NAHC’s Dombi: Threat of Payment Cuts Can’t Be Ignored

It’s been a hectic time since Bill Dombi officially took over as president of the National Association for Home Care & Hospice (NAHC) about 11 months ago. Perhaps more than anything, though, it’s been a period punctuated by the introduction of the Patient-Driven Groupings Model (PDGM), the biggest payment overhaul the home health industry has seen in years.

In his role at NAHC, Dombi is working to ensure agencies are prepared for the major change, while also advocating on their behalf on Capitol Hill by leveraging the industry’s vast grassroots potential. The association is taking on PDGM’s behavioral adjustments and is supporting providers’ preparation efforts — which may not be far enough along.

NAHC is also paying attention to important Medicare Advantage (MA) developments and the ongoing threat of Medicare fee-for-service cuts. Dombi discussed NAHC’s priorities and plans during his recent appearance on the Disrupt podcast for Home Health Care News.

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Below are some highlights of Dombi’s comments, edited for length and clarity:

HHCN: Bill, you took over as NAHC’s interim president in 2017. You were officially named president in early 2018. What have been your top priorities since taking over the reins?

Dombi: The priority really is to prepare NAHC for today — and, even more importantly, tomorrow — in terms of advocacy and education. That means transforming NAHC in ways that we haven’t operated in the past, primarily focusing in on a transformation to a member-driven, member-engaged organization.

We see the real power of home care advocacy comes not only from NAHC here in Washington, D.C., but from our members at large. They all can have a compelling voice and perspectives.

It’s the transformation into a powerhouse voice above Washington and throughout the rest of the country.

It’s all about bringing the several thousand home health and home care agencies, along with hospice providers, together. And that army of caregivers and employees.

Exactly. Home care and hospice is real life. Bringing that real-life experience into the advocacy side of things is in contrast to your typical Washington, D.C., silver-tongued, heavy-monied lobbyist with fundraisers for politicians on a regular basis. We really think that the convincing of policymakers — be they in Congress or at regulatory agencies — comes by way of bringing that real-life experience to them. That comes from our members, the people who provide care on a day-to-day basis.

NAHC hopes to be able to guide that.

Let’s amplify our efforts by using every one of those millions of workers who provide home care — and the thousands of companies that arrange for those services.

Speaking of advocacy efforts, it’s a great time to have you on Disrupt. There’s a lot of change going on in home care, home health and hospice. There’s a lot of change happening on Capitol Hill, especially with the uncertainty of a new Congress. What are your thoughts on the new Congress? What can providers expect in the near-term?

Home care and hospice has had long-standing bipartisan, bicameral support. We expect Congress to deal with small-ball things rather than big-time reforms. We don’t expect major reforms to the structure of Medicare or Medicaid as was contemplated in previous years.

Instead, there are a lot of smaller reforms that can be done that we think could be helpful. We think Congress is ready to take on some of those kinds of reforms. We would expect to see a bipartisan willingness with White House support.

It’s really just ongoing improvement as well as maintenance in very important health care programs.

What are some examples of smaller reforms?

Well, we certainly think there’s room to continue the regulatory relief efforts that started in 2018. There have been a number of steps taken both by CMS as well as by Congress to reduce paperwork burdens and some of the traps in administrative structures. We’re talking about some of the documentation issues that affect hospice and home care providers, some of the Conditions of Participation (CoPs).

Smaller reforms even include things that might modernize the Medicare program. The top of the list for me in terms of modernizing it would be allowing non-physician practitioners to actually certify Medicare eligibility for home health, in particular.

We’ve talked fairly recently about cuts coming down possibly from the White House, with the Trump administration looking to, perhaps, trim government spending. Is that something providers should be on the lookout for as well?

Absolutely. An unfortunate consequence of working with government programs is the unpredictability of payment rates. The White House last year proposed cuts to all post-acute care providers in the Medicare program. We do anticipate that the proposal will come about again this year in 2019.

The Medicare Payment Advisory Commission (MedPAC) met in December and again in January. A report will go to Congress in March. The handwriting is on the wall already from MedPAC — it’s going to be recommending a cut in payment rates for home health of 5%. This is a repeat of something we’ve seen in previous years, and they’re going to recommend that hospice receive a 2% reduction in their inflation update, which is pretty close to freezing hospice rates.

This is something we look out for every year, but there’s just a lot of buzz going on regarding reducing the spending for post-acute care services in a variety of ways. Straight inflation rate cuts and the like are a threat we cannot ignore.

That’s in contrast to steps CMS has taken for home health care reimbursement for 2019. CMS actually increased the home health payment rate in 2019 to 2.2%. Will that bump make a difference for home health providers and their ability to thrive in today’s market?

That was actually not CMS’ choice to do that rate increase. It was built into a law that Congress had put in place. We don’t know where CMS would go itself. We think we have an idea — and it’s not good. But the 2019 payment rate increase is the first since about 2011. Most of those other years were reductions and inflation updates, case-mix creep reductions, where CMS does go sometimes. Also the rate rebasing that occurred from 2014 through 2017.

Will the $400 million-plus make a difference to home health agencies? I think anybody who receives a rate increase, that will make a difference, giving them some resources to deal with staff compensation, to deal with improving their technologies, to just day-to-day ways to manage their budgets.

We are going to see an increase in base payment rates in 2020 also. It will be set at 1.5%. But with PDGM, there are a few things up in the air.

I’m sure PDGM is something you get tired of talking about, but I have to bring it up. There are a lot of aspects we could talk about — halving the 60-day unit of payment, LUPAs — but I thought I’d ask a more global question. In your view, how will PDGM change the home health landscape on a more macro-level?

Well, probably the greatest risk in change is for home health agencies to react to the elimination to the therapy thresholds, which affected the level of reimbursement. Back when the prospective payment system came into play in October 2000, home health agencies immediately gravitated toward the incentive of providing therapy visits. It really brought great improvement in patient outcomes as a result.

In getting away from that financial incentive, we hope the clinical incentive remains there to deliver therapy services. But there are absolutely rumblings out in the home health care community about stepping back from the volume of therapy since it’s no longer going to bring the same level of reimbursement.

We caution agencies in doing so. Health care is generally shifting toward a value-based-type payment arrangement. There are nine states already in the home health Value-Based Purchasing Model (VBPM). If the withdrawal of therapy services triggers lower patient outcomes, they are going to be financial consequences that outweigh whatever benefits come in reducing visits.

From a transformational perspective, that’s the No. 1 area we will be watching.

One of the more controversial aspects of PDGM is the behavioral adjustment component — CMS making assumptions rather than basing things in observed behavior. Think that behavioral adjustment aspect is something we’re for sure going to see come 2020?

From the Medicare home health advocacy perspective, this is issue No. 1 for us. The 6.42% in the proposed rule was not finalized by CMS. Instead, CMS finalized they would be doing behavioral adjustment using factors such as upcoding on diagnosis, adding visits to avoid LUPA thresholds that are in the model.

We have significant congressional support. They’ve already voiced willingness to deal with us throughout 2019 on this issue. We certainly hope we can make improvements we see necessary in any behavioral adjustment processes there.

We’d be looking at two elements. One, the timing of any adjustment. Two, the depth of that adjustment. Timing wise, our advocacy focuses on waiting for changes to actually occur and be measured by CMS before they reduce rates — instead of relying on assumptions that are really dangerous. With the depth of the kind of adjustment that would be there, the law provides for possibly an upward adjustment as well as a downward adjustment. Clearly CMS focuses on the downward adjustment.

History tells us that home health agencies’ behavior is not consistent with payment models.

We think the assumption-based approach is a high-risk venture in terms of delivering care to patients under the home health benefit.

Do you think providers are prepared?

I think home health agencies are a diverse lot. They’re diverse in terms of size and diverse in terms of patient mix. That’s also true when it comes to being prepared for change. Home health agencies have been remarkably capable with dealing with change. But when I look at PDGM, I don’t see the industry across the board as prepared as they should be at this point, though PDGM isn’t going to start tomorrow. It doesn’t start until Jan. 1, 2020, but it’s going to take a lot of work beforehand to be successful.

We think agencies need to step up their preparation efforts. That means top to bottom — everything from operations and clinical practices to their financial management and even data analytics.

One of the things we’re doing in addition to advocacy is putting together a 12-sited national summit on PDGM, where faculty are the nation’s foremost financial, operations and clinical experts.

Another big topic HHCN is constantly reporting on is Medicare Advantage and its growing role. MA growth is outpacing traditional Medicare, gaining more and more beneficiaries each and every year. Is that a good thing?

At NAHC, we do see Medicare Advantage out there. Within NAHC and within our membership, we have yet to see the real positives coming from MA plans, when looking at it in a general sense. There are some plans that have recognized the value of home health services and have embraced it in so many ways in order to bring patients from in-patient settings homes — or keep them home in the first place.

But when you look at it in the aggregate, you see the following with MA: We see administrative headaches and burdens, having to jump through hoops to get a visit authorized here or there. We see bad payment rates coming from MA plans. The only reason home health agencies can continue to deliver care to MA plans today is because they’re by and large getting a margin on traditional Medicare.

We really think plans need to open up there eyes and ears to the value of home care. Unfortunately, we continue to see plans more concerned about unit prices rather than dynamic value.

Along these lines, I wanted to ask about a hospice carve-in. What are your thoughts there?

A hospice carve-in would be the biggest revolution in the hospice benefit probably since the hospice benefit began. We can’t ignore it. But at the moment, we would say it’s not a good move to make. It’s a risky thing to do, taking a well-established service delivery model and insert it into a whole new management and payment system called managed care.

You’ve got to preserve the integrity of hospice as a delivery model.

Listen to the complete episode of Disrupt with NAHC’s Bill Dombi:

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