The measurements used to track the home health industry could use some updating to better align perception with reality, according to the Medicare Payment Advisory Commission (MedPAC).
And interestingly enough, access may be one of the rare occasions where on-the-ground evidence tells a truer story than available data.
“The access to home health appears to be very good,” Evan Christman, a senior analyst for MedPAC, said during the commission’s public meeting Friday. “Eighty-eight percent of beneficiaries live in the counties served by five or more home health agencies. Ninety-nine percent of beneficiaries live in a county served by at least one home health agency.”
MedPAC’s December 2021 public meeting was held virtually this year due to the COVID-19 pandemic. In addition to access, MedPAC’s commissioners discussed home health agency margins, turnover rate, future payment recommendations and more.
MedPAC has long said that Medicare beneficiaries’ access to home health access is strong, and changes to the home health payment model did not have a negative effect on access or quality of services in 2020, Christman said.
But some health care leaders tell a different story.
“The access-data shown seems incredible,” Lynn Barr, the founder and chairwoman of Caravan Health, said during the meeting. “But we have an incredible problem getting access to home health. … I have no alternatives in post-acute care in most of my rural communities, which is a real disconnect with what [the numbers show].”
Barr – also a MedPAC member – leads the Kansas City-based Caravan Health, a company that supports about 250 hospitals and their physicians in the Medicare Shared Savings Program (MSSP).
“I was wondering if some sort of [geographic information system] study could be done on the distance between the home health agency and the patients to understand that it isn’t really about zipcodes. It’s about distance,” Barr continued. “And we have no way of compensating for that. And so I’d love if we could take a different look at access, because the numbers you have are amazing. And if it was true, I would be all in over it. But we really don’t see that. And it’s a huge problem for us.”
Harvard Medical School Professor David Grabowksi echoed Barr’s sentiment, suggesting that the current measures of tracking access may not be the best ones available.
“I’m sensing this from other people as well – some concern that maybe the measures of access aren’t fully adequate,” Grabowski said. “And it could be for different reasons in different sectors. I think the thing that jumped out to me – reading into the home health agency [access numbers] – it’s just not clear to me that that translates to [actual] access.”
Turnover rates
Despite a relatively stable payment environment for home health agencies, the turnover rate among home health care workers remains high.
Cornell’s Weill Medical College’s Dr. Lawrence Casalino pointed to that turnover rate as a troubling discrepancy in an industry with supposedly high profits.
“So this is a sector where profits are high and employee turnover is high,” Casalino said. “One has to actually ask about where all that margin is going. Pay is not the only reason for employee turnover, but it’s a big one.”
Home health agencies would likely push back against the idea that margins are too high, especially because fee-for-service Medicare often represents the highest-margin aspect of their businesses.
“So, again, we have a sector with higher profits, low pay and high turnover,” Casalino continued. “I think we all agree that in home health agencies, skilled nursing facilities – anywhere really, but certainly in those two – high turnover is probably highly correlated with poor quality.”
MedPAC’s view that margins may be too high was reflected in the fact that the commission proposed a 5% 2023 rate cut for home health care services. The U.S. Centers for Medicare & Medicaid Services (CMS) finalized a 3.2% increase for 2022 in November.
Casalino specifically feels that turnover rates should be considered a measure when looking at quality in home health care.
“In our work on looking across sectors for post-acute care and how to measure value there, and how to reward value, I hope we really look at turnover rates,” he said. “[That’s] probably a much better measure of quality.”
The idea: If turnover rate was included in quality metrics – which are tied to incentive-based payment – agencies would invest more to keep workers..
“These sectors are going to have to increase their wages, or else there’s going to be financial penalties in the inequality incentive programs,” Casalino said.
In regard to other general data coming from MedPAC, home health spending declined by 4.7% to $17.1 billion in 2020.
The average cost per 30-day period, on the other hand, increased by 3.1% in 2020, more than double the annual average growth of 1.4% from 2017 to 2019, according to the commission.
MedPAC also suggested that home health agencies should be required to report their data on telehealth use.
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