Refinement Bills Are Chance to ‘Get PDGM Right,’ Avoid Industry Destablization

Joanne E. Cunningham took over as The Partnership for Quality Home Healthcare’s executive director in August 2018. Since then, much of her focus has been spent educating policymakers on the Patient-Driven Groupings Model (PDGM) and its potentially industry-shaping impact.

So far, those advocacy returns have been promising, recently contributing to PDGM-refinement legislation in the U.S. Senate aimed at the overhaul’s widely opposed behavioral adjustment provisions. The legislation — S. 433 — also includes language waiving the homebound requirement for Medicare beneficiaries in certain instances.

A companion bill will soon be introduced in the House, Cunningham told Home Health Care News. Thanks to bipartisan backing and broad industry support, the Partnership is feeling good about its legislative outlook.


Prior to joining the Partnership last year, Cunningham served as CEO of the Home Care Association of New York State, the largest state home care organization with more than 400 home care provider members.

HHCN recently went one-on-one with Cunningham for an inside look into the Partnership’s advocacy efforts and PDGM plans.

You can find that conversation below, edited for length and clarity.


HHCN: You were appointed to the executive director position in August of last year. A lot has happened since then. What have your top priorities been?

Cunningham: When I started, we were in the middle of the [Patient-Driven Groupings Model] rulemaking process. The Partnership was already knee-deep in providing comments on the proposed rule that came out in July. A lot of what I had been doing in New York was analysis of the new payment model on what its implications would be for the provider community.

Joining the Partnership, I had to shift gears and look at PDGM from a more global standpoint [rather] than just what the New York provider community would be experiencing. The Partnership is laser-focused on federal health care policy and Medicare home health policy.

The Partnership hadn’t had an executive director for a little bit. It was restarting this full-time executive director position and re-establishing connections with policymakers on Capitol Hill, at the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS).

But the Partnership has been very, very focused on payment and the new model.

What about top challenges?

I think one of the biggest challenges has been trying to make sure that there’s a full understanding of the new payment model and the implications of it. This is a big change for the home health sector.

We haven’t had a new payment model in almost 20 years. It’s a big deal — and there’s been a lot of legwork put into this. CMS initially put out the first version of it — the Home Health Groupings Model (HHGM) — then got a lot of industry feedback, comments and recommendations. PDGM is the evolution of that.

When an entire sector shifts to an entirely new payment system, there’s a lot to that effort and a lot of analysis. There are always unintended consequences, especially to major policy initiatives.

The Partnership is working really hard to understand what those unintended consequences might be and making sure we’re helping to inform policymakers so they can get PDGM right.

As you noted, you’re coming from New York. There’s obviously a lot going on there. I’m namely thinking of the 13-hour rule legal battle, which is winding down. There’s also been ramped up wage-and-hour oversight. What’s your take on what you’re seeing there?

New York is often leading the way on policy focused on wage-and-hour issues.

In my old capacity, the conversation wasn’t really whether proposed wage-and-hour rules or regulations were right or wrong, but whether payment was adequate when you did impose some of these mandates and new requirements on providers.

New York has a very large Medicaid home care program, so when you make these changes you really have to look at ensuring the payment is covering the costs of providers.

We hear a lot about the negatives of PDGM and potential concerns. Are there any positives or opportunities for providers?

I think PDGM is a logical model that the industry supports conceptually. I think the question is more making sure to get it right, making sure to get all the fine tuning out of the system so that when we transition to this new model, we’re avoiding any unforeseen consequences.

The industry is certainly not advocating that the whole thing should be scrapped and we start over. Let’s just get it right and make sure any changes that need to be made are.

I think overall it’s a good, thoughtful approach to better align patient characteristics to payment and create a more refined system that is meant to ensure health needs are met.

The Partnership has approached our advocacy with CMS and lawmakers on the Hill to say, “This is the right direction. We just need to ensure we get it right to avoid any kind of destabilizing elements because we’ve overlooked some things.”

Therapy, in particular, is set for drastic changes under PDGM. Do you have any concerns with those plans?

The Partnership does have positive things to say about how the therapy caps and changes were made. But I think that’s another area where we want to make sure we’re not creating a system that — without intending to — disincentivizes the use of therapy.

A lot of home health patients certainly need therapy.

I’ve been in a lot of meetings with policymakers over the past months, and that’s certainly something I hear policymakers worried about.

How active is the Partnership on the lobbying front? Can you take me inside those efforts?

The Partnership is a full partner in the advocacy space and utilizes our resources to make sure we have a strong, active presence in educating folks on the Hill on things like PDGM payment policy. Part of my day — almost every day — is spent in congressional offices and with folks in various agencies to talk to them about the Partnership’s viewpoints.

I would give an emphatic “yes” to answer whether the Partnership is involved in making sure we have the industry’s voice heard.

In addition the Partnership, there are other home-based care advocacy groups, including the National Association for Home Care & Hospice (NAHC) and LeadingAge, just to name a few. How do you think the industry’s influence has changed in Washington, D.C., compared to maybe 10 years ago?

There’s a lot of activity in the health care space. There are a lot of big issues that lawmakers are talking about that command their attention — drug pricing and all kinds of things.

I think the home health sector has done a pretty good job making sure lawmakers understand the value of home-based care. One of the things I’ve noticed in my 10-plus years in the advocacy arena and home health care is how lawmakers today seem to have such a better understanding of what the value is compared to even just five years ago.

We put a lot of effort into our home visiting program, where we ask lawmakers to come out to an agency to visit one of their constituents who is a Medicare home health beneficiaries. That is always a home run. There’s always lots of lightbulbs that go on in the lawmaker’s mind when they see firsthand the care that a Medicare beneficiary can and does receive in the home setting — and the level of sophistication of that care.

It’s really eye-opening. Every time I hear a lawmaker has gone on a visit, I hear they become a real champion afterward. And I can point to some of them we work with specifically.

What members of Congress do jump out as champions? I know Senators John Kennedy (R-La.) and Bill Cassidy (R-La.) have sponsored their share of PDGM-related legislation focused on the behavioral adjustments.

There are a lot of them. Sen. Susan Collins (R-Maine) is one of our champions on the Senate side right now, along with Sen. Stabenow (D-Mich.) and the two senators from Louisiana you mentioned.

Sen. Collins was the senator I was thinking of when I was talking about how going on a home health visit really transformed her thinking about the value and importance of home health care. I was at a meeting with her soon after I started with the Partnership — a meeting that included our chairman, Keith Myers — and she talked about going on a home visit 20 years ago and how it opened up her perspective on the need for home health care.

Listening to her, you could feel it was really a transformational experience, even though it was 20 or so years ago.

On the house side, in addition to Rep. Brett Guthrie (R-Ky.), there are many champions.

One right now is Rep. Terri Sewell (D-Ala.), who’s going to be the lead co-sponsor on our house version of the PDGM-refinement legislation. She’s right now got the bill and is going to be introducing it within the next couple of weeks.

She also has some personal home health experience.

Anybody else?

We have two other republicans in the House: Dr. Ralph Abraham (R-La.) and Congressman Vern Buchanan (R-Fla.), who are teed up with Congresswoman Sewell to introduce the House bill.

There are many, many others who have been such good advocates in the past on the other challenges we’ve faced over the years.

Sounds like there’s a lot of momentum behind that PDGM-refinement bill.

I’m feeling very optimistic. You picked up on the word “momentum,” and that’s exactly how I would describe it. When I go into lawmakers offices — and I was just up on the Hill earlier — we talk about the importance of PDGM, getting it right and this behavioral-assumption-driven reduction that is slated to go into effect Jan. 1, 2020.

I get lots and lots of positive reactions from lawmakers who agree, “Yes. We have to get this right.” We need to approach the new payment system in a data-driven, evidenced-based way.

We’re expecting to have a really positive bill introduction in a couple of weeks.

What else is important to touch on before we end this conversation?

This is based on a couple of decades of work in the health care policy space, but I think home health care is poised to take its rightful place as a pivotal part of the health care system. Especially as we see a higher number of baby boomers needing Medicare services. I think you see a greater desire to receive services in the home than ever before.

Things are changing. There is a lot of exciting initiatives going on where the Partnership’s home health company members have interesting joint ventures, hospital relationships, clinical programs focused on technology.

It’s a tremendously exciting time to be in the home health care field.

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