Dombi: Regulatory Flexibilities Mean More Competition for Home Health Providers

Home-based care providers are at the forefront of the nation’s fight against the coronavirus; yet they still lack the full federal help they need to succeed. 

Meanwhile, regulatory flexibilities for hospitals and other health care providers are creating newfound competition for home health and home care agencies.

“So far, it has been difficult to measure whether or not that competition has really created any sort of material impact on home care providers, home health agencies, hospices and the like,” National Association for Home Care & Hospice (NAHC) President William A. Dombi said. “But physicians and non-physician practitioners are put in a position to do home telehealth services today, and that may substitute for what would come from a home health agency or a hospice.”

Dombi made those comments Tuesday at NAHC’s 2020 Financial Management Conference, which was held virtually due to the COVID-19 emergency.

He briefed attendees on current and future legislative matters of interest, including the potential competition threat posed by health care providers that have not traditionally been direct competitors to home-based care.

Regulatory flexibilities have made it possible for those providers to perform duties typically carried out by home health providers.

“Hospitals have been given permission — for patients that were actively in an outpatient [setting] for that facility — to send them to outpatient therapists by way of telehealth into patients’ homes,” Dombi said. “Rural health clinics and federally qualified health centers have been excused from the normal standard that they could only do care in the home if a home health agency was unavailable. Again, we really can’t quantify the level of competition that has come from that.”

While hospitals and health care providers are generally paid for providing telehealth services to patients, home health providers are not. For them, telehealth visits are still not reimbursable, nor do they count toward Low Utilization Payment Adjustment (LUPA) thresholds.

In other words, agencies often must finance telehealth services out of pocket — and on top of that, they can receive a lower-than-usual reimbursement for a 30-day period of care when doing so. 

That only makes the competition more of a potential threat. Even with Paycheck Protection Program (PPP) loans and Provider Relief Fund grants, home health providers are facing new financial challenges that are difficult to navigate.

According to survey data from NAHC, about 82% of all home health agencies have seen some sort of revenue reduction amid the COVID-19 emergency, with the median reduction coming in somewhere between 15% to 20%.

While a combination of factors — including sky-high personal protective equipment (PPE) expenses and volume disruptions — are to blame, lack of telehealth reimbursement certainly doesn’t help.

“CMS’s position is that [home health providers] are getting enough money through the episodic reimbursement to carry that kind of a cost, particularly when it’s used to substitute in-person services,” Dombi told event attendees. “But the rub is when the reduction in the volume of in-person visits brings that home health agency into a LUPA level of reimbursement, and then that provider of services is in trouble because LUPAs are losers financially for agencies.”

LUPAs — standardized per visit payments instead of a full episodic payment — reduce the reimbursement an agency receives for delivering care.

If a provider doesn’t deliver a certain number of in-person visits to a patient during a 30 day period of care, it is hit with a LUPA. Under PDGM, there are 432 different LUPA scenarios, with visit thresholds agencies must meet ranging from two to six.

Amid the coronavirus, 47% of all agencies report at least a doubling of LUPAs, according to NAHC survey data.

“What it translates to is about $1,000 to $1,500 difference per patient in revenue — so you can see why we’ve seen that revenue reduction,” Dombi said, noting LUPAs are often out of providers’ control amid the coronavirus. “Patients are saying, ‘I’ll take some care, but not all of the care that you might otherwise give in person,’ thereby reducing the full episode payments that agencies would otherwise receive.”

Securing telehealth reimbursement for agencies remains NAHC’s top priority. The Washington, D.C.-based advocacy organization is hopeful legislation will fix the issue in the near future.

Additionally, NAHC is optimistic newfound perceived competitors could be a good thing in the long run.

“We are definitely hoping that, in the end, those competitors become more partners, particularly on the physician side and other practitioner sides,” Dombi said. “But in the short term and long term, one of the greatest silver linings in this is the opportunity to show the breadth and depth of what can be done in home care.”

NAHC is also pushing for additional provider relief funding for home health, home care and hospice providers, as well as federal assistance providing appreciate pay to front-line home-based care workers.

HEALS Act proposal

Dombi’s statements were pre-recorded before Senate Majority Leader Mitch McConnell on Monday unveiled Republicans’ $1 trillion HEALS Act proposal, which would be the fifth overall coronavirus relief package if implemented.

Among its provisions, the HEALS Act would add $25 billion to the Provider Relief Fund and create new flexibilities under PPP. The Republican plan would also add some new liability protections for health care providers.

On top of that, it would extend the repayment timeline for the advanced and accelerated payments distributed by the U.S. Centers for Medicare & Medicaid Services (CMS) in the spring. Furthermore, the plan would extend telehealth wavers, reduce federal unemployment support and provide Americans with another $1,200 stimulus check.

However, home-based care critics say it doesn’t do enough to help various senior care providers.

Take the National Council on Aging (NCOA), for example. The Arlington, Virginia-based nonprofit organization advocates for services, resources and initiatives to help older Americans.

“NCOA is deeply disappointed by the Senate Republicans’ most recent attempt to address the grave and ever-growing COVID-19 pandemic affecting our country because it fails to support and protect older Americans,” NCOA Vice President for Public Policy and Advocacy Howard Bedlin said in a press release. “Older adults are among the most vulnerable Americans in this pandemic because they are facing not just potentially deadly health complications but also catastrophic financial insecurity.”

LeadingAge — a D.C.-based advocacy organization for the long-term care sector — also took aim at Republicans’ plan.

“Among our disappointments, there are no funds dedicated to aging services providers,” Katie Smith Sloan, president and CEO of LeadingAge, said during a Wednesday press conference. “The legislation includes only a fraction of the hundred billion dollars needed to protect older adults, and aging services providers will have to compete with hospitals and other care providers for those funds.”

Sloan also decried the lack of federal financial support for testing and PPE, in addition to the Republicans’ exclusion of “much-needed” hero pay for front-line senior care workers.

“The bottom line is that Congress needs to deliver more than what’s included in the HEALS Act,” she said. “Adults over 65 account for 16% of the U.S. population and 80% of the U.S. deaths to coronavirus. Our leaders must put older adults at the front, alongside hospitals.”

The good news for senior care providers is that the HEALS Act is still only a proposal. Democrats and Republicans are now in negotiations.

Democrats are pushing for more and different supports in the package — likely similar to those outlined in their HEROES Act, passed in the House a few weeks ago.

Whatever form the stimulus package takes from here, experts expect it to pass in August.