research shows that patients who are seen in the weeks after being hospitalized are less likely to be back in the hospital," said Ratner, also an associate professor of medicine at the University of Minnesota. "The idea that a patient needs skilled services, nursing or physical therapy but doesn't need a physician visit isn't even logical."
Given that home health agencies bill Medicare thousands of dollars, having doctors meet patients at a cost of a couple hundred dollars to ensure the care is appropriate makes sense, he said.
But doctors and home health providers urged the federal government to delay enforcement of the rule from January until July, contending that the government had not done enough to prepare physicians for the change. Federal officials agreed to an April 1 start.
Neil Johnson, executive director of the Minnesota Home Care Association, views the requirement as red tape that could keep some people from getting care that they need. Johnson, whose group represents 270 agencies across Minnesota, said the rule is not necessary in Minnesota because fraud isn't a major problem.
"Let's laser in on some the bad actors, and not just throw constant regulation over the people who are trying to do the right thing," he said.
The American Academy of Home Care Physicians estimates about 5 percent of patients who depend on Medicare are unable to leave their homes without help. In Minnesota, that would amount to nearly 39,000 people.
Among them is 65-year old Cuban-born Mario Fernandez, a charismatic wildlife painter and sculptor, best known in Minnesota for his 1984 pheasant and trout stamps.
Two and a half years ago, a University of Minnesota doctor diagnosed Fernandez with a serious lung condition and told him he had about two months to live.
"When I was about to leave the U of M they didn't want me to come home; they wanted me to go to hospice because I was going to die," Fernandez said. "But I told them I want to die at home."
Since then, Fernandez has lived in his modest Edina home. Gladys, his wife of 45 years, cares for him while a home health nurse visits once a week.
A hospital bed commands the center of the living room. A visitor can't miss the subtle hiss of four waist-high tanks that supply Fernandez pure oxygen a 24 hours a day. Fernandez needs so much oxygen to stay alive -- 11 liters per minute just to sit at his kitchen table -- that the only way he can leave his home is by ambulance, and even that's dicey.
"One time they ran out of oxygen and I was 10 minutes away from the hospital," he said. "It was a horrible thing."
Fernandez made it with the help of a small tank that had been overlooked.
Not all Medicare patients are subject to the new requirement. Some, like Fernandez, who had home care before April, are exempt. So are people on Medicare Advantage plans.
One solution is for doctors to visit patients. But Ratner, the home care expert, said Minnesota has comparatively few doctors who make house calls, particularly in the Twin Cities.
"It's relatively uncommon compared to some other places, and I don't have a great explanation for that," he said. "Rural doctors have always done it."
In Chicago, Detroit, Washington D.C., New York and San Diego, competing practices of doctors specialize in house calls, he said.
Ratner said one theory to explain why there are few doctors who make house calls in Minnesota is that the state's health system is very hospital- and clinic-based. Practices are set up around patients visiting doctors, not the other way around.