Potential Home Health Payment Cuts Threaten Fragile Patient-Clinician Ratio

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If the home health payment rule for 2023 is finalized by the Centers for Medicare & Medicaid Services (CMS) as proposed, it will likely affect quality of care.

There are a few reasons why.

The number of patients per clinician already represents a troubling ratio. And if CMS goes through with reimbursement cuts, that ratio is likely to worsen.


“It does seem like the rubber band has been stretched very thin and has a risk of breaking,” Scott Pattillo, chief strategy officer for Homecare Homebase, told Home Health Care News. “You take these existing clinician shortages, you add on all these additional costs, you reduce the reimbursement rate and you create a situation where it’s just incredibly challenging to employ the number of clinicians needed.”

Home health leaders are arguing that the payment proposal for 2023 is unfair for a variety of reasons. They are arguing it is nonsensical for other reasons.

But all the while, they are trying to remind CMS and other stakeholders that cuts would create significant risks when it comes to patient outcomes.


“I think what you’re going to end up with are patients slipping through the system,” AccentCare CEO Steve Rodgers told HHCN. “Where it’s going to hurt most is exactly the area that CMS has said [needs more help].”

Dallas-based AccentCare is one of the largest providers of home health care in the country. The company also provides personal care and hospice services in 32 states.

In 2019, before the pandemic and before home health agencies had to adjust to the Patient-Driven Groupings Model (PDGM), home health clinicians were seeing an average of 1.3 more patients than previous years, according to data from Homecare Homebase.

Credit: Homecare Homebase

“It’s pretty staggering,” Pattillo said. “Considering these are home-based visits that require extensive in-home time and windshield time, it’s more challenging to deliver high quality of care when clinicians are stretched more and more thin.”

Maintaining quality care

There are less than 30 days before CMS has to finalize a ruling on reimbursement rates for home health agencies.

AccentCare has already had to adjust how it leverages its workforce as the pay rates for licensed practical nurses have “skyrocketed,” Rodgers said.

Between the high labor pay rates, the slowdown of in-home visits due to the COVID-19 pandemic and the emergence of telehealth, there have already been significant complications in that patient-per-clinician ratio.

“Capacity, and measuring capacity, is an evolving and complex process in home health,” Rodgers said. “As new caregivers come on board, they’re actually much less efficient. We’re also managing more complex patients because, since COVID, we are the preferred labor source. There are more referrals coming to us than the skilled nursing system.”

For the major players in home health like AccentCare, Rodgers has confidence that they will have the capacity and bandwidth to adjust and adapt care services.

However, that’s not the case for every provider.

“The approach we use when dealing with any kind of changes is to do things in a way where they do not compromise the quality of patient care,” Rodgers said. “But there are a lot of marginal players in the industry that might take a less refined approach. I feel very good about the quality of care among the top five players. I can’t say what it’s like below that. You’ve got a good potential of a lot of patients facing a lot of cuts to services based on the financial needs of some of these smaller agencies out there.”

A potential reimbursement cut would hurt everyone in the home health industry, Rodgers said, but especially those smaller agencies.

For now, clinical quality largely has held steady in terms of hospital readmissions, Pattillo said. However, he noted that CMS paused a lot of its quality reporting during the pandemic. Those updated numbers may tell a different story, he said.

“We can say that agencies have been very mission-focused and very intentional about deploying precious clinical resources,” Pattillo said. “But it’s getting to a point where all the innovation, all the mission-based care is just not going to be able to stretch without expecting further challenges to patient access.”

AccentCare and other home health agencies argue that the payment cuts would ultimately negatively impact access and health equity.

Statistics from HCHB also back that up.

Over a 10-year period before the pandemic, lower income and underprivileged communities showed to have had disproportionately worse referral conversion rates. That continued after the onset of COVID-19.

In areas where the median household income was less than $30,000 per year, referral conversion rates were the lowest of all income cohorts.

“The reality is that it’s harder to deliver care in an inner city or rural environment than it is in a suburban environment,” Rodgers said. “Both in terms of where your nurses are, their willingness to go into it and everything else. You cut the rates another 20% over the course of the next several years, you think [agencies] will be able to deliver the same kind of care at the level we are now? It will hurt the populations that essentially CMS wants to focus more on.”

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