Proposed Payment Rule Would Make Care Access Difficult For Complex Home Health Patients

It’s no secret that the home health proposed payment rule for 2023 is viewed unfavorably by the majority of stakeholders. It has received pushback for a number of reasons – namely a rate cut – but many also believe that if the rule is finalized, it will threaten care for complex home health patients.

What’s considered a complex patient can vary, but patients with some type of heart failure, chronic respiratory diseases and cancer are examples.

“A lot of those are very unstable conditions if they’re not monitored very closely,” Dave Davis, vice president of clinical solutions and integrity at AccentCare, told Home Health Care News. “They require more services in order to keep them out of a hospital or an institutional setting … and they have a tendency to have other comorbid conditions.”

Patients that are confined to the home and have multiple diagnoses have a very difficult time accessing care outside of the home. These individuals are dependent on the care services offered through home health services.

“The proposed payment cut leaves providers with less money to care for the most severely impacted groups, both those that are physically impacted, as well as those that are behaviorally impacted with comorbidities such as depression and anxiety, those sorts of things,” Davis said.

Indeed, the proposed rule includes a 4.2% aggregate decrease to payment rates.

At LeadingAge — a Washington, D.C.-based advocacy association of more than 5,000 nonprofit aging services providers and organizations — the majority of its members are nonprofit or mission-driven agencies. This means they tend to take on sicker populations, the type that would be directly impacted by the changes the proposed rule puts forth.

“Our members typically serve a very complex population of individuals, and it’s not just complexity on the clinical side, but also on the social determinants of health side,” Katy Barnett, director of home care and hospice operations and policy at LeadingAge, told HHCN. “Do they have access to additional family support? Do they have access to transportation to visit for other professionals?”

On its end, LeadingAge has been critical of what they believe is an inaccurate assumption on the U.S. Centers for Medicare & Medicaid Services’ (CMS) part.

“We wanted to push back against CMS’ assumption that everybody had simply up-coded their patients to the highest eligible diagnosis, or added on additional comorbidity,” Barnett said. “We recognize that the patient populations our members are serving started as very acute cases, and have become more acute, especially when we’re talking about the two years of the pandemic.”

In other words, many patients delayed receiving preventative care services that over time spiraled into larger health concerns. Providers, like the members that LeadingAge serves, have been seeing the impacts of this in the cases they take on.

It’s safe to say that removing payment of any kind will always affect the ability of a provider to provide that care, but the current landscape has made this outcome even more dire.

Further compounding the proposal’s changes is the ongoing nursing shortage, the additional funds needed to bump up clinician compensation amid the pandemic, as well as inflation, which has further driven up costs.

“Access to home health services is going to be reduced drastically,” Barnett said. “You’re going to have a lot of agencies looking for beneficiaries that pay the highest. And the beneficiaries that our members traditionally served may not be able to find a home health agency because the agency that would have taken them is limited by their capacity.”

Patients with conditions that aren’t likely to improve will particularly feel the brunt of the proposed cuts, according to Barnett.

“A really good example of that are patients who require maintenance care,” she said. “If you need maintenance care for a chronic illness that will not improve you can get that — improvement is not a standard. But those patients are very costly, and those patients stay for a long time. The way that the home health reimbursement works is over time you get less payment for patients that have multiple episodes. It’s going to get harder for these patients to find an agency willing to work with them long term.”

Davis pointed out that the proposed payment rule is antithetical to the purpose of the Patient-Driven Groupings Model (PDGM).

“The reason for the movement to PDGM, based on the reports to Congress, was to provide more money to care for these patients that had these significant comorbid conditions — expensive diagnoses,” he said. “It’s kind of a Catch 22.”

More broadly, the proposal in its current form may be viewed as an unintentional push towards more institutional care and longer hospital stays.

Plus, the cuts could spell the end of some agencies entirely, leaving even less care options for patients with complex conditions.

Davis believes that an impact study that examines what this could do to providers, while taking into account the current market forces, is needed.

Ultimately, Barnett urges CMS to go back to the drawing board and work with providers to make changes.

“Put off these cuts for another year, and really work with the community to go through the methodologies and understand where patient access to care and beneficiaries will be most impacted,” she said.