‘A Deteriorating Industry’: What Home Health Provider Margins Actually Look Like

Home Health Care News / By Andrew Donlan
 
The Medicare Payment Advisory Commission (MedPAC) paints a rosy portrait of home health margins. But an analysis of cost reporting data – that considers both traditional Medicare and Medicare Advantage (MA) payments – shows that providers are generally not sitting atop a hill of money. Instead, they are struggling to stay above water. 
 
Kalon Mitchell sold his company to the post-acute technology organization WellSky in 2018. He then worked for WellSky for five more years, learning the ins and outs of the home health industry in the meantime. 
 
After leaving WellSky, and with some more time on his hands, Mitchell decided to start “Project Sword”, which leverages cost reporting data to analyze the financial position of home health providers at large. 
 
The data shows not an industry enjoying close to 20% margins, but instead one that is in a deeply precarious position moving forward. 
 
The Centers for Medicare & Medicaid Services (CMS) has proposed cuts to home health payments three years in a row. Though its last two final payment rules have not been as harsh as its proposals, they have still come with permanent cuts to payments. 
 
Providers have multiple gripes with these cuts. The first is over the payment methodology that CMS applies, which most providers and advocates strongly disagree with. The second is the rising costs that home health agencies have recently faced. While CMS is cutting home health payment in traditional Medicare, the cost of providing services has skyrocketed – namely due to the cost of labor. 
 
But the final gripe is the one that has turned into a “generational battle” for providers, and that is MA penetration and payment. 
 
Over 50% of Medicare beneficiaries are now under an MA plan, and those plans generally pay far less for home health care than traditional Medicare. 
 
Providers have regularly told Home Health Care News that MA payment for home health services doesn’t cover the cost of delivering care. But providers tend to be mission driven, and also have referral relationships to uphold. Therefore, they continue to take on MA patients, which sinks their overall margins. 
 
Essentially, traditional Medicare subsidizes MA plans in home health care. It’s true that if providers only took traditional Medicare, they would likely enjoy healthy margins. On the other end, though, if they only took MA, they’d likely have inoperable businesses. 
While providers have shared these MA payment horror stories anecdotally, it’s been hard to get a good overall picture of what the average home health provider’s margin looks like of late – as both MA penetration and traditional Medicare rate cuts continue unabated…

Read Full Article

Opinion: Harris Wants Medicare to Cover Home Care. How Will She Pay for That?

Washington Post / By the Editorial Board
 
Too many American families know the struggle of caring for an aging parent who doesn’t want to leave their home but can no longer fully take care of themself. According to the Niskanen Center, more than 14 million Americans require long-term support services. That number is projected to grow to 24 million by 2030.
 
Government provision of home health-care services is spotty, and family members often take up the slack, a burden that can amount to a full-time job as a home health-care aid, in addition to existing work and family obligations. Many such caregivers probably took notice when, in a Tuesday appearance on ABC’s “The View,” Vice President Kamala Harris announced a new proposal to have Medicare pay for more home care services.
Unfortunately, her proposal is hazy on the details — exactly what it will cover and how much it will cost taxpayers — and it is these very details that have doomed other such efforts in the past.
 
Every time Washington has taken a shot at fixing this vexing problem of long-term care expenses — going all the way back to Medicare’s enactment — cost has proved to be the Achilles’ heel. In 1965, the year Medicare was enacted, “it was anticipated a long-term care benefit would be added in short order,” wrote political scientist Robert Saldin, who authored the Niskanen report. That expectation was frustrated by “tough economic realities.”
 
In 1988, Congress passed the Medicare Catastrophic Coverage Act but dropped an amendment that would have added long-term care coverage. And even the slimmed-down bill proved too much for voters: Seniors wanted protection against extreme medical expenses but were so angry about paying higher premiums that a pack of booing, screaming seniors chased then-House Ways and Means Committee Chair Dan Rostenkowski out of a town hall. Congress repealed most of the program after 17 months. Finally, in 2010, the Affordable Care Act included a long-term care program called the Class Act, but this program, too, lasted barely a year and a half. The Obama administration gave up on it in October 2011, after determining it could not be simultaneously self-sustaining, financially sound for 75 years and affordable to consumers.
 
In her appearance on “The View,” Ms. Harris gave an emotional speech about the burdens on caregivers that will resonate with anyone who has been through the experience of caring for an elderly loved one. For that matter, it could appeal to those who dread consigning an elderly loved one to a nursing home — most of which are already paid for by Medicaid. But while a winning proposal starts with empathy, it can’t be viable without a realistic plan for sufficient benefits, at an economically and politically sustainable cost.
 
And the outline that the campaign presented in a fact sheet Tuesday was vague on all of those crucial issues. Medicare would evaluate the home care needs of individual Medicare enrollees, the document suggested, then provide appropriate coverage for those with modest incomes, while seniors with higher incomes would share in the cost. That cost could be about $40 billion per year, according to a Brookings Institution estimate cited in the fact sheet. According to the campaign, the money will mostly come from the savings generated by negotiating lower drug prices for Medicare, as well as “implementing international tax reform so that we stop encouraging companies to shift jobs and profits overseas” and savings from sending fewer people to nursing homes.
 
We have our doubts. KFF, a nongovernmental organization that tracks health trends, reports that “in 2023, the median annual costs of care in the U.S. were $62,400 for full-time homemaker services … $68,640 for full-time home health aide care … and $288,288 for round-the-clock home health aide services.” Long-term care needs vary enormously, and any effort to “tailor” them, as the Harris proposal envisions, would likely involve trade-offs families would resist. Ms. Harris says she wants to expand the caregiver workforce (there’s a shortage now) and raise wages; both might be necessary, but both also push in the direction of higher costs.
 
Yes, there could be savings from less use of nursing homes, but subsidizing home care will push up demand for that as grateful families rush to get their seniors services they cannot currently afford and substitute subsidized professional care for the unpaid labor they’re now providing. That’s the point, after all: to help seniors live with more comfort and dignity, and to ease the burden on caregivers.
 
In a policy area where many other politicians have tried and failed to make progress, Ms. Harris deserves credit for restarting a necessary discussion. She would deserve even more credit if her plan were not itself a work in progress.

Trump Campaign Responds to Harris’ Medicare Home Care Proposal

McKnight’s Home Care – By Adam Healy
 
In response to Vice President Kamala Harris’ proposal to create a new Medicare benefit covering home care, Donald Trump’s presidential campaign outlined its own plans to support seniors aging in place.
 
“President Trump will prioritize home care benefits by shifting resources back to at-home senior care, overturning disincentives that lead to care worker shortages, and supporting unpaid family caregivers through tax credits and reduced red tape,” the campaign said yesterday in a statement.
 
The campaign drew a contrast to the home care policies implemented under President Joseph Biden’s administration. It claimed that, under the current administration, seniors have seen the largest increase in Medicare Part B premiums in history, and that many have been forced to delay retirement or spend emergency savings to make ends meet.
 Trump’s plan involves strengthening Medicare solvency, enhancing chronic disease management and long-term care services and expanding primary care policies that allow seniors to remain home as they age, according to a platform summary. The campaign also noted that, in 2020, Trump’s administration enacted changes to help Medicare Advantage beneficiaries access home modifications, respite care services, transportation and additional in-home support services. 
 
Steve Landers, MD, chief executive officer of the National Alliance for Care at Home, noted that both Trump’s and Harris’ proposals are only campaign promises — suggestions, rather than material policy changes. He said that, regardless of the candidate, what matters most is their support for home-based care providers and their patients.
 
“We’re here to work with any candidate and any policymaker in any party that is interested in advancing care at home,” Landers said Tuesday in an interview with McKnight’s Home Care Daily Pulse. “This is not a partisan issue for us; this is about our families and our communities and what type of care is available to them.”
 
Additionally, the Alliance said it supports neither the Democratic nor the Republican party. Instead, it supports the “care at home party,” which includes members of all political parties and leanings.

CMS Memo Hints at What Hospices Can Expect Under Special Focus Program

McKnight’s Home Care / By Adam Healy

Hospices subjected to Special Focus Program (SFP) scrutiny will undergo frequent surveys, and noncompliant providers may face termination from the Medicare program, according to the Centers for Medicare & Medicaid Services.

Under the SFP, hospices will receive surveys no less than every six months, and follow-ups may be needed, CMS said in a memo to state hospice survey agencies. Hospices that are found to have condition-level deficiencies will be required to complete appropriate  enforcement remedies, which include suspension of payment, civil money penalties, directed plans of correction, directed in-service training or termination, according to CMS’ state operations manual. 

Hospices that have completed two SFP surveys within 18 months, have zero uncorrected condition-level deficiencies and zero pending immediate jeopardy or condition-level complaints may graduate from the SFP, CMS said. However, any hospice that does not comply with all of CMS’ requirements within the necessary timeframes may be considered for termination. Both completion and termination will be certified by a letter from CMS, the agency noted.

CMS instructed state survey agencies to conduct complaint investigations and inform CMS of all medium- and low-level complaints that do not qualify as being an immediate jeopardy. Meanwhile, CMS will communicate to providers regarding their selection for SFP, process informal dispute resolutions and impose enforcement remedies. Additionally, CMS will process informal dispute resolutions for hospices in the SFP that contest findings of condition-level deficiencies.

CMS will choose 50 hospices during the fourth quarter of each calendar year to participate in the SFP. The first group will be selected in November, CMS said. After the SFP is completed, hospice programs will receive a recertification survey and begin a new standard 36-month survey cycle.

CMS enacted the SFP in its home health rule for 2024. At the time, CMS said the program was an attempt to monitor “poor performing” hospice providers. However, industry advocates warned that the SFP may unfairly target larger hospice organizations, which may be more likely to receive complaints due to their larger patient populations.