Hundreds Of Stakeholders Voice Concerns As Home Health Proposed Rule Commenting Period Ends

The public comment window for the home health proposed payment rule closed on Tuesday. Overall, industry stakeholders had submitted 691 comments to the U.S. Centers for Medicare & Medicaid Services (CMS) as of Tuesday morning.

From the start, home health stakeholders took issue with CMS’ methodology for determining whether the Patient-Driven Groupings Model (PDGM) led to budget-neutral spending in 2020.

For the National Association for Home Care & Hospice (NAHC), this comment period has given the organization the opportunity to review the methodology that CMS used to undertake its assessment, at least to a point, William A. Dombi, president of NAHC, told Home Health Care News.


“We were handicapped in terms of the depth that we could analyze CMS’ methodology, as they refused to supply a variety of data that we think is necessary to replicate what they’ve done,” he said. “There are a lot of holes in the information they provided, but there was enough information provided to indicate to almost a universe of commenters that CMS really wasn’t compliant with the law, and wasn’t using an evaluation methodology that made sense.”

Along these lines, the industry is also collectively on the same page about CMS’ permanent behavioral assumption adjustment of -7.69%, according to Dombi.

“It’s strangely inconsistent with the way CMS approached the skilled nursing facility sector — essentially the same kind of evaluation need — looking whether or not movement from one payment model to another was budget neutral,” he said. “I think the consensus is extraordinarily strong that CMS needs to go back to the drawing board.”


On its end, NAHC submitted its formal comments on Tuesday.

Commenters also took issue with the proposal’s failure to fully address operational inflation pressures home health providers have been facing.

“Home health payments should reflect the cost of inflation, gas prices and increased cost for recruitment and retention,” a commenter lamented. “Home health agencies are struggling to hire staff and compete with huge increases in pay by hospitals who have received huge amounts of COVID money.”

The proposed payment update percentage is 2.9%. This is below current inflation, which peaked at 8.5% in March.

“Although a 2.9% increase is insufficient to allow agencies to keep up with inflation and other financial pressures, we believe any increase in reimbursement will help beleaguered agencies,” the Association of Home Care Coding and Compliance wrote in its official comments.

Many expressed that businesses would take a hit and access to care services would be severely compromised.

“The impact of this proposed change would be devastating for home care agencies, and more importantly, it will limit access of care to beneficiaries that need it, as agencies can only reduce efficiencies so much before the quality of care [and] patient satisfaction are impacted,” another commenter said.

Comments from one organization, however, did receive pushback from NAHC.

“One set of comments we did review was those supplied by the Medicare Payment Advisory Commission (MedPAC),” Dombi said. “MedPAC has been saying for years that home health payment rates should be cut, so they like what CMS is proposing. But at no point did MedPAC even evaluate the bona fides of what CMS was proposing. What stood out for me was that MedPAC cares about the outcome of reduced payment rates, rather than the validity and the consequences of it.”

Dombi also took CMS to task for the contradictions surrounding the agency’s goals for the Home Health Value-Based Purchasing Model (HHVBP) expansion.

“CMS is betting on the success of a Home Health Value-Based Purchasing Model expansion nationwide to garner almost $3.5 billion in Medicare savings through reduced hospitalizations and the like,” he said. “Yet they’re pulling resources away from home health agencies to reach those goals. It seems so counterproductive what CMS is doing in cutting payment rates, increasing costs and undervaluing the inflation that all of health care is going through.”

While home health stakeholders were submitting comments for CMS’s consideration, industry advocates were also working on the legislative front.

Last month, the Preserving Access to Home Health Act was introduced into the Senate. The bill was introduced by Sens. Debbie Stabenow (D-Mich.) and Susan Collins (R-Maine); it would stop CMS from decreasing home health payments until 2026.

Not long after, an identical bill was also introduced in the House of Representatives. This bill was introduced by Reps. Terri Sewell (D-Ala.) and Vern Buchanan (R-Fla.).

Ultimately, Dombi believes that the efforts on the legislative side could be a way forward.

“We are getting very favorable responses from House and Senate, Republicans and Democrats, to what that legislation is intended to do,” Dombi said. “We do see it as a failsafe of sorts, should CMS choose not to fix what it proposed. We will continue that advocacy as long as necessary.”

LeadingAge and several of its home health provider members likewise submitted comments before Tuesday’s deadline.

“On the one hand, the Biden administration has consistently and publicly promoted its commitment to ensuring older Americans’ access to quality aging services – with an emphasis on care in the home and community,” Katie Smith Sloan, president and CEO of LeadingAge, said. “Yet in its actions, the administration is undermining providers’ ability to deliver these critical services. Just as it did with nursing homes, CMS is unfairly assuming all providers are bad actors. This is not acceptable.”

Mark McPherson, president and CEO of Trinity Health at Home, echoed those remarks.

“Payment cuts now will be devastating,” he said. “CMS’ 2.9% inflationary factor assumption is wrong on multiple levels. Our base wages, coupled with sign ons and referral bonuses, increased labor costs by 4.5%. Gas prices, as well as those of personal protective equipment and other supplies, have ballooned. We’ve been making hard decisions for months; we turn away 250 admissions a week because we do not have enough staff. CMS must understand that with this rate cut and staffing challenges, older adults simply will not get much needed care.”

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