Vowing to flex political muscle its built in the nation’s capital and throughout the country, home health providers and advocates are prepared to fight a new proposal to bring back the controversial pre-claim review.
This is not an empty threat, a Home Health Care News (HHCN) review of lobbying data and recent advocacy efforts suggests.
Over the last couple decades, the in-home care industry has roughly tripled the amount of money spent annually on federal lobbying efforts. Organizations like the National Association for Home Care & Hospice (NAHC), the Partnership for Medicaid Home-Based Care, the Partnership for Quality Home Healthcare and the Visiting Nurse Associations of America (VNAA) have led the charge, as have state-level associations and providers’ own emerging government affairs departments.
In 1998, in-home care providers and interest groups representing them spent at least $2.3 million on combined lobbying activities, according to publicly available data under the Lobbying Disclosure Act. Last year, they spent at least $6.9 million—a substantial leap that doesn’t include the growing list of entities just starting to dip their toes into the in-home care waters.
Large home health companies such as Lafayette, Louisiana-based LHC Group, Inc. (Nasdaq: LHCG), Baton Rouge-based Amedisys, Inc. (Nasdaq: AMED) and Moorestown, New Jersey-based Bayada Home Health Care combined to account for at least $2.2 million of that 2017 sum, nearly eclipsing the industry’s 1998 total by themselves.
“It’s been very effective,” David Totaro, chief government affairs officer for Bayada, told HHCN, referring to the privately held company’s overall political advocacy efforts. “Our chief financial officer has said. ‘You guys have paid for yourself 10 times over.’”
The government affairs team, currently made up of 15 people, contributed to 24% of the growth in revenue and half of Bayada’s growth in gross margin during the third and fourth quarters of 2016, according to Totaro.
While a look at the data reveals an impressive spike in lobbying power, it only reveals a fraction of the in-home care industry’s current clout.
Sharpening grassroots strategy
As lobbying has picked up on Capitol Hill, the industry has simultaneously bolstered its grassroots strategy to galvanize the ever-increasing army of home health aides, personal caregivers and patients scattered throughout the United States to support—or fight against—a common cause, Bill Dombi, NAHC president, told HHCN.
Those grassroots efforts get stronger every day, as more baby boomers sign up for in-home services and millennials fill open positions at agencies, he said.
For proof of its grassroots success, look no further than the industry’s initial battle with pre-claim review or the proposed home health groupings model (HHGM), Dombi said. CMS eventually nixed them both, though each appears to be back on the table in different forms in 2018.
“We were looking to get the Senate to support us, to get CMS to back off on the [HHGM] proposal,” he said. “We had—within a 48-hour time period and just from our own NAHC efforts—about 25,000 emails that went out to senators. At the end of that, we ended up with a the Senate supporting us [against HHGM].”
Forty-nine senators ultimately documented that support in a letter to CMS.
Similarly, when Congress threatened to cut Medicaid and Medicare in the summer of 2017 with the American Health Care Act and Better Care Reconciliation Act, Bayada was able to mobilize its network of employees and clients, urging them to contact their legislators. Federal legislators received more than 138,000 emails as a result, said Totaro, who also serves as chairman for the Partnership for Medicaid Home-Based Care’s board of directors.
Bayada, which provides clinical care and support services in the home, has more than 22,000 employees in communities across 22 states. It created its government affairs office shortly after Totaro joined the company in 2009 as its then chief marketing officer.
“We’re developing our movement through getting more and more of our clients, more and more of families and caregivers involved in the process,” he said. “Government affairs is very similar to building a brand. … You take a message and deliver it consistently, uniformly, making sure the message is carried to all those who have an important relationship with you.”
The launch of home care association ElevatingHOME last year did raise some questions about how unified home health providers are in their advocacy approach, but the in-home care industry has typically been able to operate in D.C. under a single, unified message, experts say. It’s an idea supported by Lobbying Disclosure Act filings, which often mention the same key issues among companies and interest groups.
“ElevatingHOME launched in the midst of having just worked to beat back [the Pre-Claim Review Demonstration] and rolled directly into concerns about HHGM,” Joy Cameron, the group’s vice president of policy and innovation, told HHCN via email. “It took a truly unified approach to delay HHGM and bring Congress and the administration to the table to consider the industry’s concerns. … There are several hurdles in front of the home-base care industry, and it will take all of the players to achieve our goals.”
Although ElevatingHOME grew out of VNAA, which advocates on behalf of non-for-profit providers and was founded in 1983, its main focus has been making sure potential legislation and proffered solutions are workable for the full spectrum of providers, Cameron said.
In the beginning
The in-home care industry’s rise to relevance in D.C. didn’t happen overnight, according to Dombi. In fact, its ascent can actually be traced to a jumping off point more than three decades ago.
In 1987, long before the industry began closely working together on advocacy efforts, the predecessor of CMS, the Health Care Financing Administration (HCFA), attempted to narrow its interpretation of “part-time or intermittent” care for home health and redefine what “medically necessary” meant. As part of the re-interpretations, HCFA began making a series of retroactive claims audits, denying about one out of every three claims that had already been paid and, effectively, denying home health care benefits to eligible patients.
“The industry was in a downward tailspin,” Dombi said. “It was falling apart.”
NAHC, founded just a few years earlier, decided to challenge the agency’s interpretation in one of its first major lawsuits, bringing in Dombi to serve as chief legal counsel. As part of the case, known as Duggan vs. Bowen, NAHC won the support of more than a dozen members of Congress, getting them to sign on as plaintiffs in opposition to HCFA. Several state-level home health agencies also joined the lawsuit.
“That was when we really started seeing this industry coming together,” Dombi said.
Ultimately, a federal district court found that Medicare’s interpretation of the phrase “part-time or intermittent” was too narrow, resulting in unlawful denial of care to eligible beneficiaries. It was a major victory for home health providers, one that completely changed the way regulators viewed the industry at large, Dombi said.
After the lawsuit and HCFA revising its guidelines for Medicare coverage of home health, the utilization of services skyrocketed. From 1989 to 1992, there was a 210% increase in Medicare expenditures for home health services, reaching $7.5 billion in 1992, according to CMS.
“That kind of spurred on a much more focused and intelligent advocacy effort going forward,” Dombi said.
In the past, advocacy efforts were somewhat hindered by the fact not many people were familiar with home health, home care or hospice services, Totaro said. Instead of focusing on influencing policy, providers and interest groups had to focus on education. That’s no longer the case, though, as members of Congress have more frequently used services personally or have arranged care for aging family, he said.
“They had no idea what home care was,” Totaro said. “As legislators are aging and their parents are aging, it’s becoming more common.”
As utilization has risen, home health care companies have also grown, giving them more capital to deploy on advocacy efforts.
Home health lobbying in 2018
The top 10 home health providers based on market size, as defined by the most recent LexisNexis rankings, have spent at least $1.6 million combined on lobbying so far in 2018, according to the HHCN review of disclosure data. The three biggest spenders, in order, are Louisville, Kentucky-based Kindred Healthcare, Inc. (NYSE: KND), LHC Group and Encompass Health Corp. (NYSE: EHC). Kindred is in the process of being acquired by insurance giant Humana (NYSE: HUM) and two private equity firms.
Issues these companies have lobbied on—apart from Medicare and Medicaid, generally—included the Home Health Care Planning Improvement Act, the Preserve Access to Medicare Rural Home Health Services Act, the Home Health Documentation and Program Improvement Act, the Bipartisan Budget Act of 2018, the Medicare Post-Acute Care Value-Based Purchasing Act of 2015, the Patient Choice and Quality Care Act and several other pieces of legislation.
The in-home care industry’s steady increase in lobbying expenditures is reflective of a broader trend happening across the health services sector, data show.
“Back in the 70s, 80s and even into the 90s, we were dealing with kind of elementary aspects of things, mostly to the understanding of what home care would be in terms of breadth and depth,” Dombi said. “We’ve had to step up our game in terms of how we work in partnership with federal agencies and in partnership with Congress.”
Written by Robert Holly