‘Choose Home’ Legislation Gaining Significant Support in Congress, Nearing Formal Introduction

“Choose Home,” major legislation designed to help more people age in place, is gaining momentum on Capitol Hill. There’s even a chance a Choose Home bill is introduced before Congress’s July 4 recess.

That’s according to National Association for Home Care & Hospice (NAHC) President Bill Dombi.

If introduced and eventually enacted, Choose Home would create a new payment pathway for providers using both medical and non-medical in-home care services to keep Medicare beneficiaries out of skilled nursing facilities. The legislation has plenty of supporters in both chambers of Congress and throughout each major political party, Dombi said.

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To learn more, Home Health Care News sat down with Dombi for its latest episode of the “Disrupt” podcast. In addition to Choose Home, Dombi and HHCN touched on the latest with the Provider Relief Fund while also going over NAHC’s policy priorities for the remainder of the year.

Highlights from HHCN’s conversation with NAHC’s leader are below, edited for length and clarity. Subscribe to Disrupt via Apple Podcasts, Google Play Music, SoundCloud or your favorite podcast app.

HHCN: There was a recent announcement from the U.S. Department of Health and Human Services (HHS) that had to do with Provider Relief Fund reporting deadlines. What’s the latest with that?

Dombi: This has been an open issue for a number of months. It actually has two elements to it. One is the reporting deadlines, but there’s also the “use-by date.” When we go to the supermarket and look at something we’re buying, we often look at a use-by date. Well, the use-by date applies to the use of the Provider Relief funds, too. There had been an effort to try to extend the date that the funds had to be used by. HHS responded to those requests by making some modifications. Those modifications are then tied to what the reporting requirements are.

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For home health, hospice and other Medicare providers generally, the use-by date stays the same. That’s because they broke it up into various periods from the calendar year last year, with the first period being the April through June window. That’s when most home health agencies received 6.9% of their 2019 Medicare revenues as a Provider Relief Fund distribution. That was under what’s known as General Distribution No. 1. The use date stays the same for that; it’s the end of the month of June.

For the second distribution period, they also continued it toward the end of June because all those general distribution funds in No. 2 were received before June 30. Later funds, a number of them were received by home health agencies when they demonstrated either that they didn’t get what they were entitled to or that they needed additional monies. Those move into Phase 3 distribution, which is extended in terms of a use-by date to the end of the calendar year.

So, it all depends on when you got the funds. That then triggers when you need to report on use. For most home health agencies, the reporting deadline will be 90 days. So a July 1 start date is Sept. 30, for example, for end-date reporting responsibilities. For more information, the best thing to do is simply Google “HHS Provider Relief Fund,” and that will take you to a very robust section of the HHS website with all that information.

And what’s going on with the Provider Relief Fund broadly? Have those funds been totally depleted? Should home health providers expect any new rounds of relief?

Last week, HHS Secretary Xavier Becerra indicated that there’s approximately $25 billion left in the Provider Relief Fund. The intention with those remaining funds, at this point, is to target them in an undesignated targeting. We continue to make a push that some of those monies be targeted toward home care. But we don’t have any word back on that, so far. I would say that it’s probably safe to assume that the majority of home health agencies would not be well-positioned to expect any further distribution out of the Provider Relief Fund. Unless, of course, we see something change in the status of where we are with the public health emergency now.

If there was one sector of home-based care that might keep its eyes and ears open, it’s the non-medical side of home care that is not Medicaid as well — private-pay services or some other funding besides Medicare and Medicaid, in other words.

The kind of targeting that they would be looking at might be in rural areas. It might be when you could demonstrate a special need on a very individualized basis, as compared to a general distribution approach. We do not expect to see any more of that.

The Medicare Payment Advisory Commission (MedPAC) recently released its June report to Congress. There wasn’t a ton in there about home health care, but there were some interesting comments on alternative payment models and a need to roll them back. What stood out to you?

In terms of the alternative payment models, I think NAHC shares MedPAC’s view. It’s difficult to understand what is triggering the outcomes that the Center for Medicare and Medicaid Innovation (CMMI) is trying to measure with these alternative payment models because so many of them are in play. Now, none of them are very specific to home health care. But our providers are there with the BPCI Advanced model. ACOs obviously integrate home health into the mix.

Liz Fowler, now the head of CMMI, is a very experienced individual. It wouldn’t surprise me if she and her team were already working on the same issues before MedPAC even came out with its June report.

What else stood out? And speaking of alternative payment models, what’s happening with the expansion to the Home Health Value-Based Purchasing Model (HHVBPM)?

The most notable thing I found in the June report was actually on the Skilled Nursing Facility Value-Based Purchasing Program. MedPAC recommended it immediately cease and be replaced with a completely different program, one that relies upon objective measures.

I offer that because there may be a tie-in to the way CMMI looks at HHVBPM. The previous administration had planned on expanding it nationwide, to start Jan. 1, 2022. But that interest got caught up in the change of administrations, when regulation and regulatory actions were frozen. We have had conversations with CMMI about where they may go with home health value-based purchasing now that it’s in its last year. We were left with a very distinct impression that they will be expanding it as was planned, at least in some form or fashion.

We have suggested some reforms to HHVBPM, such as a shared-savings approach. The program, in four years of evaluation, has saved over $600 million. The way it operates is, there are winners and losers from within the home health community on a state basis. We think that an added incentive of sharing some of the savings the Medicare program gets will further result in the kind of outcomes CMS and CMMI want to see.

One reason we’re supportive of expanding value-based purchasing: It has so firmly established what we’ve all been saying for a long time. Home health brings dynamic value. The $600 million in savings comes primarily from reducing hospitalizations and rehospitalizations.

What we expect — and again, this is our best estimate of where things will be — is that the upcoming home health payment rule will include a proposal to expand HHVBPM nationwide.

*Editor’s note (June 28, 2021): This interview took place before CMS released the proposed payment rule for 2022. In its proposed rule, the agency did outline plans for a nationwide expansion of HHVBP.

What else do you think will be included in the home health proposed payment rule for 2022? Do we really know?

We don’t know. And here’s what I’ll tell you about why we don’t know. If someone at CMS tells us what’s in that proposed rule and gets caught doing that, they not only lose their job — they may go to jail. This is when that cone of silence comes down around CMS, relative to rulemaking.

What would we want to see in it? What do we expect to see? Well, what we would want to see in it would be CMS rolling back the 4.36% behavioral adjustment that was in the 2020 payment rule and was continued in the 2021 rule. We believe that during 2020, PDGM was not budget neutral, in particular because of the high-volume increase in LUPAs. But also because of other factors such as the patient-census changes. The areas of behavioral change that were expected did not materialize.

We’d like to see that adjustment in there. But what do we expect to see? That probably comes by way of what we learned through the skilled nursing facility rule. CMS, in the skilled nursing facility proposed rule, said, “We think that you have been overpaid with the new payment model, but we’re not going to take any money back from you yet, not until we have a full year’s worth of data — at the earliest.” They want to be able to really crunch the numbers to determine whether it was budget neutral or not. We expect CMS, even though we’d like to see a rollback of the 4.36%, to say they’re not ready yet.

Apart from that, we expect to see a kind of a plain-vanilla market-basket index increase of payment to the providers of services, plus more stability around PDGM — not messing at all, really, with the architecture of the payment model.

I’ll put a footnote on what else we might expect to see. It’s not related to home health, but to hospice: We expect to see that the proposed home health rule will include a proposal for intermediate sanctions on survey and certification for hospice, as was mandated by end-of-the-year legislation in 2020.

There’s always a little bit of tweaking that they’ll do around measures for Care Compare and the like, but nothing really dramatic that we expect to see. In the middle of a pandemic, you kind of appreciate predictability and stability.

And as it relates to end-of-life care, it’s my understanding that you and your team have been promoting the inclusion of a specific palliative care coverage as part of the home health benefit. Can you elaborate on that?

This is something that has long been missing from the guidelines and standards around the home health benefit, though there are home health agencies that have successfully provided skilled palliative care. What we’ve done is, we’ve taken the benefit standards that are in the guidance from CMS and put in, wherever appropriate, either the word “palliation” or “palliative.” We put in quite a few references to it as a skilled service. Then we added to it, guidance by way of examples of skilled palliative care from nurses and therapists that could make up a qualification for the home health benefit.

From a design standpoint, it fits within the design of the home health manual. This is in line with a recognition that palliative care is very important at end of life, but also important at any point in life. You may have people getting curative services who recover, but who could still benefit from skilled palliative care by a home health agency. If you look at the universe of palliative care, in its whole sense, there is a portion of it that home health agencies do and can provide very capably, likewise with hospice as well. But there’s more to the universe than that. The prime message we’re trying to send on this is that palliative care is not limited to end-of-life palliative care.

Let’s talk about one of the biggest items in Congress right now: the infrastructure bill. What are the latest developments on that, as we talk on June 17?

It’s pretty clear to us that caregiving is part of the infrastructure of our society. As much as it is important to have good roads and bridges, it’s important, particularly with an aging population, to have a framework for caring for individuals. It’s clearly related to the economy. The vast majority of personal care support provided to people in their homes comes from family members, which often means the individual has to leave their job, taking that productivity away from our country. That also then reduces household income generally, putting them in a position of not contributing back to the economy with their own purchases and the like.

We agree with the Biden administration, that care infrastructure is as valid a part of infrastructure as bridges, roads, airports and harbors. From the perspective of where it stands in Congress today, this is something that has not been embraced by Republicans as part of what they want to do on infrastructure — or more moderate Democrats, for that matter.

Now, the administration has said, one way or another, whether it’s in this round one of infrastructure or otherwise, they are going to continue their efforts to get home care supported through Congressional action. And there is still very strong interest in Congress. I would bet there’s interest among a number of Republicans as well, but perhaps through a different vehicle other than the infrastructure legislation.

There are some other hot-button issues. One of the hot-button issues focuses mostly on Medicaid. Medicaid is a program that first requires pauperization of individuals; they have to be poor to qualify for Medicaid. There have been some questions raised: “Can we do better than the pauperization of people before we provide them care?”

*Editor’s note (June 28, 2021): This interview took place shortly before the White House announced it had reached an infrastructure agreement with a bipartisan group of Senators. It likewise took place before the introduction of the Better Care Better Jobs Act.

Another advocacy point for NAHC and others has been the “Choose Home” legislation, which we’ve previously reported on. Has there been any movement with that?

Well, if the wishes and prayers I make every morning and night happen, then we’ll see the Choose Home legislation introduced before the July 4 Congressional recess. My prayers weren’t answered last year, when I had hoped this would be done before the end-of-the-year recess.

We have a legislative draft that came from the Senate Legislative Council in hand. It has gone through many iterations. We’ve garnered significant support from both houses of Congress, from both Republicans and Democrats. We think we’ve lined up the sponsors of the legislation. We’re waiting to hear from a couple of stakeholders that might make a difference on who comes on board with it. But that’s the pathway we see for it now.

We’re firmly convinced that this has legs to it. The level of enthusiasm we’ve seen from Congressional offices, not just staffers but from members of Congress themselves, has been significant. We’ve talked to three dozen members of Congress, at least, directly about Choose Home. What it does is, it provides an alternative to the Medicare skilled nursing facility benefit at home. Without getting too far into the details, it provides a viable option for many of the people who otherwise would go from the hospital into a skilled nursing facility, sometimes never coming out again. This gives them a quicker bridge to health care at home.

What else has your attention at the moment?

We think it’s time to pass the legislation that’s in both the House and the Senate that would authorize the Medicare program to pay for telehealth services in the home setting by home health agencies. That is a rerun of last year’s legislation. It’s Senate Bill 1309 and House Bill 3371, otherwise known as the HEAT Act. That is a priority, without a doubt.

We also believe a priority should be the reinstatement (with some reforms) of rural add-on under the Medicare home health benefit. That is essentially phased out at this stage or near phasing out completely. In our conversations on the Hill, we know it needs to be targeted. There’s a difference between a rural Maryland location, a rural Oklahoma location and a rural Washington state location.

The other area that we think crosses all aspects of care in the home is workforce. This is a special time for health care at home, with the opportunities that are rising. The challenge is primarily around the workforce, whether it’s home health, hospice, home-infusion therapy, or private-duty, non-medical home care — everything.

We’ve got workforce issues, nurses and home care aides, in particular. We think the country needs a commitment to a multi-dimensional workforce support effort to address what we know is happening already. Baby boomers are reaching that age of 75, which seems to be the age when people start having a greater and greater need for health care support, especially in the home care setting.

We need the workforce to make that happen.

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