Home Health Value-Based Purchasing Model Could Limit Access to Care, Critics Caution

In January, the U.S. Department of Health and Human Services (HHS) revealed plans to expand the Home Health Value-Based Purchasing (HHVBP) Model — a Medicare demonstration that aims to tie reimbursement to quality of care.

While HHVBP has gained popularity within the home health industry, some experts believe there are potential downsides to scaling the model.

Broadly, HHVBP rewards or penalizes home health providers based on their quality performance. The idea is to move toward value-based payment instead of volume-driven reimbursement, something that has been a challenge for the U.S. health care system.


The HHVBP model was originally implemented in 2016. It is currently active in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska and Tennessee.

In 2020, providers that were able to keep patients healthy and away from the hospital could have received a Medicare payment adjustment of 6%. On the flip side, providers that didn’t measure up to key standards could have been hit with a 6% penalty.

In 2021, this upside-downside figure is 7%. It will again increase to 8% in 2022, though HHS and the U.S. Centers for Medicare & Medicaid Services (CMS) may opt to tweak HHVBP before any geographic expansion.


In the past, CMS officials have pointed to HHVBP as one of the government’s most successful alternative payment arrangements. After a prolonged period with no updates to its framework, they’re now looking to expand the model to increase care options and encourage home-based care during the public health emergency.

“I think it’s clear that CMS believes in paying for value over volume, and this is one way to start down that path,” Chris Attaya, vice president of product strategy at Strategic Healthcare Programs (SHP), told Home Health Care News.

Santa Barbara, California-based SHP is a national health care data analytics company.

Broadly, the HHVBP model has largely been embraced by home health providers.

Baton Rouge, Louisiana-based Amedisys Inc. (Nasdaq: AMED) CEO and President Paul Kusserow, in particular, threw his support behind a nationwide rollout of the model after the expansion news broke. In fact, the home health CEO had communicated regularly with Brad Smith, director of the Center for Medicare & Medicaid Innovation (CMMI), throughout 2020, calling for such a move.

When it comes to rallying support for a cause, in many ways, HHVBP expansion was a no-brainer. Since its implementation, the model has resulted in an average 4.6% improvement in home health agencies’ quality scores.

Additionally, the HHVBP model averages annual savings of $141 million to Medicare, according to CMS.

Despite these results, some experts have pointed to some flaws in the HHVBP model.

“Essentially [HHVBP] looks at criteria that incorporate improvement in a person’s condition,” Kathleen Holt, associate director of the Center for Medicare Advocacy, told HHCN. “We went back to CMS and said, ‘You’re not measuring everybody.’ When you have a program that is built on a bell curve, where you essentially have winners and losers, … you end up with a program that incentivizes agencies to serve the people who will be measured.”

The Center for Medicare Advocacy is a Washington, D.C.-based nonprofit law organization that is focused on health equity and improving access to comprehensive Medicare coverage.

Holt pointed out the HHVBP Model, for example, works in cases where a patient receives home health care after leaving the hospital post-knee replacement. The model doesn’t take into account patients with more permanent conditions that won’t necessarily improve, such as paralysis patients or multiple sclerosis.

“It’s easier to measure improvement than it is to measure somebody who is not getting better — but [care services] are keeping them from declining in their disease state,” she said.

The Center for Medicare Advocacy has urged CMS to figure out a way to measure the quality of care delivered to people who are not expected to get better.

The response from CMS has been unsatisfactory when it comes to solving this issue, according to Holt.

“CMS essentially responded back and said, ‘No, we’re just not going to count them because we don’t really know how to count them,” she said. “We can change the measurements in that maybe you’re not going to improve in mobility, but you could improve in your ability to independently bathe yourself or something.’”

Since under the HHVBP model home health providers are penalized for performance, it creates a financial incentive to take on a specific kind of patient.

Holt believes that if CMS fails to find a way to properly measure patients who may not improve, these individuals will fall off the radar of home health providers.

Another cause for concern, according to Holt, is the idea that the HHVBP model creates an environment where it’s difficult for smaller providers to thrive.

Meanwhile, larger providers will be able to leverage resources to easily attract “the right patients,” Holt argued.

“It’s a dangerous way of basically saying to the industry [that] the little guys are going to get pushed out,” she said. “It comes down to … the larger agencies with more resources are going to figure out ways to make themselves the winners in this.”

Holt is also skeptical about the 4.6% improvement in home health agencies’ quality scores.

“I think if you look at that improvement in quality scores, you’re going to improve what you measure,” she said. “That’s just logical. If the home health agencies know what’s being measured, the more organized [providers] can say, ‘These are the things we’re being measured on. Let’s just focus on improving these scores.’ I’m surprised it’s not higher than 4.6%, frankly.”

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