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During the last week of March, hundreds of stakeholders vied on behalf of home-based care in Washington, D.C., either physically or through Zoom.
Personal home care provider and advocate voices did so with an excitement for the future, fresh off the high of the president mentioning multiple times in a month.
Conversely, home health care’s voices advocated with a more somber tone, concerned about worsening patient access and businesses shuttering if the Centers for Medicare & Medicaid Services (CMS) doesn’t renege on payment cuts promised for next year and beyond. They did so on a stakeholder call with CMS representatives, where there were a lot of questions allowed, but not a lot of answers given in response.
“It doesn’t seem like the rate update addressed all the massive cost increases that have been occurring since 2021,” VNA Health Group President and CEO Dr. Steve Landers told those CMS reps.
CMS responded to that assertion – among others Landers made – by noting they “appreciated the suggestion” and recognizing “that is always a source of topic.”
By law, CMS is now required to offer more insight into how they are creating the payment rates for home health care agencies year by year. But Wednesday’s 90-minute Zoom meeting felt like satisfying the law and nothing more.
“It is very clear that we continue to disagree with the methodology that CMS employed to determine budget neutrality. The reality is that CMS has rebased payment rates to account for the reduction of therapy visits that came about solely because of PDGM,” National Association for Home Care & Hospice (NAHC) President William A. Dombi Bill Dombi said afterward in a statement shared with Home Health Care News.
Home health providers don’t want rate cuts for obvious, bottom-line reasons. But it also frustrates them because, as Dombi said, home health care is one of the few sectors that can actually create savings.
“CMS must withhold any further rate cuts to avoid the flaws of PDGM combining with uncontrolled cost inflation to destroy access to one of the few Medicare benefits that brings savings to the Medicare program,” he said.
Another cut incoming
In CY2023, home health providers saw a 0.7% aggregate payment bump compared to CY2022. But a cut was disguised as a bump, really, because of the inflationary adjustments included.
Essentially, providers are seeing a 4% cut to payments this year. Heading into Wednesday’s Zoom Call, sources told HHCN they believed they’d likely see an even worse proposed rule this June than they did last year.
After Wednesday, that seems even more likely.
Providers were hoping that, once they got on a level playing field with CMS, they’d win out. But you can’t win out if one side refuses to play ball.
More than half of the call was CMS running through slides and fulfilling those lawful obligations. Then the Q&A session began.
“I’m very concerned about access issues that we’re seeing and also just our overall sustainability as a community agency,” Landers said. “The concerns are most heavily weighted towards high-poverty, urban areas and more diverse communities.”
The Holmdel, New Jersey-based VNA Health Group is a nonprofit provider of home-based health services in New Jersey and Ohio.
Landers pointed to the IRS mileage rate that VNA Health Group uses to reimburse its clinicians, which went up by 12% in one year. CMS’ payment rate update was not requisite with that.
This disparity is recognizable in other areas, too.
“Considering that Social Security was given an 8% increase because of cost of living and we got 4%, to me, is ridiculous,” Amedisys Chairman and CEO Paul Kusserow told HHCN in January.
Competing with hospital wages has also become increasingly difficult, Landers said.
“Labor costs for nurses home health aides are up – in some places, you can’t even find folks,” he said. “And one of the reasons you can’t find them is because we’re competing with the hospitals. And the hospitals have differential treatment by CMS under wage index policy. So, for example, hospitals might be using an imputed rural floor on their wage index calculation, they might reclassify their wage index. With the transition policy from the old wage index system to new one, hospitals were given a longer runway.”
That has caused home health providers to miss out on talent, and, in turn, created worsened access to care.
Referral rejection rates in home health care are higher than they ever have been, according to data from WellSky.
CMS’ home health reps responded by essentially saying that the hospital wages, or other inflationary measurements outside of home health care, were not up to them.
“I also am a vice president of a nonprofit home health and hospice agency,” another leader said on the call. “Even if these payment rates seem to make sense to accountants, to people in the industry who are trying to run a home health agency, it’s just not viable. CMS really needs to consider what their priorities are, because we’re the lowest cost to Medicare.”
CMS’ response was, again, likely not satisfactory for the home health stakeholders on the call.
“I didn’t sense a question there,” a CMS rep said. “So I’m not going to answer, I guess.”
Here are the three takeaways that NAHC and the Partnership for Quality Home Healthcare (PQHH) came away with after the call.
– “CMS does not believe it is required to demonstrate how certain changes in provider behavior affected expenditures under PDGM and the calculation of the revised payment rates for CY2023. CMS’ justification for this position is that examining overall expenditures under PDGM equates to assessing the impact of behavior changes.”
– “CMS acknowledged that it has discretion in when and how any adjustments are applied to future payment years and that it exercised that discretion in reducing the permanent adjustment for 2023 from 7.85% to 3.95% and did not apply any temporary adjustment due to its concerns about the impact on providers.”
– “CMS stated that it is monitoring the impact of the rate changes on care and noted consideration of cost increases in the current inflationary environment.”
Home health leaders from across the country are hoping that their Washington, D.C., trips are not all for naught.
Educating lawmakers on the value of home health care – and on context about the wider payment landscape in the space, not just in Medicare fee for service – could end up in intervention, after all, from Congress.
But, without that intervention, it sure seems like CMS isn’t going to budge much.
“We appreciate the opportunity to participate in this presentation and look forward to further responses to outstanding questions,” PQHH CEO Joanne Cunningham said in a statement shared with HHCN. “It is crucial that CMS take into account that the cost of care has significantly increased, and providers are in no position to withstand further rate cuts without additional negative impact on care access beyond what PDGM has wrought.”
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