How CMS’ Proposed Rule Would Build Palliative Care Into The Home Health System

The U.S. Centers for Medicare & Medicaid Services’ (CMS) proposal to add palliative care as a billable service under the Medicare Home Health Benefit could expand home health agencies to develop relationships with different types of providers.

However, adding palliative care as a billable service could also make it difficult for home health providers to provide palliative services as robust as those delivered through the hospice benefit.

Home health providers have celebrated the inclusion of palliative care in CMS’ proposed CY2027 home health payment rule.

“The inclusion of palliative care as a bona fide reason for home health services was one of the standout positives in the rule for me,” Beau Sorensen, chief operating officer of First Choice Home Health & Hospice, previously told HHCN.

The proposed rule review aligns with the 2013 Jimmo Settlement, which clarified that the Medicare home health benefit allows providers to support and bill based on the services a patient needs, not solely on whether or not the patient’s condition is expected to improve, Katie Wehri, vice president of regulatory affairs, quality and compliance at the Alliance for Care at Home, told Home Health Care News’ sister publication, Palliative Care News.

“So what it’s doing is it’s really going back to review the home health requirements for homebound status, skilled services and the coverage requirements and saying, ‘In addition to all of the coverage requirements that we have outlined in the existing home health manual, we want to clarify that these skilled services that are covered can be palliative in nature,’” Wehri said.

The rule will not change eligibility requirements for the home health care benefit. To qualify, a patient must:

• Be homebound and require part-time or intermittent skilled services 
• Have an in-person appointment with a doctor or health care professional who confirms home health care is needed
• Receive services from a Medicare-approved home health care agency

CMS indicated in a fact sheet that it plans to provide sub-regulatory guidance that includes examples of skilled palliative care.

Those examples may give some home health agencies the confidence to work with patients who are eligible but whose needs are not clearly identified.

”They’ll feel more comfortable taking these patients on because they will have some support in the manual to show those reviewers that this is an appropriate case, that this still meets the coverage requirements,” said Wehri.

The clarification may also encourage home health agencies to develop relationships with different types of providers, Katy Barnett, director of home care, hospice operations and Policy at LeadingAge, told Palliative Care News.

“You might see more relationships with oncologists who need help managing an individual’s care in the home,” Barnett said. “There may be some [physical therapy] and [occupational therapy] opportunities in there as well, helping a patient who may be in need of palliative support to ambulate appropriately, given a new chronic condition or a new diagnosis.”

However, current payment structures can make it difficult for home health agencies to offer robust interdisciplinary palliative services like those provided through the hospice benefit, according to Barnett.

Home health agencies receive a bundled payment for an individual patient based on their condition and acuity level. Often, after paying for nursing visits, home health care agencies have limited funds from a patient’s bundle to pay for social, spiritual or aide visits.

“So if the priority is making sure that they’re taking their meds so they don’t get nausea, if it’s making sure that you’re in there fixing significant wounds that they received from being in the hospital for so long, those things take priority, because that’s the comfort measure for that individual,” Barnett said.

Offering a comprehensive, interdisciplinary palliative care plan is cost-prohibitive for most home health care agencies under the current payment structure, according to Wehri.

“So if a home health agency is hanging out a shingle today that says they provide palliative care services, it’s probably a sister company that they have that’s usually a [Medicare] Part B provider that’s like a physician visiting service that’s delivering that care,” she said.

However, Wehri believes that the clarification is part of a process of building a holistic approach to care that places patients at the center of home health care plans.

“That palliative approach means that I am the decision maker. I’m at the center of that plan of care,” said Wehri. ”And that’s really what we should have as our approach throughout the system. But like we do here in healthcare, we’ve defined certain programs like hospice care and home health and we don’t want to define palliative care to exclude certain patients. We want to be inclusive. So I think we’re building palliative care into the system. I think that’s what CMS is doing.”

Additional reporting by Kevin Ryan