Kalon Mitchell sold his company to the post-acute technology organization WellSky in 2018. He then worked for WellSky for five more years, learning the ins and outs of the home health industry in the meantime.

After leaving WellSky, and with some more time on his hands, Mitchell decided to start “Project Sword”, which leverages cost reporting data to analyze the financial position of home health providers at large.

The data shows not an industry enjoying close to 20% margins, but instead one that is in a deeply precarious position moving forward.

The Centers for Medicare & Medicaid Services (CMS) has proposed cuts to home health payments three years in a row. Though its last two final payment rules have not been as harsh as its proposals, they have still come with permanent cuts to payments.

Providers have multiple gripes with these cuts. The first is over the payment methodology that CMS applies, which most providers and advocates strongly disagree with. The second is the rising costs that home health agencies have recently faced. While CMS is cutting home health payment in traditional Medicare, the cost of providing services has skyrocketed – namely due to the cost of labor.

But the final gripe is the one that has turned into a “generational battle” for providers, and that is MA penetration and payment.

Over 50% of Medicare beneficiaries are now under an MA plan, and those plans generally pay far less for home health care than traditional Medicare.

Providers have regularly told Home Health Care News that MA payment for home health services doesn’t cover the cost of delivering care. But providers tend to be mission driven, and also have referral relationships to uphold. Therefore, they continue to take on MA patients, which sinks their overall margins.

Essentially, traditional Medicare subsidizes MA plans in home health care. It’s true that if providers only took traditional Medicare, they would likely enjoy healthy margins. On the other end, though, if they only took MA, they’d likely have inoperable businesses.

While providers have shared these MA payment horror stories anecdotally, it’s been hard to get a good overall picture of what the average home health provider’s margin looks like of late – as both MA penetration and traditional Medicare rate cuts continue unabated.

The whole picture

Whereas traditional Medicare subsidizes MA in home health care, the opposite dynamic exists for hospitals.

MedPAC has repeatedly said that it can only consider Medicare payments when analyzing the home health industry.

“The Commission’s review indicates that FFS Medicare’s payments for home health care are substantially in excess of costs,” MedPAC wrote in its March report. “Home health care can be a high-value benefit when it is appropriately and efficiently delivered, but these excess payments diminish that value.”

At the same time, MedPAC includes all-payer data for hospitals in its reports. For instance, it acknowledged that aggregate hospital margins on traditional Medicare had fallen to -11.6% in 2022, while aggregate “all-payer” margins were at about 2.6%.

But in home health care, the other side of the payment picture is not acknowledged.

“In the MedPAC report, they say one of the supposed foundations of what they’re supposed to do is look at all-payer margins,” Mitchell told HHCN. “And in the chapter on home health, there is no mention of all-payer margins.”

What Mitchell found while working on Project Sword was that MA payments were erasing the healthy margins that could potentially come with a revenue mix dominated by traditional Medicare.

Project Sword and MedPAC’s analyses spit out similar data for Medicare margins, lending credence to Mitchell’s all-payer margin calculations.

When it came to the all-payer outlook, Mitchell found that home health margins sunk below the break-even point.

While 59% of home health agency revenue still comes from traditional Medicare, those beneficiaries now account for only 45% patient censuses.

Cost reporting generally lags, which is why much of the data Mitchell used is from 2022.

But since that point, it’s likely that the situation has exacerbated. MA penetration has continued, while CMS has gone through with another payment cut in traditional Medicare.

“We can see a deteriorating industry, and yet the narrative from CMS and MedPAC is that there’s no better industry to be in than home health care,” Mitchell said. “They have the highest profit margins, and that’s what Congress sees when they look at their report. That’s what they hear when they talk to CMS and MedPAC. But when they talk to agencies and advocates, they hear the opposite.”

Mitchell has been cleaning and trimming the data as much as possible to ensure that his project can turn into a meaningful tool for the industry.

Providers have also told him – and HHCN – that the numbers are on par with what they’re seeing internally.

“We want to take care of everybody, but the reality is that the payments we get from fee-for-service Medicare Advantage don’t typically cover our costs,” Michael Johnson, the chief researcher of home care innovation at Bayada Home Health Care, recently told HHCN. “So, we’ve got to make sure we have the right and best mix. That isn’t any different [than in years past], but we have to take even more clarity and focus on that approach now.”

Bayada has been around for nearly 50 years. It also has hundreds of locations, both in the U.S. and abroad.

While the current payment dynamics are tough, the company has the means to survive. It has the means to find a better payer mix, to become more efficient operationally.

Bayada and other larger home health providers also have a chance to get a better deal with MA plans. That could mean a better per-visit rate or some sort of value-based arrangement.

For smaller providers, that’s not the case.

“We have been very selective on what payers that we work with because of this,” LTM Group CEO David Kerns told Home Health Care News. “But I think especially smaller agencies, they may not have a payer innovation team, for instance. We’re not a huge agency, but we do have some scale. For smaller agencies, it’s hard to get payers to even credential your contract, let alone negotiate a value-based arrangement with you.”

As a result, fewer home health providers exist today than five years ago.

In total, there were 11,353 active home health agencies in 2022, 11,474 in 2021, 11,565 in 2020, and 11,569 in 2019, according to the Research Institute for Home Care (RIHC).

Last month, one of the oldest home-based care providers in the country – VNA Of Greater Philadelphia – closed its doors amid “unsustainable financial losses.”

A home health leader recently told Home Health Care News that one of its MA contracts hadn’t been updated for a decade. When it approached the payer about a rate adjustment, the plan offered a $3 increase.

The Preserving Access to Home Health Act of 2023 included a provision that would have forced MedPAC to consider all-payer margins in home health care, but that did not make it through.

So, with MA reimbursement that sometimes only covers a portion of the cost of care, and CMS reducing traditional Medicare rates, providers are left to their own devices to survive.

A closer look at the data

Mitchell is aware that there are errors in the data used for Project Sword. But those errors aren’t necessarily ones that would change the overall story that the data is telling.

“There are errors in the data. And I don’t know how many people, as I’ve worked on this project, have said, ‘You can’t use that data. It’s full of errors,’” Mitchell said. “My reply to that is, MedPAC and CMS are using it, and they’re providing a very limited perspective on what they’re doing.”

Mitchell has also shown his work as much as possible, and has included spreadsheets and his methodologies on his website.

But another area where there are definitely errors are the cost reports themselves. And that, too, could be hurting home health providers.

“I’ve never heard of a single agency that is making sure that every single one of their expenses is on these cost reports,” Kerns said. “They don’t have every little thing on there that should be on there. You need to recognize a lot of those expenses, and really work closely with whoever is doing your cost reports to make sure those are accurate.”

If anything, that would mean that margins are worse off than they’re portrayed in the reports.

“This has been haunting us for years,” Robert Markette, an attorney with the law firm Hall, Render, Killian, Heath & Lyman, previously told HHCN. “The numbers are all over the place. The baseline problem is that we don’t report it accurately because we don’t take cost reporting seriously. We give CMS the ammunition they need to make their argument that we’re being paid too much. When in fact, I think we’re severely underpaid.”

As for Mitchell, he plans to get the data in front of as many stakeholders as possible in the near-term future.

The final payment rule is generally released in late October or early November, but CMS also plans to continue cutting payments in the coming years.

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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.

CMS proposed a permanent prospective adjustment to the CY 2025 home health payment rate of -4.067% back in June. All in all, the agency proposed a 1.7% cut to aggregate home health payments next year.

Providers have experienced cuts in the previous two years, but have also seen CMS back off more severe cuts in the time between the proposed and final payment rules in 2022 and 2023.

“[CMS] thinks, ‘How much can we threaten to reduce the current payment rate, so that when we drop a few breadcrumbs [in the final rule], providers will feel good about picking a little something up?” Pinnacle Home Care CEO Shane Donaldson said on stage at Home Health Care News’ FUTURE conference last month. “History tells us that the final rule will probably be a net neutral event.”

Based in Oldsmar, Florida, Pinnacle Home Care is one of the largest home health providers operating in its home state. The New York-based HCS-Girling recently acquired Pinnacle Home Care, which plans to significantly expand in the coming years.

While providers are hoping that they at least see those breadcrumbs in the final rule, they’re not banking on it.

Instead, they’re working toward becoming sustainable shops in spite of a turbulent payment environment.

“If you’re not really good at something – whether that is collecting your AR, doing your coding, OASIS review – it’s time to look at people who are really good at that, and maybe make some different decisions,” Interim HealthCare President and COO Rexanne Domico also said on stage at FUTURE. “What I would really suggest to people at this stage in the game is to think about your efficiency in all of your locations.”

Based in Sunrise, Florida, Interim HealthCare is a home health and home care franchise with more than 330 locations across the U.S.

Efficiency is a broad term, but Domico was specifically referring to outsourcing certain tasks, reducing redundancies and also exploring home health-applicable AI.

AI was a major talking point at FUTURE, and the vast majority of providers were bullish on what new technology could do for the industry in terms of efficiency, especially in light of recent rate cuts.

On top of that, Domico mentioned utilization as an area for providers to keep an eye on.

“I think there’s a lot of times we don’t focus on utilization,” Domico continued. “And I think there’s a tremendous opportunity to focus on there. And that can be part of your increase, if you work it the right way.”

Donaldson added that clinicians should be working at the top of their licenses, which also helps drive efficiency.

“What we’ve got to do is improve our margins, and that means we’ve got to get evaluating clinicians to do as many evaluations and assessments as possible, and we’ve got to get the non-evaluating clinicians doing the majority of the straight visits,” he said.

There are home health providers trying to do more to be a better partner to payers and referral sources. But, sometimes – to Domico’s point – less is more.

In general, providers agreed with the idea that they should focus on their strengths, and find a way to outsource their weaknesses, or at least level up in those areas.

“If [that margin] is not going to be given to you, how are you going to get it?” Domico said. “I think you get it by really being an expert at what you’re really good at, which is delivering care. And if those other things are not working for you, then I think it’s time to look at doing something different.”

Working with other payers

As those fee-for-service rates become less reliable than they’ve been in the past, providers are having to spend far more time thinking about their Medicare Advantage (MA) strategies.

With less growth in traditional Medicare payment, it’s paramount to avoid MA payers that reimburse at a subpar rate. For the most part, providers don’t expect – but do hope for – MA rates on par with traditional Medicare rates.

But 40% lower, for instance, is unsustainable.

“In the state of Florida, we have 850 home care agencies, and so Medicare Advantage plans still consider us to be largely commodities,” Donaldson said. “When they can find an agency next door that’s willing to do a visit for $80, they’re not going to pay us $130. Irrespective, it seems, to how much we can prove that our quality is better than any of our neighbors.”

Pinnacle has had success with one MA plan, however. That plan has agreed to pay the company with some upside opportunity.

That came about when the plan moved from being managed internally to being managed by a third party.

“We had a good relationship with the third party,” Donaldson said. “In negotiating, we said, ‘Look, this really needs to be an episodic relationship, even if it’s at a percentage of Medicare. Give us the opportunity to control our own destiny, give us a pot of money and let us run with it.’”

While some improvements have been made in home health contracts between MA plans and providers of late, Domico still sees providers largely as “price takers” in the relationship.

“I think we are price takers, and I think the negotiations are really very one-sided,” she said.

But she also believes that there’s still plenty of opportunity out there for providers to be paid more fairly, and that starts with regional plan partnerships.

Well Care Health COO Rebecca Higbee, also on stage at FUTURE, said her company has seen most success with those local-level health plans.

“Some of our best partners are those regional partners,” she said. “Those local partners where you can speak to the actual decision makers of the plan.”

Well Care Health provides home health and hospice services across North Carolina and the upper part of South Carolina.

Higbee also emphasized that health plan relationships need to be nurtured on a daily basis.

“It still takes years to make progress,” she said. “We have made progress of late. There’s a handful of payers that are finally seeing the value, while at the same time, there’s also payers that in years past have seen value and are now looking to move backwards. It’s really a mixed bag. I think it’s something we have to be working on daily, and something we have to be thinking about daily.”

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Home-based care leaders are gaining some gusto. They are at the helm of the organizations that should, theoretically, be the beneficiaries of an overload of demand over the next decade.

In the past, providers have pleaded for a “seat at the table” in the health care continuum. But, to a certain extent, they now hold the cards.

That may not always be evident, particularly in conversations with Medicare Advantage (MA) plans and the Centers for Medicare & Medicaid Services (CMS).

But with the right tools and strategy, providers have the leverage to potentially change the course of those conversations, and also vouch for themselves on much higher ground.

“I think all of us would love to see this industry mature and take hold of the advantage that we’re creating for the U.S. health care system and for Medicare Advantage payers,” Compassus CEO Michael Asselta told me on stage Thursday at Home Health Care News’ FUTURE conference in Nashville. “But there’s a maturation that we all have to undergo to capture that opportunity.”

What home health providers need to do to mature, and what that maturation could lead to, is the topic of this week’s exclusive, members-only HHCN+ Update.

A maturing industry

On the first panel of the FUTURE conference Thursday, the home health leaders on stage stripped themselves of the woe-is-me mentality that can sometimes hamstring the industry.

Asselta – who is relatively new to the industry, having joined Compassus in May – acknowledged the gap between providers and the significant opportunities that could be waiting for them in the near- to long-term future.

One of the first recommendations that he had was building out what he called “wraparound services” in addition to home health care.

“These recurring hospital visits are very expensive,” Asselta said. “Managed care understands this already, and they’re willing to reimburse us. So we have to ask. We have to build and ask. We have to weave things together a little differently for traditional Medicare, and that is providing reimbursable services under our umbrella. That means expanding, it means growing up quite a bit, and that’s sort of a theme we’ve heard, too.”

Based in Brentwood, Tennessee, Compassus provides home health care, home infusion, palliative care and hospice care. It has about 7,000 team members and more than 270 “touch points” across 30 states.

Outside of wraparound services, Axxess CEO John Olajide acknowledged the need for providers to collect and utilize data in a more practical manner.

“You cannot accomplish what you want with the payers – or whoever the stakeholder is – if you don’t have data. And to have data, you need to have the right technology,” Olajide also said on stage. “If there’s not a large data set, there’s not a lot of information to leverage in [those conversations].”

Founded in 2007 and based in Dallas, Axxess is a home health technology company.

Gentiva CEO David Causby offered up an example.

The company’s home-based palliative care business can take a payer’s most at-risk patients, which readmit to the hospital at a 30% clip, and get that number down below 10%, Causby said.

That ability, plus the data, creates leverage.

“For the industry to continue to move forward, … I think you have to scale companies,” Causby also said on stage. “You’ve got to be sophisticated. You’ve got to have a playbook on effective and efficient operations. You’ve got to be innovative. You’ve got to have data.”

Based in Atlanta, Georgia, Gentiva provides palliative care, hospice care and other home-based care services via about 600 locations across 38 states.

“You’ve got to stop being the downstream, waiting for the phone to ring,” Causby continued. “Move up, and truly show the value add. There’s no doubt, over the next 30 to 50 years, this will be the fastest-growing sector in the health care space. For those that are willing to get out there, get after it, do it the right way, be very fundamentally sound in how you operate and take the lead on innovation, technology and analytics – those are the people that will be successful in this space.”

Home-based care providers are in the right business, the right setting. But that alone won’t be enough.

Providers across the home-based care continuum need to take the next step.

“We need to continue to press for a discussion around what leverage we’re bringing to the managed care payer,” Asselta said. “Can we collectively, as an industry, start to say, ‘Hey, look, if I deliver X results, you can hold me accountable for Y. And I don’t know if we’re going to be able to change the narrative until we’re unwilling to take rates that don’t reflect the value that we provide.”

The post Why Home Health Providers Need To ‘Mature’ Before They’re Paid Fairly appeared first on Home Health Care News.

The company joins nearly 400 participants in developing nationwide dementia care programs (DCPs). These programs intend to enhance care coordination and improve access to services and support.

Contessa Health has provided comprehensive in-home care since 2015. The company is based in Nashville, Tennessee, and partners with 11 health systems and multiple health plans, serving patients in nine states.

“CMS is excited to partner with Contessa under the GUIDE Model,” CMS Administrator Chiquita Brooks-LaSure said in a press release. “GUIDE is a new approach to how Medicare will pay for the care of people living with dementia. GUIDE participants are envisioning new ways to support not only people living with dementia but also to reduce strain on the people who care for them so that more Americans can remain in their homes and communities, rather than in institutions.”

The GUIDE Model, launched on July 1, tests a new payment approach for critical supportive services to improve the quality of life for individuals with dementia. These services include comprehensive, person-centered assessments and care plans, care coordination, 24/7 access to an interdisciplinary care team member or helpline and specific respite services to support caregivers.

“Our team of nurse practitioners, nurses and social workers have tremendous experience in helping patients and caregivers navigate the complex world of health care,” Gavin Baumgardner, Contessa’s Vice President and National Medical Director of Palliative Care at Home, said in a statement. “Through the GUIDE Model, we can apply this clinical model for dementia patients and their caregivers to allow this vulnerable population to live at home longer and achieve a better quality of life.”

Contessa’s involvement in the GUIDE Model will assist individuals with dementia and their caregivers in accessing education and support. This includes training programs focused on best practices for caring for a loved one with dementia.

Respite services are being evaluated under the GUIDE Model to determine their impact on helping caregivers continue to care for their loved ones at home, potentially delaying or preventing the need for facility-based care.

GUIDE participants represent a wide range of health care providers, including large academic centers, small group practices, community-based organizations, health systems, hospice agencies and other practices.

The model delivers on the Biden Administration’s Executive Order on increasing access to high-quality care and supporting caregivers and aligns with the national plan to address Alzheimer’s disease. 

Amedisys acquired Contessa Health in 2021 for $250 million. Since then, the latter has been a major focus of the former’s. Amedisys’ high-acuity care revenue – driven by Contessa Health – has steadily increased, quarter by quarter.

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Home health providers looking to achieve HHVBP success will need to prepare for this updated version of the model.

“You need to be thinking about how you’re doing in 2024, and then preparing for 2025 and making sure that you’re improving in the right areas,” Yancey McManus, senior director of solutions management at WellSky, said during a presentation at last month’s National Association for Home Care & Hospice (NAHC) Financial Management Conference.

Staying on top of utilization management, as well leaning on accurate data, will be key for providers looking to gain HHVBP wins.

“To prove our value and leverage insight, we really need to bank on data-informed decisions, especially as the machines are learning, and helping us understand what else is going on, because we know that our care doesn’t just happen during our visits,” Cindy Campbell, senior director of advisory services at WellSky, said during the presentation.

Campbell also pointed out areas where providers are leaving money on the table, so to speak.

She noted that purchasing analytics and not using them optimally was one way providers leave money on the table. Investing in RPM but not implementing it, and not leveraging patient engagement tools and check-in calls, were other ways providers sometimes fall short.

Ultimately, there are three key areas providers who are looking to stay on top can set their sights on mastering — OASIS-E, claims and HHCAHPS.

Indeed, providers need a strong assessment technique for OASIS-E and accurate documentation capture.

HHCAHPS is one area that McManus believes doesn’t receive enough attention, but one that could have the power to help providers differentiate their organization.

“HHCAHPS together represent 30% of your TPS score, so while individually they may not seem that important, together it’s incredibly important,” she said.

When it comes to claims, it’s important to be goal directed and aligned with the patient, Campbell noted.

“Focus on OASIS competence, we know that’s really important in the assessment technique, and look at what’s going on under the claims data to see where we are having problems with hospitalization,” she said.

Campbell also urged leaders to remember that throughout their efforts to improve, things may get worse before they get better.

“When we lead value-based purchasing differently, our staff will respond differently,” she said. “There might be some pushback. Behaviors may get a little worse, when suddenly we’re controlling utilization better, right before they ever get better, but they will.”

The post How Home Health Providers Can Prepare For HHVBP In 2025 appeared first on Home Health Care News.

The Centers for Medicare & Medicaid Services (CMS) launched the Guiding an Improved Dementia Experience (GUIDE) Model on July 1, which aims to create more comprehensive, coordinated dementia care. Some home-based care providers have been named participants in the program, and many more plan to get involved.

CMS hopes the GUIDE Model will improve the quality of life for people with dementia, enabling them to live longer in their homes and communities and reducing strain on their unpaid caregivers. It is a long-term commitment, set to run for eight years.

It will promote improved dementia care by defining and requiring a comprehensive, standardized care delivery approach that includes a standardized set of services for patients and their caregivers, an interdisciplinary care team and a training requirement for care navigators who are part of the care team, according to CMS.

The interdisciplinary care team will deliver services by creating and maintaining a person-centered care plan that details the patient’s goals, strengths and needs, as well as comprehensive assessment results and recommendations for service providers and community-based social services and supports.

“Working with a direct participant benefits the clients and family caregiver by providing a team-based approach to care,” Senior Helpers COO Mari Baxter told Home Health Care News. “This ensures comprehensive care for the client and involves all parties in the process, maintaining consistency and quality. The GUIDE Model also introduces families and clients to home care, keeping them safer at home and reducing hospital admissions.”

The Maryland-based Senior Helpers is one of the largest home care franchises in the country. And while it is not a direct participant in the GUIDE Model, it plans to be strategically involved with it moving forward.

CMS said nearly 400 participating organizations, including Lifespark, InHome Connect, Providence Home Care, and Andwell Health Partners, are building Dementia Care Programs (DCPs).

Given that GUIDE is a voluntary, nationwide model for Medicare Part B providers, it can benefit home care providers in several ways.

One such way is that it pays organizations to help them expand their DCPs and provides care coordination and service management. Another benefit is that GUIDE participants can contract with other providers, suppliers and organizations to meet care delivery requirements. These partner organizations can include both Medicare-enrolled and non-Medicare-enrolled entities. Home care providers may be able to partner with other organizations to gain participation if they don’t meet all the necessary guidelines.

“Participating in the model as a provider ultimately improves outcomes and reduces the burden on caregivers,” Baxter said. “This support can reduce caregiver strain and improve their ability to care for the client.”

The model is also expected to reduce Medicare and Medicaid expenditures by preventing or delaying long-term nursing home stays and reducing hospital, emergency department and post-acute care usage.

“We want to do whatever it takes to keep people out of the nursing home,” Lifespark COO Matt Kinne told Home Health Care News. “There’s a time and a place for nursing homes, but they are expensive. We know that by surrounding people with longitudinal, trusting, holistic relationships supported by geriatric expertise, which is how we’ve contemplated the GUIDE Model, we can eliminate a lot of low-value care.”

Lifespark, headquartered in St. Louis Park, Minnesota, offers a wide range of senior care services, including home health care, home care, home-based primary care and home-based urgent care.

Kinne emphasized that the GUIDE Model is valuable because it enables home-based care companies to focus not only on addressing dementia and comorbidities in patients, but also by providing support for families when they need it.

“GUIDE allows us to provide a care coordinator and resources that otherwise wouldn’t exist to support families and individuals living with dementia,” Kinne said. “It is funding, resources and the ability to support people with real care coordination, with real geriatric nurse practitioner expertise that can work alongside families with complicated medical issues and dementia.”

The GUIDE Model also aims to assist businesses in creating services that align with people’s needs, providing additional support within the currently fragmented system. Kinne said that given the U.S. health care system’s lack of coordination among caregivers, that is what will help individuals move toward a better quality of life.

However, Kinne emphasized that companies must prioritize long-term benefits for themselves and the families they care for when participating in this model.

“This is not an opportunity for the short term,” he said. “When we evaluate things like GUIDE, we think about something built to last for a decade that will change people’s lives. This is a long-term commitment and, I think, a really good move by CMS to invest in this and give companies like us the opportunity to demonstrate and show that there is a better way to care for seven million people in the U.S. living with dementia, many of which have informal caregivers.”

The post How Home-Based Care Providers Are Approaching The GUIDE Model appeared first on Home Health Care News.

Though payment factors are top of mind, there are other areas of the proposal that providers should also be paying attention to as well.

One of these areas is the OASIS updates for the home health quality reporting program (HHQRP), which begin in January 2027.

Though 2027 is down the line, providers should begin preparing now, according to J’non Griffin, senior vice president at the home health consulting firm SimiTree.

“I want you to start thinking about how you’re going to start preparing and how you’re going to collect this information,” she said during a recent webinar hosted by SimiTree. “It’ll be on OASIS, but start thinking about how you’ll train your staff.”

In 2027, there will be four additional questions added. The questions focus on living situation, food security and utilities.

Griffin noted that this was an area where social workers could aid providers.

“I’m going to go ahead and advocate for social workers,” she said. “Social workers have kind of fallen off in the past few years [and] really are a very important part of your organization. They can help with things like this, but you have to know it to even make that referral.”

Another OASIS update will be the slight change to the transportation (A1250) question.

The proposed rule also lifts the suspension of all payer OASIS submissions. 

Additionally, CMS has invited public comment and a request for information for several things including composite of vaccinations, depression, pain management, substance use disorders, and rehabilitative therapists conducting the initial and comprehensive assessment.

“I strongly suggest that agencies not only comment on everything, but especially comment on [rehabilitative therapists conducting the initial and comprehensive assessment],” Griffin said. “It’s basically saying, if a nurse is on the referral, they have to do the initial and comprehensive assessment. But what this is saying is, if rehab is also there, rehab can do that. They had that temporarily during COVID, but they’re trying to make this a permanent thing.”

Plus, CMS is looking to integrate concepts of health equity into future value-based purchasing program expansion.

“They’re looking at measures for underserved communities, and measures based on provider differences in performance for underserved communities,” Griffin said. “They are measuring based on the worst performing group.”

Griffin considers this a move towards population management.

The proposed rule also includes proposed changes to the home health conditions of participation. Specifically, changes to 484.105.

“These are fairly big,” Griffin said. “It would require agencies to develop, implement and maintain an acceptance to service policy that is applied consistently to each prospective patient referred for home health care. CMS has recognized that agencies are having a hard time because of staffing, trying to maintain that 48 hour period.”

Ultimately, Brian Harris, vice president of financial consulting at SimiTree, pointed out that the proposed rule lines up with recent payment proposals for the industry.

“There is nothing earth shattering, I would say about the general structure of what we’re looking at,” he said during the webinar. “That’s not to say everything’s good. It’s not to say everything’s bad — but it’s following a lot of the same format and building off of a lot of the past rules.”

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CMS said that there will be almost 400 participating organizations building Dementia Care Programs (DCPs) to serve Medicare beneficiaries at first.

“DCPs represent a wide range of health care providers, including large academic medical centers, small group practices, community-based organizations, health systems, hospice agencies, telehealth organizations and other practices,” the agency wrote.

Those include Lifespark, InHome Connect, VNA Health System, Memory Care Home Solutions, CaringAtHome, Honest Home Health Services, Andwell Health Partners, Preferred Choice Home Healthcare and Providence Home Care and Hospice, among many others.

The GUIDE Model, initially announced in July of last year, is aimed at improving the quality of life for people living with dementia. One of its primary goals is keeping dementia patients out of brick-and-mortar facilities and in their homes and communities.

Currently, it falls under the jurisdiction of the CMS Innovation Center. It is a “key deliverable” of President Joe Biden’s April 2023 executive order on “Increasing Access to High-Quality Care and Supporting Caregivers,” according to CMS.

There are many ways for home-based care providers to get involved with the GUIDE Model, whether they are direct participants or not.

The model represents yet another way for providers to engage with alternative payment sources. That’s particularly true for non-medical home care providers, who often deal with dementia patients, but don’t always work with Medicare as a payer.

“If the participant can’t meet the GUIDE care delivery requirements alone, they have the ability to contract with other Medicare providers/suppliers to meet the care delivery requirements,” CMS wrote in an explainer last year.

On a Home Health Care News webinar last month, Senior Helpers COO Mari Baxter said the GUIDE Model was something all home care providers should be trying to get involved in.

“We’re looking at that as a real opportunity for us, and I think everybody is,” Baxter said. “You’d have to have your head in your sand not to.”

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“Much of what we see in the rule is just, on the payment side of it in particular, an update from ‘23 and ‘24,” he said during a recent webinar hosted by NAHC.

On June 26, the U.S. Centers for Medicare & Medicaid Services (CMS) unveiled its home health proposed payment rule for 2025.

The proposal includes a payment decrease in the aggregate by 1.7%, or by about $280 million.

“That needs qualification,” Dombi said. “That’s $280 million, not to what it would otherwise have been, but rather, in contrast to what it’s expected to be for 2024.”

Providers examining the proposed rule will also see a 2.5% net inflation rate update.

“The 2.5% is a creature of the annual inflation update of 3%, minus the productivity adjustment of 0.5, netting out at 2.5%,” Dombi said. “This is in the same range that we saw for proposed rules affecting inpatient hospital services, skilled nursing facility care and hospice services that were issued by and large in April of this year, and are moving towards final visitation sometime probably in the neighborhood of the end of July. This number of 2.5% will be updated in the final rule, using more recent data than they use for this calculation.”

Dombi pointed out that CMS has refused to increase the inflation updates, for all sectors, based on what wasn’t accounted for each year.

The proposed payment rule also comes with a $100 million reduction in the spending tied to a change in the outlier formula. The change will decrease the frequency of episodes qualifying for outlier payment, Dombi noted.

“The outlier fixed dollar loss ratio is the element of the outlier formula that’s going to be leading to a decrease in the number of outlier episodes,” he said. “When the FDL goes up, it means you have fewer and fewer episodes that will qualify because you’ve got to be above the normal PDGM episodic rate, in terms of cost, at a higher level, before you trigger outlier payments.”

Additionally, CMS proposed a permanent prospective adjustment to the 2025 home health payment rate of -4.067%.

The budget neutrality adjustment is a combination of what was left over when CMS took the almost 5.8% projected, permanent adjustment and cut it in half to 2.89%.

“Kicking the can down the road doesn’t kick the can into a trash can, it just postpones the application of that, so now we see CMS taking that 2.89% leftover from last year and adding to an additional 1.125%,” Dombi said. “They don’t add up together to 4.067 because of the compounding effects of these kinds of things.”

During the webinar, Dombi reiterated NAHC’s view that CMS current methodology is not compliant with Medicare law.

“CMS is on the opposite side of it — their feet are in concrete on this methodology,” he said. “They didn’t even try to defend it this time around. They had been doing so for the last several years.”

Dombi also pointed out that CMS is still tweaking PDGM, including an annual recalibration of the 432 case mix weights, and a resetting of LUPA thresholds. He also urged providers to pay close attention to the wage index.

“I’ve done 38 years of payment rate updates on the Medicare program,” Dombi said. “I’ve probably said it all 38 times — always check out the wage index. This year, there are more changes than there normally are. They have not only applied the 5% cap on any decreases in wage indices. There has been a significant change in the geographic areas that are designated for your particular counties where you provide service.”

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