ALBANY, N.Y. (AP) Stethoscope? Check. Bandages and medications? Check. Money for fuel? Uh-oh.

U.S. home health care workers, particularly those in rural areas, are suffering from financial headaches caused by the escalating cost of transportation, forcing some to borrow cash from co-workers in between paychecks and others to consider leaving the industry altogether.

Providers of home care in New York, California and other states are doling out prepaid gas cards, rental cars and other perks in an effort to retain their workers, who care for roughly 12 million elderly and disabled patients nationwide and drive an estimated 5 billion miles a year, according to a recent study by the National Association for Home Care and Hospice.

The industry is also contemplating abandoning uneconomical home visits in far-flung locations, and increasingly checking patients' blood pressures, heart rates, blood-sugar levels and other vital signs via remote monitoring systems, which many companies previously deemed too expensive.

Industry officials said they had not heard of any instances where a patient's care was compromised by the high cost of getting a health care professional to their home, though they are worried it could happen. After some home health providers threatened earlier this year to cease operations in rural parts of South Dakota, Democratic Sen. Tim Johnson said he would push Congress to revamp the Medicare payment system to account for the industry's rising fuel bill.

While lots of industries are suffering as a result of gasoline prices that have risen more than 80 percent in the past 18 months, experts said it's a particularly knotty problem for nurses, aides and other employees of home health care agencies -- many of whom are responsible for their own travel expenses and depend on government reimbursements that haven't yet caught up with the rising prices at the pump.

A recent survey by the National Association of Area Agencies on Aging underscores the impact: Half of the respondents said they had already cut back on home visits because of surging fuel costs -- and 90 percent said they expected to make cuts in 2009.

The Northern Montana Home Health Care and Bear Paw Hospice, a not-for-profit company based in Havre, Mont., that covers two counties made up of 24,000 people across 7,136 square miles, is looking at discontinuing service in the state's back country.

The company's director, Lisa Genereux, said the formula underpinning Medicare reimbursements simply doesn't account for $4.09-a-gallon gasoline, the average price at the pumps in the Rocky Mountain states these days.

Donald Wagoner, a nurse who travels up to 100 miles a day traversing New York's Adirondack region, said his newest professional challenge these days is simply not running out of fuel. "I've come close a couple of times," said Wagoner, who drives a Saturn Vue SUV that gets around 25 miles to the gallon.

For the most part, providers are taking steps to make sure their staffs can afford to travel from home to home and, when they cannot, that patients continue to get the care they need.

AristoCare Home Health Services, which operates in Arizona and California, recently began paying a $10-$15 travel stipend for trips outside downtown Tucson, and uses computer mapping software to reduce the number of miles home care workers drive between assignments.

"With as much driving as they do, we had to do something," said Cyndy Michaud, the Tucson, Ariz.-based company's branch relations manager.

Bons Secours Home Care in Newport News, Va., has arranged with a rental-car company to provide 15 fuel-sipping Toyota Corollas for its registered nurses. The nurses pay $150 a month for the car, they can drive it for personal use, and the agency picks up the cost of gas for the first 20,000 miles driven each year.

"As soon as we were able to start offering these cars, I had people knocking down my doors," said Sharon Riddick, the agency's director. "Now I'm fully staffed for the first time in seven years."

For its part, the Home Care Technology Association of America is lobbying Congress for changes in Medicare to allow companies that use remote monitoring systems to get reimbursed for it -- a major reason more companies haven't embraced the technology.

Even if remote monitoring technology becomes more widely embraced, patients requiring wound care, physical therapy and other hands-on attention will always receive it, the trade group's executive director, Bob Walters, said.

Many home health agencies reimburse workers for fuel on a per-mile basis. But with paychecks often two weeks or more apart, employees must cover rising gas costs out-of-pocket -- an extra burden for those working in rural areas, where pay tends to be lower but the distances between patients is higher.

Kathy Liddell, assistant director of patient services of North Country Home Services in New York's Adirondack Mountains said some home health aides -- who start at $9 an hour -- have had to borrow gas money from office staff to make it from one paycheck to the next. The Saranac Lake company's 250 employees collectively travel about 7,000 miles a day serving patients in a 5,000-square-mile patch in northern New York.

Part of the problem is that the agency can't afford to keep raising its reimbursement rate to keep pace with the price of gas.

"When gas was around $2 a gallon, we were paying 30.5 cents a mile. Now we're up to 42.5 cents," she said.

The Internal Revenue Service as of July 1 raised the automobile mileage rate that businesses and others can claim from 50.5 cents per mile to 58.5 cents per mile.

Most home care is funded through Medicaid and Medicare programs using fixed payment rates -- some of which are only adjusted annually -- based on estimates of the cost of providing care. But those costs -- like gasoline -- can rise sharply between adjustments. That makes it difficult for some to raise the fuel reimbursement for employees without busting its own budget, said North Country's Liddell.

The Association for Home Care and Hospice -- a trade group representing publicly traded companies such as Amedisys Inc. and Gentiva Health Services as well as smaller agencies -- also is pushing for changes in Congress.

Among them is to reinstate Medicare's rural "add-on," which would provide a 5 percent increase in reimbursements to home care providers who serve patients in rural areas. The payment system expired at the end of 2006 and wasn't included in subsequent budgets.