Alternative Payment Proposal Loosens Home Health Requirements

A new pilot program is up for consideration in the Senate following the introduction of legislation that intends to improve care for Medicare beneficiaries with advanced illnesses, such as Alzheimer’s disease, cancer and heart disease. The legislation would create new coverage options for end-of-life care and reduce some patient requirements to qualify for home health care.

Senator Sheldon Whitehouse, D-RI, introduced a bill last week that would create 20 advanced care collaboratives of health care provide and community-based service organizations, including home health. The program would be administered by the Centers for Medicare & Medicaid Services (CMS) and provide coordinated care to this population of seniors with the help of a planning grant.

The new payment model, named the Removing Barriers to Person-Centered Care Act, aims to “promote better coordination between health care providers and place greater emphasis on the preferences of Medicare beneficiaries with advanced illnesses,” according to a press release on the introduction of the bill.

With a focus on caring for persons with advanced illnesses, the legislation could potentially have a huge impact, as approximately 90 million Americans are living with advanced illnesses, according to the Senator’s office.That number is expected to double over the next 25 years.

“Too many Rhode Island Medicare patients battling difficult illnesses are struggling to get the right care at the right time,” Whitehouse said in a statement. “We need to break down the barriers between patients and the care they need. Because so many of the rules and incentives in our health care system are tied to the payment structure, we should design payment systems that support new models of coordinated care that are focused on human beings and not some rule or regulation.”

Home- and community-based providers may already be involved in other alternative payment models that incentivize care coordination, such as bundled payments, but few new regulations target these services directly. Recent data from palliative care providers revealed significant value for the larger health care system by targeting this patient population and expanding access to care. The bill also underscores a growing push for home- and community-based services, including palliative and hospice care.

Coverage Changes 

The bill has several major changes in end-of-life care coverage options for Medicare beneficiaries, including waiving the current regulations that force patients to choose either hospice care or curative treatment and prohibiting coverage for both services at the same time. Another waiver would grant patients coverage for a skilled nursing stay without a required three-day inpatient hospital stay prior to receiving skilled nursing care.

Perhaps the biggest change for home health care agencies is the waiver for the homebound requirement for patients to receive these services. Current regulations maintain that a patient must be homebound and therefore denies this care to patients who are seriously ill but may still be mobile, according to the Senator’s office.

Whitehouse has also proposed allowing nurse practitioners to sign home health and hospice care plans and certify patients for these benefits. Under current rules, only doctors can certify the benefits, though nurse practitioners typically administer home health and hospice care. This expansion of nursing abilities follows in the footsteps of another bill in New York that similarly seeks to reduce barriers to delivering efficient care.

The bill would create two new coverage options under Medicare’s hospice benefit for beneficiaries with terminal illnesses. The coverage option would allow Medicare coverage of room and board at inpatient facilities for routine hospice care for qualified individuals if their home environment is not safe for home-based routine hospice care. Currently, Medicare does not pay for room and board for inpatient hospice care at the routine level, leading some dying patients to opt to receive rehabilitative services to keep Medicare inpatient coverage if their homes are not suitable for home-based care. This rehab care is often unnecessary and potentially harmful, according to Senator Whitehouse’s office.

The second proposed coverage options would provide coverage for short-term, home-based respite care for individuals who are certified for routine hospice care. The option is an alternative to inpatient care that aims to alleviate the stress of transporting a dying patient to and from a facility.

“The Removing Barriers to Person-Centered Care Act is a critical step forward to achieving high-quality, coordinated care for those with advanced illnesses,” Tom Koutsoumpas, co-chair of the Coalition to Transform Advanced Care’s (C-TAC) board of directors, said in a statement. “This legislation allows for important innovations in care delivery and removes obstacles to support patients throughout the care continuum.”

C-TAC is a non-profit, non-partisan organization based in Washington, D.C. that is dedicated to and advocates for the ideal that all Americans with advanced illness receive comprehensive, high-quality person-centered care. The Act was introduced in the U.S. Senate on June 23.

Written by Amy Baxter