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The tug of the heart and the pull of the purse strings at the center of the nationwide health care debate take on a different tone when statistics in an agency report translate into a neighbor’s hurting face or a friend’s immutable fate.

Local government, as the saying goes, impacts the lives of those it serves more tangibly because through it, big picture economic trends as well as federal and state laws hit closest to home.

Like frontline workers operating in times of crisis, local government servants often carry the burden of having to reconcile the irreconcilable — the collision of morality and money.

This very issue came to bear before the Bremer County Board of Health recently, when the board faced the difficult decision to act on a proposal to decertify the county’s home health program.

This means that starting Feb. 1, the county will no longer be providing home health care for patients with Medicare and Medicaid, as well as veterans and private insurance.

The existing clients currently served by home health will be redirected to other area agencies for care.

Only those able to pay privately and those without insurance will continue to receive home health care through the county as long as funds are available.

Once the new policy is implemented, Bremer County will become only the third county in Region 2, which includes 16 others, and the 32nd county in Iowa to decertify their home health program.

The other two counties which have decertified in Region 2, where Bremer County falls, are Humboldt and Wright counties.

During an interview with the Bremer County Board of Supervisors Monday, which the newspaper requested and the board accommodated, starting their session at 8:30 a.m. to make themselves available, supervisor Dewey Hildebrandt, the vice chair of the board of health, and the supervisor liaison, said it was a difficult decision.

He summed it up like this: Should the taxpayers be in the business of backfilling for Medicare and Medicaid reimbursements, especially in a market where health care agencies specializing in services like home health, are present and offer the same services?

Hildebrandt said he remains conflicted about the Oct. 14 decision of the health board.

But, he added, he and his colleagues on the board of supervisors saw the “writing on the wall” several years ago, when then-new administrator of the department, Lindley Sharp, was first hired.

For several years, he added, the reimbursement rates for Medicare and Medicaid had continued to fall, forcing the county to pitch in a sizable chunk — $250,000 for each the past two fiscal years — an amount which is expected to continue to rise.

In the past few years, the amount allocated to home health from the county budget has grown exponentially, according to data cited in a business plan prepared by the health department.

That report, dated October 2020, was crafted at the request of the Bremer County Board of Health “in order to see the full scale of a decision to decertify, but still gap-fill home health services using taxpayer dollars instead of utilizing state grant funding, and increase public health programs.”

According to the data in the Business Plan report, in Fiscal Year 2017, the county contributed $75,000 to the county’s health department, with 60% of that amount, or $45,216, supporting public health and 40%, or $29,784 going to home health. At that time, there were 24,747 county residents and 354 clients using the home health services. Put otherwise, the county spent $1.83 per person on public health and $84.14 per client on home health.

By contrast, in FY 20, the county’s contribution to keep the health department afloat jumped to $250,000 for a second year in a row. (The first noticeable spike happened in FY 2018, when the amount doubled to $150,000 from FY 2017.)

In FY 20, the reporting of which includes data from the pandemic months, of the $250,000 allocated by the county, 30% or $76,642 went to public health and 70% or $173,358 went to support home health. In other words, the department spent $3.06 per person based on the county’s 25,062 residents, and $619.14 per client, based on the 280 clients who received home health services.

Home health services include skilled nursing and home care aide. The county subcontracts therapy services, including physical, occupational, speech and medical social workers, Sharp said.

During the interview with the paper on Monday, Hildebrandt said that the health board faced a dilemma.

“I think that I do agree that the writing’s on the wall that we just can’t simply continue to succeed unless we want to pump huge amounts of tax dollars into home health and I already think that a quarter million dollars is a pretty huge amount,” he said, “but do we want to continue to pump more when we know we’re competing directly with healthcare providers to do that?”

He added that knowing the clients will be picked up by health care agencies in the area made it “a little easier” for him.

“I’d be having a harder time if we were discontinuing something that there was no replacement for,” he said, “but these days we do have choices of other providers.”

Oct. 14 meeting

The health board meeting on Oct. 14, which took place at 6:30 p.m. at the Civic Center in Waverly, was animated and lengthy, according to stakeholders present at the public meeting.

The newspaper did not attend but interviewed several participants who did.

Waverly Newspapers reached out to Erin Barkema, the Region 2 Community Health consultant with the Iowa Department of Public Health, for comment, but she directed the paper to the public information officer of the department.

No substantive connection was made by either by press time.

Sharp, the health department administrator, said the declining number of staff members, and resignations caused the department to struggle to provide home health. She said many staffers sought other opportunity due to the uncertainty and rumors that home health might be closing.

At the Civic Center meeting, affected clients testified to the importance of the service to their lives.

Many of them had received letters, advising them of the potential decertification of the home health program before the meeting had taken place and hence prior to the board of health’s vote.

“It felt like the decision was already made,” said one former home health employee who had worked for the agency for years.

That former employee had found another job while the layers were shifting. The person asked not to be identified in a story, but provided the paper with their name and dates of employment.

“It was a service that was very necessary and a lot of other agencies provided the same service,” the former employee said, “but we are the only ones in the rural area and we had the same patients for years and years.

“As for the employees, most of us thought we were going to be working there forever. And the choice was made or us that we were not going to be. The fact is that not everyone used our service in the county, but we were always there for anyone who would need it. Clinics relied on us for patient care and families relied on us to care for their loved ones, so we didn’t just affect the patient, we affected the whole community, basically.”

In an Aug. 12 meeting, the health board reviewed four options moving forward, ranging from retaining the status quo to completely eliminating home health and focusing only on public health services and programs.

They chose option 3, a middle ground which decertified home health, meaning they can no longer bill Medicare and Medicaid, but will continue to provide non-certified home health care “as the budget allows,” but also increase the public health programs.

The newspaper asked the supervisors on Monday about the Business Plan solution, which was presented at the Oct. 14 meeting.

It shows a robust series of public health engagement and programming.

The plan also calls for a department of six, with a total wage and benefits of $379,964.

Supervisor Hilderbrandt said that budget had not been discussed with the board.

“So to clarify that plan is nothing but a preliminary plan,” he said.

He added that the county took home health over from the hospital in 2008.

“It’s a piece of work that is going to need a lot of work before any decision,” he said.

He noted there is “significant pressure” to provide a “robust public health department because of the pandemic,” so focusing on public health may be the new direction for the county.

“You could argue that Bremer County has not had a real robust Public Health Department,” he said. “We’ve actually probably had a more robust home health agency than public health so there again, it’ll be a challenging decision. I frankly am hopeful that we don’t end up putting the same dollars into that to begin with. I don’t think that we should. I think that we should probably reduce our amount but I might have my mind changed there too.”

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