Less than a month before election day, the Democratic and Republican candidates for president are dueling over home-based care plans.

Vice President Kamala Harris announced on “The View” this week a proposal that would allow home care to be administered through traditional Medicare.

On the same day, former President Donald Trump and his campaign released a rebuttal, pointing toward home care-related policy implemented from 2017-2020, plus additional plans for a potential second term.

Harris’ proposal is a more lofty one. It would also – if implemented – create a massive tailwind for home care providers across the country. But, as LeadingAge President and CEO Katie Smith Sloan pointed out after the proposal, “we cannot overstate that without staff, there is no care.”

Trump, meanwhile, pointed to expanded supplemental benefits in Medicare Advantage (MA) as a way for seniors to access more home care-related services. His campaign team also focused on economic points that it believes will make aging in place easier for Americans under his leadership.

In this exclusive, members-only HHCN+ Update, I make the mistake of venturing into the presidential candidates’ plans for home-based care. Specifically, I examine how viable the plans are, and what they could mean for providers, if implemented.

Home-based care takes center stage

Home-based care providers were likely pulling their hair out over the predictable confusion that arose from Harris’ proposal Tuesday.

Home health care is already a robust benefit provided under the Medicare program, and generally includes services delivered to seniors after an acute health event.

Home care is not currently available under traditional Medicare, however, and generally includes non-medical services to help with activities of daily living.

The only place where home care is paid for under Medicare is through MA supplemental benefits, and MA pays for just a sliver of all home care provided currently.

So, yes, Harris’ proposal would be groundbreaking, if implemented. It would completely change the scope of the Medicare program.

As for the companies it would directly impact, pick a notable name in home care.

Currently, home care providers have a large addressable market: seniors with the ability to pay out of pocket for home care services; Medicaid beneficiaries in need of home- and community-based services (HCBS); veterans in need of home care, paid for through Veterans Affairs (VA); and a small portion of MA beneficiaries and long-term care insurance clients.

If home care were paid for by Medicare in the future, that would take the concept of “unlimited demand” to a new level. There are over 30,000 home care agencies in the country, almost all of which would have a new market opportunity if Medicare became another means to pay for home care.

The one potential downfall for providers would be former private-pay home care clients being able to use Medicare to pay for services. Private-pay home care doesn’t come without challenges, but it remains one of the most profitable forms of home-based care business.

Home health providers – which already provide care to Medicare beneficiaries, almost exclusively – would also see a business boon. Many of them already provide home care, and the ability to care for clients through one revenue source in both service lines would be massively beneficial.

After all, home-based care is responsible for one of the only successful Center for Medicare and Medicaid Innovation (CMMI) demonstrations of late. The Home Health Value-Based Purchasing (HHVBP) Model – now implemented nationwide – has already saved Medicare billions, and is likely to save many more billions moving forward.

“We think access to personal care services could at least double from six million customers today. By our estimate, the extra spending would expand the [total addressable market] by ~30% to $110 billion per year,” Macquarie Capital wrote in an analyst note this week. “Since Medicare covers home-based medical services, we expect a wider adoption of the integrated care model following added personal care services coverage. This could also expedite the transition to value-based care. Providers could benefit from aligned incentives, streamlined operations and cost synergies.”

Then comes the question of viability, however.

Harris is not the first person to propose such an idea. Home care stakeholders have suggested it for years, but so have other policymakers.

“When the Affordable Care Act was passed, a component similar to this was included and that ultimately was stripped out,” Tyler Giesting, a director of health care and life sciences at West Monroe, told me this week. “I think we’ve seen it fail in the past for reasons that come down to: can it be economically viable? The challenge would be getting something like this passed, in the way that it has been described so far.”

The Harris campaign has suggested that it would pay for the proposal, in part, by cutting Medicare payments for drugs. It estimated that the proposal would cost around $40 billion per year.

But other estimates suggest that it would cost closer to $400 billion.

Harris sees the proposal as a way to aid the “sandwich generation” – adults that have aging parents to take care of, as well as children. Those responsibilities make it tough to maintain employment.

For Harris, the key would be to convince the right stakeholders of the overall value of home care. It wouldn’t be enough to just prove that more Americans could continue contributing to the economy if they had additional help at home for their older relatives.

Harris’ team would need to instead pitch this as a long-term cost savings project. If more seniors had access to home care, less seniors would be driving up U.S. health care costs in hospitals, emergency rooms and more costly brick-and-mortar facilities.

That is already a battle home care providers face. They are regularly trying to convince payers that more home care equals less overall cost. But a concrete plan, and concrete evidence of those potential savings, would have to be laid out.

“It’s one thing to have this idealistic proposal perspective, and it’s another to actually put it into action with a detailed plan,” Giesting said. “Then, there’s also getting it passed and put into law.”

A detailed plan is key. Even if we accept the idea that more access to home care could ease burden on Americans, while also keeping overall health care costs down, the implementation of the proposal through Medicare would need to be tirelessly thought out.

For instance, New York’s Consumer Directed Personal Assistance Program (CDPAP) – which allows family members to be paid to care for loved ones in need of home care – has been a fiscal disaster for the state.

Self-directed care has potential. It allows unpaid caregivers to be compensated, and for home care recipients to direct their own care. But it’s also hard to oversee.

For what it’s worth, if the proposal did move forward, I think the best way to go about it would be to prioritize care from existing, quality home care agencies. Agencies that train and vet their caregivers, ones that have been providing care professionally for a long time.

Trump proposals

The Trump campaign’s home care proposals are more understated. And, like Harris’ plans, more details would be needed to project true impact – for potential home care beneficiaries and providers.

“President Trump will prioritize home care benefits by shifting resources back to at-home senior care, overturning disincentives that lead to care worker shortages and supporting unpaid family caregivers through tax credits and reduced red tape,” the Trump campaign wrote in a release, in preparation for Harris’ announcement this week.

The campaign also evoked MA supplemental benefits. MA supplemental benefits – through the primarily health related pathway and the Special Supplemental Benefits for the Chronically Ill (SSBCI) pathway – were created during Trump’s presidential term.

The benefit that allows for home care services is dubbed In-Home Support Services (IHSS). MA plans have pulled back on offering IHSS in 2024, however.

“The Trump administration provided new Medicare Advantage supplemental benefits that included modifications to help keep seniors safe in their homes, respite care for caregivers, transportation coverage, additional in-home support services and assistance and non-opioid pain management alternatives,” the release continued.

The campaign also pointed out other indirect factors that have led to home care inaccessibility of late, such as inflation, which it believes it can continue to bring down.

Spotlight and policy

Home-based care being in the nationwide spotlight is a good thing for providers and older Americans.

But it’s also worth taking stock of where that spotlight has gotten us before. The Biden-Administration has been laser-focused on home care, but mostly HCBS through Medicaid.

Meanwhile, home health providers have been left behind. Advocates are in the throes of a three-year long fight against continued rate cuts from the Centers for Medicare & Medicaid Services (CMS), as other home-based care proposals are taking shape from both campaigns.

Home health providers are seeing their traditional Medicare payments cut, while also receiving payments from MA plans that often don’t cover the cost of care. All the while, MA penetration continues.

In April of 2023, I wrote about why federal support for home-based care is missing the mark.

While proposals from both campaigns this week contain some good elements, that fact remains true.

As home-based care takes center stage once again, Medicare-certified home health providers are forced to stand behind the curtains, at a time when their margins are evaporating.

“I would also want to remind the Biden, Harris administration that the existing Medicare home health program is under assault currently, and has been since 2020, with billions of dollars in cuts that have diminished access to care, so I think that investment and a stabilization of the existing Medicare home health benefit is something that is also needed,” Partnership for Quality Home Healthcare CEO Joanne Cunningham told HHCN this week. “With this news, I would just offer that recommendation and reminder.”

The post With The Election Nearing, Candidates Battle Over Home-Based Care appeared first on Home Health Care News.

To rebalance the Patient-Driven Groupings Model (PDGM) and make it budget neutral, at least according to its internal methodology, CMS is proposing a permanent prospective adjustment to the CY 2025 home health payment rate of -4.067%.

For CY 2023 and CY 2024, CMS previously applied a 3.925% reduction and a 2.890% reduction, respectively.

“This adjustment accounts for differences between assumed behavior changes and actual behavior changes on estimated aggregate expenditures due to the CY 2020 implementation of the PDGM and the change to a 30-day unit of payment,” CMS wrote in a fact sheet on the proposed rule.

The CMS proposed rule includes a CY 2025 home health payment update of 2.5%, which is offset by an estimated 3.6% decrease related to the PDGM rebalancing and an estimated 0.6% decrease that reflects a proposed fixed dollar loss.

Overall, CMS estimates that Medicare payments to home health agencies in CY 2025 would decrease in the aggregate by 1.7%, or by about $280 million, compared to 2024 levels.

Continued cuts

Over the last few years, CMS has generally proposed large cuts, then finalized smaller cuts. But even when the cut is lowered between the proposed and final rule, providers lose out on those finalized cuts.

So, for instance, even a 1.7% cut may not appear very large. But an over 4% permanent cut is extremely significant.

Additionally, CMS also mentioned the clawbacks it intends to collect from the industry for perceived past overpayments. Those now sit at about $4.55 billion.

“The Administration has repeatedly expressed its support for care in the home, recognizing it as a high quality, lower cost alternative to institutional care settings that expands access to Medicare beneficiaries in the location in which they prefer to receive care: Their homes,” Stacey Smith, the vice president of public policy at AccentCare, said in a statement shared with Home Health Care News. “The home health community has repeatedly offered solutions to CMS that would reduce spending, while at the same time maintaining payment levels for those agencies that deliver high quality care and play by the rules. Yet CMS persists in its mathematical gymnastics that will give rise to nothing short of inferior health outcomes, lower patient satisfaction and stranding at-risk, older adults in higher cost, institutional care settings.”

Smith went on to describe the cuts as “draconian,” and called for Congressional action.

Home health access has been reduced and referral rejection rates have skyrocketed over the last few years, partly due to cuts. Providers have advocated against further cuts – and potential clawbacks – nonstop since CMS began revisiting the PDGM framework.

“For the third consecutive year, CMS has proposed cuts that make it significantly harder for home health providers to meet the care demands for an increasingly complex and aging patient population,” Partnership for Quality Home Healthcare CEO Joanne Cunningham said in a statement. “The status quo of continuous cuts is unsustainable: Medicare’s continued application of permanent cuts to home health further undermines a community that is facing historic labor costs and workforce shortages. We fear that CMS’s proposed actions for 2025 will have unintended consequences on older Americans who want to receive care at home.”

In addition to the cuts, CMS is also proposing: a recalibration of PDGM case-mix weights; updates to the Low-Utilization Payment Adjustment (LUPA) system, including an occupational therapy LUPA add-on factor; further delineations for the home health wage index; and more.

“Each of the 432 payment groups under the PDGM has an associated case-mix weight and LUPA threshold,” CMS explained. “CMS’ policy is to annually recalibrate the case-mix weights and LUPA thresholds using the most complete utilization data available at the time of rulemaking. In this proposed rule, CMS is proposing to recalibrate the case-mix weights – including the functional levels and comorbidity adjustment subgroups – and LUPA thresholds using CY 2023 data, to more accurately pay for the types of patients HHAs are serving.”

The association of nonprofit providers, LeadingAge, also pointed out the mounting staffing pressures that are materializing in home health care, due to payment cuts and other regulatory decisions. 

“As the only association that represents providers across multiple aging services care settings, we take a holistic view of proposed rules. Payment decreases, including this proposed 1.7% cut to home health providers, jeopardize older adults’ and families’ ability to access needed care and services,” LeadingAge CEO Katie Smith Sloan said in a statement. “Put today’s action from CMS into context: registered nurses are a core component of home health care. Our mission-driven and nonprofit members battle daily in a very competitive labor market to recruit and retain RNs, which are in short supply. Coupled with the Biden administration’s nursing home staffing rule’s nurse-onsite 24/7 component, already stiff competition for RNs will only grow. A payment decrease presents real challenges for our members. Without staff, there is no care; ultimately, older adults and families will suffer.”

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The Medicaid Access Rule has been finalized, with six years until the implementation of the 80-20 provision. There’s no time to rest for home-based care providers and advocates on the regulation front, however. Summer is near, and that means so is the home health proposed payment rule from the Centers for Medicare & Medicaid Services (CMS).

In 2022, a significant proposed cut to home health payment mostly took providers by surprise. In 2023, it was expected. And, unfortunately, the home health industry is expecting more of the same in the next proposal.

The counter to CMS’ rate cuts and attempted clawbacks remains the same in 2024, and it is all-encompassing: grassroots action from providers locally; a lawsuit against CMS and the U.S. Department of Health and Human Services (HHS); a push for Congressional support and direct pleas to CMS to rethink its methodologies.

In 2024, there’s already been a few major developments on those fronts.

For one, at the end of April, the National Association for Home Care & Hospice’s (NAHC) lawsuit against CMS – first filed in July of last year – was dismissed by a federal judge. Though an unfortunate update to the situation, NAHC President William A. Dombi proclaimed the legal battle far from over.

“We are disappointed with the court’s ruling,” Dombi said. “However, it is a minor setback that we can readily overcome. Often justice delayed is justice denied. Here, we will have our day in court. This battle is far from over.”

Meanwhile, last week, Sens. Debbie Stabenow (D-Mich.) and Susan Collins (R-Maine) sent a letter to CMS Administrator Chiquita Brooks-LaSure strongly advocating against further cuts to home health payment.

“We appreciate CMS’ commitment to helping people get the care they need, where they need it,” the senators wrote. “This must include home health services for people with Medicare. As CMS proceeds to develop Medicare home health payment rates for 2025, we urge you to consider the value home health care provides to the Medicare program and its beneficiaries.”

There’s a lot going on in Washington, D.C., this year. Providers and advocates will have to find a way to cut through the noise to get the attention of lawmakers with the ability to prevent further cuts.

This week’s members-only, HHCN+ Update focuses on the next five months in home health payment policy, and what the industry expects is ahead of them.

More cuts ahead

There’s not a provider I’ve talked to this year that expects anything but further proposed cuts in June or early July. That’s because CMS made it clear in last year’s final rule that there would be more to come on the cutting front.

Partnership for Quality Home Healthcare (PQHH) CEO Joanne Cunningham forecasted another “doomy, gloomy” home health policy landscape for 2024 in January.

But Cunningham also believes that 2024 being an election year works in the industry’s favor.

“We know that Congress in an election year is very keenly tuned into the needs of their constituents,” she told me. “We are very hopeful. With some of our Congressional advocates, we’re looking for solutions that could make their way into a package that Congress will undoubtedly be moving, dealing with Medicare provisions. Our goal is to make sure that home health is part of that.”

Previously, lawmakers have introduced the Preserving Access to Home Health Act. Similar bills were introduced in 2022 and 2023, both in the Senate and the House. The latest version would have mitigated cuts, and also forced The Medicare Payment Advisory Commission (MedPAC) to take a more holistic view at home health reimbursement by including Medicare Advantage (MA) payments.

After two years of cuts – a 2.890% cut last year, and a 3.925% cut the year before – providers would likely take any respite, but respite is not the goal.

CMS has proposed more severe cuts than it has finalized of late, allowing the overall aggregate payment adjustments to come in as slightly positive. But those positive adjustments are just positive on the surface, which is a story PQHH, NAHC and the provider community are trying to tell.

Since 2020, CMS has either implemented or announced over $19 billion in cuts through 2029, according to PQHH. As laid out on the chart above, these cuts will have a compounding effect over time.

CMS has dismissed providers’ access-to-care concerns over the last few years, and it has not wavered on its strategy.

“In working with folks from CMS, I find I’m generally very impressed with smart people trying to do good work,” Michael Johnson, the president of home health and hospice at Bayada, told me last year. “I always try to make sure I don’t vilify these folks, because I think they really are trying to do good work. But the primary tool they have is payment. All they have is a hammer. So, if you need a screw adjusted, you’re still using a hammer, and we know what the outcomes of that look like.”

Clawbacks

Providers are up against that hammer, and the result of it is the chart shown above.

But CMS is also attempting to claw back “overpayments” it made to providers in 2020-2022: $873 million in 2020, $1.2 billion in 2021 and $1.4 billion in 2022.

At this point, every year that the home health industry does not fully win its fight against CMS, the potential impact of cuts and clawbacks for future years gets worse.

VitalCaring President Luke James and I had a conversation about those clawbacks on stage last month at Home Health Care News’ Capital + Strategy conference.

“I hate to beat a dead horse, but this temporary payment adjustment, the longer it just sits out there and doesn’t get enacted – it’s just growing in terms of size,” James said. “I know we’ve been talking about it for three years. And I think we’ve become maybe somewhat numb to that. But the numbers are very large, and they’re like problems; they only get worse if they fester.”

I then asked if James would rather have those clawback cuts implemented now.

“I’d rather have them not implemented at all,” he continued. “I’d rather them see the failed logic that they’re applying. … But if they’re going to implement them, I think I’d rather take a rip-the-Band-Aid-off approach. Because a lack of certainty is what creates a really hard dealmaking market. Certainty – rather than a perpetuity of uncertainty – is a better place, in my opinion.”

At this point in the game, morale is certainly a part of the equation, almost as much as the nuts and bolts relating to fighting cuts. Providers have fought tooth and nail to both survive and advocate for over two years now.

Stabenow and Collins’ letter to CMS is further evidence of the bipartisan support the industry has in Washington, D.C.

But if 2024 isn’t the year that things turn for the better for home health providers, it will be tough to convince smaller providers that the fight is still worth it – yet again.

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Since the adoption of the Patient-Driven Groupings Model (PDGM) in 2020, the Centers for Medicare & Medicaid Services (CMS) has cut home health payment by $19 billion through 2029, according to a new analysis conducted by the Partnership for Quality Home Healthcare (PQHH) and the National Association for Home Care & Hospice (NAHC).

Many of the cuts CMS has implemented are permanent, and multiple cuts on top of each other moving forward – plus unsatisfactory adjustments for inflation – are putting significant pressure on providers.

For instance, CMS finalized a 0.8% increase to aggregate payments for 2024 last fall. But in actuality, the agency implemented another permanent prospective adjustment of -2.890%. The year prior, a -3.925% cut was implemented.

Future cuts paint a bleak outlook for providers, which is what NAHC and PQHH are trying to educate lawmakers on.

“One of things we wanted to make sure that we could showcase to Congressional allies was how much home health really has been cut,” PQHH CEO Joanne Cunningham told Home Health Care News. “Providers are suffering and feeling such stress, and having difficulty maintaining their status to deliver care and fulfill their missions. We started off PDGM with a sizable cut. The cuts that have been implemented since then are permanent, they don’t go away. The chart illustrates the stacking effect of these cuts. Then, we projected what we know is coming with future cuts.”

Though this year will be a hectic one in Washington, D.C., due to it being an election year, Cunningham believes that will actually work in providers’ favor.

It will mean that lawmakers have their ears to the ground on the most pressing issues facing their constituents, she said.

“This is the causation,” Cunningham said. “And why we’re seeing the access-to-care issues that patients are experiencing.”

As Cunningham noted, CMS has stated that it will continue to phase in cuts moving forward.

Providers are set to get far less reimbursement for their services in the future.

All the while, more of their patients than ever are under Medicare Advantage (MA) plans. MA tends to already pay far less for home health services compared to fee-for-service Medicare.

“It’s concerning,” Cunningham said. “And it is something that is contrary to what most policymakers want, what most Americans want, what most Medicare beneficiaries want and families want. It is a disconnect. But the good news is that lawmakers seem to understand that.”

What’s more, CMS has also teased future payment clawbacks for perceived overpayments to providers in the past.

Specifically, CMS believes it overpaid by $873 million in 2020, $1.2 billion in 2021 and $1.4 billion in 2022.

Those clawbacks would throw gas onto an already uncontrollable fire for providers.

“The clawbacks are unconscionable,” Cunningham said. “These will be essentially clawbacks for payments that providers received for care that was delivered to patients in prior years. It is unthinkable that any policymaker would want to destabilize the Medicare home health program by instituting those clawback cuts.”

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After the U.S. Centers for Medicare & Medicaid Services (CMS) released its CY 2024 final payment rule Wednesday, home health providers found themselves in a position they know all too well.

Is a 0.8% aggregate payment increase better than the 2.2% decrease that was proposed? Of course. Was the rule, in its totality, effective in easing the payment concerns of providers moving forward? Of course not.

The home health industry’s last few years have been filled with long, hard advocacy battles between the proposed rule and final rule. Like the early 90s Buffalo Bills, those advocacy seasons have been successful, but none of them have ended up with the ultimate goal achieved: a Super Bowl win, or a total nixing of present and future home health cuts.

Both last year’s final rule – a 0.7% increase – and this year’s final rule offered providers a breather. It’s a breather that doesn’t last long.

CMS stands by its methodologies for evaluating the budget neutrality of the Patient-Driven Groupings Model (PDGM), and also believes it overpaid providers to the tune of $3.4 billion from 2020-2022. That means providers will likely be back in the same position from June to October 2024 as they were from June to October of this year.

It’s an arduous process for everyone that calls the industry home, and it reminds me of something Amedisys Inc. (Nasdaq: AMED) Chairman Paul Kusserow told me in January.

“My concern is the game that we play with CMS,” Kusserow said. “It’s a long, exhausting game. They come up with a proposed significant cut. The whole industry gets all worked up about it and runs to Washington. I’ve done this, and everybody in our business has. We lobby, lobby lobby, they get a lot of pressure, and then they come back with something that is just mediocre. It’s not enough for us to get Congress all worked up about it to pass legislation. But it’s enough to keep us in purgatory. We have to get through this dribbling sense of inadequate reimbursement.”

In 2024, CMS and the home health industry will continue to play that game. CMS has not to this point gotten what it wants, and nor has the home health industry.

This week’s exclusive, members-only HHCN+ Update addresses Wednesday’s final rule, but also addresses what it could mean for the home health industry moving forward.

Short-term wins

Immediately after the rule dropped, trade associations rushed to make sure those paying attention didn’t miss the forest for the trees.

Some of the trees, for instance: the final rule’s difference from the proposed rule will amount to a revenue boost of $26 million for Amedisys and a $18 million boost for Enhabit Inc. (NYSE: EHAB), according to the Jefferies Group.

Smaller agencies will see similar relief from projections stemming from the 2024 proposed rule, relative to their overall revenue. But that shouldn’t satisfy them, the Partnership for Quality Home Healthcare CEO Joanne Cunningham argued.

“To put these numbers into context, the rule finalizes a base rate year-over-year increase of less than $1 per day to care for Medicare’s sickest patients,” she said in a statement. “And while CMS is slightly delaying implementation of the permanent cut for next year, those dollars will be cut from home health in future years.”

In its statement, the National Association for Home Care & Hospice (NAHC) reiterated that it would need continued support from its lawmaker allies in Congress if there was any hope to put an end to future cuts.

The New York-based home health provider VNS Health called CMS’ current path “not good policy, not a good use of taxpayer dollars and not good for patients.”

Its CEO, Dan Savitt, argued that the continued cuts would further reduce patient access, which, in turn, would end up costing the Medicare program more.

“Faced with longer stays, patients with more complex medical needs, and fewer available beds, hospitals are trying to discharge more and sicker patients to home health care agencies,” he said in a statement shared with Home Health Care News. “But amidst a severe and persistent workforce crisis, VNS Health and home care agencies across the country are not able to keep up with this rising demand. Last year, agencies had to turn away about 75% of hospital referrals to home health care. The situation is worse in ‘home health deserts’ – areas already suffering from disparate levels of care where the workforce crisis is even more challenging.”

That’s nearly the exact same tone that Carrie Edwards – the director of home care services at Mary Lanning Healthcare – struck at an aging-in-place hearing held by the Senate Finance Committee’s Subcommittee on Health Care in September.

Edwards painted a more specific picture. As a result of CMS policy, Mary Lanning’s home health arm had reduced its coverage from a 60-mile radius to a 25-mile radius in just two years, undoubtedly leaving home health-needy patients behind.

But CMS either does not seem to buy these claims. That much was evident in the agency’s 531-page final rule.

“In any event, CMS looked closely at our data to ensure the payment rate adequately covers the costs reported by HHAs, without creating unnecessary hardship to providers and maintaining access to quality services for all beneficiaries,” the agency wrote. “Maintaining access is one of CMS’s priorities when making policy decisions. We do not intend to obstruct the provision of home health services to any beneficiary who qualifies for this benefit.”

What’s more, CMS reminded home health stakeholders that even if it did buy the access argument, its hands are tied by law. Congress mandates that PDGM must be budget neutral, and the agency won’t budge from its stance that the model has not been

CMS rebuttals

While CMS backed off more severe cuts, it did not back off its reasoning for proposing those cuts, nor its reasons for implementing the cuts it did.

It even fought back against analyses and comments submitted by providers during the public comment period in its final rule.

On taking into account Medicare Advantage (MA) home health rates, CMS said – more or less – “not our problem.”

“We have never endorsed the view that Medicare funds should be used to subsidize reimbursement rates from other payers – a policy that would be inconsistent with our obligation to be responsible stewards of the Medicare Trust Funds and would ultimately increase costs to Medicare beneficiaries, taxpayers, or both,” CMS wrote. “As we noted in the CY 2023 HH PPS final rule, we responded to this assertion stating: ‘Medicare has never set payments to [cross-subsidize] other payers.’”

Even if that’s the case, though, CMS should refrain from claiming home health providers have sky-high margins. The agency is at least aware that Medicare fee-for-service payments are not home health providers’ singular revenue stream.

And, if home health providers were to ignore those MA patients to chase after the higher margin, over 50% of the Medicare population would be left without access to home health care.

“We observed many methodological weaknesses in the analyses submitted by commenters,” CMS continued. “It is unclear whether the proprietary data on which commenters base their analyses includes referrals from only Medicare FFS beneficiaries or also includes referrals from patients covered by other payers, which means the entire analysis may be inapt for Medicare FFS policy.”

CMS also took issue with the referral rejection rate numbers, insinuating that more referrals being rejected did not ultimately mean fewer patients were receiving care.

“In addition, the proportion of hospital referrals rejected by HHAs does not equate to the

proportion of qualifying beneficiaries who are denied care,” the agency wrote. “The data fails to capture why the beneficiary was rejected – for example, because the analysis focuses on numbers of referrals denied rather than numbers of beneficiaries denied care, the rejection referral proportion could be inflated by a small number of beneficiaries rejected from multiple HHAs, or by beneficiaries rejected from one HHA but who ultimately received care from another HHA.”

All of this is to say, CMS is unconvinced by messaging from the provider community. What matters now is whether Congress is convinced, and willing and able to act on the issue.

If not, home health providers will remain in payment purgatory.

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Sens. Debbie Stabenow (D-Mich.), Kyrsten Sinema (D-Ariz.), Kirsten Gillibrand (D-N.Y.), Tammy Duckworth (D-Ill.), Mazie K. Hirono (D-Hawaii), Jeanne Shaheen (D-N.H.), Tina Smith (D-Minn.) and Maggie Hassan (D-N.H.) all signed the letter.

“We are writing today to urge your Administration to continue protecting Medicare beneficiaries’

access to home health care,” the senators wrote. “We strongly support the Medicare home health benefit, which provides vital services to beneficiaries across the country, creating value for the Medicare program by serving patients in lower cost settings while allowing them to receive high quality skilled care. Home health services are essential to increasing the health, safety, and quality of life for beneficiaries and their families. We are concerned that significant reductions to home health care reimbursement would create access to care issues for Medicare beneficiaries.”

In June, the Centers for Medicare & Medicaid Services proposed a 2.2% aggregate decrease to home health payments for 2024. Home health providers also viewed the CY2023 final rule as unfavorable.

In their letter, the senators got into those payment specifics – including potential market basket errors from CMS – as well as the notable increase in referral rejection rates over the past few years in home health care.

“For CY2024, CMS has proposed a further -5.653% permanent adjustment to the 30-day base payment rate, resulting in a significant and concerning -9.36% permanent reduction,” the letter read. “This year’s Medicare cut is on top of $3.7 billion in cuts to the Medicare home health program since 2020. These cuts are having a devastating impact on Medicare patients who rely on these services to stay in their homes while recovering and rehabilitating from serious conditions.”

In all likelihood, the final payment rule is going to be released at some point this week. It generally is released at the end of October or beginning of November.

Sen. Stabenow introduced the Preserving Access to Home Health Act with Sen. Susan Collins (R-Maine) earlier this year.

The Senate Finance Committee’s Subcommittee on Health Care also held a home health-related hearing in September, which demonstrated more lawmaker support for home health providers in their fight against payment cuts.

“We strongly support the Medicare home health benefit, which provides vital skilled home care services to beneficiaries and strengthens the Medicare trust fund by providing such services in a relatively low-cost setting,” the letter read. “We look forward to working with you to improve the Medicare program and ensure beneficiaries have access to care in their homes.”

The Partnership for Quality Home Healthcare (PQHH) thanked the senators for their support on Tuesday.

“The Partnership commends Senator Stabenow and her female colleagues in the Senate for calling attention to the importance of home health to American families across the country and the need for Medicare to consider the impact cuts to home health will have on access to care for beneficiaries,” PQHH CEO Joanne Cunningham said in a statement.

The post Senators Call On President Biden To Help Protect Home Health Benefit appeared first on Home Health Care News.

In anticipation, home health providers and advocates have been appealing to Congress, educating, calling to action on social media and more.

All of these efforts are the final push from an industry that has been very vocal about its opposition to the proposed rule, which was released in June.

Home Health Care News recently caught up with many of those providers and advocates to learn more about what they’ve been doing to push for a more favorable final rule.

At this point we are focused on a combination of the White House and Congress, pushing for a pause of the proposed rate cut in 2024. Congressional allies are working on our behalf in that respect. We are also hedging our bets by setting up for a congressional effort to stop the cut during the budget process. We need all hands on deck, particularly with home health agency staff contacting their local congressional delegation.

— William A. Dombi, president of the National Association for Home Care & Hospice

***

With the final rule quickly approaching, Bayada Home Health Care has been all hands on deck, diligently mobilizing our employees and advocates to make sure congressional members hear our voices. In conjunction with PQHH and NAHC’s industry-wide efforts, advocates have called and emailed federal lawmakers and published op-eds to urge lawmakers to support the Preserving Access to Home Health Act. Additionally, Hearts for Home Care – Bayada’s 501 (c)4 advocacy arm – has been active online and in-person, posting on social media and traveling to Washington, D.C., to further enforce our message that congressional action is needed to stop CMS’ proposed Medicare cuts. From our positive conversations with members, we are hopeful that our efforts have been recognized and have helped to move the needle forward on behalf of the entire home health care community.

— David J. Totaro, chief government affairs officer at Bayada Home Health Care

***

Last year’s home health payment reduction forced many providers to make difficult decisions, from reducing service area to letting go of staff, in order to keep their organizations afloat. Should this year’s proposed 2.2% cut to home health payment be finalized, providers will need to brace for the same impact in 2024. We urge CMS to postpone cuts for this year while we continue work on avenues for permanent relief.

For instance, we see opportunities in ensuring that the Home Health Value-Based Purchasing (HHVBP) Model focuses on the right measures of care. We have also seen an interest from Congress in holding Medicare Advantage plans accountable, which is increasingly important both for providers and the system as a whole as more home health episodes occur in Medicare Advantage. Plans must cover the true cost of service.

We’re already working with members of Congress to begin rethinking how the home health benefit should work. We know it’s on their minds too, as evidenced by the Senate Finance Committee hearing last month and the introduction of the Preserving Access to Home Health Act of 2023, which we support. There’s incredible support for these services, but CMS says its hands are tied on the payment methodology. Change is needed to best support beneficiaries who need these services the most, specifically those in rural and underserved areas. We believe that developing payments to support providers serving these communities will be invaluable. We are also looking into how to better track actual access to home health services. MedPAC’s current definition of access is failing millions of Americans. It’s time to rethink what true access means in terms of choice, in terms of services, and in terms of location.

— Mollie Gurian, vice president of home-based and HCBS policy at LeadingAge

***

In anticipation of the final rule, the Partnership and our members are using every tool in our toolbox to influence the outcome of the HHPPS for 2024. We are meeting with – and reaching out to – administration officials at the White House, HHS, CMS, and OMB. We are coordinating with our champions in Congress to put pressure on the Biden Administration. We have broadly activated our grassroots army to ask Congress to use its muscle in stopping the proposed cuts. We’re working with NAHC this week to beef up the conversation on social media among our advocates and working with our state association partners to elevate the issue on the local level. It’s critical that all home health stakeholders use their voice right now to speak out about how these cuts will harm patient care.

Once the rule is finalized, the Partnership will be evaluating its impact on access to care for the Medicare population and how it impacts ensuring that providers can meet the high demand for home health services which has been diminishing under the weight of the cuts. I encourage all of us to carefully analyze the final rule to determine whether CMS has taken any action to eliminate or significantly mitigate the deep cuts that have been proposed. Home health has already been cut by billions since 2020 and the market basket has been woefully inadequate to cover the costs of inflation. We, and the entire provider community of caregivers, are ready to intensify our efforts to seek a permanent legislative solution to stabilize home health and protect access to care for the most vulnerable of the Medicare population. The future of the home health program depends on these efforts.

— Joanne Cunningham, CEO of the Partnership for Quality Home Healthcare

***

We are engaged in a multi-faceted approach to minimize an unfavorable home health final payment rule. We are leveraging our extensive network and resources to layer advocacy action from grassroots to grasstops, engaging not only our 1,000 employees, but also leading on education and technology tools for the industry. By equipping providers with the necessary knowledge and tools, we are helping them prepare for every outcome.

In addition, Axxess is committed to the industry’s viability and the accessibility of home-based care for everyone. We are leveraging our political action committee, the Axxess PAC, to support the united voice and work of our national associations, ensuring that our advocacy efforts are amplified and impactful.

For providers preparing for the possibility of an unfavorable final rule, we recommend staying informed and engaged. By joining forces with industry associations and leveraging resources like the Axxess PAC, providers can collectively work toward influencing positive change and protecting the interests of the home health community.

— Deborah Hoyt, senior vice president of public policy at Axxess

***

Between now and the issuance of the final rule, Enhabit Home Health & Hospice (NYSE: EHAB) is focused on bringing as much attention as possible to what we know is true: patient access to home health care is being impacted by Medicare’s continued cuts.

In August, our public comment letter and those of many others highlighted to CMS what the impact will mean for patients and providers; then in September, home health experts testified to Congress about the same; and here in October, we are working to focus the attention of the Biden Administration on what will happen if CMS moves forward with its proposal to further cut the Medicare home health benefit. Our elected officials need to be aware of the impacts of the CMS proposal given the priorities around health equity, increasing access to high-quality care and avoiding cuts to Medicare. And importantly, administration officials should know that CMS has the discretion under existing authority to move away from the agency’s proposal.

On top of these efforts, there are also many incredible people from all over the country – many of whom work in home health and understand the importance of this moment – that are taking the time to call Capitol Hill, write a letter to a member of Congress, or even author an op-ed in a local paper, all in a community-wide effort to let our government know that these proposed cuts should not be finalized.

In terms of preparation for the final rule, our local leaders remain focused on managing their resources to continue to deliver our high quality of care in the most efficient manner.

— Andrew Baird, vice president of government affairs & policy counsel at Enhabit Inc.

***

Home health is the foundation of home-based care. The long-standing benefit has opened the door to broader thinking about what’s possible at home. Innovation like hospital-at-home, SNF at home, or home-based services like home dialysis or home infusion would not be possible without the underpinning home health provides.

As we look to a future where seniors are aging in place and higher acuity services are offered at home, we cannot allow this foundation to erode. While the reimbursement structures differ, new care models rely on the precedent and groundwork set by the home health benefit. As providers look toward the possibility of an unfavorable rule, it’s important to share data, patient stories and paint the picture of the detrimental effects of further cuts to this valuable benefit.

— Krista Drobac, founder of Moving Health Home

The post The Last-Ditch Efforts Home Health Providers, Advocates Are Making To Nix Payment Cuts appeared first on Home Health Care News.

For this episode of Disrupt, we caught up with Joanne Cunningham, the CEO of the Partnership for Quality Home Healthcare. During the conversation, Cunningham shined further light on the recent home health care hearing conducted by the Senate Finance Committee’s Subcommittee on Health Care.

Listen to this episode of Disrupt to learn:

– What took place during the hearing, and why home health advocates are optimistic coming out of it

– Where Cunningham believes advocacy is making a difference in Washington, D.C.

– What she expects from the forthcoming final payment rule from CMS

– And more!

Subscribe to Disrupt to be notified when new episodes are released. Listen today!

The post Podcast: Joanne Cunningham, CEO, Partnership for Quality Home Healthcare appeared first on Home Health Care News.

Home health providers have been hearing about the bipartisan support they have in Washington, D.C., for a long time. But last week, they were able to see it in a way that they hadn’t been able to before.

That’s at least the case for those that live streamed – or attended in person – the Senate Finance Committee’s Subcommittee on Health Care’s Sept. 19 hearing on home health care.

Sen. Ron Wyden (D-OR) – the chair of the Senate Finance Committee – remarked that the country “can’t afford not to” invest in home health care. Sen. Ben Cardin (D-MA) – the chair of the subcommittee on health care – said that “reimbursement challenges have added to the challenges for people being able to get the home health care they need.” Sen. Steve Daines (R-MT) said that lawmakers needed to be “certain that patients are able to receive the right care, at the right time, in the right setting, with appropriate payment.”

The hearing could not have come at a better time. The final home health payment rule from the Centers for Medicare & Medicaid Services (CMS) is due in just over a month. The agency’s CY2024 home health proposed rule again included cuts.

Since the June proposed rule, home health provider leaders and advocates have been fighting hard against those cuts.

It was evident at the hearing that their voices are being heard.

“We are hearing from our providers in Tennessee, and there’s a tremendous amount of concern about the payment policy,” Sen. Marsha Blackburn (R-TN) said during the hearing. “It is creating some instability and uncertainty. … I have visited with many who have looked at how next year’s payment rates were proposed in June, and how it would make matters worse for these patients.”

Home health providers have experienced regulatory ups and downs for as long as they’ve been in business. But that’s especially been the case over the last two years.

Since the CY2023 proposed rule, there’s never been more positive momentum in Washington, D.C., for providers than there is right now.

I talked to two of the top advocate voices – National Association for Home Care & Hospice (NAHC) President William A. Dombi and Partnership for Quality Home Healthcare CEO Joanne Cunningham – this week to dive deeper into that momentum.

This exclusive, members-only HHCN+ Update is about how near-term home health payment expectations have taken a turn for the better.

‘An emotional high’

Dombi was one of the witnesses at the hearing. During a nearly 7-minute testimony, he laid out the issues that most home health providers are currently facing. 

Those included reimbursement challenges caused by both CMS and Medicare Advantage (MA) plans, extreme staffing shortfalls and the referral rejection rates that have skyrocketed as a result of both of those issues.

“Home health spending today is virtually the same as it was in 1997, despite 24 years of cost inflation,” Dombi said during the hearing. “In 1997, the Congressional Budget Office estimated that 10 years later $40 billion per year would be spent on home health services. It’s still under $17 billion per year. It’s a telltale that we cannot continue to see happening. In comparison, inpatient hospital spending rose from $80 billion to $130 billion, while skilled nursing facility care – what home health is trying to avoid – rose from $11 billion to $27.2 billion.”

A week later, he joined me on an episode of HHCN+ Talks, which will be released next week.

Dombi called the home health industry’s struggles “obvious and ominous” during the hearing. But afterward, he was met with a positive “emotional high” – a rare feeling for a home health advocate these days.

“I left that hearing on an emotional high,” he told me. “It really increased my respect for the senators, in terms of the level of awareness and understanding they had already on home health services, and the values that they’ve seen from them, both on a personal level as well as on the professional side of things.”

While lawmakers have regularly showed support for home health care, the past few weeks have felt different.

They were not only well educated on home health services and the struggles providers face, but they also seemed to be squarely in agreement with the advocates during the hearing.

“It was just a really good discussion,” Cunningham told me on an episode of HHCN’s Disrupt podcast, which is set to be released this week. “The best part about it was just how brightly it shined a light into how important care in the home is, and, in particular, how the Medicare home health program is such a lifeline for for older Americans. … The hearing was just a great showcase of just how important that is.”

The Preserving Access to Home Health Act of 2023 has already been introduced in the Senate and the House. It would block CMS’ home health cuts, while also forcing the Medicare Payment Advisory Commission (MedPAC) to take a more holistic view of home health providers’ financials – including MA payments to paint a fuller, better picture of overall margins.

NAHC has also filed a lawsuit against CMS over the home health cuts.

Advocacy, legislation and litigious action has been the three-pronged approach.

The hearing seemed to merge the advocacy and legislative approaches. And while the statements during it were great, deliberate action after the fact is what providers are waiting for.

Having the Preserving Access to Home Health Act pass would be ideal, Dombi said, but could be a heavy lift for lawmakers to get done by year end.

“So, in addition, we’re getting members of Congress to connect with the CMS administrator, the HHS secretary and the White House to say, ‘Look, we may not be able to get done what we’d like to with some reforms in home health, but you can help us by putting a pause on these 2024 rate cuts,’” he said.

It’s not always easy to get a projection on what may happen in the future, especially when it comes to CMS and home health payments.

But Dombi, who “never has been accused of being a Pollyannaish,” according to him, is feeling more confident than he may have been a month ago. 

“I’m not trying to put on a phony face of positivity here,” he said. “But I think, seriously, that there is a good expectation for mitigation of the cuts. It’s pedal to the metal, though, from our end of it relative to pushing on the advocacy side to try to see that happen.”

Cunningham, on the other hand, has likely been accused of being an optimist more than once in her life. But she is in alignment.

“You know, I’m always optimistic,” she said. “I talked to a lot of policymakers on the Hill, and I think there’s a lot of support for home health care. There’s an understanding of how important it is. And it does make me more hopeful.”

The post Why There’s Now A ‘Good Expectation’ That Home Health Medicare Cuts Will Be Mitigated appeared first on Home Health Care News.

This is not an empty threat, a Home Health Care News (HHCN) review of lobbying data and recent advocacy efforts suggests.

Over the last couple decades, the in-home care industry has roughly tripled the amount of money spent annually on federal lobbying efforts. Organizations like the National Association for Home Care & Hospice (NAHC), the Partnership for Medicaid Home-Based Care, the Partnership for Quality Home Healthcare and the Visiting Nurse Associations of America (VNAA) have led the charge, as have state-level associations and providers’ own emerging government affairs departments.

In 1998, in-home care providers and interest groups representing them spent at least $2.3 million on combined lobbying activities, according to publicly available data under the Lobbying Disclosure Act. Last year, they spent at least $6.9 million—a substantial leap that doesn’t include the growing list of entities just starting to dip their toes into the in-home care waters.

Large home health companies such as Lafayette, Louisiana-based LHC Group, Inc. (Nasdaq: LHCG), Baton Rouge-based Amedisys, Inc. (Nasdaq: AMED) and Moorestown, New Jersey-based Bayada Home Health Care combined to account for at least $2.2 million of that 2017 sum, nearly eclipsing the industry’s 1998 total by themselves.

“It’s been very effective,” David Totaro, chief government affairs officer for Bayada, told HHCN, referring to the privately held company’s overall political advocacy efforts. “Our chief financial officer has said. ‘You guys have paid for yourself 10 times over.’”

The government affairs team, currently made up of 15 people, contributed to 24% of the growth in revenue and half of Bayada’s growth in gross margin during the third and fourth quarters of 2016, according to Totaro.

While a look at the data reveals an impressive spike in lobbying power, it only reveals a fraction of the in-home care industry’s current clout.

Sharpening grassroots strategy 

As lobbying has picked up on Capitol Hill, the industry has simultaneously bolstered its grassroots strategy to galvanize the ever-increasing army of home health aides, personal caregivers and patients scattered throughout the United States to support—or fight against—a common cause, Bill Dombi, NAHC president, told HHCN.

Those grassroots efforts get stronger every day, as more baby boomers sign up for in-home services and millennials fill open positions at agencies, he said.

For proof of its grassroots success, look no further than the industry’s initial battle with pre-claim review or the proposed home health groupings model (HHGM), Dombi said. CMS eventually nixed them both, though each appears to be back on the table in different forms in 2018.

“We were looking to get the Senate to support us, to get CMS to back off on the [HHGM] proposal,” he said. “We had—within a 48-hour time period and just from our own NAHC efforts—about 25,000 emails that went out to senators. At the end of that, we ended up with a the Senate supporting us [against HHGM].”

Forty-nine senators ultimately documented that support in a letter to CMS.

Similarly, when Congress threatened to cut Medicaid and Medicare in the summer of 2017 with the American Health Care Act and Better Care Reconciliation Act, Bayada was able to mobilize its network of employees and clients, urging them to contact their legislators. Federal legislators received more than 138,000 emails as a result, said Totaro, who also serves as chairman for the Partnership for Medicaid Home-Based Care’s board of directors.

Bayada, which provides clinical care and support services in the home, has more than 22,000 employees in communities across 22 states. It created its government affairs office shortly after Totaro joined the company in 2009 as its then chief marketing officer.

“We’re developing our movement through getting more and more of our clients, more and more of families and caregivers involved in the process,” he said. “Government affairs is very similar to building a brand. … You take a message and deliver it consistently, uniformly, making sure the message is carried to all those who have an important relationship with you.”

The launch of home care association ElevatingHOME last year did raise some questions about how unified home health providers are in their advocacy approach, but the in-home care industry has typically been able to operate in D.C. under a single, unified message, experts say. It’s an idea supported by Lobbying Disclosure Act filings, which often mention the same key issues among companies and interest groups.

“ElevatingHOME launched in the midst of having just worked to beat back [the Pre-Claim Review Demonstration] and rolled directly into concerns about HHGM,” Joy Cameron, the group’s vice president of policy and innovation, told HHCN via email. “It took a truly unified approach to delay HHGM and bring Congress and the administration to the table to consider the industry’s concerns. … There are several hurdles in front of the home-base care industry, and it will take all of the players to achieve our goals.”

Although ElevatingHOME grew out of VNAA, which advocates on behalf of non-for-profit providers and was founded in 1983, its main focus has been making sure potential legislation and proffered solutions are workable for the full spectrum of providers, Cameron said.

In the beginning 

The in-home care industry’s rise to relevance in D.C. didn’t happen overnight, according to Dombi. In fact, its ascent can actually be traced to a jumping off point more than three decades ago.

In 1987, long before the industry began closely working together on advocacy efforts, the predecessor of CMS, the Health Care Financing Administration (HCFA), attempted to narrow its interpretation of “part-time or intermittent” care for home health and redefine what “medically necessary” meant. As part of the re-interpretations, HCFA began making a series of retroactive claims audits, denying about one out of every three claims that had already been paid and, effectively, denying home health care benefits to eligible patients.

“The industry was in a downward tailspin,” Dombi said. “It was falling apart.”

NAHC, founded just a few years earlier, decided to challenge the agency’s interpretation in one of its first major lawsuits, bringing in Dombi to serve as chief legal counsel. As part of the case, known as Duggan vs. Bowen, NAHC won the support of more than a dozen members of Congress, getting them to sign on as plaintiffs in opposition to HCFA. Several state-level home health agencies also joined the lawsuit.

“That was when we really started seeing this industry coming together,” Dombi said.

Ultimately, a federal district court found that Medicare’s interpretation of the phrase “part-time or intermittent” was too narrow, resulting in unlawful denial of care to eligible beneficiaries. It was a major victory for home health providers, one that completely changed the way regulators viewed the industry at large, Dombi said.

After the lawsuit and HCFA revising its guidelines for Medicare coverage of home health, the utilization of services skyrocketed. From 1989 to 1992, there was a 210% increase in Medicare expenditures for home health services, reaching $7.5 billion in 1992, according to CMS.

“That kind of spurred on a much more focused and intelligent advocacy effort going forward,” Dombi said.

In the past, advocacy efforts were somewhat hindered by the fact not many people were familiar with home health, home care or hospice services, Totaro said. Instead of focusing on influencing policy, providers and interest groups had to focus on education. That’s no longer the case, though, as members of Congress have more frequently used services personally or have arranged care for aging family, he said.

“They had no idea what home care was,” Totaro said. “As legislators are aging and their parents are aging, it’s becoming more common.”

As utilization has risen, home health care companies have also grown, giving them more capital to deploy on advocacy efforts.

Home health lobbying in 2018

The top 10 home health providers based on market size, as defined by the most recent LexisNexis rankings, have spent at least $1.6 million combined on lobbying so far in 2018, according to the HHCN review of disclosure data. The three biggest spenders, in order, are Louisville, Kentucky-based Kindred Healthcare, Inc. (NYSE: KND), LHC Group and Encompass Health Corp. (NYSE: EHC). Kindred is in the process of being acquired by insurance giant Humana (NYSE: HUM) and two private equity firms.

Issues these companies have lobbied on—apart from Medicare and Medicaid, generally—included the Home Health Care Planning Improvement Act, the Preserve Access to Medicare Rural Home Health Services Act, the Home Health Documentation and Program Improvement Act, the Bipartisan Budget Act of 2018, the Medicare Post-Acute Care Value-Based Purchasing Act of 2015, the Patient Choice and Quality Care Act and several other pieces of legislation.

The in-home care industry’s steady increase in lobbying expenditures is reflective of a broader trend happening across the health services sector, data show.

“Back in the 70s, 80s and even into the 90s, we were dealing with kind of elementary aspects of things, mostly to the understanding of what home care would be in terms of breadth and depth,” Dombi said. “We’ve had to step up our game in terms of how we work in partnership with federal agencies and in partnership with Congress.”

Written by Robert Holly

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