to the editor: We were thrilled to read an article devoted to home health care in a recent issue of American Family Physician.¹ Family physicians are increasingly called on to supervise simple and sophisticated medical care that is provided to frail elderly patients in their homes. We would like to clarify several important points.

To be eligible for home health care under current Medicare guidelines, the patient must require one or more of the following three primary skilled services: nursing, physical therapy or speech therapy. A need for either occupational therapy or social work alone would not qualify the patient for home health services. However, once services have begun, occupational therapy may be the only skilled component in continued care. Social work services, without other primary skilled services, do not qualify the patient for home health care that is covered by Medicare.²

We agree that physicians face financial barriers for full participation in the supervision of home health care. The physician receives no reimbursement for the detailed referral necessary to generate the home care plan. Only if the physician is able to meet the complex requirements of the care plan oversight codes is reimbursement available for physician supervision. However, reimbursement for physician house calls has increased dramatically in recent years. In our area of the United States, for example, reimbursement for a typical physician home visit (CPT code 99348) is approximately $60.

Medicare will cover the nursing and equipment costs of intravenous (IV) antibiotic therapy that is provided in a patient's home. The cost of fluids and antibiotics is generally not reimbursed by Medicare, so use of these therapies depends on billing the patient or another payer. This severely limits the physician's ability to supervise the infusion of fluids or antibiotics in the home for patients who are insured by Medicare.²

We encourage family physicians to master the rather arcane knowledge necessary to supervise Medicare home health.^2–4 Physicians should also advocate for coverage of other needed services, such as physician oversight, IV antibiotics, periodic venipuncture and the provision of unskilled services, such as bathing, in the absence of skilled needs.

in reply: I would like to thank Dr. Ackermann and Ms. Huyck for their letter. As they are no doubt aware, the nuances of home care can be confusing. Their points on eligibility add significant information worth noting. My article should have read “A physical therapist may perform the initial assessment, and a nurse need not be involved.” Their points on the lack of coverage for infusion medications are also well taken. Additionally, in most states, even patients who have Medicaid in addition to Medicare are poorly covered for intravenous medication; reimbursement is such that agencies often lose money on these patients.

Although I agree that physician financial reimbursement has increased dramatically, $60 per home visit is very little for physicians who do only minimal home care, such as those who wish to follow their long-term patients who have become homebound. Because I have a number of home care patients, I have the option to see three or (rarely) four in a two-hour period away from my office ($90 to $120 per hour to cover my cost and that of my office personnel and maintenance). A physician who goes to a patient's home that is 20 minutes away may only bill $60 for that hour (depending, of course, on the complexity of the visit). When I was in this situation before I increased my home care, I still made home visits a priority, but financial incentives (disincentives?) make it more difficult for many physicians.