‘Lot Of Work To Be Done’: What Home Health Leaders Expect From Payment Rulemaking In 2024

In recent years, home health care has faced relentless cuts from the Centers for Medicare & Medicaid Services (CMS). It has plagued the industry, but providers and advocates alike are still hopeful a light at the end of the tunnel is ahead.

Organizations such as the Partnership for Quality Home Healthcare (PQHH) and Hearts for Home Care have been the engine behind making home health care a “squeaky wheel,” which they hope will gain the attention of legislators.

Home Health Care News recently caught up with PQHH CEO Joanne Cunningham and David Totaro, the president and executive director of Hearts for Home Care. Totaro also serves as the chief government affairs officer for Bayada Home Healthcare. During the conversation, Cunningham and Totaro shared their predictions for the upcoming home health proposed rule.

Plus, Cunningham explained why an election year is a good opportunity to push forward home health advocacy efforts, and Totaro explained past “wins” from home-based care advocacy.

Below is that conversation, edited for length and clarity.

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HHCN: What do you expect from the proposed home health payment rule, which usually drops in late June or early July?

Cunningham: I anticipate that what we will see, given CMS’s posture and prior rulemaking cycles, is the continuation of the policy that will put in place permanent cuts to the Medicare home health program. We’re bracing ourselves for an additional sizable permanent cut. We don’t know exactly what CMS has planned for the temporary cuts, otherwise known as the clawback cuts. We will certainly see, at a minimum, CMS identify what their new projected value of the temporary cuts are. At the end of last year, it was in the final rule, $3.4 billion in clawbacks that they were planning at some point, and we will see updated temporary adjustment numbers. That $3.4 billion is expected to go up.

Totaro: I think Joanne summarized that very well. There hasn’t been anything that I’ve seen over the last, say, six to nine months, that doesn’t signal more of the same. CMS hasn’t changed their rate setting model at all, so I think we’re going to see additional cuts and clawbacks. That’s why my team and I have been advocating on the Hill since the rule was released last year. We still have a lot of work yet to be done.

What have cuts done to the home health care industry over the last couple of years? What has been compromised? What has changed for the worse?

Totaro: I think we can all agree that when you get cuts of this magnitude, and you’ve got red flags indicating that there are going to be future cuts, it all sets up a planning scenario for your providers that’s just fraught with uncertainty. This impacts investments. Investments are important to home care. Investment in technology, investment in solving the workforce shortage situation, through developing programs for recruitment and retention, and even expanding into regions where access to care has not yet been achieved. All of these supposedly are goals of CMS as well, but these cuts really act in an opposite direction. Without a doubt, it has impacted our rural and hard to access urban regions. It has caused many agencies to begin to assess their ability to even sustain their business. I’ve seen data, just recently, which suggests that more than half of the agencies providing care are considering whether they can actually continue to sustain their business, or certainly must reduce services altogether.

Joanne, Dave has mentioned that he and his team have been on the Hill since the rule last year. Can you detail what the schedule in a given year looks like for home health advocacy?

Cunningham: What we’re doing, really throughout the entire calendar year, is policy and advocacy. Policy, because we’re always trying to think through policy responses, either through the legislative process or the regulatory process, that would present a way for the proposed rule, the payment model that we’re living under, ways for it to be improved. Then the other piece of that is advocacy. Since 2020, we have been working under this PDGM payment model, which going into this, I think the industry and the home health community writ large was excited about. Its promise was that this would be a more refined coding system and payment system that would better match a patient’s condition to payment. Instead, since 2020, we have seen growing cuts that are accelerating, with essentially cuts going into at least 2028 and probably beyond.

We’ve had to deal with a mounting level of cuts, so part of what we constantly have to do is make sure that policymakers understand, very vividly, the impact of these. The other thing that’s worth really talking about and digging into is the fact that at a time when the general population not just prefers care in the home, but is clamoring for more of it, we have a Medicare home health program that is dwindling. [One that] is under such financial strain and pressure, its future is uncertain. I just don’t know how that syncs up with what the public at large wants and needs. Demographics are pointing to more care in the home, not less.

Dave, on that note, can you detail some of the wins you’ve seen at Bayada over the years when it comes to advocacy?

Totaro: I would just like to add one thing to what Joanne was saying. Our schedule has always been go-go-go. There is no stop and go with advocacy. Consistency is what really matters. One of the things that we’ve learned over the last six to nine months is that our role as providers is to change the narrative from a discussion about cost and cuts, to a narrative about why or how these cuts are going to impact the lives of our legislators’ constituents. We heard through many of our meetings that they’re very interested in understanding how actions they have taken or will take, affect the lives of these folks. That’s why we believe that you never stop. You continue to bring folks to your meetings that are going to be able to humanize this issue, rather than have it based on data.

To address your other question. I’ve been very happy to lead one of the industry’s strongest advocacy teams, Hearts for Home Care, which is a separate, but affiliated social welfare organization of Bayada Home Health Care. We were formed, dedicated to solely supporting advocacy efforts. We did this because we believe strongly that advocacy works. I know it’s hard for many today to believe that it’s worth the time and effort to actually sit down with your legislator, because we’ve seen what goes on in DC or in Harrisburg, Pennsylvania, or almost in any state capitol. I’ve said this to many, I’ve questioned whether a bill that would designate the second Sunday in May as a day to honor all mothers would actually get passed today in the U.S. Congress, but consistency does work.

For example, last year alone [my team] participated in 17 different advocacy efforts around Medicaid in the markets that we support. Through our efforts, we realized more than $325 million in home- and community-based investments by state legislatures. We also, just recently, completed a study where we showed consistent advocacy initiatives and compared the results to those states where we have not had consistency in our efforts. We discovered that since 2015, in the states where we’ve had a consistent advocacy effort, year after year, our Medicaid rates have actually increased on average by 23%. In those states where we have not had a consistent effort, for a number of different reasons, our Medicaid rates have actually been cut, on average by about 7%. I could go on and on about the success we’ve had at state and federal levels, but just let me say that Congress actually saw home health as a solution rather than a cost during the COVID crisis. That’s because, I believe, that we all came together as one industry with one strong loud voice.

Joanne, when we talk about grassroots advocacy, what do we really mean by that? What do providers need to do in order to be a part of those efforts?

Cunningham: It’s really simple. They can go to our website or NAHC’s website and get engaged with a click of a button.

What we mean is that there are thousands and thousand and thousands of home health advocates around the country, including many of those who work for home health organizations and home care organizations. If you ever did a visit with an agency like Bayada, you’re going to meet an awful lot of people who have a lot of choices in the health care sector, regarding where to work, and they choose to work for an organization that delivers care in the home. One of the reasons is that they’ve experienced it firsthand, they’ve seen the benefit, and how valuable it is to the people who receive care in the home. They’ve never looked back. They’ve never left the sector, so we do have a passionate workforce.

We also have what I call grass tops, and that is the senior leaders of home health organizations who tend to have very strong relationships with policymakers in their communities. Some of those individuals are folks like Dave Totaro, as well as other senior leaders at Bayada and every home care organization in the country. We really rely on them to lend they’re personal commitment to deliver that message to senior policymakers either on Capitol Hill or in state capitals all across the country.

What’s the single most important thing providers can do?

Cunningham: Whatever you have already done, whether it’s a phone call, an email, a visit, do it again, because repetition matters in advocacy. It’s going to take more than a single person making a single phone call, or a single email. It has to be done over and over and over again, in order to have the punch that it needs. Home health is competing with not just every other sector of health care, who also is expressing their desire to see policy and legislative change. We’re competing against all kinds of other interests, transportation, the environment, taxes, housing. We’ve got to make sure that we keep our message front and center with lawmakers and policy makers more than just once. It’s got to be repeated and sustained and consistent over a period of time. Otherwise, our voices get drowned out by others. Volume matters, and the number of voices matters. That’s the reason why we’ve got to dial up anything that we’ve done before by another 50%. If every advocate did that, then we would see some significant massive change and increase in uptick in our advocacy.

What’s the ultimate goal for advocacy this year? What, realistically, can be achieved by advocacy this year, in order to put home health providers in a better spot by year end?

Totaro: Our ultimate goal this year is to stop those cuts, whether its current or future clawbacks. We have a bill in Congress that’s been sponsored by Senator Stabenow and Collins, both very respected longtime advocates for home health care, and Representative Sewell and Smith, that we’re advocating for. It’s our goal to get that legislation passed this year.

Joanne, we spoke maybe last month and you said that it was a good thing that it’s an election year because legislators are more in touch with their constituents.

Cunningham: I think that anytime it’s an election year, Congress is acutely aware of the fact that they’re all up for reelection. We will use that to our advantage. We will make sure that the squeaky wheel of home health gets the grease this year, and make sure that we are putting in place a policy that can be supported, and ensure that we have removed any obstacles in our way. We do look at an election year as an opportunity.

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