CMS Proposed Rule Risks Stability of Home Health Care

NAHC analysis of payment information & more The Centers for Medicare and Medicaid Services (CMS) issued its annual proposed rule regarding Medicare home health services payment rates for CY 2023. As usual, the rule also includes a hodgepodge of non-rate related proposals as well. This article provides a summary of the proposed rule. NAHC will…

CMS Revises Instructions for NPPs Ordering Home Health Services

In the April 27, 2022 Transmittal, the Centers for Medicare & Medicaid Services (CMS) set out to clarify requirements for NPPs in the Medicare program by adding the following  language from long standing regulations that define non-physician practitioners (NPPs): “Physician assistant means an individual as defined at § 410.74(a) and (c). Clinical nurse specialist means…

NAHC to Congress: Time for a Big Permanent Investment in HCBS

NAHC and a group of likeminded organizations have written to leaders of Congress, urging them to make a large permanent investment in home and community-based services (HCBS). The American Rescue Plan Act funding allowed states to provide hazard pay to the direct care workforce and maintain access to vital HCBS that have enabled people with disabilities and older adults to remain living safely in their own homes during the pandemic.

However, those rescue funds are temporary and have stopped accruing. Without a large permanent investment in HCBS, the direct care workforce crisis will worsen and HCBS access will decrease. Timely investment is needed to provide greater sustainability for states, individuals who rely on HCBS, their family caregivers, and the paid workforce providing these critical services.

While the House of Representatives passed a $150 billion investment in HCBS last year, the Senate has not yet done so. The Senate should pass the $150 billion HCBS investment as soon as possible. This investment is essential for building a sustainable HCBS infrastructure that can begin to address the magnitude of need in our communities. This investment will both increase access to Medicaid HCBS and create more high-quality direct care jobs to support the people who do this work as well as people with disabilities of all ages and their families. HCBS are also more cost effective for states and the federal government than institutional care, making this investment an all-around win for individuals, families, workers, and state and federal governments.

When older adults who want to age in place and people with disabilities who need support to work, live independently, and be a part of their communities are left waiting, the responsibility for care and support often falls on unpaid family caregivers, who also need financial assistance. Over 90% of people with disabilities and aging adults living in the community receive unpaid support. The workforce and earnings losses related to unpaid family caregiving are significant and well-documented. The costs of this inadequate system fall disproportionately on people of color with limited income and wealth. For example, family caregivers spend on average 26% of their annual income on caregiving expenses, but the share of income African American/Black and Hispanic/Latino family caregivers report spending is 34% and 47%, respectively.

To address the long-standing inequities the pandemic exposed and exacerbated, this investment is critical to fortify a workforce that must expand to meet a rapidly increasing level of need. The HCBS workforce provides vital services, and yet these workers–who are primarily women of color–have been devalued and underpaid for decades, leading to severe staff shortages that result in crucial gaps in service availability, lengthy waiting lists, service line closures, and additional obstacles to achieving a high quality of life for workers and recipients alike.

This investment is also necessary to help people who are in nursing facilities and other institutions return to the community. Many people are in institutions who do not need to be because persistent underfunding and bias have created an inadequate HCBS infrastructure to meet the demand. The HCBS legislation passed by the House would directly address this issue by making the widely successful Money Follows the Person program permanent. It would also help married individuals who rely on Medicaid to remain living at home with their spouse by permanently extending the federal spousal impoverishment protections to HCBS.

Investing in home-based care has strong bipartisan support. An April 2022 survey of over 1200 likely voters shows that affordable long-term care for seniors and people with disabilities is the most popular provision in the investment package with support from 87% of all respondents and 85% of Republicans. A survey last year of 1,400 voters age 50 and older found that 87% supported increasing resources for in-home care, including 82% of Republicans, and another survey of 800 people age 18 and older found that 89% of Americans support an increased public investment in affordable home care services.

NAHC to Congress: Time for a Big Permanent Investment in HCBS

NAHC and a group of likeminded organizations have written to leaders of Congress, urging them to make a large permanent investment in home and community-based services (HCBS). The American Rescue Plan Act funding allowed states to provide hazard pay to the direct care workforce and maintain access to vital HCBS that have enabled people with disabilities and older adults to remain living safely in their own homes during the pandemic.

However, those rescue funds are temporary and have stopped accruing. Without a large permanent investment in HCBS, the direct care workforce crisis will worsen and HCBS access will decrease. Timely investment is needed to provide greater sustainability for states, individuals who rely on HCBS, their family caregivers, and the paid workforce providing these critical services.

While the House of Representatives passed a $150 billion investment in HCBS last year, the Senate has not yet done so. The Senate should pass the $150 billion HCBS investment as soon as possible. This investment is essential for building a sustainable HCBS infrastructure that can begin to address the magnitude of need in our communities. This investment will both increase access to Medicaid HCBS and create more high-quality direct care jobs to support the people who do this work as well as people with disabilities of all ages and their families. HCBS are also more cost effective for states and the federal government than institutional care, making this investment an all-around win for individuals, families, workers, and state and federal governments.

When older adults who want to age in place and people with disabilities who need support to work, live independently, and be a part of their communities are left waiting, the responsibility for care and support often falls on unpaid family caregivers, who also need financial assistance. Over 90% of people with disabilities and aging adults living in the community receive unpaid support. The workforce and earnings losses related to unpaid family caregiving are significant and well-documented. The costs of this inadequate system fall disproportionately on people of color with limited income and wealth. For example, family caregivers spend on average 26% of their annual income on caregiving expenses, but the share of income African American/Black and Hispanic/Latino family caregivers report spending is 34% and 47%, respectively.

To address the long-standing inequities the pandemic exposed and exacerbated, this investment is critical to fortify a workforce that must expand to meet a rapidly increasing level of need. The HCBS workforce provides vital services, and yet these workers–who are primarily women of color–have been devalued and underpaid for decades, leading to severe staff shortages that result in crucial gaps in service availability, lengthy waiting lists, service line closures, and additional obstacles to achieving a high quality of life for workers and recipients alike.

This investment is also necessary to help people who are in nursing facilities and other institutions return to the community. Many people are in institutions who do not need to be because persistent underfunding and bias have created an inadequate HCBS infrastructure to meet the demand. The HCBS legislation passed by the House would directly address this issue by making the widely successful Money Follows the Person program permanent. It would also help married individuals who rely on Medicaid to remain living at home with their spouse by permanently extending the federal spousal impoverishment protections to HCBS.

Investing in home-based care has strong bipartisan support. An April 2022 survey of over 1200 likely voters shows that affordable long-term care for seniors and people with disabilities is the most popular provision in the investment package with support from 87% of all respondents and 85% of Republicans. A survey last year of 1,400 voters age 50 and older found that 87% supported increasing resources for in-home care, including 82% of Republicans, and another survey of 800 people age 18 and older found that 89% of Americans support an increased public investment in affordable home care services.

NAHC Submits Comments on Proposed FY2023 Hospice Rule

  • Focus on Wage Index Cap, Payment Update, and Health Equity

On Wednesday, March 30, 2022, the Centers for Medicare & Medicaid Services (CMS) issued Medicare Program; FY 2023 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements (https://www.federalregister.gov/public-inspection/2022-07030/medicare-program-fy-2023-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting), the proposed rule governing hospice payment and other policies for fiscal year (FY) 2023.  The rule included:

  • A proposed 2.7% payment update for hospice services for the coming year;
  • Proposed imposition of a permanent 5% cap on reductions in wage index values from one year to the next (a policy CMS is proposing for all Medicare institutional providers);
  • A request for input on specific steps hospices are taking to advance health equity and views on creation of a structural composite measure that would assess a provider’s activities to address access to and quality of care for underserved populations;
  • Updates on elements of the Hospice Quality Reporting Program (HQRP); and a
  • An update on Advancing Health Information Exchange.

NAHC Report summary of the rule is available here.

Since publication of the rule, the National Association for Home Care & Hospice (NAHC) solicited input from hospice members through numerous “listening sessions.”  Following is a summary of NAHC’s comments on the rule that were submitted to CMS:

Proposed Permanent 5% Cap on Wage Index Decreases:  Across the years when wage index values in a large number of geographic areas have undergone changes that could have a significant negative impact on provider payments, CMS has utilized various methods to limit the impact of those changes in the first year so that providers could prepare for the financial impact of the wage index changes.  These methods include applying a 50/50 blend of the existing wage index value and the prospective wage index value for the first year or (as used during 2021) applying a 5% cap on wage index decreases for the first year in which changes to the wage index values are being applied. Given the potential that wage index changes have to create instability and significant negative impacts on certain providers even when wage index values change in only a small number of geographic areas, as part of the proposed FY2023 hospice payment rule CMS proposed a permanent approach to smooth year-to-year changes in providers’ wage indexes by placing a 5% cap on all wage index decreases in future years, regardless of the reason for the decrease.   Under this change, a geographic area’s wage index would not be less than 95% of its wage index calculated in the prior FY. NAHC has had a long-standing policy position that CMS should develop and implement a wage index model that is consistent across all provider types so that all providers have a level playing field from which to compete for personnel, and that supports limiting wage index losses from year to year to minimize dramatic payment reductions due to wage index value changes.

NAHC’s comments support action by CMS to impose a permanent cap on losses due to wage index value declines but suggest that in addition to a 5% cap that CMS analyze the impact of imposing a smaller cap (such as 2% or 3%), provide the public with details of their findings, and impose the most appropriate cap value as part of final action.  Based on their findings, CMS should determine and implement the most appropriate value for the cap on wage index decreases. NAHC also expressed concern that while CMS extended a FY2021 transitional policy imposing a 5% cap on wage index reductions to FY2022 for hospital providers but did not extend that policy to other provider types. NAHC is recommending that CMS retroactively apply the FY2021 transitional policy to hospice and other providers whose wage index values dropped more than 5% between 2021 and 2022.

Proposed FY2023 Hospice Payment Update Percentage 

While CMS has limited discretion when calculating the annual market basket update for hospice providers, NAHC has concerns that the projected 2.7% update is insufficient to address the accelerating financial demands that hospices have faced over the course of the last three years. NAHC’s comments include a wide variety of issues that have resulted in financial strains for hospice providers, including:

  • The Continuing COVID-19 Public Health Emergency
  • Inflationary Pressures
  • Workforce Issues
    • Caregiver Burnout
    • Increased Costs Related to Management Fees, Outsourcing, Recruitment, and Retention
    • Reduced Productivity/Lost Revenue Related to Staff Turnover
  • Resumption of the 2% Sequester
  • Resumption of/Increased Regulatory Oversight

Based on these concerns, NAHC’s comments urge CMS to explore all options available to address the financial strains that providers are undergoing, including the following:

  • Examine trends relative to IHS Global’s forecasts to determine whether more recently available data than used for the final FY2023 rule would result in a higher market basket update and determine whether additional updates could be made during the course of FY2023 to provide additional support to hospice and other providers.
  • Direct various divisions of CMS to examine potential options for hospice regulatory relief, with a particular focus on policies that could help to address issues that contribute to the existing workforce crisis, including reductions in paperwork and more appropriate utilization of various clinical personnel.
  • Engage stakeholders in discussions regarding current waivers and flexibilities related to the COVID-19 PHE, providers’ experience during the PHE relative to these waivers and flexibilities, and policy changes that might be advisable as a result of those experiences.

Updates on elements of the HQRP

While there were no proposed changes to the HQRP NAHC did submit some comments relative to elements of the program. The HOPE (Hospice Outcome and Patient Evaluation) tool is currently in beta testing which is expected to be completed later this year after which time CMS will complete its analysis. It is possible that CMS will include in next year’s proposed hospice rule the full implementation of the HOPE. Hospices and stakeholders such as EMR vendors are requesting CMS share more information about the HOPE prior to any future proposal for full implementation. NAHC also encouraged CMS to include race and ethnicity and SDOH in the HOPE and consider how the HOPE could be utilized as a tool to help hospices with health equity initiatives.

NAHC reiterated recommendations submitted previously urging CMS to develop codes or modifiers for telehealth visits in hospice and supports the recommendation by MedPAC that technology-based visits be reported on claims.

Advancing Health Equity

In this year’s proposed rule, CMS expanded on last year’s Request for Information (RFI) on health equity. This year, CMS sought feedback on four questions and a structural composite measure related to health equity. NAHC supports embedding the principles of health equity in the design, implementation, and operationalizing of policies and programs to improve health and reduce disparities for all people served by the Medicare program. In general, hospice readiness to develop and implement health equity initiatives varies greatly. Some hospices report that health equity concepts are new to their organization while others report collecting and analyzing data related to health equity for some time and using it as part of their performance improvement program. Consistent feedback from members indicates that there are hospices operating all along this spectrum and it is important for CMS to consider this variation as it looks to implement requirements and measures related to health equity. NAHC did explain in its comments that hospices are eager to implement health equity initiatives but have been impacted by the workforce shortage and other effects of the COVID-19 pandemic requiring a refocusing of priorities. Therefore, additional time and resources are necessary.

Social determinants of health (SDOH) and other data such as race and ethnicity need to be collected and analyzed for the advancement of health equity initiatives. However, our systems lack standardization for the collection, reporting and analysis of this data. NAHC encouraged CMS to expand its systems to allow for the submission of such data and for CMS to develop and share meaningful reports with this information for hospices that will help them move forward or expand.

NAHC’s comments support introducing a structural composite measure on health equity into the hospice quality reporting program. We believe such a measure is a good starting point for the HQRP and will help hospices learn what is expected and best practices. Dialogue with stakeholders about the development of a structural composite measure is necessary to ensure all components are included and the reporting of such a measure is meaningful while not being overly burdensome to hospice providers. We believe hospices must learn how to incorporate much of the health equity framework into their daily practice before data collection for a structural composite measure is considered. We provided feedback on each of the three domains CMS included as possible components of a structural measure and scoring of the domains. NAHC strongly recommended the utilization of a Technical Expert Panel (TEP) to consider the identification of appropriate measures and their implementation as was done with hospitals in the development of the “Hospital Commitment to Health Equity” measure. We also recommended that as the hospice measure is developed, data be gathered from hospices with feedback and learning opportunities provided to them before any public reporting is considered. NAHC emphasized that CMS should allow for adoption of health equity initiatives with hospices in a manner like that utilized with hospitals – slowly and over the course of years.

Finally, NAHC thanked CMS for its plans to utilize a TEP for the development and implementation of the Special Focus Program (SFP) that is part of the hospice survey reforms finalized last year. NAHC recommended that nomination opportunities to serve on the TEP be open to the public and that the proceedings of the TEP be as transparent as possible and include multidisciplinary and patient/caregiver perspective and that the TEP be charged with advising CMS on the details of implementation of the SFP, including the terms of selection, enforcement, and technical assistance criteria. Due to the complexity of the SFP and potential long-term impacts, this program should not be implemented until the TEP has completed its work in this area and has had the opportunity to consider SFP eligibility, use of other data for SFP eligibility, and SFP graduation.

Advancing Health Information Exchange

NAHC also took the opportunity to respond to the section of the rule highlighting the importance of interoperable health information exchange (HIE) across provider types and settings. NAHC staff reminded CMS that a major reason the majority of hospice and home health providers lack certified EHR technology is as a result of not being eligible for funding from the federal Meaningful Use EHR Incentive program created in 2009, a federal initiative that has provided billions of dollars over the last decade to hospitals, health systems, and physician practices to adopt and maintain Office of the National Coordinator for Health Information Technology (ONC)-certified health information technology (HIT). Not including hospices or other post-acute care (PAC) providers in that program has created an uneven playing field, one in which home-based care providers are further behind in their capacity to procure ONC-certified products which facilitate the kind of seamless interoperability CMS is seeking across the health care system. Special mention was made of how important it is for CMS to work with ONC and Congress to develop an analogous EHR/HIT incentive program for hospice and the PAC sector, particularly if they intend to make progress on their overarching goal to improve social determinant of health (SDOH) data collection and exchange. In order for SDOH information to be valuable, it will need to follow patients across care settings, making interoperability critically important. But merely providing the money to develop the data-sharing tools will not be sufficient to deliver on the health equity promise of more robust SDOH activity – CMS must also begin to articulate the specific expectations it has for providers related to the collection, storing, sharing, and use of SDOH data. In the absence of guidance, many providers are likely to create their own approaches to this work, which will hamper the ability to develop meaningful standards in the future that will help formalize CMS and ONC’s regulatory stance towards health care providers’ SDOH obligations and responsibilities.

NAHC Submits Comments on Proposed FY2023 Hospice Rule

Focus on Wage Index Cap, Payment Update, and Health Equity On Wednesday, March 30, 2022, the Centers for Medicare & Medicaid Services (CMS) issued Medicare Program; FY 2023 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements (https://www.federalregister.gov/public-inspection/2022-07030/medicare-program-fy-2023-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting), the proposed rule governing hospice payment and other policies for fiscal year (FY) 2023.  The rule…

NAHC to Congress: Time for a Big Permanent Investment in HCBS

NAHC and a group of likeminded organizations have written to leaders of Congress, urging them to make a large permanent investment in home and community-based services (HCBS). The American Rescue Plan Act funding allowed states to provide hazard pay to the direct care workforce and maintain access to vital HCBS that have enabled people with disabilities…

Palliative & Hospice Workforce Development Legislation Re-Introduced in the Senate

On Thursday, May 19th, US Senators Tammy Baldwin (D-WI) and Shelley Moore-Capito (R-WV) reintroduced the Palliative Care & Hospice Education and Training Act (PCHETA) (S.4260) (Bill text HERE; 1-pager HERE). Long a priority for NAHC and the broader end-of-life and serious illness care community, PCHETA would authorize funding for major investments to build, support, and…

Choose Home Care Act Picks Up Sponsors in Congress

  • Click Here to Urge Congress to support the Choose Home Care Act!

The Choose Home Care Act continues to build support in Congress with the recent addition of three new cosponsors in the House of Representatives. Reps. Lisa Blunt Rochester (D-DE), John Moolenaar (R-MI), and James McGovern (D-MA) have joined 33 of their colleagues in the House in supporting the legislation.

We thank the new sponsors of this legislation for their leadership on this issue.

The Choose Home Care Act seeks to provide an option to patients in where they receive their post-acute care upon discharge from a hospital within the Medicare program. If deemed a good fit by the hospital and home health agency for the Choose Home model, a patient could elect to continue their recovery at home with enhanced services and supports added onto the traditional home health benefit. The added services could include personal care services, meal delivery, and respite care, among several others.

The Choose Home Act is a top legislative priority for NAHC. In addition, other supporting organizations include AARP, the Partnership for Quality Home Health Healthcare (PQHH), LeadingAge, the National Council on Aging (NCOA), the Moving Health Home Coalition and others.

Imminent legislative activity is not expected as attention will shift towards reelection campaigns during the summer and early fall. In the meantime, NAHC will continue to build knowledge of the legislation on Capitol Hill, as well as add new supporters to optimize the Choose Home Care Act‘s chances of coming up for a vote.

NAHC encourages all members and home care professionals to urge their Senators and Representatives to support the bill. This can easily be done through the NAHC Legislative Action Center here.

New Home Care Workforce Action Alliance Aims to Solve Staffing Crisis

There is a massive workforce crisis in home care and personal care servics and a massive national effort will be needed to solve this crisis, said leading members of the Home Care Workforce Action Alliance during a web-based press conference on Wednesday.

The Home Care Workforce Action Alliance is a new organization devoted to attracting more people into home care and personal care services, as well as keeping them in the industry. To accomplish this task, members said, the industry must work together as it never has before.

“[Home care stakeholders] would include representatives of patients, the direct care professionals, congress, governors and state legislators, educators and many more,” said William Dombi, president of the National Association for Home Care & Hospice (NAHC). “We’ve all recognized this is a problem that needs to be addressed, but we all continue to work within our silos. By joining together, we can succeed.”

Among the issues to be tackled, said Dombi, are insufficient compensation, benefits, training, and career growth opportunities

In addition , the effort will require “reform on federal and state policies, reform regarding education, reform on worker supports, and an overall increase in the workforce,” added Dombi.

Some key facts about the crisis are:

  • Since March of 2020, providers have seen a 23% decrease in home care aides working for them, which led to a 28% increase in open shifts since before COVID. The pandemic has only made things worse, exposing the vulnerability of not only older individuals and people with disabilities, but also those who care for them.
  • Providers of in-home care report having to turn down 50% of those seeking care due to a lack of staffing.
  • Nearly half of all direct-care workers abandon the field each year.
  • This hard-working, yet underpaid home care workforce disproportionately comprises women and people of color.
  • The Build Back Better Plan currently being considered by lawmakers in Washington D.C. only skims the surface of America’s home care problem. The original goal of $400 billion in funding has been cut down to $150 billion which will not adequately address the current caregiving crisis.
  • The caregiving workforce needs to increase by 8.2 million jobs to accommodate future needs.

This problem is only going to worsen if it is not addressed. By 2040 there will be 81 million people in the U.S. 65 years or older, compared to only 72 million under the age of 18. What’s more, people turning 65 today have a nearly 70 percent chance to require long-term care and support.

David Totaro, government affairs director at Bayada, and a member of the NAHC Board of Directors, said virtually all providers in Pennsylvania had to deny new cases during the last two years. Bayada is declining an all-time high of new cases, said Totaro. In September 2021, Bayada had to decline about 50 percent of new cases it received, but by the end of March 2022, the company declined almost two-thirds of new cases.

“When there isn’t enough supply to meet the demand, the nation’s most vulnerable population suffers,” Totaro during the press conference. “When this occurs consistently and frequently, most are forced to seek health care services from much more costly settings, such as nursing homes and hospitals.”

The Bureau of Labor Statistics predicts there will be almost 600,o00 home health and personal care aide job openings each year this decade. Vicki Hoak of the Home Care Association of America, also a leading member of the Home Care Workforce Action Alliance, said it is estimated there will be a shortage of 151,000 paid direct care workers by 2030, with that number to swell to an astounding 355,000 by 2040.

NAHC urges you to go to the Home Care Workforce Action Alliance website to learn more about this critical issue, how you can help, and share your home care story.