This article is part of the HHCN+ membership
In the last home health rule proposed by the Centers for Medicare and Medicaid Services (CMS), the federal agency responsible for reimbursement rates issued a request for information on the use of home health aides.
Specifically, the agency wondered why visits and utilization of Medicare-covered home health aides have fallen off a cliff over the past several decades.
According to the Medicare Advocacy Center, home health aide visits decreased by 90% from 1998 to 2019.
Many home health workers and those who work around them were surprised by CMS's request and believed the agency itself was one of the main culprits.
“We laughed out loud when we saw that included in the proposed rule,” Bill Dombe, president of the National Association of Home Care and Hospice (NAHC), told Home Health Care News.
History of home health aids
In 1987, Dombi participated in a class action lawsuit against the Medicare program on behalf of NAHC and home health patients. There were a number of issues in the case, Dombi recalled, one of which he said had to do with the accessibility of home health support services.
The lawsuit was successful and created standards that were eventually incorporated into the law itself.
“Congress amended the law to almost codify the outcome of litigation,” Dombi said. “This law established a standard that within the definition of part-time or intermittent care, an individual would be eligible for 28 to 35 hours of home health aide services per week. It was part of the law.”
At that time, home health aide services were the main area of care people received as a service and were much more than nursing care.
Then two things happened. In the Balanced Budget Act of 1997, Congress removed blood draws from the list of benefits eligible for home health assistance benefits.
This benefit dilution was further exacerbated by major changes to the interim payment system, the reimbursement model for home health services.
This system was intended to change the way Medicare pays for home health services. Rather than paying providers based on costs incurred, Medicare has moved to a prospective payment system.
Under IPS, Medicare did not reimburse home health agencies for actual medical costs, but rather made fixed payments based on the patient's condition and the services needed. This change was intended to control costs and improve the efficiency of Medicare home health benefits.
“Home health agencies and home health services have been devastated,” Dombi said. “Forty percent of home health agencies closed within 18 months. The number of patients covered by the Medicare program increased from 3.5 million to 2.1 million over the same 18 months.” has increased to.”
Before IPS, agents received more reimbursement the more services they provided. Under IPS, agents had a cap on the amount they would pay.
“This has really discouraged health care providers from accepting patients receiving high levels of home health support services,” Dombi said. “Because it raised the payment level, but then you hit the cap. And once you hit the cap, you couldn't get paid.”
When the Prospective Payment System (PPS) system was introduced in 2000, home health support services were already shrinking.
Payment for home health services is approximately $2,000 for 30 days of care. Dombi estimated that adding 30 days of home health aide services, which average about four hours a day, would increase medical costs by $3,000 to $4,000.
“You can't expect a home health agency to pay you $2,000 to provide $5,000 to $6,000 worth of care,” he says. “As an existing provider, if you start doing that, it's going to take a matter of seconds. So right now, it's all about reimbursement.”
This moves the timeline back to 2023, when CMS essentially asked, “Why is it so difficult for patients to access home health assistance services?”
CMS and provider are disconnected
CMS received nearly 100 comments highlighting a number of challenges, all of which were similar. This means that lower utilization rates do not reflect the need for home health support services.
Commenters stated that although the Medicare law allows for significant assistance hours, the actual hours provided are decreasing and require a combination of skilled and ancillary services for optimal health and safety at home. He pointed out that this is having an impact on patients who need it.
One commenter noted that CMS' temporary reimbursement for home health care does not adequately support strong staffing, particularly in rural areas. For this reason, agencies may have a hard time justifying separate visits by home health aides when nurses and therapists can perform similar functions within their scope of practice during skilled or therapeutic visits. A situation arises.
As Dombi pointed out, the biggest detractor is the payment.
“We have always provided home health support services to our clients,” Vince Moffitt, president and CEO of Basin Health Companies, told HHCN. “However, years of declining reimbursement rates have forced us to limit these services. cannot support additional services.”
Basin Health's portfolio includes Basin Home Health & Hospice, a New Mexico-based provider with 700 employees. Serving rural communities in the Four Corners region.
One of the most disappointing aspects of having to reduce the provision of these services is the inherent trust that is built between clients and home health aides.
“Home health aides provide care during vulnerable times by facilitating activities of daily living multiple times a week,” said Cleemon Moorer Jr., president and CEO of American Advantage Home Care. It provides both physical support and emotional comfort,” he told HHCN via email. “Their regular presence often acts as a lifeline and improves mental health through meaningful companionship.”
American Advantage Home Care provides skilled nursing, rehabilitation and specialty care services in seven counties in the southeastern Michigan region.
There are also insurance company and payer issues when it comes to home health assistance. Not all insurance companies cover home health aide visits, Moorer noted, putting pressure on reimbursements for agencies.
“I may speak for many in the industry who are striving for reimbursement increases that are broadly consistent with information from a cross-section of Medicare cost report data,” Moorer said.
Many CMS commenters argued that the PDGM payment model does not allow agencies to hire aides or provide necessary services, particularly for patients with severe impairments or multiple comorbidities. He emphasized his concern that it is preventing people from doing so.
“Home health aides spend a lot of time with patients, depending on the type of service they provide,” Moffitt says. “This allows us to make sure the patient is safe and following the treatment plan. It also helps with care by allowing clinician eye time with the patient.”
As Moffitt pointed out, this improves outcomes. CMS has gotten better at that in recent years.
What now?
When CMS asked for information, agencies weren't shy about what they needed to do to get home health aide utilization back on track.
Commenters urged CMS to overhaul current reimbursement coverage to better facilitate the provision of home health support services. One proposal would establish a new payment mechanism specifically designed to ensure fair compensation for home health aides that reflects the critical nature of their role and impact on patient care. It included.
Moorer agreed with some of those ideas.
“We need clearer career paths and support for home health aides who want to move up the clinical career ladder,” Moorer said. “More specifically, it is a financial incentive for employers who are agile and flexible enough to support home health aide education efforts.”
More flexibility for agencies often requires more resources.
“The solutions are complex,” Moffitt said. “Labor costs for all employees have increased, vendor costs have increased as well. On top of fuel, utilities, and supplies…if the rate of episodes increases, those additional resources can easily be used for those needs.” I guess.”
Moorer said mandatory reimbursement for visits by certified home health aides should be considered, regardless of insurance company.
CMS has addressed these comments in the final rule.
“CMS appreciates the valuable feedback received regarding the use of home health aide services, coordination between Medicare and Medicaid, physician care planning, recruitment and retention challenges, and pay disparities,” the rule states. “Comments and suggestions provided by stakeholders will guide CMS' efforts to strengthen home health policy and optimize access and quality of care for Medicare beneficiaries.”
I felt that the response was not enough for Donbi.
“I thought they kept dodging the real question,” he said. “And if anything, they're trying to shift the blame away from themselves and from Congress, because it's not just CMS that's responsible for all of this. Congress made major cuts to home health care. In 1997. Back in 1999, the Congressional Budget Office estimated a $16 billion reduction in spending over five years. It ended up being about $70 billion.”
