At first glance, it might be hard to spot a connection between the impeachment activity swirling around President Donald Trump and the home health industry. A deep dive into the current Washington, D.C.-landscape and national priorities, however, suggests the two are inevitably linked.
With all eyes and ears tuned into impeachment talks on Capitol Hill, key legislation targeting the Patient-Driven Groupings Model (PDGM) and its widely opposed, assumption-based behavioral adjustments has fallen somewhat to the wayside. That’s according to National Association for Home Care & Hospice (NAHC) President William A. Dombi, who gave Home Health Care News his annual policy update last week at the organization’s leadership conference in Seattle.
The PDGM legislation making its way through Congress — via two companion bills, H.R. 2573 and S. 433 — is formally known as the Home Health Payment Innovation Act. Among its goals, the legislation requires the Centers for Medicare & Medicaid Services (CMS) to use hard evidence and observed data when making payment adjustments to the Medicare home health benefit.
So far, H.R. 2573 and S. 433 have received ample bipartisan support from well-known congressional leaders. But taking over the spotlight from impeachment is a difficult task, especially with less than three months to go before PDGM begins.
While speaking with HHCN, Dombi weighed in on the PDGM legislation’s chances and what it will take to carry it across the finish line. Highlights from that conversation are below, edited for length and clarity.
HHCN: There are less than three months to go before PDGM starts. What are you hearing from NAHC’s members and other home health stakeholders?
Dombi: From our members, we hear that the preparation continues. But they’re not yet ready for primetime. It’s not because of a lack of trying. You can only do so much before the final rule comes out.
We’re hearing that providers are having that education, that PDGM awareness going on not only at the leadership level, but down into the day-to-day management level. I’ll balance that with one other thing: We know that some people are slow to the uptake.
There are some agencies that are behind others in terms of preparation.
People know there’s a lot of work to be done once the final rule is out. IT partners will need to put together final systems and run final tests, too. Three months may sound like a long time, but it’s definitely not for such a major change, especially when we’re still waiting for all the details.
It’s one thing to talk about home health agencies being ready. What about CMS? Is CMS ready?
If I were to pick out an area of uncertainty, it’s whether their systems will work as they intend them to work. Too many experiences have shown that when you bring in a new system with Medicare and their contractors, the dry runs didn’t find all the holes.
That usually leads to a problem for the provider of services getting paid.
CMS will say the Medicare Administrative Contractor (MAC) is ready. They’ll say the system has been tested. Then, lo and behold, in the first week, things that didn’t come up in the test will pop up — serious flaws.
And we haven’t had such a massive change in the last two decades. The risk factors are heightened because it’s a wholesale change.
There is legislation in Congress targeting PDGM’s 8.01% behavioral adjustment. All your chips on the table — what happens with that?
There are so many factors in play.
In the broadest of sense, the question can be validly raised of will the impeachment activities going on take all the air out of Washington between now and Jan. 1. Even if there’s an attempt to have an accelerated investigation.
And PDGM isn’t exactly at the top of health care priorities right now with Medicare for All, drug pricing and drug transparency.
If we were talking about drug pricing and drug transparency, the issue of impeachment comes up even for that.
But yes, if impeachment doesn’t get in the way of moving forward with Medicare legislation, then those two other issues do come up. Will drug pricing and drug transparency get resolved enough so that there are time and people available to handle other Medicare-related issues pending before Congress?
Right now, the early prognosis is Congress will have time to do impeachment and the drug initiatives with time left for PDGM. But nobody has a calendar of commitments that says, “You’re going to have that time available.”
That’s obviously a big hill to climb. Does that PDGM legislation have anything working in its favor?
There’s bipartisan and bicameral support absolutely there — including support from people in power who make a difference. Apart from impeachment, the hangup that I’ll go to next is really the Congressional Budget Office (CBO).
Rep. Terri Sewell (D-Ala.), the lead sponsor of the House legislation, is on the Ways and Means Committee. She secured a meeting — which we already had — with CBO. To the extent that they can make such a commitment, CBO has worked with the congresswoman’s office on any modifications to make that legislation budget neutral.
That remains a wildcard. Will CBO have the time to do the scoring and analysis? We believe we’ve heightened the priority of this bill, yes. But another version of a drug-pricing bill can come in and detour that.
Several months ago, our concerns were having a vehicle and the CBO scoring. The vehicle issue took on new elements with the impeachment activity. The scoring issue is fairly much where we thought it would be.
I’m still rating this with cautious optimism. We have a much better chance of success than failure.
I’ll add one other footnote: The legislative track is just one of two advocacy tracks we’re taking. We also continue to engage CMS.
A general priority for CMS is access to care. Do you think PDGM would decrease access to home health services?
PDGM is a major disruption. In a disruptive environment, things simply don’t go as you wish or as you plan all of the time. That could create serious access issues — unique to one provider, one region or one contractor. You run that risk.
And the risk is heightened when you add other elements to the disruption — the Review Choice Demonstration (RCD), a behavioral adjustment, a change to LUPA standards and the RAP phaseout.
There also could be a knee-jerk reaction to PDGM in the therapy realm. There could be people who say, “You’re not paying as much as you used to for therapy patients. We’re going to stay away from them because we’re going to lose money.”
We’re already seeing that with the Patient-Driven Payment Model (PDPM).
I’ve followed that. Can we anticipate a similar reaction? It would be imprudent for us to not think that will happen.
I’ve talked to some outsource therapy companies. They’re not seeing it much so far, but maybe a layoff of an employee triggers use of outsource services, which can be purchased on a unit basis.
You’ve been a voice of caution when it comes to Medicare Advantage (MA) as it relates to home health care and, increasingly, non-medical home care. President Trump recently signed an MA-focused executive order. Any important takeaways from that?
For me, the one that hit the hardest was the order’s reference to making Medicare fee-for-service rates comparable to those rates paid by MA plans. If that were to happen in home health services — without a change in MA plans from where they are today — it would be a disaster relative to home health care.
By and large, MA plans pay agencies less than the cost of care. If regulators made traditional Medicare pay at that same level … I don’t know if there will be home health services. I have strong doubts.
There were some potentially positive things, too, right? For example, language preaching the importance of health care workers operating at the top of their respective licenses.
That’s clearly a positive takeaway. But the devil in the details.
We’ve advocated that nurse practitioners and physician assistants be recognized for the full scope of their practice for quite some time now. We want to get authority for them to certify Medicare eligibility — and if it within their scope of practice, then order services.
There’s some evidence that [CMS] would first favor Medicare Advantage plans in taking that step.
How is the evolution of NAHC coming along?
We believe NAHC 2.0 is well underway. The evidence of that comes in a variety of forms. But for me, the first indication that we’re succeeding in bringing about the cultural change we wanted is the 160 people who signed up for committees and advisory boards and so on.
That’s a cultural change of ownership, engagement and transparency.
We also wanted to strengthen our voice as related to advocacy. We have thousands of people who have signed up and are more actively involved in getting messages to Congress, whether hat’s face-to-face or virtual, locally or in D.C.
We also find ourselves in a more collaborative approach with other voices in home care and other voices in health care relative to our advocacy issues. There isn’t a formal merger or anything like that, but there’s very strong collaboration.