[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
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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.
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\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\
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\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.
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\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.
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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\
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\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\
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\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\
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\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.
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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\
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\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
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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.
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\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.
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\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\
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\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
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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.)
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\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\
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\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\
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\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\
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\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\
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\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\
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\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\
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\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\
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\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.
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_______________________________________________________________________
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\
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\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.
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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.
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\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\
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\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:
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\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\
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\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
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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\
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\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\
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\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\
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\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:
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\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.
---------------------------------------------------------------------------
\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.
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\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.
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\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
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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\
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\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\
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\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
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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.
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\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-
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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.
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\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
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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.''
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\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.
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\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.
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\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
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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