At-home care is reaching a crisis point, according to Scott Levy, chief government affairs officer  at the National Alliance for Care at Home (the Alliance).

The pressure on providers is not only unsustainable – it threatens access to cost-saving in-home care. Already, over one-third of patients referred to home health fail to receive those services.

Home health is facing a triple threat, with deepening patient-driven groupings model (PDGM) payment cuts, Medicare rate updates that fail to keep up with real inflation and increased Medicare Advantage (MA) penetration.

Meanwhile, home- and community-based services are in the crosshairs of the budget reconciliation bill passed by Congress and now in the Senate’s hands. Access to care is sure to be impacted, Levy said, but questions remain as to what extent.

Current policies and regulations have caused “choppy waters” for home-based care providers, but the industry demonstrated that it could step up and support the health care system during the COVID-19 pandemic, Levy said, so it can do so again despite a growing storm.

Home Health Care News sat down with Levy to discuss the policy shifts that stand to remake the in-home care industry, the real-world impact of lessened access to home-based care services and what providers should brace for as key legislation moves forward.

Below is that conversation, edited for length and clarity.

HHCN: What policies or regulations should home-based care providers be watching the most closely right now?

Levy: Anything that’s impacting access to care, whether it’s on the home health, hospice, home- and community- based services, or palliative care standpoint, particularly as it relates to payment reforms that might be happening, or payment cuts that are coming or have been coming through at CMS over the years.

We have some data that shows what happens when there is delayed access or a lack of access, and what it means to the Medicare trust fund on the home health side, and what it means for patients. That information is critical from a policy standpoint that we need to be following day in, day out.

On the hospice side, I think any policy discussion that we have, whether it’s around payment or benefit, modernization, fraud, waste and abuse, anything that impacts hospice policy, you have to keep at the core of that discussion that these are patients and families that have made a very tough decision to forgo curative car. Whatever policy discussions we have, we have to make sure that nothing interrupts that sacred decision that they’ve made.

Can you narrow in on the specific policies that could impact access to care?

I’ll talk specifically about home health. With the implementation of the patient-driven groupings model on the home health side, which started in 2020, but really with the calendar year 2023 proposed rule, CMS started implementing payment cuts to achieve what, in their view, is budget neutrality by measuring the old payment model to the new payment model. Year after year, we’ve seen benefit payment cuts. Those payment cuts were happening at a time when you saw generational inflation that was not being kept up with through the annual market basket updates. You have also seen increased Medicare Advantage penetration. So all three of those things have had an impact on access to care for home health.

Studies from CareJourney on patients referred for home health show the differences between those who get it and those who don’t. Less than 63% of the people who are referred to home health are actually able to access it. So access is clearly a problem. Simply being able to say that a home health agency exists within an area a zip code is not an adequate measure for access.

However, for those who don’t understand, we know from the CareJourney studies that individuals who don’t receive home health services are more likely to be readmitted to the hospital within a 90-day period after discharge. They’re more likely to die during that 90-day period if they don’t receive home health, compared to those who do. And their increased spending in the 90-day post-hospitalization is 6% higher.

That is a perfect example that we’re not measuring the impact of what access to home health care does. So when you have payment cuts on top of inflationary updates that are insufficient, on top of the increased Medicare Advantage penetration, you’ve got a crisis that’s happening where millions of Americans across the country aren’t being able to access the home health benefit. If we want to have a health care system that values health in the home, we can’t continue to cut it.

What are your top three federal policy priorities right now?

Making sure that the hospice benefit is protected from fraudulent providers, and that we maintain the integrity of the Medicare Hospice Benefit so that there are no interruptions in access to care, whether that’s from Medicare Advantage starting to cover hospice or if it is a large-scale payment redesign.

On the home health side, as I talked about previously, it’s a reimbursement issue. So protecting from further cuts on the Medicare fee-for-service reimbursement side, so that there is a very wholesome benefit there for providers to deliver to the Medicare beneficiaries in this country. That is the single top priority for the home health side.

On Medicaid, home- and community-based services, it’s right in the crosshairs of things that are going on with the reconciliation bill. We understand that this Congress is moving forward with changes to the Medicaid program at the state level, through funding. They’re not dictating how states are going to change the programs, but we know that there’s going to be an impact to Medicaid home- and community-based services that go beyond just elimination of fraud, waste and abuse. So continuing to work with members of Congress in the days ahead, as they wrap up on the Senate side reconciliation, that whatever policies that they’re going to finalize in this reconciliation have the least impact to access to care for those eligible beneficiaries who deserve and need home- and community-based services.

If the proposed budget reconciliation bill passes in the Senate, what will be the impact on home-based care?

Well, that’s the hard part, because home- and community-based services are all at the state level. So these are directions to the Medicaid programs and it’s an optional program for state Medicaid programs. How those funding mechanisms that are being addressed in the H.R.1, the “big, beautiful bill,” how those are implemented at the state level will dictate home- and community-based services impacts. Whether that’s work requirements or provider taxes, all of these things.

There are going to be impacts downstream whenever you’re taking away mandatory programs’ funding. They’re going to have to figure out how to make up for that funding, and unfortunately, it’s going to be home- and community-based services and other optional Medicaid programs that are going to be impacted. We know when you cut HCBS funding that you’re going to see increased wait times and what that does to the overall spending of state Medicaid programs. They need care, so they’re going to have to go somewhere to get it.

If there’s one thing you would say to home-based care providers, what would it be?

I would say, don’t get discouraged. This is a very trying time in the policy world. Any time there’s change happening on payment and policies, it’s difficult, but we still have a very unique opportunity with the way America is aging and where they want to be. We can make it through some challenging times and continue to show the value, both to the Medicare trust fund, but also to the families of patients that our clinicians, operators and providers serve. We can have them join us in telling the story about why this is such a unique and specialized benefit, for home health, hospice and home- and community-based services, and why we need to do everything we can to protect it. Getting other people involved in that movement will help us do that, but don’t be discouraged by the choppy waters that we might be swimming through right now, because here is an opportunity for this industry to really shine, much like it did during COVID.

The home-based care community really stepped up during COVID and provided a lot of support to the health care system. There’s no reason that that should just happen during a time of generational pandemics. This is something that the home- and community-based services and the general home care community can do all the time.