Physician, NAHC Make Case for Home Care Coverage Under Medicare

Over the past few years, non-medical home care has become a pillar service within the broader health care continuum for its ability to improve outcomes and increase patient satisfaction. Due to that success, some believe home care should be covered under Medicare, just like home health or hospice care.

Dr. Laurie Archbald, an associate professor of geriatric medicine at the University of Virginia (UVA), recently touched on this exact topic in an op-ed appearing in The Hill. Home Health Care News caught up with her to explore the issue — and its viability in the modern U.S. health care landscape.

From a medical standpoint, there is a case to be made for the value of non-medical home care and, by extension, professional caregiver services being covered under Medicare, according to Dr. Archbald, who also serves as the medical director of the UVA Geriatrics outpatient Clinic at JABA.

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“In situations where things work well, we see a decrease in social isolation, which is medically beneficial for a variety of reasons,” Dr. Archbald said. “It also allows us a bit of oversight for things like making sure [patients] are taking their medication, and it allows us to be more proactive in preventing bad events like falls. Having an additional set of eyes from an in-home care provider can assist our patients.”

For older adults, things like falls, social isolation and the inability to adhere to their medication regimen can often negatively impact overall health, according to Dr. Archbald. In fact, multiple studies over the past few years have suggested that social isolation can be as harmful to a person’s health as smoking a pack of cigarettes.

Despite the positive impact home care can have on seniors, they are often hindered by their lack of coverage for these services. Often, paying for home care means out-of-pocket expenses starting at $20 or more per hour.

“We are often limited by what can be covered in their insurance,” Dr. Archbald said. “If a patient were to have an event, require hospitalization, require post-acute or short-term care, it’s typically a covered benefit under Medicare. However, getting covered home care is really limited.”

To some extent, that’s starting to change, thanks to new flexibilities provided under Medicare Advantage, an offshoot of Medicare administered by private insurers. After federal policymakers created a new pathway for caring for the chronically ill in 2019, some health plans are now offering non-medical home care and similar services.

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Another overlooked factor is that many older adults — roughly 44 million, according to Family Caregiver Alliance — currently rely on informal or family caregivers. But this form of care isn’t always a sustainable long-term solution.

“There are certainly wonderful family or friend caregivers that our patients have, but for a lot of them this isn’t the case,” Dr. Archbald said. “There may not be a family member who is able to devote the amount of time and resources that it takes to provide care. We see patients that have children or grandchildren that are involved in their health care, but are not local and are unable to provide day-to-day care.”

In cases like the one Dr. Archbald describes, seniors often have to leave their communities and uproot their lives to move in with family that can provide care. It’s a process that can be disruptive — and one that prevents them from aging in place.

“Having the ability to provide the preventative services our patients need, which in the scheme of health care, is much less expensive than events that cause hospitalization, would be an ideal option for our patients to be able to age in place,” she said.

Dr. Archbald isn’t alone in her belief that home-based caregivers should be available through Medicare.

The National Association for Home Care & Hospice (NAHC) has long held the position that Medicare should cover home- and community-based services programs.

“We’ve had a longstanding policy position that Medicare could learn from the experiences of the Medicaid program,” Bill Dombi, president of NAHC, told HHCN. “Medicaid programs looked at the cost of nursing homes and the cost of not providing supportive services. As a result, they created a series of programs under the label of home- and community-based services, most of them wavier-type programs.”

Despite the clear need for services, the biggest challenge that prevents home care coverage under Medicare is cost.

“If they were to just do it through a legislative change, the Congressional Budget Office (CBO) would probably come up with an analysis saying it would cost untold billions of dollars,” Dombi said. “In their view, everybody would access it to the fullest and it wouldn’t bring the savings necessary to justify its existence.”

Still, federal policymakers may learn from home care’s emerging role in Medicare Advantage, which often acts as a testing ground for traditional fee-for-service Medicare.

In 2018, the Centers for Medicare & Medicaid Services (CMS) announced that some non-medical home-based care services would be allowed as supplemental benefits under Medicare Advantage plans.

CMS would eventually broaden the scope to mean benefits that “have a reasonable expectation of improving or maintaining health or overall function” for 2020. It’s a move that Dombi calls a “step in the right direction,” but he points out that it may take more time before we see the same under Medicare.

“We hope that through this approach the traditional Medicare program can learn something too,” he said. “The reality at the moment is that very few plans have adopted this service … hopefully, the learning will accelerate. I don’t think the information that could give enough confidence to expand it beyond Medicare Advantage plans is there yet.”

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