Whether Decreased Home Health Utilization Is Helping Or Hurting The Health System

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Following the U.S. Centers for Medicare & Medicaid Services’ (CMS) implementation of the Patient-Driven Groupings Model (PDGM), the total number of home health visits per 30-day period fell by nearly 17%.

That’s according to CMS data.

Some health care organizations, like AARP, are concerned that this trend may be the result of unintended consequences tied to PDGM, such as early discharge from home health or limitations on the number of visits or types of services provided.

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Others, however, don’t believe that it’s as simple as less quantity equaling less quality.

“I think it’s easy to equate value with volume,” Tim Ashe, chief clinical officer at the post-acute care technology and analytics company WellSky, told HHCN. “If we see a decline in utilization, it’d be easy for an organization to say, well, there are fewer visits, therefore the value or the quality of care is going down. However, it’s not a pure ‘volume equals better outcomes’ equation.”

Concern over low utilization numbers

On average, people who received home health services through Medicare in 2021 were visited 8.2 times by health care professionals per 30-day period of care. That was down from 9.8 in 2018, according to CMS data.

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Visits from home health aides, specifically, dropped 35% over the same period.

Although AARP would agree that volume does not equal outcomes, it does believe that steep drop is something to be alarmed about.

“We do have some concerns about beneficiary access to home health care,” Rhonda Richards, a senior legislative representative in government affairs with AARP, told HHCN. “In Medicare, we want to make sure, obviously, that all beneficiaries have access to the home health care that they’re eligible for and that they need.”

In a letter to CMS, AARP stressed the need for CMS to collect more data and conduct more real-time monitoring in home health care to help better understand the impact of access-to-care and payment-system changes.

Specifically, AARP believes CMS should expand the data it collects to include geographic, racial, ethnic, socioeconomic and other identifiers to get a clearer picture of what beneficiaries need.

The shift in payment incentives for providers may be encouraging agencies to focus on serving post-hospital clients for short periods of time, discouraging them from serving people with longer-term needs, Richards said.

“If this trend continues to decline, Medicare beneficiaries may not get the care they need and that would obviously impact their health and their wellbeing,” Richards said. “It could mean they have unnecessary visits to the hospital, bad health outcomes and poor experiences in the health care system.”

Quality versus quantity

Since the implementation of PDGM – and with the rise of value-based care – home health providers may be adjusting best practices when providing services to patients.

That’s why Ashe does not see the decline in home health visits as a negative. In fact, he sees it as a positive.

“I don’t necessarily view this dynamic as a negative,” Ashe said. “I view it entirely the opposite. As organizations find more efficient ways of meeting specific individual patient needs, visits may decline. That’s actually a good thing, because making unnecessary visits to home health is not a good use of resources in the health care landscape.”

Ashe argues that making fewer visits, in some cases, is a better example of being good stewards to the Medicare dollar.

The goal for home health providers, Ashe said, is not to maintain 2018 levels of home health visits, but to find the “sweet spot” for the number of visits.

“There’s a sweet spot in visit utilization and an even sweeter spot when you break that utilization down into different disciplines,” Ashe said. “There’s a mix of visits made by a multidisciplinary team to achieve the highest level of quality and the highest level of patient and family satisfaction.”

The versatility of a home health provider in 2023 is a benefit for the industry as a whole. Providers are doing more and offering more services. When they can’t, they’re making an effort to partner with companies that can fill those gaps.

“It’s purposeful, meaningful, evidence-based best practices as part of a holistic plan of care that achieves the best possible quality and satisfaction outcomes,” Ashe said. “I think the disconnect is fairly easy to understand, right? If a constituency says, ‘Volume equals value,’ and we see a decline in volume, then there must be a decline in quality. But it’s not that simple.”

Telehealth’s role

Another wrench in the accounting system when it comes to home health visits is the emergence of telehealth. AARP recognizes that the increased use of telehealth services during the public health emergency may explain some of the decline of in-person visits.

However, telehealth should not completely replace in-person care for those who need it, Richards said.

“There can certainly be benefits of that for individuals, but it shouldn’t be a replacement for face-to-face visits,” Richards said. “For home-based Medicare beneficiaries that have chronic conditions or limited mobility, it can obviously be helpful.”

AARP also suggests that CMS start collecting claims-level data on telehealth in
home health care to monitor its use.

WellSky also sees the value in telehealth and other tech-enabled features coming into the home.

“We’re going to double down on how we’re using technology and how telehealth, remote monitoring and analytics all come together to actually improve outcomes and improve efficiency,” Ashe said. “Which, big picture, is a good thing for health care.”

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