Home Health & Hospice Week

Biden administration stresses transparency with new database.

Will Medicare’s new listing of home health and hospice agency ownership data shift referrals and utilization, or is it much ado about nothing?

Industry experts are making predictions as the Centers for Medicare & Medicaid Services makes public “for the first time” a database with “detailed information on the ownership of more than 6,000 hospices and 11,000 home health agencies certified to participate in the Medicare program,” according to a release.

The information CMS has newly posted includes enrollment information such as:

• organization name, type, and practice location address;
• National Provider Identifier (NPI);
• CMS Certification Number (CCN);
• detailed information about each owner such as whether it is an organization or an individual and whether it is a direct owner or indirect owner (that is, there is at least one subsidiary between it and the provider); and
• a numerical associate ID for each owner to enable linkage to the enrollment file.

Plus: “Additional files that include data on mergers, acquisitions, consolidations, and changes of ownership since 2016 for hospices and home health agencies enrolled in Medicare are also being made available as part of this release,” CMS adds.

Releasing this data shows that “the Biden-Harris administration has made promoting competition and protecting consumers a top priority,” CMS says in the release. It “builds on the Department [of Health and Human Services]’s historic releases of data and unprecedented efforts to increase transparency,” including releasing the same type of information for skilled nursing facilities and hospitals in 2022 and 2023.

“It’s plain and simple: families deserve transparency when making decisions about hospice and home health care for their loved ones,” HHS Secretary Xavier Becerra says in the release. “President Biden has called for unprecedented action to increase transparency — and we are making more data publicly available than ever before.”

The President issued an Executive Order in July 2021 “to promote competition in the American economy,” the White House said in a fact sheet about the order at the time.

“Transitioning to hospice care is often an emotionally overwhelming time for many families,” CMS Administrator Chiquita Brooks-LaSure says in the agency’s release. “Making this data public increases transparency, giving families the information needed to help them identify the best care for their loved one. Providing information is a hallmark of this administration’s efforts to improve care because we understand that having good information allows people to make the best choices possible.”

CMS plans to update the data sets quarterly, notes attorney Rachel Hold-Weiss with law firm ArentFox Schiff in online legal analysis.

The move is in line with federal agencies’ efforts lately. “DHHS and CMS have placed significant focus on program and provider integrity as evidenced by recent efforts, including proposed and final rules,” points out consulting firm The Health Group in Morgantown, West Virginia. “Ownership is a critical element of any integrity effort,” the group notes in its electronic newsletter.

“Increasing the transparency in healthcare has been a key focus under the Biden-Harris administration,” highlight attorneys Kaitlyn Heintzelman and Alan E. Schabes with law firm Benesch in online analysis.

PE, For-Profits May Be Targets

CMS appears to hope that the public release of this data will furnish potential patients and other referral sources with information that will steer them toward better quality care. “Transparent ownership data benefits the public by assisting patients, and their loved ones, in making more informed decisions about care,” CMS says in the release.

“It may be an eye-opener for beneficiaries with larger providers when they see the ownership,” allows attorney Robert Markette Jr. with Hall Render in Indianapolis. “That could be used by competitors to show who is really the ‘local provider,” Markette tells AAPC.

The information “could be a help to the smaller entries, as local preference should favor them,” predicts industry veteran Tom Boyd, CEO of Aftercare Nursing Services. “Would you prefer ABC HHA owned by people in your community to [an] HHA owned by LHC or someone out of the area?” Boyd asks.

Another scenario: “Maybe there are individuals in ownership with good or bad reputations in a community that this disclosure might ... impact,” Markette suggests.

Biden administration officials may be highlighting at least two perceived trouble spots with ownership.

“The feds have expressed concerns about increasing ownership of healthcare providers by private equity,” notes healthcare attorney Elizabeth Hogue. Their “agenda may be to make it clear which providers are owned by private equity,” Hogue suggests.

CMS’ fiscal year 2024 proposed hospice rule includes “the categories of ‘private equity company’ and ‘real estate investment trust’ to the list of possible options for hospice ownership,” points out the National Hospice and Palliative Care Organization in a release about the data set.

“The feds seem to have the perception that ownership by private equity means that quality of care suffers for the sake of increased profits,” Hogue tells AAPC. “This is, of course, not necessarily the case at all. There is definitely another side to that story,” she maintains.

CMS’ hospice proposed rule cites Medicare Payment Advisory Commission stats showing that “for more than a decade, the increasing number of hospice providers is due almost entirely to the entry of for-profit providers.” And the rule notes MedPAC’s assertion “that long stays in hospice have been very profitable and this has attracted new provider entrants with revenue-generating strategies specifically targeting those patients expected to have longer lengths of stay.”

Specifically, “MedPAC has also stated that private equity involvement in the health care sector has been growing and that private equity funds have invested in home health and hospice,” the rule adds.

Various federal agencies have also implied that for-profit providers in general, especially in the hospice industry, are causing care quality problems — or at least financial abuse.

CMS may be trying “to encourage patients and their families to choose providers based on ownership,” Hogue says. They “may perceive that patients and their families will reject providers owned by private equity or perhaps even for-profit entities,” she notes.

CMS may “intend to embarrass people” with the data, Boyd tells AAPC.

But experts think the feds may be overestimating the impact of the new data.

“I am not sure how much difference it will make to beneficiaries,” Markette says. “I am just not sure people look into their providers that deeply,” he notes.

“I have serious doubts about whether releasing ownership information will have any effect on patient choice at all,” Hogue says.

And “I also seriously doubt that this information will make any difference to referral sources, especially in light of increasing numbers of patients referred but not admitted, ongoing staffing shortages, etc.,” Hogue continues. “Referral sources just want providers who will care for patients when discharged,” she maintains.

The idea is “probably not very practical,” Markette concludes. “Transparency is a word people like to use these days, but I think star ratings, Home Health Compare and value-based purchasing will have more practical benefit to patients, as they provide data related to quality of care,” he says. “I just am not sure in most cases it means too much.”

However, don’t be surprised to see ownership data migrated over to Home Health Compare eventually, some observers say. CMS specifically asks for feedback on that topic in the 2024 hospice proposed rule. “Given some of the differences between for-profit and not-for-profit utilization and spending patterns highlighted in this proposed rule, how can CMS improve transparency around ownership trends? For example, what and how should CMS publicly provide information around hospice ownership? Would this information be helpful for beneficiaries seeking to select a hospice for end of life care?” the rule asks.

While industry experts are skeptical about the impact of the new data release, there is still a chance that providers will be affected.

But agencies don’t have significant grounds for objection to the practice, believes John Reisinger with Innovative Financial Solutions for Home Health. “The owners of any organization that’s operating and receiving remuneration from tax-payer dollars — and any Medicare organization falls in this category — [do] not have any right to an expectation of privacy, at least from an ownership-level perspective,” Reisinger maintains. “After all, this is one of the ways that conflicts of interest can be identified,” he highlights.

Plus, the data isn’t exactly a secret. “Ownership information is readily available from the Offices of Secretary of State in each state” already, Hogue points out.

Note: Access the HHA ownership data at https://data.cms.gov/provider-characteristics/hospitals-and-other-facilities/home-health-agency-enrollments and the hospice ownership data at https://data.cms.gov/provider-characteristics/hospitals-and-other-facilities/hospice-enrollments. A fact sheet about the 2021 Executive Order is at https://www.whitehouse.gov/briefing-room/statements-releases/2021/07/09/fact-sheet-executive-order-on-promoting-competition-in-the-american-economy.