Home Health & Hospice Week

For home health and hospice agencies wondering why the Medicare Payment Advisory Commission is so hard on their payment rates, comments at its latest public meeting spell it out.

“We need to do more work to get rid of the bad actors” in hospice, said Commissioner Marjorie Ginsburg in MedPAC’s Dec. 9 meeting. “If we do that … we can then focus the resources to the rural communities,” said Ginsburg, an RN formerly with the nonprofit Center for Healthcare Decisions Inc. in California. The MedPAC commissioners discussed in the meeting the issue of hospice access and utilization in rural areas, particularly frontier areas.

“We have far too many bad actors in this one category, more so, I think, than almost any other category that I’m familiar with,” Ginsberg claimed in the meeting’s discussion of hospice payment adequacy.

“I … hope in future work we can look at hospice[s] with very high live discharge rates … because there seems like there’s some questionable actors in that category,” said Commissioner Brian DeBusk, CEO of healthcare tech firm DeRoyal Industries in Tennessee.

Multiple commissioners remarked on the industry’s relatively high profit margin of 13.4 percent in 2019. That was up from 12.4 percent in the previous year, MedPAC staff Kim Neuman pointed out in the meeting. MedPAC projects hospices’ 2022 margin will be back down to 12 percent.

All commissioners gave tentative approval to two recommendations for the advisory body’s forthcoming annual report to Congress in March — freezing Medicare payment rates for hospices in 2023, and cutting the aggregate cap amount by 20 percent that year. They also want to wage-adjust the cap amount.

Reducing the cap by 20 percent would cut 3.7 percent from Medicare hospice spending, Neuman said. In 2019, 19 percent of hospices exceeded the cap.

These draft recs are “a repeat of recommendations from the previous two reports,” notes the National Association for Home Care & Hospice. Congress has not yet taken up the freeze or cap reduction suggestions.

HHAs With High Staff Turnover Should Get Lower Rates, Commissioners Suggest

On the home health side, MedPAC calculates a whopping 20.2 percent profit margin for 2020. The Commission estimates the 2022 margin will be back down to 17 percent.

“This is a sector where profits are high and employee turnover is high,” noted Commissioner Lawrence Casalino, a physician and professor at the Weill Cornell Medical School in New York. “So one has to actually ask, well, where is all that margin going?” he asked in the Dec. 10 meeting discussion of home health payment adequacy.

“It is outrageous that you have places with 20 percent margin and 300 percent turnover, because the money is only sucked up to the top,” Casalino maintained. “It’s not going to the people who work there, not for their salaries, not for their working conditions.”

Multiple commissioners then expressed interest in integrating employee turnover considerations into quality and even payment mechanisms. “Is there a way to actually put it into the payment system, where those with lower turnover might get higher rates?” asked MedPAC Vice Chair Paul Ginsburg with the Brookings Institution in Washington, D.C., and professor of health policy at the University of Southern California.

Commissioner Pat Wang also recommended potentially including turnover rates on Medicare Compare. “If you are looking for care for a loved one … that might be something relevant to consider,” said Wang, an attorney and CEO with nonprofit health plan Healthfirst.

While that idea is a longer term discussion, all commis­sioners did give tentative support to a recommendation for the March report — a 5 percent reduction to home health payment rates.

Telehealth Visit Reporting May Be On The Horizon

Payment rates weren’t the only recommendation topics for home health and hospice. Commissioners also voiced unanimous support for requiring agencies to report telehealth services on Medicare claims.

“The lack of information about the frequency, duration, or mode of telehealth services received during home health care makes it challenging to characterize service use under the benefit,” MedPAC staffer Evan Christman noted during the Dec. 10 meeting’s home health discussion.

For once, NAHC and MedPAC are in agreement. NAHC “has strongly urged the Centers for Medicare & Medicaid Services (CMS) to begin collection of data related to telecommunications-based visits to ensure more complete knowledge of services that are being provided as part of the hospice benefit,” the trade group notes in its member newsletter.