Capitol Hill Action Stokes Hopefulness For Home-Based Care Providers

For once, most representatives from both parties agreed that action is necessary.

“I was encouraged by the engagement from lawmakers on both sides of the aisle,” Empath Health CEO Jonathan Fleece told me in an email after the March 11 hearing, at which he testified. “There was real recognition that home-based care is not only what patients and families want – it’s a cost-effective, patient-centered solution that benefits the entire health care system.”

At the hearing, Fleece offered compelling arguments regarding the paramount importance of home-based care.

“Home-based care isn’t just for those actively dying,” Fleece testified. “It supports people managing chronic illnesses, recovering from surgery and navigating terminal diagnosis. Patients want it. Families need it, and taxpayers benefit. Keeping patients at home prevents costly hospitalizations and reduces strain on the health care system. Today, in a time of financial and workforce challenges, we should be expanding access to care at home, not cutting it.”

The hearing was not the only action in the nation’s capital this week, as the House also passed a continuing resolution that includes extensions of the hospital-at-home and telehealth waivers that at-home care providers have been pushing for.

While that is welcome news, the ongoing wrangling over the budget also underscores just how unlikely it will be that the bipartisan tenor of the hearing will translate into actual policy changes. And the hearing also surfaced some of the tensions about policies that could benefit some post-acute providers but might not be the best moves for at-home care.

In this week’s exclusive HHCN+ Update for members only, I provide an analysis and key takeaways, including:

• Issues surrounding further reimbursement cuts
• Reactions from industry leaders 
• Legislation to keep home care viable

High stakes

In his testimony, Fleece laid out policy priorities and also emphasized the high stakes involved.

He called on lawmakers to pursue three goals: expanding government investment in home-based care, expanding pay-for-performance models to reward high-quality providers and enhancing value-based care models.

“These are not just policy decisions,” Fleece said. “They represent urgent threats to access, quality and patient choice. The decisions made here will shape the future of home care. Let’s protect and expand access before it’s too late.”

As of 2024, 58.9 million Americans age 65 or older were enrolled in Medicare. Nearly 40% of Medicare beneficiaries are discharged to post-acute care, with home health being the most commonly used setting, according to the National Institutes of Health.

Most seniors want to receive care in this setting — in the comfort of their surroundings with family and friends — often achieving better patient outcomes than facility-based services. However, further reimbursement cuts threaten these positive outcomes, and in some cases, patient lives are at stake.

My 78-year-old mother had a knee replacement a couple of years ago. She was told she would need physical therapy after her surgery. She resisted because she thought that meant remaining in the hospital.

While in the hospital, she experienced heightened anxiety and depression due to being away from her home and animals. After she was assured a therapist would come to her house to deliver care, she agreed immediately and was discharged within a day.

Without home health care, my mother would have declined a much-needed service. She has since had a second knee replacement surgery and lives a healthy, active life.

With the policy and regulation changes currently on the table, this type of care could become obsolete, and seniors like my mother will walk away from acute-care settings with only a fraction of the care they need being provided. Our aging population deserves better than that.

Fleece acknowledged that the hearing was a step forward, but work is still left to do.

“I hope that Congress takes meaningful action to support home-based care – expanding access, reducing barriers and investing in the people who make this care possible,” he said. “I look forward to continuing this conversation in the weeks and months ahead.”

Future of unified payments

As Fleece made clear in his comments, the need for more comprehensive support for post-acute care is urgent, but different types of providers do not necessarily agree on the specific actions to be taken. One case in point, which was a topic of the hearing, is a unified post-acute care payment system.

In 2014, the Improving Medicare Post Acute Care Transformation (IMPACT) Act was signed into law. The main goal of this Act was to establish a unified post-acute care prospective payment system (PAC PPS). Congress mandated CMS to deliver operational specifications of a payment system that is ready for implementation.

The Trump administration’s 2021 budget proposal included reforms to implement the PAC PPS. If implemented, the reform would have saved $80 billion in the 10-year budget window, according to the Congressional Budget Office (CBO).

“To further advance efforts toward a unified PAC PPS, CMS submitted the technical prototype to Congress in 2022,” Lisa Grabert, Marquette University research professor, testified during the hearing. “The main finding was the prototype is capable of Congress’s intent toward a unified payment approach for post-acute services. Simply put, the unified PAC PPS is ready. I strongly recommend that Congress give CMS the authority to implement the unified PAC PPS.”

Grabert went on to say that a unified PAC PPS may eliminate the need for several existing policies, including the home-bound requirement for home health services, the three-day inpatient hospital stay requirement for nursing homes, the 60% rule for rehab hospitals and the site-neutral payment criteria for long-term care hospitals.

“There may also be rules that are appropriate to waive in the interim while the transition to a unified PAC PPS is underway,” she noted. “Congress should only consider regulatory relief in tandem with a unified PAC PPS. These regulatory policies are of high value to the industry-specific providers who receive FFS payments and are likely to add to the deficit. Revenue generated from implementing a non-budget-neutral unified PAC PPS is necessary to offset spending related to regulatory relief.”

Not all industry insiders believe Grabert’s proposal is good for home-based care.

“The panel of witnesses brought many of the concerns we see in post-acute care,” Kornetti & Krafft Health Care Solutions CFO Sherry Teague told me. “However, the unified payor bill that Ms. Grabert lauded does not consider the uniqueness of home health. All other settings have a consistent brick-and-mortar aspect. We in home health never know what we are walking into. I feel she disregarded Medicare Advantage’s impact on everything in post-acute care. This impact is almost always negative and more costly than traditional fee-for-service Medicare.”

Hospital-at-home and telehealth reprieve

In a small win for home-based care, the House passed a continuing resolution on March 11, including a provision to extend the CMS Hospital-at-Home (HaH) waiver program and telehealth flexibilities through Sept. 30, pending Senate approval.

The HaH program was initially scheduled to end on March 31. In February, the in-home care advocacy group Moving Health Home and nearly 100 backers sent a letter to Congress urging a five-year extension for the waiver.

As of November 2024, 378 hospitals across 140 systems in 39 states have received approval to provide HaH services to patients, according to the American Hospital Association (AHA).

And Fleece spoke about the importance of telehealth to home-based care organizations.

“Telemedicine is a critical part of ensuring access to care, whether its recertification of hospice eligibility or ensuring that in crisis we can get access from a communications perspective to all of our patients,” Fleece said. “It is also mission critical to our home-based care organizations that those that are suffering chronic disease or are post-acute to ensure that home-based care is there for the rural communities through telemedicine to reduce hospitalizations, readmissions that home-based care has been proven to demonstrate.”

Telehealth flexibilities are important to a variety of providers, with the AHA also weighing in on their potential extension.

“The American Hospital Association appreciates the House of Representatives extending these vital health policies that enable hospitals and health systems to serve their patients and communities without disruption,” an AHA spokesperson told me. “We remain committed to advocating for long-term solutions that advance health within Congress this year.”

Now, it is all in the hands of the Senate. Hopefully, we will see an acceptable resolution soon that will extend the telehealth and HaH programs. But even more than that, here’s hoping that the hearing this week is a step toward Congress considering not just money matters but what really matters – quality patient care at home.