Home Health & Hospice Week

Number of HHAs has dropped 10 percent in 7 years.

While MedPAC is headed toward recommending a 5 percent cut to home health spending for 2023, there was also a bright side to commissioners’ discussion of home health in the advisory body’s meeting last month.

Recap: On Dec. 10, 2021, the Medicare Payment Advisory Commission staff and commissioners decried home health agencies’ profit margin and pushed for use of staff turnover stats in quality and even payment mechanisms. Commissioners also voiced unanimous approval to two recommendations — the 5 percent cut, and telehealth claims reporting requirements (see HCW, Vol. XXX, No. 45). MedPAC will make a final vote in its meeting on Jan. 13-14, with a resulting March report to Congress.

But some commissioners’ comments in the December meeting shed light on problems Medicare beneficiaries are having accessing home health services, particularly in rural areas.

In a presentation at the meeting, MedPAC staffer Evan Christman noted that 88 percent of benes live in a county served by five or more HHAs, and 99 percent live in a county served by at least one agency. This is despite the fact that the number of HHAs fell 1 percent from 2019 to 2020, to 11,456 agencies. And that the number of HHAs has fallen from 12,788 in 2013 — a 10 percent drop.

“The decline in agency supply of 1 percent [in 2020] was actually lower than the average decline for recent years,” which has been 1.7 percent since 2013, Christman highlighted in the meeting. “The access to home health appears to be very good,” he told commissioners.

But commissioners pushed back on that assertion.

“We have an incredible problem getting access to home health,” reported Commissioner Lynn Barr. Barr heads up Caravan Health, “which guides and supports more than 200 health facilities … in value-based payment models, such as accountable care organizations (ACOs),” according to the MedPAC website. Many of those are rural facilities.

“I have no alternatives in post-acute care in most of my rural communities, which is a real disconnect with what you’re seeing,” Barr told Christman. “It isn’t really about Zip codes, it’s about distance. And we have no way of accommodating for that,” she explained in the meeting.

“I’d love if we could take a different look at access, because the numbers you have are amazing, and if it was true, I would be all over it. But we really don’t see that, and it’s a huge problem for us,” Barr continued.

“The frontier agencies have lower margins, but they were still well over 10 percent,” Christman responded. “We have a hard time seeing it happen in the data and seeing a relationship to payment,” he said.

Barr suggested MedPAC staff talk to case managers in rural hospitals. “If they tell you they can, then they’re going to have to talk to me, because I don’t have access,” Barr said.

Christman pointed out that urban HHAs report commute time problems due to traffic as well, and security costs for some areas.

“I don’t doubt that,” Barr said. “Travel costs are not accounted [for] in the home health rates, and that seems ridiculous because it can be very high in both urban and rural areas, and it is an important factor,” she stressed. “But I believe most urban patients can get home health and … we can’t,” she repeated. “So if you can get some different data, I’d love to see it.”

Barr wasn’t the only commissioner to criticize the access data. Referring to the 88 percent and 99 percent figures cited, “it’s just not clear to me that that translates to access,” said Commissioner Jonathan Jaffery, physician and senior VP with the University of Wisconsin School of Medicine and Public Health. “We own a home health agency, and there’s a lot of challenges with access here for those services, even for our own patients,” Jaffery offered.

Bottom line: “Having the presence of a business there” isn’t necessarily “equating [to] access,” Jaffery said.

Other home health topics discussed in the meeting included:

• Further cuts. Commissioners implied the 4.36 percent behavioral adjustment probably wasn’t enough to keep the new payment model budget neutral. There was an “extra 6 percent of payment that was introduced through the PDGM,” which should be adjusted, said Commissioner Brian DeBusk, CEO of health IT firm DeRoyal Industries in Powell, Tenn. “That 6 percent adjustment … has to be made,” DeBusk said in the meeting. (Reminder: In its 2022 proposed home health payment rule, the Centers for Medicare & Medicaid Services said, “We determined the CY 2020 30-day base payment rate was approximately 6 percent higher than it should have been, and would require temporary retrospective adjustments for CY 2020 and subsequent years until a permanent prospective adjustment could be implemented in future rulemaking.”)
• Targeting cuts. “Is there perhaps a better way to make that [6 percent] adjustment?” DeBusk asked in the meeting. “Does it have to be applied to the base rate? Or … is this an opportunity to address either access, equity, or even quality concerns through that 6 percent adjustment?” he posted. “I’d be interested to see if there are other ways that that 6 percent could be applied in a more focused and targeted way.” The 6 percent cut would be separate from MedPAC’s 5 percent reduction recommendation, further discussion indicated.
• Telehealth reporting. All commissioners supported the draft recommendation for HHAs to report telehealth services on claims. But Commissioner Lawrence Casalino, physician and professor at the Weill Cornell Medical School, wants to make sure the requirements are specific. Including each visit’s specific date and requiring information on whether the visit is audio-only or audiovisual is important, Casalino suggested.
• “Low-value” visits. HHAs provide lots of unnecessary visits. So was the thrust of comments by Commissioner David Grabowski, a health care policy professor at Harvard Medical School. “Back in the 1990s, we paid based on visits. Not surprisingly, we got lots of visits. Many of them were low-value,” Grabowski said in the meeting. “Starting in the year 2000, we started paying based on therapy. Not surprisingly, we got lots of therapy and … once again, lots of it low-value therapy,” he judged. Under PDGM, “not surprisingly, I think we’re going to get lots of patient charac­teristics and lots of acuity,” he predicted. Medicare needs better quality measures to make sure it’s getting high-value home health visits, he suggested.
• HAH. MedPAC needs to start thinking about how the home health landscape may change in response to the COVID-inspired move to care at home. “The hospital-at-home movement … is certainly going to explode, I believe,” said Commissioner Betty Rambur, RN and professor of nursing at the University of Rhode Island. “Then how do we have this nexus between acute care delivered in the home and other kinds of what we would normally have considered post-acute or long-term custodial care?” Rambur asked.