House Lawmakers Move to Scrap PDGM’s Widely Opposed Behavioral Assumptions

The home health industry won a major victory in its battle to scrap widely opposed provisions of the Patient-Driven Groupings Model (PDGM) Wednesday, as a group of bipartisan House lawmakers introduced a new bill targeting the payment overhaul’s behavioral assumptions.

Introduced by Reps. Terri Sewell (D-Ala.), Vern Buchanan (R-Fla.) and Ralph Abraham (R-La.) — along with eight other co-sponsors — H.R. 2573 is the House version of S. 433 introduced in February.

In general, the introduction of H.R. 2573 — the Home Health Payment Innovation Act — is yet another example of the broad support home health providers have on Capitol Hill, especially as decisionmakers look to lower U.S. health care spending and reinforce older Americans’ ability to age in place.


“Preserving access to quality home health care is critical for our growing senior population in Florida,” Rep. Vern Buchanan said in a statement. “This bill would help ensure that seniors avoid re-hospitalization and receive the care they need in their own home.”

If passed into law, H.R. 2573 would require the Centers for Medicare & Medicaid Services (CMS) to make behavioral-based payment adjustments to the Medicare home health benefit based only on hard evidence and observed data.

While PDGM was mandated to be budget neutral by the Bipartisan Budget Act of 2018, certain assumption-based provisions associated with, for example, upcoding and LUPA claims could pose a 6.42% rate cut to providers once the overhaul is implemented Jan. 1, 2020.


Industry leaders immediately voiced their support of the bill following its introduction.

“This bill will prevent disruptions in patient care by ensuring that home health payments to providers of care are not cut by $1 billion in 2020,” Keith Myers, chairman of the Partnership for Quality Home Healthcare and CEO of LHC Group Inc. (Nasdaq: LHCG), said in a statement. “This legislation also protects the home health program at a time when we are moving to a new payment system that will better align payment with a patient’s true health needs and conditions.”

NAHC President William A. Dombi likewise lauded the legislative effort.

“This legislation is a crucial check on Medicare’s regulatory actions that threaten access to home health,” Dombi said in a statement. “CMS’s arbitrary reimbursement cuts in the new 2020 payment model will create barriers to the full scope of the Medicare benefit. CMS should not be able to rely on speculation and assumptions as to how a home health agency might act in establishing a new payment system.”

If included, PDGM’s behavioral assumptions would set a dangerous precedent that puts home health care “needlessly in jeopardy,” he added.

In addition to targeting PDGM, H.R. 2573 also allows for waivers to the restrictive homebound requirement in certain circumstances, which could expand access to home health services. The Senate companion bill included a similar provision.

Loosening the homebound requirement isn’t a recent development, according to Myers, who told investors Thursday during LHC Group’s Q1 earnings call that the industry attempted to make similar changes roughly a decade ago after conversations with the Medicare Payment Advisory Commission (MedPAC).

“I think it’s a huge sign, a signal, if you will, of where we’re going,” Myers said. “The challenge was how to guarantee the savings and who was going to take the risk. That was, you know, pre-bundles and all of that.”

After being introduced, H.R. 2573 was referred to the House Committee on Ways and Means and the House Committee on Energy and Commerce.

Other members of Congress who have actively rallied against PDGM’s behavioral assumptions include Sens. Rand Paul (R-Ky.) and Susan Collins (R-Maine).

“When the federal government tries to predict or assume something, it usually gets it wrong, in my opinion,” Paul told Home Health Care News in April. “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.”

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