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Untangling The History, Causes Behind The Precipitous Home Health Aide Utilization Drop
Home Health Care News | By Patrick Filbin
In the last home health proposed rule from the Centers for Medicare & Medicaid Services (CMS), the federal agency in charge of reimbursement rates sent out a request for information on home health aide utilization.
Specifically, the agency wondered why Medicare-covered home health aide visits and utilization had fallen off a cliff over the last few decades.
According to the Center for Medicare Advocacy, home health aide visits declined by 90% from 1998 to 2019.
Many people who work in and around home health were surprised by the CMS request, believing the agency itself was one of the main culprits. “When we saw that go into the proposed rule, we laughed out loud,” National Association for Home Care & Hospice (NAHC) President Bill Dombi told Home Health Care News.
Home health aide history
In 1987, Dombi took part in a class action lawsuit on behalf of NAHC and home care patients against the Medicare program. There were a whole host of issues within the lawsuit, Dombi recalled, but one of them had to do with the accessibility to home health aide services. The lawsuit was successful, and created a standard that ultimately found itself into the statute itself.
“Congress modified the law to pretty much codify the outcome of the lawsuit,” Dombi said. “It set a standard that an individual could qualify for 28 to 35 hours a week of home health aide services within the definition of part-time or intermittent care — which had been the part of the statute that I litigated around.”
At that point in time, home health aides services were the primary discipline of care that people were receiving for services — more than even nursing care.
Then, two things happened. In the Balanced Budget Act of 1997, Congress eliminated blood draws from the list of benefits that could qualify a person for the home health aide benefit. That dilution of the benefit was compounded by a major change in the reimbursement model for home health services — the Interim Payment System.
This system aimed to change the way Medicare paid for home health services. Instead of paying providers based on the costs they incurred, Medicare transitioned to a prospective payment system.
Under the IPS, Medicare made fixed payments to home health agencies based on the patient’s condition and the services needed rather than reimbursing them for the actual costs of care. This change was intended to control costs and improve efficiency in the Medicare home health benefit.
“It devastated home health agencies and home health services,” Dombi said. “Forty percent of home health agencies shut down within an 18-month period of time. The volume of patients served in the Medicare program went from 3.5 million to 2.1 million in that same 18-month period of time.”
Prior to the IPS, agencies received more reimbursement for the more services they provided. With IPS, agencies had a cap on what would be payable.
“That really chilled the providers’ willingness to take on patients that had high levels of home health aide services,” Dombi said. “Because it raised the level of payment, but you then hit against the cap. And when you hit the cap, you didn’t get the payment.”
When the Prospective Payment System (PPS) system was implemented in 2000, home health aide services were already dwindling.
The episode of payment for home health services is around $2,000 for 30 days worth of care. Adding 30 days of home health aide services — at an average of about four hours a day — would add between $3,000 to $4,000 to the cost of care, Dombi estimated.
“You can’t expect a home health agency to get paid $2,000 to deliver $5,000 to $6,000 worth of care,” he said. “As an existing care provider, they would last a nanosecond if they started doing that. So at the moment, it’s all reimbursement related.”
That brings the timeline to 2023 when CMS essentially asked, “Why are home health aide services so difficult to get for patients?”…
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Proposed Legislation Would Create Tax Credits for Family Caregivers
Hospice News | By Jim Parker
A bill to strengthen support for family caregivers is working its way through Congress. If enacted, it would create tax credits to help offset the financial burdens of caring for the seriously ill.
Two U.S. Senators recently reintroduced the Credit for Caring Act, first proposed in 2021. The bill would establish a tax credit up to $5,000 for eligible, working family caregivers. The sponsors of the Senate bill included Sens. Shelley Moore Capito (R-West Virginia) and Michael Bennet (D-Colorado). Meanwhile, U.S. Reps. Linda Sánchez (D-California) and Mike Carey (R-Ohio) introduced a similar bill in the House.
“As someone who helped care for both of my parents as they battled Alzheimer’s at the end of their lives, I understand the emotional and physical toll it can take on individuals and families,” Capito said in a statement. “The Credit for Caring Act is a great tool to help to ease the financial burden caregivers face and I am proud to join with my colleagues today in reintroducing this bill. By passing this bill, we can help caregivers focus more on their loved ones and less on how much it will cost them.”
The proposed tax credits would apply to incurred family caregiving expenses greater than $2,000.
The nation’s health care system is lacking in support for caregivers of the terminally ill, who are often left with a heavy financial and logistical burden. Without assistance or relief, these difficulties can impede access to hospice and other types of home-based care.
Research has shown that patients who are faced with end-of-life decisions may be less likely to choose hospice unless they have a network of friends or family who can serve as home caregivers. Even when a caregiver is present, that person may be elderly or ill themselves, or unable to be in the home around the clock due to work or other obligations.
The expense alone can be a struggle for the 48 million unpaid family caregivers in the United States.
Roughly three-quarters of them spend upwards of $7,200 annually for costs related to caring for loved ones, AARP reported. For many caregivers, this amounts to 26% of their income, according to AARP. These costs can include patient medical and non-medical needs or lost income due to missed work days. Around 30% of caregivers cover rent or mortgage payments for their loved ones, while 17% pay for medical costs, AARP indicated.
While the financial costs are measurable, the emotional and physical toll of caregiving is substantial but difficult to quantify. For most families, caregiving comes with an onslaught of constant stress, essentially living in “fight-or-flight mode,” according to Jessica Kim, co-founder of the care navigation and caregiver support company ianacare.
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How Beneficiaries Really Feel About Medicare Advantage vs Traditional Medicare
MedPage Today | By Cheryl Clark
Survey results released today contradict widely-held beliefs that Medicare Advantage enrollees are more satisfied because they receive better health services than those in traditional Medicare.
On the contrary, respondents in the two types of Medicare plans reported equal satisfaction, although more Medicare Advantage (MA) enrollees than traditional Medicare (TM) beneficiaries said their care was delayed because of the need for prior approval.
The reportopens in a new tab or window by The Commonwealth Fund analyzed responses from 3,280 Medicare beneficiaries between November 6, 2023, and January 4 in an effort to learn "What Do Medicare Beneficiaries Value About their Coverage?" Those surveyed gave their opinions on the ease of their access to benefits, care coordination, services, and satisfaction.
"Overall, the experiences seem to be similar for those in traditional Medicare versus Medicare Advantage, with some notable exceptions," Gretchen Jacobson, PhD, vice president of Commonwealth's Medicare program, told MedPage Today.
The comparison of beneficiary experiences in each model is important because roughly half, or 52% of 66 million eligible people, are now enrolled in MA plans, to which federal funds pay billions more than for TM care. In 2024, for example, MA plans are expected to receive $88 billionopens in a new tab or window more than what would have been spent if the same people were in TM.
Although there are efforts underway to contain that spending through new payment policiesopens in a new tab or window, MA enrollment is projected to continue rapid growth. So it's important that taxpayers understand what they're getting for all that extra money.
A perhaps surprising finding of the survey was MA enrollees' relatively low use of their "extra benefits," such as vision, hearing, and dental care, considering that plans aggressively market these benefits to encourage signups. Jacobson noted that Medicare pays the plans $1,915 a year per enrollee for these benefits, according to the 2023 annual reportopens in a new tab or window from the Medicare trust funds' trustees. These extras are not covered under TM…
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U.S. Opens UnitedHealth Antitrust Probe
The Wall Street Journal | By Anna Wilde Mathews and Dave Michaels
The Justice Department has launched an antitrust investigation into UnitedHealth, owner of the biggest U.S. health insurer, a leading manager of drug benefits and a sprawling network of doctor groups.
The investigators have in recent weeks been interviewing healthcare-industry representatives in sectors where UnitedHealth competes, including doctor groups, according to people with knowledge of the meetings.
During their interviews, investigators have asked about issues including certain relationships between the company’s UnitedHealthcare insurance unit and its Optum health-services arm, which owns physician groups, among other assets.
Investigators have asked about the possible effects of the company’s doctor-group acquisitions on rivals and consumers, the people said…
…The new Justice Department inquiry, reported earlier by the Examiner News, a news organization based in New York’s Hudson Valley, is partly examining Optum’s acquisitions of doctor groups and how the ownership of physician and health-plan units affects competition, according to the people with knowledge of the matter.
Investigators have asked whether UnitedHealthcare favored Optum-owned groups in its contracting practices, potentially squeezing rival physicians out of certain types of attractive payment arrangements.
Investigators have also explored whether Optum’s ownership of healthcare providers could present challenges to health insurers that are rivals to UnitedHealthcare.
In addition, the Justice Department officials are investigating Medicare billing issues, including the company’s practices around documenting patients’ illnesses.
Payments to Medicare plans go up if patients have more health conditions, so aggressive documentation practices by doctors and other healthcare providers can be lucrative for insurers such as UnitedHealthcare.
And investigators have asked whether and how the tie-up between UnitedHealthcare and Optum medical groups might affect its compliance with federal rules that cap how much a health-insurance company retains from the premiums it collects from customers…
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Communicating Bad News to Patients
Medscape Medical News | By Paolo Spriano
Communicating bad news to patients is one of the most stressful and challenging clinical tasks for any physician, regardless of his or her specialty. Delivering bad news to a patient or their close relative is demanding because the information provided during the dialogue can substantially alter the person's perspective on life. This task is more frequent for physicians caring for oncology patients and can also affect the physician's emotional state.
The manner in which bad news is communicated plays a significant role in the psychological burden on the patient, and various communication techniques and guidelines have been developed to enable physicians to perform this difficult task effectively.
Revealing bad news in person whenever possible, to address the emotional responses of patients or relatives, is part of the prevailing expert recommendations. However, it has been acknowledged that in certain situations, communicating bad news over the phone is more feasible.
Since the beginning of the COVID-19 pandemic, the disclosure of bad news over the phone has become a necessary substitute for in-person visits and an integral part of clinical practice worldwide. It remains to be clarified what the real psychological impact on patients and their closest relatives is when delivering bad news over the phone compared with delivering it in person.
Right and Wrong Ways
The most popular guideline for communicating bad news is SPIKES, a six-phase protocol with a special application for cancer patients. It is used in various countries (eg, the United States, France, and Germany) as a guide for this sensitive practice and for training in communication skills in this context…
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