The data analysis – which comes from the Partnership for Quality Home Healthcare (PQHH) and CareJourney by Arcadia – examines Medicare home health fee-for-service claims from 2022 through 2023, in order to determine access to care, and how it has been impacted by payment rate cuts.

An analysis of 2022 data found that almost 35% of patients who leave the hospital, and receive a home health discharge, don’t access this care within a seven-day period.

Additionally, the findings show that patients who didn’t receive home health care had a death rate that was 41% higher than patients who accessed this care in a timely manner.

“There’s abundant data from all over the place about what kind of impact home health care has on a patient’s outcomes, their ability to stay out of the hospital, readmission rates, all of those things,” PQHH CEO Joanne Cunningham told Home Health Care News. “This was yet another confirming data point that actually looked at mortality rates. I found that very interesting, and not surprising at all for the home health provider community.”

The analysis also found that, in 2023, access to home health care led to a 34% decrease in hospital readmission rates. Despite this benefit, 35.7% of Medicare patients that were directed to receive this care after a hospitalization did not.

Plus, the home health referral rejection rate has seen a major increase, jumping from 49% in 2020 to 71% in 2022.

Broadly, the referral rejection rate tracks how often providers turn down new referrals, generally due to staffing or capacity constraints.  

One of the main takeaways from the analysis was that these access-to-care issues are related to cuts made to home health care’s base rate in recent years.

“We think it points to an emerging crisis in the Medicare home health program,” Cunningham said. “Unless it is addressed by Congress, with the legislation we’re pushing for, and CMS with the cuts that are on the table through the rulemaking system, you’re going to see the home health care program just disappear over time.”

The latest home health proposed payment rule includes a payment decrease in the aggregate by 1.7%, or by about $280 million.

Cunningham emphasized the need for stability in the payment structure.

“One of the ways that Congress can address this is by ending CMS’ authority to make any more cuts to the home health care program,” she said. “It would allow for agencies to get on some more stable footing.”

Ultimately, Cunningham believes the results of the data analysis shouldn’t come as a surprise for those watching closely.

“This is what you get after you see sustained, destabilizing, repeated cuts to a program that is a really important program to America’s seniors and disabled community,” she said.

The post As CMS Cuts Payments, Home Health Patients Are Seeing Reduced Access To Care appeared first on Home Health Care News.

Organizations such as the Partnership for Quality Home Healthcare (PQHH) and Hearts for Home Care have been the engine behind making home health care a “squeaky wheel,” which they hope will gain the attention of legislators.

Home Health Care News recently caught up with PQHH CEO Joanne Cunningham and David Totaro, the president and executive director of Hearts for Home Care. Totaro also serves as the chief government affairs officer for Bayada Home Healthcare. During the conversation, Cunningham and Totaro shared their predictions for the upcoming home health proposed rule.

Plus, Cunningham explained why an election year is a good opportunity to push forward home health advocacy efforts, and Totaro explained past “wins” from home-based care advocacy.

Below is that conversation, edited for length and clarity.

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HHCN: What do you expect from the proposed home health payment rule, which usually drops in late June or early July?

Cunningham: I anticipate that what we will see, given CMS’s posture and prior rulemaking cycles, is the continuation of the policy that will put in place permanent cuts to the Medicare home health program. We’re bracing ourselves for an additional sizable permanent cut. We don’t know exactly what CMS has planned for the temporary cuts, otherwise known as the clawback cuts. We will certainly see, at a minimum, CMS identify what their new projected value of the temporary cuts are. At the end of last year, it was in the final rule, $3.4 billion in clawbacks that they were planning at some point, and we will see updated temporary adjustment numbers. That $3.4 billion is expected to go up.

Totaro: I think Joanne summarized that very well. There hasn’t been anything that I’ve seen over the last, say, six to nine months, that doesn’t signal more of the same. CMS hasn’t changed their rate setting model at all, so I think we’re going to see additional cuts and clawbacks. That’s why my team and I have been advocating on the Hill since the rule was released last year. We still have a lot of work yet to be done.

What have cuts done to the home health care industry over the last couple of years? What has been compromised? What has changed for the worse?

Totaro: I think we can all agree that when you get cuts of this magnitude, and you’ve got red flags indicating that there are going to be future cuts, it all sets up a planning scenario for your providers that’s just fraught with uncertainty. This impacts investments. Investments are important to home care. Investment in technology, investment in solving the workforce shortage situation, through developing programs for recruitment and retention, and even expanding into regions where access to care has not yet been achieved. All of these supposedly are goals of CMS as well, but these cuts really act in an opposite direction. Without a doubt, it has impacted our rural and hard to access urban regions. It has caused many agencies to begin to assess their ability to even sustain their business. I’ve seen data, just recently, which suggests that more than half of the agencies providing care are considering whether they can actually continue to sustain their business, or certainly must reduce services altogether.

Joanne, Dave has mentioned that he and his team have been on the Hill since the rule last year. Can you detail what the schedule in a given year looks like for home health advocacy?

Cunningham: What we’re doing, really throughout the entire calendar year, is policy and advocacy. Policy, because we’re always trying to think through policy responses, either through the legislative process or the regulatory process, that would present a way for the proposed rule, the payment model that we’re living under, ways for it to be improved. Then the other piece of that is advocacy. Since 2020, we have been working under this PDGM payment model, which going into this, I think the industry and the home health community writ large was excited about. Its promise was that this would be a more refined coding system and payment system that would better match a patient’s condition to payment. Instead, since 2020, we have seen growing cuts that are accelerating, with essentially cuts going into at least 2028 and probably beyond.

We’ve had to deal with a mounting level of cuts, so part of what we constantly have to do is make sure that policymakers understand, very vividly, the impact of these. The other thing that’s worth really talking about and digging into is the fact that at a time when the general population not just prefers care in the home, but is clamoring for more of it, we have a Medicare home health program that is dwindling. [One that] is under such financial strain and pressure, its future is uncertain. I just don’t know how that syncs up with what the public at large wants and needs. Demographics are pointing to more care in the home, not less.

Dave, on that note, can you detail some of the wins you’ve seen at Bayada over the years when it comes to advocacy?

Totaro: I would just like to add one thing to what Joanne was saying. Our schedule has always been go-go-go. There is no stop and go with advocacy. Consistency is what really matters. One of the things that we’ve learned over the last six to nine months is that our role as providers is to change the narrative from a discussion about cost and cuts, to a narrative about why or how these cuts are going to impact the lives of our legislators’ constituents. We heard through many of our meetings that they’re very interested in understanding how actions they have taken or will take, affect the lives of these folks. That’s why we believe that you never stop. You continue to bring folks to your meetings that are going to be able to humanize this issue, rather than have it based on data.

To address your other question. I’ve been very happy to lead one of the industry’s strongest advocacy teams, Hearts for Home Care, which is a separate, but affiliated social welfare organization of Bayada Home Health Care. We were formed, dedicated to solely supporting advocacy efforts. We did this because we believe strongly that advocacy works. I know it’s hard for many today to believe that it’s worth the time and effort to actually sit down with your legislator, because we’ve seen what goes on in DC or in Harrisburg, Pennsylvania, or almost in any state capitol. I’ve said this to many, I’ve questioned whether a bill that would designate the second Sunday in May as a day to honor all mothers would actually get passed today in the U.S. Congress, but consistency does work.

For example, last year alone [my team] participated in 17 different advocacy efforts around Medicaid in the markets that we support. Through our efforts, we realized more than $325 million in home- and community-based investments by state legislatures. We also, just recently, completed a study where we showed consistent advocacy initiatives and compared the results to those states where we have not had consistency in our efforts. We discovered that since 2015, in the states where we’ve had a consistent advocacy effort, year after year, our Medicaid rates have actually increased on average by 23%. In those states where we have not had a consistent effort, for a number of different reasons, our Medicaid rates have actually been cut, on average by about 7%. I could go on and on about the success we’ve had at state and federal levels, but just let me say that Congress actually saw home health as a solution rather than a cost during the COVID crisis. That’s because, I believe, that we all came together as one industry with one strong loud voice.

Joanne, when we talk about grassroots advocacy, what do we really mean by that? What do providers need to do in order to be a part of those efforts?

Cunningham: It’s really simple. They can go to our website or NAHC’s website and get engaged with a click of a button.

What we mean is that there are thousands and thousand and thousands of home health advocates around the country, including many of those who work for home health organizations and home care organizations. If you ever did a visit with an agency like Bayada, you’re going to meet an awful lot of people who have a lot of choices in the health care sector, regarding where to work, and they choose to work for an organization that delivers care in the home. One of the reasons is that they’ve experienced it firsthand, they’ve seen the benefit, and how valuable it is to the people who receive care in the home. They’ve never looked back. They’ve never left the sector, so we do have a passionate workforce.

We also have what I call grass tops, and that is the senior leaders of home health organizations who tend to have very strong relationships with policymakers in their communities. Some of those individuals are folks like Dave Totaro, as well as other senior leaders at Bayada and every home care organization in the country. We really rely on them to lend they’re personal commitment to deliver that message to senior policymakers either on Capitol Hill or in state capitals all across the country.

What’s the single most important thing providers can do?

Cunningham: Whatever you have already done, whether it’s a phone call, an email, a visit, do it again, because repetition matters in advocacy. It’s going to take more than a single person making a single phone call, or a single email. It has to be done over and over and over again, in order to have the punch that it needs. Home health is competing with not just every other sector of health care, who also is expressing their desire to see policy and legislative change. We’re competing against all kinds of other interests, transportation, the environment, taxes, housing. We’ve got to make sure that we keep our message front and center with lawmakers and policy makers more than just once. It’s got to be repeated and sustained and consistent over a period of time. Otherwise, our voices get drowned out by others. Volume matters, and the number of voices matters. That’s the reason why we’ve got to dial up anything that we’ve done before by another 50%. If every advocate did that, then we would see some significant massive change and increase in uptick in our advocacy.

What’s the ultimate goal for advocacy this year? What, realistically, can be achieved by advocacy this year, in order to put home health providers in a better spot by year end?

Totaro: Our ultimate goal this year is to stop those cuts, whether its current or future clawbacks. We have a bill in Congress that’s been sponsored by Senator Stabenow and Collins, both very respected longtime advocates for home health care, and Representative Sewell and Smith, that we’re advocating for. It’s our goal to get that legislation passed this year.

Joanne, we spoke maybe last month and you said that it was a good thing that it’s an election year because legislators are more in touch with their constituents.

Cunningham: I think that anytime it’s an election year, Congress is acutely aware of the fact that they’re all up for reelection. We will use that to our advantage. We will make sure that the squeaky wheel of home health gets the grease this year, and make sure that we are putting in place a policy that can be supported, and ensure that we have removed any obstacles in our way. We do look at an election year as an opportunity.

The post ‘Lot Of Work To Be Done’: What Home Health Leaders Expect From Payment Rulemaking In 2024 appeared first on Home Health Care News.

The hearing covered a number of topics, including the Centers for Medicare & Medicaid Services’ (CMS) home health payment cuts, referral rejection rates, the Medicare Payment Advisory Commission’s (MedPAC) view of the industry and more.

The general consensus of many of the home health stakeholders that attended was that the hearing was a success.

Joanne Cunningham, the CEO of the Partnership for Quality Home Healthcare, agrees with this line of thinking. She joined Home Health Care News for the latest episode of the Disrupt podcast to discuss the ins and outs of the hearing and her optimism regarding the upcoming home health payment rule.

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Below are takeaways from that conversation, edited for length and clarity.

HHCN: Last week there was this hearing put on by the Senate Finance Committee’s Subcommittee on Health Care. The hearing focused on aging in place, and challenges facing the home health care provider and patient community in the US. How did this hearing come about in the first place?

Cunningham: Way back in the beginning of the year, we had been speaking with many of our allies on the Hill who are very interested in home health. Sen. Ben Cardin (D-Md.) was very interested in holding a hearing on home health, and his staff had been working with us since February. We gave a lot of ideas, and they had their own ideas, and through that process came about the hearing.

Can you explain the format of the hearing and what was discussed over the two hours or so?

The hearing had a total of five witnesses, and these were folks that we suggested, and, as mentioned, Senator Cardin. We had Bill Dombi, who is the president of the National Association for Home Care & Hospice. He was there, not just as an expert on the Medicare home health program, but really home care and care in the home generally. They also invited a provider from the state of Nebraska. Her name was Carrie Edwards. They also had an academic from the University of Washington, who has done a lot of research in the area of care at home, especially from a rural perspective. Then there was Judy Stein from the Center for Medicare Advocacy and a former MedPAC commissioner.

In terms of who was there, including in the audience, what were your feelings on that? It seemed like it was well attended.

It was a packed room. I saw a lot of folks who understand the provider perspective and advocate for home health care.

From the get-go, the hearing seemed like it was immediately off to a good start. There were many members of the Senate Finance Committee, both Republicans and Democrats. The chair of the Senate Finance Committee, Sen. Ron Wyden (D-Ore.) came for a good chunk of the early part of the hearing. Sen. Debbie Stabenow (D-Mich.), who’s been a huge advocate for home health and care in the home, came.

I was also struck by how much engagement there was, and really the insightful questions that Senators asked.

I talked to Bill Dombi yesterday, who, as you mentioned, was a witness at the hearing. He said that he left the meeting on an emotional high. How did you feel afterward?

I agree, it was a really good discussion.

The best part about it was just how brightly it shined a light into how important care in the home is. In particular, the Medicare home health program. It’s such a lifeline for older Americans.

I’m not surprised that Bill felt on an emotional high. We all felt that. Many of us have been working in this home health sphere for many, many years. We believe in this program. There’s nothing better than seeing someone — who has gone through a surgery, or is in need of some kind of services to help monitor their condition, or recover or rehabilitate — receive those services in their home. I thought the hearing was just a great showcase of just how important that is.

You mentioned the home health provider voice that was there. That was Carrie Edwards from Mary Lanning Healthcare. I’ll just lay out a few of the things that she mentioned. Her agency previously covered a 13-county, 60-mile radius; they had to reduce that because of staffing issues and rate cuts to a 40-mile radius earlier this year. And then, more recently, to a 25-mile radius. Her agency is declining 50% of referrals. I thought that was really important because sometimes MedPAC views access as how many agencies there are per zip code.

I thought that was a great thread of questioning and discussion. We see the data and the very limiting metric that is used. You have “access” just because that agency serves your zip code as part of their delivery area. But we all know that unless you can actually receive services when you need them, your access is not real.

I thought that whole thread of discussion was just so revealing of some of the challenges that patients have. I think Carrie did such a good job of highlighting what happens to that Medicare patient who’s in a hospital bed, who needs home health care services. The discharging physician has ordered the services, and there’s no capacity for an agency to deliver them. That patient either stays in the hospital, or they go home without services, and they probably end up back in the hospital via the emergency room. Sometimes they’re headed for a skilled nursing facility.

Were there any other big takeaways that you had from things that were said during the hearing, whether it was from witnesses, or from senators?

The other takeaway, I would say, was just the knowledge level of home health care from the senators. They each had their own lens and asked questions that were through that lens. I thought the discussion on workforce was also a really good deeper dive into a huge problem that is exacerbated by CMS policy. We need resources in order to pay those nurses and pay those clinicians appropriately.

It seems like we’re moving in the opposite direction, and the CMS policy is exactly the wrong policy at the wrong time. I thought that there was just a lot of base knowledge that was very deep from really all of the senators.

As we approach October, with the final rule coming then, or maybe in early November, what is your feeling now on how that final rule will end up? Are you more optimistic than you were prior to the hearing?

I’m always optimistic. I talked to a lot of policymakers on the Hill. There’s a lot of support for home health care.

There’s an understanding of how important it is. When we have a hearing which showcases that, it does make me more hopeful. We have to make sure our message is heard by CMS. These reimbursement cuts are a direct line to a decrease in access to care. We need CMS to feel the pressure of policymakers from lots of different corners who are saying this doesn’t make sense.

Let’s re-do this, let’s retract these cuts, because they’re having a detrimental impact on seniors’ ability to access health care at home. Let’s pause, let’s take a step back here. I’m optimistic, but I’m on pins and needles, as all of us who work in the home health community are. We’re going to keep working until the final moment in order to make sure that our voices are loud and that they’re heard.

The post ‘The Wrong Policy At The Wrong Time’: Home Health Industry Continues To Fight CMS Cuts appeared first on Home Health Care News.

Chief among their concerns was the impact that the rule – if finalized in its current form – would have on patients’ ability to access care, especially at a time when providers are already facing staffing shortages and rising supply costs.

Many of the organizations leveraged data to illustrate the ways providers already struggle to meet the demand for care seen across the country.

Others detailed specific actions that it urged CMS to take in order to prevent dire circumstances for providers and patients alike.

Home Health Care News highlighted standout statements from six organizations’ comment letters to CMS.

***

CMS understands [home health agencies], like all health services providers, will reduce costs in reaction to payment reductions. Cost reductions often can include service reductions involving the admission of patients, the scope of services offered, and the extent of services provided. Correspondingly, the CMS budget neutrality methodology will trigger further payment rate reductions that will eventually destroy the value of the home health services benefit. CMS has the authority and the responsibility to prevent such an outcome under 42 USC 1395fff to determine the “time and manner” of applying any rate adjustments under PDGM. CMS has the full discretionary power to go forward with the 2024 rate setting without the proposed 5.653% rate cut.

— National Association for Home Care & Hospice

***

Access to home health is already diminished. If CMS cuts payments further as proposed for 2024, access will be decimated.

CMS already recognizes the clear connection between access to care and payment rate reduction. In a recent proposed rule advanced by the Biden Administration to improve access to Medicaid services, including access to home- and community-based services (HCBS), CMS discusses the need for analysis when states engage in ‘rate reductions or payment restructurings’ in order to avoid hindering access to care.

CMS emphasizes the need for state Medicaid agencies to conduct further analysis regarding the sufficiency of proposed payment rates after reduction or restructuring in order to avoid reducing access to care. Given the tenuous state of access to home health under current levels, CMS should proceed with caution in moving forward with further Medicare payment rate reductions, consistent with its proposed policy regarding Medicaid rate-setting.

— The Partnership for Quality Home Healthcare

***

We commend the Biden Administration, from the early days of the campaign, for taking a strong stand on ensuring quality in long-term care services and particularly for promoting services

in home and community settings. However, the articulation of this vision is impeded by the Administration’s proposed 2.2% cut to home health services in this proposed rule. If implemented, CMS will have cut home health payment permanently by nearly 10% in two years (-9.356%). As we detail below, these cuts are coming at times when our members’ costs and demand for services are rising and cannot be met. Continuing to implement these cuts will have a devastating effect on older adults who rely on these services.

Further, it runs counter to the Administration’s stated goals of promoting equity and the use of home- and community-based care. From our vantage point, the combined impact of the proposed payment changes and current workforce and inflationary pressures would lead to waves of closures and the inability of providers that remain to take on new referrals.

The impact of CMS’ proposals stands in stark contrast to the Administration’s stance on the importance of long-term care.

— LeadingAge

***

We urge the agency to adequately resource [home health] providers as they are a critical part of the care continuum. We are particularly concerned about the substantial size of the agency’s proposed budget neutrality adjustment, a cut of 5.653%, and again call on CMS to withdraw it.

Instead, we urge the agency to revise its methodology to more accurately account for changes in care delivery and payment dynamics due to the implementation of the PDGM. We also have concerns about the inadequacy of the proposed market basket update given the financial pressures facing [home health] agencies, including critical staffing shortages and rising supply costs. In addition, final data from CYs 2021 and 2022 indicate that the market basket forecasts underpaid [home health] agencies by a combined 5.1% for these years. This, combined with the difficult inflationary environment and the large budget neutrality adjustment proposed in this rule, risks putting [home health] agencies in serious financial peril. As such, we urge CMS to utilize its authority to provide a market basket adjustment to account for these extraordinary circumstances.

— American Hospital Association

***

In addition to the impact of the proposed rule on home health providers and, therefore, Medicare beneficiaries, it is important to note the downstream consequences for overall Medicare spending. While there is an increasing demand for home health — a 33% increase in referrals sent to home health — home health acceptance rates have decreased by 15% as [home health agencies] have been forced to turn beneficiaries away due to labor costs and staffing shortages. Additional reductions in reimbursement to home health providers will further exacerbate these pressures and result in fewer home health options, as demand for skilled healthcare in the home grows.

Fewer home health options translate into an increase in unnecessary hospitalizations and referrals to higher cost care settings. We already saw these trends prior to the COVID-19 pandemic when Medicare beneficiaries were often more likely to be referred to other post-acute care settings. In addition, hospital discharge planners are having difficulty finding home health providers for beneficiaries, which is leading to increases in average inpatient hospital lengths of stay. For patients discharged to home health, hospital average length of stay increased 11% from 2019 to 2022. Should the home health provider market constrict further, Medicare costs are at risk of increasing, an unintended consequence of the proposed rule.

— WellSky

***

As of July 2023, patient referral conversions — a measure of the number of patients that were referred to home health and subsequently admitted — have now plummeted to 55%. This means that 45% of all patients seeking home health are being turned away from service, which extrapolates to 6.2 million patients being turned away annually.

Access-to-care issues are extremely frustrating for these 6.2 million annual patients denied home health services, and they may ultimately experience worse health outcomes and overall spending in the Medicare program. Home health is a low-cost, high-value service option when compared to alternatives, such as longer acute stays or placement at skilled nursing facilities or other long-term care facilities. A portion of these 6.2 million patients turned away from care end up in those higher cost alternatives, where, in addition to increasing Medicare spending, they also occupy beds and utilize clinical resources that are in short supply.

The decade-long trend around access to home health care is also very alarming. A decade ago, referral conversions, patients accepted into service after being referred to home health, stood at 79%. This number declined to 69% in 2019, which was the last full year before PDGM, and before the public health emergency started due to the COVID pandemic. Since the start of

2020, referral conversions have fallen from 69% to 55%, a staggering drop in less than four years. The timing of this access to care trend correlates with the CMS payment rate adjustments. The cause of this correlation is a shortage of home health clinicians, creating a situation where home health agencies simply do not have the clinical capacity to admit millions of patients needing home health services. A significant factor in this deficit of home health clinicians is the Medicare annual payment updates that have not kept up with inflation.

— Homecare Homebase

***

It behooves CMS to provide financial predictability to this sector in order for it to
accept an increased number of patient referrals from high-cost institutions, and
deliver patient-preferred, low-cost, high-quality care in the home.

As a technology company that processes millions of claims, Axxess has witnessed
the home health claims payer mix shift from traditional Medicare to Medicare Advantage (MA). While Medicare margins have historically been favorable for home health, the increase in Medicare Advantage cases to more than 50% has quickly reduced overall home health agency margins due to inadequate MA
reimbursement. [Home health agencies] must subsidize their MA case losses with traditional Medicare margins to remain financially viable, accept referrals and support CMS’ desire to shift more healthcare into the home setting.

Ongoing reimbursement cuts to Medicare [home health agencies] to drive down Medicare margins is shortsighted. [Home health agencies] have no leverage with MA and Medicaid to negotiate better payment rates. CMS must consider the overall [home health agency] payer mix when proposing payment adjustments, particularly inadequate reimbursement by MA and Medicaid. In 2023, [home health agencies] are experiencing a greater percentage of cases with zero or negative margins. The proposed Medicare cuts to address profit margins solely under Medicare without a more wholistic view of the payer landscape that CMS oversees, will topple the provider community. Further, limited financial resources reduce the ability for [home health agencies] to invest in measures that achieve success in CMS’ Home Health Value-Based Purchasing (HHVBP) model.

— Axxess

The post Home Health Industry Groups Slam CMS’ Proposed Payment Rule During Public Comment Period appeared first on Home Health Care News.

On Friday, the National Association for Home Care & Hospice (NAHC) and the Partnership for Quality Home Healthcare (PQHH) submitted a joint comment letter that called for “corrective action” in the final rule expected in October.

“The purpose of this letter is to sound the alarm for CMS, which bears critical responsibility for overseeing the Medicare program,” NAHC and PQHH wrote in the letter. “The cuts proposed by CMS in the CY 2024 HH PPS Proposed Rule must not be finalized. Doing so risks irreparable fracturing of the foundation of skilled home health care in America and the erosion of seniors’ ability to receive care in their home.”

The proposed payment rule, which was released in June, includes a 2.2% aggregate reduction in Medicare fee-for-services payments for next year. It also includes a 5.653% permanent rate cut, which would reduce home health payments by an estimated $870 million in 2024. 

NAHC, in particular, has taken aim at what it considers to be a flawed methodological approach to calculating home health payment. Earlier this month, NAHC filed a lawsuit against CMS and the U.S. Department of Health and Human Services (HHS).

In their joint letter, NAHC and PQHH focused on Medicare beneficiaries and the long-term impact the rule will have if finalized.

The organizations cited the recent proposed rule on Medicaid home- and community-based services (HCBS) as an acknowledgement from CMS that rate reductions and access reductions are linked.

“CMS already recognizes the clear connection between rate reductions and access reductions,” the organizations wrote. “In CMS’ recent proposed rule on Medicaid [HCBS], the agency is proposing that states must conduct thorough access analyses when proposing ‘rate reductions or payment restructurings’ in order to assure that such proposed rate reductions will not hinder access to care.”

Broadly, the cost of care delivery has risen quickly and substantially.

“In many places, the salaries for skilled clinical workers have increased by double-digit percentages year over year,” NAHC and PQHH wrote. “At the same time, the U.S. Treasury has repeatedly increased borrowing rates. Supplies, including fuel, cost more than they used to. Yet, CMS is choosing to propose massive cuts that would put the Medicare home health benefit at grave risk.”

Even prior to the proposed payment rule, providers were struggling to keep up with the demand for home health care. In 2022, the home health referral rejection rate reached an all-time high at an average of 76%, compared to 54% in 2019, according to CarePort data.

Rejections that are related to staffing shortages have also gone up, according to Homecare Homebase data. This went up from 3.8% at the beginning of 2020 to 12.1% at the beginning of 2023.

“Together, these trends indicate that patients referred to HHAs are now less able to receive HHA care,” the organizations wrote. “Importantly, these patients who are not taken into the care of an HHA do not simply disappear. Rather, they often are instead directed to institutional settings that cost far more and are typically a non preferred care setting. Patients who cannot access home health may also go home without adequate support.”

The post NAHC, PQHH Sound The Alarm Over ‘Irreparable Fracturing Of The Foundation Of Skilled Home Health Care In America’ appeared first on Home Health Care News.

Broadly, CMS calculates the expected impact of cost inflation for home health agencies annually. In order to do this, CMS relies on a forecasting methodology from a private entity that is applied to the most recent cost data available for home health care.

“That forecasting tool attempts to gauge cost trends as an indicator of where future costs in the upcoming year will end up,” William A. Dombi, the president of the National Association of Home Care & Hospice, told Home Health Care News in an email. “As with any forecasting, errors can and do occur once actual cost changes are known. Over the years, these errors have sometimes been in the provider’s favor and other times not.”

The forecasting errors for 2021 and 2022 were significant, according to Dombi.

They resulted in a 5.1% shortfall in the annual payment rate updates for those years.

Last month, The Partnership for Quality Home Healthcare (PQHH) and the NAHC penned a joint letter to CMS. In the letter, PQHH and NAHC recommended that CMS advance a proposal for a one-time forecast error correction for 2021 and 2022 in the upcoming proposed rule.

“After a conversation we had with senior officials at CMS – who were asking about some of the economic conditions related to workforce, and the costs of retention and recruitment – we did take the opportunity to follow up our conversation with a letter that really focused on showcasing the fact that in 2021 and 2022, for home health, the market basket was significantly off,” PQHH CEO Joanne Cunningham told HHCN. “This translates to billions of dollars that did not go into the rate structure for home health, which is really important.”

Cunningham noted that the economic conditions that home health agencies are working under are not being reflected in that market basket update appropriately.

“Workforce issues continue to be a serious and significant challenge for providers, and this is one way for CMS to recognize that reality,” she said. “The data is pretty clear. The question is if CMS is going to do anything about it.”

If CMS chooses not to address the forecast error, home health stakeholders fear that it will have a long-term effect because the shortfall is permanently built into the base rates.

Over the course of a ten-year period, a 5-point error will lead to a $10 billion or more loss.

On the flip side, if CMS agrees to make the adjustment, the 2024 base rates will increase by 5% or about $850 million, according to Dombi.

“With that change permanently in the base, [home health agencies] will avoid a $10 billion loss,” he said.

Dombi pointed out that CMS is in a position to correct the forecast error without further congressional authorization.

“We are hopeful that CMS will recognize the need to do so,” he said. “Similar support came to nursing homes in 2003.”

Similarly, Cunningham believes that PQHH and NAHC data-backed push could make a difference for providers. 

“I’m always optimistic that when you present data and a solid policy argument to CMS, they respond accordingly,” she said.

Enhabit Inc. (NYSE: EHAB) also weighed in on the forecast error – and the rest of its expectations for the upcoming proposed rule – during a first-quarter earnings call earlier this month.

“I don’t think that we would be surprised to see the other half of that behavioral adjustment come through,” Barb Jacobsmeyer, Enhabit’s CEO, said during the company’s recent earnings call. “I think we will be surprised if they propose to implement any of the temporary cuts in 2024 on top of the other half of the permanent. It’s possible they would lay out some sort of schedule for how it would be applied. A forecast error correction has been requested of CMS when we look at the market basket rate. I anticipate we get that other half, I think what’s going to be critical is what sort of market basket we get with that.”

The post Home Health Stakeholders Call On CMS To Rectify ‘Significant’ Forecast Errors From 2021, 2022 appeared first on Home Health Care News.

Home health stakeholders often talk about the need to modernize the Medicare home health benefit.

What they are often getting at is the need to make it easier for providers to deliver crucial care, while, in turn, creating better access to care.

“We constantly need to be thinking about what’s ahead, how to improve this benefit, how to make it more available, how to expand what you can receive in the home … because home is the preferred setting,” Joanne Cunningham, CEO of the Partnership for Quality Home Healthcare, told Home Health Care News.

HHCN recently caught up with home health industry advocates who suggested key changes that they believe would update and enhance the Medicare home health benefit.

Greater flexibility around homebound status

Under Medicare, a patient is considered homebound if they need supportive devices such as crutches, canes, wheelchairs and walkers due to illness or injury, or if they need the assistance of another individual to leave their home.

To be considered homebound, leaving the home must require “a considerable and taxing effort.”

While eliminating homebound status entirely could present a number of challenges, broadening the definition is worthwhile, according to Bill Dombi, president of the National Association for Home Care & Hospice (NAHC).

Plus, there is some precedence behind this idea. Congress has introduced flexibility around homebound status in the past.

“Congress at one point added to the homebound standard the ability to leave the home for religious services,” Dombi told HHCN. “Prior to that time, people were being denied coverage because they would go to religious services on occasion and then being told ‘Well, sorry, you left your home.’”

This isn’t the first time NAHC has called for more flexibility around homebound status. Back in March 2020, the organization submitted a letter to the U.S. Centers for Medicare & Medicaid Services (CMS) asking for accommodations that would enable providers to be more effective amid the COVID-19 emergency.

At the time, NAHC asked CMS to expand the existing “homebound” requirement so that providers could treat individuals dealing with COVID-19.

Sen. Susan Collins (R-Maine) — a longtime home-based care advocate — pointed out that the requirement is “extremely strict.”

As of now, changing the homebound status would take an act of Congress.

“The barrier more than anything else is the need to change the law,” Dombi said.

Aside from homebound status, Dombi also noted the need for more flexibility around the eligibility requirements needed to qualify for home health.

Telehealth reimbursement

Telehealth is not a reimbursed service under home health care.

Yet this hasn’t stopped providers from embracing telehealth, virtual care and remote patient monitoring — especially during the pandemic.

“I think it’s being used effectively as an additional resource gap filler that provides a high level of additional service for patients in the home who are being monitored by a home health provider,” Cunningham said. “I think policy needs to seriously examine how you further take that to the next level.”

Taking things to the next level means paying providers when they utilize these services, according to Cunningham.

On its end, CMS has recognized the value of telehealth by allowing its costs to be recorded in the cost report.

“That’s a good step, but the [public health emergency] has shown that telehealth has become such a linchpin for the delivery of care to patients in the home,” Cunningham said. “We need to think long and hard about policy change that incentivizes and standardizes the use of appropriate telehealth. I think the way to do that is to reimburse for it.”

Over the years, the legislative efforts around home health telehealth have largely been stalled and unsuccessful.

Cunningham believes that educating policymakers about home health care may push the needle forward.

“I think the more up close and personal an understanding policymakers have of the home health benefit — its capacity and the kind of patients that are being cared for in the home — the better off we’re all going to be,” she said. “Policymakers will see a service delivery model that in the past five years has advanced, certainly in the past 15 years.”

Recognition of providers’ role in educating family caregivers

The ability to receive care in the home is often dependent on informal or family caregivers.

Broadly, informal caregivers are spouses, partners, friends or family members who assist with activities of daily living (ADLs) and possibly even medical tasks, according to the San Francisco-based nonprofit Family Caregiver Alliance.

Providers play an important role in the education of informal caregivers, according to Mollie Gurian, vice president of home-based and HCBS policy at LeadingAge.

“They do a lot of caregiver education – teaching family caregivers how to do the exercises or how to clean a wound or helping them figure out how to support a dementia patient while they’re going through their skilled care episode,” she told HHCN. “If caregiver education and support are lifted up, and paid for appropriately, it would be a more holistic benefit.”

Gurian noted that this would help improve home health episodes for everyone.

Plus, it would compensate providers for the work that they are already doing.

“It takes a lot of time to educate the caregiver on the complex tasks that come within a home health benefit, so it’s recognizing the actual time that is spent by nurses, therapists or other people on the team to educate those families,” Gurian said. “[Currently], it’s part of the bundle, it’s part of the expectations, but it’s not reimbursed at a level that allows them to focus on it as much as it might need to be focused on.”

Looking ahead, Gurian believes that this is a period of change for the health care system.

“CMS has focused on an equity strategy about the different kinds of things that we can pay for that will help with outcomes,” she said.

Ultimately, she believes paying for that informal caregiver education is a way to do just that.

The post 3 Ways To Modernize Medicare’s Home Health Benefit appeared first on Home Health Care News.

The letter detailed the challenges the home-based care sector has been facing, and also included possible solutions. Among the potential solutions is recent state legislation that PQHH and others believe could work on a national level.

The Senate — specifically U.S. Senators Bill Cassidy, M.D. (R-LA) and Bernie Sanders — originally released an RFI on March 2.

Ultimately, the Senate is hoping to come up with bipartisan solutions to include in future legislation based on the information and ideas it receives from providers and stakeholders.

PQHH CEO Joanne Cunningham is encouraged by the Senate’s efforts to tackle staffing shortages in health care and – by extension – home-based care.

“It feels different to me,” she told Home Health Care News. “It feels like there is some renewed interest and effort to, on a bipartisan basis, work together on creative solutions that leverage all the interest and all the good ideas out there, to see something happen. I’m hopeful and I think this momentum is exciting.”

PQHH’s letter identifies four key things that its members would need to have in place to address the labor crisis.

These four things are: resources to increase wages; partnerships with educational institutions; tuition assistance and loan forgiveness for educational advancement in the home health field; and resources to address worker needs, such as transportation expenses and child care costs.

“These are all long-standing policy ideas that have been talked about for many years as ways to address the workforce labor shortage in the health care setting,” Cunningham said.

The letter also identified state legislation like the Kentucky Healthcare Workforce Development Act as a possible blueprint for a national solution.

The bill addresses workforce challenges by establishing the Kentucky Healthcare Workforce Investment Fund. The fund will create a public-private partnership that centers around workforce training and education initiatives.

Earlier this month, the bill passed in the Kentucky House in a 92-1 vote. Last week, the bill passed the Kentucky senate in a 35-1 vote, and delivered to Gov. Andy Beshear.

This particular state legislation stands out because it brings together both public and private sector entities, according to Cunningham.

“It’s a partnership that engages the private sector, health care organizations, insurers, others, as well as the government, to try to incentivize [all] to work together on this,” she said. “That is one of the reasons it has such an appeal in the Kentucky state government, but also in Washington. I’ve heard a number of members of the House and Senate recently talk about bipartisan solutions being the way we should be approaching these thorny policy issues. The Kentucky proposal certainly lands squarely in that category.”

The PQHH letter calls for Congress to incentivize states to implement health care workforce investment funds. In order to do this, Congress will need to bump up each state’s federal Medicaid match (FMAP).

Overall, Cunningham applauds the proactivity of Senators Cassidy and Sanders when it comes to looking for ways to end the workforce shortage.

“The impetus behind it really shows the seriousness of not just the need, but the desire by senators on both sides of the aisle to do something on addressing the health care workforce shortage,” she said.

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The words from the industry leaders highlighted here weigh in on everything from tensions with Medicare Advantage (MA) plans to staffing shortages kneecapping industry growth and more.

Perhaps most importantly, the statements are indicative of what’s in store for home health and home care in 2023 and beyond — as many of these issues raised remain unresolved.

“The main thing we’re looking at is the rate reduction of 7.69% – will it happen or not? We have been engaged in the most intense advocacy effort I’ve experienced in my lifetime. And I’ve been around a few years advocating. The effort that we have underway brings in all forms of advocacy.”

— William A. Dombi, President, National Association for Home Care & Hospice (NAHC) (Oct. 24, 2022)

This quote from NAHC’s Dombi set the scene for the home health payment rate battle that would consume 2022.

As things stand, the final rule includes an estimated increase to 2023 home health payments of 0.7%, or $125 million, compared to 2022 aggregate payments. The final rule also included a cap on negative wage index changes, and a recalibration of the case-mix weights and Low-Utilization Payment Adjustments (LUPA) thresholds for 2023.

But more importantly, the final rule locked in major reimbursements cuts moving forward.

NAHC and other advocates will continue to urge CMS to reconsider its plan. They’re also appealing to members of Congress directly. Litigation is another avenue NAHC may take, though it’s not the organization’s first strategy.

“We haven’t hit and been predictable on earnings, so that’s the reason I’m back. We need to stand by what we say and deliver on our numbers. And there’s no reason, with these initiatives, that we should not deliver on our numbers and beat our numbers.”

— Paul Kusserow, CEO and Chairman, Amedisys (Dec. 6, 2022)

The home health world was rocked when it was announced that long-time Amedisys Inc. (Nasdaq: AMED) CEO Paul Kusserow would be returning to the helm of the company after then-CEO Chris Gerard served for less than a year. The move even drew comparisons to the recent leadership change taking place at mass media and entertainment conglomerate The Walt Disney Company (NYSE: DIS).

These words show how despite skyrocketing demand for home-based care services, many providers struggled to meet their financial benchmarks. That struggle was mostly due to headwinds stemming from staffing constraints and reimbursement challenges. Amedisys was not immune to these challenges.

The company’s failure to meet its own expectations prompted this quote from Kusserow during his first major appearance following his return as CEO. More generally, his statement also clued in stakeholders about what led to his return.

Looking ahead, Amedisys is looking to rebound by leaning into staffing and improving its MA contracts.

“I think we’ve done a lot more with managed care [because of our JVs with hospitals], and I have really good relationships with executives. … But I think our biggest problem are the conveners in the middle of all of this.”

— Keith Myers, Chairman and CEO, LHC Group (July 26, 2022)

With relationships between MA and home health already being shaky, many providers believe that conveners add even more fuel to the fire. In other words, working with conveners isn’t always practical for providers.

Conveners are meant to serve as a middleman between payers and providers, but providers have told HHCN — both on and off the record — that coveners “skim off the top of” their bottom lines. This is especially alarming because home health providers struggle with low MA rates. For context, MA plans have paid up to 40% to 60% less than fee-for-service Medicare.

This quote from LHC Group’s (Nasdaq: LHCG) leader captures that tension.

“I think it’s the same reason that consumer brands spend so much money on the younger segment where brand loyalty is seeded, right? … If we’re not with our seniors as they begin utilizing their Medicare Advantage benefit, we’re going to miss the opportunity to be with them when they exceed the hours Medicare Advantage pays for and they need private pay.”

— Shelly Sun, CEO and Founder, BrightStar Care (Nov. 17, 2022)

Since 2019, there’s been this question of whether MA is truly an opportunity for home care agencies. Instead of weighing in on this debate, Sun’s statement moves past this and explains why it’s imperative for providers to plant seeds now, as an investment in the future.

There’s no question that MA enrollment is on the rise. As of 2022, more than 28 million people are MA enrollees. This is almost half of the Medicare population, according to Kaiser Family Foundation data.

Signs only point to further increases in the future, which will make it impossible for home care to ignore MA.

“It’s not just about the clinics; it’s now about the home and the community.”

— Andrew Witty, CEO, UnitedHealth Group (Dec. 1, 2022)

As HHCN begins to look back at 2022, UnitedHealth Group’s plan to purchase LHC Group is arguably one of the biggest deals to take place. 

And while these two giants, in their respective sectors, coming together is a big enough story on its own, the news also represents a major shift in health care at large, and Witty’s statements get to the heart of this.

It speaks to where UnitedHealth Group sees health care going, and the company’s investment in being at the center of this change.

“Health care workforce challenges are not stabilizing, they are intensifying [in regards to] how organizations are experiencing recruitment and retention, wage pressures, benefit incentives, and just trying to manage staffing in this environment right now.”

— Joanne Cunningham, CEO, Partnership for Quality Home Healthcare (Oct. 21, 2022)

When considering the issues home health providers are facing, it’s seemingly one thing after another. Still, staffing remains the No. 1 issue.

In her above statement, Cunningham breaks down why the staffing landscape continues to worsen and explains how this has created a perfect storm of care delivery barriers for providers.

In October, the Partnership for Quality Home Healthcare conducted a labor cost study with Dobson DaVanzo & Associates. It found that only 59% of positions at agencies were filled in Q1 2022. On top of this, home health agencies often reported that they often struggled with competition with hospitals that can pay higher wages for staff.

Additionally, in the survey, 71% of respondents said that having to turn down referrals altered the amount of care services their organization was able to deliver.

“I think home health, in the past, [it] has been a bit exploited because it’s been a very fragmented industry. … There’s been an element of treating it like a commodity by some of the payers, knowing that if one agency wouldn’t care for the patient, well, there’d be others that would be willing to step up.”

— Mark Tarr, CEO and President, Encompass Health Corporation (May 11, 2022)

Much has been said about the difficult relationship between MA plans and home health providers. And Tarr’s comments speak to why he believes this has become the status quo between providers and payers.

Tarr isn’t alone in his belief that providers often get the short end of the stick in these partnerships. But as more leaders in home-based care speak out, and as companies begin to increasingly turn away MA business that doesn’t make sense in light of capacity constraints, it’s likely that providers may slowly begin to see change in the future.

In July, Enhabit Home Health & Hospice (NYSE: EHAB) completed its spinoff from Encompass Health. Tarr still serves as CEO of the latter while Barb Jacobsmeyer is CEO of Enhabit.

Now, Enhabit is one of the largest home health entities in the country. Its footprint includes 35 states and more than 350 locations.

“The biggest trend in 2023 is the rising cost of private pay home care services. Over the last year, our rates have increased between 20% and 40%. So even though the need for home care has grown, the market of individuals that can afford care on a long-term basis has shrunk.”

— Ryan Iwamoto, President and Co-founder, 24 Hour Home Care (Dec. 16, 2022)

For all of the reasons touched on above and more, the cost of home care services has risen dramatically in 2022. Iwamoto, president and co-founder of the Los Angeles-based 24 Hour Home Care, captures that trend with his words here.

According to Genworth’s annual Cost of Care Survey, the monthly median cost of homemaker services was $4,957 nationally last year, with the monthly median cost of home health aide services being $5,148. Those figures are based on clients needing 44 hours of care per week.

At least in 2022, skyrocketing home care prices haven’t outpriced clients yet. Beyond Iwamoto, home care executives have told HHCN that their families have been able to dig deeper without stopping service.

But if labor dynamics, economic factors and general demand exacerbate the issue, 2023 could see more older adults priced out of home care – causing the overall home care market to shrink. It’s a problem that more home care operators should be thinking about.

The post 8 Quotes That Tell The Story Of Home-Based Care In 2022 — And Beyond appeared first on Home Health Care News.

Nearly five months after the unveiling of the proposed payment rule caused a stir among home health stakeholders and advocates, the U.S. Centers for Medicare & Medicaid Services (CMS) released its final payment rule on Monday.

Back in June, CMS proposed a 4.2% aggregate decrease for 2023, a cut the industry at large felt would be devastating.

Though CMS will still usher in other cuts and permanent adjustments related to the rebalancing of the Patient-Driven Groupings Model (PDGM), the final rule comes with an increase in the aggregate by 0.7%, or $125 million, compared to 2022.

While many in the industry acknowledge that CMS has made efforts to address the concerns of providers, most are still stressing that the methodologies CMS is following will eventually crush operators and reduce access to care .

“CMS has rightly recognized the challenging operating environment providers are currently navigating and reduced payment cuts from the 7.69% proposed in June to the 4% announced today,” LeadingAge President and CEO Katie Smith Sloan said in a statement. “That, along with the 4% market basket update that addresses rising costs of providing services, indicate CMS is cognizant of current realities. We appreciate that — but at the same time, we remain concerned.”

CMS decided to take a phased-in approach to the PDGM behavioral adjustment and impose about a 3.5% adjustment for a 30-day period. This is an overall $635 million decrease in reimbursement for agencies. 

“Agencies need to understand that this is only half of what will be imposed after this year,” J’non Griffin, senior vice principal of coding and the OASIS department at SimiTree, told Home Health Care News in an email. “The remaining permanent adjustment, along with any other potential adjustments needed to the base payment rate to account for behavior change based on data analysis, which are all required by law, will be proposed in future rulemaking.”

In the wake of the proposed payment rule’s release, many took aim at the behavioral adjustment methodology CMS used. With the final rule out, it is still viewed as problematic.

“We still have serious concerns regarding the agency’s continued reliance on a flawed budget-neutrality methodology that produced the proposed rule and today’s result,” Amedisys Inc. (Nasdaq: AMED) said  in a statement.

Still, the company felt that slight progress had been made, especially when compared to the proposed rule.

“While not the ideal outcome, today’s release of the CY 2023 Home Health Final Rule is a welcomed improvement over what was proposed by CMS this summer in regard to the overall payment update for next year,” the organization said in its statement. “The unprecedented inflation we are experiencing across the country led to a 4.0% market basket update, the highest update we have seen for home health agencies. CMS’ decision to reduce the behavioral adjustment cuts calculated by half for CY 2023 is also helpful.”

Amedisys noted that mass volume of comments and continued advocacy efforts from providers, clinicians and industry trade associations likely played a role in the more positive improvements seen in the final rule.

The Partnership for Quality Home Healthcare (PQHH) likewise voiced its concerns. 

“This 7.85% cut is worse than initially proposed and when fully implemented in 2024, will result in an immediate decline in access to home health,” PQHH CEO Joanne Cunningham said in a statement. “This will have negative effects on the availability of care for the most chronically ill of the Medicare population and result in access to care problems. While this short-term phase-in blunts the immediate impact, the long-term consequences of this rule, unless mitigated, will devastate access to care in the home.”

Ultimately, providers will need to make major changes in order to survive in a challenging environment that includes other headwinds such as labor challenges, inflation and COVID-19. 

“Agencies are faced with tightening their belt, while still striving to maintain outcomes under HHVBP,” Griffin said. “It feels like, yet again, home health agencies are being asked to do more with less. Agencies will have to think of creative ways to stretch their dollar — possibly to outsource some services that traditionally have been housed internally, and utilize those staff members in other areas of the business.”

Griffin believes that providers should find ways to become “leaner” in their approach to business.

“Think of creative ways to look at RCM and ROI in house staff versus outsourcing, and the benefits of experts handling your OASIS,” she said. “While there is a cut now, we have to look ahead to HHVBP reimbursement and how that may be affected. Agencies should financially model what the rule means to them, and see the impact for themselves and how it affects their population.”

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