Home Health Industry Dogged by Improvement Standard Myths

Some home health care providers believe that chronically ill patients who stand no chance of getting better don’t qualify for Medicare coverage—but they’re mistaken.

A 2013 settlement in the court case Jimmo v. Sebelius put that “improvement standard” to rest. As set by that case, Medicare does cover skilled nursing and therapy services, including in-home care, to maintain a patient’s current condition or prevent a slow decline. Simply put, a patient’s improvement is not a condition for Medicare coverage.

Still, some home health agencies wrongfully deny Medicare-covered services to chronically ill people specifically because their conditions won’t improve, according to a Jan. 17 report from NPR and Kaiser Health News. One such case is that of Colin Campbell, a 58-year-old Los Angeles resident with Lou Gehrig’s disease who spends nearly $4,000 on home health care per month.


Although Campbell has Medicare coverage, 14 home health care agencies told him they couldn’t treat him, according to the report. Some agencies told him Medicare would only cover rehabilitation, while others said Medicare didn’t cover home health care at all. They’re both wrong.

“Myths die hard, particularly when the holder of the myth determines whether to pay the claim,” Bill Dombi, president of the National Association for Home Care and Hospice (NAHC) told Home Health Care News. “That reality, combined with a system that puts individuals with chronic needs on the low end of payment rates and value recognition, has perpetuated the roadblocks to home health care.”

One reason solutions aren’t in place to fix the problem is that CMS efforts to build a new payment model “mirror past practices,” Dombi added. Another reason is that some agencies might fear they won’t get paid for treating patients on a long-term basis, especially as federal authorities crack down on home health fraud.


And new rules that recently took effect could compound the issue, the Kaiser report found.

Under Medicare’s value-based purchasing pilot program, for example, regulators will either reward or punish home health providers in nine states based on how well they care for patients—and some of the criteria used to measure performance includes patient improvement. Likewise, Medicare’s Home Health Compare website grades agencies based in part on their ability to help patients get better.

Read the full story on NPR.

Written by Tim Regan

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