Senator Rand Paul Slams PDGM, ‘Guesses by Government Bureaucrats’

House lawmakers have yet to introduce a companion bill to the Home Health Payment Innovation Act (S. 433), legislation introduced in the Senate in February focused on the Patient-Driven Groupings Model (PDGM).

That doesn’t mean the home health industry has lost the attention of Congress when it comes to PDGM and future payment, however.

Kentucky Sen. Rand Paul, a republican, is the latest to openly speak out about PDGM and its widely opposed behavioral assumptions. He did so while connecting with Home Health Care News in his office in Washington, D.C., on Thursday.


Apart from being one of the co-sponsors of S. 433, Paul also views PDGM from a physician’s perspective. As a senator, Paul continues to practice medicine by performing free eye surgeries in Kentucky and around the world. Recently, for example, he led mission trips to help restore the vision of individuals in Guatemala and Haiti.

Moving forward, it’s imperative that policymakers preserve patient choice and access to home health care services in all markets, according to Paul, who said any payment reform that jeopardizes those ideas needs to be re-evaluated.

Below are the highlights from HHCN’s conversation with Paul.


HHCN: As a physician, you have a different level of familiarity with the U.S. health care system and quality of patient care. As a senator, of course, you also need to be in tune with overall spending. In your view, how does home health fit into the equation, so to speak?

Sen. Paul: First of all, we have to let people have the freedom to choose how they want to treat their loved ones. I think if you asked most people — like your parents or grandparents — if they’d like to be treated at home or in the hospital, almost all of them would rather be treated at home.

I think having that option out there is important. A lot of our health care is paid for out of Medicare now, so it’s government money, but it was our money before it became the government’s. We should have, I think, freedom in how we use it.

All you have to do is turn on the TV and you see there’s this superbug — the Candida superbug. Your parents don’t want to go to the hospital and get that.

I think having that choice is important.

So, my fear is if you end up dramatically cutting home health at some point, then you may wind up with home health providers going out of business or with areas where there are no home health services at all, leading to people choosing the hospital.

We often see or hear how somebody becomes a supporter of home health care by seeing its value firsthand, perhaps with a family member even. Do you have any of those experiences?

We currently have family members who are on home health and have sort of an assisted-living kind of care, where caregivers come in and help them at home. Definitely, you see the benefit as a family member.

As your colleague Sen. Susan Collins (R-Maine) pointed out to HHCN when we recently connected, you’re among the bipartisan group of lawmakers who have sponsored S. 433 – what the industry is calling a PDGM refinement bill. Why support that effort?

As a physician, I have always supported the option of providing health care to seniors in their own homes when appropriate, instead of institutionalized care. Most patients and seniors prefer to stay in the comfort of their own homes, which also happens to be the most cost-effective way for Medicare programs.

Additionally, I strongly support key provisions of the bill to ensure that adjustments under the new payment model are based on evidence, as opposed to assumptions or guesses by government bureaucrats.

When the federal government tries to predict or assume something, it usually gets it wrong, in my opinion.

I think just cutting money without a rational basis for why we’re cutting money or based on assumptions that we don’t know to be true — not really based on evidence — leads to a real danger. It’s a big problem. What we need to figure out is how we have enough money to pay for what we do.

We have to figure out a way to maintain what people want with the dollars that we have. I mean, Medicare overall is like $35 to $40 trillion dollars short. Something has to give. What [policymakers] do is they come in and they’re going to cut somebody’s fees, but they don’t realize what might happen if you put people out of business.

I think ultimately the big reform that we’re all going to have to address at some point is — if we’re living longer, I’ve said this for years — you’re going to have to gradually raise the age of Medicare eligibility. Instead, what we’re doing is keeping the age — when we don’t have enough money — and then cutting everybody that Medicare pays.

One of the other things they’re talking about is how they define who is eligible, you know, for home health care. If you keep restricting that definition, you’re saving money by basically rationing care. You’re going to make people ineligible for things.

Q: Can you elaborate a little bit more about the aspects of PDGM you find particularly concerning?

No two patients are alike. As a physician, I understand the importance of assessing each patient individually based on their needs.

CMS is setting a dangerous precedent with their inclusion of assumptions to predetermine how providers will care for patients and what a provider will be paid for that service, even before they have a chance to assess that individual’s clinical characteristics and needed treatment. Any new model needs to be evidence-based and not structured on random assumptions.

If it’s not evidenced based, you’d have to live with so many unintended consequences — and one of the unintended consequences would be a lot less home health care for people. That’s one thing I’m worried about.

Q: People in the home health industry have pointed out how CMS isn’t including behavioral assumptions in the skilled nursing facility (SNF) industry’s payment overhaul.

Yeah. They’ve kind of gotten a clue in one area. They need to wake up in this area too.

Q: I wanted to ask you about non-medical home care as well. Increasingly, it seems like policymakers are more widely viewing home care as a pre-acute service — something to keep people away from hospitals in the first place. For example, we need only look at CMS’ efforts to expand in-home services and supports under the Medicare Advantage. What’s your take on this type of care and what we’re seeing, broadly?

I support the provision of non-skilled services in the home, which helps to reduce institutionalization and lets patients remain in their own homes.

It is the direction we’re headed.

Medicare Advantage plans offering additional services to keep patients from being hospitalized, or reducing the length of a hospital stay by providing access to services to keep them independent at home for as long as possible, is a good thing.

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