[Senate Hearing 118-698]
[From the U.S. Government Publishing Office]






                                 ______


                                                        S. Hrg. 118-698
 
                   AGING IN PLACE: THE VITAL ROLE OF 
                     HOME HEALTH IN ACCESS TO CARE

=======================================================================

                                HEARING

                               before the

                      SUBCOMMITTEE ON HEALTH CARE

                                 of the

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 19, 2023

                               __________
                               
                               
       [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
                        

                                     
                                     

            Printed for the use of the Committee on Finance
            
            
                  U.S. GOVERNMENT PUBLISHING OFFICE                    
61-308 PDF                   WASHINGTON : 2025                     
            
            


                          COMMITTEE ON FINANCE

                      RON WYDEN, Oregon, Chairman

DEBBIE STABENOW, Michigan            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey          JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware           JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland         TIM SCOTT, South Carolina
SHERROD BROWN, Ohio                  BILL CASSIDY, Louisiana
MICHAEL F. BENNET, Colorado          JAMES LANKFORD, Oklahoma
ROBERT P. CASEY, Jr., Pennsylvania   STEVE DAINES, Montana
MARK R. WARNER, Virginia             TODD YOUNG, Indiana
SHELDON WHITEHOUSE, Rhode Island     JOHN BARRASSO, Wyoming
MAGGIE HASSAN, New Hampshire         RON JOHNSON, Wisconsin
CATHERINE CORTEZ MASTO, Nevada       THOM TILLIS, North Carolina
ELIZABETH WARREN, Massachusetts      MARSHA BLACKBURN, Tennessee

                    Joshua Sheinkman, Staff Director

                Gregg Richard, Republican Staff Director

                                 ______

                      Subcommittee on Health Care

                 BENJAMIN L. CARDIN, Maryland, Chairman

RON WYDEN, Oregon                    STEVE DAINES, Montana
DEBBIE STABENOW, Michigan            CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey          JOHN THUNE, South Dakota
THOMAS R. CARPER, Delaware           TIM SCOTT, South Carolina
ROBERT P. CASEY, Jr., Pennsylvania   BILL CASSIDY, Louisiana
MARK R. WARNER, Virginia             JAMES LANKFORD, Oklahoma
SHELDON WHITEHOUSE, Rhode Island     TODD YOUNG, Indiana
MAGGIE HASSAN, New Hampshire         JOHN BARRASSO, Wyoming
CATHERINE CORTEZ MASTO, Nevada       RON JOHNSON, Wisconsin
ELIZABETH WARREN, Massachusetts      MARSHA BLACKBURN, Tennessee

                                  (II)
                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Cardin, Hon. Benjamin L., a U.S. Senator from Maryland, chairman, 
  Subcommittee on Health Care, Committee on Finance..............     1
Daines, Hon. Steve, a U.S. Senator from Montana..................     3
Wyden, Hon. Ron, a U.S. Senator from Oregon......................     4
Cantwell, Hon. Maria, a U.S. Senator from Washington.............     6

                               WITNESSES

Edwards, Carrie, R.N., BSN, MHA, LSSGB, director, home care 
  services, Mary Lanning Healthcare, Hastings, NE................     7
Stein, Judith A., J.D., executive director/attorney, Center for 
  Medicare Advocacy, Willimantic, CT.............................     9
Mroz, Tracy M., Ph.D., OTR/L, FAOTA, associate professor, 
  Department of Rehabilitation Medicine, University of 
  Washington, Seattle, WA........................................    11
Dombi, William A., J.D., president, National Association for Home 
  Care and Hospice, Washington, DC...............................    13
Grabowski, David C., Ph.D., professor, Department of Health Care 
  Policy, Harvard Medical School, Boston, MA.....................    15

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Cantwell, Hon. Maria:
    Opening statement............................................     6
Cardin, Hon. Benjamin L.:
    Opening statement............................................     1
Daines, Hon. Steve:
    Opening statement............................................     3
    Prepared statement...........................................    35
Dombi, William A., J.D.:
    Testimony....................................................    13
    Prepared statement...........................................    36
    Responses to questions from subcommittee members.............    45
Edwards, Carrie, R.N., BSN, MHA, LSSGB:
    Testimony....................................................     7
    Prepared statement...........................................    47
Grabowski, David C., Ph.D.:
    Testimony....................................................    15
    Prepared statement...........................................    54
    Responses to questions from subcommittee members.............    59
Mroz, Tracy M., Ph.D., OTR/L, FAOTA:
    Testimony....................................................    11
    Prepared statement...........................................    62
    Responses to questions from subcommittee members.............    69
Stein, Judith A., J.D.:
    Testimony....................................................     9
    Prepared statement...........................................    78
    Responses to questions from subcommittee members.............    87
Wyden, Hon. Ron:
    Opening statement............................................     4

                             Communications

Hillcrest Home Care..............................................    91
International Caregivers Association.............................    92
Justice in Aging.................................................    94
National Academy of Elder Law Attorneys..........................    97
Private Care Association, Inc....................................    99
Texas Association for Home Care and Hospice......................   101


                   AGING IN PLACE: THE VITAL ROLE OF 
                     HOME HEALTH IN ACCESS TO CARE

                              ----------                              


                      TUESDAY, SEPTEMBER 19, 2023

                               U.S. Senate,
                       Subcommittee on Health Care,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:05 
a.m., in Room SD-215, Dirksen Senate Office Building, Hon. 
Benjamin L. Cardin (chairman of the subcommittee) presiding.
    Present: Senators Stabenow, Cantwell, Carper, Casey, 
Whitehouse, Hassan, Lankford, Daines, Young, Barrasso, and 
Blackburn.
    Also present: Democratic staff: Martha P. Cramer, Staff 
Director for the Subcommittee on Health Care of the Senate 
Committee on Finance and Health Policy Advisor for Senator 
Cardin; Michelle Galdamez, Legislative Aide for Senator Cardin; 
and Matt Kearney, Legislative Correspondent for Senator Cardin. 
Republican staff: Grace Bruno, Health Policy Advisor for 
Senator Daines; and Micah Robertson, Staff Assistant for 
Senator Daines.

 OPENING STATEMENT OF HON. BENJAMIN L. CARDIN, A U.S. SENATOR 
FROM MARYLAND, CHAIRMAN, SUBCOMMITTEE ON HEALTH CARE, COMMITTEE 
                           ON FINANCE

    Senator Cardin. The Subcommittee on Health Care of the 
Senate Finance Committee will come to order. Our hearing today 
is ``Aging in Place: The Vital Role of Home Health in Access to 
Care.'' First, I want to start by thanking Senator Daines for 
his help and cooperation in putting together this hearing. I 
think there is a great deal of interest among both Democrats 
and Republicans on the subject, and I thank him for his help.
    I want to thank Senator Wyden and Senator Crapo for 
allowing the subcommittee to hold this hearing, and for the 
help in arranging for the witnesses and for the preparations 
for the hearings. So, thank you, Senator, our chairman. We 
appreciate that very much.
    Now, CDC defines aging in place as the ability to live in 
one's own home and community safely, independently, and 
comfortably regardless of age, income, or ability level. I must 
tell you, when I meet with seniors, who are my contemporaries, 
their number one fear many times is the fact that they are not 
going to be able to stay in their community; they are going to 
be put into an institution or nursing home. And they point out 
that if they do that, the government picks up a large part of 
the cost.
    So what they want to do, they want to stay in their homes; 
they want to stay in their communities. But they believe they 
are going to be forced into an institution because of a lack of 
other options. We have excellent continuing care facilities, 
but they are beyond the financial reach of most of our seniors. 
Now, there have been some excellent examples of communities 
coming together for aging in place. And I want to give a shout-
out to my own community in Baltimore, which over a decade ago 
established a government-
private partnership for aging in place, sponsored by The 
Associated, that has became a national model.
    We have those individual examples where we have been able 
to combine private resources with government resources to help 
our seniors age in place. They recognize that if they can stay 
in place--that is their preference--it is less costly, and it 
gives them more dignity and a better quality of life.
    But the number one challenge, in my view, is the failure of 
our Nation to have a coordinated long-term care strategy. We do 
not. Our committee has jurisdiction over the health-care 
components of Medicare and Medicaid, but it goes well beyond 
the jurisdiction of our committee. And because of the lack of a 
coordinated policy, seniors often end up in a more costly 
environment, in a less desirable environment, and I would 
suggest a more dangerous environment, for their long-term 
health. And that is what the purpose of this hearing is: to go 
over the Federal role under the jurisdiction of our committee, 
the Medicare and Medicaid programs.
    We have, under Medicare and Medicaid, home health-care 
services that are provided. They are recommended by health-care 
professionals and carried out by health-care professionals. 
They may be issues such as wound care or physical occupation or 
speech therapy or injection and nutrition therapies. In 2021, 3 
million Medicare beneficiaries participated in home health 
services. About a quarter of those got their services after a 
hospital or institutional post-acute care setting. So, what are 
the challenges within the confines of home health services?
    Well, first is workforce. Can we get the people to provide 
those services? And that has been complicated greatly because 
of COVID-19. COVID-19 just underscored the challenges we had in 
our health-care workforce. They are front-line workers, and we 
need them. And it was a challenge during COVID, and we are 
still suffering from a tight labor market and not having the 
trained people to be able to carry out those services.
    But I would also suggest that the reimbursement structure 
has added to the challenges for people being able to get the 
home health care that they need. It is a complicated formula, 
so I am not even going to try to outline it here today. Maybe 
some of our witnesses will talk about it. But it is a 
challenge. But I do know this, that it, in many cases, did not 
offer the appropriate incentives for access to care, for home 
health care under Medicare.
    And then we have, equally important, the nonmedical 
benefits under Medicaid, the assistance with activities of 
daily life, ADL, such as bathing, dressing, the transportation, 
meal preparations, and the list goes on and on. They are 
generally provided by home care aides. In 2021, 1.9 million 
Americans participated in the program, and they have a similar 
problem that we have with the home health medical services, 
which is a shortage of providers. It is very difficult to get 
trained people in this field, and we also have a reimbursement 
issue as to whether we are going to get access to care.
    So, we have challenges in both the health component and in 
the assistance with activities of daily living. I hope that we 
will have an opportunity to talk about that with the witnesses 
we have today.
    There are long wait lists, long wait lists to get home 
health services. In my State, for the nonmedical benefits, we 
have 30,000 on the wait list. That is unacceptable. We can do 
better than that.
    So, I recognize the challenges we have with long-term care 
strategy coordination. But we can do better in the Medicare and 
Medicaid programs in providing home health services. We are not 
optimizing the opportunities.
    I hope this panel of witnesses will help us in 
understanding that and what we can do, and recommending changes 
to the system that will provide greater access for services 
that our constituents desperately need and want. I want to 
thank all of our witnesses for being here today. I will 
introduce you shortly, with the assistance of at least one of 
my colleagues.
    But now, let me yield to Senator Daines.

            OPENING STATEMENT OF HON. STEVE DAINES, 
                  A U.S. SENATOR FROM MONTANA

    Senator Daines. Chairman Cardin, thank you, and a big 
``thank you'' to our witnesses for being here this morning for 
a conversation on home health.
    The home health benefit is a critical component of the 
Medicare program, and it is of increasing importance as our 
Nation's senior population continues to grow. In fact, in my 
home State of Montana, 20 percent of our population is age 65 
and older. In fact, Montana is currently ranked sixth in the 
Nation for States with the highest percentage of residents aged 
65 and older. And we know from countless surveys and research 
that Americans overwhelmingly, overwhelmingly prefer to age in 
place, which allows them to remain in the comfort of their own 
homes, preserve their quality of life and dignity, and retain 
their independence to the greatest extent possible as they grow 
older.
    Home health care plays an essential role in allowing our 
Nation's seniors to do just that: to receive certain essential 
health-care services in their homes, where they are the most 
comfortable. However, facilitating this kind of care comes with 
a number of unique challenges, challenges not found in a 
traditional institutional health-care setting--for example, 
accounting for the time and the resources staff need to travel 
in order to see patients in their homes. And in more rural 
States like Montana, that is a really big deal.
    As is so often the case, the difficulties of providing care 
to patients at home are exacerbated when you get to more rural-
type environments. Earlier this year, the committee hosted a 
thoughtful discussion on the opportunities and obstacles that 
exist when it comes to facilitating health care in rural 
communities across the country. Many of the concerns raised in 
that hearing, including access, transportation, and of course 
the big issue of workforce, are applicable to administering 
home health care in rural States as well.
    I am glad we are joined today by panelists who can speak to 
these particular challenges, as well as the nuances. Another 
value and intention of the home health benefit is the aim to be 
cost-
effective. By offering services such as skilled nursing, 
physical therapy, and occupational therapy in the home, the 
benefit can help provide savings to the Medicare program by 
avoiding unnecessary and costly institutional care.
    As we are all aware, the Medicare Hospital Insurance trust 
fund is fragile, and the rampant inflation over the past 
several years has had devastating effects throughout our 
economy. The health-care sector in particular has felt these 
pressures deeply. Going forward, we need to consider how the 
benefit can continue to be administered effectively, while also 
ensuring patients are able to receive the care that they need.
    The concept and the benefit of home health have evolved 
significantly since its inception in 1965. That was a long time 
ago, Mr. Chairman. As Congress deliberates the future of home 
health, we need to be thoughtful as to what the benefits should 
look like, how they can best continue to serve America's 
seniors. And our ultimate goal is to make certain that patients 
are able to receive the right care, at the right time, in the 
right setting, with appropriate payment. Not an easy task, but 
I am glad we have the opportunity to dive into these topics 
today.
    Thanks again to our witnesses for making the trip here, for 
being with us to lend their expertise and their experience to 
this conversation. I will look forward to the discussion, Mr. 
Chairman, and I will turn it back to you.
    [The prepared statement of Senator Daines appears in the 
appendix.]
    Senator Cardin. Thank you very much, Senator Daines.
    With that, I will recognize the chairman of our committee, 
Senator Wyden, who has been a real champion on home health and 
on moving forward in our health-care system, and has been 
responsible for a lot of action in our committee to improve 
access to health care and affordability of health care.
    Senator Wyden?

             OPENING STATEMENT OF HON. RON WYDEN, 
                   A U.S. SENATOR FROM OREGON

    Senator Wyden. Thank you very much, Chairman Cardin and 
Senator Daines. We've got a terrific bipartisan duo here, and I 
am going to talk just very briefly and close by mentioning the 
committee's bipartisan tradition in tackling home health care, 
and just make a couple of points very quickly.
    The first is, it is very rare in the public policy field 
when you have an opportunity to make sure that families and 
communities get more of what they want, which is care at home, 
than the alternative, which is institutional care. Since my 
days as codirector of the Oregon Gray Panthers, I have always 
thought that this was a pretty straightforward proposition.
    When people ask about the cost of designing home health-
care services, I always say you cannot afford not to. You 
cannot afford to pass up this kind of option: giving people 
more of what they want at less cost to taxpayers. So that is 
number one.
    Number two, now is exactly the time for us to look at this 
issue beyond the next few weeks and towards the long term. We 
all know that Medicare has some long-term challenges. We have 
seen in the papers recently that the rate of growth has 
subsided a little bit. I would like to think that the 
Affordable Care Act has had something to do with that. We also 
know that the challenges are real.
    So, I am only going to wrap up with this, Chairman Cardin. 
If you look down towards the last few seats in the dais on the 
Republican side, you will get a little sense of the history, 
because Senator Olympia Snowe, Republican of Maine, was a great 
champion of home care. Where Catherine Cortez Masto is sitting, 
there was a Senator from the other end of the country who had a 
full head of hair and rugged good looks--and that was me--and 
we were always talking about home health care. So I would just 
make an appeal to Chairman Cardin and Senator Daines: let us 
pick up on the bipartisan tradition in the Senate Finance 
Committee of pursuing long-term solutions to big health issues.
    Let us do for this, colleagues, what we did for chronic 
disease, where we moved Medicare from being an institutional 
program to also focusing on cancer and diabetes and heart 
attacks and stroke and all the chronic conditions. We have 
excellent leadership in Chairman Cardin and Senator Daines, and 
I very much look forward to working with them.
    And by the way, before we wrap up, let's take note of the 
fact that Senator Stabenow, who unfortunately I cannot talk out 
of retirement, has also been a terrific advocate on these 
issues.
    So, I look forward to working with my colleagues.
    Senator Cardin. Thank you, Senator Wyden. I am glad you 
acknowledged Senator Stabenow--who was the previous chair of 
the subcommittee--and the work that she did. We are carrying on 
in that legacy, so let me thank our colleagues for the work 
that they have done.
    I want to now introduce our five witnesses. I will 
introduce all five in order, with the help of Senator Cantwell 
with one, and after the introductions, you will be able to give 
your opening statements. We would ask that you limit them to 
around 5 minutes so we have time for exchanges; and without 
objection, your full statements will be made part of the 
record.
    We will start with Carrie Edwards, who received her BSN in 
2002 from Creighton University, and obtained her MHA in 2013 
from Bellevue University. Carrie has been employed by Mary 
Lanning Healthcare for 24 years, currently working as the 
director of home care since 2010, and has worked in the home 
care arena since 2004.
    Carrie started as an aide in the private duty agency in 
1999, and enjoyed spending one-on-one time with patients and 
their families. I understand that you brought your daughter 
Caitlin with you today. Hello, Caitlin. It is nice to have you 
in our committee, and if I am correct, I think your class is 
streaming this hearing, so we have a larger audience. Thank you 
for giving us a larger audience. We appreciate that very much.
    And our second witness is Ms. Judith Stein, who is the 
executive director of the Center for Medicare Advocacy, which 
she founded in 1986. She has focused on legal representation of 
older people since beginning her career in 1975. From 1977 
until 1986, she was the codirector of the legal assistance for 
Medicare patients, where she managed the first Medicare 
advocacy program in the country.
    She has extensive experience in developing and 
administrating Medicare and related advocacy projects and 
conferences, representing Medicare beneficiaries, producing 
educational material, teaching, and counseling. She is the 
author of the Medicare handbook. So, we have a lot to learn 
from Ms. Stein's presentation.
    Our third witness is Dr. Tracy Mroz, and I will yield to 
Senator Cantwell.

           OPENING STATEMENT OF HON. MARIA CANTWELL, 
                 A U.S. SENATOR FROM WASHINGTON

    Senator Cantwell. Thank you, Mr. Chairman, and thank you 
for this important hearing. I would like to introduce Dr. Tracy 
Mroz from the University of Washington. She is an associate 
professor in the Department of Rehabilitation Medicine at the 
University of Washington School of Medicine.
    This is an important institution in our country because it 
is the number one site for production of primary care 
physicians in the United States of America. And I am sure Dr. 
Mroz will tell you how important it is to have the actual 
physician productivity to see this growing population.
    She is a health service researcher and background 
occupational therapist, and she spent her academic career 
conducting research on access and quality of the home health-
care system. So, I think she will be able to give us a pretty 
broad range of how those issues are changing, particularly home 
health care in rural communities. And her impressive work has 
received funding from the National Institutes of Health and the 
Health Resources and Services Administration, the agency for 
health-care research and quality.
    And just like my colleagues, I am anxious to hear the panel 
overall, but particularly Dr. Mroz, on this issue of the fact 
that our population reaching 65 and older is expected to double 
in the next 30 years. And so, we have a big challenge here, 
particularly not just with the production of physicians and the 
home delivery, but actually homes.
    If we do not have affordable housing, we do not have a way 
to keep people in their homes, and my guess is, we will have a 
much more expensive Medicaid budget because of it, because then 
people will be in assisted living, and then it will be more 
costly. So this is a really important task for us. So I very 
much appreciate your masters of science in occupational therapy 
and doctor of philosophy in health services research from Johns 
Hopkins.
    So, we will look forward to hearing your thoughts on how we 
tackle this very important quality of health care issue, 
workforce issue, housing issue, and certainly the impact on our 
Federal budget issue. I definitely think this panel can lead us 
to more affordable solutions for both the residents we are 
talking about, but also for our government as well.
    Thank you.
    Senator Cardin. Thank you, Senator Cantwell. And, Dr. Mroz, 
welcome.
    Mr. William Dombi is the president of the National 
Association of Home Health Care and Hospice. As a key part of 
his responsibility, Bill specializes in legal, legislative, and 
regulatory advocacy on behalf of patients and providers of home 
health and hospice care.
    With over 40 years of experience in health-care law and 
policy, Bill Dombi has been involved in virtually all 
legislative and regulatory efforts affecting home care and 
hospice since 1976, including the expansion of Medicare home 
health benefits in 1980, the formation of the hospice benefits 
in 1983, the institution of Medicare PPS for home health in 
2000, and the national health-care reform legislation in 2010. 
So we can blame you for all the problems it looks like we have 
in the system. [Laughter.]
    Dr. David Grabowski is the professor of health-care policy 
at Harvard Medical School, where he studies long-term care and 
post-acute care. He has published over 235 peer-reviewed 
studies on this topic. He is a former member of the Medicare 
Payment Advisory Commission, MedPAC, and has served on several 
CMS technical expert panels, including one related to Medicare 
home health-care payments.
    As you can see, we have real experts on this subject 
matter, and I just want to underscore what Senator Wyden said. 
We look forward to your suggestions as to how this committee 
can proceed in a bipartisan manner, to provide the type of 
services that the people of our community want in home health 
care.
    And we will start with Ms. Edwards.

 STATEMENT OF CARRIE EDWARDS, R.N., BSN, MHA, LSSGB, DIRECTOR, 
   HOME CARE SERVICES, MARY LANNING HEALTHCARE, HASTINGS, NE

    Ms. Edwards. Mr. Chairman, Ranking Member Daines, and 
members of the committee, thank you for the opportunity to 
testify at this important hearing focusing on the Medicare home 
health benefits. I would like to thank Senators Stabenow and 
Collins for their unwavering support to ensure that Medicare 
beneficiaries have access to high-quality home health services, 
by introducing Senate bill 2137, the Preserving Access to Home 
Health Act. I encourage every Senator to join as cosponsors.
    My name is Carrie Edwards. I serve as the director of home 
care services at Mary Lanning Healthcare, located in Hastings, 
NE. Our home health agency is a hospital-based, nonprofit rural 
provider. At Mary Lanning Home Health, we have over 50 years of 
experience bringing health-care services into the homes of 
central Nebraska residents. We offer a variety of services to 
meet patient needs right in the comfort of their own home, 
including skilled nursing; physical, occupational, and speech 
therapy; lymphedema therapy; medical social work; and home 
health aide services.
    From my nearly 25 years of experience in the home health 
field, I can confirm that home is where the heart is. Most of 
us just feel better when we are at home. That is why I fell in 
love with helping people stay in their homes, even when facing 
significant health challenges. But our ability to deliver 
patient-preferred, high-
quality, cost-effective lifesaving home health services is in 
jeopardy, and not due to any service failures of Mary Lanning 
Home Health, but rather because of decisions being made right 
now by CMS that threaten my home health agency and thousands of 
other agencies across the country.
    Our long history of service to the residents of Nebraska is 
at risk due to the significant payment reductions that CMS 
started in 2020, with the new payment model. Mary Lanning Home 
Health previously covered a 13-county, 60-mile radius of 
Hastings, located in Adams County. In March of this year, we 
had to decrease our service area to a 40-mile radius. Several 
months later in May, we had to make the difficult decision to 
further reduce our service area to only cover Adams County, 
which covers a 25-mile radius, including the city of Hastings. 
Some of the previous counties that we once served no longer 
have coverage by any home health provider.
    So for this year, we have declined services to 50 percent 
of the referrals we used to see because those 55 referrals fell 
outside of our reduced service area. Our average daily census 
count was reduced by more than 60 percent since the 
implementation of the new payment model, from an average of 88 
patients in 2020 to a census count in September 2023 of 32.
    CMS's actions are also having a direct impact on our 
ability to retain our existing workforce. We have had three 
registered nurses resign due to fear that the payment cuts 
being proposed by CMS will force our agency to close. The three 
nurses did not leave nursing; instead, they went to work for 
other health-care providers rather than risk remaining with 
Mary Lanning Home Health.
    Hospitals are seeing higher-acuity patients than in 
previous years, and our agency is providing more intensive home 
health services to a population that has more complex needs and 
increased comorbidities. When a patient is not able to be 
admitted to a home health agency, the result is a longer stay 
in the hospital, placement in a skilled nursing facility, or 
foregoing care altogether.
    I am very proud of the quality of care we have provided at 
Mary Lanning Home Health. In 2022, our home health agency 
prevented 93.5 percent of patients we served from being 
readmitted to the hospital, averaging a low of 7.6 percent 
readmission rate that was well below the State and national 
averages. Year to date, we have prevented 93.7 percent of the 
patients we serve from being rehospitalized, and our patients 
have been extremely satisfied with our level of care, as we 
have a five-star patient satisfaction rating on Home Health 
Compare.
    As we look to prepare for 2024 with the pending payment 
reductions that CMS has proposed, and the potential for payment 
reduction spanning past 2030, we are doing everything possible 
to remain operational. There are agencies throughout Nebraska 
and the country that are at serious risk of closures.
    If I can leave the committee with one takeaway from my 
testimony, it is that CMS and policymakers should be finding 
every way possible to make increased investments in Medicare 
home health services, instead of the current path of year-
after-year payment cuts that are jeopardizing my agency's 
ability to care for Medicare beneficiaries, and for me to 
continue my calling to service, so that Nebraskans can safely 
recover at home, where most of us just feel better.
    Thank you.
    [The prepared statement of Ms. Edwards appears in the 
appendix.]
    Senator Cardin. Thank you very much for your contribution.
    Ms. Stein?

    STATEMENT OF JUDITH A. STEIN, J.D., EXECUTIVE DIRECTOR/
    ATTORNEY, CENTER FOR MEDICARE ADVOCACY, WILLIMANTIC, CT

    Ms. Stein. Good morning, Chairman Cardin, Ranking Member 
Daines, and distinguished members of the committee. Thank you 
for inviting me to testify today. I am Judith Stein. I am the 
founder and executive director of the Center for Medicare 
Advocacy.
    The Center is a national, private, nonprofit, nonpartisan 
law organization based in Connecticut and Washington, DC, with 
attorneys in Maryland, Massachusetts, and California. The 
Center works to advance access to comprehensive Medicare 
coverage, quality health care, and health equity. We provide 
education and direct legal assistance to help Medicare 
beneficiaries throughout the country. Among other things, we 
respond to 7,000 calls and emails annually and pursue thousands 
of Medicare appeals of wrongful denials of coverage and care.
    Our policy work is based on the real-life experience of the 
beneficiaries and families we hear from every day. Our health-
care system is in dire need of reform, including Medicare. I 
have many ideas about how to do so, and I am sure my fellow 
panelists and members of this committee do too. And while there 
are many improvements to the Medicare home health benefit that 
I would like to recommend, when it comes to the Medicare home 
health benefit, my main message today is simple: enforce the 
law that already exists. Currently, this is not the case.
    Instead, Medicare home health coverage is incorrectly 
understood and implemented as a short-term acute-care benefit 
by those who administer the Medicare program, home health 
providers, and those who make Medicare coverage decisions. 
Under the law, Medicare home health coverage can be an 
important resource for Medicare beneficiaries who need health 
care at home. When properly implemented, the Medicare home 
health benefit provides coverage for a constellation of skilled 
and nonskilled services, all of which add to the health, 
safety, and quality of life of beneficiaries and their 
families.
    Under the law, Medicare coverage is available for people 
with acute and chronic conditions, and for services to improve 
or maintain, or slow decline of, an individual's condition. 
Further, coverage is available even if the services are 
expected to last over a long period of time.
    With an intent to expand home health services, in 1980 
Congress removed a 100 home health visit cap in the Omnibus 
Budget Reconciliation Act of 1980--removed a cap of 100 visits. 
Congress again recognized the ongoing nature of Medicare's home 
health coverage in the Balanced Budget Act of 1997, when it 
established a Medicare Prospective Payment System that 
recognized the benefit was not just short-term, and it arranged 
for payments under Part B--for people who have both Part A and 
B--for more than 100 visits, and arranged that if people do not 
have Part B, more than 100 visits will be paid for under Part 
A.
    Federal regulations and Medicare policy reiterate that 
there is no duration of time to the Medicare home care benefit. 
The Center, unfortunately, hears regularly from people who meet 
Medicare coverage criteria but are unable to access Medicare-
covered home care or the appropriate amount of care.
    Perhaps most glaringly, access to Medicare home health 
aides is disappearing. Home health aides provide help with 
personal hands-on care. The care is often key to the well-being 
of patients who want to age in place, as well as for their 
families and caregivers. Unfortunately, Medicare beneficiaries 
are often misinformed about Medicare home health coverage in 
general, and home health aides in particular. They are told 
that it is 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 
a home health aide's personal hands-on care. Instead, this care 
is being shifted to State Medicaid programs and families. 
Currently, statistics demonstrate the dramatic change in 
coverage. Home health aide utilization declined steadily over 
the past 2 decades by almost 94 percent.
    Access to the full array of Medicare-covered home health 
services is lacking for beneficiaries in traditional Medicare, 
but it is even worse for those enrolled in Medicare Advantage. 
In 2021, the Center surveyed 200 home health agencies across 17 
States about Medicare-covered care. When we asked the home 
health agencies whether things were worse when their 
beneficiaries and patients were enrolled in Medicare Advantage, 
they said Medicare Advantage plans often fight tooth and nail 
on the number of visits they will allow. That was from a home 
health agency in Connecticut.
    ``There is a difference. Medicare Advantage plans do not 
approve as much services,'' said an agency in Louisiana. 
``Abso-freakin-lutely, Medicare Advantage plans in our area are 
rotten,'' said a provider in Kansas. Today, Medicare payment 
policies, oversight measures, audits, and quality measures 
create disincentives to provide necessary, ongoing home health 
care.
    These policies and practices must be reviewed and revised 
by Congress and by CMS. They must be geared to ensuring that 
public Medicare funds are actually used to provide the full 
array of home care for all people who qualify under the law. 
Congress must ensure that Medicare's home health payment model 
is structured to encourage home health agencies to provide all 
these services for all who qualify.
    If the law was properly understood and implemented, 
vulnerable Medicare beneficiaries would be able to obtain the 
care they need to live well and safely at home. If the law was 
properly enforced, there would be positive, transformational 
change for older people, people with disabilities, and their 
families throughout the country.
    Thank you, and I hope you will read my testimony, which I 
prepared with a long bibliography of all we have written about 
this incredibly important benefit. Thank you so much.
    [The prepared statement of Ms. Stein appears in the 
appendix.]
    Senator Cardin. I have enjoyed your testimony so much, I 
will read your full statement. So, thank you very much. I 
appreciate that.
    Ms. Stein. Thank you.
    Senator Cardin. Dr. Mroz?

  STATEMENT OF TRACY M. MROZ, Ph.D., OTR/L, FAOTA, ASSOCIATE 
PROFESSOR, DEPARTMENT OF REHABILITATION MEDICINE, UNIVERSITY OF 
                    WASHINGTON, SEATTLE, WA

    Dr. Mroz. Good morning, Mr. Chairman, Ranking Member 
Daines, and distinguished members of the committee. My name is 
Tracy Mroz, and I am an associate professor in the Department 
of Rehabilitation Medicine at the University of Washington.
    Thank you for inviting me to provide testimony about 
opportunities and challenges for home health in supporting 
aging in place. I will focus my comments today on the role of 
home health for aging in place, disparities in access to home 
health in rural communities, and key drivers of access to care.
    Medicare's home health benefit provides an opportunity to 
support aging in place for the 3 million beneficiaries who 
receive home health annually. Admission to home health 
following a hospitalization, known as post-acute home health, 
helps bridge the transition from a hospital back to home.
    Admission to home health directly from the community, known 
as community-entry home health, supports beneficiaries with 
chronic conditions who experience a change in health or 
functional status that does not require hospitalization, but 
would benefit from services to promote recovery, stabilization, 
or prevent further decline, so the beneficiary can remain 
safely at home.
    Both post-acute and community-entry home health are crucial 
for rural beneficiaries, because they tend to be older and they 
are in poorer health compared to their urban counterparts. But 
the promise of home health to support aging in place relies on 
the beneficiary's ability to access this care.
    While the vast majority of beneficiaries live in 
communities served by at least two home health agencies, the 
reality of access to home care for rural beneficiaries is far 
more nuanced. The number of agencies serving a community 
represents supply, which is a necessary but not sufficient 
measure of access to care. Rural agencies may refuse referrals 
for new admissions when they do not have adequate capacity. For 
beneficiaries who are admitted to home health, visits may be 
delayed or reduced due to the amount of what we call 
``windshield time,'' which is the travel time that is required 
when patients are dispersed widely across large geographic 
areas.
    So it is perhaps unsurprising that there is a growing body 
of evidence on disparities in access to home health based on 
rural/urban status. Rural beneficiaries are less likely to be 
discharged to home health following hospitalization, and 
beneficiaries in the most remote rural communities are at the 
highest risk for unmet need.
    Further, fewer than 60 percent of rural beneficiaries with 
a planned discharge to home health actually receive this care. 
Even when rural beneficiaries are admitted to home health, they 
face disparities in access to specific services. Rural 
beneficiaries who experience a stroke or have a knee 
replacement are less likely to receive rehab services, despite 
the essential role of rehabilitation for these patients.
    Adequacy of financial resources and health workforce are 
two key drivers of access to home health for rural 
beneficiaries. Please refer to my written testimony for 
additional factors. Rural agencies cannot serve their 
communities without adequate resources. Even though average 
Medicare margins for agencies are high, more of the agencies 
that serve rural communities are nonprofit or governmental 
versus for-profit, and hospital-based versus freestanding.
    These distinctions are important, because margins tend to 
be lower in nonprofit and governmental agencies, and hospital-
based agencies often rely on their relationship with the 
hospital to remain financially viable. In recognition of extra 
costs required to serve rural beneficiaries, Medicare has 
intermittently provided a percentage increase in payments to 
home health agencies for providing that care. Rural add-on 
payments may help maintain supply of agencies serving rural 
communities, and even reduce hospitalizations, but these 
payments have decreased over time and are being sunsetted. 
Agencies are also navigating other changes that impact Medicare 
reimbursement.
    The Patient-Driven Groupings Model implemented in January 
2020, shortly before the emergency of COVID-19, presents a 
major redesign in reimbursement that can disincentivize 
community-entry home health, longer stays, and rehab service 
provision, which in turn may hinder opportunities to support 
aging in place for the most vulnerable beneficiaries.
    Further, the national rollout of the home health value-
based purchasing model is underway, putting lower-quality 
agencies at risk for severe financial penalties. This is 
problematic when rural beneficiaries have no other options for 
care. Access to home health also depends on successful 
recruitment and retention of qualified workers. Rural agencies 
have cited multiple barriers to recruiting and retaining staff, 
including geographic isolation, unreliable transportation, and 
wages that are not competitive with rural hospitals and similar 
jobs in urban areas.
    The home health aide workforce is much lower per capita in 
rural communities, and is particularly fragile due to low 
wages, unpredictable hours, and emotionally and physically 
demanding work. Policies to support this workforce are urgently 
needed, because without a workforce, there is no care.
    In conclusion, the Medicare home health benefit is 
currently supporting beneficiaries' ability to age in place, 
but the full potential of home health has not been realized, 
particularly for rural beneficiaries. Research suggests the 
need for targeted solutions that incentivize service provision 
for beneficiaries at risk for reduced access and poor outcomes. 
As agencies continue to adapt to multiple policy changes and 
emerge from the public health emergency, it is essential to 
monitor the stability of rural agencies and its impact on rural 
beneficiaries.
    Thank you, and I look forward to the discussion.
    [The prepared statement of Dr. Mroz appears in the 
appendix.]
    Senator Cardin. Well, I thank you very much for your 
testimony.
    Mr. Dombi?

   STATEMENT OF WILLIAM A. DOMBI, J.D., PRESIDENT, NATIONAL 
     ASSOCIATION FOR HOME CARE AND HOSPICE, WASHINGTON, DC

    Mr. Dombi. Good morning, Chair Cardin, Ranking Member 
Daines, and the remainder of the host Subcommittee on Health 
Care. I want to thank you for the opportunity to present my 
views on the vital role that home health services play in our 
continuum of care, and the challenges faced today in preserving 
access to these essential services. I currently serve as 
president of the National Association for Home Care and 
Hospice, and I could probably say I was codirector with Judy 
Stein years ago in Medicare advocacy in Connecticut.
    I come to you today to present information on the state of 
the Medicare home health services benefit. I may bore you with 
some statistics, but I think they are necessary numbers to 
hear. While it continues to provide significant care support 
for millions of beneficiaries each year, the home health 
agencies providing care and beneficiaries receiving care really 
need your help.
    The Medicare home health benefit covers an increasingly 
essential service, and as Senator Wyden referenced, it is one 
of the areas that has brought the parties together, both in the 
House and the Senate, over many years. We actually have a 
poster in our office exemplifying that. Notably, it is the only 
benefit available under both Medicare Part A and Part B, and 
Congress has implemented and enacted improvements in the 
benefit design, standards, coverage, and care for many years.
    These improvements include the elimination of cost sharing 
on services to incentivize patients to select care in the home; 
extending the scope of coverage to an unlimited number of 
service visits for the same purpose; refining the definition of 
``confined to home'' to allow non-medically related absences 
from the home, such as attending religious services; and 
establishing patient rights, quality of care measures, and 
compliance standards that ensure care quality.
    The benefit is quite a wide coverage area in skilled 
nursing, therapy, medical social services, and home health aide 
services, when meeting all the eligibility standards. These 
services are available to patients without regard to whether 
their condition is acute, chronic, or at end of life.
    While the benefit design and standards of coverage present 
a valuable Medicare benefit, in practice the benefit's 
trajectory is deteriorating. Since 2011, Medicare beneficiaries 
have experienced reductions in care and losses in care access 
not experienced in other sectors.
    Statistics on your way. In 2011, 3.5 million users of home 
health services received an average of 36 visits per year. Ten 
years later, after changes in the payment model, only 3 million 
users, 500,000 fewer patients, were receiving home health 
services. A drop in average visits also accompanied that, to 
25.4 million, a half-million people less 10 years later 
receiving services.
    Since 2011, the number of home health agencies also has 
dropped by over 1,000 nationwide. Rural areas have been 
especially hit hard, as the testimony of Carrie Edwards 
suggests, but it is not just rural areas. Inner cities are 
losing home health services as well, causing great disparities 
in access to care.
    Senator Cardin, in Baltimore, it takes security escorts in 
order to bring home health care to some of the neighborhoods in 
Baltimore. They deserve the care, and the caregivers deserve 
the security in doing so, but it has reduced access to care in 
the end.
    Medicare spending data shows the same roller-coaster 
journey of the benefit. Home health spending today is virtually 
the same as it was in 1997, despite 24 years of cost inflation. 
In 1997, the Congressional Budget Office estimated that 10 
years later, $40 billion a year would be spent on home health 
services. It is still under $17 billion a year all these years 
later. It is a tell-tale sign that we cannot continue to see 
happening.
    In comparison, inpatient hospital spending rose from $80 
billion to $130 billion, while skilled nursing facility care, 
what home health is trying to avoid, rose from $11 billion to 
$27.2 billion. The future presents an outlook that calls for 
significant action from all stakeholders. The correlation of 
payment cuts and reduced access is obvious and ominous.
    There are several signs that the existing difficulties in 
care access will continue. The American Hospital Association 
reports significant increases in the length of stay due to the 
inability to place patients in home health services. Patient 
referral rejections have increased by 50 percent. Only 55 
percent of the referrals are actually being converted to 
patient admissions, and only 67 percent of discharges from 
hospitals actually result in admission to home health services.
    CMS data shows that 52.7 percent of freestanding home 
health agencies are projected to have financial margins below 
zero with the cuts proposed for 2024. It is overall financial 
margins that really measure financial stability, not the 
incomplete analysis presented by MedPAC.
    Medicare margins, to the extent they exist, are subsidizing 
other payers like Medicaid and Medicare Advantage. Care is 
going to patients, not into people's pockets. To restore and 
preserve the Medicare home health services benefit, we offer 
the following recommendations.
    Number one, Congress should pass S. 2137 and H.R. 5159, the 
Preserving Access to Home Health Act of 2023, and we strongly 
support and applaud Senators Stabenow and Collins for bringing 
this legislation to the Senate. CMS should withdraw its 
proposal for the significant cuts in Medicare payment rates 
scheduled to take effect on January 1, 2024. They have the 
authority to do that, and Congress should mandate the 
development of a comprehensive analysis of the root causes of 
the ongoing deterioration of the home health services benefit.
    Thank you for the opportunity to present this testimony. I 
look around this room, and I see Senators who, if they take a 
look at what is going on in their States, they will see 
closures. Senator Hassan, New Hampshire; Senator Whitehouse, 
Providence, RI, VNA--a 100-year-old operation--closing; Senator 
Stabenow in Michigan; Senator Lankford.
    All across the country, we are seeing closures. It is deja 
vu for me. I came to Washington in 1987 to prosecute a lawsuit 
against the Medicare program to restore it to its full 
important purpose. I expected to stay 3 years. I am still here. 
I think, as I told Senator Cardin, I have become a Baltimore 
Orioles fan--who could not be? But I intend to stay here until 
we can finish this mission with all of you, to make the home 
health benefit the true value that it is.
    So, thank you for the opportunity.
    [The prepared statement of Mr. Dombi appears in the 
appendix.]
    Senator Cardin. Well, you know how to get my attention. All 
you have to do is mention the Baltimore Orioles.
    Mr. Dombi. Thirty-seven years in Washington taught me some 
of those things.
    Senator Cardin. Right. Last night they won in the 9th 
inning again.
    Dr. Grabowski?

 STATEMENT OF DAVID C. GRABOWSKI, Ph.D., PROFESSOR, DEPARTMENT 
   OF HEALTH CARE POLICY, HARVARD MEDICAL SCHOOL, BOSTON, MA

    Dr. Grabowski. Good morning, Chairman Cardin, Ranking 
Member Daines, and distinguished members of the Subcommittee on 
Health Care. Thank you for the opportunity to testify today on 
this important topic.
    I am here today speaking in my capacity as a researcher who 
has studied home health care for over 2 decades. Care is 
shifting out of institutions and into the home. This shift to 
home-based care is consistent with the preferences of Medicare 
beneficiaries and their caregivers to age in place. From a 
policy perspective, a key objective is to provide individuals 
with the necessary services to not just age in place, but to 
age in place safely and successfully. The Medicare home health 
benefit can potentially help beneficiaries to do this. Yet 
there have been recent reports of access issues, especially in 
rural areas.
    I want to focus my testimony today on ways that Congress 
can ensure strong access to home-based services for all of our 
beneficiaries. First, let us talk about payment. I want to 
stress that Medicare fee-for-service home health-care payments 
are generally adequate to ensure access.
    The 2023 MedPAC report to Congress found Medicare margins 
have reached an all-time high of 24.9 percent. Agencies serving 
rural areas had an even higher Medicare margin of 25.2 percent. 
If the Congress is going to address rural access through 
payment, I would recommend they do so through a rural payment 
add-on or some other targeted rural policy.
    They should not try to solve the potential rural access 
problem through an adjustment to the overall payment system, 
which is currently paying home health agencies well above cost. 
Medicare adopted the Patient-Driven Groupings Model, or the 
PDGM, payment system for home health care right before the 
start of the pandemic.
    I would argue that it is not yet possible to determine 
whether and how the model has impacted home health access, 
because we cannot disentangle what changes are due to the PDGM 
and what changes are due to the pandemic. I would caution the 
Congress about making major changes to the PDGM at this time. 
Let us wait for more data.
    Also, we know that enrollees in Medicare Advantage plans 
use less home health care, often from lower-rated agencies. 
Beneficiaries in these plans face mechanisms like prior 
authorization review and utilization management that are not 
used in fee-for-
service Medicare. Because we currently have a poor 
understanding of home health access for Medicare Advantage 
enrollees, the Congress should request a comprehensive 
evaluation of this issue.
    Next, we know that labor challenges are contributing to 
home health access issues. The most direct policy to increase 
the size of the labor force is through wage increases. Once 
again, Medicare fee-for-service payments are well above costs, 
such that most agencies should be able to pay home health-care 
workers the prevailing market wage rate.
    If there are certain markets where this is not the case, 
Congress could once again consider targeted policies for home 
health agencies to use towards the higher cost of labor in 
these markets. Also, we are flying blind with respect to 
whether beneficiaries are accessing high-quality home health 
care.
    Unfortunately, we have a limited set of validated quality 
measures in this space. Home health agencies are mandated to 
collect detailed assessment data, but MedPAC and others have 
questioned the accuracy of the assessment data because they are 
agency-
reported and not subject to consistent audit or review. The 
Congress should encourage the development of improved quality 
measures, including the increased auditing and oversight of the 
existing 
agency-reported assessment data.
    Finally, I would argue that Medicare home health care is 
necessary but not sufficient for Medicare beneficiaries to age 
in place. Many individuals receiving care in the community also 
have extensive long-term care needs. They typically rely on 
family caregivers, paid help, or Medicaid for their long-term 
care.
    As such, there are disparities by race, ethnicity, and 
income as to who can age in place with Medicare home health-
care services. I would encourage the Congress to pursue 
policies to continue to support family caregivers. I would also 
strongly recommend that the Congress continue to invest in 
policies to expand Medicaid home and community-based services. 
And finally, I would push the Congress to expand models that 
strongly integrate Medicare and Medicaid services for dually 
eligible beneficiaries.
    In summary, access to Medicare home health care is 
generally strong, but there are some steps that Congress can 
take to further improve access. I look forward to working with 
the members of this subcommittee on this effort.
    Thank you.
    [The prepared statement of Dr. Grabowski appears in the 
appendix.]
    Senator Cardin. Thank you very much for your contribution. 
I thank all of you. We will start a 5-minute round of 
questions.
    A couple of things you said are very disturbing, Mr. Dombi. 
I would have intuitively thought that we would see a 
significant increase in home health care over that period of 
time, and that would be a success--keeping people in their home 
environment, less costly than institutional care--but that is 
not the case.
    Ms. Stein, you got our attention by saying ``enforce the 
law.'' You know, something about Congress when we pass laws is, 
we like to see them enforced. The fact that, particularly in 
Medicare Advantage, they look at this as an acute-care need 
rather than a long-term need, I think is pretty obvious when 
you look at the numbers that are out there on the utilization 
in managed and Medicare Advantage programs.
    So how do we overcome that, because, as I said in my 
introductory comments, we do not have a really coordinated 
long-term care strategy in this Nation. It goes well beyond 
health-care needs. We know that. How do we make the Medicare/
Medicaid reimbursement programs and benefits more functional to 
the long-term needs of individuals who really want to stay in 
their community as long as they possibly can but need to be 
able to get the services they need?
    So, enforce the law sounds great, but can you expand on 
that a little bit? And I will start with Ms. Stein, and we will 
give Mr. Dombi a chance.
    Ms. Stein. Thank you. I am happy to do so. The main thing 
about enforcing the law I meant to really emphasize is, to 
ensure that Congress knows and insists that CMS knows and 
implements this benefit in a way that does not constantly imply 
and enforce the myth that this is a short-term, acute-care 
benefit.
    There are policies and practices that incentivize the 
program to be short-term and acute-care, and CMS says it all 
the time. We have corrected myriad handbooks and pamphlets that 
come from CMS indicating that this is a short-term benefit when 
it is not. That myth really needs to be dispelled.
    Then the payment model, the quality measures, and the 
auditing and oversight of the benefit all need to be geared to 
ensure that people who qualify under the law--they are 
homebound, they have a physician or authorized practitioner's 
order, and they need a skilled service--that they can get all 
the services that they need for as long as they need them.
    Currently, the PDGM payment model actually creates 
disincentives for this to be the case. It pays more for the 
first 30 days of service. It pays more for people who come from 
a hospital or an institution. It pays less for people over the 
long term and if they came from their home and did not need a 
hospital stay.
    Audits are done for outliers, as they call them, for 
agencies that provide services for more than 30 days. There 
should be oversight of underutilization, underprovision of 
services. There should not be a disincentive to provide 
services for people who need them to maintain or slow the 
decline of their condition.
    Senator Cardin. Let me give Mr. Dombi a chance. Let me hear 
about Medicare Advantage.
    Mr. Dombi. I think Medicare Advantage offers a great 
promise for care in the home, but it is a fully unfulfilled one 
at this point. Medicare Advantage should be one of the 
strongest partners with home health because, as Medicare fee-
for-service has demonstrated, home health services bring 
dynamic value to the Medicare program, a value-based purchasing 
program.
    One of the only ones that was successful at CMMI is in home 
health, returning billions of dollars to Medicare by keeping 
people out of hospitals and readmissions to hospitals through 
home health services. I think the plans need to wake up, you 
know, read the data, and understand the value that is there. 
And then maybe they could respect home health services not only 
in terms of utilization, but in terms of payment rates. Right 
now, Medicare Advantage plans pay about 80 to 85 percent of the 
cost of care.
    Senator Cardin. Dr. Grabowski, let me give you a chance. 
One of the studies that I have looked at on the effectiveness 
of home health care, studied by the National Institute on 
Aging, found that racial minorities showed less functional 
improvement as a result of home health care than White 
patients, giving us the clear indication that, once again, the 
underserved community is underserved. Your comments about that.
    Dr. Grabowski. Health care is local, and very similar to 
nursing homes, we have 11,000 home health agencies, so they 
very much reflect the communities in which they operate. And 
so, there is that huge variation we see across areas showing up 
in the home health-care data, and we need to do better there by 
not just improving their home health care and giving more 
support there to these individuals, but also this is about 
Medicaid; this is about their long-term care and, obviously, 
broader community resources as well.
    Thanks.
    Senator Cardin. Senator Daines?
    Senator Daines. Chairman Cardin, thank you.
    I will get into the topic of access as it relates to home 
health. Earlier this year, the Medicare Payment Advisory 
Committee reported to Congress that almost all beneficiaries 
have access to home health services based on data indicating 
that 98 percent of beneficiaries live in ZIP codes served by 
two or more home health agencies. So they are kind of claiming 
success here through that at least particular analysis. 
However, simply living near a health-care facility does not 
necessarily guarantee a patient's access to services.
    Dr. Grabowski, could you speak to the challenge of access 
in home health and why living in proximity to an agency is not 
necessarily an ideal indicator of access in this context?
    Dr. Grabowski. Yes. I love the way that Dr. Mroz framed it 
earlier. It is necessary that you have a home health agency in 
your ZIP code, but it is not sufficient. And because you have 
one in the ZIP code does not mean they are regularly accepting 
new patients; it does not mean they are delivering timely 
visits.
    So, it is great that we have this strong supply of home 
health agencies around the country, but it is not always clear 
that supply alone is an indicator that individuals have strong 
access. Thanks.
    Senator Daines. So, they are scoring this as a 98, which 
usually is an ``A'' on most tests, but it suggests perhaps 
there is a problem here.
    Dr. Grabowski. And I do not want to--I cannot speak for 
MedPAC and why they do that, but I think the issue is data. We 
just do not have the kind of data on timely visits, whether 
they are accepting new patients. So, the supply is a nice proxy 
for access, but it does not tell the whole story.
    Senator Daines. Well, Dr. Grabowski mentioned you, Dr. 
Mroz. I think you probably have some thoughts on this as well.
    Dr. Mroz. Yes, thank you. So, as we mentioned, there is 
quite a gap between referrals to home health and actual 
admission to home health, and Ms. Edwards spoke to this point 
as well. I mentioned that fewer than 60 percent of 
beneficiaries with a discharge order for home health coming 
from the hospital actually wind up admitted to a home health 
agency and get that care.
    So I am 100 percent a believer that the number of home 
health agencies that serve a ZIP code is not going to give an 
accurate picture. As Ms. Edwards also said--I will call out as 
well her personal experience in this with her home health 
agency. We hear it from our research too, that many home health 
agencies do not have the capacity to accept every referral and 
every admission that comes their way.
    Senator Daines. So, if--and again, it may not be the ideal 
proxy. Any thoughts around what might be a better proxy here as 
we try to evaluate access?
    Dr. Mroz. Yes. We need to compare actual rates of use of 
home health, and we do see disparities, particularly in the 
most rural communities. And we also need to look at refusals--
referrals that are refused. We need to talk to the home health 
agencies to see how much they are being asked to provide 
services, and whether or not they do that.
    The one challenge in that though, is there are communities 
where they stop even referring to home health because they know 
their patients are not going to be accepted. So, there will 
still be a gap in measurement, but that is a start to moving 
towards a better picture.
    Senator Daines. Well, it is helpful though. That may not be 
a perfect analysis, but perhaps better is possible as we start 
to look at this, to get a more accurate picture of reality.
    Since 2001, Medicare has intermittently provided an add-on 
payment for home health agencies serving rural communities 
through various reimbursement percentage increases. The most 
recent rural add-on payment was a 1-percent increase to home 
health agencies providing services in low-population-density 
areas for the duration of 2023.
    Dr. Mroz, we are from kind of the same side of the country 
out there at UW. Could you share your perspective on the value 
of this add-on payment and how it affects the service delivery 
and accessibility of home health for rural patients in 
Medicare?
    Dr. Mroz. Thank you, Senator Daines. I would be happy to 
comment on that. We have found in our research, and research 
from other universities has actually found that 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.
    So the decrease and then sunsetting of the rural add-on 
payment is of great concern. So, 1 percent--our research shows 
that that's probably not enough to make a difference for home 
health agencies to be able to serve more rural beneficiaries, 
and to provide the services once they are being admitted to the 
service.
    So I will say, research also really supports targeting. 
Rural is not homogenous. You know this. Anyone who lives in a 
rural State knows this. Not every rural county is the same. So 
we also need to make sure that those rural add-on payments are 
targeted towards those beneficiaries that are truly not going 
to receive care otherwise.
    Senator Daines. Lastly, Ms. Edwards, I mentioned in my 
opening remarks some of the difficulties providers face when 
operating in a rural and less populous service area. Could you 
share with us some of the challenges you are experiencing at 
Mary Lanning and maybe perhaps a best practice that you put in 
place that might help address these challenges?
    Ms. Edwards. Yes, I would be happy to. Thank you, Senator 
Daines. Our biggest challenge was, we are rural, and we still 
are rural, just covering one county. When we covered those 13 
counties previously, that was 42,000 Medicare beneficiaries, 
not including the pediatric patient population that we serve.
    We are one of the only home health agencies in our region 
that takes pediatric patients, so that impacts all patients of 
all ages. Now that we've decreased, there's about 7,000 
Medicare beneficiaries just in Adams County. So that impacts a 
lot of the beneficiaries, because some of those counties are 
still not covered.
    I would say, best practice--the tenured staff we have. They 
love what they do. They are focused on high-quality care, and 
we try to accept every referral we possibly can within our area 
if we are contracted with their payer type. That is always a 
challenge as well.
    Senator Daines. Thank you.
    Senator Cardin. Senator Blackburn?
    Senator Blackburn. Thank you, Mr. Chairman, and thank you 
to our witnesses for being here today. This is an issue I have 
worked on since I was in the State Senate: how we increase 
options and choices for seniors. And home health is an 
important part of that.
    Right now, what we have found is, there are 74,000 
Tennesseans who are on the Medicare home health benefit. 
Eighty-seven percent of those Tennesseans have three or more 
chronic conditions. So these are complex medical conditions, 
and they require high-quality home health care.
    And 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. 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.
    And as we have discussed today, and as you all have 
discussed in your testimonies, seniors want and deserve the 
ability to be able to stay in their homes. But you look at this 
payment policy and then you look at this historic inflation, 
and also the workforce challenges that we have, especially in 
rural areas, and you can see that this is creating what will 
end up being a perfect storm, in the most negative sense, for 
many seniors with complex medical issues.
    Mr. Chairman, I will tell you, I think CMS should have been 
at this table today, to talk about this payment policy and 
about this proposed rule.
    So, Ms. Edwards, let me come to you first. Just for a 
moment, talk about what would happen to your agency if this 
rule were finalized and put in place?
    Ms. Edwards. Yes. Thank you for the question. If this 
payment policy goes through with additional reductions, I have 
no doubt that our agency would probably have to close. We have 
already reduced to the bare minimum that we possibly can right 
now, and much further would indicate a closure.
    Senator Blackburn. Yes. You cannot work without making some 
money.
    Mr. Dombi, when you look at small health-care agencies--we 
have 95 counties in Tennessee, and just about every one of them 
has a home health agency. They are small. Talk about the impact 
on these small independent providers that are out there trying 
to meet the needs in their community, trying to work alongside 
a rural hospital, trying to work alongside a long-term care 
facility, and trying to provide the service in-home.
    Mr. Dombi. Yes, I have the fortune and misfortune of 
traveling around the country and talking to the home-care 
providers. The word of the year for them that I heard in 
Georgia this week, in Texas last week, and other States over 
the previous weeks, is survival.
    Most home health agencies are, just as you described, small 
operations. Even the very large companies are very local, small 
companies in that respect. So, their fear and anxiety are 
growing, and when you look at what they are doing, they are 
saying ``no'' to patients. There is no harder thing for a 
health-care professional to do than to say ``no,'' and to say, 
``No, you are not going to be able to come home. You are going 
to end up in another institutional care setting instead.''
    That crushes them, and it crushes their hearts and their 
souls, and the families are absolutely affected by that as 
well. And sometimes the ``no'' is because they do not have 
capacity, but a lot of the capacity actually is due to their 
financial circumstances.
    A home health agency reported recently to me that they made 
job offers to 160 nurses, and every one of the nurses said 
``no,'' because they could get paid higher----
    Senator Blackburn. Yes, and those health-care worker 
challenges are important. I want you to talk for just a moment 
too about the lack of interoperable electronic health records 
and the impact that this has. Having helped care for someone 
who was elderly, you see some of these gaps.
    Mr. Dombi. Yes, and this is very ironic, because so many 
resources have been directed towards physicians and hospitals 
for interoperable health records. Nothing was directed towards 
home care. Yet home care actually was first out of the gate and 
ready to go to health care with interoperable health-care 
records.
    We have a nurse in an individual's home right at this very 
moment who has point-of-care planning with her, either her 
phone or her iPad, with electronic connections to physicians, 
to hospitals, to their own office. But they do not talk the 
same language--the ability to respond immediately to someone's 
needs in the home setting when something exacerbates and their 
clinical condition requires that kind of interoperability. So 
we are looking at saying, ``Will the rest of the world catch up 
with us some day, so that we can have the full value of those 
interoperable health-care records to provide the highest-
quality care to the patients as well?''
    Senator Blackburn. Thank you. My time has expired.
    Dr. Mroz, I am going to submit a question in writing to 
you. Thank you.
    Thank you, Mr. Chairman.
    Senator Cardin. Senator Stabenow?
    Senator Stabenow. Well, thank you so much, Mr. Chairman and 
Ranking Member Daines, for this very, very important hearing. I 
have been working on these issues, I think, most of my 
professional life, and certainly starting in the House of 
Representatives. I cannot thank all of you enough for your very 
important testimony.
    For the life of me, I can never understand how, as we move 
forward on health-care policy, one of the proposals is always 
somehow to cut home health care, even though people want more 
home health care; even though, during the pandemic and now 
afterwards, we are seeing increased needs as a result of this. 
But somehow home health-care payments are always a part of the 
equation, which I think is the opposite of what we should be 
doing.
    So, I also want to say that we know we have serious 
workforce shortages that need to be addressed in so many areas, 
and we need to continue to be doing that. I do have to say I 
appreciate the support that has been given for the bill that 
Senator Collins and I have, the Preserving Access to Home 
Health Care Act. I think it would provide the certainty and 
stability to home health-care providers that is needed right 
now by preventing additional cuts. I hope, Mr. Chairman, we 
will be able to move forward on that as quickly as possible.
    But let me start, Ms. Edwards, with you first. Thank you so 
much for coming and telling your story, and for supporting our 
legislation. One of the things that I kept thinking about 
though as you were talking was, you keep shrinking your service 
area, right?
    So you had 13 counties. Now you have one county. What 
happens to the rest of the people in those other counties? What 
is happening for them?
    Ms. Edwards. Thank you for the question. They have options 
for other home health agencies. Many do not serve the full 
county they are in. Many of them will not accept those higher-
need patients for--again, like I mentioned before, they might 
not be in contract with the payer. So a lot of them----
    Senator Stabenow. Are just not getting service.
    Ms. Edwards [continuing]. Are not getting service.
    Senator Stabenow. Or they maybe get really, really sick and 
they end up in a hospital, right?
    Ms. Edwards. Or, if they are referred from the hospital, 
they might end up staying there longer. We have had patients in 
the hospital for 40, 50, sometimes 200 days because there is no 
place for them to go.
    Senator Stabenow. And so, it is really just like the 
proverbial punching bag, right? If we are not providing 
adequate home health care for people, they could very much end 
up in the hospital at a higher cost of care--or not getting any 
care and then getting sicker, and then something else 
happening.
    And so, home health care is incredibly important in the 
equation for people, and it is what people want for themselves 
and their families.
    Ms. Edwards. Yes.
    Senator Stabenow. Let me ask Mr. Dombi: in talking about 
payments--I mean, it is people, but we have to talk about 
reimbursement, because that is how we get the services and pay 
for the workers to be able to provide the services that people 
need. Could you talk a little bit more about the current and 
proposed payment policies that are cuts? Let us just call it 
what it is. It is cuts, and really, what does that means for 
the average provider of home health services?
    Mr. Dombi. I mean, as you noted, there is an intimate 
relationship between payment and service. I am really tired of 
talking about payment policy and payment rates, but it is still 
essential to do so. Medicare's proposal would cut payment rates 
by 5.653 percent in 2024, and there is a $3.5-billion ``debt'' 
hanging over the heads of home health agencies right now, 
contributing to their anxiety.
    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 percent for the years 2021 
and 2022. And particularly, labor costs rose significantly. 
That is now baked in permanently into the payment rate. So that 
5-percent shortfall will continue ad infinitum. CMS has refused 
to correct that forecasting error. So, when we are looking at 
it, it adds up. CMS added it up itself: an $870-million 
reduction in spending for home health, just in 2024.
    And $870 million will repeat itself over and over and over 
again for the rest of the Medicare home health benefit's life. 
So we are really talking about some long-term negative impacts 
as a result of that. And these are on top of cuts that took 
place in 2023. And so, the other thing that stands out is that 
CMS was required to create this new model in a budget-neutral 
fashion.
    It seems really kind of elementary when you see that 
spending and utilization of home health has gone down from the 
previous 2019 model of care, in 2019. I mean, losing half a 
million patients over a short period of time should tell CMS 
this was not a neutral transition at all.
    Senator Stabenow. Thank you, and thank you, Mr. Chairman. I 
just want to say in concluding that we know that, as we are 
fortunate enough to really live longer and health care is 
allowing us to do that, our needs on home health care are only 
going to grow. And so, we need to right-size this and stop 
putting patches on it over and over again.
    So, thank you, Mr. Chairman.
    Senator Cardin. Thank you, Senator Stabenow.
    Senator Cortez Masto?
    Senator Cortez Masto. Thank you. I want to thank the 
chairman and ranking member of the subcommittee. It is an 
incredible conversation that we need to have, and I have a 
number of questions, but I have only got 5 minutes. So, I am 
going to try to get through them. But let me caveat it by this.
    This is such a timely conversation, because in my own 
family, my mother has a first cousin who can no longer live by 
himself. He would prefer to age in place, but he cannot. And I 
am assuming, and maybe I am assuming wrong, but part of the 
challenge may be--and, Ms. Stein, this is why I am going to ask 
you to address this a little bit more--is this idea that CMS is 
enforcing Medicare as a short-term acute-care benefit.
    What he needs is some sort of assisted living, long-term 
care. So here is his option: if he cannot get that from 
Medicare, then he has to sell his house, take $50,000, $60,000 
from whatever he sells it for, give it to the assisted living, 
and still pay $5,000 a month to be eligible for assisted 
living, and really monitor his own medication.
    This is the option we are giving seniors. This is the 
option for individuals if they cannot age in place because they 
cannot access the benefits that we are providing for them 
through Medicare and/or Medicaid. So can I ask, is that part of 
the problem we are seeing here? Is it--should we be looking at 
this implementation of the law, that it is incorrectly being 
implemented by CMS at this point in time? Is that part of the 
challenge we are seeing here?
    Ms. Stein. Yes, it is definitely part of the challenge.
    Senator Cortez Masto. Go ahead.
    Ms. Stein. Audits look to overutilization. If an agency 
provides care for longer than 30-60 days, then they are afraid 
that they will be audited for providing more care than is the 
norm. And of course, the more that agencies provide care for 
shorter periods of time, the more the norm becomes short-term.
    Quality measures are based on improvement, so that people 
who cannot improve in ambulation but may be able to maintain 
what they have if they have physical therapy come in, if they 
have aides help them at home, their agencies will not get 
quality star ratings sufficiently because the quality measures 
are based on improvement.
    So we need to have quality measures that show that they 
have maintained or slowed declined. We need auditing that looks 
at underutilization, not just so-called overutilization. We 
need an increase on the cap of outlier payments--outlier 
meaning people who get longer-term care.
    And the PDGM, that payment model needs to be revised so 
that people who are able to avoid a hospitalization are not 
less popular to home health agencies because they are paid less 
to take care of them from home, and because they are paid less 
after 30 days of care.
    So the payment model, the quality measures, and the 
auditing all need to be revised so that it looks to and tries 
to incentivize getting the full array of care that patients 
need for the length of time that they need it.
    Senator Cortez Masto. And does anyone on the panel disagree 
with what Ms. Stein has just said, as part of the challenges 
that we should be focused on here in Congress? Nobody disagrees 
with that? Okay; I thank you, because I think it is exactly 
what I am looking for, and I know my colleagues are as well.
    Let me add one thing to this--and we have talked about it; 
it is the workforce issue. Let me just couch it in this way, 
that we have the Guinn Center in Nevada, and it found that 
Nevada will need 5,300 more home health aides by 2026 to meet 
the growing demand for home health services.
    Nevada currently has around 13,000 home health workers, the 
backbone of our health-care system. But in Nevada, every county 
is a designated health-care workforce shortage area. And so the 
question is, what else do we need to be doing besides--I agree. 
I hear from home health-care workers all the time. We have got 
to increase their wages and benefits.
    What else should we be thinking about? What else needs to 
be done here to bring in and really grow that workforce? That 
is a challenge. Mr. Dombi, I heard what you just said about the 
nurses and the choices that they are making, rightfully so, 
based on the wages that they can get somewhere else. What else 
should we be thinking about here? What else needs to be done?
    Mr. Dombi. I mean, there are all those kinds of things that 
involve money, but I want to focus on something that does not. 
We really need to show respect to that workforce. We need to 
raise their image, celebrate the heroes that they are, 
delivering the care, and recognize that they are more essential 
to our economy, to our families and everything else, than the 
people who work at Dunkin' Donuts who make more money than they 
do.
    But they are not getting that kind of respect that they 
deserve. I mean, they are caring for grandparents and aunts and 
uncles and my age group, people I went to high school with. 
Yes, Senator, I really am 110 years old. But you know, it may 
sound ethereal, but it really does matter, you know?
    We need to get people to want to aspire to do that work, 
and I know that Carrie Edwards's daughter is one of those 
individuals right now, as a high school student delivering 
those kinds of services. We need more people like her out there 
to demonstrate that this is a value that our country truly, 
truly honors.
    Senator Cortez Masto. I could not agree more, Mr. Dombi. 
Thank you.
    I know my time is up. Thank you.
    Senator Cardin. Senator Whitehouse?
    Senator Whitehouse. Thank you, Mr. Chairman.
    Our Rhode Island experience through COVID was pretty 
illuminating about telehealth. There had been a huge row about 
whether telehealth made sense, whether it should be paid for--a 
big squabble. When it became absolutely necessary to go to 
telehealth, period, because of COVID, a lot of the objections 
and concerns evaporated.
    The use of telehealth proved itself very quickly, and we 
leapt through what had been a lot of barriers. Did anything 
similar happen with respect to home health care as a result of 
the COVID experience, Ms. Stein?
    Ms. Stein. Yes. There was telehealth provided for people 
who wanted to and could access it in their home. But you know, 
one of the things that I----
    Senator Whitehouse. But how did that roll into the home 
health service side of the equation?
    Ms. Stein. It helped for people, for instance, who needed 
physical therapy and could access video and follow instructions 
from a therapist in that way. We had people who we knew were 
getting physical therapy. But if it is wound care--it depends 
on the need of the patient, and it depends on the availability, 
what tech they have available, and how well they can use it.
    Home health aides provide hands-on personal care, so it is 
less effective with that kind of care.
    Senator Whitehouse. One other big shift in Rhode Island was 
when two of our major primary care providers became ACOs, 
Accountable Care Organizations.
    Ms. Stein. Yes, yes.
    Senator Whitehouse. Coastal Medical was one, Integra was 
another. Both of them were among the highest-performing ACOs in 
the country, and they ramped up home health service delivery on 
a patient-by-patient basis, because it was in their interest, 
once they were somewhat freed from fee-for-service, to make 
sure that each patient was getting the best care that they 
needed to keep them healthy and therefore to keep costs down. 
And so, that has worked really well.
    Mr. Dombi, do you see expanding--what more can we do to 
have that ACO example improve the experience of patients with 
access to home health services?
    Mr. Dombi. You are so correct, that the successful ACOs 
have relied upon home health services to their own financial 
business benefits, in addition to the patients' benefit. And 
the learnings from those ACOs are now being transmitted to 
other ACOs, to managed care programs and the like, because it 
has been ambitious to bring home health-care services to the 
home, but it has been an underappreciated and underutilized 
benefit.
    So, a lot of the learning that you have noted that was 
there is now being passed on to others, to see that kind of 
benefit. So, as I mentioned, the value-based purchasing program 
with home health in the Medicare program has shown that dynamic 
value.
    And so, it is taking longer than we had hoped, but it would 
really benefit for more to take advantage of it. I want to add 
to what Judy was offering on telehealth services. During the 
pandemic in particular, there were millions of telehealth 
visits done by home health agencies to patients in their homes, 
working in concert with physicians and nurse practitioners and 
the like to substitute for in-person services. And they did 
that in the context of a program that prohibits recognition of 
the cost of telehealth services, as part of setting payment 
rates for that. So we are looking to modernize the Medicare 
program, to recognize that telehealth is valuable.
    Senator Whitehouse. Yes. So, my time is getting a little 
bit short. So I would like to ask any witness who cares to 
respond in writing, as a question for the record, about any 
specific recommendations that you have on how we can use the 
ACO model, and how we can use the telehealth means to expand 
home services.
    Are there things that we can do with CMS regs, or things 
that we can do with CMMI models, or the things we can do with 
legislation, that would expand what appear to be two very 
productive gateways, both for lowered cost and for improved 
patient care and patient experience? And if I am not mistaken, 
the home health value-based program--I do not know if anybody 
is tracking that on the panel--it appears to have saved a lot 
of money.
    I am getting some nods. So that actually creates--it is not 
just Rhode Island's experience that a well-run ACO can deliver 
home health services effectively to people and save money, or 
that telehealth can facilitate inexpensive home health service 
delivery, but also you've got this model program that worked 
and that created savings.
    Mr. Dombi. And we worked in partnership with the Department 
of Health and Human Services to expand nationwide the value-
based purchasing this year. Medicare projects it will save $3.5 
billion over 4 years in avoidance of higher-cost care, 
particularly in hospitals, for that. So we would be glad to 
work with you.
    Senator Whitehouse. Thanks.
    Well, Mr. Chairman, it sounds like we know of some things 
that work. We need to do more of them. Thank you for the 
hearing.
    Senator Cardin. Thanks, Senator Whitehouse.
    Senator Young?
    Senator Young. Dr. Grabowski, I am going to ask you a 
series of questions. I ask that maybe you reply quickly. Some 
of them--I apologize if they have been asked earlier today. But 
you mentioned in your testimony care shifting out of 
institutions and into the home, and seniors want to be at home, 
which is no surprise, I think, to any of us.
    We need to ensure policies support that trend in a sound 
way--which is one of the reasons we are here today--ensuring 
appropriate access, quality care, and consistent health 
outcomes. You comment that there is adequate access to Medicare 
fee-for-service for home health agencies, but is it timely 
access, sir?
    Dr. Grabowski. Yes. This is such an important issue, that 
supply does not equal access, that obviously we need better 
data. Are they getting timely visits, as you suggest, and I do 
not know that we know that nationally right now. That would be 
great if we could get such a data set.
    Senator Young. Noted and appreciated.
    When a patient has been referred to home health, how long 
does it take for those services to begin, typically?
    Dr. Grabowski. They should start relatively quickly, and 
that is actually a measure of quality, like timely initiation 
of care.
    Senator Young. Right.
    Dr. Grabowski. So you would hope within 48 hours.
    Senator Young. Okay. Are hospitals able to routinely 
identify a home health agency for patients when they are ready 
for discharge?
    Dr. Grabowski. Sometimes yes, sometimes no. It can vary. 
There is software where they can sort of give beneficiaries a 
roster of places, but----
    Senator Young. And who is measuring this quality outcome?
    Dr. Grabowski. We know----
    Senator Young. Rewarding it, presumably.
    Dr. Grabowski. We have data on timely initiation of care, 
but we do not really know about refusals, we do not really know 
the process of how that happens. Kind of--that is all 
underneath the surface.
    Senator Young. Okay. Are seniors or families reasonably 
able to find a home health agency with availability?
    Dr. Grabowski. That, once again, can really vary by market. 
And yes, they can go on Home Health Compare and compare the 
star ratings, but they do not know if that particular home 
health agency is accepting patients at that time. So there is a 
lot of blurriness on the part of, I think, our patients and 
their family members.
    Senator Young. Yes. And we are, I think, appropriately 
asking patients to be consumer-oriented, discerning shoppers. 
We need to empower them to do that, I think.
    Dr. Grabowski. Absolutely. I would say very quickly, there 
is legislation that hospitals--I know not every home health 
patient comes through the hospital, but for those leaving the 
hospital, the Congress has put legislation in place that they, 
the hospital, should be helping them. But hospitals are not 
always doing that, and the hospitals do not want to play too 
heavy of a role in that. But they should be providing 
information to beneficiaries.
    Senator Young. Okay. So we need to persuade them and 
incentivize them, perhaps, to comply with existing law?
    Dr. Grabowski. Right; and by incentivize as well--Senator 
Whitehouse mentioned ACOs. That is a perfect example of an 
entity that is very incentivized to worry about cost and 
placement. As was suggested earlier, there has been a lot of 
transition out of skilled nursing facilities to home health 
agencies when you incentivize hospitals under an Accountable 
Care Organization, or ACO.
    Senator Young. All right. Thank you, Doctor.
    Can you speak to the health outcomes for patients who 
utilize home health, compared to those that do not?
    Dr. Grabowski. You know, there is absolutely a benefit to 
home health. My only sort of tweak--and I said this in my 
testimony--is that I wish we had better data, and I wish the 
assessment data were better that the agencies report, because I 
think oftentimes it is----
    When you track over time, a lot of the claims-based 
measures that we think are more objective, seem to be 
suggesting stagnant quality or even declining quality, where 
these agency-reported quality measures seem to be suggesting 
improvement. I worry that we do not have a great set of quality 
measures here.
    Senator Young. Sure, sure. What data is missing to ensure 
patient access to quality home health services?
    Dr. Grabowski. I think it goes back to a lot of those 
agency-
reported measures like physical functioning. Are they 
improving? Are they maintaining their physical functioning? So 
I do not know that we have great accuracy with the current data 
that are being reported.
    Senator Young. Okay. As you answered these questions, I see 
some real opportunities for us to eye some things up, so to 
speak.
    Dr. Grabowski. Absolutely.
    Senator Young. You cautioned Congress about making major 
changes to the Patient-Driven Groupings Model, PDGM, that 
payment system, given this new system was adopted at the start 
of the pandemic. Based on the design of the payment model, what 
should we expect in terms of access under the PDGM?
    Dr. Grabowski. Well, the PDGM, just to back up a little 
bit, really changed incentives pretty dramatically. Under the 
old payment system, home health agencies were paid based on the 
amount of therapy that they delivered.
    And so, as you can expect, when you pay for therapy, you 
get lots of therapy. Under the new system, they are paid based 
on patient characteristics. And so, we should see higher-acuity 
patients being admitted into home health. That would be the 
expectation.
    I think it is a little early, given the pandemic, to really 
track what has happened under the PDGM. So I would just caution 
Congress about making changes until we are able to move out of 
the pandemic and really get a sense of how this policy is 
working.
    Senator Young. And then as we come to a close, I am going 
to ask you a two-part question. How long will it take for 
researchers to, in your words, disentangle what changes are due 
to the PDGM, and what is due to the pandemic? So how long will 
it take for that, and do you feel there is the potential for 
access concerns, as researchers and CMS navigate post-pandemic 
data?
    Dr. Grabowski. So, I think it will take several years. I 
think it will be over the next several years that we will get a 
sense of how things are working, so the next 2 to 3 years, when 
we begin to get data. I hope we are able to look at access. It 
has to move, as you said, as you indicated with your very first 
question. It has to move beyond supply and utilization-based 
measures, and really look at timely visits--whether agencies 
are able to accept new patients, what types of patients are 
being admitted into home health.
    Senator Young. Thank you, Doctor, Mr. Chairman.
    Dr. Grabowski. Thanks.
    Senator Cardin. Thank you, Senator Young.
    Senator Carper?
    Senator Carper. Thanks, Mr. Chairman. Welcome, everybody. 
Nice to see you. Thank you for joining us for this important 
conversation. I think we would all agree that home-based health 
care plays an essential role in ensuring that everyone receives 
the care that they need, when they need it, and where they want 
it.
    We saw the demand for home-based health care rise during 
the COVID-19 pandemic. Hospitals and health-care facilities 
were over capacity, as you will all recall. Patients preferred 
to receive care at home where possible and when appropriate.
    One program out there that was established to meet this 
demand was the acute hospital care at home waiver program, 
known as Hospital at Home, because it allows Medicare 
beneficiaries to receive hospital-level health-care services in 
their home. Since its enactment, hospitals and health systems 
across, I think the last time I checked it was 34 States, 
including my own home State of Delaware, have utilized the 
Hospital at Home program to provide safe, high-quality 
hospital-level services in the homes of patients.
    The Hospital at Home program has been a true success story. 
It has delivered positive outcomes. It has delivered higher 
reported patient satisfaction, and I understand that it has 
also delivered potential cost savings. Where I come from, that 
is a win-win-win situation.
    To ensure that patients and their providers would have 
access to the Hospital at Home program for 2 years, beyond the 
duration of the COVID-19 public health emergency, last Congress 
Senator Tim Scott, a member of this committee, and I introduced 
the Hospital Inpatient Service Modernization Act. I am proud 
that the Congress passed our bipartisan bill, and it was signed 
into law by President Biden last year.
    A question, initially for Mr. Dombi and I think for Dr. 
Grabowski. The same question for each. Mr. Dombi, could you 
please share how the Hospital at Home program has continued to 
serve patients past the end of the public health emergency?
    Mr. Dombi. Well, you know, I will call it the demonstration 
program of enlightenment.
    Senator Carper. Oh, I like that.
    Mr. Dombi. I thought of it just moments ago, but----
    Senator Carper. You don't mind if I steal it?
    Mr. Dombi. It is all yours. What I meant by that is, we 
built the Medicare program in 1965 on a continuum of care 
concept that was setting-focused, and the Hospital at Home 
demonstration program shows that the continuum of care should 
be patient-focused, rather than setting-focused. The capability 
of delivering a high level of acuity of care to individuals in 
their own home, bringing high-
quality results, cost savings, and certainly a lot of 
satisfaction--none of us wants to go out of our home for health 
care if there is a way of avoiding it.
    So more than anything else, put aside the technical aspects 
of the program and the like. It is just that this has created 
an environment for innovation and the delivery of health care 
that is even wider than the Hospital at Home program. That is 
what I would love to be able to have conversations with this 
committee about instead of payment rates, for a program that 
actually established that care in the home is cost-effective, 
high-quality--the home health benefit under the Medicare 
program.
    So I am hoping, before I am needing Hospital at Home 
services, to be able to have those kinds of conversations.
    Senator Carper. All right; good. Thank you.
    Dr. Grabowski, same question. Could you share with us how 
the Hospital at Home program has continued to serve patients 
past the end of the emergency?
    Dr. Grabowski. Yes. It is an incredibly innovative program. 
We have a model in Boston just down the street from where I 
work, at Brigham and Women's Hospital. Some colleagues there 
have a Hospital at Home program, and when they actually put it 
out in the field to test it, they actually had to self-finance 
it, because there was no payment mechanism to support Hospital 
at Home for patients in the Boston market at that time.
    This is a place where I think a lot of the delivery-level 
innovations are maybe ahead of some of the payment innovations 
that are out there. So I am also, similar to Mr. Dombi, very 
excited about this kind of model and its potential.
    Senator Carper. Good; thank you.
    A follow-up question, and for each of you, for Mr. Dombi 
and for Dr. Grabowski. What lessons have we learned from the 
success of the Hospital at Home program? What should we as 
legislators keep in mind as we work toward making Hospital at 
Home a permanent program?
    Mr. Dombi. We learned, among other things, that marriage 
between professional services and technology actually enhances 
the quality of care. We have learned that we should not hold 
ourselves back from creativity and innovation and live in the 
1965 era of the Medicare program. We should learn also to 
listen to the providers of health-care services. It was at 
Johns Hopkins that Hospital at Home was born as a concept many 
years ago, but it took quite a while to take off after that.
    So I think we have learned a lot that could be there, and 
we have learned a lot still as it is unfolding on how we can 
refine it, improve it, and really make it the full value that 
is out there, including how it can be a transition to segue 
back to the Medicare home health benefit, a segue back to home 
health services, when an individual's level of care needs are 
satisfied from the hospital level back to the home health side.
    Senator Carper. All right; thank you for that. Same 
question, Dr. Grabowski. What should we as legislators keep in 
mind as we look at possibly making Hospital at Home a permanent 
program?
    Dr. Grabowski. Sure. The title of this hearing is ``Aging 
in Place,'' and I think sometimes we have a very narrow view of 
aging in place. The Hospital at Home program suggests we should 
not limit ourselves to very particular models, but think quite 
broadly, because there are incredibly innovative models that 
are out there.
    Hospital at Home, really, I think is pushing the envelope, 
and I hope that policy catches up with kind of some of what is 
happening at Hopkins and also at Harvard. Mr. Dombi called out 
Hopkins, but also--it may have started at Hopkins, but lots of 
great work is going on elsewhere.
    Senator Cardin. He was right to call out Hopkins. 
[Laughter.]
    Mr. Dombi. Are we dealing with a rivalry here?
    Senator Carper. All right. Thanks to all of you. Thanks for 
joining us today. It is a good discussion, and we appreciate it 
very much.
    Senator Cardin. Senator Hassan?
    Senator Hassan. Thank you, Chair Cardin, and I want to 
thank you and Ranking Member Daines for having this hearing. 
Thank you to our witnesses for being here today. Thank you, 
Senator Carper, for the line of questioning you just had. I 
would also say that if we can partner with families like mine, 
which have been dealing with children, who are now adults with 
complex medical conditions, at home for an entire generation, 
there is a lot of creativity and innovation to be had, and I 
would really look forward to working with these witnesses and 
all of my colleagues on improving things like Hospital at Home 
and implementing them.
    But I did want to start with a more specific question to 
you, Ms. Stein. Senators Duckworth, Blackburn, Casey, and I 
recently urged the Centers for Medicare and Medicaid Services 
to conduct a comprehensive review of its coverage of mobility-
assistive equipment, such as wheelchairs, canes, and scooters. 
CMS currently has a really narrow interpretation of what 
equipment should be covered and when. We were just talking 
about silos and specificity that reference back to very 
outdated models. Medicare right now covers equipment for daily 
activities within the home, but many people also need equipment 
that is more appropriate for use outside of the home.
    We are asking CMS to reassess this standard to ensure that 
individuals with disabilities can get the support that they 
need to live independently and to participate in their 
communities. So, Ms. Stein, can you speak to how Medicare's 
limited coverage of mobility equipment impacts patients and 
their families, as well as the implications it has for 
individuals' participation in their communities?
    Ms. Stein. Absolutely; thank you for the question. And I 
think this is a place where both Congress and CMS need to 
revise outdated law and policies. As you know, it is said in 
order to get Medicare coverage for most equipment prosthetics 
and orthotics, they need to be primarily for medical reasons, 
and primarily used in the home. And by the way, the home cannot 
be your SNF, your nursing home.
    The definition of ``home'' needs to be changed by Congress. 
But the use in the community is incredibly important, and as an 
example, what we thought were the horizons for people with 
disabilities have fortunately been expanded. So we do not want, 
nor do people with various disabilities need to remain in home 
with their equipment. And in 2023, the equipment can often 
allow them to exit home to work, to be with family, whether it 
is mobility devices, whether it is technology so that they can 
speak, which Congress fortunately covered a few years ago under 
Medicare.
    These things definitely need to be looked at. CMS has 
authority under its current mantle to define the medical use 
and the value of this equipment, where and when it can be used. 
They should push the envelope with regard to the use of this 
equipment and standardize equipment so that people can use it 
given their particular disabilities. And then legislation would 
be helpful to expand the notion of what is primarily medical 
use, and to be able to use it in the community.
    Senator Hassan. Well, thank you very much for that input.
    Ms. Stein. I hope that is helpful.
    Senator Hassan. That is helpful, thank you.
    Ms. Stein. And if we can help you from the Center for 
Medicare Advocacy, we would greatly like to offer our legal 
acumen and stories from our clients. This is a very important 
area.
    Senator Hassan. Thank you very much. We will follow up with 
you on that.
    Mr. Dombi, I wanted to ask you a question. As you know, the 
Centers for Medicare and Medicaid Services are currently 
working to finalize a payment rule for Medicaid home health 
services. This rule includes important updates to the Medicaid 
home care benefit to preserve the quality and safety of home 
health care. It would require that home health organizations 
direct 80 percent of their Medicaid payments towards workers' 
wages.
    So, I strongly support fair wages for essential workers 
such as home health aides, but I am concerned that this 
requirement may have really unintended consequences. New 
Hampshire has an unemployment rate right now just under 2 
percent. It is the lowest in the country. Home health 
organizations face significant vacancies for positions and 
competition for workers. The requirements outlined in CMS's 
recent proposed rule would require a level of staffing that 
simply may not be available in the short term.
    So, can you speak to these workforce challenges and the 
potential impact of this rule on access to home health care?
    Mr. Dombi. Yes. We as an organization have long supported 
better compensation to the caregiving workforce, and I think 
the proposed rule has that intention. It is just not a good 
execution on the intention that is there. We have analyzed 
multiple States and whether or not their systems would lead to 
positive or negative outcomes as a result of it.
    That 20 percent that is there goes towards such things as 
supervision, training of the aide, as well as the day-to-day 
business stuff of billing their Medicaid program on that. So, 
we do not find a single State that could meet that standard, 
and if they cannot meet that standard, what happens with the 
program, because the consumer of services is on the outside 
looking in?
    So we certainly would like to work with you, work with the 
White House, and work with CMS to come up with better 
approaches to achieve the same end. I know Senator Casey, one 
of your colleagues, has also been very actively involved in 
this issue.
    So I think there is--you know, so long as there is a will, 
there is a way, and I think we need to take a different path, 
but we can get there.
    Senator Hassan. Thank you very much for that, and I thank 
you for the indulgence, Mr. Chair. I have one more question 
that I will submit for the record to Dr. Mroz about the waiting 
lists, and I appreciate very much this hearing. Thank you.
    Senator Cardin. Thank you, Senator Hassan. Let me thank all 
of our witnesses again. You could tell by the number of members 
and their participation that this is an area of great interest 
to this committee. We understand the importance of home health 
care, and we recognize that we have not achieved the level that 
we need or expect for our country.
    And yes, when the PDGM reforms were put in, it was before 
the pandemic, which made it much more challenging to understand 
its impact. There have been a lot of changes in our health-care 
system since COVID. Its intent was to deal with access and 
reward for those who have more complicated needs. That was 
certainly worthwhile and worthy, and it was to be budget-
neutral.
    It is questionable whether it has achieved either one of 
those objectives, and it may very well have cost resources that 
otherwise should be in home health care. Your observations here 
are very helpful for us. I think we all are looking for ways to 
make our health-care system more efficient. I appreciate 
Senator Whitehouse's comments about the ACO plan; that was part 
of our efforts to deal with that.
    Telehealth is an area that this committee has taken strong 
bipartisan positions on to try to institutionalize a lot of the 
practices during COVID-19, moving forward on reimbursements for 
telehealth as a preferred option for a lot of health-care 
needs. Certainly home health can take advantage of that. That 
is efficiency with access to care.
    My own State of Maryland has a total cost of care model, 
the only one in the country that deals with hospital and 
related costs on the total cost of individuals, which would 
include home health. So there are models out there that can be 
looking at efficiency.
    But one thing we do know is that the current reimbursement 
is having a major impact on the workforce: lack of confidence 
that there will be a future in government reimbursements for 
home health services. It has not provided the incentives needed 
for access to care in many communities. We have a lot of 
underserved communities, whether they are rural or minority 
communities.
    So we have challenges with the reimbursement structure that 
we need to deal with. And then, as you pointed out, we look at 
home health care as a long-term care need. We do not look at it 
as acute care. That is how Congress set it up, because we want 
to have a more efficient overall health-care system.
    And yes, we have done a lot in regards to acute care under 
the Affordable Care Act, but we really have not taken up long-
term care, which is one of the challenges we have as a Nation. 
And this is just one of the reactions of not taking up a 
rational policy and not having the most efficient way to 
provide home health services that we should.
    So, as Chairman Wyden indicated, this committee has a 
strong reputation of working in a bipartisan manner. As you can 
tell by the questions asked by both Democrats and Republicans, 
there is really no difference in our views on how we have to 
deal with this subject. I can assure you that this will be a 
major interest of our committee, and we recognize that there 
are urgencies out there. Ms. Edwards, your program and services 
in your community, obviously we see it being contracted, and 
that is not what we want to see.
    So, I just want to thank you all again for your testimonies 
and contribution to this debate. As is the tradition of our 
committee, members will be asking questions for the record. A 
couple have already given you an indication of what that will 
look like. We would ask that you would respond to those 
questions in a prompt manner. We have a way of our committee 
putting those together and getting them out to you.
    And with that, as there is no further business before the 
subcommittee, the subcommittee will stand adjourned, with our 
thanks to our witnesses.
    [Whereupon, at 11:53 a.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


               Prepared Statement of Hon. Steve Daines, 
                      a U.S. Senator From Montana
    Thank you, Mr. Chairman. And thank you to all of our witnesses 
joining us this morning for a conversation on home health.

    The home health benefit is a critical component of the Medicare 
program, and it is of increasing importance as our Nation's senior 
population continues to grow. In my home State of Montana, 20 percent 
of the population is age 65 and older. In fact, Montana is currently 
ranked as sixth in the Nation for States with the highest percentage of 
residents aged 65 and above.

    We know from countless surveys and research that Americans 
overwhelmingly prefer to ``age in place,'' which allows them to remain 
in the comfort of their own homes, preserve their quality of life, and 
retain their independence to the greatest extent possible as they grow 
older. Home health care plays an essential role in allowing our 
Nation's seniors to do just that--to receive certain essential health-
care services in their homes, where they are most comfortable.

    However, facilitating this kind of care comes with a number of 
unique challenges, challenges not found in a traditional institutional 
health-care setting--for example, accounting for the time and resources 
staff need to travel in order to see patients in their homes.

    As is so often the case, the difficulties of providing care to 
patients at home are only exasperated when it comes to rural America. 
Earlier this year, this committee hosted a thoughtful discussion on the 
opportunities and obstacles that exist when it comes to facilitating 
health care in rural communities across the country. Many of the 
concerns raised in that hearing--including access, transportation, and 
workforce--are applicable to administering home health care in rural 
States as well. I'm glad we are joined today by panelists who can speak 
to these particular challenges and nuances.

    Another value and intention of the home health benefit is the aim 
to be cost-
effective. By offering services such as skilled nursing, physical 
therapy, and occupational therapy in the home, the benefit can help 
provide savings to the Medicare program by avoiding unnecessary and 
costly institutional care.

    As we are all aware, the Medicare hospital insurance trust fund is 
fragile, and the rampant inflation over the past several years has had 
devastating effects throughout our economy. The health-care sector in 
particular has felt these pressures deeply. Going forward, we need to 
consider how the benefit can continue to be administered effectively, 
while also ensuring patients are able to receive the quality care they 
need.

    The concept and benefit of home health have evolved significantly 
since its inception in 1965. As Congress deliberates the future of home 
health, we need to be thoughtful as to what the benefit should look 
like, and how it can best continue to serve America's seniors.

    Our ultimate goal is to make certain that patients are able to 
receive the right care at the right time and in the right setting, with 
the appropriate payment. Not an easy task, but I'm glad we have the 
opportunity to dive into these topics today.

    Thank you again to our witnesses for being with us to lend their 
expertise and experience to the conversation. I look forward to the 
discussion.

                                 ______
                                 
       Prepared Statement of William A. Dombi, J.D., President, 
             National Association for Home Care and Hospice
    Chair Cardin, Ranking Member Daines, members of the Subcommittee on 
Health Care, thank you for the opportunity to present my views on the 
vital role that home health services plays in our continuum of care and 
the challenges faced today in preserving access to these essential 
services.

    I serve as president of the National Association for Home Care and 
Hospice, a trade association representing the home health agencies that 
serve patients in the setting of their choice, their own home. Our 
members consist of the full panoply of such providers across the 
country including nonprofit, proprietary, and government-based entities 
of all sizes from small, family-owned agencies in rural areas to large 
companies operating nationwide. These home health agencies are both 
freestanding providers and divisions within multifaceted health 
systems.

    In my 47 years representing Medicare beneficiaries and home care 
providers before Congress, State legislatures, Federal and State 
administrative agencies, and in numerous courts across the country, I 
have had the great honor of witnessing the importance of health-care 
services at homes across the country. My immediate family has been 
fortunate enough to have received this incredible care, including my 
mother, father, sister, and son.

    I come to you today to present information on the state of the 
Medicare home health services benefit. While it continues to provide 
significant care support for millions of beneficiaries each year, the 
home health agencies providing care and the beneficiaries receiving 
care need your help if such is to continue in the years ahead. I hope 
my testimony will be helpful as you consider how Congress can restore 
and protect this benefit for existing and future Medicare enrollees. 
The American people far prefer their home as the setting of choice for 
their health care and home health services has proven its value to both 
Medicare beneficiaries and the Medicare program as a high quality, 
cost-effective service since 1965.

    The Medicare home health benefit covers an increasingly essential 
health service. The original 1965 design of the benefit put it in a 
unique class within Medicare as it is the only benefit that is 
available under both Medicare Part A and Part B. Since the beginning of 
Medicare, Congress has enacted multiple improvements in the benefit 
design and standards of coverage and care. These improvements include:

          Elimination of beneficiary cost sharing on services.
          Extending the scope of coverage to an unlimited number of 
        service visits.
          Elimination of the prior-hospitalization requirement.
          Defining the scope of ``part-time or intermittent'' services 
        to include certain daily care.
          Refining the definition of ``confined to home'' to allow 
        non-medically related absences from the home, such as attending 
        religious services.
          Establishing patient rights, quality of care measures, and 
        compliance standards that ensure care quality.

    As implemented in Federal regulations by the Department of Health 
and Human Services and the Centers for Medicare and Medicaid Services, 
beneficiaries are entitled to coverage of medically necessary skilled 
nursing, physical therapy, speech-
language pathology, occupational therapy, medical social services, and 
home health aide services when meeting the eligibility standards. These 
services are available to patients without regard to whether their 
condition is acute, chronic, or at end-of-life. Further, eligibility is 
based on whether the patient is homebound and in need of intermittent 
skilled nursing or therapy services.

    While the benefit design and standards of coverage present a 
valuable Medicare benefit, in practice it falls short of intended 
purposes.

    Over the last 25 years, the benefit has been subject to many 
changes in payment, payment models, and scope of coverage brought on by 
a combination of congressional action, regulatory changes, and 
operational shortcomings. Providers of care face multiple barriers to 
the provision of services that include wholesale misunderstanding of 
coverage standards by Medicare contractors along with reimbursement 
pressures that affect patient service and clinical practice. The 
environment surrounding the benefit operation has not been stable for 
many years with events such as the OIG Operation Restore Trust, the 
elimination of provider protections from retroactive claim denials, 
expanded claims audits and oversight, and a misperception by MedPAC and 
others that the benefit was becoming something akin to a ``long-term 
care'' program because of extended services and patient length of stay. 
In addition, justifiable concerns have been raised at various points 
that the benefit wrongly has focused only on patients with a potential 
for functional restoration to the exclusion of patients whose needs are 
for care that maintains function or prevents accelerated deterioration 
in their condition.

    Fortunately, the home health benefit continues to provide access to 
high quality, medically necessary services to millions of Medicare 
beneficiaries each year. However, the benefit trajectory is 
deteriorating and requires reforms if it is to ensure its significant 
value to Medicare beneficiaries and the Medicare program itself. CMS 
recognizes that value in that it expanded the Home Health Value-Based 
Program (HHVBP) nationwide this year after a 4-year demonstration that 
proved significant Medicare savings and improved patient outcome in 
using home health services. Over the next few years, CMS projects 
savings on nearly $3.5 billion through reduced inpatient hospital and 
skilled nursing facility costs.

    Since 2011, Medicare beneficiaries have experienced reduction or 
loss in access to care and reduction in the level of care and scope of 
services provided. The data from CMS offers a stark picture of the 
future of the home health services benefit. (Appendix, Table 1.)

          In 1997, with 33 million Original Medicare enrollees, there 
        were 3.6 million unique users of home health services, 
        receiving an average of 74 visits during the year.
          Following the onset of a payment model reform known as the 
        Interim Payment System, 500,000 fewer beneficiaries received 
        home health services, with the average visits per patient 
        dropping to 51 in 1999.
          By 2011, after several years of stability under another 
        payment system reform, 3.5 million users of home health 
        services out of 36.5 million enrollees received an average of 
        36 visits per year.
          However, by 2021 after two more changes to the payment 
        model, only 3.0 million users out of 36.4 million enrollees, a 
        drop of 500,000 patients, received an average of 25.4 visits.
          Since 2011, the number of available home health agencies has 
        dropped by over 1,000 nationwide. Rural areas have been 
        especially hit, as the testimony of Carrie Edwards suggests. 
        Closures are occurring across the country, including providers 
        that had been in operation for decades.

    These losses in care are not the direct result of legislative or 
regulatory actions seeking to address ``out of control spending'' in 
home health services. In fact. home health spending in 2021 was $16.9 
billion compared to $16.7 billion in 1997 without regard to 24 years of 
cost inflation. In comparison, inpatient hospital spending rose from 
$80.7 billion to $131.3 billion while Skilled Nursing Facility spending 
rose from $11.2 billion to $27.2 billion over that same time. In 2019, 
the year before the payment model changed, spending was $17.8 billion, 
and as stated previously, the expenditure in 2021 was nearly $1 billion 
less. Medicare continues to spend less money on home health.

    While the past 25 years in home health services have been an 
extended roller coaster ride for beneficiaries and providers alike, the 
future presents an outlook that calls for significant action from 
Congress, HHS, CMS, and all other stakeholders. Certainly, not 
everything happening is the outcome of payment model and payment rate 
changes. However, the correlation of such changes is obvious and 
ominous as the 1998 Interim Payment System debacle showed. It took more 
than a decade to recover to an adequate level for care access from that 
point only to see history repeating itself over the decade that 
followed.

    Once again, we are at a crossroad on the future of the home health 
services benefit. A new payment model, the Patient Driven Groupings 
Model or PDGM began in January 2020. Amazingly, despite the chaos that 
normally ensues with such a dramatic change in systems, home health 
agencies distinguished themselves from the very beginning of the COVID-
19 pandemic in March 2020, filling a void in health-care services left 
by closed nursing facilities and unavailable hospitals. However, the 
pressures of PDGM have now taken over and providing access to care is 
challenging, at best.

    The evidence is mounting that patients in need of home health 
services are dealing with major barriers to access to care today, some 
of which may reach a point where they are insurmountable. The deep 
labor shortages, particularly in nurses and home health aides are 
getting worse rather than improving. Home health agencies are spending 
greater time recruiting and retaining staff because of their precarious 
financial status that does not permit competitive compensation to 
clinicians in comparison to hospitals and other care settings.

    Home health agencies are fully reliant on payments from Medicare, 
Medicaid, Medicare Advantage, and other government-based programs that 
have not raised reimbursements commensurate with labor cost changes. 
The proposed 2024 rate cut of 5.653 percent on top of the 3.925 percent 
cut in 2023 and combined with the 5.2-percent shortfall in the 2021-22 
inflation updates will only make matters worse. These rate cuts are 
just the latest in an extended series of rate cuts over the years. 
(Appendix, Table 2.) It was fully foreseeable that these rate cuts 
would reduce care access.

    There are several signs of the existing difficulties in care 
access. For example, hospital discharge data shows that hospitals are 
facing a growing level of patient referral rejections for prospective 
home health patients. This has led to delays in discharging patients to 
their homes, and extending costly inpatient stays as reported by the 
American Hospital Association. CarePort, a data analytics are of EMR 
vendor Wellsky, reports a nearly 50-percent increase in the rate of 
referral rejections by home health agencies. Homecare Homebase, another 
EMR vendor, shows a similar access problem with only 55 percent of 
patient referrals converted to patient admissions so far in 2023. 
Finally, data analytics company Care Journey explains that only 63 
percent of inpatient discharges are securing and initiating home health 
services within 7 days with racial minorities least likely to find care 
access. (Appendix, Table 3.)

    A story just this last week in Modern Healthcare pointed out how 
the lack of available post-acute care, specifically home health care, 
has led to increased penalties for hospitals due to rising readmission 
rates.

    The PDGM system is greatly contributing to this growing access 
problem. For example, under the proposed 2024 model there is shift of 
reimbursement away from patients with medically complex and multiple 
chronic conditions. Patients in the current 2023 payment model that are 
determined to have a ``high'' functional impairment level shift down to 
``medium'' functional impairment level in the proposed 2024 model with 
a corresponding reimbursement reduction even though their clinical and 
functional condition is unchanged. The reimbursement change for some 
cases is as much as 18 percent from 2023 levels. This will affect home 
health agencies serving some of the sickest Medicare beneficiaries 
receiving home health-care services.

    To understand the true financial status of home health agencies 
facing the proposed rate cuts in 2024 requires a comprehensive review 
of the state of the industry. Using the cost reports filed with CMS and 
available directly from CMS, NAHC undertook such an analysis. Notably, 
NAHC examined both the data on Original Medicare home health services 
costs and revenue along with the data on the overall financial status 
of home health agencies that includes all costs and all payers of care. 
The results are very concerning. It shows that 52.7 percent of 
freestanding home health agencies are projected to have financial 
margins below zero with the cuts proposed for 2024. (Appendix, Table 
3.) The actual percentage is likely to be greater because the data does 
not include ``hospital-based'' home health agencies where the margins 
are typically lower.

    NAHC strongly believes that overall margins are the most accurate 
measure of the financial stability of home health agencies in contrast 
to the MedPAC analysis that limits the focus to the ``Medicare 
margin.'' No business, health care or otherwise, limits its assessment 
of financial stability to one revenue source or service line. MedPAC 
instead conveys ``Medicare margins'' that only offer an illusion of the 
true financial status of home health agencies. Not only does the MedPAC 
approach provide an uninformed picture of financial stability, that 
analysis is further compromised as it excludes certain usual and 
customary business costs such as marketing and current health-care 
costs like telehealth services and remote patient monitoring. In 
addition, MedPAC's failure to include hospital-based home health 
agencies is particularly concerning given the significant presence of 
those providers in rural areas.

    To the extent that there is a financial margin in traditional 
Medicare home health services, it primarily is used to subsidize 
longstanding payment shortfalls from Medicare Advantage plans and State 
Medicaid programs, a financial deficit facing most health-care sectors. 
However, home health agencies, unlike most other sectors, do not have a 
material level of commercial insurance revenue that can offset 
financial losses from Medicare Advantage or Medicaid. As a result, 
Medicare margins primarily go towards patient care, not profit.

    As with any business, an operating margin is essential just to 
supply the means to meet routine payroll costs on a timely basis. In 
health care, a margin is also needed to provide the opportunity to 
invest in innovative technologies for improvements in care quality and 
operational efficiencies. Additionally, investment capabilities are 
essential for health-care providers to participate in potentially game-
changing innovations such as Accountable Care Organizations.

    To restore and preserve the Medicare home health services benefit, 
NAHC offers the following recommendations:

        1.  Congress should pass S. 2137/H.R. 5159, the Preserving 
        Access to Home Health Act of 2023.
        2.  CMS should withdraw its proposal to reduce Medicare home 
        health services payment rates by an additional 5.653 percent in 
        2024 and correct its 5.2-
        percent forecasting error on the rate of cost inflation.
        3.  Congress should mandate the development of a comprehensive 
        analysis of the root causes of the ongoing deterioration of the 
        home health services benefit and institute the corrective 
        actions needed to restore and preserve the benefit consistent 
        with the intentions of multiple Congresses since 1965.

    Thank you for the opportunity to present this testimony. The 
National Association for Home Care and Hospice stands ready to work 
with the subcommittee to bring the full value of health care at home to 
the millions of Medicare beneficiaries that need this essential and 
cost-effective care.

    I can be reached at wad@nahc.org and 202-236-6992.

APPENDIX

                                                     TABLE 1
----------------------------------------------------------------------------------------------------------------
                       TRADITIONAL                                         MEDICARE HH
         YEAR            MEDICARE      USERS      VISITS PER   VISITS PER    PAYMENTS     PAYMENTS     PAYMENTS
                        ENROLLEES     (1000s)       PERSON      EPISODE      (1000s)     PER PERSON  PER EPISODE
----------------------------------------------------------------------------------------------------------------
1990                           N/A       1967.1           36          N/A   $3,713,652       $1,892          N/A
----------------------------------------------------------------------------------------------------------------
1991                           N/A       2242.9           45          N/A    5,369,051        2,397          N/A
----------------------------------------------------------------------------------------------------------------
1992                           N/A       2506.2           53          N/A    7,396,822        2,955          N/A
----------------------------------------------------------------------------------------------------------------
1993                           N/A       2874.1           57          N/A    9,726,444        3,389          N/A
----------------------------------------------------------------------------------------------------------------
1994                        34,076       3179.2           66          N/A   12,660,526        3,987          N/A
----------------------------------------------------------------------------------------------------------------
1995                        34,062       3469.4           72          N/A   15,391,094        4,441          N/A
----------------------------------------------------------------------------------------------------------------
1996                        33,704       3599.7           74          N/A   16,756,767        4,660          N/A
----------------------------------------------------------------------------------------------------------------
1997                        33,009       3557.5           73          N/A   16,718,263        4,704          N/A
----------------------------------------------------------------------------------------------------------------
1998                        32,349       3061.6           51        31.6*   10,456,908        3,420          N/A
----------------------------------------------------------------------------------------------------------------
1999                        32,179       2719.7           42          N/A    7,936,513        2,921          N/A
----------------------------------------------------------------------------------------------------------------
2000                        32,740       2461.2           37          N/A    7,215,958        2.936          N/A
----------------------------------------------------------------------------------------------------------------
2001                        33,860       2402.5           31        21.4*    8,513,702        3,545          N/A
----------------------------------------------------------------------------------------------------------------
2002                        34,977       2544.4           31          20*    9,550,683        3,765     $2,329 *
----------------------------------------------------------------------------------------------------------------
2003                        35,815       2681.1           31      18.39**   10,069,628        3,770          N/A
----------------------------------------------------------------------------------------------------------------
2004                        36,345       2835.6           31       18.0**   11,402,560        4,039          N/A
----------------------------------------------------------------------------------------------------------------
2005                        36,685       2975.6           32      18.21**   12,779,158        4,314     $2,366 *
----------------------------------------------------------------------------------------------------------------
2006                        35,647       3026.2           34      18.45**   13,912,750        4,619          N/A
----------------------------------------------------------------------------------------------------------------
2007                        35,490       3099.5           37      18.19**   15,565,441        5,046     $2,566 *
----------------------------------------------------------------------------------------------------------------
2008                        35,320       3171.6           38       19.1**   16,872,735        5,361      2,705 *
----------------------------------------------------------------------------------------------------------------
2009                        35,360       3281.1           40       18.7**   18,733,108        5,747          N/A
----------------------------------------------------------------------------------------------------------------
2010                        35,910       3434.4           37       18.0**   19,407,218        5,688          N/A
----------------------------------------------------------------------------------------------------------------
2011                        36,458       3463.9           36       17.0**   18,362,264        5,357     $2,916 *
----------------------------------------------------------------------------------------------------------------
2012                        37,214       3459.6           34       17.0**   18,025,554        5,256          N/A
----------------------------------------------------------------------------------------------------------------
2013                        37,613       3452.0           32        16.79   17,924,989        5,193       $2,687
----------------------------------------------------------------------------------------------------------------
2014                        37,790       3417.2           32        16.66   17,736,862        5,190        2,703
----------------------------------------------------------------------------------------------------------------
2015                        38,025       3454.4           32        16.60   18,203,863        5,280        2,762
----------------------------------------------------------------------------------------------------------------
2016                        38,610       3451.5           31        16.63   18,117,018        5,249        2,780
----------------------------------------------------------------------------------------------------------------
2017                        38,668       3392.9           31        16.60   17,830,844        5,255        2,823
----------------------------------------------------------------------------------------------------------------
2018                        38,665       3365.9           31        16.67   17,934,054        5,328        2,876
----------------------------------------------------------------------------------------------------------------
2019                        38,577       3281.4           31        16.57   17,850,864        5,440        2,952
----------------------------------------------------------------------------------------------------------------
2020 ***                    37,776       3054.5        27.57         9.27   17,082,332        5,592        1,881
----------------------------------------------------------------------------------------------------------------
2021 ***                    36,356       3018.5        25.44         8.27   16,872,835        5,590       1,818
----------------------------------------------------------------------------------------------------------------
Sources: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/
  cmsproPgramstatistics; https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/
  Archives/MMSS.
* Data from Medicare Payment Advisory Commission (MedPAC) various March Reports to Congress.
** Data from CMS HHA cost reports.
*** The payment model shifted to a 30-day episode.


                                 TABLE 2
------------------------------------------------------------------------
                                             BUDGET
                        PRODUCTIVITY     NEUTRALITY AND      REBASING
YEAR  MBI  REDUCTION     ADJUSTMENT      CASE MIX WEIGHT     REDUCTION
                                          ADJUSTMENT **
------------------------------------------------------------------------
FY                                               11.577%
 200
 1
------------------------------------------------------------------------
FY
 200
 2
------------------------------------------------------------------------
FY              1.1%                                  7%
 200
 3
------------------------------------------------------------------------
FY
 200
 4
------------------------------------------------------------------------
CY              0.8%
 200
 5
------------------------------------------------------------------------
CY              0.8%
 200
 6
------------------------------------------------------------------------
CY
 200
 7
------------------------------------------------------------------------
CY                                                 2.75%
 200
 8
------------------------------------------------------------------------
CY                                                 2.75%
 200
 9
------------------------------------------------------------------------
CY                                                 2.75%
 201
 0
------------------------------------------------------------------------
CY              1.0%                               3.79%
 201
 1
------------------------------------------------------------------------
CY              1.0%                               3.79%
 201
 2
------------------------------------------------------------------------
CY              1.0%                               1.32%
 201
 3
------------------------------------------------------------------------
CY                                                         $80.65 (3.5%)
 201
 4
------------------------------------------------------------------------
CY                                0.5%                     $80.65 (3.5%)
 201
 5
------------------------------------------------------------------------
CY                                0.4%             0.97%   $80.65 (3.5%)
 201
 6
------------------------------------------------------------------------
CY                                0.3%             0.97%   $80.65 (3.5%)
 201
 7
------------------------------------------------------------------------
CY              2.0%                               0.97%
 201
 8
------------------------------------------------------------------------
CY                                0.8%             1.69%
 201
 9
------------------------------------------------------------------------
CY                                                 4.36%
 202
 0
 PDG
 M
 beg
 ins
------------------------------------------------------------------------
CY                                0.3%
 202
 1
------------------------------------------------------------------------
CY                                0.5%
 202
 2
------------------------------------------------------------------------
CY     5.2% forecast             0.20%            3.925%
 202           error
 3
------------------------------------------------------------------------
CY                               0.30%            5.653%
 202
 4
 (Pr
 opo
 sed
 )
------------------------------------------------------------------------
TOTA           12.9%              3.3%           54.265%         $322.60
 L                                                              (14.0%)
 RED
 UCT
 ION
 S *
------------------------------------------------------------------------
Source: https://www.cms.gov/medicare/payment/prospective-payment-systems/
  home-health/home-health-prospective-payment-system-regulations-and-
  notices.
* This represents the sum of the cuts. However, the cumulative impact is
  much greater as each cut affects the base rate on a permanent basis.
** Reductions unrelated to adjustments made to achieve budget neutrality
  with case mix weight or wage index recalibrations.


[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
  
  


------------------------------------------------------------------------
                              Overall Financial Projected
      State         HHAs                Status                Percentage
------------------------------------------------------------------------
Alabama                84  Percent of margins below 0%             47.6%
------------------------------------------------------------------------
Alaska                  6  Percent of margins below 0%             50.0%
------------------------------------------------------------------------
Arizona                91  Percent of margins below 0%             65.9%
------------------------------------------------------------------------
Arkansas               53  Percent of margins below 0%             47.2%
------------------------------------------------------------------------
California            774  Percent of margins below 0%             58.3%
------------------------------------------------------------------------
Colorado               65  Percent of margins below 0%             61.5%
------------------------------------------------------------------------
Connecticut            28  Percent of margins below 0%             53.6%
------------------------------------------------------------------------
Delaware                7  Percent of margins below 0%             42.9%
------------------------------------------------------------------------
District of             4  Percent of margins below 0%              0.0%
 Columbia
------------------------------------------------------------------------
Florida               484  Percent of margins below 0%             57.0%
------------------------------------------------------------------------
Georgia                58  Percent of margins below 0%             48.3%
------------------------------------------------------------------------
Guam                    2  Percent of margins below 0%             50.0%
------------------------------------------------------------------------
Hawaii                  6  Percent of margins below 0%             16.7%
------------------------------------------------------------------------
Idaho                  34  Percent of margins below 0%             55.9%
------------------------------------------------------------------------
Illinois              265  Percent of margins below 0%             53.2%
------------------------------------------------------------------------
Indiana                87  Percent of margins below 0%             54.0%
------------------------------------------------------------------------
Iowa                   28  Percent of margins below 0%             39.3%
------------------------------------------------------------------------
Kansas                 38  Percent of margins below 0%             50.0%
------------------------------------------------------------------------
Kentucky               37  Percent of margins below 0%             32.4%
------------------------------------------------------------------------
Louisiana              98  Percent of margins below 0%             49.0%
------------------------------------------------------------------------
Maine                  11  Percent of margins below 0%             63.6%
------------------------------------------------------------------------
Maryland               19  Percent of margins below 0%             21.1%
------------------------------------------------------------------------
Massachusetts          56  Percent of margins below 0%             42.9%
------------------------------------------------------------------------
Michigan              178  Percent of margins below 0%             55.1%
------------------------------------------------------------------------
Minnesota              25  Percent of margins below 0%             48.0%
------------------------------------------------------------------------
Mississippi            24  Percent of margins below 0%             16.7%
------------------------------------------------------------------------
Missouri               57  Percent of margins below 0%             70.2%
------------------------------------------------------------------------
Montana                 7  Percent of margins below 0%             42.9%
------------------------------------------------------------------------
Nebraska               19  Percent of margins below 0%             52.6%
------------------------------------------------------------------------
Nevada                 84  Percent of margins below 0%             50.0%
------------------------------------------------------------------------
New Hamphire            5  Percent of margins below 0%             60.0%
------------------------------------------------------------------------
New Jersey             26  Percent of margins below 0%             38.5%
------------------------------------------------------------------------
New Mexico             22  Percent of margins below 0%             63.6%
------------------------------------------------------------------------
New York               54  Percent of margins below 0%             51.9%
------------------------------------------------------------------------
North Carolina         63  Percent of margins below 0%             30.2%
------------------------------------------------------------------------
North Dakota               Insufficient Data
------------------------------------------------------------------------
Ohio                  156  Percent of margins below 0%             56.4%
------------------------------------------------------------------------
Oklahoma              134  Percent of margins below 0%             41.8%
------------------------------------------------------------------------
Oregon                 22  Percent of margins below 0%             45.5%
------------------------------------------------------------------------
Pennsylvania          115  Percent of margins below 0%             41.7%
------------------------------------------------------------------------
Puerto Rico            18  Percent of margins below 0%             50.0%
------------------------------------------------------------------------
Rhode Island           14  Percent of margins below 0%             64.3%
------------------------------------------------------------------------
South Carolina         35  Percent of margins below 0%             60.0%
------------------------------------------------------------------------
South Dakota            4  Percent of margins below 0%             50.0%
------------------------------------------------------------------------
Tennessee              65  Percent of margins below 0%             49.2%
------------------------------------------------------------------------
Texas                 703  Percent of margins below 0%             51.9%
------------------------------------------------------------------------
Utah                   51  Percent of margins below 0%             51.0%
------------------------------------------------------------------------
Vermont                 3  Percent of margins below 0%             66.7%
------------------------------------------------------------------------
Virgin Islands          2  Percent of margins below 0%            100.0%
------------------------------------------------------------------------
Virginia              116  Percent of margins below 0%             54.3%
------------------------------------------------------------------------
Washington             47  Percent of margins below 0%             46.8%
------------------------------------------------------------------------
West Virginia          29  Percent of margins below 0%             62.1%
------------------------------------------------------------------------
Wisconsin              32  Percent of margins below 0%             37.5%
------------------------------------------------------------------------
Wyoming                11  Percent of margins below 0%             45.5%
------------------------------------------------------------------------
National                   Percent of margins below 0%            52.70%
------------------------------------------------------------------------


                                 ______
                                 
      Questions Submitted for the Record to William A. Dombi, J.D.
               Questions Submitted by Hon. James Lankford
    Question. The Bipartisan Budget Act of 2018 instructed CMS to 
implement a new home health payment system in a budget-neutral manner.

    In your opinion, has the agency implemented the new system as 
Congress intended?

    Answer. No, CMS has not implemented the new system in a budget-
neutral manner as Congress intended. Consequently, fewer Medicare 
beneficiaries are accessing home health services and those receiving 
care are getting less care. The law requires CMS to compare what 
Medicare would have been expended for home health services without the 
changes in provider behavior that occurred under the new payment model 
with the amount of actual expenditures under the new payment model. 
Instead, CMS compared the amount that would have been expended under 
the old payment model with the provider behavior changes that were 
triggered by the new payment model with the actual expenditures under 
the new payment model. Those behavior changes would not have occurred 
under the old payment model. As such, the CMS budget neutrality 
methodology compares actual spending to a projected spending amount 
that would not have occurred.

    Many of my Oklahoma HHAs think that there is no way this payment 
system can be budget-neutral since payment cuts have been so 
significant.

    Question. Does the home health industry have an appropriate level 
of data from CMS to understand how CMS is making payment decisions?

    If not, what exact data points would be helpful for you all to have 
to best be able to engage in a helpful and constructive conversation 
with CMS?

    Answer. CMS's failure to implement the new payment system in a 
budget-neutral manner stems from the use of a methodology that is both 
noncompliant with the law and illogical. That was confirmed earlier 
this year when CMS revealed more details on the methodology employed 
along with the data used in that methodology.

    Congress required CMS to set payment rates at a level that would 
result in spending equivalent to the level of spending that would have 
occurred in the absence of a change in the payment model. Congress 
permitted CMS to make assumptions about any provider behavioral changes 
that could occur through incentives and disincentives under the new 
payment model with later adjustments for any actual behavioral changes. 
However, CMS took behavioral changes that would only occur under the 
new model into account when determining the level of spending that 
would have occurred under the preexisting payment model. In other 
words, the CMS budget neutrality assessment methodology relied on 
provider behavior changes that would not have occurred under the 
preexisting payment model to determine the level of spending that would 
have occurred under that earlier system. CMS does not need to supply 
more data. Instead, CMS must use a compliant budget neutrality 
methodology.

    Question. What percentage of Medicare beneficiaries who are 
referred to home care actually receive it? Where do most patients end 
up if they are not able to receive the care for which they were 
referred?

    Answer. According to CareJourney, a health care data analytics 
company, during Q-1 to Q-3 2022, 62.6 percent of individuals referred 
to home health services were admitted to care within 7 days, 34.9 
percent went home without home health services, and 2.5 percent were 
admitted to another type of post-acute care setting. It is believed 
that the difficulties in placing patients in home health services led 
to fewer referrals at the outset, thereby deflating the potential 
number of patients unable to access home health care. Still, nearly 35 
percent of referred patients lost access to home health care.

    Question. Durable Medical Equipment (DME) providers are facing 
similar payment adjustment problems that are disincentivizing providers 
from remaining in nonurban areas. I am a cosponsor of my colleagues 
Senators Thune and Stabenow's bill--the Competitive Bidding Relief 
Act--which would ensure the continuation of an adjusted Medicare rate 
for certain DME providers that are not considered urban or rural, 
allowing them to be paid fairly.

    What are the implications in the home health space of the problems 
within the DME and oxygen provider industry? How much do these two 
industries rely on one another?

    Answer. A significant portion of home health patients utilize DME, 
including oxygen. Home health patients can access DME through the home 
health benefits or separately from a DME supplier. In the event that 
DME is unavailable for patients in need of DME, it is highly likely 
that the patient will not be admitted to care by the home health agency 
as it will not be an overall safe care setting.

                                 ______
                                 
             Questions Submitted by Hon. Sheldon Whitehouse
    Question. What specific recommendations do you have on how we can 
use the ACO model and telehealth to expand home health, including 
changes with CMS regulations, CMMI models, and legislation, to lower 
costs and improve patient care?

    Answer. Recommendations:

          Permit waiver of the ``homebound'' requirement for home 
        health eligibility within the ACO model. With the care 
        management coming from an ACO, the flexibility of providing 
        home health services to the non-homebound patient population 
        can save Medicare spending while assuring protection against 
        abuse.

          Permit waiver of the physician/practitioner requirement of a 
        face-to-face visit to certify home health eligibility. The ACO 
        care management is a sufficient program integrity check, 
        allowing the cost of the face-to-face encounter to be avoided.

          Allow telehealth virtual visits to be considered ``visits'' 
        under the Medicare home health payment model for ACO patients. 
        Currently, home health agencies are discouraged from using 
        virtual visits as the reimbursement system does not recognize 
        such for calculation of the payment amount as it is prohibited 
        under the Medicare statute, 42 U.S.C. 1395fff(e).

          Provide guidance and support for home health agencies to be 
        part of an ACO as a partner or participant. The ACOs that have 
        made appropriate use of home health services have shown a great 
        degree of success in contrast to those that do not fully 
        integrate with home health.

                                 ______
                                 
            Questions Submitted by Hon. Robert P. Casey, Jr.
    Question. In your written testimony, you mentioned that the 
pandemic has exacerbated home health labor challenges, with the number 
of workers per beneficiary declining over time not only in the home and 
community-based services workforce but in other post-acute and long-
term care settings. These declining direct care ratios, which are a 
result of a shrinking home health workforce, make it more difficult for 
beneficiaries to have meaningful one-on-one care. The vast majority of 
older adults indicate they prefer to age at home, even when, or 
especially when, they have health complications. In your testimony, you 
suggest increasing the size of the labor force through wage increases 
and that Congress continue to invest in policies to expand Medicaid 
HCBS.

    Could you speak to the importance of expanding HCBS and the impact 
that significant investment in the direct care workforce will have on 
patient care?

    Answer. Health care at home, particularly Medicaid HCBS, has proven 
to be a wise investment for Medicaid programs and the patient served by 
those programs. Significant savings have been achieved with high 
quality of care. However, there are several hundred thousand 
individuals on wait lists for a combination of reasons including staff 
shortages. A major reason for the difficulties in accessing HCBS is 
that the direct-care workers have many employment options that would 
better compensate them for the work they do. The need for a strong HCBS 
program nationally is a societal issue, not just one for those facing 
the need for care.

    Currently, family, friends, and others are often called on to care 
for an individual who has an unmet care need due to professional staff 
shortages. This leads to impacts on the economy as the substitute 
caregivers take time away from their own jobs to fill the void. It also 
puts significant pressure on already-stressed family and friends. 
Support for Medicaid HCBS would reduce the stresses on our economy as 
well as informal caregivers. It would also stabilize long term care 
resulting in savings accruing through reduced institutional care 
spending.

    Question. In your testimony, you mention the importance of 
increased coordination between programs to support beneficiaries that 
are dually eligible for both Medicare and Medicaid. You also spoke to 
the fragmentation in care and coverage that occurs when benefits are 
not integrated across programs and spoke to the variability of the 
types of programs that are available to dually eligible individuals.

    In your research, what have you found as being most important to a 
more coordinated approach to care, and how can these programs improve 
their alignment to better serve dually eligible beneficiaries?

    Answer. A coordinated Federal-State effort to take Medicare and 
Medicaid out of their respective silos, including both care and the 
providers of care, into a single care planning process with coordinated 
reimbursement to the provider would reduce administrative costs for 
those programs as well as the care providers while increasing the value 
of the services to the patients. This could be done with a focus on 
home care patients alone without needing to integrate the whole of 
Medicare and Medicaid.

                                 ______
                                 
     Prepared Statement of Carrie Edwards, R.N., BSN, MHA, LSSGB, 
         Director, Home Care Services, Mary Lanning Healthcare
    Chairman Cardin, Ranking Member Daines, and members of the 
committee, thank you for the opportunity to testify at this important 
hearing focusing on the Medicare home health benefit, which provides 
skilled medical care to older adults and individuals with disabilities. 
Home health allows eligible individuals to receive care in their homes 
instead of at more costly institutional sites of service.

    I would also like to thank Senators Debbie Stabenow (D-MI) and 
Susan Collins (R-ME) and Representatives Terri Sewell (D-AL) and Adrian 
Smith (R-NE) for their unwavering support to ensure that Medicare 
beneficiaries have access to high-quality home health services by 
introducing the Preserving Access to Home Health Act (S. 2137/H.R. 
5159). I encourage every member of the Senate to join as cosponsors of 
S. 2137 to ensure that Medicare beneficiaries in their state have 
access to home health services.

    My name is Carrie Edwards. I serve as the director of home care 
services at Mary Lanning Healthcare, located in Hastings, NE. Our home 
health agency is a hospital-based, nonprofit, rural provider. Mary 
Lanning Home Health offers a variety of services to meet patient needs 
right in the comfort of their own home, including skilled nursing; 
physical, occupational, and speech therapy; lymphedema therapy; medical 
social work; and home health aide services. We are the only home health 
agency within 60 miles that will accept pediatric patients that have 
complex medical needs that can be cared for in the home instead of an 
institutional setting.

    From my nearly 25 years of experience in the home health field, I 
can confirm that home is where the heart is for the millions of older 
adults and individuals with disabilities that are able to receive home 
health-care services in their home and community, even despite their 
health issues. Most of us just feel better when we are home.

    That's why I fell in love with helping people stay in their homes 
even when facing significant health challenges.

    At Mary Lanning Home Health, we have over 50 years of experience 
bringing health-care services into the homes of central Nebraska 
residents. But our ability to deliver patient-preferred, high-quality, 
cost-effective, lifesaving home health services is in jeopardy, and not 
due to any service failures at Mary Lanning Home Health, but rather to 
decisions being made right now by CMS that threaten my home health 
agency and thousands of other home health agencies across the country.

    I am extremely concerned that our long history of service to the 
residents of Nebraska is at risk due to the significant payment 
reductions that CMS started in 2020 when the new payment model, the 
Patient-Driven Groupings Model (PDGM), was implemented, and what 
appears to be a lack of appreciation by CMS and others of the role home 
health plays in the broader health-care delivery system.

    I want to stress that we are at an inflection point within the home 
health delivery system.

    If CMS does not retract the payment cuts being proposed for 2024, 
if the administration allows the payment cuts to proceed, and if 
Congress does not act to reverse CMS's policy to impose double-digit 
payment reductions, we could likely see the complete collapse of the 
home health payment system.

    Mary Lanning Home Health has seen our average daily census count 
reduced by more than 60 percent since the implementation of PDGM, from 
an average of 88 patients in 2020 to a census count in September 2023 
of 32. It's not because there is not a need and demand for home health 
services, but rather due to a perfect storm of a workforce crisis, high 
inflation, and Medicare payment reductions for home health services 
that are not only putting a financial strain on our agency but also 
limiting our ability to recruit and retain the nurses, therapists, and 
home health aides that are vital to our ability to deliver care in the 
home.

    Mary Lanning Home Health previously covered a 13-county, 60-mile 
radius of Hastings, which included Adams, Buffalo, Clay, Fillmore, 
Franklin, Hall, Hamilton, Howard, Kearney, Merrick, Nuckolls, Thayer, 
and Webster counties. In March of this year, we had to decrease our 
service area to 40 miles. Several months later, in May, we had to make 
the difficult decision to further reduce our service area to cover only 
Adams County, which covers a 25-mile radius including the city of 
Hastings.

    Some of the previous counties that we served have no coverage by 
any home health provider. One home health provider moved their office 
from Hastings because they were down to one registered nurse. They have 
now joined with their partnered location in Grand Island. Several other 
home health agency providers do not accept Medicaid patients or only 
take patients who are in-network or those that require too much care.

    Hospitals are seeing higher-acuity patients than in previous years, 
and our agency is providing more intensive home health services to a 
population that has more complex needs and increased comorbidities. We 
have limited admitting patients that require too much skilled care 
because we simply lack the workforce to provide the high-quality care 
necessary for a successful home health outcome.

    When a patient isn't able to be admitted to our home health agency, 
the result is either longer lengths of stay in the acute setting, 
placement in a skilled nursing facility, or foregoing post-acute care 
all together.

    The decision for a home health agency to reduce its service area, 
especially in rural counties, is incredibly difficult since we know 
there will be patients living in those areas that need our services. 
However, reducing our service area is the only path forward that allows 
our home health agency to remain financially viable and continue to 
serve some patients who need home health services, albeit in a reduced 
geographic location.

    As I noted, reducing our service area from 13 counties to one was 
necessary to survive and provide care to some patients in our area. We 
very much wish we did not have to take this drastic step, particularly 
because we knew there would be no alternative home health agencies for 
the affected areas.

    The drastic reduction in our service area just to remain 
operational is having a direct impact on Medicare beneficiaries. This 
year alone, we have declined services to 55 referrals because the 
patients were outside our reduced service area. That is a rejection 
rate of over 50 percent through August of this year. Our dedicated 
staff is heartbroken because their mission is patient care, but we had 
no choice.

    Since 2020, our traditional Medicare home health agency payments 
have been cut by more than 8 percent. The annual payment updates in 
2021 and 2022 didn't begin to cover the dramatic rise in labor costs 
due to the increased demand in nursing services caused by the COVID-19 
pandemic and the ongoing workforce shortage, or the rapid rise in our 
supply costs due to the surge in inflation. As Medicare payments for 
services started to be cut, our revenue started to decline. From 2020 
to 2022, we experienced a 15-percent reduction in revenue for our 
services.

    CMS's actions to reduce home health payments are also having a 
direct impact on our ability to retain our existing workforce.

    We have had three registered nurses resign due to fear that the 
looming payment cuts being proposed by CMS will force the agency to 
close. The three nurses did not leave nursing; instead, they went to 
work for other health-care providers rather than risk remaining with 
Mary Lanning Home Health.

    We are now down to three full-time registered nurses and one part-
time registered nurse. Since we have reduced our service area, we have 
reduced our costs as much as possible. We have eliminated a billing and 
coding specialist and are now providing those functions within a shared 
service arrangement with our hospice. We had our registered nurse 
clinical manager resign, and that position has been eliminated. We no 
longer provide on-call availability after 4:30 p.m. during the week and 
now have a voicemail set up for follow-up the next morning.

    The instability that is being created within the home health 
program by CMS is forcing the home health workforce to seek employment 
elsewhere rather than risk working at a home health agency that could 
close at any time due to insolvency. Think about what I just said: the 
Medicare program is failing to fulfill its promises to Nebraskans and 
the millions of Medicare beneficiaries who need home health services.

    Inpatient stays are expensive. Daily room and board costs can reach 
$3,000 per day, and this does not count medications, tests, and 
treatments. The cost is significantly higher if a patient is 
rehospitalized and admitted to the ICU. The loss of home health 
services is highly likely to trigger these added costs to the Medicare 
program.

    In 2022, Mary Lanning Home Health prevented 93.5 percent of the 
1,059 patients we served from being readmitted to the hospital, 
averaging a 7.6-percent readmission rate that was well below the State 
and national averages. Year to date through July 2023, Mary Lanning 
Home Health has prevented 93.7 percent of the 558 patients we served 
from being rehospitalized. We have a 5-star patient satisfaction rating 
on Home Health Compare.

    In addition to the skilled care provided within the home health 
benefit, our clinicians assist patients with transitioning to their 
home after being hospitalized by teaching and training new medications 
and advocating for adaptations in the home for patient safety.

    The high-quality home health services we provide are not only 
patient-preferred but also improve patient outcomes and provide savings 
to the Medicare program. And you don't have to take my word for the 
savings to the program; CMS's own data has confirmed the value of the 
home health program through its Home Health Value-Based Purchasing 
(HHVBP) Model, which has reduced Medicare spending by hundreds of 
millions of dollars already.

    As we look to prepare for 2024, with the pending payment reductions 
that CMS has proposed and the potential for payment reductions spanning 
past 2030, we are doing everything possible to remain operational.

    There are agencies throughout Nebraska and the country that are at 
serious risk of closure.

    I understand that some have already closed or reduced service 
areas, as we have at Mary Lanning Home Health. Agencies simply cannot 
cut expenses any more than we have already and remain viable without 
impacting the quality of care and the level of services we provide.

    At Mary Lanning Home Health, the only alternative we will have if 
CMS does not reverse course is for the agency to close or hope that 
another home health provider comes to take over our service area. We 
should not have to hope that Medicare adequately supports the vital and 
essential care covered under the home health services benefit.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]



----------------------------------------------------------------------------------------------------------------
                                                                                    Traditional      Medicare
                                                    Traditional      Medicare        Medicare        Advantage
         Nebraska County             Medicare        Medicare        Advantage     Enrolled % of   Enrolled % of
                                     Eligible        Enrolled        Enrolled        Medicare        Medicare
                                                                                     Eligible        Eligible
----------------------------------------------------------------------------------------------------------------
Adams                                      7,015           4,865           2,150             69%             31%
----------------------------------------------------------------------------------------------------------------
Buffalo                                    9,280           6,328           2,952             68%             32%
----------------------------------------------------------------------------------------------------------------
Clay                                       1,522           1,162             360             76%             24%
----------------------------------------------------------------------------------------------------------------
Fillmore                                   1,569           1,197             372             76%             24%
----------------------------------------------------------------------------------------------------------------
Franklin                                     837             606             231             72%             28%
----------------------------------------------------------------------------------------------------------------
Hall                                      11,061           6,848           4,213             62%             38%
----------------------------------------------------------------------------------------------------------------
Hamilton                                   2,301           1,705             596             74%             26%
----------------------------------------------------------------------------------------------------------------
Howard                                     1,545           1,104             441             71%             29%
----------------------------------------------------------------------------------------------------------------
Kearney                                    1,310             869             441             66%             34%
----------------------------------------------------------------------------------------------------------------
Merrick                                    1,904           1,387             517             73%             27%
----------------------------------------------------------------------------------------------------------------
Nuckolls                                   1,295           1,128             167             87%             13%
----------------------------------------------------------------------------------------------------------------
Thayer                                     1,398           1,111             287             79%             21%
----------------------------------------------------------------------------------------------------------------
Webster                                      910             630             280             69%             31%
================================================================================================================
Total                                     41,947          28,940          13,007
----------------------------------------------------------------------------------------------------------------


                                     Nebraska Medicare Enrollment by County
                                            As of September 15, 2023
----------------------------------------------------------------------------------------------------------------
                                                                                       Traditional    Medicare
                                                           Traditional    Medicare      Medicare      Advantage
              Nebraska County                 Medicare      Medicare      Advantage    Enrolled %    Enrolled %
                                              Eligible      Enrolled      Enrolled     of Medicare   of Medicare
                                                                                        Eligible      Eligible
----------------------------------------------------------------------------------------------------------------
Adams                                              7,015         4,865         2,150           69%           31%
----------------------------------------------------------------------------------------------------------------
Antelope                                           1,651         1,251           400           76%           24%
----------------------------------------------------------------------------------------------------------------
Arthur                                               110           110             0          100%            0%
----------------------------------------------------------------------------------------------------------------
Banner                                               270           253            17           94%            6%
----------------------------------------------------------------------------------------------------------------
Blaine                                               120           120             0          100%            0%
----------------------------------------------------------------------------------------------------------------
Boone                                              1,438           974           464           68%           32%
----------------------------------------------------------------------------------------------------------------
Box Butte                                          2,617         2,397           220           92%            8%
----------------------------------------------------------------------------------------------------------------
Boyd                                                 655           569            86           87%           13%
----------------------------------------------------------------------------------------------------------------
Brown                                                735           711            24           97%            3%
----------------------------------------------------------------------------------------------------------------
Buffalo                                            9,280         6,328         2,952           68%           32%
----------------------------------------------------------------------------------------------------------------
Burt                                               1,910         1,354           556           71%           29%
----------------------------------------------------------------------------------------------------------------
Butler                                             1,898         1,475           423           78%           22%
----------------------------------------------------------------------------------------------------------------
Cass                                               5,742         3,758         1,984           65%           35%
----------------------------------------------------------------------------------------------------------------
Cedar                                              2,083         1,381           702           66%           34%
----------------------------------------------------------------------------------------------------------------
Chase                                                918           857            61           93%            7%
----------------------------------------------------------------------------------------------------------------
Cherry                                             1,365         1,353            12           99%            1%
----------------------------------------------------------------------------------------------------------------
Cheyenne                                           2,407         2,196           211           91%            9%
----------------------------------------------------------------------------------------------------------------
Clay                                               1,522         1,162           360           76%           24%
----------------------------------------------------------------------------------------------------------------
Colfax                                             1,609         1,281           328           80%           20%
----------------------------------------------------------------------------------------------------------------
Cuming                                             2,225         1,797           428           81%           19%
----------------------------------------------------------------------------------------------------------------
Custer                                             2,706         2,065           641           76%           24%
----------------------------------------------------------------------------------------------------------------
Dakota                                             3,508         2,027         1,481           58%           42%
----------------------------------------------------------------------------------------------------------------
Dawes                                              1,810         1,588           222           88%           12%
----------------------------------------------------------------------------------------------------------------
Dawson                                             4,431         3,672           759           83%           17%
----------------------------------------------------------------------------------------------------------------
Deuel                                                557           500            57           90%           10%
----------------------------------------------------------------------------------------------------------------
Dixon                                              1,243           751           492           60%           40%
----------------------------------------------------------------------------------------------------------------
Dodge                                              8,435         5,567         2,868           66%           34%
----------------------------------------------------------------------------------------------------------------
Douglas                                           95,335        54,191        41,144           57%           43%
----------------------------------------------------------------------------------------------------------------
Dundy                                                504           455            49           90%           10%
----------------------------------------------------------------------------------------------------------------
Fillmore                                           1,569         1,197           372           76%           24%
----------------------------------------------------------------------------------------------------------------
Franklin                                             837           606           231           72%           28%
----------------------------------------------------------------------------------------------------------------
Frontier                                             618           510           108           83%           17%
----------------------------------------------------------------------------------------------------------------
Furnas                                             1,369         1,122           247           82%           18%
----------------------------------------------------------------------------------------------------------------
Gage                                               5,744         3,913         1,831           68%           32%
----------------------------------------------------------------------------------------------------------------
Garden                                               625           545            80           87%           13%
----------------------------------------------------------------------------------------------------------------
Garfield                                             477           326           151           68%           32%
----------------------------------------------------------------------------------------------------------------
Gosper                                               544           442           102           81%           19%
----------------------------------------------------------------------------------------------------------------
Grant                                                183           183             0          100%            0%
----------------------------------------------------------------------------------------------------------------
Greeley                                              607           463           144           76%           24%
----------------------------------------------------------------------------------------------------------------
Hall                                              11,061         6,848         4,213           62%           38%
----------------------------------------------------------------------------------------------------------------
Hamilton                                           2,301         1,705           596           74%           26%
----------------------------------------------------------------------------------------------------------------
Harlan                                               915           725           190           79%           21%
----------------------------------------------------------------------------------------------------------------
Hayes                                                205           191            14           93%            7%
----------------------------------------------------------------------------------------------------------------
Hitchcock                                            803           703           100           88%           12%
----------------------------------------------------------------------------------------------------------------
Holt                                               2,651         2,117           534           80%           20%
----------------------------------------------------------------------------------------------------------------
Hooker                                               251           227            24           90%           10%
----------------------------------------------------------------------------------------------------------------
Howard                                             1,545         1,104           441           71%           29%
----------------------------------------------------------------------------------------------------------------
Jefferson                                          2,005         1,394           611           70%           30%
----------------------------------------------------------------------------------------------------------------
Johnson                                              899           684           215           76%           24%
----------------------------------------------------------------------------------------------------------------
Kearney                                            1,310           869           441           66%           34%
----------------------------------------------------------------------------------------------------------------
Keith                                              2,253         1,772           481           79%           21%
----------------------------------------------------------------------------------------------------------------
Keya Paha                                            273           252            21           92%            8%
----------------------------------------------------------------------------------------------------------------
Kimball                                            1,035           976            59           94%            6%
----------------------------------------------------------------------------------------------------------------
Knox                                               2,329         1,519           810           65%           35%
----------------------------------------------------------------------------------------------------------------
Lancaster                                         55,926        37,778        18,148           68%           32%
----------------------------------------------------------------------------------------------------------------
Lincoln                                            8,191         5,869         2,322           72%           28%
----------------------------------------------------------------------------------------------------------------
Logan                                                170           145            25           85%           15%
----------------------------------------------------------------------------------------------------------------
Loup                                                 176           125            51           71%           29%
----------------------------------------------------------------------------------------------------------------
Madison                                            7,464         4,744         2,720           64%           36%
----------------------------------------------------------------------------------------------------------------
McPherson                                            101            87            14           86%           14%
----------------------------------------------------------------------------------------------------------------
Merrick                                            1,904         1,387           517           73%           27%
----------------------------------------------------------------------------------------------------------------
Nance                                                684           509           175           74%           26%
----------------------------------------------------------------------------------------------------------------
Nemaha                                             1,609         1,311           298           81%           19%
----------------------------------------------------------------------------------------------------------------
Nuckolls                                           1,295         1,128           167           87%           13%
----------------------------------------------------------------------------------------------------------------
Otoe                                               3,917         2,814         1,103           72%           28%
----------------------------------------------------------------------------------------------------------------
Pawnee                                               635           477           158           75%           25%
----------------------------------------------------------------------------------------------------------------
Perkins                                              712           612           100           86%           14%
----------------------------------------------------------------------------------------------------------------
Phelps                                             2,157         1,744           413           81%           19%
----------------------------------------------------------------------------------------------------------------
Pierce                                             1,591         1,112           479           70%           30%
----------------------------------------------------------------------------------------------------------------
Platte                                             6,949         5,527         1,422           80%           20%
----------------------------------------------------------------------------------------------------------------
Polk                                               1,372         1,127           245           82%           18%
----------------------------------------------------------------------------------------------------------------
Red Willow                                         2,564         2,374           190           93%            7%
----------------------------------------------------------------------------------------------------------------
Richardson                                         2,185         2,017           168           92%            8%
----------------------------------------------------------------------------------------------------------------
Rock                                                 397           328            69           83%           17%
----------------------------------------------------------------------------------------------------------------
Saline                                             2,693         1,932           761           72%           28%
----------------------------------------------------------------------------------------------------------------
Sarpy                                             29,698        19,149        10,549           64%           36%
----------------------------------------------------------------------------------------------------------------
Saunders                                           4,651         3,095         1,556           67%           33%
----------------------------------------------------------------------------------------------------------------
Scotts Bluff                                       8,508         6,199         2,309           73%           27%
----------------------------------------------------------------------------------------------------------------
Seward                                             3,732         2,782           950           75%           25%
----------------------------------------------------------------------------------------------------------------
Sheridan                                           1,381         1,221           160           88%           12%
----------------------------------------------------------------------------------------------------------------
Sherman                                              893           616           277           69%           31%
----------------------------------------------------------------------------------------------------------------
Sioux                                                282           258            24           91%            9%
----------------------------------------------------------------------------------------------------------------
Stanton                                            1,108           720           388           65%           35%
----------------------------------------------------------------------------------------------------------------
Thayer                                             1,398         1,111           287           79%           21%
----------------------------------------------------------------------------------------------------------------
Thomas                                               202           166            36           82%           18%
----------------------------------------------------------------------------------------------------------------
Thurston                                             998           727           271           73%           27%
----------------------------------------------------------------------------------------------------------------
Valley                                             1,085           777           308           72%           28%
----------------------------------------------------------------------------------------------------------------
Washington                                         4,649         2,830         1,819           61%           39%
----------------------------------------------------------------------------------------------------------------
Wayne                                              1,612         1,194           418           74%           26%
----------------------------------------------------------------------------------------------------------------
Webster                                              910           630           280           69%           31%
----------------------------------------------------------------------------------------------------------------
Wheeler                                              174           137            37           79%           21%
----------------------------------------------------------------------------------------------------------------
York                                               3,289         2,634           655           80%           20%
----------------------------------------------------------------------------------------------------------------
Source: Centers for Medicare and Medicaid Services, State County Penetration Data for Medicare Advantage,
  September 2023.

      Prepared Statement of David C. Grabowski, Ph.D., Professor, 
        Department of Health Care Policy, Harvard Medical School
    Chairman Cardin, Ranking Member Daines, and distinguished members 
of the Subcommittee on Health Care, thank you for the opportunity to 
testify today on this important topic. I am a professor of health care 
policy at Harvard Medical School. I am here today speaking in my 
capacity as a researcher who has studied home health care for over 2 
decades.

    Care is shifting out of institutions and into the home. Several 
prepandemic policies \1\, \2\ contributed to this change, but the 
pandemic further increased the delivery of care at home.\3\ This shift 
to home-based care is consistent with the preferences of Medicare 
beneficiaries and their caregivers to ``age in place.''\4\ From a 
policy perspective, a key objective is to provide individuals with the 
necessary services to not just age in place, but to age in place safely 
and successfully.
---------------------------------------------------------------------------
    \1\ Barnett, M.L., Mehrotra, A., Grabowski, D.C. Postacute Care--
The Piggy Bank for Savings in Alternative Payment Models? The New 
England Journal of Medicine 2019;381(4):302-303. (In eng). DOI: 
10.1056/NEJMp1901896.
    \2\ Huckfeldt, P.J., Escarce, J.J., Rabideau, B., Karaca-Mandic, 
P., Sood, N. Less Intense Postacute Care, Better Outcomes for Enrollees 
in Medicare Advantage Than Those in Fee-For-Service. Health Affairs 
2017;36(1):91-100. (Research Support, NIH, Extramural). (In eng). DOI: 
10.1377/hlthaff.2016.1027.
    \3\ Werner, R.M., Bressman, E. Trends in Post-Acute Care 
Utilization During the COVID-19 Pandemic. J Am Med Dir Assoc 
2021;22(12):2496-2499. DOI: 10.1016/j.jamda.2021.09.001.
    \4\ Geng, F., McGarry, B.E., Rosenthal, M.B., Zubizarreta, J.R., 
Resch, S.C., Grabowski, D.C. Choosing Home: Patients and Caregivers 
Prioritize Post-Acute Care at Home over Facilities--A Discrete Choice 
Experiment. Unpublished working paper: Harvard University; 2023.

    The Medicare home health benefit can potentially help beneficiaries 
to do this. As the Medicare Payment Advisory Commission (MedPAC) wrote 
in its March 2023 Report to the Congress, ``home health care can be a 
high-value benefit when it is appropriately and efficiently 
delivered.''\5\ Three million fee-for-service Medicare beneficiaries 
used home health care from 11,474 agencies in 2021, accounting for 8.3 
percent of all beneficiaries. The fee-for-service Medicare program 
spent $16.9 billion in 2021 on home health-care services.
---------------------------------------------------------------------------
    \5\ Medicare Payment Advisory Commission. Report to the Congress: 
Medicare Payment Policy. Washington, DC: March 2023.

    Overall, most Medicare beneficiaries live in an area served by home 
health care. According to the March 2023 MedPAC Report to the Congress, 
over 98 percent of fee-for-service Medicare beneficiaries live in a ZIP 
code served by at least one home health agency, while 87.6 percent live 
in a ZIP code with five or more agencies.\5\ The MedPAC report also 
found utilization of home health care was relatively comparable across 
rural and urban areas. However, a literature review of earlier peer-
reviewed studies examining urban-rural home health access found that 
rural beneficiaries had significantly lower home health-care 
utilization rates and physical therapy utilization rates.\6\ Rural home 
health patients had 6 percent fewer home health rehabilitation visits 
after intensive-care unit stays, 11 percent lower physical therapy 
utilization after total knee arthroplasty, and 5.7 percent fewer visits 
from rehabilitation specialists.
---------------------------------------------------------------------------
    \6\ Quigley, D.D., Chastain, A.M., Kang, J.A., et al. Systematic 
Review of Rural and Urban Differences in Care Provided by Home Health 
Agencies in the United States. J Am Med Dir Assoc 2022;23(10):1653 e1-
1653 e13. DOI: 10.1016/j.jamda.2022.08.011.

    Importantly, utilization of home health services does not 
necessarily equate directly to access. For example, just because a home 
health agency may see one patient in a ZIP code does not mean they 
regularly accept new patients or provide timely visits. Moreover, it is 
important to acknowledge a lag in the fee-for-service Medicare data, 
and the extenuating circumstances of the last several years with the 
---------------------------------------------------------------------------
pandemic and accompanying labor shortages.

    My testimony focuses on how the Congress can address access to 
Medicare home health-care services with the goal of increasing the 
number of beneficiaries who can age in place safely and successfully.

    Medicare fee-for-service payments are adequate to ensure access: 
The 2023 MedPAC report \5\ to Congress found Medicare margins for 
freestanding HHAs reached an all-time high in 2021 of 24.9 percent. 
(The Medicare home health margin is calculated by MedPAC using the 
following formula: (Medicare payments - Medicare allowable costs)/
Medicare payments.) From 2001 to 2019, Medicare margins for 
freestanding HHAs averaged 16.4 percent. In 2020, this increased to 
20.2 percent. MedPAC has consistently recommended a reduction in the 
base payment rate for home health agencies, including a 7-percent 
reduction for Calendar Year 2024. In 2021, freestanding agencies 
serving rural areas had a higher Medicare margin (25.2 percent) 
relative to those serving urban areas (24.8 percent).

    If the Congress is going to address rural access through payment, I 
would recommend they do so through a rural payment add-on \7\ or some 
other targeted rural policy. They should not try to solve a potential 
rural access problem through an adjustment to the overall fee-for-
service payment system, which is currently paying home health agencies 
well above costs.
---------------------------------------------------------------------------
    \7\ Mroz, T.M., Patterson, D.G., Frogner, B.K. The Impact of 
Medicare's Rural Add-on Payments on Supply of Home Health Agencies 
Serving Rural Counties. Health Aff (Millwood) 2020;39(6):949-957. DOI: 
10.1377/hlthaff.2019.00952.

    Because the Medicare Patient Driven Groupings Model (PDGM) payment 
system was adopted at the start of the pandemic, it is not yet possible 
to determine whether and how the PDGM has impacted home health access: 
In January 2020, the method of Medicare fee-for-service payment for 
home health agencies shifted from one that paid agencies based on the 
delivery of therapy services to one that paid based on patient 
characteristics.\8\ The new payment system, termed the Patient-Driven 
Groupings Model (or PDGM), shifted the payment episode from 60 days to 
30 days. Through 2021, home health agencies nationally are doing better 
financially during the pandemic and under the new PDGM payment system.5 
Once again, MedPAC reported higher Medicare margins in 2020 and 2021 
relative to prior years.
---------------------------------------------------------------------------
    \8\ Navathe, A.S., Grabowski, D.C. Will Medicare's New Patient-
Driven Postacute Care Payment System Be a Step Forward? JAMA Health 
Forum 2020;1(6):e200718. DOI: 10.1001/jamahealthforum.2020.0718.

    One rationale for the new payment system was to limit the incentive 
to overprovide therapy. Because the PDGM model is based on patient 
characteristics, it should encourage greater home health-care access 
for higher acuity patients. Under the prior system, the most lucrative 
patients were those who received the most therapy. Under the PDGM, the 
most lucrative patients are those with the greatest number of care 
needs. It will be important to examine whether the PDGM has changed the 
use of services and the mix of patients. Given the timing of the PDGM 
however, researchers have not yet been able to disentangle what changes 
---------------------------------------------------------------------------
are due to the PDGM and what is due to the pandemic.

    Thus, I would caution the Congress about making major changes to 
the PDGM at this time. I believe it is too early to draw strong 
conclusions about how this policy has impacted access given it was 
introduced at the start of the pandemic.

    Enrollees in Medicare Advantage plans use less home health care, 
often from lower-rated agencies. A growing share of home health 
patients are enrolled in Medicare Advantage plans. Beneficiaries in 
these plans use less home health, partly because of mechanisms like 
prior authorization and utilization management that are not allowed in 
fee-for-service Medicare.\9\ The plans can also use networks to steer 
patients to certain home health agencies. Research has shown that 
enrollees in Medicare Advantage typically use lower star-rated agencies 
relative to their fee-for-service counterparts.\10\ Medicare Advantage 
plans also pay home health agencies below the fee-for-service Medicare 
rate. When you factor in care from all payers (including Medicaid and 
other sources), the overall margin for HHAs was estimated at 11.9 
percent in 2021, which is well below the Medicare margin of 24.9 
percent.
---------------------------------------------------------------------------
    \9\ Skopec, L., Zuckerman, S., Aarons, J., et al. Home Health Use 
In Medicare Advantage Compared to Use in Traditional Medicare. Health 
Aff (Millwood) 2020;39(6):1072-1079. DOI: 10.1377/hlthaff.2019.01091.
    \10\ Schwartz, M.L., Kosar, C.M., Mroz, T.M., Kumar, A., Rahman, M. 
Quality of Home Health Agencies Serving Traditional Medicare vs 
Medicare Advantage Beneficiaries. JAMA Netw Open 2019;2(9):e1910622. 
DOI: 10.1001/jamanetworkopen.2019.10622.

    An important question is the amount of unmet demand for home health 
services among Medicare Advantage enrollees in the context of prior 
authorization requirements and utilization management. Thus far, 
research has not found declines in claims-based outcomes like 
hospitalizations and mortality when the amount of home health is 
decreased.\11\ However, these outcomes only tell a part of the story.
---------------------------------------------------------------------------
    \11\ Huckfeldt, P.J., Sood, N., Escarce, J.J., Grabowski, D.C., 
Newhouse, J.P. Effects of Medicare payment reform: Evidence from the 
home health interim and prospective payment systems. Journal of Health 
Economics 2014;34:1-18. (In eng). DOI: 10.1016/j.jhealeco.2013.11.005.

    The Congress should request a comprehensive evaluation of home 
---------------------------------------------------------------------------
health-care access for enrollees in Medicare Advantage plans.

    Labor challenges are contributing to home health access issues: The 
pandemic has magnified home health labor challenges, especially in 
rural areas.\12\, \13\ Using the 2021 Occupational Employment and Wage 
Statistics dataset, one study estimated that there are, on average, 
32.9 home health aides per 1,000 older adults (age 65+) in rural areas 
and 50.4 home health aides per 1,000 older adults in urban areas.\14\ 
In an analysis of the Medicaid home and community-based services 
workforce through 2020, the number of workers per beneficiary has been 
declining over time.\15\ We have seen similar shortages for workers in 
other post-acute and long-term care settings during the pandemic.\16\, 
\17\
---------------------------------------------------------------------------
    \12\ Rowland, C. Seniors are stuck home alone as health aides flee 
for higher-paying jobs. Washington Post 2022.
    \13\ Oldenburg, A. Nationwide Caregiver Shortage Felt By Older 
Adults. AARP. 2022. (https://www.aarp.org/caregiving/basics/info-2022/
in-home-caregiver-shortage.html).
    \14\ Dill, J., Henning-Smith, C., Zhu, R., Vomacka, E. Who Will 
Care for Rural Older Adults? Measuring the Direct Care Workforce in 
Rural Areas. J Appl Gerontol 2023;42(8):1800-1808. DOI: 10.1177/
07334648231158482.
    \15\ Kreider, A.R., Werner, R.M. The Home Care Workforce Has Not 
Kept Pace With Growth in Home and Community-Based Services. Health Aff 
(Millwood) 2023;42(5):650-657. DOI: 10.1377/hlthaff.2022.01351.
    \16\ McGarry, B.E., Grabowski, D.C., Barnett, M.L. Severe Staffing 
and Personal Protective Equipment Shortages Faced By Nursing Homes 
During the COVID-19 Pandemic. Health Aff (Millwood) 2020;39(10):1812-
1821. DOI: 10.1377/hlthaff.2020.01269.
    \17\ Brazier, J.F., Geng, F., Meehan, A., et al. Examination of 
Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic. 
JAMA Netw Open 2023;6(7):e2325993. DOI: 10.1001/
jamanetworkopen.2023.25993.

    The most direct policy to increase the size of the labor force is 
through wage increases. Once again, Medicare fee-for-service payment 
rates are well above costs such that most agencies should be able to 
---------------------------------------------------------------------------
pay home health-care workers the prevailing wage rate.

    If there are certain markets where this is not the case (e.g., 
rural markets with few available workers), Congress could consider 
targeted policies for home health agencies to use towards the higher 
cost of labor in these markets.

    Another potential policy to ensure competitive home health wages 
and sufficient staffing involves increasing the accountability of home 
health agencies. Most home health agencies are for-profit owned, and 
multi-agency chains have expanded their ownership role in the home 
health sector over the past decade.\18\ Moreover, we have seen 
increased common investor associations across hospitals and home health 
care in recent years too.\19\ Similar to nursing homes and other post-
acute providers, these agencies have become more complex in terms of 
their ownership. A key question is whether these complex entities are 
putting sufficient dollars back into direct patient care. In April 
2023, CMS announced the release of public ownership information for 
home health-care agencies.\20\
---------------------------------------------------------------------------
    \18\ Geng, F., Mansouri, S., Stevenson, D.G., Grabowski, D.C. 
Evolution of the home health-care market: The expansion and quality 
performance of multi-agency chains. Health Serv Res 2020;55 Suppl 
3(Suppl 3):1073-1084. DOI: 10.1111/1475-6773.13597.
    \19\ Fowler, A.C., Grabowski, D.C., Gambrel, R.J., Huskamp, H.A., 
Stevenson, D.G. Corporate Investors Increased Common Ownership in 
Hospitals and the Postacute Care and Hospice Sectors. Health Affairs 
2017;36(9):1547-1555. (In eng). DOI: 10.1377/hlthaff.2017.0591.
    \20\ Donlan, A. CMS to Publicly Release All Ownership Info of Home 
Health, Hospice Agencies. Home Health Care News 2023.

    Continuing to publish financial and ownership data for home health 
agencies can help policymakers ensure that public payments are being 
---------------------------------------------------------------------------
used on staffing as intended.

    Finally, it is important to note that many home health workers are 
immigrants.\21\ In a recent study, we found increased immigration led 
to more nursing home workers and ultimately higher quality.\22\ I would 
hypothesize similar relationships exist for home health care. 
Historically, Federal policies on immigration visas have been used to 
grow the health care labor market.
---------------------------------------------------------------------------
    \21\ Zallman, L., Finnegan, K.E., Himmelstein, D.U., Touw, S., 
Woolhandler, S. Care for America's Elderly and Disabled People Relies 
on Immigrant Labor. Health Aff (Millwood) 2019;38(6):919-926. DOI: 
10.1377/hlthaff.2018.05514.
    \22\ Grabowski, D.C., Gruber, J., McGarry, B.E. Immigration, the 
Long-Term Care Workforce, and Elder Outcomes in the U.S. NBER Working 
Paper #30960. National Bureau of Economic Research 2023.

    The Congress could expand the home health care labor force by 
creating a new visa category for workers in home health care and other 
---------------------------------------------------------------------------
related jobs.

    Data gaps prevent us from determining whether beneficiaries are 
accessing high-quality home health care: Unfortunately, we have a 
limited set of validated home health quality measures.\5\ For this 
reason, MedPAC tends to rely on claims-based measures such as hospital 
readmissions in evaluating home health quality. Readmissions are an 
important measure, but they do not provide the full story. Home health 
agencies are mandated to collect detailed assessment data through the 
Outcome Assessment Information Set (or OASIS), but MedPAC and others 
have questioned the accuracy of the OASIS data because they are agency-
reported and not subject to consistent audit or review. The OASIS could 
provide policymakers with important information on functional 
improvement and other key measures, but accuracy issues severely limit 
the usability of these data. It is troubling that agency-reported 
measures have been showing improvement over time, while claims-based 
measures have been stagnant or declining.\5\

    The Congress should encourage the development of improved quality 
measures, including the increased auditing and oversight of the 
existing agency-reported OASIS data.

    Medicare beneficiaries may not be able to access home health care 
due to additional caregiving needs: The home health-care benefit 
typically consists of a mix of skilled nursing, therapy, and home 
health aide visits. Many individuals receiving care in the community 
also require extensive home care, which is assistance with their long-
term care needs like bathing, dressing, and toileting. Because the 
Medicare home health-care benefit does not include comprehensive home 
care, enrollees often must rely on family caregivers, paid help, or 
Medicaid for these needs. As such, there are disparities by race, 
ethnicity, and income as to who can age in place in a high-quality 
setting.\23\ Not everyone has sufficient resources or familial support 
to access the Medicare home health-care benefit.
---------------------------------------------------------------------------
    \23\ Fashaw-Walters, S.A., Rahman, M., Gee, G., Mor, V., White, M., 
Thomas, K.S. Out of Reach: Inequities in the Use of High-Quality Home 
Health Agencies. Health Aff (Millwood) 2022;41(2):247-255. DOI: 
10.1377/hlthaff.2021.01408.

    Accessing home care can be challenging.\24\ Family caregivers are 
often overburdened.\25\, \26\ Medicaid has a waiting list for home care 
services in many States.\27\ Private duty home care is expensive,\28\ 
with many older adults caught in the ``forgotten middle'' of not being 
able to afford adequate care but also not qualifying for Medicaid based 
on the income and assets test.\29\
---------------------------------------------------------------------------
    \24\ Sterling, M.R., Grabowski, D.C., Shen, M.J. Obtaining and 
Paying for Home Care--Navigating Patients Through the Complex Terrain 
of Home Care in the US. JAMA Intern Med 2023;183(8):755-756. DOI: 
10.1001/jamainternmed.2023.2072.
    \25\ Grabowski, D.C., Norton, E.C., Van Houtven, C.H. ``Informal 
Care.'' In: Jones AM, ed. The Elgar Companion to Health Economics, 
Second Edition. Cheltenham, UK: Edward Elgar Publishing, Inc; 2012:318-
328.
    \26\ Tumlinson, A. What I Learned From My Family's Home Health 
Experience. Health Affairs Forefront 2022 (https://
www.healthaffairs.org/content/forefront/i-learned-my-family-s-home-
health-experience).
    \27\ Burns, A., O'Malley Watts, M., Ammula, M. A Look at Waiting 
lists for Home and 
Community-Based Services from 2016 to 2021. 2022. (https://www.kff.org/
medicaid/issue-brief/a-look-at-waiting-lists-for-home-and-community-
based-services-from-2016-to-2021/).
    \28\ Genworth Financial. Cost of Care Trends and Insights. 2022. 
(https://www.genworth.com/aging-and-you/finances/cost-of-care/cost-of-
care-trends-and-insights.html).
    \29\ Pearson, C.F., Quinn, C.C., Loganathan, S., Datta, A.R., Mace, 
B.B., Grabowski, D.C. The Forgotten Middle: Many Middle-Income Seniors 
Will Have Insufficient Resources for Housing and Health Care. Health 
Affairs 2019;38(5):851-859. (In eng). DOI: 10.1377/hlthaff.2018.05233.

    One important area that has been largely ignored is the issue of 
family caregiving in the context of home health care. On the one hand, 
home health care has been found to decrease family caregiving burden 
relative to the receipt of no home health-care services.\30\ However, 
home health care requires much greater family caregiving time compared 
to skilled nursing facility care.\31\ In a study of individuals being 
discharged from a Boston-area hospital, we found living alone was a 
strong predictor of discharge to a skilled nursing facility, even after 
accounting for the health of the patient.\32\ The Biden administration 
recently announced a package of reforms to provide more support to 
family caregivers during the hospital discharge planning process.\33\
---------------------------------------------------------------------------
    \30\ Golberstein, E., Grabowski, D.C., Langa, K.M., Chernew, M.E. 
Effect of Medicare home health-care payment on informal care. Inquiry 
2009;46(1):58-71. (In eng). (http://www.
ncbi.nlm.nih.gov/entrez/
query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=
19489484).
    \31\ Werner, R.M., Van Houtven, C.J. In the Time of COVID-19, We 
Should Move High-
Intensity Postacute Care Home. Health Affairs Forefront 2020 (https://
www.healthaffairs.org/content/forefront/time-covid-19-we-should-move-
high-intensity-postacute-care-home).
    \32\ Lage, D.E., Jernigan, M.C., Chang, Y., et al. Living Alone and 
Discharge to Skilled Nursing Facility Care after Hospitalization in 
Older Adults. Journal of the American Geriatrics Society 
2018;66(1):100-105. (In eng). DOI: 10.1111/jgs.15150.
    \33\ The White House. Fact Sheet: Biden-Harris Administration 
Announces Most Sweeping Set of Executive Actions to Improve Care in 
History. April 18, 2023. Accessed on June 22, 2023. (https://
www.whitehouse.gov/briefing-room/statements-releases/2023/04/18/fact-
sheet-biden-harris-administration-announces-most-sweeping-set-of-
executive-actions-to-improve-care-in-history/).

    The Congress should continue to pursue policies to support family 
---------------------------------------------------------------------------
caregivers to ensure greater access to the home health-care benefit.

    For Medicare-Medicaid dually eligible beneficiaries, they can 
potentially qualify for home care services alongside Medicare home 
health care. Medicaid home and community-based services (HCBS) have the 
potential to substitute for high-cost nursing home services and allow 
dually eligible beneficiaries to age in place.\34\ Congress has enacted 
policies in the past including the increased Federal match rate for 
Medicaid HCBS under the American Rescue Plan Act and the Affordable 
Care Act's Balancing Incentive Program.\35\
---------------------------------------------------------------------------
    \34\ McGarry, B.E., Grabowski, D.C. Medicaid home and community-
based services spending for older adults: Is there a ``woodwork'' 
effect? J Am Geriatr Soc 2023. DOI: 10.1111/jgs.18478.
    \35\ Miller, E.A., Beauregard, L.K. Enhancing Federal Revenue under 
the American Rescue Plan Act: An Opportunity to Bolster State Medicaid 
Home and Community-Based Services Programs. J Aging Soc Policy 2022:1-
15. DOI: 10.1080/08959420.2021.2022952.

    To encourage safe and successful aging in place, I would strongly 
recommend that the Congress continue to invest in policies to expand 
---------------------------------------------------------------------------
Medicaid HCBS.

    Even in States that have invested in HCBS, Medicare and Medicaid 
services are often not well integrated.\36\ The 12.2 million dually 
eligible beneficiaries in the U.S. often face issues related to 
fragmented care and poor health outcomes associated with inadequate 
coordination of benefits and services across the two programs. There 
are currently three approaches in place to encourage care integration 
for dual beneficiaries: State Medicare-Medicaid plans (MMPs), the 
Federal Program of All-Inclusive Care for the Elderly (PACE), and 
Federal dual-eligible special-needs plans (D-SNPs). MMPs and PACE have 
strong models of care integration but relatively low enrollment. 
Capitated State MMPs cover slightly more than 400,000 dual eligibles, 
and PACE covers roughly 50,000 dual eligibles nationwide. In contrast, 
more than 4 million dual eligibles are enrolled in D-SNPs. However, 
these plans are highly variable in terms of their degree of integration 
across Medicare and Medicaid. Standard D-SNPs are poorly integrated 
while fully integrated dual-eligible plans (FIDE-SNPs) and highly 
integrated dual eligible plans (HIDE-SNPs) are better. Overall, only 10 
percent of dually eligible beneficiaries are enrolled in strongly 
integrated care models (MMPs, PACE, or FIDE-SNPs), and integrated care 
is unavailable in many parts of the United States.
---------------------------------------------------------------------------
    \36\ Grabowski, D.C. Improving Care Integration for Dually Eligible 
Beneficiaries. N Engl J Med 2023;388(15):1347-1349. DOI: 10.1056/
NEJMp2215502.

    As I outlined in a recent piece in the New England Journal of 
Medicine,\36\ I would strongly recommend the Congress undertake a 
series of activities to strengthen these Medicare-Medicaid integrated 
models including: (1) increased use of passive enrollment; (2) improved 
program alignment; (3) conversion of standard D-SNPs to FIDE-SNPs; (4) 
make investments in data and measures used to evaluate care of dual 
eligibles; and (5) begin to unify these disparate approaches to 
---------------------------------------------------------------------------
integrating care.

    In summary, access to Medicare home health care is generally 
strong, but there are some steps the Congress can take to ensure this 
benefit is helping individuals to age in place safely and successfully. 
I look forward to working with the members of this Subcommittee on this 
effort.

                                 ______
                                 
    Questions Submitted for the Record to David C. Grabowski, Ph.D.
             Questions Submitted by Hon. Benjamin L. Cardin
    Question. In your testimony, you discussed the need to pair the 
home health-care benefit with long-term care services.

    Can you say more about this relationship and why it is so important 
for allowing individuals to age in place?

    Answer. The Medicare home health-care benefit largely consists of 
skilled, therapy services. These services are important for aging in 
place, but many home health-care recipients also require extensive 
assistance with long-term care needs such as bathing, dressing, and 
toileting. The Medicare benefit includes some home health aide services 
but not enough to allow most individuals to age in place safely and 
effectively. For this to occur, Medicare home health care must be 
paired with long-term care services. Currently, families must either 
provide this long-term care themselves, pay for services in the private 
market, or receive services via Medicaid coverage. Each of these routes 
is challenging. Caregiving places a huge financial and health burden on 
family members. Private duty services are expensive and not affordable 
for many families. And finally, Medicaid services are limited and often 
have long waiting lists. Thus, investing in support for family 
caregivers and additional Medicaid services are key policy priorities.

    Question. What gaps exist in quality measurement for home health 
care, and what can we do to address them?

    Answer. Two major gaps exist in home health care quality 
measurement. First, many of the most important home health measures on 
the Care Compare Medicare.gov website are reported by the agencies 
themselves. They are not subject to any oversight or auditing. It is 
troubling that these agency-reported measures have shown improvement in 
recent years, while claims-based measures have largely declined. 
Because of uncertainty about the accuracy of the measures, groups such 
as the Medicare Payment Advisory Commission (MedPAC) have not used 
agency-
reported measures in evaluating home health quality. I would strongly 
encourage increased oversight and monitoring of these agency-reported 
assessments such that these data can be used for policy purposes. 
Second, the five-star rating on Care Compare based on patient 
satisfaction is largely topped out in that many agencies have 
relatively high satisfaction scores. The share of HHA patients 
providing a positive score ranges from 78 percent to 88 percent 
depending on the measure. I would encourage the Congress to investigate 
the use of more meaningful measures that provide a signal to consumers 
and policymakers.

               Questions Submitted by Hon. James Lankford
    Question. Home health providers in my State have expressed concerns 
that the impending and continuous CMS reimbursement cuts coming down 
from CMS will squeeze providers to urban areas and more patients to 
higher acuity locations of care such as skilled nursing facilities.

    Do you share these concerns? Do the current area wage index 
adjustments make up for the CMS cuts to ensure that access to home care 
in rural America is not impacted?

    Answer. I do think we need to continue to monitor home health-care 
access in rural areas. I am encouraged by the large operating margins 
that rural home health agencies report from Medicare. As I suggested in 
my testimony, rural margins are larger than urban margins. If we are 
having a rural payment crisis, it is in a select group of agencies. 
Thus, I would encourage Congress to focus any payment reforms on areas 
where there is truly an access crisis. Most rural home health agencies 
appeared to be doing well as of the March 2023 MedPAC report.

    Question. According to MedPAC ``access'' standards, it appears that 
an entire county has access to home health services if one HHA has 
served one patient in that county at all.

    Do you think these standards accurately display access to home 
health in America?

    Answer. To ensure access, I would argue that it is necessary that 
Medicare beneficiaries have an HHA operating in their county. However, 
it is far from sufficient. This measure doesn't tell us whether HHAs 
are accepting new patients or whether patients have timely access to 
nurse visits. MedPAC reports this measure due to data constraints. 
MedPAC can look at home health use, but it is not privy to measures 
about patient referrals or visit delays.

    Question. From your previous experience at MedPAC, how would you 
recommend those access standards change?

    Answer. I would like to see new access measures reported to CMS and 
used by MedPAC to evaluate home health access. These measures might 
include HHA denial and acceptance data of new Medicare patients, survey 
data on visit timeliness, and hospital data on challenges related to 
HHA discharges.

    Question. Does CMS have their own standards, or do they rely on 
MedPAC's standards?

    Answer. I am not aware of the standards CMS applies in evaluating 
Medicare home health-care access.

    Question. CMS is still using 2019 base data sets to operate from in 
making additional payment adjustments.

    Do you think those data are sufficient and accurate enough for CMS 
to continue using?

    Answer. The tradeoff here is that the 2019 data pre-date the 
pandemic and the shift to the Patient-Driven Groupings Model (PDGM) in 
January 2020. Thus, I think it is okay to trade off use of older data 
to minimize bias from the 2020 changes.

                                 ______
                                 
             Question Submitted by Hon. Sheldon Whitehouse
    Question. What specific recommendations do you have on how we can 
use the ACO model and telehealth to expand home health, including 
changes with CMS regulations, CMMI models, and legislation, to lower 
costs and improve patient care?

    Answer. Our team has found that ACOs generate savings for the 
Medicare program by shifting post-acute patients out of skilled nursing 
facilities and into home health agencies. This shift has not been found 
to impact quality negatively. Telemedicine was used widely in home-
based care at the start of the pandemic. There is incredible 
opportunity for risk-bearing models like ACOs to further incorporate 
such innovations in the delivery of care moving forward.

                                 ______
                                 
            Questions Submitted by Hon. Robert P. Casey, Jr.
    Question. In your written testimony, you mentioned that the 
pandemic has exacerbated home health labor challenges, with the number 
of workers per beneficiary declining over time not only in the home and 
community-based services workforce but in other post-acute and long-
term care settings. These declining direct care ratios, which are a 
result of a shrinking home health workforce, make it more difficult for 
beneficiaries to have meaningful one-on-one care. The vast majority of 
older adults indicate they prefer to age at home, even when, or 
especially when, they have health complications. In your testimony, you 
suggest increasing the size of the labor force through wage increases 
and that Congress continue to invest in policies to expand Medicaid 
HCBS.

    Could you speak to the importance of expanding HCBS and the impact 
that significant investment in the direct-care workforce will have on 
patient care?

    Answer. The expansion of Medicaid HCBS has been one of the most 
important changes in long-term care over the past few decades. Most 
disabled older adults prefer to receive care in the community. Our 
research suggests that States that have invested in HCBS have fewer 
individuals receiving care in nursing homes and more individuals 
receiving long-term care overall. Some of this HCBS expansion has been 
cost saving in that each dollar spent on HCBS is associated with lower 
nursing home use. Moving forward, State Medicaid programs should 
consider further HCBS expansion to maximize their long-term care 
spending and allow older adults to age in place.

    Question. In your testimony, you mention the importance of 
increased coordination between programs to support beneficiaries that 
are dually eligible for both Medicare and Medicaid. You also spoke to 
the fragmentation in care and coverage that occurs when benefits are 
not integrated across programs and spoke to the variability of the 
types of programs that are available to dually eligible individuals.

    In your research, what have you found as being most important to a 
more coordinated approach to care, and how can these programs improve 
their alignment to better serve dually eligible beneficiaries?

    Answer. One step would be to increase the use of passive 
enrollment. A key barrier to boosting enrollment in integrated models 
has been the voluntary nature of the Medicare program. Medicaid can 
mandate participation in a particular plan, but Medicare must allow 
beneficiaries to choose their type of coverage. Many dual-
eligibles have opted to remain covered under traditional Medicare, 
rather than enroll in an integrated Medicare Advantage plan. Passive-
enrollment policies could increase participation by making integrated 
care the default and requiring dual eligibles to ``opt out'' of this 
model.

    Another approach would be to improve program alignment. Financing 
in integrated models is not always aligned across Medicare and 
Medicaid; dual beneficiaries may be enrolled in one plan for their 
Medicaid coverage and another plan (sponsored by a different company) 
for their Medicare coverage. This lack of financial alignment prevents 
meaningful care integration because Medicare and Medicaid dollars 
aren't pooled across the two companies and put toward their most 
efficient use. Moreover, care won't be integrated as extensively if 
different plans cover services under each program. All integrated care 
models could be required to rely on coverage from a single company 
rather than Medicare and Medicaid coverage from separate companies.

    Third, standard dual-eligble special needs plans (D-SNPs) could be 
converted to fully integrated dually eligible special needs plans 
(FIDE-SNPs). Many dually eligible beneficiaries are enrolled in D-SNPs 
that don't meaningfully integrate Medicaid benefits. D-SNPs are 
designated as FIDE-SNPs when Medicaid-covered long-term care and 
behavioral health services are covered by the same legal entity as the 
other components of the plan under a capitated contract with the State. 
Congress could make such integration a requirement for all D-SNPs. Many 
States don't have capitated Medicaid plans that would permit such 
integration, but the goal would be to encourage States to begin to 
capitate Medicaid-covered long-term care, thereby making care 
integration possible. In the meantime, it's unclear whether most D-SNPs 
offer much upside for dual-eligibles relative to traditional Medicare 
Advantage plans. Congress could therefore eliminate ``Medicare-only'' 
D-SNPs and work with States to transition D-SNPs to FIDE-SNPs, where 
possible.

    Fourth, CMS could improve the data and measures used to evaluate 
care of dual-eligibles. Studies of these integrated programs have 
generally found that, as compared with nonintegrated care, they are 
associated with better or similar outcomes, but they have higher total 
costs. Evidence regarding the performance of integrated plans is 
limited, however. An important limitation is the lack of valid quality 
measures for assessing these programs. Analyses using process-based 
measures of quality that aren't tied to clinical outcomes have come to 
mixed conclusions regarding which plans are associated with the highest 
quality of care. Future research could incorporate measures related to 
enrollee satisfaction and claims-based outcomes. Data regarding 
Medicare Advantage encounters are improving, which could permit a more 
meaningful evaluation of measures such as hospitalizations for dual 
eligibles receiving care under various models.

    Finally, it will be important to move toward a unified approach to 
integrated care. Access to a strongly integrated care model for dually 
eligible beneficiaries is largely a function of whether their State has 
a capitated Medicaid long-term care program. Nine States that currently 
have such programs implemented Medicare-Medicaid plans through the CMS 
demonstrations. Twelve States with managed long-term care programs have 
FIDE-SNPs in place in at least some markets. The program of all-
inclusive care for the elderly (PACE) is in operation in most States 
but covers a small fraction of the dually eligible population, in part 
because of the requirement that team-based care be provided through 
designated PACE centers. Dual-eligibles living in most markets don't 
have meaningful access to integrated care models. One option for moving 
toward a more unified approach would be to combine current Medicare and 
Medicaid funding in a new program; another proposal would retain the 
existing Medicare and Medicaid programs but require States to adopt a 
fully integrated coverage model. Either approach would break down the 
current administrative silos. The goal would be for all States to begin 
to capitate Medicaid-covered long-term care services so that a single 
plan could manage all health and long-term care services. Such an 
approach isn't feasible in the short term, but if the goal is to enroll 
more dually eligible beneficiaries in integrated care models, Congress 
could take steps to make it a reality in the future.

                                 ______
                                 
  Prepared Statement of Tracy M. Mroz, Ph.D., OTR/L, FAOTA, Associate 
    Professor, Department of Rehabilitation Medicine, University of 
                               Washington
    Good morning, Chairman Cardin, Ranking Member Daines, and 
distinguished members of the committee. My name is Tracy Mroz, and I am 
an associate professor in the Department of Rehabilitation Medicine at 
the University of Washington. Thank you for the opportunity to provide 
testimony about opportunities and challenges for home health in 
supporting Americans' ability to age in place, particularly in rural 
America.

    My expertise in this area comes from my experience as a health 
services researcher and an occupational therapist. I have studied 
access to and quality of home health care with an emphasis on care 
provided in rural communities for over a decade as an Investigator with 
the WWAMI Rural Health Research Center, funded by the Health Resources 
and Services Administration (HRSA)--Federal Office of Rural Health 
Policy, as well as through grants funded by the Agency for Healthcare 
Research and Quality, National Institutes of Health, and the National 
Institute on Disability, Independent Living, and Rehabilitation 
Research. I am also an Investigator with the HRSA-funded Center for 
Health Workforce Studies which focuses on research to inform health 
workforce planning and policy. My clinical background as an 
occupational therapist has given me frontline experience working with 
older adults to optimize their ability to participate in the activities 
they find most meaningful, from self-care and home management to work 
and leisure.

    Based on my expertise, I will focus my comments on three main 
topics:

        1.  The role of home health in supporting aging in place for 
        Medicare beneficiaries.
        2.  Disparities in access to home health in rural communities.
        3.  Drivers of access to care, including resource constraints, 
        benefit requirements, and workforce challenges.

The Role of Home Health in Supporting Aging in Place

    The majority of American prefer to age in place in their own 
homes.\1\-\3\ Medicare's home health benefit provides an 
opportunity to support aging in place for the approximately 3 million 
fee-for-service beneficiaries who receive home health care annually.\4\ 
The home health benefit covers skilled nursing, rehabilitation 
(physical therapy, occupational therapy, and speech language 
pathology), medical social work, and home health aide services. These 
services can help facilitate beneficiaries' ability to remain in the 
community. For example, beneficiaries can utilize home health to 
receive skilled nursing services to provide medications, monitor health 
status, and learn about self-management of their condition. 
Beneficiaries can receive rehabilitation services to facilitate 
performance of daily activities, increase strength and balance, assess 
safety at home, and make recommendations for assistive devices, home 
modifications, and adaptive strategies to maximize function. Home 
health aides can provide temporary assistance with self-care and home 
management during the home health stay, and medical social workers can 
help beneficiaries coordinate resources needed to manage their care at 
home. Home health staff may also provide training for family caregivers 
so that the caregivers can better support the beneficiary and reduce 
unmet care needs.
---------------------------------------------------------------------------
    \1\ Binette, Joanne, and Fanni Farago. 2021 Home and Community 
Preference Survey: A National Survey of Adults Age 18-Plus. Washington, 
DC: AARP Research, November 2021.
    \2\ Robinson-Lane, S., Singer, D., Kirch, M., Solway, E., Smith, 
E., Kullgren, J., Malani, P. Older Adults' Preparedness to Age in 
Place. University of Michigan National Poll on Healthy Aging. April 
2022.
    \3\ The Associated Press and NORC Center for Public Affairs 
Research. Long-Term Care in America: Americans Want to Age at Home. May 
2021. https://apnorc.org/wp-content/uploads/2021/04/
LTC_Report_AgingatHome_final.pdf.
    \4\ Medicare Payment Advisory Commission (MedPAC). Report to 
Congress: Medicare Payment Policy; Chapter 8: Home health-care 
services. March 2023.

    The home health benefit allows for direct referral from the 
community (community-entry home health) in addition to referral 
following hospitalization (post-acute home health). Regardless of 
entry-point into home health, home health services can support aging in 
place.
Post-Acute Home Health
    Home health can help bridge the transition from an acute care 
hospital stay back to the community for a beneficiary who has been 
hospitalized. For example, beneficiaries may need care at home after 
being hospitalized following an emergent event, such as a stroke, heart 
attack, or fall that causes major injury. Beneficiaries may also 
receive home health following a planned hospitalization for a 
procedure, such as a total knee replacement or cancer treatment.
Community-Entry Home Health
    Home health can support beneficiaries with chronic conditions who 
experience a change in health or functional status that does not 
necessitate hospitalization, but does require skilled services for 
recovery, stabilization, or to help the beneficiary stay safe at home. 
For example, beneficiaries may experience a decline in health or 
functional status due to an exacerbation of chronic obstructive 
pulmonary disease or heart failure, a flare up of multiple sclerosis 
symptoms, worsening arthritis, or a fall causing minor injury. 
Beneficiaries referred to home health from the community are more 
likely to be older, be dually eligible for Medicaid, have more 
cognitive impairment, lower functional status, and a higher need for 
caregiver assistance compared to beneficiaries referred to home health 
following hospitalization.\5\, \6\
---------------------------------------------------------------------------
    \5\ Burgdorf, J.G., Mroz, T.M., Wolff, J.L. Social Vulnerability 
and Medical Complexity Among Medicare Beneficiaries Receiving Home 
Health Without Prior Hospitalization. Innov Aging. 2020;4(6):igaa049. 
Published 2020 October 3.
    \6\ Mroz, T.M., Andrilla, C.H.A., Garberson, L.A., Skillman, S.M., 
Patterson, D.G., Wong, J.L., Larson, E.H. Different Populations Served 
by the Medicare Home Health Benefit: Comparison of Post-acute versus 
Community-entry Home Health in Rural Areas. Policy Brief #165. Seattle, 
WA: WWAMI Rural Health Research Center, University of Washington, July 
2018.

    Both post-acute and community-entry home health can provide 
valuable supports for beneficiaries who wish to remain in their homes. 
Home health to support aging in place may be particularly important for 
Medicare beneficiaries living in rural communities because these 
beneficiaries tend to be older, have poorer health, and have fewer 
financial resources compared to their urban counterparts.\7\ However, 
the promise of the home health benefit as a means to support aging in 
place relies on the ability of beneficiaries to access home health 
care.
---------------------------------------------------------------------------
    \7\ Centers for Medicare and Medicaid Services. CMS Rural Health 
Strategy. https://www.
cms.gov/About-CMS/Agency-Information/OMH/Downloads/Rural-Strategy-
2018.pdf.
---------------------------------------------------------------------------

Access to Home Health in Rural Communities

    While the most recent MedPAC report to Congress on Medicare Payment 
Policy notes that over 98 percent of Medicare beneficiaries live in a 
ZIP code served by at least two home health agencies, and nearly 88 
percent live in a ZIP code served by five or more home health 
agencies,\4\ the reality of access to care for rural beneficiaries is 
more nuanced. The number of home health agencies serving a community 
represents supply, which is a necessary but not sufficient measure of 
access to home health. Even when a home health agency is ostensibly 
serving a rural community, the agency may not always have the capacity 
to admit new patients, provide services in a timely fashion, or provide 
all types of services the beneficiary needs.\8\, \9\ Indeed, 
some rural home health agencies report capacity constraints that result 
in only being able to cover part of their licensed service areas and 
they may refuse new admissions if they do not have adequate staffing to 
provide care at the time of referral.\8\ For beneficiaries that are 
admitted to home health, the number of visits they receive may be 
limited due to the amount of ``windshield time'' (i.e., travel time) 
required by home health-care staff when driving long distances to visit 
patients dispersed widely across rural areas.\8\, \9\
---------------------------------------------------------------------------
    \8\ Knudson, A., Anderson, B., Schueler, K., Arsen, E. Home is 
Where the Heart Is: Insights on the Coordination and Delivery of Home 
Health Services in Rural America. University of North Dakota Center for 
Rural Health and NORC Walsh Center for Rural Health Analysis, August 
2017.
    \9\ Skillman, S.M., Patterson, D.G., Coulthard, C., Mroz, T.M. 
Access to Rural Home Health Services: Views from the Field. Final 
Report #152. Seattle, WA: WWAMI Rural Health Research Center, 
University of Washington, February 2016.

    So, despite reports that most rural beneficiaries are served by at 
least one home health agency, there is a growing body of evidence on 
disparities in access to home health based on rural-urban status.\10\ 
Rural beneficiaries who are hospitalized are less likely to be 
discharged to home health compared to their urban counterparts, and 
this gap is wider for beneficiaries living in non-urban-adjacent rural 
counties compared to urban-adjacent rural counties.\11\, 
\12\ Furthermore, when rural beneficiaries have a planned discharge to 
home health following hospitalization, fewer than 60 percent of them 
are admitted to a home health agency to receive this planned care 
following hospital discharge.\13\ When considering both post-acute and 
community-entry home health, an increasingly smaller percent of 
Medicare beneficiaries use home health care as rurality increases, with 
beneficiaries in the most remote rural communities at highest risk for 
unmet need, though geographic region also drives variation in 
utilization.\14\ Rural beneficiaries may also have trouble accessing 
high-quality home health care because a greater percentage of rural 
home health agencies in small rural and isolated small rural 
communities are considered low-quality based on Medicare's 5-star 
quality of care rating and perform worse on individual quality measures 
like hospital readmissions and emergency department 
visits.\15\, \16\ Of note, rural home health agencies are 
more likely to have high-quality 5-star ratings for patients' 
experience of care,\16\ recognizing that quality of care and the 
experience of care are separate domains.\17\
---------------------------------------------------------------------------
    \10\ Quigley, D.D., Chastain, A.M., Kang, J.A., et al. Systematic 
Review of Rural and Urban Differences in Care Provided by Home Health 
Agencies in the United States. J Am Med Dir Assoc. 2022;23(10):1653.e1-
1653.e13.
    \11\ Burke, R.E., Jones, C.D., Coleman, E.A., Falvey, J.R., 
Stevens-Lapsley, J.E., Ginde, A.A. Use of post-acute care after 
hospital discharge in urban and rural hospitals. Am J Accountable Care. 
2017;5(1):16-22.
    \12\ Kosar, C.M., Loomer, L., Ferdows, N.B., Trivedi, A.N., 
Panagiotou, O.A., Rahman, M. Assessment of Rural-Urban Differences in 
Postacute Care Utilization and Outcomes Among Older US Adults. JAMA 
Netw Open. 2020;3(1):e1918738.
    \13\ Mroz, T.M., Garberson, L.A., Andrilla, C.H.A., Skillman, S.M., 
Larson, E.H., Patterson, D.G. Post-acute Care Trajectories for Rural 
Medicare Beneficiaries: Planned versus Actual Hospital Discharges to 
Skilled Nursing Facilities and Home Health Agencies. Policy Brief. 
WWAMI Rural Health Research Center, University of Washington; March 
2021.
    \14\ Mroz, T.M., Garberson, L.A., Wong, J.L., Andrilla, C.H.A., 
Skillman, S.M., Patterson, D.G., Larson, E.H. Variation in Use of Home 
Health Care among Fee-for-Service Medicare Beneficiaries by Rural-Urban 
Status and Geographic Region: Assessing the Potential for Unmet Need. 
Policy Brief #169. Seattle, WA: WWAMI Rural Health Research Center, 
University of Washington, February 2020.
    \15\ Ma, C., Devoti, A., O'Connor, M. Rural and urban disparities 
in quality of home health care: A longitudinal cohort study (2014-
2018). J Rural Health. 2022;38(4):705-712. ,
    \16\ Mroz, T.M., Garberson, L.A., Andrilla, C.H.A., Patterson, D.G. 
Quality of Home Health Agencies Serving Rural Medicare Beneficiaries. 
Policy Brief. WWAMI Rural Health Research Center, University of 
Washington; February 2022.
    \17\ Schwartz, M.L., Mroz, T.M., Thomas, K.S. Are Patient 
Experience and Outcomes for Home Health Agencies Related?. Med Care Res 
Rev. 2021;78(6):798-805.

    Disparities in access to rehabilitation services are also evident 
for specific patient populations receiving home health. Rural 
beneficiaries who experience a stroke are less likely to receive 
rehabilitation services than urban beneficiaries, which is concerning 
because rehabilitation is a critical component of post-stroke care.\18\ 
Rural beneficiaries receive fewer physical therapy visits following 
total knee replacement compared to urban beneficiaries, despite 
physical therapy's essential role in recovery following lower extremity 
joint replacement.\19\ Beneficiaries recovering from critical illnesses 
that necessitate intensive care unit stays during hospitalization also 
receive fewer rehabilitation visits during home health if they lived in 
rural versus urban communities.\20\ These findings of fewer visits of 
rehabilitation services may stem in part to due to specialized services 
being less widely available in rural counties, particularly remote 
rural counties.\21\
---------------------------------------------------------------------------
    \18\ Iyer, M., Bhavsar, G.P., Bennett, K.J., Probst, J.C. 
Disparities in home health service providers among Medicare 
beneficiaries with stroke. Home Health Care Serv Q. 2016;35(1):25-38.
    \19\ Falvey, J.R., Bade, M.J., Forster, J.E., et al. Home-Health-
Care Physical Therapy Improves Early Functional Recovery of Medicare 
Beneficiaries After Total Knee Arthroplasty. J Bone Joint Surg Am. 
2018;100(20):1728-1734.
    \20\ Falvey, J.R., Murphy, T.E., Gill, T.M., Stevens-Lapsley, J.E., 
Ferrante, L.E. Home Health Rehabilitation Utilization Among Medicare 
Beneficiaries Following Critical Illness. J Am Geriatr Soc. 
2020;68(7):1512-1519.
    \21\ Probst, J.C., Towne, S., Mitchell, J., Bennett, K.J., Chen, R. 
Home Health Care Agency Availability in Rural Counties. South Carolina 
Rural Health Research Center, University of South Carolina; June 2014.
---------------------------------------------------------------------------

Drivers of Access to Home Health

Resource Constraints
    Even though historically high average Medicare margins for home 
health agencies, including rural home health agencies, have received 
much attention,\4\ it is important to know that averages can mask the 
reality that while some home health agencies are very profitable, 
others are less so. To fully understand the resources of rural home 
health agencies, the wider context of the rural home health market must 
be considered. Compared to urban home health agencies, a significantly 
higher percentage of rural agencies are nonprofit or governmental 
versus for-profit and 
hospital-based versus freestanding.\15\, \16\ These 
distinctions are important because margins tend to be lower in 
nonprofit and governmental agencies and margins are only reported for 
freestanding.\4\ Half of Critical Access Hospitals and three-fifths of 
other rural hospitals offer home health-care services either on their 
own or as part of a health system or joint venture, in order to 
increase access to care in rural communities.\22\ Furthermore, 
hospital-based agencies often rely on their relationship with the 
hospital to remain financially viable.\8\ Some rural home health 
agencies also rely on local foundations, county general funds, levies, 
and county-wide health district funds to bolster their financial 
resources and maintain their current coverage areas.\8\
---------------------------------------------------------------------------
    \22\ Croll, Z., Gale, J. Community Impact and Benefit Activities of 
Critical Access, Other Rural, and Urban Hospitals, 2021. Flex 
Monitoring Team--University of Minnesota, University of North Carolina 
at Chapel Hill, University of Southern Maine, May 2023.

    In recognition of the extra costs often required to serve rural 
beneficiaries, Medicare has intermittently provided a percentage 
increase in payments to home health agencies for care provided to rural 
beneficiaries. When active, the rural add-on payment has varied over 
the past decade and has been as high as 10 percent when initially 
implemented to as low as 1 percent, the current rural add-on 
percentage. Rural add-on payments are in the process of being sunsetted 
following a phaseout process in which rural add-on payment percentages 
were changed from a single percentage for caring for all rural 
beneficiaries to targeted amounts based on the utilization and 
population density of the community in which the rural beneficiary 
lived due to the Bipartisan Budget Act of 2018.\23\ Concerns have been 
raised about the impact of targeting, reduced amounts, and eventual 
sunset of rural add-on payments on access to care for rural 
beneficiaries. While research supports targeting of the rural add-on 
payment in terms of its effect on home health agency supply, only 
higher rural add-on payments (e.g., 5 percent, 10 percent) have 
historically led to supply changes in non-urban-adjacent rural 
communities that have kept pace urban communities.\24\ However, even a 
lower 3 percent rural add-on payment resulted in reductions in 
rehospitalizations for rural beneficiaries receiving post-acute home 
health.\25\ Together these findings suggest a reconsideration of the 
sunset of rural add-on payments, with the caveat that the appropriate 
number of home health agencies serving a community depends both on 
capacity of the home health agencies and the outcomes achieved by 
providing services.
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    \23\ Bipartisan Budget Act of 2018, Pub. L. No. 115-123.
    \24\ Mroz, T.M., Patterson, D.G., Frogner, B.K. The Impact of 
Medicare's Rural Add-On Payments on Supply of Home Health Agencies 
Serving Rural Counties. Health Aff (Millwood). 2020;39(6):949-957.
    \25\ Loomer, L., Rahman, M., Mroz, T.M., Gozalo, P.L., Mor, V. 
Impact of higher payments for rural home health episodes on 
rehospitalizations. J Rural Health. 2023;39(3):604-610.

    Moreover, the impact of decreasing rural add-on payments and their 
eventual sunset are unclear in part due to the overlapping 
implementation of a new payment system, the Patient-Driven Groupings 
Model (PDGM), in January 2020 and the emergence of the COVID-19 
pandemic shortly thereafter. PDGM represents a massive shift in 
reimbursement for home health agencies, the intent of which is to base 
payments on patient characteristics at admission and remove the prior 
incentive for rehabilitation services under which higher volumes of 
rehabilitation visits resulted in higher payments. PDGM also introduces 
admission source into payment calculations for the first time such that 
post-acute home health is incentivized over community-entry home health 
and multi-episode home health stays (e.g., longer than the initial 30-
day payment episode of care) are paid less after the first 30 days of 
care. Thus, PDGM may result in decreases in rehabilitation services, 
fewer beneficiaries accessing home health via community-entry, and 
---------------------------------------------------------------------------
shorter stays, but the impact is not yet known.

    Additional research is also needed on the impact of the COVID-19 
pandemic on home health agencies, staff, and patients, both to 
understand short- and long-term consequences and opportunities of the 
public health emergency as well as to better prepare for future 
disasters by learning from the responses to the pandemic.\26\-
\30\ Much of the home health evidence base relies on studies 
performed with data prior to implementation of PDGM, the emergence of 
the COVID-19 pandemic, and changes to rural add-on payments. Therefore, 
studies using the most current data are urgently needed to understand 
the impact of these overlapping events as well as payer mix on the 
stability of rural home health agencies and their ability to provide 
needed care for rural beneficiaries.
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    \26\ Franzosa, E., Wyte-Lake, T., Tsui, E.K., Reckrey, J.M., 
Sterling, M.R. Essential but Excluded: Building Disaster Preparedness 
Capacity for Home Health Care Workers and Home Care Agencies. J Am Med 
Dir Assoc. 2022;23(12):1990-1996.
    \27\ Shang, J., Chastain, A.M., Perera, U.G.E., et al. COVID-19 
Preparedness in U.S. Home Health Care Agencies. J Am Med Dir Assoc. 
2020;21(7):924-927.
    \28\ Sterling, M.R., Tseng, E., Poon, A., et al. Experiences of 
Home Health Care Workers in New York City During the Coronavirus 
Disease 2019 Pandemic: A Qualitative Analysis. JAMA Intern Med. 
2020;180(11):1453-1459.
    \29\ Tyler, D.A., Squillace, M.R., Porter, K.A., Hunter, M., 
Haltermann, W. COVID-19 Exacerbated Long-standing Challenges for the 
Home Care Workforce [published online ahead of print, 2022 November 3]. 
J Aging Soc Policy. 2022;1-19. doi:10.1080/08959420.2022.2136919.
    \30\ Videon, T.M., Rosati, R.J., Landers, S.H. COVID-19 infection 
rates early in the pandemic among full time clinicians in a home health 
care and hospice organization. Am J Infect Control. 2022;50(1):26-31.

    To be clear, not all rural home health agencies are facing resource 
constraints and struggling to remain operational to serve their 
communities. Many are profitable. Rather, the financial constraints of 
rural home health agencies that are struggling deserve further 
attention with respect to how resource availability impacts access to 
and quality of care for rural beneficiaries. Payment policies should be 
monitored for unintended consequences and revised to ensure that rural 
home health agencies that admit less profitable patients and face 
increased costs to deliver care have the resources to serve rural 
beneficiaries in their communities and support their ability to remain 
at home.
Benefit Requirements
    Beneficiaries are required to be ``homebound'' in order to be 
eligible for the home health benefit. To be considered homebound, the 
beneficiary must need the aid of supportive devices (e.g., wheelchair, 
walker) or the help of another person to leave their home or leaving 
home is medically contraindicated, and the beneficiary must be unable 
to leave the home or leaving home requires considerable and taxing 
effort. While the homebound requirement does allow for short, 
infrequent trips outside the home, this allowance may not be sufficient 
for rural beneficiaries to maintain their homebound status when 
resources to meet their basic needs require long travel times and may 
even lead some beneficiaries to be unwilling to agree to the homebound 
requirement even if advisable.\9\ Rural home health agencies have also 
reported challenges in interpretation of the homebound requirement, 
which may also reduce access for rural beneficiaries.\8\

    Recent changes to other home health requirements may mitigate some 
of the challenges that rural beneficiaries face in accessing care. The 
original face-to-face requirement for physicians to certify a 
beneficiary for home health is burdensome in some rural communities due 
to the more limited physician supply and travel 
distances.\8\, \9\ However, during the COVID-19 pandemic the 
practitioners permitted to certify a beneficiary for home health was 
expanded to non-physician practitioners, including nurse practitioners, 
clinical nurse specialists, and physician assistants.\31\, 
\32\ In addition, the use of telehealth services was permitted for the 
face-to-face encounter with a beneficiary's home allowed as a 
originating site of care (versus a provider's office); this allowance 
will continue through December 2024.\31\, \32\ Whether these 
changes will increase or help maintain access to home health care in 
rural communities longer-term remains to be seen; nevertheless, these 
changes were welcomed by rural home health agencies as they decreased 
barriers for certification of home health.
---------------------------------------------------------------------------
    \31\ Centers for Medicare and Medicaid Services. COVID-19 Emergency 
Declaration Blanket Waivers for Health Care Providers. https://
www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf.
    \32\ Centers for Medicare and Medicaid Services. Home Health 
Agencies: Flexibilities to Fight COVID-19. https://www.cms.gov/files/
document/home-health-agencies-cms-flexibilities-fight-covid-19.pdf.
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Workforce Challenges
    Access to home health is dependent on the ability of home health 
agencies to recruit and retain qualified workers. Rural home health 
agencies have cited multiple barriers to recruiting and retaining home 
health staff, including geographic isolation, workers' desire to spend 
more time caring for patients versus driving to their homes, and lack 
of competitive wages compared to other types of rural care settings 
like hospitals and similar jobs in urban areas.\8\, \9\ In 
addition, small volume home health agencies may not have enough 
patients to support full-time staff.\8\, \9\ Needing to 
contract with local hospitals to fill vacancies for therapists due to 
the inability to hire for full-time status can be more expensive for 
home health agencies and lead to delays in care when therapists' 
caseloads are already full or they need to prioritize hospital patients 
over home health patients.\8\, \9\ Even when nurses and 
therapists are available to work in a rural community, home health 
requires a level of experience and independence for providers such that 
newer graduates may be underqualified or unwilling to take available 
positions.\8\, \9\

    The home health aide workforce is particularly fragile. Wages for 
home health aides are usually low and hours may be unpredictable or 
insufficient, leading to economic precarity for these 
workers.\9\, \33\ The additional barrier of unreliable 
transportation for low income workers may be especially challenging for 
home health aides in rural communities.\9\ Also, home health aides are 
often managing their own chronic conditions while working and many 
express an intent to leave the profession after experiencing on-the-job 
injuries.\33\-\35\ The emotion demands of their work may 
also impact their well-being, further leading to challenges with 
retention.\36\, \37\ The fragility of the home health aide 
workforce is concerning for rural home health agencies as there is a 
significantly lower home health aide workforce in rural areas, with 
only 32.9 home health aides per 1,000 older adults, as compared with 
urban areas where there are 50.4 home health aides per 1,000 older 
adults.\38\
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    \33\ Stone, R., Wilhelm, J., Bishop, C.E., Bryant, N.S., Hermer, 
L., Squillace, M.R. Predictors of Intent to Leave the Job Among Home 
Health Workers: Analysis of the National Home Health Aide Survey. 
Gerontologist. 2017;57(5):890-899.
    \34\ Cho, J., Toffey, B., Silva, A.F., et al. To care for them, we 
need to take care of ourselves: A qualitative study on the health of 
home health aides. Health Serv Res. 2023;58(3):697-704.
    \35\ McAuley, W.J., Spector, W., Van Nostrandm, J. Home health-care 
agency staffing patterns before and after the Balanced Budget Act of 
1997, by rural and urban location. J Rural Health. 2008;24(1):12-23.
    \36\ Franzosa, E., Tsui, E.K., Baron, S. ``Who's Caring for Us?'': 
Understanding and Addressing the Effects of Emotional Labor on Home 
Health Aides' Well-being. Gerontologist. 2019;
59(6):1055-1064.
    \37\ Tsui, E.K., Wyka, K., Beato, L., Verkuilen, J., Baron, S. How 
client death impacts home care aides' workforce outcomes: an 
exploratory analysis of return to work and job retention. Home Health 
Care Serv Q. 2023;42(3):230-242.
    \38\ Dill, J., Henning-Smith, C., Zhu, R., Vomacka, E. Who Will 
Care for Rural Older Adults? Measuring the Direct Care Workforce in 
Rural Areas. J Appl Gerontol. 2023;42(8):1800-1808.
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Other Considerations
    While outside the primary focus of my comments, it is worth briefly 
noting several other considerations for home health policy. First, I 
have emphasized home health for rural beneficiaries in my comments, but 
there are other inequities in home health that must be highlighted. 
Research has shown disparities in home health utilization, timeliness 
of care, patient outcomes, and admission to high-quality home health 
agencies based on race, ethnicity, and socioeconomic status of 
beneficiaries.\39\-\45\ It is critical that these inequities 
are addressed to ensure all Medicare beneficiaries have the ability to 
benefit from home health.
---------------------------------------------------------------------------
    \39\ Fashaw-Walters, S.A., Rahman, M., Jarrin, O.F., et al. Getting 
to the root: Examining within and between home health agency inequities 
in functional improvement [published online ahead of print, 2023 June 
25]. Health Serv Res. 2023;10.1111/1475-6773.14194.
    \40\ Fashaw-Walters, S.A., Rahman, M., Gee, G., Mor, V., White, M., 
Thomas, K.S. Out of Reach: Inequities in the Use of High-Quality Home 
Health Agencies. Health Aff (Millwood). 2022;41(2):247-255.
    \41\ Karmarkar, A.M., Roy, I., Lane, T., Shaibi, S., Baldwin, J.A., 
Kumar, A. Home health services for minorities in urban and rural areas 
with Alzheimer's and related dementia [published online ahead of print, 
2023 April 27]. Home Health Care Serv Q. 2023;1-17.
    \42\ Li, J., Qi, M., Werner, R.M. Assessment of Receipt of the 
First Home Health Care Visit After Hospital Discharge Among Older 
Adults. JAMA Netw Open. 2020;3(9):e2015470. Published 2020 September 1.
    \43\ Rosati, R.J., Russell, D., Peng, T., et al. Medicare home 
health payment reform may jeopardize access for clinically complex and 
socially vulnerable patients. Health Aff (Millwood). 2014;33(6):946-
956.
    \44\ Smith, J.M., Jarrin, O.F., Lin, H., Tsui, J., Dharamdasani, 
T., Thomas-Hawkins, C. Racial Disparities in Post-Acute Home Health 
Care Referral and Utilization Among Older Adults With Diabetes. Int J 
Environ Res Public Health. 2021;18(6):3196. Published 2021 March 19.
    \45\ Towne, S.D., Jr, Probst, J.C., Mitchell, J., Chen, Z. Poorer 
Quality Outcomes of Medicare-Certified Home Health Care in Areas With 
High Levels of Native American/Alaska Native Residents. J Aging Health. 
2015;27(8):1339-1357.

    Second, the impact of value-based care models, including 
accountable care organizations, bundled payment models, and the newly 
expanded Home Health Value-Based Purchasing (HHVBP) program, needs to 
be considered in conjunction with other policies. The final evaluation 
of the nine-State demonstration of the HHVBP does not suggest HHVBP had 
a differential impact on access to care for rural beneficiaries;\46\ 
however, given regional variation in home health, it will be important 
to monitor the impact of the nationwide expansion of HHVBP on access to 
home health for rural beneficiaries. Also, since rural home health 
agencies have lower performance on certain quality measures included in 
total performance scores for HHVBP compared to urban home health 
agencies and a higher percentage of rural home health agencies have 
lower overall quality of care ratings, particularly agencies in small 
rural and isolated small rural communities,\10\, \15\-
\16\, \47\ there will be rural home health agencies at 
risk for penalties under HHVBP. While the threat of penalties is meant 
to incentivize home health agencies to improve quality, penalties 
imposed on lower resourced home health agencies may actually decrease 
their ability to improve quality. For rural communities that are served 
by only one or two home health agencies, loss of one agency may 
drastically reduce access to home health care within that community. 
So, careful monitoring is warranted to ensure payment adjustments do 
not diminish opportunities to implement quality improvement initiatives 
in these lower performing agencies and do not hasten closures in 
underserved communities where low-quality home health agencies are the 
only option for care.
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    \46\ Arbor Research Collaborative for Health. Home Health Value-
Based Purchasing Final Evaluation Report. September 2023. https://
www.cms.gov/priorities/innovation/data-and-reports/2023/hhvbp-seventh-
ann-rpt.
    \47\ Chen, H.F., Landes, R.D., Schuldt, R.F., Tilford, J.M. Quality 
Performance of Rural and Urban Home Health Agencies: Implications for 
Rural Add-On Payment Policies. J Rural Health. 2020;36(3):423-432.

    Third, continued growth in enrollment in Medicare Advantage plans 
may have ramifications for home health care. Much of the research thus 
far on home health utilization comparing beneficiaries enrolled in 
Medicare Advantage to fee-for-service Medicare has found lower 
utilization among Medicare Advantage beneficiaries, particularly when 
plans include cost sharing,\48\, \49\ but regional variation 
exists in these differences.\50\ In addition, Medicare Advantage 
beneficiaries are more likely to receive care from lower quality home 
health agencies.\51\ Even though the rate of growth in enrollment in 
Medicare Advantage plans is increasing more rapidly in rural counties, 
enrollment in Medicare Advantage is still lower for rural versus urban 
beneficiaries and distribution of plan types (e.g., HMO, PPO) differ by 
rural-urban status.\52\, \53\ Continued research on Medicare 
Advantage's impact on access to home health and specific services as 
well as patient outcomes by rural-urban status is needed.
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    \48\ Loomer, L., Kosar, C.M., Meyers, D.J., Thomas, K.S. Comparing 
Receipt of Prescribed Post-acute Home Health Care Between Medicare 
Advantage and Traditional Medicare Beneficiaries: an Observational 
Study. J Gen Intern Med. 2021;36(8):2323-2331.
    \49\ Skopec, L., Zuckerman, S., Aarons, J., et al. Home Health Use 
in Medicare Advantage Compared to Use in Traditional Medicare. Health 
Aff (Millwood). 2020;39(6):1072-1079.
    \50\ Waxman, D.A., Min, L., Setodji, C.M., Hanson, M., Wenger, 
N.S., Ganz, D.A. Does Medicare Advantage enrollment affect home 
healthcare use? Am J Manag Care. 2016;22(11):714-720.
    \51\ Schwartz, M.L., Kosar, C.M., Mroz, T.M., Kumar, A., Rahman, M. 
Quality of Home Health Agencies Serving Traditional Medicare vs 
Medicare Advantage Beneficiaries. JAMA Netw Open. 2019;2(9):e1910622.
    \52\ Shane, D., Ejughemre, U., Ullrich, F., Mueller, K. 
Distributional Analysis of Variation in Medicare Advantage 
Participation Within and Between Metropolitan, Micropolitan, and 
Noncore Counties. August 2023, RUPRI Center for Rural Health Policy 
Analysis, Brief 2023-8.
    \53\ Lazaro, E., Ullrich, F., Mueller, K. Medicare Advantage 
Enrollment Update 2022. RUPRI Center for Rural Health Policy Analysis, 
Brief No. 2023-3.

    Fourth, research is needed to understand how dually eligible 
beneficiaries utilize Medicare's home health benefit and Medicaid's 
home and community-based services, whether there is substitution or 
duplication of services, and whether there are opportunities for 
integration of services. Since Medicaid's home and community-based 
services vary by State and may be subject to waiting lists, it is 
possible that Medicare's home health benefit may provide dually 
eligible beneficiaries with key supports to remain at home. There may 
also be opportunities to learn from innovative programs available to 
some Medicaid beneficiaries, such as the Community Aging in Place--
Advancing Better Living for Elders (CAPABALE) program, an 
interdisciplinary short-term intervention to address difficulty 
performing activities of daily living through nursing, occupational 
therapy, and handyman services, that has been successful in helping 
older adults remain in their homes.\54\
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    \54\ Community Aging in Place Advancing Better Living for Elders 
(CAPABLE). https://capablenationalcenter.org/.

    Finally, while spending on home health is expected to grow year 
over year by an average of nearly 8 percent annually from 2022-2031, it 
remains a relatively small percentage of overall health-care 
expenditures.\55\ Post-acute care costs are higher for beneficiaries 
who could be served by a home health agency but instead receive care in 
a skilled nursing facility due to lack of access to home health.\56\ 
Emerging research on small populations also suggests that increased 
spending on home health may be associated with reduced overall health-
care spending due to reductions in expensive hospital 
admissions.\57\-\59\ While research on a national scale that 
uses current data on home health agencies operating under PDGM is 
needed, there may be a tradeoff between increased spending on home 
health and potential cost savings elsewhere for Medicare.
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    \55\ Office of the Actuary in the Centers for Medicare and Medicaid 
Services. National Health Expenditure Projections--Table 10. Home 
Health Care Expenditures; Aggregate and per Capita Amounts, Percent 
Distribution and Annual Percent Change by Source of Funds: CY 2015-
2031. https://www.cms.gov/data-research/statistics-trends-and-reports/
national-health-expenditure-data/projected.
    \56\ Werner, R.M., Coe, N.B., Qi, M., Konetzka, R.T. Patient 
outcomes after hospital discharge to home with home health care vs to a 
skilled nursing facility. JAMA Intern Med. 2019;179(5): 617-23.
    \57\ Howard, J., Kent, T., Stuck, A.R,, Crowley, C., Zeng, F. 
Improved cost and utilization among Medicare beneficiaries 
dispositioned from the ED to receive home healthcare compared with 
inpatient hospitalization. Am J Accountable Care. 2019;7(1).
    \58\ Racsa, P., Rogstad, T., Stice, B., et al. Value-based care 
through postacute home health under CMS PACT regulations. Am J Manag 
Care. 2022;28(2):e49-e54.
    \59\ Xiao, R., Miller, J.A., Zafirau, W.J., Gorodeski, E.Z., Young, 
J.B. Impact of Home Health Care on Health Care Resource Utilization 
Following Hospital Discharge: A Cohort Study. Am J Med. 
2018;131(4):395-407.e35.
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                              conclusions
    The Medicare home health benefit is currently supporting 
beneficiaries' ability to age in place, but the full potential of home 
health may not be realized, particularly for rural beneficiaries. 
Research on home health suggests the need for targeted solutions that 
incentivize service provision to beneficiaries at risk for reduced 
access and poorer outcomes, including rural beneficiaries, and do not 
create or exacerbate challenges for home health agencies that 
disproportionately serve the most vulnerable patients. As home health 
agencies continue to adapt to multiple policy changes and emerge from 
the public health emergency, it remains essential to monitor access to 
and outcomes of home health services and ``apply a rural lens to 
programs and policies'' in alignment with the CMS Rural Health 
Strategy.\7\

                                 ______
                                 
  Questions Submitted for the Record to Tracy M. Mroz, Ph.D., OTR/L, 
                                 FAOTA
             Questions Submitted by Hon. Benjamin L. Cardin
    Question. Are there COVID-era waivers that if made permanent would 
be helpful in making access to home health care easier for rural 
beneficiaries?

    Answer. There are three COVID-era waivers for home health that have 
expired that have the potential to make access to home health easier 
for rural beneficiaries if made permanent: (1) allowance for required 
face-to-face encounters to be conducted via telehealth with the 
patient's home as an originating site, (2) permission for home health 
agencies to complete the initial assessment remotely via telephone or 
medical record review to establish eligibility for home health, and (3) 
the ability of rehabilitation professionals to perform the initial and 
comprehensive assessments when skilled nursing services are included in 
the plan of care.

    Since completion of the required face-to-face encounter may be 
challenging in rural communities due to the limited supply of allowed 
practitioners and long travel distances for patients to see available 
practitioners, the ability for the face-to-face encounter to be 
conducted via telehealth with the patient's home as an originating site 
increases access to home health for rural beneficiaries. While the 
originating site waiver was originally slated to end following the 
COVID-19 Public Health Emergency (PHE), this allowance has been 
extended through December 2024 through the Consolidated Appropriations 
Act of 2023. Permanent allowance of the patient's home as the 
originating site for a telehealth visit for the face-to-face encounter 
may be especially important to increase or maintain access to home 
health care for beneficiaries living in the most remote rural 
communities and health professional shortage areas.

    During the PHE, home health agencies were permitted to conduct 
initial assessments remotely via telehealth or medical record review to 
determine eligibility for home health (i.e., homebound status and care 
needs). Since the initial assessment visit must be held within 48 hours 
of referral or within 48 hours of a patient's return home, or on the 
ordered start of care date, flexibility in completing the initial 
assessment remotely via telehealth or medical record review may allow 
rural home health agencies to accept referrals when capacity does not 
allow for an in-home visit to complete the initial assessment within 48 
hours but does allow for a start of care visit within a reasonable 
timeframe based on patient needs.

    Rehabilitation professionals, including occupational therapists, 
physical therapists, and speech-language pathologists, are already 
permitted to complete the initial and start of care comprehensive 
assessments for cases in which only therapy services are included in 
the plan of care (i.e., skilled nursing services are not included). 
Rehabilitation professions are also permitted to complete all 
comprehensive assessments subsequent to the start of care comprehensive 
assessment for cases which include nursing services. The waiver to 
allow rehabilitation professionals to complete initial and start of 
care comprehensive assessments for cases in which skilled nursing is 
included in the plan of care expired following the PHE. Making a 
permanent change to allow rehabilitation professionals to complete the 
initial and start of care comprehensive assessments for cases in which 
skilled nursing is included in the plan of care provides flexibility 
for rural home health agencies in allocating staff for completing the 
start of care comprehensive assessment. This flexibility may enable 
rural home health agencies to accept referrals they have have otherwise 
declined when they are experiencing capacity constraints with nurses 
but have rehabilitation professionals available to complete the start 
of care comprehensive assessment.

    Note that several other COVID-era waivers and flexibilities have 
already been made permanent which are considered helpful for access to 
care for rural beneficiaries. These include the expansion of allowed 
practitioners to order and certify eligibility for home health services 
to non-physician practitioners (nurse practitioners, physician 
assistants, and clinical nurse specialists) and the ability to provide 
some home health services via telehealth. Making the three 
flexibilities described above permanent will serve to further promote 
access to care for rural beneficiaries.

    Question. What is the role of rehabilitation services in home 
health to support aging in place, both for post-acute and community-
entry home health?

    Answer. Rehabilitation services, including occupational therapy, 
physical therapy, and speech language pathology, play an important role 
for supporting aging in place for Medicare beneficiaries. Post-acute 
home health care following an acute hospitalization serves as a bridge 
to facilitate the transition from the hospital back to the community. 
For patients receiving post-acute home health care, rehabilitation 
services address new or worsening functional limitations resulting from 
the illness, injury, and/or surgery that was the reason for the 
hospitalization as well as secondary loss of function resulting from 
long hospital stays when applicable. In these cases, rehabilitation 
services often focus on restoring function to prior levels before 
hospitalization or maximizing function within the context of new 
limitations that are expected to persist.

    Community-entry home health care supports beneficiaries with 
chronic conditions who experience a change in health or functional 
status that does not necessitate a hospitalization, but does lead to a 
need for skilled services. Like rehabilitation services during post-
acute home health, rehabilitation services during community-entry home 
health can promote return to the level of functioning that was present 
prior to the status change that led to home health referral or maximize 
function with the context of limitations that may have increased due to 
that status change. Rehabilitation services during community-entry home 
health for patients with conditions with expected trajectories of 
functional decline (e.g., neurodegenerative conditions like multiple 
sclerosis, Parkinson's disease, and amyotrophic lateral sclerosis) may 
focus on temporary stabilization or slowing functional decline as well 
as compensatory strategies to support participation in daily activities 
and safety as functional limitations increase over time. It is 
important to note that even when entry point into home health care 
differs, the overall goal of rehabilitation is the same--assess and 
address the functional limitations which impact the patients' ability 
to do what they need and want to do to successfully age in place in 
their homes.

    The three rehabilitation services available through the home health 
benefit have distinct focus areas that complement each other. Depending 
on their needs, patients may benefit from one, two, or all three 
rehabilitation services. Occupational therapy focuses on participation 
in activities of daily living, including basic self-care tasks like 
dressing and bathing, more complicated tasks like meal preparation, 
medication management, household chores, and money management, and 
social and leisure activities. Physical therapy focuses on safe 
functional mobility, including walking, managing stairs and curbs, and 
transfers with or without a mobility device (e.g., cane, walker, 
crutches) as well as factors related to functional mobility including 
strength, range of motion, balance, endurance, and pain management. 
Speech-
language pathology services focus on addressing language and 
communication impairments, including improving communication between 
patients and their family caregivers and health-care providers, as well 
as cognition and safe swallowing. All three rehabilitation services 
also provide training in their areas of expertise to family caregivers 
so that family caregivers can support their loved ones safely and 
effectively with reduced caregiver burden. Together these 
rehabilitation services promote successful aging in place by optimizing 
the home health patient's ability to perform the activities they want 
and need to do to live safely in the community for as long as possible.

    Rehabilitation services provided via the home health benefit are 
especially well-suited to support aging in place because they address 
patients' needs in their home environments, enabling assessment and 
tailored treatment in their actual context versus a clinic which cannot 
fully replicate the home environment. That is, recommendations and 
treatment strategies in home health not only align with patients' 
abilities and preferences, but also with their home environments and 
available resources. Some treatments may be more effective when 
implemented in their real-life context versus simulated in a clinic 
(e.g., navigating their own home environment safely with a walker, 
using adaptive strategies and devices to prepare meals in their own 
kitchens). Patients may also be more comfortable and experience less 
stress receiving care in their homes and therefore may be better able 
to participate in therapy. In addition, there are no travel or time 
costs associated for patients for whom leaving the home is extremely 
challenging per the homebound criteria. For these beneficiaries who are 
homebound, the home health benefit provides access to rehabilitation 
services that may otherwise be out of reach. Rehabilitation services 
provided via the home health benefit may reduce overall costs of care 
by helping patients remain safely in their homes and avoiding 
hospitalizations due to challenges managing chronic conditions and 
accidents such as falls.

    Due to value of rehabilitation services to promote aging in place, 
it is important to monitor access to rehabilitation services for home 
health patients as home health agencies adapt to multiple payment 
policy changes. The Patient-Driven Groupings Model (PDGM), implemented 
in 2020, removed the prior incentive for rehabilitation service 
provision in reimbursement determinations for home health agencies, but 
the impact of PDGM on provision of rehabilitation services to home 
health patients and their subsequent outcomes remains to be seen. Since 
PDGM has structured payments in a way that emphasizes the need for 
rehabilitation services for patients with neurological conditions 
(e.g., stroke) and musculoskeletal conditions (e.g., hip fractures, 
lower extremity joint replacement), it is possible patients with other 
conditions who may benefit from rehabilitation services (e.g., chronic 
obstructive pulmonary disease, heart failure, pneumonia) will be less 
likely to receive them, resulting in a missed opportunity to support 
aging in place. Research on provision of rehabilitation services under 
PDGM and patient outcomes, including functional status, successful 
discharge to the community, and hospital admissions, is needed to 
assess for unintended consequences of PDGM.

    The impact of the nationwide expansion of the Home Health Value-
Based Purchasing model on access to rehabilitation services in home 
health and patient outcomes should also be monitored. In addition, 
since disparities in access to rehabilitation services for rural home 
health patients have been documented, it will be important to assess 
the impact of the sunset of rural add-on payments to home health 
agencies on utilization of rehabilitation services by rural 
beneficiaries. Finally, while rehabilitation services for maintaining 
function, slowing decline in function, and adapting to functional 
limitations that are expected to be long-term (often referred to 
collectively as maintenance therapy) are covered by Medicare under the 
home health, skilled nursing facility, and outpatient benefits, there 
have been persistent concerns that beneficiaries who would benefit from 
maintenance therapy have had difficulty accessing rehabilitation 
services despite the clarification issued by CMS following the Jimmo 
Settlement Agreement in 2013. In order for the full potential of 
rehabilitation services to support successful aging in place to be 
realized, Medicare will need to ensure benefit design and payment 
policies do not limit access to rehabilitation services when they can 
provide valuable benefits both to patients and to Medicare by helping 
beneficiaries age in place.

    Question. Can you also share what is the role of occupational 
therapy?

    Answer. As noted in my response above on the role of rehabilitation 
services in home health to support aging in place, occupational therapy 
focuses on participation in daily living activities, ranging from basic 
self-care tasks like dressing and bathing to more complicated tasks 
like meal preparation, medication management, household chores, and 
money management to social and leisure activities. Successful aging in 
place means not only being safe in the home and community by reducing 
or adapting to functional limitations to enable completion of daily 
living tasks, but also the ability to participate in valued activities 
that are important for well-being and quality of life. Though the 
breadth of occupational therapy treatment strategies is extensive given 
the wide range of activities that fall within the occupational therapy 
scope of practice and the types of physical, sensory, cognitive, 
psychological, and social-emotional conditions that can impact 
performance of these activities, the common thread is supporting home 
health patients' ability to do what they want and need to do to age in 
place successfully.

    Perhaps the best way to illustrate the role of occupational therapy 
services in home health to supporting aging in place is to provide some 
examples of these varied treatment strategies for home health patients. 
These examples are not meant to be exhaustive but rather are 
illustrative of a selection of occupational therapy approaches that can 
benefit multiple patient populations through the common goal of 
supporting participation in necessary and valued daily living 
activities. Common occupational therapy treatment strategies include 
(but are not limited to):

          Home safety assessments and recommendations for home 
        modification to reduce environment risk for injuries (e.g., 
        falls, burns) and to increase ability to perform daily living 
        activities.

          Recommendations for and training with durable medical 
        equipment, adaptive equipment, assistive technology, and 
        adaptive strategies to enable performance of daily living 
        activities for patients adapting to temporary or permanent 
        physical, sensory, cognitive, and psychosocial limitations.

          Energy conservation techniques such as pacing, task 
        prioritization, planning, and simplification, use of adaptive 
        equipment, sleep hygiene, and efficient and safe body mechanics 
        to support performance for patients with low endurance.

          Lifestyle modification and self-management strategies to 
        promote health, prevent and manage chronic conditions, and 
        reduce related functional limitations.

          Fall risk assessment and education and training to reduce 
        fall risk.

          Functional cognition training and compensatory techniques to 
        enable patients to complete complex tasks like meal planning 
        and online shopping, scheduling appointments, and paying bills.

          Techniques to increase engagement in activities and manage 
        behavioral symptoms for patients with dementia.

          Education on joint protection principles to reduce pain and 
        joint deformity, enabling less functional limitation for 
        patients with arthritis or other conditions affecting their 
        joints.

          Non-pharmacological pain management techniques to promote 
        participation in daily activities for patients with chronic 
        pain.

          Medication management strategies that fit into patients' 
        daily habits and routines for patients with chronic conditions 
        requiring medication.

          Therapeutic activities and exercises to increase upper 
        extremity functioning for daily living activities.

          Caregiver training to support needs of both the patient and 
        the caregiver.

    Because of the role occupational therapy plays in supporting aging 
in place for Medicare beneficiaries, I recommend legislation to make 
occupational therapy a qualifying service for the home health benefit. 
Please see my response to Senator Daines for additional information on 
this issue as well as examples where stand-alone occupational therapy 
can benefit home health patients and their ability to age in place.

    Question. Given the labor shortage you and others have discussed, 
what are some ideas for growing the home health-care workforce?

    Answer. Given the longstanding challenges many home health agencies 
face in recruiting and retaining qualified health-care workers, uneven 
distribution of health-care workers, the additional challenges created 
by the COVID-19 pandemic, and the growing demand for home health 
services as the U.S. population ages, there is a clear need for 
policies that support a robust and well-trained home health-care 
workforce so that all patients can access high-quality home health care 
when they need it. Many Federal and State policy recommendations to 
strengthen the health workforce generally apply to the home health-care 
workforce and may also be targeted specifically to the home health-care 
workforce. Recommendations include:

          Invest in Health Resources and Services Administration 
        programming to support health workforce development, training, 
        and research.

          Invest in State workforce agencies, including support for 
        cross-agency coordination and Federal-State partnerships.

          Expand existing and create new grants and loan forgiveness 
        and repayment programs for health-care workers; programs can be 
        designed to target home health-care workers directly and/or 
        include all health-care professions that are part of the home 
        health benefit (e.g., rehabilitation therapy practitioners are 
        not currently included as eligible professions for the National 
        Health Service Corps Loan Repayment Program).

          Provide supports for community colleges and public 4-year 
        colleges and universities that provide health-care professional 
        training programs for future home health-care workers (nurses, 
        rehabilitation therapists and assistants, medical social 
        workers), including targeted financial supports for students 
        and faculty loan repayment programs.

          Include or enhance didactic content on home health care as a 
        work setting within health-care professional training programs 
        and offer clinical training opportunities with home health 
        agencies; provide incentives to home health-care workers for 
        contribute to educational opportunities, including clinical 
        training, to account for decreased patient care time.

          Support portability and streamlining of licensing for 
        health-care workers across State lines, including license 
        reciprocity agreements and licensure compacts.

          Streamline processes for licensure for qualified health-care 
        workers who trained outside the U.S. and support immigration 
        policies that expand the health-care workforce (e.g., visa 
        programs targeted towards home health-care workers).

          Establish and incentivize apprenticeship programs, career 
        pathway programs, career ladders, and continuing education 
        opportunities for home health-care workers including home 
        health aides, licensed practical nurses, physical therapist 
        assistants, and occupational therapy assistants.

          Improve wages and working conditions for low-wage health-
        care workers like home health aides through minimum base wages, 
        benefits, and professional development opportunities.

          Increase funding for Medicare and Medicaid home health and 
        home care reimbursement where needed to allow for competitive 
        wages to recruit and retain home health-care workers, and 
        structure policies to ensure an appropriate percentage of 
        program payments are directed to compensation for home health-
        care workers over profits.

          Support collection and rapid dissemination of current 
        workforce metrics (e.g., supply and demand of specific health-
        care workers, retention/turnover rates) to policymakers, 
        educators, and employers to inform policy and planning (e.g., 
        the Washington's Health Workforce Sentinel Network--https://wa.
        sentinelnetwork.org/); include home health-care workers and 
        home health care as a setting in these efforts.

                                 ______
                                 
                Questions Submitted by Hon. Steve Daines
    Question. Currently the need for occupational therapy does not 
qualify someone to receive home health unless they are already 
receiving other qualifying services.

    Would there be an advantage to beneficiaries and their ability to 
age in place if occupational therapy were to be a qualifying service 
for the home health benefit?

    Answer. Yes, the advantage of occupational therapy as a qualifying 
service for the home health benefit is that beneficiaries who meet 
homebound criteria and would benefit from intermittent occupational 
therapy services alone would not be prevented from receiving these 
services to promote safe and successful aging in place due to lack of 
eligibility for home health. For example, beneficiaries with low vision 
may not require nursing or physical therapy services, but would benefit 
from occupational therapy services to provide training in adaptive 
strategies, devices, and technologies to increase independence and 
safety when performing activities of daily living, which in turn may 
prevent falls or other injuries. Beneficiaries with chronic conditions 
like diabetes, chronic obstructive pulmonary disease, and heart failure 
who do not need skilled nursing services for active management of their 
conditions or physical therapy for mobility, may benefit from 
occupational therapy for self-
management training, adaptive strategies to increase independence in 
activities of daily living, and stress management and lifestyle 
modifications to improve well-being, all of which promote successful 
aging in place. Beneficiaries with dementia can also benefit from 
occupational therapy services for improving engagement in activities, 
reducing behavioral symptoms, and training for their family caregivers, 
but they would not qualify for home health without a concurrent need 
for nursing or physical or speech therapy which may not be necessary. 
Without occupational therapy as a qualifying service for home health, 
there are populations of homebound beneficiaries that may not have 
access to occupational therapy services and may experience poorer 
quality of life and greater dependence on caregivers as well as 
increased risk for adverse outcomes like falls, emergency department 
visits, and hospitalizations.

    Making occupational therapy a qualifying service for home health is 
also an issue of parity with other rehabilitation professions. The 
historical reason why the need for occupational therapy services alone 
does not qualify beneficiaries for home health is due to occupational 
therapists not being licensed in all 50 States at the time the home 
health benefit was initially established. Occupational therapy 
practitioners are now licensed in all 50 States, the District of 
Columbia, Puerto Rico, and Guam. The home health benefit already 
recognizes the value of occupational therapy as a stand-alone service 
in that occupational therapy only is allowed as a continuing service 
(i.e., after home health patients are discharged from qualifying 
services of nursing, physical therapy, and/or speech-language pathology 
services, the benefit will allow the home health stay to remain open 
for provision of occupational therapy only as long as the patient 
remains homebound and in need of skilled occupational therapy 
services). In addition, occupational therapists may open cases by 
performing the initial and start of care comprehensive assessments for 
patients whose plans of care include physical therapy and/or speech-
language pathology services only (and/or rehabilitation only cases) due 
to the passage of the Medicare Home Health Flexibility Act as part of 
the omnibus spending package passed in late 2020. Allowing occupational 
therapy as a qualify service would not only serve as an overdue update 
from historical State licensing regulations and align rehabilitation 
services within home health, but would also remove an unnecessary 
barrier to accessing services through the home health benefit that have 
the potential to further support the ability of beneficiaries to age in 
place, improve patient outcomes, and decrease costly adverse events.

    For these reasons, I recommend establishing occupational therapy as 
a Medicare home health qualifying service (suggested by the American 
Occupational Therapy Association as the Medicare Home Health 
Accessibility Act). Please see the American Occupational Therapy 
Association's fact sheet on the Medicare Home Health Accessibility Act 
for additional information (https://www.aota.org/-/media/corporate/
files/advocacy/federal/fact-sheets/
medicarehomehealthaccessibilityactfact
sheet2023.pdf).

    Question. Do you have policy recommendations that could help 
address the workforce challenges faced by home health agencies, 
particularly in rural communities?

    Answer. In my response to Senator Cardin's question about growing 
the home health-care workforce, I provided recommendations to 
strengthen the health-care workforce generally, which includes home 
health-care workers, as well as ways to target the home health-care 
workforce specifically. Please refer to that response for 
recommendations that have the potential in grow the home health-care 
workforce and thus help address the workforce challenges faced by home 
health agencies, including home health agencies that serve rural 
communities. Here I will extend those recommendations to target the 
home health-care workforce in rural communities specifically per the 
emphasis of this question.

          Increase existing and create new loan repayment programs 
        that include all home health-care professions (nurses, 
        rehabilitation therapists and assistants, medical social 
        workers) and are targeted towards practice in rural 
        communities, without necessarily limiting practice commitments 
        specifically to home health care since health professionals in 
        rural communities may work across settings due to low work 
        volumes in individual settings.

          Expand rural didactic tracks and clinical training 
        opportunities for health-care professions educational programs 
        within public colleges and universities (e.g., HRSA's Area 
        Health Education Center Scholars program), include home health 
        content and training opportunities and home health-care 
        professions in these programs, and provide scholarships and 
        loan forgiveness programs targeted towards students who commit 
        to practicing in rural communities.

          Expand supports for rural-serving community colleges and 
        public 4-year colleges and universities that provide health-
        care professional training programs for future home health-care 
        workers (nurses, rehabilitation therapists and assistants, 
        medical social workers), including targeted financial supports 
        for students and faculty loan repayment programs; note that 
        rural-serving institutions of higher education include both 
        institutions located in rural communities and institutions that 
        are not classified as rural-located but contribute to rural 
        communities such as certain large land-grant universities and 
        regional colleges in urbanized areas.\1\
---------------------------------------------------------------------------
    \1\ Koricich, A., Sansone, V.A., Hicklan, Fryar A., Orphan, C., 
McClure, K.R. Introducing Our Nation's Rural-Serving Postsecondary 
Institutions: Moving Towards Greater Visibility and Appreciation. 
Alliance for Research on Regional Colleges; January 2022.

          Support portability and streamlining of licensing for 
        health-care workers across State lines, including license 
        reciprocity agreements and licensure compacts; note that easing 
        licensure burden may be particularly useful for increasing 
        access to home health services in rural communities located 
---------------------------------------------------------------------------
        near more populous communities across State borders.

          Streamline processes for licensure for qualified health-care 
        workers who trained outside the U.S. and support immigration 
        policies that expand the health-care workforce (e.g., visa 
        programs); note that these strategies may be especially helpful 
        for increasing access to home health services in rural 
        communities as research suggests non-U.S.-born health-care 
        workers are more likely to work in home health and in medically 
        underserved areas compared to U.S.-born health-care workers.\2\
---------------------------------------------------------------------------
    \2\ Commodore-Mensah, Y., DePriest, K., Samuel, L.J., Hanson, G., 
D'Aoust, R., Slade, E.P. Prevalence and characteristics of non-US-born 
and US-born health-care professionals, 2010-2018. JAMA Netw Open. 
2021;4(4):e218396.

          Consider tax incentives and housing supports (e.g., mortgage 
        assistance programs) to recruit and retain rural home health-
---------------------------------------------------------------------------
        care workers.

          Ensure rural-serving home health agencies are aware of and 
        leveraging existing resources to support the rural health-care 
        workforce such as the National Rural Recruitment and Retention 
        Network (3RNet).

          Increase funding for Medicare and Medicaid home health and 
        home care reimbursement where needed to allow for competitive 
        wages to recruit and retain home health-care workers, and 
        structure policies to ensure an appropriate percentage of 
        program payments are directed to compensation for home health-
        care workers over profits.

              For home health agencies that serve rural 
        communities, extending and increasing targeted rural add-on 
        payments will help account for the additional challenges and 
        unavoidable inefficiencies of providing care to patients spread 
        out across large geographic areas. While the Consolidated 
        Appropriations Act of 2023 extended a 1-percent rural add-on 
        payment for serving beneficiaries living in counties with low 
        population density and without high home health utilization for 
        a year beyond the planned sunset, it will expire at the end of 
        2023 without legislative action. Loss of the rural add-on 
        payment may exacerbate payment cuts for home health that were 
        implemented in the final rule for CY 2024.

              A better understanding of home health agency 
        financial performance will also help determine how feasible it 
        is, given current reimbursement levels, for rural-serving home 
        health agencies to raise wages and benefits for health-care 
        workers as a mechanism to increase recruitment and retention. A 
        key component of understanding financial performance is 
        examining payments from all payer sources (traditional 
        Medicare, Medicare Advantage, Medicaid, and other payers) with 
        respect to cost of care. The Preserving Access to Home Health 
        Act of 2023 (S. 2137/H.R. 5159) instructs the Medicare Payment 
        Advisory Commission to include all payers in analysis of home 
        health agency margins and consider how payer mix impacts home 
        health access for traditional Medicare beneficiaries. Data on 
        all payer margins for rural-serving home health agencies will 
        provide a more complete picture of their financial performance 
        and ability to pay competitive wages and benefits to support 
        recruitment and retention of home health-care workers. 
        Monitoring of the impact of the Patient-
        Driven Groupings Model and the expanded Home Health Value-Based 
        Purchasing model on financial performance of rural-serving home 
        health agencies is also warranted.

    Question. Skilled nursing facilities and home health agencies 
provide the majority of post-acute care for Medicare beneficiaries, yet 
your research and other studies have found that rural beneficiaries are 
less likely to receive care following an acute hospitalization.

    Could you speak to this discrepancy and the importance of home 
health to the continuity of care and recovery for rural beneficiaries?

    Answer. The discrepancy between referral to home health following 
acute hospitalization and receipt of home health is indeed concerning. 
Our research suggests that fewer than 60 percent of rural beneficiaries 
in the traditional Medicare program with a planned discharge to home 
health following an acute hospital stay actually receive home health 
care; the gap between planned versus actual receipt of home health 
services was seen across the rural continuum, including large rural, 
small rural, and isolated rural communities.\3\ Another study of both 
traditional Medicare and Medicare Advantage beneficiaries found a 
similar gap between referral to and receipt of home health services 
following hospital discharge as well as disparities based on race, 
ethnicity, and socioeconomic status.\4\
---------------------------------------------------------------------------
    \3\ Mroz, T.M., Garberson, L.A., Andrilla, C.H.A., Skillman, S.M., 
Larson, E.H., Patterson, D.G. Post-acute Care Trajectories for Rural 
Medicare Beneficiaries: Planned versus Actual Hospital Discharges to 
Skilled Nursing Facilities and Home Health Agencies. WWAMI Rural Health 
Research Center, University of Washington; March 2021.
    \4\ Li, J., Qi, M., Werner, R.M. Assessment of receipt of the first 
home health care visit after hospital discharge among older adults. 
JAMA Netw Open. 2020;3(9):e2015470.

    There are multiple potential explanations for why this discrepancy 
exists. Patients may discharge from the hospital with a referral for 
home health care but without arrangements made for the first visit or 
clear instructions on how to schedule the first visit. Home health 
agencies that have not received timely information about the patient 
may decline the referral due to capacity constraints, concerns about 
patient eligibility (e.g., homebound status), inability to care for 
patients with complex needs, or preferences in patient selection. 
Patients may agree to home health while still in the hospital, but then 
refuse services once they are back home. Research has suggested 6-28 
percent of patients eligible for home health refuse care for a variety 
of reasons such as not feeling they actually need help to manage at 
home, having a prior negative experience with home health care, not 
understanding the types of home health services provided or the purpose 
of home health, and not wanting health-care workers in their homes.\5\
---------------------------------------------------------------------------
    \5\ Levine, C., Lee, T. I Can Take Care of Myself! Patients' 
Refusals of Home Health Care Services. United Hospital Fund and the 
Alliance for Home Health Quality and Innovation. May 2017.

    Why the discrepancy between planned versus actual discharge to home 
health occurs will require further investigation in order to determine 
how best to address the issue and ensure continuity of care following 
hospital discharge. Strategies may include improved care coordination 
and transition planning processes between the hospital and home health 
agency, education for patients about home health and support during the 
hospital stay for scheduling the first visit, and education for 
physicians and non-physician practitioners about appropriate home 
health referrals and eligibility. It is unclear whether recent updates 
to Conditions of Participation on discharge planning requirements for 
hospitals, including Critical Access Hospitals, which occurred just 
prior to the emergence of the COVID-19 pandemic, have decreased this 
gap between planned versus actual discharge to home health. The 
percentage of hospital patients with a planned discharge to home health 
who receive care should be tracked longitudinally and research should 
examine whether certain provider and/or patient characteristics are 
associated with unsuccessful transitions to home health care. This 
metric will provide a more complete picture of home health availability 
for Medicare beneficiaries beyond supply of home health agencies 
serving a particular ZIP code, the measure of home health availability 
currently used by the Medicare Payment Advisory Commission which does 
not account for capacity of home health agencies to accept patients or 
---------------------------------------------------------------------------
other reasons for declined referrals.

    In addition to better understanding of the drivers of this 
discrepancy between planned versus actual discharge to home health, 
research is urgently needed on which patient populations do not receive 
planned care and their outcomes. Referral to home health at hospital 
discharge suggests some need for continued skilled care in the 
community, which may include continued nursing management of a specific 
condition and/or rehabilitation services to optimize functional status 
and safety in the home. These services are important to promote 
successful aging in place and homebound rural beneficiaries who do not 
receive these services through the home health benefit may not be to 
access otherwise. Not receiving planned care may result in an increased 
risk for adverse events such as falls, worsening of symptoms, condition 
exacerbation, decline in function, and safety concerns, any of which 
could lead to costly emergency department visits and hospital 
readmissions and reduce the ability of the beneficiary to remain in the 
community.

                                 ______
                                 
             Questions Submitted by Hon. Sheldon Whitehouse
    Question. What specific recommendations do you have on how we can 
use the ACO model and telehealth to expand home health, including 
changes with CMS regulations, CMMI models, and legislation, to lower 
costs and improve patient care?
                               telehealth
    Answer. COVID-19 waivers allowed for home health agencies to 
provide more services to beneficiaries via telecommunications 
technology as long as these services are part of the plan of care and 
do not serve as a substitute for necessary in-person visits per the 
plan of care. The permanency of this allowance beyond the COVID-19 PHE 
represents an important opportunity for home health agencies to expand 
services to include greater frequency of phone and audio-video 
telehealth visits to check in with patients in between in-person 
visits. This provides home health agencies with the potential for with 
greater efficiency in staff resource use, particularly in rural areas 
where travel times limit the number of in-person visits that can be 
provided by individual home health-care workers. In addition, the 
ability to conduct remote patient monitoring allows for more frequent 
monitoring of patients with acute or chronic conditions who are at high 
risk for exacerbations and/or complications that may lead to emergency 
department visits and hospitalizations. Quicker recognition of 
concerning changes in status may allow for patients to be successfully 
treated at home, thus providing the patient with a more seamless home 
health care experience and avoiding both the stress and the expense of 
needing to visit an emergency department or being admitted to the 
hospital.

    In order for the full potential of telehealth in home health to be 
realized, home health-care workers will need additional training on 
telehealth services, home health agencies will need to work to 
determine best practices for telehealth in home health and integrate 
telehealth services into their care processes, and Medicare will need 
to ensure reimbursement does not disincentivize adoption of telehealth 
where warranted. It should also be noted that many rural communities 
still lack access to reliable, high-speed Internet services that are 
required for some telehealth services. Infrastructure funding to ensure 
equitable access to broadband Internet services in rural communities 
will be necessary to enable successful adoption of telehealth practices 
into home health. Finally, an extension of the waiver or permanent 
change to allow a patient's home as an originating site for telehealth 
visits for the required face-to-face encounter for home health is a 
useful mechanism to expanding home health access for patients for whom 
face-to-face encounters present a challenge due to local availability 
of physicians and allowed non-physician practitioners.
                     accountable care organizations
    The incentives to provide efficient, high-quality care to 
beneficiaries under the Medicare Shared Savings Program, the largest 
ACO in the Medicare program, have resulted in modest savings for 
Medicare. While ACO participation could be hypothesized to increase use 
of lower-cost home health services over higher-cost institutional post-
acute care in skilled nursing facilities and inpatient rehabilitation 
facilities, research thus far has suggested reductions in skilled 
nursing facility use and length of stay without corresponding increases 
in home health use (i.e., no change or reductions in home health use as 
well) associated with ACO participation. The focused on decreased 
spending for ACOs may limit the expansion of home health services 
unless there is a clear reduction in costs elsewhere attributable to 
this expansion (e.g., increased home health services leading to reduced 
hospital readmissions). Continued evaluation of utilization of home 
health services under Medicare ACO models is warranted to better 
understand ACO factors associated with changes in home health service 
utilization, patient populations receiving home health services, and 
subsequent outcomes for beneficiaries and the Medicare program. 
Opportunities for expansion of home-based care services outside of home 
health, such as hospital at home and home-based primary care are not 
within my area of expertise.

                                 ______
                                 
    Prepared Statement of Judith A. Stein, J.D., Executive Director/
                 Attorney, Center for Medicare Advocacy
    Good morning, Chairman Cardin, Ranking Member Daines, and 
distinguished members of the committee. Thank you for inviting me to 
testify today. I am Judith Stein, founder and executive director of the 
Center for Medicare Advocacy (the Center). The Center is a national 
private, nonprofit, nonpartisan law organization based in Connecticut 
and Washington, DC with additional attorneys in Massachusetts and 
California.

    The Center works to advance access to comprehensive Medicare 
coverage, quality health care, and health equity. We provide education 
and legal assistance to assist Medicare beneficiaries throughout the 
United States. We respond to over 7,000 calls and emails annually, host 
a website, educational programs, webinars, and a national convening of 
Medicare beneficiary stakeholders and policymakers, publish a weekly 
electronic newsletter, and pursue thousands of Medicare appeals. Our 
policy work is based on the real-life experiences of the beneficiaries 
and families we hear from every day.

    Our health-care system is in dire need of reform, including 
Medicare. We have many ideas about how to do so, as I'm sure my fellow 
panelists and members of this committee do. But, when it comes to the 
Medicare home health benefit, my basic message is very simple: enforce 
the law that already exists. Payment policies, oversight measures, 
audits, and quality measures must be geared to ensuring public Medicare 
funds are used to provide necessary home health care for all who 
qualify under the law. If the law was properly enforced, and the 
benefit administered as intended, there would be transformational 
change for so many people who could obtain the care they need to live 
well and safely at home.
our experience assisting medicare beneficiaries in need of home health 
                                  care
    The Center for Medicare Advocacy hears from people from all over 
the country who are trying to obtain Medicare coverage for sufficient 
home health care to remain safely at home. In particular, people living 
with longer-term and debilitating conditions find themselves facing 
significant access problems. For example, patients have been told 
(incorrectly) that Medicare will only cover one to five hours per week 
of home health aide services, or only one bath per week, or that they 
aren't homebound (because they roam outside due to dementia), or that 
their condition must first decline before therapy can commence (or 
recommence). Consequently, these individuals and their families 
struggle with too little care, or no care at all.

    Here is the experience of an individual who contacted the Center 
for help in August 2023:

    Ms. S is quadriplegic having suffered a spinal cord injury. She 
clearly qualifies for Medicare's home health benefit. In fact, unlike 
so many people who cannot even gain access to Medicare home care, she 
had been successfully living at home with traditional Medicare coverage 
for many years. (Nursing from a home health agency for catheter changes 
2 times week, each preceded by a suppository, necessary to prevent 
severe, chronic urinary tract infections. She also received 20 hours a 
week of personal hands-on home health aide care.) However, this summer, 
her home health agency completely stopped this care (although the 
agency is accepting new patients for home health aide services who 
private pay.) She manages to sponge bathe herself, but her lower body 
doesn't get cleaned.

    In June, Ms. S called her home health agency to confirm she could 
visit her family for a brief period and still be considered homebound 
and not lose services. They said yes, that was okay. However, the day 
she returned, the agency called to tell her she'd been discharged from 
care. She was not given any other notice. She appealed the discharge. 
The agency refused to provide medical records or cooperate with the 
appeal. Kepro, the Medicare Quality Improvement Organization 
responsible for the appeal, agreed that Ms. S qualified for care and 
that the discharge was not appropriate. Nonetheless, the home care 
agency told Ms. S it made no difference what Kepro said, they would not 
recommence care. Kepro's medical leadership said this case was 
``appalling,'' adding:

        Despite our communication with the home health agency regarding 
        our concerns that this beneficiary's care has been improperly 
        terminated, they refuse to provide services. I am escalating 
        these concerns to CMS. Please let me know if there is anything 
        else you think we can do on our end. This case is very 
        concerning.

    While Ms. S pursued efforts with Kepro, she also sought care from 
the twelve other Medicare-certified home health agencies in her 
geographic area. None of them would even agree to assess her for care. 
Thus, she began going to the hospital emergency room for catheter 
changes, but the hospital told her she can't continue to use the ER. 
Although she seems incredibly calm and resourceful, she has no idea who 
can provide her the necessary catheter changes and related care.

    An attorney from my office contacted the home health agency on Ms. 
S's behalf. The agency has committed numerous violations of the 
Medicare Conditions of Participation: It did not obtain clearance from 
Ms. S's doctor to discharge her, it did not provide Ms. S with any 
notice regarding the discharge, it made no attempt to recertify her for 
care, and it made no effort to transfer her care to another provider. 
Ms. S is currently out of options.

    While this may seem like an extreme example, it is not. Older and 
disabled Medicare beneficiaries are constantly denied adequate or all 
necessary home health care. It has become more the norm than the 
exception.
     medicare home health coverage: reality conflicts with the law
    Medicare home health coverage can be an important resource for 
Medicare beneficiaries who need health care at home. When properly 
implemented, the Medicare home health benefit provides coverage for a 
constellation of skilled and nonskilled services, all of which add to 
the health, safety, and quality of life of beneficiaries and their 
families. Under the law, Medicare coverage is available for people with 
acute and/or chronic conditions, and for services to improve, or 
maintain, or slow decline of the individual's condition. Further, 
coverage is available even if the services are expected to continue 
over a long period of time.\1\
---------------------------------------------------------------------------
    \1\ 42 CFR Sec. 408.48(a)-(b); MBP Manual, Ch. 7, Sec. Sec. 401.1 
and 70.1. See, Jimmo v. Sebelius, No. 11-cv-17 (D.Vt.), filed January 
18, 2011; Settlement 2013; Corrective Action Plan 2017. See, https://
medicareadvocacy.org/medicare-info/improvement-standard/. See, https://
www.cms.gov
/Center/Special-Topic/Jimmo-Center.

    Unfortunately, however, people--like Ms. S.--who legally qualify 
for Medicare coverage have great difficulty obtaining and affording 
necessary home care. There are legal standards that define who can 
obtain coverage, and what services are available. However, the criteria 
are often narrowly construed and misrepresented by providers and 
policymakers, resulting in inappropriate barriers to Medicare coverage 
for necessary care. This is increasingly true for home health aide 
services--the very kind of personal care services vulnerable people 
---------------------------------------------------------------------------
often need to remain safely at home.

    Here is an example from the daughter of a Medicare beneficiary that 
typifies what we hear:

        My dad is in the end stages of Parkinson's disease. He has been 
        informed that he qualifies for Medicare home health coverage 
        and that means 2 hours per week of Medicare-covered home health 
        aides. We were told he could receive the daily aide care he 
        needs if we can pay for it. However, the financial burden for 
        paying for home health care is too much for us--and the average 
        family. We were shocked to hear from home health agencies that 
        Medicare only covers a few hours per week. We would like to see 
        changes to allow more coverage for individuals living with a 
        long term, progressive, terminal disease.

    The harm to people in need of home care is compounded by the 
incorrect information constantly promulgated about Medicare coverage, 
namely that it is a short term, acute care benefit. This is incorrect. 
In fact, Medicare does cover far more than a few hours of home health 
aides per week--28 to 35 hours per week combined with nursing under the 
law. But Medicare providers and contractors constantly tell people 
otherwise, maintaining incorrectly that the Medicare home care benefit 
is short-term, for acute care, and that aides are only available a few 
hours per week. The law is clearly otherwise. For example, here some of 
what my organization's staff were told when we interviewed staff from 
200 home agencies from 17 States in 2021:

          ``A home health aide is a maximum of an hour visit twice a 
        week. That's what Medicare allows.'' (Maryland)
          ``The agency can provide one hour of aide per week. This is 
        all Medicare covers.'' (Utah)
          ``As long as I have been with this agency, we have provided 
        no more than 1 or 2 aide visits a week. It doesn't matter if it 
        was before or during COVID.'' (Michigan)
          ``They can't cover a chronic condition under Medicare.'' 
        (Massachusetts)

    News from providers about Medicare Advantage home health coverage 
was only more dispiriting. When asked if there were differences in 
services they could provide to traditional Medicare versus Medicare 
Advantage patients, agencies commented that, in their experience, 
Medicare Advantage plans provide less to patients and require more of 
agencies. Common themes included, MA plans deny more, allow fewer 
visits, delay onset of care, require more changes to care plans, and 
there are major challenges from their Prior Authorization process. 
Comments included:

          ``Abso-freakin-lutely! Medicare Advantage plans in our area 
        are rotten.'' (Kansas)
          ``Very much so, there's a difference. Medicare Advantage 
        plans don't approve as much services.'' (Louisiana)
          ``Medicare Advantage plans often fight tooth and nail on the 
        number of visits they will allow. [. . .] is the worst. They 
        use [. . .], a company for prior authorization work and allow 
        very few visits.'' (Connecticut)

    When we called the 1-800-MEDICARE help line we often received 
inaccurate information. We were told,

          ``[Home health care] is not long-term care. There must be 
        recovery to be covered.''
          ``Medicare only covers aides for bathing, showering, or 
        grooming.''

    As geriatrician Dr. Laurie Archbald-Pannone states, ``While family 
caregivers truly do selflessly give of themselves in the care of 
others, they need more than our recognition of their work. They need 
the Medicare system to provide appropriate resources for the care of 
their family members.'' \2\ (Emphasis added.)
---------------------------------------------------------------------------
    \2\ The Hill, ``Family Caregivers Need Support, Medicare Should 
Cover In-Home Aides,'' by Laurie Archbald-Pannone, M.D. (November 15, 
2019), available at: https://thehill.com/opinion/healthcare/470677-
family-caregivers-need-support-medicare-should-cover-in-home-care-
aides.

    Medicare coverage does provide significant resources under the law. 
In practice it does not. This must change. People who are eligible for 
Medicare home health coverage are living and aging at home, but they 
are doing so unsafely, without the care they need and should be 
receiving under the Medicare home health benefit.
     the law: what home care is covered under the medicare act? \3\
---------------------------------------------------------------------------
    \3\ For a fuller discussion of Medicare home health coverage, see, 
Chiplin Jr., Alfred, Stein, Judith, Medicare Handbook, Chapter 4, Home 
Health Coverage (Wolters Kluwer, 2020; updated annually).

    Home health access problems have ebbed and flowed over the years, 
depending on the reigning payment model, systemic pressures, and 
misinformation about Medicare home health coverage. Regrettably, as 
discussed here, these problems are increasing. If current and proposed 
policies and practices continue, they will only get worse. Accordingly, 
it is important to know what Medicare home health coverage should be 
under the law, especially for people with longer-term, chronic, and 
debilitating conditions.
1. Medicare Home Health Qualifying Criteria
    Medicare covers home health services under both Parts A and B when 
the services are medically ``reasonable and necessary,'' and when: \4\
---------------------------------------------------------------------------
    \4\ 42 U.S.C. Sec. 1395f(a)(2)(C); 42 CFR Sec. Sec. 409.42 et seq.

          A physician or other authorized practitioner has established 
        a plan of care for furnishing the services that is periodically 
        reviewed as required;
          The individual is confined to home (commonly referred to as 
        ``homebound''). This criterion is generally met if non-medical 
        absences from home are infrequent, and leaving home requires a 
        considerable and taxing effort, which may be shown by the 
        patient needing personal assistance or the help of an assistive 
        device, such as a wheelchair or walker. (Occasional ``walks 
        around the block'' are allowable. Attendance at an adult day 
        care center, religious services, or a special occasion is also 
        not a bar to meeting the homebound requirement.);
          The individual needs skilled nursing care on an intermittent 
        basis, or physical therapy or speech-language pathology (or, in 
        the case of an individual who has been furnished home health 
        services based on such a need, but no longer requires skilled 
        nursing care or physical or speech therapy, the individual 
        continues to need occupational therapy); and
          Such services are furnished by, or under arrangement with, a 
        Medicare-
        certified home health agency.\5\
---------------------------------------------------------------------------
    \5\ 42 U.S.C. Sec. 1395x(m).

2. Medicare-Covered Home Health Services
    If the qualifying conditions described above are satisfied, 
Medicare coverage is available for an array of home health services. 
Home health services that can be covered by Medicare include: \6\
---------------------------------------------------------------------------
    \6\ 42 U.S.C. Sec. 1395x(m)(1)-(4).

          Part-time or intermittent nursing care provided by or under 
        the supervision of a registered professional nurse;
          Physical therapy, speech-language pathology, and 
        occupational therapy;
          Part-time or intermittent services of a home health aide;
          Medical social services; and
          Medical supplies.

    As described above, skilled nursing, physical therapy, and speech-
language pathology services are defined as ``qualifying skilled 
services'' for the purpose of establishing eligibility for Medicare 
home health coverage.\7\ A patient must initially require and receive 
one of these skilled services in order to receive Medicare for other 
covered home health services.\8\ Home health aide, medical social 
worker, and occupational therapy services \9\ are defined as 
``dependent services'' (dependent upon a skilled service being in 
place) as are certain medical supplies.\10\ While occupational therapy 
is not considered a skilled service to begin Medicare home health 
coverage, if the individual was receiving skilled nursing, physical or 
speech therapy, but those services end, coverage can continue if 
occupational therapy continues.\11\
---------------------------------------------------------------------------
    \7\ 42 CFR Sec. 409.42.
    \8\ 42 CFR Sec. 409.44.
    \9\ Occupational therapy services can be either a qualifying 
service or a dependent service. Occupational therapy services that are 
not qualifying services under 42 CFR Sec. 409.44(c) can be covered as 
dependent services if the requirements of reasonableness and necessity 
are met. 42 CFR Sec. 409.45.
    \10\ 42 CFR Sec. 409.45.
    \11\ 42 CFR Sec. 409.42(c)(4); Medicare Beneficiary Policy Manual, 
Ch. 7, Sec. 30.4.

    The term ``part-time or intermittent'' means skilled nursing and 
home health aide services furnished any number of days per week as long 
as they are provided less than 8 combined hours each day and 28 or 
fewer hours each week (or, subject to review on a case-by-case basis as 
to the need for care, less than 8 hours each day and 35 or fewer hours 
per week).\12\
---------------------------------------------------------------------------
    \12\ 42 U.S.C. Sec. 1361(m).

3. Medicare Home Health Coverage Can Be Long-Term
Importantly, and contrary to what is often stated, Medicare home health 
coverage is not just a short-term, acute-care benefit.\13\ Indeed, with 
an intent to expand home health services, Congress passed the Omnibus 
Budget Reconciliation Act of 1980 (OBRA 80, Pub. L. 96-499) which 
removed the annual 100 home health visit limitation for both Parts A 
and B, the 3-day prior hospital stay requirement, and the Part B 
deductible.\14\ In addition, effective in 2000, the Balanced Budget Act 
of 1997 (BBA 97, Pub. L. 105-33) implemented a prospective payment 
system (PPS) for home health (and in certain other care settings), and 
gradually transferred some home health expenditures from Part A to Part 
B (episodes not preceded by a hospitalization or skilled nursing 
facility stay or exceeded the 100-visit Part A cap). Part A also 
provided payment beyond 100 visits if a beneficiary was not enrolled in 
Part B.\15\
---------------------------------------------------------------------------
    \13\ 42 CFR Sec. Sec. 409.48(a)-(b); Medicare Beneficiary Policy 
Manual, Ch. 7, Sec. Sec. 40,1.1 and 70.1.
    \14\ Davitt, Joan K. and Choi, Sunha (2008) ``Tracing the History 
of Medicare Home Health Care: The Impact of Policy on Benefit Use,'' 
The Journal of Sociology and Social Welfare: Vol. 35: Iss. 1, Article 
12. Available at: https://scholarworks.wmich.edu/jssw/vol35/iss1/12.
    \15\ Congressional Research Service Report (2014), ``Medicare Home 
Health Benefit Primer: Benefit Basics and Issues,'' Congressional 
Research Service, R42998.

---------------------------------------------------------------------------
_______________________________________________________________________

  There Is No Duration of Time Limit for Medicare Home Health Coverage

        So long as the law's qualifying criteria are met, coverage can 
        continue for an unlimited number of visits. ``to the extent 
        that all coverage requirements specified in this subpart are 
        met, payment may be made on behalf of eligible beneficiaries . 
        . . for an unlimited number of covered visits.''

   (42 CFR Sec. Sec. 409.48(a)-(b); Medicare Benefit Policy Manual, 
                         Chapter 7, Sec. 70.1)

_______________________________________________________________________

   the reality: access to medicare coverage and home care is limited
    The Center for Medicare Advocacy hears regularly from people who 
meet Medicare coverage criteria but are unable to access Medicare-
covered home health care, or the appropriate amount of care. As 
similarly reported in Health Affairs in November 2019:

        When asked how much costs had burdened their family, 25 percent 
        of the seriously ill said that costs were a major burden, and 
        30 percent said that they were a minor burden. . . . When asked 
        about getting help in recent years, 60 percent said that family 
        members and friends helped a lot, 25 percent said that they 
        helped a little, and 14 percent said that they provided no 
        help. Family members and friends experienced considerable 
        strain as a consequence of providing help, including financial 
        problems, lowered income, and lost or changed jobs or reduced 
        hours. Twenty-nine percent of respondents said that there was a 
        time when they did not get outside help because of cost.\16\
---------------------------------------------------------------------------
    \16\ Health Affairs, ``Financial Hardships of Medicare 
Beneficiaries With Serious Illness,'' by Kyle, Blendon, et al., Vol. 
38, No. 11, pp. 1801-1806 (November 2019). Note: The authors define 
``serious illness'' as individuals ``reported having a serious illness 
or condition that, over the past 3 years, had required two or more 
hospital stays and visits to three or more physicians.'' P. 1802.
---------------------------------------------------------------------------
            A. Access to Medicare-Covered Home Health Aides Is 
                    Shrinking
    Help with personal hands-on care is key to the well-being of 
patients, as well as their families and caregivers. Unfortunately, 
access to Medicare coverage for such care has declined. This is true 
even when individuals have an order and meet the law's homebound and 
skilled care requirements--and thus qualify for coverage. 
Unfortunately, Medicare beneficiaries are often misinformed. They are 
told they can only get home health aide services a few times a week, 
for a short time, and/or only for a bath. Sometimes they are told 
Medicare simply does not cover home health aides. The Center for 
Medicare Advocacy has even heard of an individual being told he could 
not receive home health aide coverage because he was ``over income''--
although Medicare has no income limit.

    As noted above, under the law, Medicare authorizes up to 28 to 35 
hours a week of home health aide (personal hands-on care) and nursing 
services combined.\17\ While personal hands-on care does include 
bathing, it also includes dressing, grooming, feeding, toileting, and 
other key services to help an individual remain healthy and safe at 
home.\18\ In the past, this level of home health aide coverage was 
actually available. Indeed, the Center for Medicare Advocacy has helped 
many clients remain at home because these services were in place.
---------------------------------------------------------------------------
    \17\ 42 U.S.C. Sec. 1395x(m)(1)-(4). Note, receipt of skilled 
therapy can also trigger coverage for home health aides.
    \18\ 42 CFR Sec. 409.45(b)(1)(i)-(v). See also, Medicare Benefits 
Policy Manual, Chapter 7, Sec. Sec. 50.1 and 50.2.

    Currently, however, this level of coverage and care is almost never 
obtainable. Data demonstrate this dramatic change in coverage. Home 
health aide utilization has declined steadily over the past 2 decades 
by almost 94 percent--from a 30-day average of 6.7 visits in 1998 \19\ 
to less than half a visit a month in 2022.\20\ As a percent of total 
visits from 1997 to 2021, home health aides declined from 48 percent of 
total services to 5 percent.\21\
---------------------------------------------------------------------------
    \19\ Medicare Payment Advisory Commission (MedPAC), ``Report to 
Congress: Medicare Payment Policy'' (March 2021), Ch. 8, page 236: 
https://www.medpac.gov/wp-content/uploads/2021/10/
mar21_medpac_report_ch8_sec.pdf.
    \20\ Centers for Medicare and Medicaid Services (CMS), Proposed 
Home Health Rule (CMS-1780-P), 88 Fed Reg 43654 (July 10, 2023), at pp. 
43663, 43671.
    \21\ Medicare Payment Advisory Commission (MedPAC), ``Report to 
Congress: Medicare Payment Policy'' (March 2023), Ch. 8, p. 250, 
available at: https://www.medpac.gov/wp-content/uploads/2023/03/
Ch8_Mar23_MedPAC_Report_To_Congress_SEC.pdf; Medicare Payment Advisory 
Commission (MedPAC), ``Report to Congress: Medicare Payment Policy'' 
(March 2019), Ch. 9, pp. 234-235, available at: http://www.medpac.gov/
docs/default-source/reports/mar19_
medpac_ch9_sec_rev.pdf?sfvrsn=0.

    The real, personal impact of this reduced access to home health 
aides was highlighted in a 2019 Kaiser Health News article.\22\ The 
article includes stark findings about the unmet needs of vulnerable 
Americans struggling to live at home with little or no help. For 
example:
---------------------------------------------------------------------------
    \22\ Kaiser Health News, ``Seniors Aging in Place Turn to Devices 
and Helpers, but Unmet Needs Are Common,'' by Judith Graham (February 
14, 2019), available at: https://khn.org/news/seniors-aging-in-place-
turn-to-devices-and-helpers-but-unmet-needs-are-common/. See also, 
Kaiser Health News, ``Home Care Agencies Often Wrongly Deny Medicare to 
Chronically Ill,'' Susan Jaffe (January 18, 2018), https://khn.org/
news/home-care-agencies-often-wrongly-deny-medicare-help-to-the-
chronically-ill/.

          ``About 25 million Americans who are aging in place rely on 
        help from other people and devices such as canes, raised 
        toilets or shower seats to perform essential daily activities, 
        according to a new study documenting how older adults adapt to 
        their changing physical abilities.''
          ``Nearly 60 percent of seniors with seriously compromised 
        mobility reported staying inside their homes or apartments 
        instead of getting out of the house. Twenty-five percent said 
        they often remained in bed. Of older adults who had significant 
        difficulty putting on a shirt or pulling on undergarments or 
        pants, 20 percent went without getting dressed. Of those who 
        required assistance with toileting issues, 27.9 percent had an 
        accident or soiled themselves.''
          ``60 percent of the seniors surveyed used at least one 
        device, most commonly for bathing, toileting and moving around. 
        (Twenty percent used two or more devices and 13 percent also 
        received personal assistance.)'' and
          ``Five percent had difficulty with daily tasks but didn't 
        have help and hadn't made other adjustments yet.''

    The Medicare home health benefit is misunderstood, inaccurately 
articulated, and narrowly implemented. Medicare-certified home health 
agencies have all but stopped providing necessary, legally-authorized 
home health aide services, even when patients are homebound and are 
receiving the requisite skilled nursing or therapy to trigger coverage. 
The Centers for Medicare and Medicaid Services (CMS) does not monitor 
or rebuke agencies for failure to provide this mandated and necessary 
care.
    As Dr. Archbald-Pannone notes,

        As a geriatrician, every week I see patients who are fortunate 
        enough to have family who are able to provide medical care and 
        support. However, I also see more patients who do not have 
        family available to provide full care, are in desperate need of 
        more home care support, but cannot afford the price tag . . . 
        Without in-home care, we're leaving our family members alone 
        and at risk. . . . We may not be available to stay home with 
        them, but Medicare should support trained care aides who can 
        be.\23\
---------------------------------------------------------------------------
    \23\ The Hill, ``Family Caregivers Need Support, Medicare Should 
Cover In-Home Aides,'' by Laurie Archbald-Pannone, M.D. (November 15, 
2019), available at: https://thehill.com/opinion/healthcare/470677-
family-caregivers-need-support-medicare-should-cover-in-home-care-
aides.

    When Medicare doesn't cover in-home care, patients and families 
often must go without. Those who can afford to, pay out-of-pocket, from 
savings, or with credit cards. Others, who are, or become, poor (often 
due to health-care costs) look to their State's low-income Medicaid 
program for help. Thus, costs are regularly shifted to people in need 
and, their families, and for those who are dually eligible for Medicaid 
as well as Medicare, to State Medicaid programs. The needs and costs of 
---------------------------------------------------------------------------
caring for people who are dually eligible are substantial:

        In 2019, there were 12.3 million individuals simultaneously 
        enrolled in Medicare and Medicaid. These dually eligible 
        individuals experience high rates of chronic illness, with many 
        having long-term care needs and social risk factors. Twenty-
        seven percent of dually eligible individuals enrolled in 
        Medicare fee-for-service have six or more chronic conditions, 
        compared to 15 percent of beneficiaries with Medicare only.\24\
---------------------------------------------------------------------------
    \24\ Centers for Medicare and Medicaid Services (CMS), Medicare-
Medicaid Coordination Office, Fact Sheet: ``People Dually Eligible for 
Medicare and Medicaid'' (March 2023), available at: https://
www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-
coordination/medicare-medicaid-coordination-office/downloads/
mmco_factsheet.pdf.

    In summary, as the authors in the November 2019 Health Affairs 
article concluded, ``Medicare insurance is broadly popular, but 
seriously ill beneficiaries who most need financial protection report 
widespread problems affording care and financial instability.''\25\
---------------------------------------------------------------------------
    \25\ Health Affairs, ``Financial Hardships of Medicare 
Beneficiaries With Serious Illness,'' by Kyle, Blendon, et al., Vol. 
38, No. 11, pp. 1801-1806 (November 2019).

    The harm to Medicare beneficiaries and their families would be 
greatly reduced if home health aide coverage was provided as intended 
by law. As it is, access to help with personal care and activities of 
daily living is minimal.\26\
---------------------------------------------------------------------------
    \26\ See also, Johns Hopkins University Bloomberg School of Public 
Health study that also finds people with limitations in activities of 
daily living (ADLs) experience significant harm when they cannot access 
adequate help with ADLs at home. ``Medicare Spending and the Adequacy 
of Support with Daily Activities in Community-Living Older Adults with 
Disability,'' by Jennifer L. Wolff, Lauren H. Nicholas, Amber Willink, 
John Mulcahy, Karen Davis, and Judith D. Kasper, Commonwealth Fund and 
National Institutes on Aging (May 2019), as reported by American 
Association for the Advancement of Science (AAAS) EurekAlert website 
at: https://www.
eurekalert.org/pub_releases/2019-05/jhub-msh_1052819.php.

            B. Medicare's Home Health Payment System Influences Access 
                    to Care
    On January 1, 2020, CMS implemented a new Medicare payment system 
for home health services called the ``Patient-Driven Groupings Model'' 
(PDGM). PDGM changed home health agencies' financial incentives and 
disincentives to admit or continue care for Medicare beneficiaries.\27\ 
Unfortunately, the financial motivations are often harmful to 
vulnerable beneficiaries, particularly those with chronic conditions 
and longer-term health-care needs. Although CMS has stated that ``PGDM 
relies more heavily on clinical characteristics,'' \28\ such as 
functional levels and co-morbidities, the most significant components 
of PDGM consider admission source and timing, not patient needs.
---------------------------------------------------------------------------
    \27\ See, Center for Medicare Advocacy ``Home Health Practice 
Guide: Medicare Home Health Coverage and Care Is Jeopardized By the New 
Payment Model--The Center for Medicare Advocacy May Be Able to Help'' 
(January 7, 2020), available at: https://medicareadvocacy.org/home-
health-practice-guide/; also see, e.g., Center for Medicare Advocacy 
Weekly Alert ``Medicare Coverage of Home Health Care Has Not Changed 
Under the New Payment System (PDGM)'' (February 20, 2020), available 
at: https://medicareadvocacy.org/medicare-coverage-of-home-health-care-
has-not-changed-under-the-new-payment-system-pdgm/.
    \28\ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HomeHealthPPS/HH-PDGM.

    PDGM's financial incentives include higher rates for the first 30 
days of home care. Payments are also higher for beneficiaries who are 
admitted after an inpatient institutional stay (hospitals and skilled 
nursing facilities), and lower for those admitted from the community. 
(The ``community'' category includes hospital outpatients, including 
hospitalized patients in ``observation status,'' as well as patients 
who start care from home, without a prior hospital or SNF stay.) The 
new payment model also reduced the billing period from 60 days to 30 
days, encouraging shorter periods of care. Additionally, PDGM lowered 
the financial incentive to provide physical, occupational or speech 
language pathology therapy by removing therapy service utilization 
---------------------------------------------------------------------------
payment thresholds.

    The current Medicare home health payment system and shift in 
financial incentives have reduced access to necessary care.\29\ Home 
Health Care News reports that ``[s]tories of widespread layoffs of PTs, 
OTs and SLPs persist--and now new reports of agencies incorrectly 
telling their patients that Medicare no longer covers therapy under the 
home health benefit. . . .'' \30\ Reductions in skilled therapy not 
only harm the individual who needs that care; they can also end access 
to home health aides, because aide coverage is dependent on the 
individual's also receiving skilled therapy or nursing.
---------------------------------------------------------------------------
    \29\ https://www.cms.gov/medicare/quality/home-health;
    The Medicare payment structure creates incentives for home health 
agencies to provide care for beneficiaries with shorter-term, post-
acute care conditions. Further, CMS policies and practices create 
barriers to Medicare-covered home care for people with longer-term and 
chronic conditions. These barriers and incentives include:
        Inaccurate and/or incomplete training for entities that make 
Medicare coverage determinations;
        Home Health Quality Reporting Program (HHQRP);
        Home Health Value-Based Purchasing (HHVBP) models;
        Office of Inspector General, Medicare Contractor, and other 
audits of Home Health 
      Agencies pointing to so-called ``overutilization.''
    \30\ Home Health Care News, ``CMS Watching Home Health Providers 
Closely Amid Shifting Therapy Strategies,'' by Robert Holly (February 
12, 2020), available at: https://homehealthcare
news.com/2020/02/cms-watching-home-health-providers-closely-amid-
shifting-therapy-strategies/.

    In response to misinformation and service changes in light of PDGM, 
CMS released a special edition Medicare Learning Network (MLN) Matters 
article on February 10, 2020.\31\ The MLN made clear that, while the 
reimbursement system had changed, Medicare coverage law and rules had 
not:
---------------------------------------------------------------------------
    \31\ CMS, MLN Matters article, ``The Role of Therapy under the Home 
Health Patient-Driven Groupings Model (PDGM)'', Number: SE20005 
(February 10, 2020), available at: https://www.cms.gov/files/document/
se20005.pdf. ``. . . [E]ligibility criteria and coverage for Medicare 
home health services remain unchanged. . . . as long as the individual 
meets the criteria for home health services as described in the 
regulations at 42 CFR 409.42, the individual can receive Medicare home 
health services, including therapy services. . . . Citing to the Jimmo 
v. Sebelius Settlement Agreement, the MLN also states ``there is no 
improvement standard under the Medicare home health benefit and therapy 
services can be provided for restorative or maintenance purposes.'' 
(Emphasis added.)

          Home health services can continue as long as individuals 
        meet the Medicare coverage criteria; and Medicare home health 
        coverage and service rules have not changed;
          Beneficiaries can receive home health services to improve 
        their condition, and to maintain their current condition, or to 
        slow or prevent further decline.\27\

    Since the PDGM bundled payment model, access to all home health 
care has diminished, particularly for longer-term patients. Access to 
home health aides and therapy have also decreased. The Medicare payment 
system must be revised to ensure it creates proper, fiscally sound 
incentives so that Medicare-certified home health agencies actually 
provide all legally authorized, necessary home care included in the 
benefit. Medicare Advantage plans must be required to do nothing less.
                               conclusion
    All too often, older adults and people with disabilities are 
unfairly denied access to necessary, Medicare-covered home health care. 
As a result, they and their families suffer. The Center for Medicare 
Advocacy urges Congress, CMS, and CMS contractors to ensure that 
Medicare beneficiaries obtain the Medicare home health coverage and 
necessary services they qualify for under the law. Payment policies, 
oversight measures, audits, and quality measures must be geared to 
ensuring public Medicare funds are used to provide necessary home 
health care for all who qualify under the law. Congress must insist the 
law that already exists is properly implemented and fully enforced.

                                APPENDIX

    As the Center for Medicare Advocacy has long asserted, when 
properly implemented, the Medicare home health benefit provides 
coverage for a constellation of skilled and nonskilled services. People 
with Medicare, however, have had growing difficulty obtaining and 
affording necessary home care, particularly home health aide services.

    The following is a sample of some of the Center for Medicare 
Advocacy's writings on these issues over the last several years:

          CMA Comments to CMS' 2024 Notice of Proposed Rule Making 
        (NPRM) for Home Health Care (August 2023): https://
        medicareadvocacy.org/wp-content/uploads/2023/08/Home-Health-
        Aides-2024-NPRM-RFI-Response.pdf.
          CMA Comments to CMS CY 2023 Proposed Home Health Rule 
        (August 2022): https://medicareadvocacy.org/home-health-
        comments-2023/.
          Bipartisan Policy Center (BPC) Paper ``Optimizing the 
        Medicare Home Health Benefit to Improve Outcomes and Reduce 
        Disparities'' (including Appendix authored by CMA) (April 
        2022): https://bipartisanpolicy.org/wp-content/uploads/2022/04/
        Optimizing-the-Medicare-Home-Health_R0_Web-Ready.pdf.
          Commonwealth Fund Blog, ``The Medicare Home Health Benefit: 
        An Unkept Promise,'' by Judith A. Stein and David A. Lipschutz, 
        Center for Medicare Advocacy (April 28, 2022): https://
        www.commonwealthfund.org/blog/2022/medicare-home-health-
        benefit-unkept-promise.
          CMA Home Health Survey: ``Medicare Beneficiaries Likely 
        Misinformed and Underserved'' (December 2021): https://
        medicareadvocacy.org/wp-content/uploads/2021/12/CMA-Survey-
        Medicare-Home-Health-Underservice.pdf.
          CMA Comments on CY 2022 HH Prospective Payment System and 
        More (August 5, 2021): https://medicareadvocacy.org/cma-
        comments-on-cy-2022-hh-prospective-payment-system-more/.
          CMA Alert: ``79 Organizations Call on CMS and ACL to Ensure 
        Access to Medicare-Covered Home Health Care'' (June 2021): 
        https://medicareadvocacy.org/orgs-to-cms-enforce-home-health-
        coverage/.
          CMA Issue Brief: ``Medicare Home Health Coverage: Reality 
        Conflicts with the Law'' (April 2021): https://
        medicareadvocacy.org/issue-brief-medicare-home-health-coverage-
        reality-conflicts-with-the-law/.
          CMA Alert ``Shrinking Medicare Home Health Coverage: It's 
        Time to Act'' (April 2021): https://medicareadvocacy.org/
        shrinking-medicare-home-health-coverage-its-time-to-act/.
          CMA Comments on Proposed Home Health Rules (August 27, 
        2020): https://medicareadvocacy.org/center-comments-on-
        proposed-home-health-rules/.
          CMA Issue Brief ``Medicare and Family Caregivers'' (June 
        2020) (Drafted for ACL's RAISE Family Caregiver Advisory 
        Council): https://medicare
        advocacy.org/wp-content/uploads/2020/06/Medicare-and-Family-
        Caregivers-June-2020.pdf.
          CMA Issue Brief: ``Medicare Payment vs. Coverage for Home 
        Health and Skilled Nursing Facility Care'' (March 2020): 
        https://www.medicareadvocacy.
        org/wp-content/uploads/2020/03/Issue-Brief.-Medicare-Payment-
        vs.-Coverage.pdf.
          CMA ``Home Health Practice Guide'' (January 2020): https://
        medicare
        advocacy.org/home-health-practice-guide/.
          CMA Alert: ``Potential Impacts of New Medicare Payment 
        Models on Skilled Nursing Facility and Home Health Care'' 
        (October 31, 2019): https://medicareadvocacy.org/potential-
        impacts-of-new-medicare-payment-models-on-skilled-nursing-
        facility-and-home-health-care/.
          CMA Comments on 2019 Proposed Home Health Rule (September 
        12, 2019): https://medicareadvocacy.org/center-comments-on-
        2019-proposed-home-health-rule/.
          CMA Alert: ``As Home Care Needs Increase, Access Issues Must 
        Be Addressed'' (September 5, 2019): https://
        medicareadvocacy.org/as-home-care-needs-increase-access-issues-
        must-be-addressed/.
          CMA Alert: ``Inadequate Personal Care at Home Increases 
        Overall Medicare Costs'' (June 13, 2019): https://
        medicareadvocacy.org/inadequate-personal-care-at-home-
        increases-overall-medicare-costs/.
          CMA Alert: ``Home Health Aide Coverage Continues to Shrink: 
        Attention Must Be Paid'' (February 21, 2019): https://
        medicareadvocacy.org/home-health-aide-coverage-continues-to-
        shrink-attention-must-be-paid/.
          CMA Alert: ``Home Health Aide Coverage Continues to Shrink 
        in Traditional Medicare While CMS Enhances it in Medicare 
        Advantage'' (November 15, 2018).
          CMA Alert: ``Home Health Telephone Survey'' (November 15, 
        2018): https://medicareadvocacy.org/home-health-aide-coverage-
        continues-to-shrink-in-traditional-medicare-while-cms-enhances-
        it-in-medicare-advantage/ https://medicareadvocacy.org/home-
        health-telephone-survey/.
          CMA Issue Brief Series: ``Medicare Home Health Crisis'' 
        (April 2017-October 2018): https://www.medicareadvocacy.org/wp-
        content/uploads/2018/11/HH-Issue-Brief-Full.pdf.
          CMA Comments on Proposed Medicare Home Health Rule (August 
        30, 2018): https://medicareadvocacy.org/center-comments-on-
        proposed-medicare-home-health-rules/.
          CMA Alert: ``Medicare Home Health Rules Proposed by CMS to 
        `Improve Access to Solutions' Will Further Reduce Patient 
        Access to Care'' (July 5, 2018): https://medicareadvocacy.org/
        medicare-home-health-rules-proposed-by-cms-to-improve-access-
        to-solutions-will-further-reduce-patient-access-to-care/.
          CMA Alert: ``Medicare Home Health Coverage is Not a Short 
        Term Benefit--Congress Reiterated This in the Balanced Budget 
        Act of 1997 (BBA '97)'' (May 3, 2018): https://
        medicareadvocacy.org/medicare-home-health-coverage-is-not-a-
        short-term-benefit-%e2%80%92-congress-reiterated-this-in-the-
        balanced-budget-act-of-1997-bba-97/
          CMA Comments on Proposed Home Health Payment Rules 
        (September 25, 2017): https://medicareadvocacy.org/center-
        comments-on-proposed-home-health-payment-rules/.
          CMA Issue Brief: ``The Promise and Failure of Medicare Home 
        Health Coverage'' (December 15, 2016): https://
        medicareadvocacy.org/the-promise-and-failure-of-medicare-home-
        health-coverage/.
          CMA Comments on Proposed Home Health Payment Changes (August 
        26, 2016): https://medicareadvocacy.org/center-comments-on-
        proposed-home-health-payment-changes/.
          CMA Comments on Medicare Prior Authorization of Home Health 
        Services Demonstration (April 6, 2016): https://
        medicareadvocacy.org/center-comments-on-medicare-prior-
        authorization-of-home-health-services-demonstra
        tion/.
          CMA Comments on Proposed Rules: CY 2016 Home Health 
        Prospective Payment System Rate Update; Home Health Value-Based 
        Purchasing Model; and Home Health Quality Reporting 
        Requirements (September 1, 2015): https://medicareadvocacy.org/
        comments-on-proposed-rules-cy-2016-home-health-prospective-
        payment-system-rate-update-home-health-value-based-purchasing-
        model-and-home-health-quality-reporting-requirements/.
          Also, see, generally, CMA website at: https://
        medicareadvocacy.org/medicare-info/home-health-care/.

                                 ______
                                 
      Questions Submitted for the Record to Judith A. Stein, J.D.
             Questions Submitted by Hon. Benjamin L. Cardin
    Question. Over the past decade, home health aide visits per episode 
have declined significantly from 48 percent of all billed MHH hours in 
1997 to only 5 percent in 2021.

    What are the factors driving the turnover rates of home health 
aides?

    Answer. There are a number of reasons for the significant decline 
in covered home health aide visits. As the Center for Medicare Advocacy 
noted in our response to CMS's July 2023 Request for Information (see 
https://medicareadvocacy.org/wp-content/uploads/2023/08/Home-Health-
Aides-2024-NPRM-RFI-Response.pdf), these include:

        1.  CMS and HHA policies and practices have devalued and 
        disincentivized the provision of aide services in Medicare-
        covered home health care for decades, helping to lead to the 
        current crisis.

        2.  There is competition for available aides in other care 
        settings while the demand for aide services grows substantially 
        (both Medicare-covered and non-covered).

        3.  HHAs contend that aides are not available, although many 
        workforce issues are addressable and preventable.

    Further, as noted in our RFI comments, home health aides are often 
available, but not through the Medicare-covered home health benefit. We 
are aware that home health agencies (HHAs) have transferred aide staff 
to affiliates through related party transactions for additional payment 
sources. HHAs enrolled in Medicare often tell patients that they do not 
have aide staff available in their Medicare-certified agency, but aides 
can be available to the patient through an affiliated entity (often 
with the same company name) for private pay. This strategy often allows 
the HHA to receive the full Medicare payment for other services, while 
the affiliate simultaneously bills for aide services. This practice 
reduces the amount of aide hours staffed and available through the 
Medicare-certified HHA and it provides an unacceptable alternative to 
Medicare-covered services for patients, who should be able to make full 
use of their covered Medicare home health benefit, including receiving 
the aide services they qualify for. Forcing beneficiaries to obtain 
aide services outside Medicare is not financially possible for most 
people living with chronic and longer-term conditions. It is also 
inappropriate since Medicare coverage for this care is available under 
the Medicare law.

    At the same time, there is increasing competition for the limited 
number of available aides in the job market. Currently in the United 
States, 5 million people rely on home health aides to keep them safe 
and healthy in their homes. The population is aging and becoming 
sicker. Within 10 years another million people will need aides, an 
increase of 25-34 percent, and the number of elderly in the U.S. is 
expected to double by 2050. In 2021, almost 3.4 million workers were 
employed in facilities and in homes holding similar positions as 
nursing assistants, home health aides and personal care assistants (for 
dually eligible Medicare and Medicaid individuals). Aides are also 
employed to work for individuals with other insurance and they are 
further engaged for private payment. The Bureau of Labor Statistics 
(BLS) has cited home health aides as one of the fastest growing jobs, 
with a need for 750,000 new workers every year, while another 332,000 
existing home health aides may retire or drop out of the occupation 
every year, and 287,000 may seek other types of work. Medicare-
certified HHAs draw from the same competitive pool of available aides 
seeking work as other employers offering similar services.

    For additional information, see our response to RFI Questions 3 to 
5 in the above-cited response to CMS's July 2023 RFI.

    Question. What additional data should be collected to better 
understand the key factors and how effective interventions can be 
designed and implemented?

    Answer. As reflected in a 2021 survey of 217 home health agencies 
by our organization, aide access problems are especially difficult for 
homebound beneficiaries with chronic, longer-term, and disabling 
conditions who need both skilled and aide services to effectively 
maintain or slow decline of their condition and stay safe and healthy 
at home. (See Center for Medicare Advocacy report CMA Home Health 
Survey | Medicare Beneficiaries Likely Misinformed and Underserved 
December 15, 2021, https://medicareadvocacy.org/cma-home-health-survey-
medicare-beneficiaries-likely-misinformed-and-underserved/.) In other 
words, individuals who require more care (higher acuity) have more 
difficulty accessing home health care in general, and aides in 
particular.

    In order to ensure that the home health benefit is accessible to 
everyone, including individuals with chronic conditions, CMS should 
collect and report data concerning individuals' health conditions, and 
track such data over time, to determine whether certain individuals 
with certain conditions are encountering more difficulty accessing 
care. Among the data CMS should collect and report are:

          Patients who need maintenance care;
          Patients without caregiving assistance; and
          Episodes of care with plans of care that have improvement 
        goals or maintenance goals.

    CMS should confirm concerns about the increasing lack of access to 
services, for all the identified compounding reasons, also recognizing 
that the proposed Discharge Function Score Measure will further 
discriminate against individuals with chronic and longer-term 
conditions. In Appendix A of the Discharge Function Score Measure 
Technical Report by Abt Associates, the number of 30-day episodes (and 
percentage of total home health cases), HHAs served individuals with 
several longer-term and chronic conditions in 2021 are identified as 
follows:

          Rheumatoid Arthritis and Inflammatory Connective Tissue 
        Disease (HCC40) 131,039--3 percent.
          Dementia With Complications (HCC51) 80,818--2 percent.
          Dementia Without Complication (HCC52) 384,481--9 percent.
          Quadriplegia (HCC70) 8,789--0 percent.
          Paraplegia (HCC71) 14,137--0 percent.
          Spinal Cord Disorders/Injuries (HCC72) 18,906--0 percent.
          Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease 
        (HCC73) 5,691--0 percent.
          Cerebral Palsy (HCC74) 15,123--0 percent.
          Muscular Dystrophy (HCC76) 3,499--0 percent.
          Multiple Sclerosis (HCC77) 36,244--1 percent.
          Parkinson's and Huntington's Diseases (HCC78) 137,681--3 
        percent.

    CMS should examine the trend of the number of 30-day episodes (and 
equivalent days prior to PDGM) for these conditions over the past 25 
years and identify CMS policies and practices that have contributed to 
an increasing lack of access to 
Medicare-covered care for individuals with these conditions.

                                 ______
                                 
             Questions Submitted by Hon. Sheldon Whitehouse
    Question. What specific recommendations do you have on how we can 
use the ACO model and telehealth to expand home health, including 
changes with CMS regulations, CMMI models, and legislation, to lower 
costs and improve patient care?

    Answer. As noted in my written and oral testimony, there are myriad 
problems with the administration of the Medicare home health benefit 
and access to Medicare-covered care. In our experience, it is 
inappropriately limited in traditional Medicare and access to Medicare-
covered home care is even more restricted for Medicare Advantage (MA) 
enrollees.

    With respect to using Accountable Care Organizations (ACOs) to 
improve patient care for those attributed to an ACO, it is critical to 
ensure that the incentives to stint on care inherent in capitated 
payment models do not migrate to ACOs. There are already incentives in 
home health payment and quality measures that lead home health agencies 
to seek out certain types of patients and avoid others. For example, 
the home health value-based purchasing (VBP) measures which, among 
other things, award home health agencies for meeting certain 
improvement standards, create disincentives to provide care for 
beneficiaries with longer-term and chronic conditions.

    As discussed in our comments to CMS's proposed 2023 home health 
rule (our comments are available here, https://medicareadvocacy.org/
home-health-comments-2023/), current quality criteria inappropriately 
favors services for individuals with conditions that can improve. 
Further, existing quality criteria reward discharge from home health 
care, thereby discriminating against beneficiaries with life-time 
conditions who continue to need care and should not be discharged. 
Above all, additional quality outcome incentives and payments 
applicable in the ACO arena should not exacerbate these problems.

    With respect to telehealth, there are certainly ways to increase 
access to services via telehealth when the patient has adequate 
equipment and sensory and cognitive capabilities. Ideally, these 
remotely provided services should ideally supplement, not supplant, in-
person care. The human contact and depth of observation and experience 
that comes with in-person visits cannot be fully replaced by 
telehealth. In particular, Medicare-covered home health aide care, 
which has been all but disappearing, calls for in-person attendance. By 
definition, this care is made up of ``hands-on personal'' services that 
cannot be properly provided virtually.

                                 ______
                                 

                             Communications

                              ----------                              


                          Hillcrest Home Care

                          1820 Hillcrest Drive

                           Bellevue NE 68005

September 19, 2023

Dear Subcommittee on Health Care members,

Thank you for the opportunity to provide a statement for inclusion in 
the hearing record for the above-named discussion.

I am currently the Administrator of a medium-sized home health agency 
serving the Omaha and Lincoln metro areas in Nebraska. I am also a 
licensed physical therapist, who has spent time during my career ``in 
the field'' serving a home health client caseload. Our agency is 
focused on providing care for the aging adult population, and we serve 
an estimated 400 persons daily under the skilled home health benefit. 
The vast majority of our clients are beneficiaries of Medicare and 
Medicare Advantage plans.

The PDGM payment model changes brought both positives and negatives to 
the operation of a home health agency in today's world. Positives 
include: including a higher reimbursement for more complex clients and 
a shared challenge to deliver care in the most cost-efficient manner. 
Negatives include: home health agencies shouldering the financial 
burden for complex clients whose needs were not adequately captured by 
the PDGM grouping system, and reimbursement models not adequately 
covering the environment of cost of living increases.

The pandemic and the resulting several years of wage and cost of living 
inflation have added significantly to the overhead costs of home 
health-care delivery. We have incurred significant increases in the 
following areas: medical supply costs, gas/mileage reimbursement costs, 
necessary wages to remain competitive for a shrinking labor supply. 
Home health clinicians (nurses, physical therapists, occupational 
therapists, certified nurse assistants) are considered advanced 
practice clinicians in their field--this work requires a high level of 
independence and critical thinking, as providers are often one-on-one 
with clients. The skills required to provide the proper care in this 
setting are above entry-level, and our industry is competing for talent 
with hospitals offering $10,000 sign-on bonuses and inflated wages. 
Skilled clinical labor is the key to provision of timely and quality 
complex medical care, and the reimbursement cuts undermine the ability 
to serve our clients. Adequate reimbursement goes right to our most 
valuable asset to preserve our ability to provide services--wages.

As mentioned during the hearing, our agency is also experiencing more 
referrals than we can manage. More clients are needing home health 
services than can be matched with accepting providers. Hillcrest Home 
Care is #1 in market share for Medicare home health episodes in our 
service area, however we currently decline approximately 40% of all 
referrals received due to capacity. We are currently one of the only 
home health providers in our metro area still accepting referrals for 
Medicare Advantage beneficiaries, due to the poor reimbursement (lower 
than the cost of providing services). Many providers ``cherry-pick'' 
referrals before accepting, making the difficult decision to evaluate 
the financial viability of accepting a patient with high care needs 
under the current reimbursement model. The statement that home health 
agencies ``have a 25% profit margin'' is categorically false. The 
expenses to provide home-based services are outpacing Medicare 
reimbursement, and the proposed cuts will absolutely threaten our 
ability to serve out our mission to deliver home health care in our 
community.

We have experienced contraction in our local market, with several local 
home health agencies in our service area closing in the past several 
years. This has resulted in a scarcity of home health providers able to 
accept new patients, which has a downstream effect of increasing more 
costly hospital and Skilled Nursing Facility stays as a result.

Our agency is a high-quality provider, earning a 4.5 star CMS quality 
rating and superior Value Based Purchasing percentile ranking. Our 
quality rating indicates our success in timely initiation of care and 
prevention of rehospitalization. We are a critical piece of our 
community's health-care system, allowing for timely throughput of 
persons discharging from hospital to home and freeing up valuable bed 
space for incoming hospital patients. Health care is pushing more 
complex care out of institutions and into the home, requiring increased 
skill and service at a time when reimbursement is going down. Today, we 
are treating patients in the home who never would have left the 
hospital five years ago. The decreasing reimbursement trend for home-
based care delivery to sicker and sicker patients is not sustainable.

The proposed additional Medicare reimbursement cuts will have a 
negative impact on service delivery to the Medicare beneficiaries in 
our community. Please consider support of the following to preserve and 
sustain the possibility of high quality care provision in the home:

      Support of the Preserving Access to Home Health Act S. 2137/H.R. 
5159
      Consideration of reimbursement for telemedicine visits in the 
home health setting

Sincerely,

Lauren Wright
Administrator

                                 ______
                                 
                  International Caregivers Association

                              P.O. Box 193

                           Mapleton, ME 04757

September 18, 2023

U.S. Senate
Committee on Finance
219 Dirksen Senate Office Bldg.
Washington, DC 20510-6200

To Whom It May Concern,

The Care Provider Partnership Agreement Program (CPPAP), an innovative 
approach to dementia care designed to provide more compassionate, 
person-centered services through new staffing models and specialized 
training is now available for home care, home health, assisted living, 
and long-term care.

CPPAP was created by ICA's founding president, Dr. Ethelle Lord, to 
address gaps in the current healthcare system and improve the quality 
of life for both dementia patients and their caregivers. Industry 
research shows that nurses are facing historically high burn-out rates.

``After caring for my late husband through his difficult journey with 
dementia, I recognized the urgent need for change in long-term care 
facilities and standards,'' said Dr. Lord. ``CPPAP introduces a fresh 
perspective centered on partnership, dignity, and preserving person 
hood. It is my life's work to transform perceptions, improve training, 
and implement this holistic model focused on relationship and 
humanity.''

The CPPAP program provides customized dementia care plans tailored to 
each individual. It is built on facilitating a partnership between 
caregivers, care recipients, and specialized coaching teams. It also 
puts forward a dynamic new framework for dementia care operations.

New staffing protocols reduce fatigue and burnout by allowing 
caregivers to work 6-hour shifts at 8-hour pay. Facilities are also 
required to provide 24/7 access to both a registered nurse and a 
dedicated dementia coach. The coach offers ongoing education and 
support to equip staff with the skills needed to provide attentive, 
knowledgeable care.

CPPAP further sets itself apart by empowering family members to become 
actively involved as Care Partners in facilities like nursing homes and 
assisted living. For at-home care, CPPAP enables agencies to offer 24/7 
care for family respite. To achieve CPPAP certification, hospitals must 
hold a Magnet or Pathway designation, which signifies excellence in 
nursing practices and healthy work environments. This ensures best 
practices are observed at all times.

About Dr. Ethelle Lord

Dr. Ethelle Lord is the pioneering founder and president of the 
International Caregivers Association, established over 20 years ago. 
She earned a doctorate in organizational leadership and devoted her 
career to advancing dementia education and services. Dr. Lord gained 
firsthand experience when she cared for her late husband through his 
journey with dementia. These insights inspired her to create the Care 
Provider Partnership Agreement Program as an innovative solution to 
transform long-term care and improve quality of life and work. Dr. Lord 
is a respected voice in the dementia field, working to shift 
perceptions, boost training, and implement holistic models centered on 
compassionate care.

In addition to being a sought-after speaker, Dr. Lord is an 
accomplished author. In her book ``Alzheimer's Coaching: Taking A 
Systems Approach in Creating an Alzheimer's Friendly Healthcare 
Workforce,'' she shares insights from caring for her husband Major 
Larry S. Potter, USAF Retired, who had Vascular Dementia (VaD). She 
also authored ``How in the World . . . and Now What Do I Do?''--an 
Alzheimer's primer in several languages (English, French, Spanish, 
Arabic) outlining 12 major points for coping better with dementia.

About ICA

The International Caregivers Association (ICA) is a leading 
organization Dr. Ethelle Lord founded over 20 years ago to advance 
dementia education and services. ICA provides coaching, training, and 
consulting to improve care in facilities worldwide. ICA has offices in 
Maine and California, USA and serves a global clientele. For more 
information, please visit the 
www.InternationalCaregiversAssociation.com.

More About CPPAP

The CPPAP establishes a new gold standard through rigorous specialized 
training, family involvement as Care Partners, and 24/7 access to 
dedicated nurses and coaches. This innovative model aims to 
revolutionize dementia care by maintaining relationships and dignity at 
the heart of person-centered services. Three major differences set 
CPPAP facilities apart: the dedicated dementia coach position, 
dramatically lower staff turnover and burnout, and high levels of 
family involvement. The program aims to revolutionize dementia care 
through new staffing models, training and a relationship-based approach 
focused on humanity. For more information, please see 
www.DementiaCarePartnership.com.

Sincerely yours,

Ethelle Lord

             Introducing a New Standard in Dementia Care: 
            The Care Provider Partnership Agreement Program

                      Prepared by Dr. Ethelle Lord

Dementia care is due for a revolution. After 21 years of caring for my 
husband with dementia, I recognized the urgent need for change in long-
term care. This inspired me to create the Care Provider Partnership 
Agreement Program (CPPAP) to set a higher standard in dementia care and 
services through a total culture change.

The CPPAP institutes three primary changes for facilities like nursing 
homes, assisted living, and home health agencies:

      Caregivers work 6-hour shifts at 8-hour pay, reducing fatigue 
and burnout.
      A registered nurse is available 24/7 to oversee care.
      A dementia coach is accessible 24/7 to educate and support 
staff.

For home care services. the CPPAP requires:

      Rigorous dementia education for all caregivers.
      Access to a dementia coach 24/7 for ongoing training.
      Ability to provide 24/7 care for family respite.

To achieve CPPAP certification, an organization must hold a Magnet or 
Pathway designation, which recognizes excellence in nursing practices 
and healthy work environments.

      The Magnet Recognition Program designates organizations 
worldwide where nursing leaders align goals to improve patient 
outcomes. It provides a roadmap to nursing excellence benefiting the 
whole organization.
      The Pathway to Excellence Program recognizes healthcare 
organizations for positive practice environments where nurses excel. 
Any healthcare setting with nurses caring for patients may apply.

The CPPAP introduces two pivotal new roles. The dementia coach 
possesses specialized expertise to educate all staff. Their role is to 
assess the engagement of those with dementia and support personalized 
care.

The CPPAP also empowers family members to become actively involved Care 
Partners. This leads to reduced stress and greater satisfaction. Three 
major differences set CPPAP facilities apart:

      The dedicated dementia coach position.
      Dramatically lower staff turnover and burnout.
      High levels of family involvement.

Most importantly, the CPPAP's individualized approach leads to improved 
quality of life. It also boosts workplace satisfaction by supporting 
staff.

The CPPAP offers a blueprint for the future of empathetic, 
knowledgeable dementia care through culture change. I aim to pay 
forward lessons learned from past caregivers. The CPPAP can transform 
your organization to lead the way.

Visit www.DementiaCarePartnership.com to find out more and contact us 
for a free consultation on how we can customize the CPPAP program to 
fit your dementia care and coaching needs.

                                 ______
                                 
                            Justice in Aging

                     1444 I Street, NW, Suite 1100

                          Washington, DC 20005

                              202-289-6976

                       https://justiceinaging.org

October 2, 2023

U.S. Senate
Committee on Finance
219 Dirksen Senate Office Bldg.
Washington, DC 20510

Justice in Aging submits this statement for the above-referenced 
hearing record. Justice in Aging is an advocacy organization with the 
mission of improving the lives of low-income older adults. We use the 
power of law to fight senior poverty by securing access to affordable 
healthcare, economic security, and the courts for older adults with 
limited resources. We focus our efforts primarily on those who have 
been marginalized and excluded from justice such as older adults of 
color, older women, LGBTQ+ older adults, older adults with 
disabilities, and older adults who are immigrants or have limited 
English proficiency. Justice in Aging has decades of experience with 
Medicare and Medicaid and improving both programs and integration for 
people dually eligible.

We appreciate the subcommittee holding this important and timely 
hearing on Medicare's role in helping older adults age in place. Our 
comments focus on how declining access to home health aide services, 
denials for people with higher needs, and premature termination of home 
health care impact people dually eligible for Medicaid.

     Robust Oversight and Enforcement of Medicare Law Is Necessary 
             to Secure Access to Home Health Aide Services

Access to home health aide services is declining due to a combination 
of discriminatory policies, home health agency (HHA) business 
decisions, and poor oversight. Advocates report that home health 
agencies often refuse to take on Medicare enrollees who are more in 
need of ``non-skilled'' aide services and tell enrollees that aide 
services are not available at all or do not cover anything beyond 
bathing.\1\ Instead of providing home health aides, agencies refer 
patients to their non-Medicare, private pay ``affiliates'' for related 
services, cost-shift home health aides for patients dually enrolled in 
Medicare and Medicaid to Medicaid, or force individuals to rely on 
family caregivers.
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    \1\ Center for Medicare Advocacy, Home Health Survey: Medicare 
Beneficiaries Likely Misinformed and Underserved (December 2021), 
https://medicareadvocacy.org/wp-content/uploads/2021/12/CMA-Survey-
Medicare-Home-Health-Underservice.pdf.

Denying access to Medicare-covered home health aides for help with 
activities of daily living as critical as bathing, toileting, grooming, 
skin care, walking, transferring, and assistance with medications, puts 
enrollees at risk of being hospitalized or entering a nursing facility 
because they do not get the support they need to stay safely at home. 
These practices are detrimental to the enrollee's health and well-being 
and costlier for Medicare. It also pushes costs onto Medicaid, 
---------------------------------------------------------------------------
straining limited HCBS dollars and contributing to unmet need.

The Centers for Medicare and Medicaid Services' (CMS) policies play a 
role in disincentivizing HHAs from providing aide services. For 
example, as the Center for Medicare Advocacy shared during the hearing, 
providing aide services and serving Medicare enrollees with greater 
needs increases the likelihood that an agency will be audited. On the 
flip side, there is no accountability for not providing aide services. 
HHAs are able to understaff aides in their Medicare lines of business, 
decline people who need these services, and maximize their profits by 
providing aides to those who can afford to pay out of pocket. The 
Office of Inspector General (OIG) and Medicare contractors do not audit 
to protect either the program or enrollees by investigating agencies 
that underserve patients, even when practices such as refusing to 
accept or prematurely discharging patients with chronic conditions may 
constitute discrimination on the basis of disability. Instead, audits 
apply incorrect standards and only focus on agencies ``overserving'' 
patients. HHA profit margins bear this out: MedPAC reported in 2021 
that home health agencies post approximately 16% profits every year 
(23.4% for ``efficient'' providers).\2\ This represents millions of 
dollars in profit that should be going to home health aide care.
---------------------------------------------------------------------------
    \2\ MedPAC, Report to Congress (March 2021), supra, p. 257-258, 
available at www.
medpac.gov/docs/default-source/reports/
mar20_entirereport_sec.pdf?sfvrsn=0.

Additionally, CMS's payment policy focuses on ``skilled'' services and 
does not incentivize agencies to provide aides nor the full 28-35 hours 
of services Medicare authorizes. Under the current payment rules, 
``profitable'' Medicare enrollees are people who need short-term care 
following inpatient institutional stays. This incentivizes HHAs to deny 
access altogether to people who are not transitioning out of an 
---------------------------------------------------------------------------
institutional stay and people who need more aide services.

Robust oversight is necessary to ensure that HHAs actually provide 
necessary care in accordance with Medicare law. It is not the need for 
aide services that is declining, but rather the access that is being 
inappropriately denied.

We urge Congress to address this issue through an equity lens and to 
measure disparities in access to Medicare home health.\3\ Not only are 
there underlying health disparities that affect the makeup of the 
people with the greatest needs for and least access to services, but 
the same social determinants of health that cause those disparities 
also make the home health system harder to navigate. For example, a 
person with limited income and resources who is returning home from a 
hospital stay and is told by an HHA that Medicare doesn't cover the 
personal care services they need has fewer financial resources, time, 
and energy to investigate or appeal the HHA's decision not to provide 
services. An individual with limited English proficiency or who has 
experienced discrimination in the past may not feel empowered to ask 
for services in the first place or dispute what the HHA tells them.
---------------------------------------------------------------------------
    \3\ See e.g., Bipartisan Policy Center, Optimizing the Medicare 
Home Health Benefit to Improve Outcomes and Reduce Disparities 
(recommending CMS ``Require MACs to report coverage denials by 
condition, service type, race, age, functional status, cognitive 
deficit, and episode trigger to identify access disparities.'')

Many low-income older adults have experienced trauma from racism, 
discrimination and poverty, as well as events such as war and corrupt 
government regimes. Therefore, interactions with government--even for 
services and benefits--are potentially stressful and triggering. Adding 
to the stress in the home health context, interactions with HHA staff 
are often first occurring at a particularly difficult time following an 
illness, rapid decline in function, or loss of support from family. 
Home health services are also very intimate, occurring inside an 
individual's own home, so ensuring HHAs are not discriminating in how 
or to whom they provide care is of particular importance. We encourage 
Congress to support training on issues of implicit bias, LGBTQ+ and 
other culturally appropriate care, and to combat discriminatory notions 
like the pervasive myth that people of color over-report pain, leading 
them to be evaluated for less care.

  Improving Access to Medicare Home Health Aide Services Will Benefit 
      People Dually Eligible for Medicaid and the Medicaid Program

Nearly half of the 12 million people dually eligible for Medicare and 
Medicaid need assistance with one or more activities of daily 
living,\4\ which are the ``non-skilled'' services Medicare home health 
covers. This means that Medicare home health aides have a significant 
role to play for this population. However, in Justice in Aging's 
experience with advocates and our observations, coordination between 
Medicare and Medicaid for home health aide services is non-existent. 
There are many benefits that both Medicare and Medicaid cover with 
varying degrees of complexity to navigate. However, home health aide 
services are not a service we hear about navigation issues with because 
HHAs are not providing these services through Medicare. Rather, 
Medicaid is paying for all the personal care services for people dually 
eligible as HCBS enrollees.
---------------------------------------------------------------------------
    \4\ KFF, A Profile of Medicare-Medicaid Enrollees (Dual Eligibles) 
(2023).

The consequence of the pervasive disinformation about Medicare home 
health aide coverage (and longevity of coverage) has led to people 
dually eligible and their advocates not knowing about or pursuing 
Medicare coverage of personal care services. While the Medicare benefit 
is not as expansive as Medicaid HCBS and is unlikely to fully meet the 
LTSS needs of many people dually eligible, it should be meeting more of 
their personal care needs and Medicaid should be wrapping around to 
provide additional hours and services such as transportation and other 
supports to facilitate community integration that Medicare does not 
cover. For example, participants in California's In-Home Supportive 
Services (IHSS) program are authorized to receive an average of about 
25 hours of personal care per week.\5\ As this is well within the 
Medicare limit of 28-35 hours, Medicare could and should be fulfilling 
many of these hours.
---------------------------------------------------------------------------
    \5\ CA Dept. Social Svcs, IHSS Program Data (last updated August 
2023).

There are multiple harmful consequences of not employing Medicare's 
home health aide benefit and over-relying on Medicaid. One is that 
dually eligible individuals are likely not getting all their needs met, 
as Medicaid programs cap the hours/frequency of personal care an 
individual can receive, even if their needs are greater. While we 
strongly urge Congress to pass legislation like the HCBS Access Act \6\ 
to end waiting lists and enrollment caps, the Medicare home health 
benefit is and will remain key to ensuring everyone who needs personal 
care support at home can access it. If Medicare were covering most of 
these personal care hours, limited Medicaid HCBS dollars could go 
further to fill in more hours and serve more people. This could help 
mitigate racial inequities in hour allocations among Medicaid HCBS 
participants.\7\
---------------------------------------------------------------------------
    \6\ Justice in Aging, Fact Sheet: The HCBS Access Act (June 2023).
    \7\ See, e.g., Justice in Aging, California's In-Home Supportive 
Services Program: An Equity Analysis (June 2023).

Another harm of people not being able to access the full Medicare home 
health benefits they are entitled to is that they have to impoverish 
themselves to qualify for Medicaid to get any of their LTSS needs met. 
As discussed above, Medicaid HCBS coverage is not available 
immediately. Individuals must apply and wait for approval, which often 
takes 2 to 3 months, before services can begin. If there is a waiting 
list, they may have to wait years. Medicare home health aide services 
could and should be providing an important stopgap for people who need 
assistance with daily activities while they wait for Medicaid coverage 
---------------------------------------------------------------------------
to start.

The greatest harm is that people dually eligible, who are low-income 
and not able to afford to fill in the gaps in care, are having to enter 
nursing facilities when they could be supported at home by Medicare 
home health. Even if they qualify for Medicaid, HCBS coverage often has 
capped enrollment and is not immediately accessible when the need 
arises,\8\ in contrast to nursing facility coverage and Medicare 
coverage of home health aides. Moreover, people of color, people with 
limited English proficiency, women, LGBTQ+ individuals and others face 
additional barriers to navigating and accessing HCBS, making proper 
provision of Medicare home health aide services--a universal benefit 
with no waiting lists or application delays--especially important to 
supporting these marginalized communities to live at home.
---------------------------------------------------------------------------
    \8\ Justice in Aging, Medicaid's Unfair Choice: Wait Months for In-
Home Assistance--or Get Nursing Facility Coverage Today--Justice in 
Aging (September 2021).
---------------------------------------------------------------------------

                  Invest in the Direct Care Workforce

Medicare home health is not immune from the direct care workforce 
crisis that is impacting Medicaid long-term services and supports. The 
work of home health aides is critically important yet undervalued. Many 
people who are passionate about doing this work--often women of color--
can find higher paying, less demanding jobs in retail or service 
industries. The fact that most home care jobs do not pay competitive 
wages worsens the shortage of direct care workers, as many people are 
forced to choose jobs in order to make a living in industries that do 
not have such urgent need. Medicare, as the primary payer, can and 
should seek to rectify this issue through its payment policies and HHA 
oversight. If payment policies value and incentivize aide services and 
HHAs are held accountable for providing those services, HHAs will have 
to make sure they are recruiting and retaining an adequate workforce to 
provide those services.

We also recommend that Congress address the direct care workforce 
holistically both in Medicare and Medicaid and ensure that efforts are 
aimed at increasing and sustaining workers that can meet the diverse 
long-term services and supports needs of older adults and individuals 
with disabilities. For example, Congress should pass legislation to 
increase Medicaid HCBS funding so that states can sustain the 
investments in the direct care workforce they made using American 
Rescue Plan Act funds.\9\ This funding is necessary to recruit and 
retain an adequate workforce to meet the growing LTSS needs and ensure 
that there are no disparities in access based on coverage. Funding 
should also support training and career development that covers the 
broad array of services individuals may need, centers culturally 
appropriate care, and empowers home health aides and all direct 
services providers to maximize their skills and better serve their 
clients.
---------------------------------------------------------------------------
    \9\ ADvancing States, ARPA HCBS Spending Plan Analysis (March 
2023).
---------------------------------------------------------------------------

                               Conclusion

Thank you for your attention to this important issue. We urge Congress 
to ensure Medicare's home health coverage law is being upheld so that 
Medicare-covered home health care, including home health aide services, 
are available to everyone who qualifies, especially those with longer-
term, more complex conditions who may not be expected to improve.

If any questions arise concerning this submission, please contact 
Natalie Kean, Director of Federal Health Advocacy, at 
nkean@justiceinaging.org.

Sincerely,

Amber Christ
Managing Director of Health Advocacy

                                 ______
                                 
                National Academy of Elder Law Attorneys

                    1577 Spring Hill Road, Suite 310

                            Vienna, VA 22182

                              703-942-5711

                             www.NAELA.org

U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510

Dear Chairman Cardin and Ranking Member Daines:

The National Academy of Elder Law Attorneys (NAELA) submits this 
statement for the record for the hearing, ``Aging in Place: The Vital 
Role of Home Health in Access to Care.''

NAELA is a nonprofit professional association of over 4,000 elder and 
special needs law attorneys that conditions membership on a commitment 
to the Aspirational Standards for the Practice of Elder and Special 
Needs Law Attorneys,\1\ recognizing the need for holistic, person-
centered legal services to meet the needs of older adults, people with 
disabilities, and their caregivers. Supporting the dignity and 
independence of these vulnerable populations is at the center of what 
we do, and we write in agreement with the spirit of this hearing that 
most Americans seek to age in place and public policy should support 
that aim.
---------------------------------------------------------------------------
    \1\ https://www.naela.org/Web/Web/About_Tab/History_and_Standards/
History_and_Stan
dards_Sub_landing/Aspirational_Standards.aspx.

The hearing held September 19, 2023, reflected a united, bipartisan 
commitment by committee members and witnesses to recognize the desire 
of most Americans to age in their homes and communities,\2\ and 
reflected thoughtful consideration of the myriad complicating issues 
and factors to be resolved in achieving this goal through public 
policy. NAELA shares that commitment, and our members, representing 
tens of thousands of Americans in all 50 states, the District of 
Columbia, and territories, are eager to engage and support thoughtful 
policymaking on federal and state levels to ensure all Americans can 
age where they choose, where they are safest, and where they can 
receive the support they need to sustain maximum independence and 
autonomy.
---------------------------------------------------------------------------
    \2\ Binette, Joanne, and Fanni Farago. 2021 Home and Community 
Preference Survey: A National Survey of Adults Age 18-Plus. Washington, 
DC: AARP Research, November 2021, https://doi.org/10.26419/
res.00479.001.

We would like to draw your attention to several critical policy areas 
that require congressional action. These areas need thoughtful 
consideration and action to ensure that older Americans have the 
---------------------------------------------------------------------------
necessary support and resources to age in place:

    1.  Medicaid HCBS Policy and Funding Reforms: We urge the committee 
to explore opportunities for strengthening Medicaid policies that 
improve access to home and community-based services (HCBS) for Medicaid 
eligible beneficiaries. Expanding Medicaid coverage and accessibility 
for HCBS can enable seniors and individuals with disabilities to 
receive essential care at home, preserving their independence and 
quality of life. Congress should also examine and standardize planning 
rules to ensure beneficiaries who qualify for HCBS can access benefits.

       In addition, Congress should mitigate Medicaid's institutional 
bias through a number of specific actions. For example, for HCBS 
provided pursuant to a state waiver under Section 1915(c) of the Social 
Security Act, coverage is prospective-only from the date on which the 
state Medicaid program (or its agent) approves an HCBS service plan 
because federal financial participation (FFP) may not be claimed for 
Section 1915(c) waiver services that are furnished prior to the 
development of the service plan or for waiver services that are not 
included in an individual's service plan. Given that most states' HCBS 
programs are authorized under Section 1915(c), Congress could reduce 
the institutional bias in Medicaid by allowing states to receive FFP 
for services provided prior to the development of the service plan in 
certain circumstances, such as for populations that are highly likely 
to be eligible for an HCBS service plan. We also echo the suggestion 
made by witness David C. Grabowski, PhD, to extend the increase in the 
federal match rate for Medicaid HCBS as Congress has done in the past 
under the American Rescue Plan Act and the Affordable Care Act's 
Balancing Incentive Program.\3\
---------------------------------------------------------------------------
    \3\ https://www.finance.senate.gov/imo/media/doc/
09192023_grabowski.pdf.

    2.  Medicare Coverage: It is essential to enhance Medicare coverage 
for home health services, including skilled nursing care and physical 
therapy. Ensuring seniors have access to these services at home can 
contribute significantly to their ability to age in place. We wish to 
reiterate the testimony from Judith Stein, JD, President of the Center 
for Medicare Advocacy, who points out that the Medicare home health 
benefit could greatly improve quality care for beneficiaries and should 
be better understood and enforced.\4\
---------------------------------------------------------------------------
    \4\ https://www.finance.senate.gov/imo/media/doc/
09192023_stein_testimony.pdf.

    3.  Telehealth Expansion: Telehealth has proven invaluable, 
especially in rural areas with limited access to healthcare facilities. 
We encourage the committee to support policies that expand telehealth 
access and reimbursement for seniors, allowing them to receive medical 
---------------------------------------------------------------------------
care remotely.

    4.  Caregiver Support: The Recognize, Assist, Include, Support, and 
Engage (RAISE) Family Caregivers Act of 2018 a vital piece of 
legislation, but more can be done to support family caregivers as was 
made clear in the National Strategy to Support Family Caregivers. One 
clear legislative action would be to make Medicaid spousal 
impoverishment protections permanent. Supporting and expanding 
caregiver support policies can ease the burden on families caring for 
aging loved ones.

    5.  Older Americans Act and Adult Protective Services (APS) 
Funding: The Older Americans Act-authorized programs provide a crucial 
lifeline for addressing social isolation, safety, and essential support 
to seniors, especially those in rural communities. Yet states and local 
service providers cannot meet the demand, particularly as more 
Americans are living longer with chronic conditions and wish to avoid 
institutionalization. Ensuring adequate, stable funding for social 
service programs--including meal delivery, legal services, and 
transportation services, as well as critical services for seniors at 
risk of fraud, neglect, or abuse--is crucial for building the 
infrastructure needed to allow Americans to age in place. To protect 
seniors from abuse and neglect, support linkages to legal services and 
medical-legal partnerships, and support post-acute and long-term care 
worker recruitment and retention, Congress should pass the Elder 
Justice Reauthorization and Modernization Act.

These policy areas have a profound impact on the lives of older 
Americans. Your leadership and advocacy can empower seniors to age in 
place, maintain their dignity, and receive the care they require in the 
safety and comfort of their homes and communities.

If you have questions, contact Mike Knaapen (mknaapen@naela.org), 
Director of Public Policy and Alliance Development at NAELA.

Sincerely,

Bridget O'Brien Swartz
President

                                 ______
                                 
                     Private Care Association, Inc.

                             P.O. Box 0911

                     Southern Pines, NC 28388-0911

                      https://www.privatecare.org/

U.S. Senate
Subcommittee on Health Care
Committee on Finance

                           September 19, 2023

    The Private Care Association (``PCA'') \1\ appreciates the 
opportunity to submit this Statement for the Record concerning the 
above-referenced hearing.
---------------------------------------------------------------------------
    \1\ PCA, is a national association representing caregiver 
registries.

    Several hearing witnesses discussed the inadequate access to home 
care, which was attributed to, among other things, the reimbursement 
rates under government programs and the difficulty in meeting the home-
---------------------------------------------------------------------------
care needs of rural populations.

    This Statement is limited to only one dimension of the home-care 
access problem. But it is a dimension which witnesses did not address, 
namely, the effect of the U.S. Department of Labor (``DOL'') issuing 
regulations in 2013 (which became effective in 2015) that significantly 
narrowed the scope of the companionship-services exemption \2\ to the 
Fair Labor Standards Act of 1938 (``FLSA''). Importantly, this 
exemption applies only to nonmedical home care. Accordingly, this 
Statement pertains only to home-care access issues that involve 
nonmedical home care.
---------------------------------------------------------------------------
    \2\ 29 U.S.C. Sec. 213(a)(15).

    By way of background, Congress enacted the companionship-services 
exemption (the ``CSE'') during 1974, when it expanded the FLSA to cover 
domestic workers. The CSE exempts from the FLSA's overtime and minimum-
wage requirements individuals employed in domestic service employment 
to provide companionship services for individuals who (because of age 
or infirmity) are unable to care for themselves. The exemption applies 
generally to individuals who provide nonmedical care in an individual's 
---------------------------------------------------------------------------
home.

    In the year following the CSE's enactment, DOL issued regulations 
\3\ to implement the CSE and make clear that the exemption applied to 
covered services--regardless of whether the caregiver provides the care 
pursuant to an agreement with the care recipient or through a ``third 
party employer.''
---------------------------------------------------------------------------
    \3\ Application of the Fair Labor Standards Act to Domestic 
Service, 40 Fed. Reg. 7404 (February 20, 1975) (amending 29 CFR Part 
552).

    The CSE reflects a trade-off Congress struck at the time that 
balanced the interests of expanding FLSA coverage to domestic workers 
against the interests of ensuring that working families could continue 
to afford home care for an elderly or disabled family member.\4\ The 
balance struck consisted of exempting families from having to pay FLSA 
wages when caregivers provide care for their elderly or disabled family 
members.
---------------------------------------------------------------------------
    \4\ DOL explained the compromise Congress struck when enacting the 
companionship-services exemption in Wage and Hour Advisory Memorandum 
No. 2005-1 (December 1, 2005), titled Application of Section 13(a)(15) 
to Third Party Employers:
         Soon after the [1975] regulations were promulgated, the 
Department explained that Congress was mindful of the special problems 
of working fathers and mothers who need a person to care for an elderly 
invalid in their home. Opinion Letter from Wage and Hour Div., 
Department of Labor, WH-368, 1975 WL 40991 (November 25, 1975). In 
particular, legislators were concerned that working people could not 
afford to pay for companionship services if they had to pay FLSA wages. 
See 119 Cong. Rec. 24,797 (statement of Senator Dominick, discussing 
letter from Hilda R. Poppell); id. at 24,798 (statement of Senator 
Johnston); id. at 24,801 (statement of Senator Burdick). That cost 
concern applies whether the working person obtains the companionship 
services by directly hiring an employee or by obtaining the services 
through a third party. . . . As explained above, Congress created the 
exemption to ensure that working families in need of companionship 
services would be able to obtain them. . . . (Emphasis added).

    Nearly 40 years later, DOL issued regulations \5\ during 2013 that 
significantly limited the scope of the CSE and completely eliminated 
its application to a ``third party employer.'' This action represented 
a stunning policy reversal of the promise Congress made to working 
families when it enacted the CSE.
---------------------------------------------------------------------------
    \5\ Application of the Fair labor Standards Act to Domestic 
Service, 78 Fed. Reg. 60,453 (October 1, 2013) (amending 29 CFR Part 
552).

    Prior to the CSE regulations going into effect in 2015, an in-home 
caregiver could work exclusively for one family for as many hours as 
the caregiver chose to work. The CSE regulations changed this, by 
subjecting nonmedical home care not meeting the narrowed terms of the 
CSE (or provided through a ``third-party employer'') to the FLSA's 
complex overtime and minimum-wage requirements. Many seniors who pay 
for home care with their private funds cannot afford to pay overtime 
rates. And long-term care insurance policies and government-funded 
programs generally pay fixed amounts for home care. Consequently, the 
2013 CSE regulations have resulted in many in-home caregivers being 
restricted to working no more than 40 hours per week per family (or 
---------------------------------------------------------------------------
agency)--to avoid the unaffordable overtime rates.

    Subjecting nonmedical home care to the FLSA's overtime requirements 
also reduces continuity of care to seniors--which can be especially 
problematic for those who suffer from Alzheimer's or dementia. And it 
disrupts the lives of many in-home caregivers by not being able to work 
exclusively for one family as many hours as they choose. Instead, such 
caregivers generally need to find other families who happen to need 
home care during the specific hours they are not working for their 
primary family.

    PCA respectfully urges the Subcommittee to consider examining the 
effect of the 2013 CSE regulations on the availability of nonmedical 
home care. Specifically, PCA submits that consideration be given to 
examining:

          The number of nonmedical in-home caregivers whose work hours 
        per week have been restricted to no more than 40 per week, to 
        avoid the FLSA's overtime requirement;

              The number of hours these caregivers are able 
        to provide nonmedical in-home care for other clients, who 
        happen to need care during the hours they are not working for 
        their primary client;

              The number of hours of nonmedical home care 
        being ``lost'' on account of these caregivers not being able to 
        find other clients who need care during the hours they are not 
        working for their primary client; and

          The number of nonmedical in-home caregivers who actually 
        earn overtime as a result of the 2013 CSE regulations.

    PCA surmises, based purely on anecdotal evidence, that the 2013 CSE 
regulations adversely affected all parties affected. Seniors who cannot 
afford to pay overtime rates have lost access to continuity of care; 
many caregivers are restricted to working no more than 40 hours per 
week per client and are unable to find other clients needing home care 
during the hours they are available; few caregivers are earning 
overtime; and the total number of hours of nonmedical home care being 
provided has been artificially reduced, thereby exacerbating the lack 
of availability of nonmedical home care.

    PCA respectfully submits that a thorough examination of the effect 
of the 2013 CSE regulations could reveal an opportunity to expand 
access to nonmedical home care while also enabling seniors, once again, 
to enjoy continuity of care and empowering in-home caregivers to work 
as many hours as they choose for one family. And this would be an 
especially attractive opportunity if the findings reveal that the vast 
majority of in-home caregivers who work more than 40 hours per week are 
not earning overtime but instead are having to move from client-to-
client (or agency-to-
agency) to work the same hours they worked before the 2013 CSE 
regulations. Now that the CSE regulations have been in effect for more 
than seven years, sufficient data should be available to conduct a 
meaningful analysis of this issue.

    PCA would appreciate the opportunity to work with the Subcommittee 
in ascertaining the effect of the 2013 CSE regulations on access to 
nonmedical home care. Thank you very much for your consideration.

Respectfully,

Russell A. Hollrah
Washington Counsel to Private Care Association, Inc.
Hollrah LLC
1025 Connecticut Avenue, NW, Suite 1000
Washington, DC 20036
(202) 659-0878
rhollrah@hollrahllc.com

                                 ______
                                 
              Texas Association for Home Care and Hospice

                9390 Research Blvd., Bldg. I, Suite 300

                            Austin, TX 78759

                             (512) 338-9293

                            f (512) 338-9496

                           https://tahch.org/

U.S. Senate
Committee on Finance
Subcommittee on Health

The Texas Association for Home Care and Hospice (TAHC&H) thanks the 
Committee for the opportunity to comment on the role of home health in 
access to care. On behalf of our concerned members, TAHC&H would like 
to reinforce concerns from the hearing about the serious and patient-
limiting access issues caused by the Centers for Medicare and Medicaid 
Services' (CMS) CY 2024 proposed rule that will slash payment rates for 
Medicare home health services. TAHC&H is concerned about the long-term 
impact of CMS' proposed payment cuts to the home health benefit which 
will place an undue burden on providers and make it harder for our most 
at risk seniors to receive medically necessary care in the most cost 
effective and preferred setting, their homes. Additionally, Texas home 
health providers that offer essential home and community-based services 
(HCBS) to Medicaid beneficiaries with complex needs, have grave 
concerns with CMS' Medicaid Access Rule proposal that requires 80 
percent of Medicaid HCBS payments are spent on direct care wages. While 
TAHC&H members desire to offer competitive rates for recruitment and 
retention of a quality workforce, it is not clear how Texas providers 
will be able to implement this requirement without exacerbating access 
issues in areas where providers are already in short supply.

The Texas Association for Home Care and Hospice represents over 1,200 
licensed Home and Community Support Services Agencies (HCSSAs) across 
the state of Texas. TAHC&H remains committed to working with the 
Committee and CMS to improve access to these services by ensuring 
providers can offer home health care to Texas beneficiaries.

    CY 24 Home Health Prospective Payment System (PPS) Proposed Rule

In 2018, Congress directed CMS to change the Medicare home health 
payment system beginning in 2020. In doing so, Congress required the 
new payment system, the Patient Driven Groupings Model (PDGM), to be 
budget neutral compared to the old system, intending that post-2020 
payments should be as if the new system had not been enacted. To 
achieve budget neutrality, CMS was authorized to make certain payment 
adjustments on both permanent and temporary basis that allowed for a 
reconciliation of assumed behavior changes and actual behavior changes.

We are extremely concerned and disappointed at CMS' decision to 
implement a 5.653% reduction to home health agencies (HHAs) in 2024. 
CMS finalized a 3.925% cut last year despite strong opposition from 
patients, providers, and lawmakers. CMS has inaccurately presented the 
payment update for CY 24 as a nominal 2.2% reduction, when the agency 
has proposed to continue a permanent payment adjustment that reflects 
an over 9% cut to HHAs in just two years. Despite Congressional intent 
that CMS implement the new home health payment model, PDGM, in a budget 
neutral manner, CMS maintains its position that it has the authority to 
make determinations based on the impact of the previous payment model. 
We urge the Committee to implore CMS to halt its proposed massive cut 
to Medicare home health services. Another year of significant cuts will 
place most Texas home health agencies at risk of closing, forcing the 
at-risk seniors we serve into higher cost nursing facilities. Notably, 
the referral rejection rate has increased significantly (from 49% in 
2020 to 71% in 2022) indicating that hospital lengths of stay are 
increasing, and patients are not able to move easily from hospital to 
home.

The cumulative impact of these proposed cuts is billions of dollars 
carved out of the Medicare home health program which is only a small 
percentage of the overall Medicare budget, further adding to the 
challenges Medicare providers face in serving their patients--the 
majority (94%) of which say they would prefer to receive necessary 
health care in their own home. Home health is estimated to save the 
Medicare Trust Fund an estimated $1.38 billion over 6 years due to 
avoided hospitalizations and decreased transfers to more expensive 
post-acute care settings, yet CMS continues to ignore data and 
recommendations from home health providers that another massive cut 
will compound these access problems leading to costlier care and worse 
outcomes for patients. Diminished access to the home health benefit 
will impact our entire health-care system--driving up costs due to 
increased hospital lengths of stay and forcing patients into costlier 
sites of care. The CMS proposal will be detrimental to Medicare 
beneficiaries in Texas that desire medically necessary care in their 
homes, particularly in rural areas, where home health providers are 
often the only source of health care. Further, chronically low payment 
rates have created ongoing disparities in care perpetuating the 
continued struggles of home care agencies to maintain their financial 
stability and a stable workforce. It is estimated that 51.9% of Texas 
home health agencies will have margins below zero and be forced to 
forgo $81.5 million in reimbursement if the 2024 cuts are implemented.

      Medicaid Program: Ensuring Access to Medicaid Services Rule

In the proposed Medicaid Access rule, CMS is proposing to require that 
at least 80 percent of all Medicaid payments, including but not limited 
to base payments and supplemental payments, be spent on compensation to 
direct care workers that provide homemaker services, home health aide 
services, and personal care services.

TAHC&H has significant concerns that the 80% payment requirement could 
have consequential damaging impacts for Medicaid Home and Community 
Based Services (HCBS) program providers. Of particular concern is the 
lack of data used to produce the calculation for an 80% payment 
threshold. While we agree that direct care workforce pay rates is an 
issue that needs to be addressed, presently there simply is not enough 
data available related to State Medicaid HCBS services to substantiate 
an industry requirement of this magnitude. Due to insufficient data and 
absent a full understanding of the state-by-state payment rate 
structures and regulatory requirements for these programs, it would be 
reckless of CMS to apply this mandate to states universally.

TAHC&H does not believe that mandating 80% of payment reimbursements to 
direct care workers will ensure higher wages for workers, instead we 
have serious concerns that this will force providers to make cuts to 
other essential programs, such as direct care worker support systems, 
day to day operations and processes, or alternatively, shut down 
entirely. We believe that small providers with low caseloads, rural 
providers with low caseloads and high mileage reimbursements, providers 
that serve certain ethnic groups, and minority owned providers will be 
crippled by this mandate. We also believe that this will negatively 
impact direct care workers who desire additional training and education 
for career development, and who rely on provider support systems that 
could be potentially cut due to lack of funds. Additionally, this 
proposed policy this will further exacerbate the staff turnover and 
retention efforts specific to home care providers because they will 
have to cut costs related to direct care worker support systems and 
support staff, as well as certain training and education opportunities 
for direct care workers due to reduced funds available to support these 
costs, which will in turn cause direct care workers to go elsewhere to 
access these benefits.

TAHC&H recommends that CMS withdraw the 80% payment requirement from 
this proposed rule and instead focus on collecting ample data to create 
viable payment and wage options to ensure payment rates to direct care 
workers are sufficient for services and quality of care. We believe 
that using Electronic Visit Verification (EVV) data would be a possible 
route for collecting ample data, as well as requiring states to do 
independent analysis of costs of care to set minimum standards for 
states and determine overall future changes to direct care worker 
compensation. We also recommend that CMS engage stakeholders in a 
workgroup type setting to ensure a better understanding of the 
differences in payment rate structures and regulatory differences of 
the Medicaid programs state by state. We believe that by taking this 
route, CMS and stakeholders will be able to find a workable solution at 
the most fundamental level as opposed to implementing a blanket mandate 
that will not work due to the differences in the structure of Medicaid 
programs at the state level. We further recommend that CMS publicly 
disclose all data and analytical methodologies regarding any future 
payment thresholds to ensure transparency.

Texas home care agencies want to continue to deliver cost-effective 
care, but it is critical that CMS recognize the need for sustainable 
support for an industry that services our most vulnerable. It is 
important that investments are made to retain, recruit, and strengthen 
the home care workforce and reverse consequential access to care issues 
due to payment cuts. Providers have been sounding the alarm on the 
inadequacy of rates for over a decade.

We appreciate your interest in ensuring seniors have the freedom to age 
in place and that low-income, disabled individuals have access to care 
in their home and community. We implore the Committee to protect and 
ensure the delivery of high-quality, cost-effective home-based care and 
services to those that need it.

Respectfully Submitted,

Jessica Boston
Director of Government Affairs