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The Center for Medicare Advocacy is concerned that proposed home health rules will further steer home health agencies away from providing care for beneficiaries who need it the most and toward beneficiaries with short-term post-acute care needs.[1]

  • Beginning in 2020, payments to home health agencies under the new model will provide higher payments for individuals who are admitted to home care after an inpatient hospital or skilled nursing facility (SNF) stay and lower payments for those who start home health from the community – which will include hospital patients in Observation Status. This will likely diminish access to care for many beneficiaries and reduce the care provided to others.
  • Fewer therapy visits will be provided to beneficiaries because therapy service utilization thresholds will be removed under the new payment model. More than 42% of for-profit home health agencies expect therapy to decrease by more than 10%.[2]
  • As in other care settings, therapy provided by therapist assistants will be coverable for home care beneficiaries who need maintenance therapy as well as for those who can improve. However, CMS should clarify that therapy for maintenance and improvement must be equally available as needed from qualified therapists, not just assistants.
  • Eliminating split-percentage provider payments (partial payment at the beginning of a period of care, and remaining payment at the end), will push smaller home health agencies out of the market if, unlike large home health entities, they cannot afford to wait until after care is provided to receive payments. (Effective in 2021)
  • Publicizing “value-based” payment statistics, when that data only includes patients who improve, will broadcast skewed, inaccurate information.
  • The description of the new home health payment system, Patient Driven Groupings Model (PDGM), is misleading and inaccurate. PDGM is touted by CMS as “shifting the focus from volume of services to a more patient-driven model that relies on patient characteristics”.[3] However, CMS gives only token weighting to patient characteristics in PDGM. For example, an agency may receive as much as 60% higher payment for a beneficiary with an “early, institutional” admission to home care than for a beneficiary who avoided hospitalization, with a “late, community” admission to home care, regardless of services needed by either beneficiary. In another example, an agency may receive as much as 25% higher payment for a beneficiary admitted to home care from an institution than for a beneficiary admitted from the community, regardless of services needed by either beneficiary.[4] Under PDGM, payment incentives are high for agencies to serve beneficiaries with short-term post-acute needs and not to serve beneficiaries with chronic long-term needs.
  • The fixed dollar loss ratio that determines outlier case payments will be re-adjusted to maintain the 2.5% cap of all payments. Since 2010, outlier payments (for more significant levels of care) have been cut by more than a billion dollars.[5] Most of the reductions have resulted in care not being provided.
  • PDGM, the home health payment system for traditional Medicare beneficiaries will likely subsidize low Medicare Advantage (MA) plan payments since home health agencies often lose money when providing care to MA enrollees.
  • Prior authorization for home infusion therapy, or any home health service, is a duplication of physician effort (who have already determined the care is reasonable and necessary), results in delay of care, and often results in a prior denial for legitimate care.
  • PDGM will worsen concerns regarding inequities in available care. Consideration of social determinants of health will be more meaningful when CMS develops a payment system that does not discriminate on the basis of illness or injury and when CMS does not allow agencies to cherry-pick beneficiaries based on inequitable policies.

For too long home health agencies have been able to limit access to care for certain beneficiaries and provide less care than is needed and ordered by patients’ physicians. The Center for Medicare Advocacy fears this situation will only get worse under the proposed rules.  We will be commenting accordingly and encourage others to do so.

August 29, 2019 – K. Holt


[3], page 34602
[4] See PDGM, example from early admission (first 30 days) with post-institutional admission versus late admission with a community admission.
[5], page 7

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