WASHINGTON, D.C. (February 14, 2020)—NAHC President William A. Dombi told the Senate Special Committee on Aging on Wednesday, Feb. 12th, that while the “Medicare home health benefit is well managed,” it needs to be modernized to improve access to quality care in the home for all Americans, especially those living in rural areas.
Committee chair Senator Susan Collins (R-Maine) opened the hearing by decrying the Patient Driven Groupings Model (PDGM), which imposes a 4.36% rate cut on home health agencies.
“I have never understood why administration after administration targets home health care for reimbursement cuts,” Collins said. “If there are bad apples in the industry, go after those agencies. Don’t penalize everyone. That makes no sense whatsoever when home health care reflects the choice that the patient wants and is the most appropriate care and saves money.”
Collins continued by saying that while “we recognize the value that home health can provide, many home health agencies are struggling in the current reimbursement and regulatory environment, precisely at the moment when we need their services more than ever.”
Home Health Planning Improvement Act
Introduced by Collins as a “long-standing champion in the field care,” Dombi pointed to the lack of physicians working in rural areas and the increasing reliance on non-physician practitioners (NPPs)—such as Licensed Practical Nurses, Nurse Practitioners, physician’s assistants—as a clear indicator of the need to pass the Home Health Care Planning Improvement Act. Medicare has increasingly recognized the value and competence of NPPs in fields outside of home health services (Medicare law was amended in 1997 to permit NPPs to certify eligibility for skilled nursing facilities and the VA recently expanded use of NPPs in all its facilities) and the modernization of the Medicare home health benefit is long overdue.
Allowing NPPs to certify patient eligibility for Medicare home health, certify the face-to-face encounter, and establish and manage a patient’s Plan of Care will improve program integrity and quality of care, as well as saving money because NPP reimbursement rates are lower and because it would reduce the cost of burdensome and duplicative paperwork created by unnecessarily handing a patient off to a physician who may know very little about the patient.
“This legislation is supported by numerous patient advocacy groups, health care professionals and physician groups,” Dombi told the senators. “There is an obvious reason why there has been such widespread support — our nation depends on non-physician practitioners every day to provide primary care to people of all ages as the availability of physician practitioners diminishes.”
In rural areas, as Dombi, noted, there is a particular need for the Home Health Planning Improvement Act to pass. “In rural areas, the problem is compounded by the fact that demand has grown with the closure of hospitals in rural areas (and) the absence of physicians, so homecare providers have become primary care practitioners.”
Home Health Rural Add-On
The current plan to sunset the Medicare home health rural add-on by 2022 would cause further disruption to care in rural areas, said Dombi. The most recent cost report data demonstrates the average financial margin for home health agencies in rural areas is -6.2% and overall, nearly 40% of rural agencies Medicare margins of less than zero. Less than 20% of non-rural agencies had a negative Medicare margin in 2018.
The 3% payment modifier to reimbursements for services provided in rural areas has been crucial to maintaining access to care. Rural agencies face higher overhead expenses due to increased travel time between patient visits, demands for extra staff, and the need to support the mandated infrastructure of a home health agency in low patient volume locales. This payment modifier is imperative so that rural agencies will be able to keep their doors open and provide necessary care to homebound patients.
With the increasing closure of rural hospitals and the continuing medically underserved populations in rural areas resulting from physician shortages, home health agencies have become a primary care lifeline for many patients.
There are higher costs for homecare in rural areas primarily due to travel time and the cost of meeting Medicare standards for operation that disadvantage small, rural providers. Further, home health care is often the substitute for primary care in rural areas with the shortage of physicians. That translates to longer patient visits and lower staff productivity than possible in a short travel time non-rural location. A loss of access to care in rural areas negatively impacts patients and Medicare as care and its costs shift to institutional care.
“Reinstate the 3% rural add-on for three years and require an expanded study on its application and any needed reforms to ensure its ongoing success,” urged Dombi. “While targeting may be an option to consider, the current targeting approach is not reliable.”
New Medicare Home Health Payment Model
Under current law, CMS is authorized to make assumptions about prospective provider behavior in rate setting. The behavior change assumptions and the assumed level of impact can be modified annually, with a resultant impact on payment rates. A payment model where new assumptions and corresponding rate adjustments can be made annually creates an unstable financial environment for providers, thereby posing an ongoing threat to continued operations and access to care for vulnerable Medicare beneficiaries.
NAHC strongly supports the Home Health Payment Innovation Act (S. 433 & H.R. 2573), which was introduced with bipartisan support in both the House and Senate. This important legislation would require rate adjustments based only on real, actual changes in provider behavior in response to the new payment model.
The Centers for Medicare & Medicaid Services does not recognize tele-homecare as a distinctly covered benefit under Medicaid, nor does it allow HHAs to be reimbursed for tele-homecare technology costs by Medicare. The absence of payment for non-physician telehealth interactions and restrictive federal Medicaid and Medicare tele-homecare guidelines are barriers to more widespread adoption of telehealth.
Senator Josh Hawley (R-Missouri) bemoaned the lack of investment in telehealth and asked Dombi if such investments are necessary. Dombi agreed they are, but noted the lack of reimbursement for telehealth is preventing many agencies from investing in that technology, to the detriment of patients, particularly those in rural areas.
“Beyond Medicare benefit limitations, many rural areas across the United States—the very areas that could most benefit from use of tele-homecare technologies—do not have Internet access sufficient to enable its use. The Administration, Congress, states, and carriers must take action to address this serious deficiency,” said Dombi in testimony to the committee.
Dombi urged Congress to establish tele-homecare services as distinct benefits within the scope of federal Medicare and Medicaid coverage to include all present forms of telehealth services, clarify that telehomecare qualifies as a covered service and permit visit equivalency under the Medicare home health and hospice benefits, and ensure rural access to sufficient quality bandwidth to take advantage of tele-medicine.
Senator Bob Casey (D-Pennsylvania), the committee’s ranking member, called for greater investment in home health care and more training of workers to address the workforce shortage.
Senator Kyrsten Sinema (D-Arizona) mentioned her state’s program that partners Arizona Medicaid with three health care insurers to help solve the state’s looming caregiver crisis, which is even more acute that the problem facing the country as a whole, and asked Dombi if such a program could work on a national level. While expressing appreciation for the program, Dombi replied that a “broad array of elements” would be necessary to address the workforce crisis.
Citing the need for adequate reimbursement rates, Dombi also stressed the need to create a career path for long-term care workers in order to keep them from dropping out of the industry. In addition, Dombi also noted that some alteration of wage and hour laws could help alleviate the problem, and stressed that an industry that relies on immigrants to fill at least 25% of its direct care workforce, would be greatly assisted by an immigration policy that takes such issues into account.
“There’s no one silver bullet solution” to workforce problem, stressed Dombi.
“With the aging of America, the shortages will only grow and grow exponentially unless a national home care workforce strategic plan is developed and implemented,” he said. The country needs a plan to address this crisis and it needs one now, said Dombi.