Congress Unlikely to Act as PDGM, Pre-Claim Loom

Washington, D.C., policymakers have hurled several challenging volleys toward the home health, personal care and hospice industries in 2018, including possible reincarnations of the Home Health Groupings Model (HHGM) and Pre-Claim Review Demonstration (PCRD).

To parry those attacks, or at least make sure they’re not overly burdensome, stakeholders will likely need to band together in grassroots advocacy efforts mobilizing everyone from agency leadership and caregivers to those receiving care.

But while there’s a pressing need for the industry to make its voice heard on a variety of regulatory matters, providers shouldn’t expect too much action from Capitol Hill in terms of legislation passed. That’s because 2018 is an election year, meaning members of Congress will largely prioritize campaign rhetoric over actual legislative action, according to William Dombi, president of the National Association of Home Care & Hospice (NAHC).


With new versions of HHGM and PCRD on the horizon, the year has been busier than anticipated, but the home health, personal care and hospice spaces have moderately stable regulatory footing and the forecast for the sector is “extraordinarily bright,” Dombi said. He made his remarks during a Washington update address kicking off NAHC’s 2018 Financial Management Conference in Austin, Texas.

NAHC is a not-for-profit organization that represents more than 33,000 home care and hospice organizations, also advocating on behalf of more than 2 million nurses, therapists, aides and other caregivers employed by such organizations.

PDGM, PCRD steal the show


During the opening night of the Financial Management Conference, most talk seemed to revolve around PDGM and PCRD. Both headlined Dombi’s Washington update as well.

On July 2, the Centers for Medicare &Medicaid Services (CMS) announced it was moving ahead with a budget neutral PDGM model in its proposed payment rule. The PDGM model halves the 60-day episode of care unit of payment to 30 days and removes incentives to over-provide therapy services based on volume.

“[The volume thresholds were] a lightning rod for potential abuse,” Dombi said.

Providers need to “get into [PDGM] deep” because it has the capability of revolutionizing how home health agencies operate, he said. If it does end up in a final rule, providers will need to ensure they have a balanced patient population made up of several different groups rather than honing in on one type of patient.

PDGM would not be implemented until Jan. 1, 2020.

PDGM is a particularly tricky issue for NAHC because half of home health agencies are projected to receive reimbursement increases and half are expected to lose reimbursement, Dombi said.

While PDGM was mandated by the Bipartisan Budget Act, the renewal of PCRD was more of a surprise. Originally rolled out in 2016 in Illinois, with plans for further implementation in four other states, PCRD asks home health providers to send in claims earlier in the care process to verify they are meeting compliance requirements.

CMS announced in May is was seeking public input on a new proposal to bring back PCRD, albeit with some subtle changes. That public comment window is primed to close at the end of the month. So far, provider response has paled in comparison to the industry outcry during the original rollout, a review of public comments shows.

“This is a very serious issue coming down the way,” Dombi said.

LHC Group (Nasdaq: LHCG) and Amedisys (Nasdaq: AMED) executives have suggested that their companies, the two largest publicly traded home health providers in the country, aren’t phased by PCRD’s return.

Policy priorities

PDGM and PCRD aren’t the only issues in NAHC’s sights.

Other policy priorities for NAHC include throwing support behind the home health rural add-on, which allots resources to agencies servicing rural areas. Rural add-on has been somewhat unofficially targeted for possible cuts, according to Dombi.

“There’s widespread belief in Washington that rural add-on is unnecessary,” he said. “We’re going to need some advocacy ground the rural add-on.”

Permitting non-physician practitioners to certify or recertify Medicare home health eligibility—a point addressed in CMS’ proposed payment rule—will be another policy priority. NAHC is optimistic that change, which isn’t widely opposed by physician groups, will come soon, Dombi said.

“We need to change that,” he said. “We are getting closer and closer to making that happen.”

NAHC will also look to expand flexibility in the use of home health in Medicare innovation models, stop Medicaid per capita caps, reform face-to-face requirements and reform electronic visit verification (EVV) requirements.

Despite the long list of issues and the looming threats of PDGM and PCRD, 2018 has the chance to, overall, be a red-tape-reduction year, Dombi said. The Trump administration is in its second year and looking to make good on its overarching promise to eliminate two pieces of regulation for every new one introduced.

NAHC 2.0

In addition to shining a spotlight on some of the top regulatory issues coming out of D.C., Dombi also discussed how NAHC is in the midst of a major identity shift, one that will prioritize transparency, grassroots efforts and service above all else.

Part of the reason for the strategic pivot, he said, is to better leverage industry strengths. Home health, personal care and hospice providers may not be able to compete with Intel, General Motors or Exxon Mobil when it comes to lobbying expenditures or campaign finance, but they can certainly make an impact along the lines of outreach and making their voices heard.

In-home care providers and interests representing them spent at least $6.9 million last year on lobbying activities, a Home Health Care News review of Lobbying Disclosure Act filings found. The automotive industry, in comparison, spent at least $8.6 million.

Still, more than 2 million Americans work as home care workers, a figure that’s only bound to increase in years to come, according to the U.S. Census Bureau. Each one of those current and future workers has the potential to influence political action by writing a letter, sending an emailing or making a phone call to his or her representative in Congress.

During the initial HHGM battle, for example, NAHC helped organize its members and their workers to send more than 25,000 emails to federal lawmakers in a span of 48 hours, an aggressive campaign that ultimately won the Senate over to the association’s side, Dombi said.

“There’s no reason we can’t get a zero at the end of that 25,000,” he said, noting the heightened importance of social media and the need for agencies to “get virtual.”

Another reason for NAHC’s identify shift—dubbed “NAHC 2.0”—is simply because times have changed and businesses have evolved.

In the past, home health, personal care and hospice providers needed NAHC to take charge in D.C. because their expertise was heavy on caregiving but light on business and policy, Dombi said. Caregiving remains a pillar for providers, but most have sharpened their skills in the other areas, lessening the need for NAHC to run point.

“The business has changed, and NAHC needs to change too,” Dombi, who has more than 30 years of experience doing home health, personal care and hospice advocacy in D.C., said. “An association means people banding together for a common cause.”

Written by Robert Holly

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