Senator Collins: Penalizing Providers with PDGM’s Behavioral Adjustment ‘Makes No Sense Whatsoever’

The ability for non-physician practitioners to certify a patient’s eligibility for home health coverage.

Extending the 3% home health rural add-on.

The creation of a national home care workforce strategic plan.


These were just a few of the topics home health advocates discussed Wednesday morning during a dedicated hearing in front of the U.S. Senate’s Special Committee on Aging. Other issues highlighted during the nearly two-hour hearing included the behavioral-adjustment aspect of the Patient-Driven Groupings Model (PDGM).

The group of industry advocates serving as witnesses included National Association for Home Care & Hospice (NAHC) President William A. Dombi and Leigh Ann Howard, the director of home health and speciality programs for Northern Light Home Care & Hospice in Maine. Home care worker Francis Adams and Warren Herbt, CEO of the Home Health Care Association of Louisiana, also participated.

Long-time home-based care supporter Sen. Susan Collins (R-Maine), chairman of the Special Committee on Aging, called the hearing to order.


“Year after year, when seniors are asked how they want to spend their golden years, they overwhelmingly answer at home,” Collins said.

During their separate testimonies, Howard and Dombi argued in support of S. 296, the Home Health Care Planning Improvement Act, introduced by Collins more than a year ago. Backed by more than 40 bipartisan co-sponsors, S. 296 seeks to widen the scope of who can certify home health services under Medicare rules beyond physicians, granting authority to physician assistants, nurse practitioners and other advanced-practice nurses.

If passed into law, such legislation would be particularly impactful in Maine’s rural areas, according to Howard.

“Some rural areas have a shortage of physicians, leaving nurse practitioners as the only primary care professionals in the area,” she said. “This creates significant barriers for rural residents needing to access home health care.”

That barrier has become even more burdensome as Maine’s Medicare Advantage plans and Medicaid program enforce the same physician-only standards, Howard said. Northern Light Home Care and Hospice is a Medicare-certified home health and hospice agency that provides home-based care throughout the Pine Tree State. 

Originally an effort to ensure program integrity and quality of care, Medicare law has required that a physician certify a patient’s eligibility for coverage of home health services since 1965.

That’s long overdue for a modernization, according to Dombi.

As of 2016, nurse practitioners comprised 25.2% of providers in primary practices in rural areas and 23% in non-rural areas, an increase from 17.6% and 15.9%, respectively, compared to 2008, he noted.

“This legislation is supported by numerous patient advocacy groups, health care professionals and physician groups,” he said during the hearing. “There is an obvious reason why there has been such widespread support — our nation depends on non-physician practitioners every day to provide primary care to people of all ages as the availability of physician practitioners diminishes.”

Although it often flies under the radar as a major industry issue, the group of home health advocates also urged lawmakers to reconsider sunsetting the rural add-on, which historically has given providers in rural or sparsely populated areas a small payment boost to stay afloat.

Prompted by findings from the Medicare Payment Advisory Commission (MedPAC) suggesting rural providers are too profitable, the U.S. Centers for Medicare & Medicaid Services (CMS) is currently on pace to eliminate any kind of rural add-on to providers following CY 2022. Until then, CMS plans to break down rural add-on payments by “high-utilization,” “low-population,” and “all other” categories, each with its own decreasing add-on.

Dombi cautioned that MedPAC’s data doesn’t take the whole picture into consideration.

The latest cost report data, he said, shows that the average financial margin for home health agencies located in rural areas is -6.2%. Overall, 39.9% of rural agencies have Medicare margins under zero.

Northern Light Home Care and Hospice is the perfect example of how difficult it is to run a home health operation in a largely rural geography. Over the last year, the provider’s clinicians drove more than 3 million miles to provide care, making close to 200,000 home care and hospice home visits.

Some of those visits to Maine’s island communities required North Light’s staff to hitch a ride on lobster boats or mail boats.

“Reinstate the 3% rural add-on for three years and require an expanded study on its application and any needed reforms to ensure its ongoing success,” Dombi urged. “While targeting may be an option to consider, the current targeting approach is not reliable.”

Citing the worsening caregiver crisis and need for more in-home care workers, NAHC’s president also called for a new strategic plan.

“With the aging of America, the shortages will only grow and grow exponentially unless a national home care workforce strategic plan is developed and implemented,” he said.

Collins takes aim at PDGM — again

Prior to PDGM’s launch on Jan. 1, Sen. Collins was one of the many lawmakers to bash the overhaul’s assumption-based behavioral adjustments. The Republican from Maine, who went on her first home care visit during her second year in office years ago, did so again on Wednesday.

As implemented, PDGM includes a potential 4.36% rate cut if agencies don’t fully adapt to the new model by upcoding, avoiding LUPAs and taking other key steps.

“I have never understood why administration after administration targets home health care for reimbursement cuts,” Collins said. “If there are bad apples in the industry, go after those agencies. Don’t penalize everyone. That makes no sense whatsoever when home health care reflects the choice that the patient wants and is the most appropriate care and saves money.”

PDGM’s behavioral adjustment is especially perplexing, she said, when taking into account skyrocketing health care spending in the U.S. Specifically, Collins pointed to studies on post-acute care discharge patterns that show how home health care helps achieve savings of more than $32 billion over 10 years.

Both the U.S. House of Representatives and Senate are weighing bills meant to refine PDGM and prevent CMS from making assumption-based payment changes in the future.

“While we recognize the value that home health can provide, many home health agencies are struggling in the current reimbursement and regulatory environment, precisely at the moment when we need their services more than ever,” Collins said.

The full testimony from Wednesday’s hearing — titled “There’s No Place Like Home: Home Health Care in Rural America” — is available here.

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