Senator Susan Collins Takes Aim at PDGM’s Behavioral Assumptions

Home health providers and advocates have carefully worked to cultivate their political clout on Capitol Hill over the past few decades. Those efforts — paired with changing U.S. demographics, proven savings to the U.S. health care system and older adults overwhelmingly expressing their desire to age in place — have helped win the support of a large pool of bipartisan lawmakers.

Sen. Susan Collins — who has witnessed the value of home health services firsthand, both on a personal level and during home visits with providers — is among the backers.

A republican from Maine, Collins outlined her many reasons for supporting the home health industry during an exclusive interview with Home Health Care News. Most recently, her support was punctuated by the introduction of S. 433 in February.


If passed, the legislation would require the Centers for Medicare & Medicaid Services (CMS) and its looming Patient-Driving Groupings Model (PDGM) to base Medicare reimbursement rates on observed evidence and data, instead of on assumed changes.

Below are highlights from HHCN’s conversation with Collins.

HHCN: In conversations with providers and industry associations, you’re often mentioned as a big supporter of home health and home care. How did you become such a proponent in the first place?

Sen. Collins: A home health care agency in northern Maine, which is where I grew up, invited me to come with some nurses on a home health care visit with them. It was an amazing experience, and it was what turned me into an advocate for home health and hospice care.


I visited an older couple who had lived in their own home for their entire married life. Each of them had health problems — and each of them was receiving home health care.

All each of them wanted was to spend the remainder of their lives together in their own home — in the privacy, comfort and security of their home. Neither wanted to be separated from the other or have institutionalized care.

It was home health care that allowed their many diverse health needs to be met. It meant for them to stay together for the rest of their lives.

It was very touching and heartwarming. Later on, I also learned it was very economical. If they had been forced to go into a nursing home, it would have cost the Medicaid program so much more than what the program was paying for their bi-weekly visit from home health care nurses.

Your support of the industry isn’t just vocal. You’ve taken action on Capitol Hill. That includes sponsoring S. 433 — the Home Health Payment Innovation Act. That’s legislation meant to refine PDGM, specifically a part that could pose a 6.42% rate cut. Why sponsor that?

My concern is that the federal government — CMS in [particular] — has proposed cutting the Medicare payment rates in 2020 by an amount that would equal over $1 billion in the first year alone. They’re developing a new payment model that I fear would be very unfair to many home health care agencies, particularly those in more rural areas where the home care providers may have to travel great distances to see their patients, meaning their volume isn’t going to be as high.

What CMS is doing is making an assumption that is very unfair. It’s making an assumption that most home health care providers are being overpaid. I just don’t believe that is the case. If there are some bad apples out there who are charging excessively, doing unnecessary visits or otherwise ripping off the Medicare program, then the answer to that is to bar those particular providers from participating in the Medicare program.

It isn’t to punish everybody based on what may be inappropriate behavior by a few.

That is my biggest concern. I believe this is a case where if you cut the payment rates by about 6.5% — which would take $1 billion out of home health — you’re going to see agencies close and people are going to be forced into much more expensive long-term care facilities. Or they’re going to be at risk of repeated hospitalizations, both of which would cost far more than the reimbursements under home health care.

The same bill also provides increased flexibility surrounding the homebound requirement.

Right now under Medicare, the definition of homebound is extremely strict. It says that the patient cannot leave home without — I believe the phrase is — a considerable and taxing effort. There are other beneficiaries who could benefit from home health care if we did not apply such an onerous restriction.

I can think of my own family, where my father had Alzheimer’s disease for eight years — it may have been even longer than that, but it was diagnosed for eight years before he died a year ago.

For about seven of those years, my mother was able to manage his care. She got a little bit of help, but she essentially miraculously did it herself. As his dementia worsened and his physical care also started to become more and more difficult, I said, “Gee, maybe he would qualify for home health care.”

But he was still able to go out in a car and go see my brothers or go in limited circumstances for a brief dinner somewhere. We didn’t meet the definition. Yet just a few months later, he went into the veteran’s nursing home in my hometown of Caribou, Maine. I believe it would have helped my mother enormously if she would have been able to access home health care for him.

It might have delayed his admission into the veteran’s nursing home. It’s amazing he was home for as long as he was, but that was due to a truly heroic effort by my mother primarily, with some help from my brothers and from friends.

Given the fact home health care is cost-effective, having such a strict requirement for the definition of homebound to qualify for services, it actually ends up costing the government more in the long-run. It also puts an extraordinarily difficult burden on the caregiver.

You’ve been in Washington, D.C., for a while now, first being elected to office in 1996. How has the perception of home-based care changed over time? Has it?

It has changed — and in a very positive way. People are much more familiar with home care. That is partially due to the fact our population is aging so rapidly and that people are experiencing home care visits themselves.

I badly broke an ankle a couple of years ago and had to have surgery — seven pins and a plate. I actually qualified for two home care visits to have the dressings changed and that sort of thing. More and more people are having personal experiences with short-term home care such as I received, or they’re experiencing it with an older relative.

They’re seeing first-hand how valuable it is.

I also believe that — because our population is not only aging, but people are eager to stay home as long as they can — that home care is becoming better known and more prevalent.

The final factor I would mention is home care is becoming increasingly sophisticated. There are patients who 20 years ago would have required hospitalization or admission to a long-term care facility that we now are able to care for in their homes due to the highly skilled nature of home care.

As I’m sure you’re aware, it’s a pretty divided time in U.S. history. But that doesn’t seem to be the case when it comes to home health and home care. They seem like truly bipartisan issues. Does that match up with what you’re seeing?


For example, I was looking at my Home Health Payment and Innovation Act that we talked about. There’s a wide range of co-sponsors we have on that bill.

Sen. Debbie Stabenow (D-Mich.) is my chief co-sponsor. We have Sen. Rand Paul from Kentucky, he’s a very conservative republican but also a physician who knows how important this is. Sen. Jeanne Shaheen, a democrat from New Hampshire. Sen. Bill Cassidy (R-La.), another physician, which I think is interesting. Sen. Doug Jones from Alabama, a democrat.

That’s just a sample of the co-sponsors. I think that demonstrates how bipartisan this issue is.

There’s one other aspect of this that I’d love to mention. The other bill I’ve introduced with Sen. Ben Cardin (D-Md.) has some really important provisions for people who are living in rural Ameria and may not have access or easy access to a physician.

It will allow nurse practitioners, physician assistants and nurse midwives to certify that Medicare patients need home health services. Probably the nurse midwife isn’t going to come into play very often there.

There are too many cases of seniors experiencing unnecessary delays in accessing home health care because a physician is simply not available to order the care promptly.

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