The Choose Home Care Act of 2021 is the collective and proverbial baby of many home health stakeholders. And for good reason: It could allow more patients to recover in the home under Medicare – and change how the entire health care system works for older adults.
Naturally, there are detractors, including skilled nursing facility (SNF) operators and advocates. One of the largest is the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), which came out vehemently against the legislation.
Choose Home – introduced in the U.S. Senate at the end of July and in the House in October – would incentivize home health agencies to provide SNF-level care in the home. Ultimately, that would mean adding another layer to the current home health benefit.
The legislation has gained significant bipartisan support in Congress, and advocates are hoping that – pending a Congressional Budget Office (CBO) analysis – it could be passed in the near future.
This week, Marquette University’s College of Nursing published a “pros-and-cons” article regarding the legislation in its current form. The “cons” side argued that while there may be a need for Medicare beneficiaries to receive more care in the home, “the [Choose Home Care Act] is the wrong way to go about it.”
As part of a larger debate series, advocates and critics were each given three main points to argue their perspectives. Home health expert Lisa Grabert – a research professor at Marquette and Georgetown universities – is the editor of the series.
The authors of the arguments are anonymous.
“As a former Hill staffer, if I were lobbied on this particular bill, I would probably cite all six of these main arguments,” Grabert told Home Health Care News. “Because I think that these are the biggest issues that the members of Congress will need to eventually address.”
The “pro” arguments pointed out that Medicare beneficiaries have an overwhelming desire to be cared for in their homes. As designed, Choose Home removes barriers preventing them from doing so.
The pro camp also argued that Choose Home leverages “novel” home health coverage and reimbursement innovations while saving an estimated $2.5 billion over a 10-year period.
Meanwhile, the “con” arguments claimed Choose Home would threaten the safety of beneficiaries because SNFs typically offer care on a 24/7 basis.
“Medicare beneficiaries eligible for facility stays, in a clinician’s judgment, require a higher level of care – daily skilled care, under the supervision of experienced nursing staff,” the argument explained. “The beneficiaries who would be eligible for the new extended care benefit under [Choose Home] are a population in need of careful supervision.”
Skeptics likewise argued the model would put an additional monetary burden on beneficiaries due to a “confusing layer of financing.”
Finally, naysayers added that Choose Home is built on top of an “already compromised [home health] benefit.”
“If you were to ask most Medicare beneficiaries, they would certainly say their preference is to receive as much care as possible in their home setting,” Grabert said. “On the other side, I do think that there needs to be some safeguards put around the level of severity that can be treated safely in the home and how beneficiaries can qualify for that.”
In support of Choose Home
The advantages of the Choose Home bill have been touted repeatedly by those in home-based care.
“There are about 2 million patients a year that are admitted to SNF,” LHC Group Inc. (Nasdaq: LHCG) Chairman and CEO Keith Myers said at FUTURE. “And we believe that roughly 35% of those could be cared for under Choose Home.”
As far as downsides, the biggest argument against Choose Home is its potential hindrance to patient care. In order to bring home health care up to the “same nursing standard” provided by SNFs, critics argue, home health would need to have a 7.4-fold increase in the number of services provided.
Joanne Cunningham, the executive director of the Partnership for Quality Home Healthcare (PQHH), doesn’t buy that logic.
“Many [health care professionals] view the home as a very safe alternative for their patients, which is actually how Choose Home came about,” Cunningham told HHCN.
PQHH has published multiple case studies showing what kind of patient could benefit from Choose Home.
Take, for instance, the 85-year-old patient who suffered a stroke, or the 81-year-old patient with mild dementia. Both were admitted to the hospital for their conditions. Neither wanted to go into a facility following discharge. In both cases, they and their families were left with no choice.
Post-acute and long-term care policy has been in the policy spotlight since the COVID-19 began, with hospital administrators and discharge planners looking to send patients to the most appropriate setting.
“I think the opposite is true – that home is a very safe setting for many Medicare beneficiaries who are post-discharge,” Cunningham said. “And the construct of Choose Home is such that it creates a benefit that builds off of the existing home health benefit. It would allow for, not every patient, but a subset of current nursing home patients to receive safe and clinically appropriate care in the comfort and safety of their homes.”
A benefit add-on
The fact Choose Home builds on the home health benefit is part of the problem, critics believe.
To support that view, they point to how agency profits increased when the average number of home health visits decreased from 2001 to 2018.
“The Medicare program continues to pay more for less service within the home health benefit,” the cons argument said.
Cunningham, again, pushed back on that.
“Home health provides a clinically appropriate benefit that is held to high-quality standards, and [agencies] routinely achieve on those quality metrics,” Cunningham said. “Patients do very well at home. If you look at the quality metrics of the home health program, they speak for themselves.”
Finally, critics argued a significant “con” was that another layer of financial confusion for beneficiaries would be a consequence, potentially increasing out-of-pocket costs.
Specifically, beneficiaries would be responsible for 10 days of excess cost-sharing obligation. That out-of-pocket (OOP) cost could be as high as $1,800 in some cases.
“This OOP expense exceeds the $1,443 average monthly social security amount a Medicare beneficiary receives,” the critics argued. “This amount reflects only the initial 30-day episode, which if renewed multiple times, is possible the beneficiary could lose all 100 covered SNF days without setting foot in a facility.
At the end of the day, Choose Home is meant to modernize a Medicare benefit that has grown overly rigid, Cunningham said.
“The intent of [Choose Home] was to come up with something that outlines a modernization of the home health benefit to allow for more choice,” she said. “And I think it’s a tremendously thoughtful approach. Frankly, I don’t think it’s confusing.”
Companies featured in this article:
Marquette University College of Nursing, Partnership for Quality Home Healthcare
