NAHC’s Dombi: We’re Not Going To Be Bullied By Congress, CMS

There’s a flood of changes surging toward the U.S. home health care industry.

But thanks to widespread recognition, improved quality and staunch advocacy efforts, providers have never been standing on higher ground.

That was the key message delivered by the National Association for Home Care & Hospice (NAHC) leadership Sunday during the Washington, D.C.-based nonprofit advocacy organization’s annual conference.

“Too often, we hear people thinking, ‘We’re just overwhelmed. We’re just pushed into the background. We’re just not where we should be,’” NAHC President Bill Dombi said to hundreds of conference attendees at the Washington State Convention Center in Seattle. “I whole-heartedly disagree with that.”

Some days, that flood of change may feel more like a 360-degree tidal wave.

From one direction, providers are staring down the Patient-Driven Groupings Model (PDGM), the biggest shock to the home health system ever since the transition from the Interim Payment System (IPS) to the Prospective Payment System (PPS) two decades ago.

As if radical payment change wasn’t enough, PDGM comes with an 8.01% assumption-based behavioral adjustment — a harsh enough threat to put plenty of providers out of business in 2020. 

Meanwhile, from another direction, the home health care industry is navigating changes to the rural add-on program, an important payment bump to providers operating in sparsely populated or rugged areas.

And then there’s the Review Choice Demonstration (RCD). And new discharge planning requirements. And rumors about a unified post-acute payment system coming sooner rather than later. 

On top of all that, it’s impossible to forget about the proposed phasing out of Requests for Anticipated Payment (RAPs).

“The path to progress has included setbacks and detours,” Dombi said. “[But] we’ve advanced to the point where we can certainly celebrate.”

Reasons for hope

While there are plenty of immediate challenges, home health owners and operators need only look toward the recent past to remember just how far the industry has come, according to Dombi.

Since the home health benefit was added to Medicare more than 50 years ago, spending has skyrocketed. The Centers for Medicare & Medicaid Services (CMS) Office of the Actuary, in fact, projects spending to hit $186.8 billion by 2027.

In 1994, there were about 4,600 free-standing Medicare-certified home health agencies, according to the most recent Chartbook compiled by Avalere Health and the Alliance for Home Health Quality and Innovation. In 2017, there were more than 10,300 — with more than 5% providing private-duty nursing in addition to Medicare-covered services.

Meanwhile, in terms of economic contribution, home health agencies were responsible for creating an estimated 2.2 million jobs last year.

That track record and steady growth, Dombi said, has put home health care squarely in the sights of federal policymakers — in a good way.

“Virtually every member of Congress and every person at CMS … knows what you do because they’ve had a personal experience [with home health care],” he said. “In Washington circles, everyone is envious of that kind of relationship.” 

The same holds true for hospice and home care, which was once seen as a “cottage industry,” Dombi added.

Policy update

Currently, there are three major home health-related legislative initiatives at the top of NAHC’s priority list.

At the very top is PDGM-refinement legislation making its way through both the U.S. House of Representatives and Senate. In addition to prohibiting CMS from making assumption-based behavioral adjustments to the Medicare home health benefit, the legislation would loosen homebound requirements, effectively expanding access to services. 

The legislation has received plenty of bipartisan support on Capitol Hill, NAHC Director of Government Affairs Calvin McDaniel told conference attendees.

“We’re not there yet. We’re not quite over the goal line,” McDaniel said. “We do anticipate that we’re going to see some movement on some meaningful legislation over the next couple of months.”

There’s also the Home Health Care Planning Improvement Act of  2019.

Introduced in April, the act seeks to broaden the scope of who is allowed to certify need for home health services under Medicare.

At last glance, the act has 117 co-sponsors in the House and 36 in the Senate, according to McDaniel, noting that even physicians have voiced support.

“Everyone agrees this is common-sense policy,” he said.

Finally, changes to rural add-on remain on NAHC’s radar.

In 2018, rural home health agencies nationwide received a 3% rural add-on payment bump to help mitigate geographic and demographic difficulties. CMS instituted a more targeted approach in 2019 and plans to progressively phase out the add-on entirely.

There are 3,246 total counties or equivalent areas when taking into account all states, Washington, D.C., and the U.S. territories of Guam, Puerto Rico, the U.S. Virgin Islands, according to an HHCN review of CMS data. More than 2,000 of those are considered rural in respect to add-on payments.

Instead of the progressive phaseout, NAHC is pushing for a 3% extension for two to three years.

“We are not going to be bullied when Congress or CMS tries to bully us,” Dombi said.