Home Health & Hospice Week

Recap: In Medicare’s 2023 proposed rule for home health payment issued on June 17, the Centers for Medicare & Medicaid Services proposes a 4.2 percent cut to home health payment rates, based largely on a -7.69 percent permanent behavioral assumption adjustment. That would reduce Medicare home health spending by $810 million in 2023 compared to 2022. And CMS is also considering implementing “a temporary adjustment of approximately $2.0 billion to reconcile retrospective overpayments in CYs 2020 and 2021,” according to the rule published in the June 23 Federal Register.

Among the 900 comment letters CMS received on the rule were many that decried the proposed cut’s effect on rural HHAs and their patients.

“Cuts of this magnitude would be devastating to patients and providers,” warns Margaret Appel, a home health RN from Camden, Alabama. “At a time when both demand for home health and the costs of delivering care are rising significantly, this proposal will significantly limit access to patient-preferred home health, especially among America’s rural and medically underserved seniors,” says Appel, whose employer operates in “the poorest county in our entire nation, Wilcox County,” according to her letter.

“The proposed payment reduction for home care results in a 6.9 percent decrease in Medicare reimbursement for Northern Light Home Care in 2023,” says Lisa Harvey- McPherson with Northern Light Health system in Maine, in her comment letter. “This is simply unbearable and cannot be absorbed within our cost structure,” Harvey-McPherson insists. “This cut is certain to decrease services, especially in rural Maine, and force more patients into higher cost facility-based care.”

Many providers offered personal anecdotes to underscore their points, while others focused on cold, hard stats (see boxes, pp. 265. 266). Regardless of method, the conclusions were the same — the impact of the cuts combined with other reimbursement policies will deliver a crushing blow to the agencies serving the most vulnerable seniors across the nation.

In New York: “Contrary to the perception that New York is largely urban/metropolitan, nearly 40 percent (24) of the state’s counties meet the latest rural designation established by CMS and many of the remaining geographic areas are essentially rural in character,” says Patrick Conole with the Home Care Association of New York State in the trade group’s comment letter. And “over the last fourteen years, most of the county-sponsored CHHAs in New York’s rural counties have either closed or sold their agency. A 2018 cost report analysis by HCA found that approximately 67 percent of all Medicare certified agencies operating in New York’s rural counties had negative operating margins, which is a contributing factor in the overall diminution of rural home health services,” Conole explains.

“Indeed, more than half of New York’s 13 rural communities have only two or fewer providers of skilled care for Medicare and Medicaid home health services. If any more of these 8 agencies close, access to skilled home care will be seriously threatened for residents in rural areas of New York,” Conole warns.

In Montana: “Our agency is the only certified home health agency providing all home health disciplines” to the four counties around Missoula in which Partners In Home Care Inc. operates, says CEO Dianne Hansen in her comment letter. “Without our agency, there would be no home health services in three of these rural CBSAs,” Hansen tells CMS.

Proposed cuts “threaten access to care for beneficiaries living in the most rural areas of western Montana,” Hansen continues. “There are 56 counties in Montana and only 11 certified home health agencies. While some organizations cover multiple counties, there are vast rural areas in the state with no access to home health services. In addition, 55 percent of home health agencies in Montana are currently running a negative margin. Further cuts would threaten many of these agencies, leaving even more counties without home health services,” she cautions.

In Alaska: “Alaska’s small, rural, and medically underserved communities will be uniquely harmed by the proposed cuts,” argues Dena Jeffers in her comment letter. “In Alaska, home healthcare is essential to our communities, partic­ularly in rural areas where options for care are already extremely limited. Additionally, our providers and fragile care system are experiencing extraordinary inflation, escalating costs, continued impact from the pandemic, and a major staffing crisis. Now is not the time to cut home health,” she insists.

In Hawaii: “We are already seeing the consequences of inadequate reimbursement on the state’s home health system,” says Robert Choy with the Healthcare Association of Hawaii in the trade group’s comment letter. “In October of 2021, Ohana Home Health — an agency based in rural Kauai — shut down due to reimbursement and workforce difficulties. Ohana Home Health served the state’s least populous county and the residents who live there now have few options to receive home health services. Cuts, especially as steep as the ones proposed, would threaten patient access to home health, especially in these rural areas where patients already face tremendous barriers in accessing the high-quality care that they need,” Choy warns.

In New Mexico: “Here in New Mexico, it is anticipated that the proposed updated home health payment for CY 2023 would have a negative difference of $3.75 million compared to CY 2022,” notes Meggin Lorino with the New Mexico Association for Home & Hospice Care in the trade group’s comment letter. “While that figure may seem small to an agency that oversees healthcare at such a large scale … in a rural state like New Mexico where we have such a limited provider network and large nursing shortage, every dollar lost puts our provider network at extreme risk,” Lorino stresses.

In Iowa: The cuts “will negatively impact access to care in most rural areas,” cautions a commenter from Iowa. “I currently oversee an agency in rural Iowa and every week we are already forced to turn away referrals due to not having the staffing capacity to take additional patients,” the anonymous commenter tells CMS. “In order for agencies to keep their doors open, reimbursement for services provided must maintain pace. Otherwise, the people who will suffer the most will be the patients that need home health care services,” the provider says.

In North Carolina: “I have worked in the home health area for over 25 years and have never submitted a comment before but this year is different,” reveals physical therapist Mary DeMeo in her letter. “I am fearful for home health agencies to survive in the midst of the proposed payment cuts and the impact this will have on patients,” DeMeo says. “I have been on many calls with other agencies voicing concerns about just being able to stay in business. With agencies closing, all patients will be affected by fewer resources to provide the home cased care that has been proven valuable. Of all patients affected, I am most concerned about the small, rural and medically underserved communities that will suffer from smaller agencies having to close their doors,” she worries.