President Biden Appears to Tout Looming ‘80-20’ Home Care Rule in Campaign Speech

Home Health Care News / By Andrew Donlan
 
President Joe Biden made remarks on the care economy – including home care – in a speech Tuesday at Union Station in Washington, D.C.
 
“You know, take home care,” he said. “The cost of long-term care for aging loved ones and people with disabilities rose 40% in the last decade. Medicaid offers help, but it can’t meet the demand. You know, there are 700,000 seniors waiting in line — 700,000 waiting in line, and people with disabilities are stuck on Medicaid home care waiting lists for as long as 10 years if they survive to be qualified. It’s amazing. Think about it.”
 
Biden at first honed in on family caregivers, saying that “no one should choose between caring for a parent who’s raised them, a child who depends on them, or a paycheck that they need.”
 
Then, he pivoted to home- and community-based services (HCBS) workers, evoking the looming “80-20 rule,” which would force HCBS providers to direct 80% of reimbursement to care workers. 
 
That rule, which was proposed last year, has drawn heavy criticism from home care providers, who believe that the rule will hurt smaller providers and disproportionately affect providers based on which states they’re operating in. 
 
A final rule is expected some time this month, and it appears Biden’s administration will be moving forward with some version of the proposed rule. 
 
“In the coming weeks, we plan to release new rules to strengthen staffing standards in nursing homes, to get home care workers a bigger share of Medicaid payments,” Biden said.
 
The president also said that his administration would work to reduce waitlists for Medicaid HCBS. 
 
“Seniors and people with disabilities, we’re going to expand Medicaid home care services and reduce that 700,000-person backlog,” he continued. “That’ll mean more folks can live and work in their own communities with dignity and independence. More home care workers will start getting a better pay and benefits and dignity they deserve.”
 
Katie Smith Sloan, the president and CEO of the advocacy organization LeadingAge, highlighted some of the home care industry’s gripes with the Biden administration’s approach after Tuesday’s speech.
 
“For the first time in decades, our federal government is committed to meaningful action to ensure America’s older adults and families can receive quality care in nursing homes, and in their homes and communities,” Sloan said in a statement. “LeadingAge and our nonprofit, mission-driven aging services providers share the Biden Administration’s goal. Caregivers, as the president noted, are critical; without staff, as our nonprofit mission-driven members know, there is no care. Yet, unfortunately, the administration’s approach misses the mark.”
 
While the Biden administration may believe that better pay will lead to more workers, and thus more home access, advocates and providers disagree. 
 
“First, on the goal of ensuring more Medicaid dollars go to the home care workforce, via the proposed Medicaid Access Rule,” Sloan continued. “While well-intentioned, the ‘80-20’ provision … will likely reduce, rather than increase, older adults’ access to care and services.”
 
LeadingAge estimates that state rates for HCBS would need to increase by 45% – on average – for the 80-20 provision to be sustainable. Providers would need to cut their non-caregiver expenses by two-thirds otherwise. 
 
“We expect that the rule, if implemented as proposed, will lead to provider closures and exits from the sector,” Sloan said. 
 
LeadingAge urged the president and his administration to take a more “broad” and wide-ranging approach to senior care needs. 
 
“Imagine what we can do — imagine what we can do for America,” Biden said. “Look, folks, imagine a future with affordable childcare, home care, eldercare, paid leave.”

New Study Calls Home Health Star Ratings into Question

McKnight’s Home Care / By Adam Healy
 
A comparison of agency-reported functional measures and claims-based hospitalization measures raises doubts about the value of star ratings as a means of evaluating home health agency (HHA) quality.
 
The study, published Wednesday in JAMA Network Open, analyzed differences between claims-based and agency-reported outcomes for nearly 23 million patient episodes before and after the introduction of the star ratings system to compare changes over time. The researchers found that observed improvement in agency-reported functional measures had corresponding increases in hospitalization rates and less timely initiation of care. The data included claims-based hospitalization measures (both during the patient spell and 30 days after HHA discharge). Agency-reported functional measures included improvement in ambulation, bathing and bed transferring.
 
“The observed functional improvement was dampened by corresponding increases in more objective measures, such as hospitalizations and declines in timely initiation of care,” study authors Amanda C. Chen, Christina Xiang Fu, PhD, and David C. Grabowski, PhD, wrote. “This raises concern about how HHA-reported outcomes should be interpreted and used to assess quality.”
 
These discrepancies are not a surprise to home care providers. The Centers for Medicare & Medicaid Services uses Outcome and Assessment Information Set (OASIS) survey responses, an agency-reported measure, and medical claims data, to determine agencies’ star ratings. The OASIS portion is not objective, affirmed Mary Carr, vice president for home health regulatory policy at the National Association for Home Care & Hospice.
 
“The disparity in OASIS-based measures [versus] claims-based measures is not surprising,” she said in a statement to McKnight’s Home Care Daily Pulse. “Responses to the OASIS items for the functional measures can be very subjective and influenced by the accuracy of the assessor when completing the item.”
 
“And, as the author(s) noted, data does not capture more recent changes for HHAs, such as the Patient-Driven Groupings Model or nationwide expansion of the Home Health Value-Based Purchasing Model, which might contribute to changes in HHA behavior and performance,” she added. 
 
The study also found that the introduction of the star ratings was associated with sustained increases in the hospitalization rate and functional improvement measures for patients with Alzheimer’s disease, those who are dual-eligible, and those who are Black and Hispanic. 
 
A widening gap between self-reported and objective measures
 
CMS launched the 5-star rating system on Care Compare to provide summary information using the number of stars to denote quality. The system began with a quality of patient care star rating in July 2015 and added a patient satisfaction star rating in January 2016.
Since the introduction of quality of patient care star ratings, the differences between agencies’ self-reported measures of patient improvement and more objective measures has only widened, study co-author Amanda Chen told McKnight’s Home Care Daily Pulse.
“In the pre-period before the star ratings were introduced, we kind of see some of these trends,” she said. “But it’s really magnified after the star ratings were introduced.”
 
Agencies might be incentivized to inflate functional improvement scores on OASIS surveys to achieve higher scores, according to the researchers. 
 
“Once these star ratings were introduced, I think there was an incentive for home health agencies to prioritize perhaps, achieving high performance on some measures that allow them to have a higher star rating,” Chen said. “Particularly, we see these in terms of self-reported measures by the agencies. So again, it’s these OASIS-based measures. And so I think it’s a little bit easier to move the needle on measures that you’re reporting yourself as a home health agency versus something that is collected — what we’re calling a little bit more of these objective measures — like hospitalization rates.”
 
She added that these issues are not unique to home care. Other healthcare sectors that use self-reporting to inform quality measures, such as nursing homes, have also seen subjectivity influence results…
 
Read Full Article

CMS May Be Mulling Changes to the Hospice Benefit

Hospice News / By Jim Parker

The U.S. Centers for Medicare & Medicaid Services’ (CMS) 2025 proposed hospice rule contained requests for information (RFIs) that could signal changes in the agency’s thinking on key issues.

Through RFIs, CMS tries to take the pulse of providers’ positions on certain questions that could impact the Medicare Hospice Benefit. In its 2025 proposal, one key RFI includes queries on higher-acuity palliative services like dialysis, transfusions, radiation or chemotherapy, among others. A second RFI addressed social determinants of health.

The agency has voiced a concern that patients in need often do not receive these services.

“The national trends that examine hospice enrollment and service utilization for those beneficiary populations with complex palliative needs and potentially high-cost medical care needs reveal that there may be an underuse of the hospice benefit, despite the demonstrated potential to both improve quality of care and lower costs … ,” CMS indicated in the proposal. “We seek to strengthen the notion that in order to provide the highest level of care for hospice beneficiaries, we must provide ongoing focus to those services that enforce CMS’ definitions of hospice and palliative care and eliminate any barriers to accessing hospice care.”

Regarding this issue, CMS posed several questions:

• Should CMS consider defining palliative services, specifically regarding high-cost treatments?
• Note, CMS is not seeking a change to the definition of palliative care but rather should CMS consider defining palliative services with regard to high-cost treatments?
• Should there be documentation that all other palliative measures have been exhausted prior to billing for a payment for a higher-cost treatment? If so, would that continue to be a barrier for hospices?
• Should there be separate payments for different types of higher-cost palliative treatments or one standard payment for any higher-cost treatment that would exceed the per diem rate?

Read Full Article

CMS Finalizes ‘Fast-Track’ for Patient Appeals of MA Plan Home Health Denials

McKnight’s Home care / By Adam Healy
 
The Centers for Medicare & Medicaid Services finalized a rule Thursday that aims to expedite the process by which beneficiaries could appeal home health claims denied by Medicare Advantage plans.
 
Traditional Medicare utilizes a Quality Improvement Organization (QIO) to review fast-tracked appeals, whereas MA plans do not. Rather, the MA plan itself is responsible for reviewing appeals for denied services. In its new rule, CMS will require QIOs to also review MA appeals, which should make fast-track appeals more accessible to MA enrollees.

“CMS is revising regulations to require the QIO, instead of the Medicare Advantage plan, to review untimely fast-track appeals of a Medicare Advantage plan’s decision to terminate services in a skilled nursing facility, comprehensive outpatient rehabilitation facility or by a home health agency,” CMS stated. 
 
The rule would also “fully eliminate the provision requiring forfeiture of an enrollee’s right to appeal a termination of services from these providers when they leave the facility,” it said. These changes will more closely align MA regulations with traditional Medicare, expanding MA enrollees’ ability to take advantage of the fast-track appeals process, according to CMS.
 
The final rule will also update standards set for Supplemental Benefits for the Chronically Ill (SSBCI). New regulations hold that MA plans must be able to demonstrate that these benefits “meet the legal threshold of having a reasonable expectation of improving the health or overall function of chronically ill enrollees,” CMS said. To prove that the benefits meet all requirements, MA plans must compile databases of research to back up their claims that SSBCI can meet beneficiaries’ heath needs.
 
Finally, CMS’ rule updated MA marketing policies to protect customers from misleading advertising. Plans must now include disclaimers in all marketing materials that mention SSCBI to ensure enrollees are aware of the benefits they can access, encourage greater utilization of these benefits and “ensure MA plans are better stewards of the rebate dollars directed towards these benefits,” CMS said in the rule.