Posted Wednesday, September 20, 2023
McKnight’s Home Care
By: Liza Berger
Responding to testimony from experts Tuesday, senators from both sides of the aisle expressed concerns about shrinking access to home health services across the United States, staffing shortages and problems more Medicare cuts could pose.
“Mr. Chairman, I will tell you, I think CMS [Centers for Medicare & Medicaid Services] should have been at this table today to talk about this payment policy and about this proposed rule,” Sen. Marsha Blackburn (R-TN) said at the hearing held by the Senate Finance Committee’s Subcommittee on Health Care.
The hearing, which focused on the importance of the home health benefit, covered a wide range of topics. These included the controversial proposed home health rule that threatens to cut home health payments, rural access problems, hospital-at-home, accountable care and durable medical equipment. Testifying were two representatives from the home health field, two researchers and a longtime Medicare advocacy attorney.
Blackburn noted that 74,000 people in Tennessee receive the Medicare home health benefit and 87% of those people have three or more chronic conditions.
“We are hearing from our providers in Tennessee a tremendous amount of concern about the payment policy that CMS put in place in 2020 and how it is creating some instability and uncertainty in the process for these individuals,” Blackburn said. “And I have visited with many who have looked at how next year’s payment rates proposed in June would make matters worse for these patients.”
Sen. Debbie Stabenow (D-MI), a longtime home health proponent who introduced legislation to stop CMS from enacting payments cuts in the home health proposed rule, echoed Blackburn’s frustration.
“For the life of me I can never understand how as we move forward on healthcare policy. One of the proposals is always somehow to cut home healthcare, even though people want more help at home healthcare, even though during the pandemic and now afterwards, we’re seeing increased needs as a result of this,” said Stabenow, who is retiring from the Senate in 2025.
Rural access challenges
One of the major issues raised at the hearing was the difficulty patients in rural areas have accessing home healthcare. One of those testifying, Tracy M. Mroz, PhD, an occupational therapist and assistant professor with the Department of Rehabilitation Medicine at the University of Washington, pointed out that the number of agencies in rural areas does not guarantee access to care.
“Rural agencies may refuse referrals for new admissions when they don’t have adequate capacity for beneficiaries who are admitted to home health visits,” she said, adding that visits may be delayed or reduced due to windshield time, or travel time. “So it’s perhaps unsurprising that there’s a growing body of evidence on disparities and access to home health.”
When asked by Sen. Steven Daines (R-MT) about the value of the rural add-on payment, Mroz said the rural add-on payment is valuable, but the 1% provided in 2023 is not enough to help agencies serve more rural patients.
“The rural add-on payment has great potential to both increase access to care, as well as provide the services that they need to provide reducing hospitalizations,” she said. “So the decrease and then sunsetting of the rural add-on payment is of great concern.”
Impact of proposed home health rule
Central to the dialogue was the impact of more Medicare cuts stemming from a pending home health final rule. William Dombi, president of the National Association for Home Care & Hospice, presented a case against reductions.
“I’m really tired of talking about payment policy and payment rates but it’s still essential to do so,” he told the subcommittee.
Dombi outlined how the home health proposal would cut payment rates by a permanent 5.653% in 2024. A $3.5 billion temporary adjustment is looming, he said.
“Combine that with the fact that there was a forecasting error in the inflation rate that led to rate changes for home health agencies, a shortage of 5.2% for the years ‘21 and ‘22 when, particularly, labor costs rose significantly,” he said. “That’s now baked in permanently into the payment race. So that 5% shortfall will continue ad infinitum.”
Carrie Edwards, RN, director of home care services for Mary Lanning Healthcare, which is located in the rural area of Hastings, NE, offered her agency’s experience of having to reduce its service area due to funding problems. She told the subcommittee her agency would have to close if the proposed cuts make it to a final rule.
“If this payment policy goes through with additional reductions I have no doubt that our agency would probably have to close,” she said. “We’ve already reduced to the bare minimum that we possibly can right now and much further would indicate a closure.”
Another view
David Grabowski, PhD, professor at Harvard Medical School, insisted that more research is needed to understand the impact of the Patient-Driven Groupings Model on home health agencies, given that the payment system began in 2020, the same year as the pandemic.
“I would argue that it’s not yet possible to determine whether and how the model has impacted home health access because we cannot disentangle what changes are due to PDGM and what changes are due to the pandemic,” he told the subcommittee. “I would caution the Congress about making major changes to the PDGM at this time. Let’s wait for more data.”
Still, Grabowski, who is a former member of the Medicare Patient Advisory Commission, which advises Congress on Medicare policy, noted that, according to a 2023 report, Medicare margins reached an all-time high of 24.9%. Margins for those agencies serving rural areas had an even higher Medicare margin of 25.2%.
Judith Stein, JD, executive director and attorney for the Center for Medicare Advocacy in Willimantic, CT, underscored that healthcare providers misinterpret the home health benefit as it is spelled out in law.
“Unfortunately, Medicare beneficiaries are often misinformed about Medicare home health coverage in general and home health aides in particular,” she said. “They are told that it’s for a short-term for a few weeks, for a bath from the home health aide, just for one to three times a week. Under the law, Medicare authorizes 28 to 35 hours a week of home health aides’ personal hands-on care. Instead, this care is being shifted to state Medicaid programs and families.”
Joanne Cunninghan, CEO of the Partnership for Quality Home Healthcare, applauded the hearing and reiterated outrage for possible pending cuts.
“Unfortunately, the severe cuts proposed by the Centers for Medicare & Medicaid Services are the exact wrong policy at the exact wrong time,” she said in a statement following the hearing.
Source: McKnight’s Home Care
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