Home is not where the heart is: looming problems of the home care industry

This analysis shows a definite trend of fiscal and social retrenchment policy by the government concerning in-home care service delivery (Tables 1 and 2). Ruggie (1990:164) notes that such shifts and changes in Medicare reimbursement patterns may be efforts of the government to realign itself to become the pivotal force in the provision or delivery of in-home care. Cost-containment pressures, although most needed in the health care industry, are the primary driving force behind retrenchment and the subsequent realignment of government. Such forces tend to impede the development of a comprehensive system for the provision of long-term care services. As noted, the movements and shifts in reimbursement patterns documented by this analysis can lead one to conclude that the same old features will continue to prevail instead of new and innovative delivery structures or public-private partnerships. In other words, the in-home care industry will become more like the nursing home industry--highly regulated and perpetually plagued by questions concerning quality of care. Although government is attempting to diminish its task as the prime provider of health services (i.e., through fiscal retrenchment) and the public's role as the dominant delivery system (i.e., social retrenchment), nevertheless the government has been unable to retrench politically in spite of its present direction of cost containment and fiscal restraint. Consequently, Ruggie (1990:147) notes that "the social welfare functions may continue to be performed" in spite of cost restraint policies. As a result, another "no care zone" is created and policy-makers will continue to develop "crisis policy" such as intense demands to hold unit costs low. The home care system has expanded many of the long-term care options and has emerged as a salient segment of our health and social service system (Applebaum and Phillips, 1990). Yet, policy-makers have not developed a comprehensive long-term care system, particularly one that defines a common policy for home care benefits and engenders the right kind of public-private partnership for the delivery of quality home care.