Despite the growing demand for home health services, fraud and abuse guardrails often limit access to the Medicare benefit, a recent Bipartisan Policy Center (BPC) report suggests.
The report highlights BPC’s recommendations for the U.S. Centers for Medicare & Medicaid Services (CMS) on how to improve home health services for Medicare fee-for-service beneficiaries.
“Given the clear changing trends in our health care delivery system today, and the increasing demand for home-based care, there are opportunities to address the current Medicare home health program, which we think does create some inequities and barriers to those who need care in their home,” Bill Hoagland, senior vice president at BPC, said during a panel discussion on the new report on Thursday.
BPC is a Washington, DC-based think tank that is focused on presenting policy solutions in a number of key areas, including health care.
In 2019, Medicare spent almost $18 billion on home health services and served about 3 million fee-for-service beneficiaries.
Still, the Medicare home health benefit does not sufficiently address the needs of beneficiaries with multiple comorbidities or complex conditions. This is largely due to the fraud and abuse guardrails, according to the report.
“A history of fraud and abuse in the home health sector has been a key driver of policymaking decisions,” BPC wrote in the report. “The Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare payment policy, has regularly highlighted program integrity issues related to home health services. In response, Congress and the U.S. Department of Health and Human Services (HHS) have worked to curb overutilization of home health services, uncovering multimillion-dollar fraud schemes in the process.”
While the increased oversight helped to decrease inappropriate care, an uptick in audits and medical necessity denials also made it more difficult for Medicare beneficiaries with complex needs to receive care services, according to the report.
The updates that have been made to payment policies also play a role in limiting access to care. Specifically, CMS changed the home health payment methodology to move away from therapy-based thresholds.
“[Therapy-based thresholds] were really a major contributor to a lot of that fraud and abuse we saw in the former system,” Ruth Katz, senior vice president of public policy and advocacy at LeadingAge, said during the discussion. “You used to have agencies avoiding patients who didn’t need therapy visits, working hard to find reasons for more therapy visits, so they could bump up their payments. CMS also reduced the length of episodes by half, from 60 to 30 days, and reduced payment for subsequent home health periods. That meant people who needed more support for longer periods of time could be left high and dry.”
Katz also noted that the end of Requests for Anticipated Payment (RAPs) has also been tough on providers, especially not-for-profit agencies that are operating on thin or non-existent margins. These providers may be hesitant about taking on patients that have complex care needs, he said.
The report also found that the structure of the home health benefit has contributed to racial and ethnic disparities.
“Black Medicare beneficiaries and Hispanic Medicare beneficiaries more often experience [start of care] delays than their white counterparts,” Chanee Fabius, assistant professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, said. “We need to examine the reasons behind either refusal or denial, and what sort of information is communicated from hospitals and nursing homes to home health agencies.”
Being unable to access home health services places Medicare beneficiaries in untenable positions, according to Gretchen Jacobson, vice president of Medicare at the Commonwealth Fund.
“For most beneficiaries, the assistance from home health aides is often needed to make skilled care at home a real option,” she said during the panel discussion. “Without coverage of home health aides, beneficiaries either pay out of pocket for that care, which many beneficiaries cannot afford to do, or rely on unpaid caregivers – like spouses or their children – which many beneficiaries don’t have. Or, they are forced to receive care at a nursing home or other institution.”
BPC recommends that CMS streamline coverage and eligibility determinations and adjust quality and payment incentives.
Additionally, the organization recommends that CMS improve beneficiary and caregiver experience and optimize service availability, including establishing staffing standards.
“Standards can always be helpful, particularly if they’re flexible and recognize a variety of different scenarios and situations that they can help normalize and communicate with the expectation of service delivery for home health agencies,” Anne Tumlinson, CEO of ATI Advisory, said.