September 9, 2019
Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 8013
Baltimore, Maryland 21244-8013
Submitted electronically to: http://www.regulations.gov
Re: CMS-1711-P; Federal Register, Volume 84, No. 138 (July 18, 2019)
The Center for Medicare Advocacy (the Center) provides these comments about CMS-1711-P and the impact of the proposed rule on access to home health care for vulnerable older and disabled people.
The Center, founded in 1986, is a national, non-profit law organization that works to ensure fair access to Medicare and quality healthcare. The organization provides education, legal assistance, research and analysis on behalf of older people and people with disabilities, particularly those with long-term conditions. The Center’s policy positions are based on its experience assisting thousands of individuals and their families with Medicare coverage and appeal issues. Additionally, when necessary, the Center provides beneficiaries with individual and class action representation to address broad patterns and practices that inappropriately deny access to Medicare and necessary care. The Center also participated on the Technical Expert Panel to discuss issues related to this proposed rule and the impact of the Patient Driven Groupings Model (PDGM) which will serve as the new reimbursement mechanism for home health agency providers going into the next decade.
The new home health prospective payment system purports “to shift the focus from volume of services to a more patient-driven model that relies on patient characteristics.” (FR 34602). Unfortunately, the Center believes that services to beneficiaries who are most in need, people with complex, longer-term and chronic conditions who are already unable to access the care they need, will be faced with even greater barriers to care under PDGM. Simply put, PDGM is not guided by the needs of patients. It will exacerbate an existing crisis in access to home care for people most in need.
As the Center has stated previously, over recent decades, Medicare payment incentives, not patient needs, have driven the delivery of care as providers seek to maximize income. Thus PDGM, based on prior care delivery patterns, will not be aligned with actual patient needs. The data will not show what patients really need, only what was delivered as a result of past payment incentives.
Home health care agencies have been encouraged by Medicare payment and quality policies to serve patients who will provide the greatest profit margin, and whose conditions will improve, while stinting on care to “less profitable” patients, with longer-term and chronic conditions. The proposed rules would further exacerbate this problem, creating additional incentives to provide care to beneficiaries with short-term, improvement goals. As lead counsel in Jimmo v. Sebelius, the case that confirmed Medicare determinations should turn on the need for skilled care, not on an individual’s ability to improve, we continue to strenuously object to the PDGM. Given the imminent implementation of PDGM, however, the Center urges CMS to closely monitor the barriers to care that will quickly emerge in addition to the access problems that already limit care under the PPS.
The Center for Medicare Advocacy is concerned that proposed home health rules will further steer home health agencies away from providing care for beneficiaries who need it the most and toward beneficiaries with short-term post-acute care needs.
Based on our experience representing thousands of Medicare home health patients for over 30 years, the Center objects to the FY 2020 proposed rule and concludes the rule will harm beneficiaries, as summarized below:
- Beginning in 2020, payments to home health agencies under the new model will provide higher payments for individuals who are admitted to home care after an inpatient hospital or skilled nursing facility (SNF) stay and lower payments for those who start home health from the community – which will include hospital patients in Observation Status. This will likely diminish access to care for many beneficiaries and reduce the care provided to others.
- Fewer therapy visits will be provided to beneficiaries because therapy service utilization thresholds will be removed under the new payment model. More than 42% of for-profit home health agencies expect therapy to decrease by more than 10%.
- As in other care settings, therapy provided by therapist assistants will be coverable for home care beneficiaries who need maintenance therapy as well as for those who can improve. However, CMS should clarify that therapy for maintenance and improvement must be equally available as needed from qualified therapists, not just assistants.
- Eliminating split-percentage provider payments (partial payment at the beginning of a period of care, and remaining payment at the end), will push smaller home health agencies out of the market if, unlike large home health entities, they cannot afford to wait until after care is provided to receive payments. (Effective in 2021)
- Publicizing “value-based” payment statistics, when that data only includes patients who improve, will broadcast skewed, inaccurate information.
- The description of PDGM, is misleading and inaccurate. It is not, in any meaningful way, “shifting the focus from volume of services to a more patient-driven model that relies on patient characteristics”, as CMS has stated. CMS gives only token weighting to patient characteristics in PDGM. For example, an agency may receive as much as 60% higher payment for a beneficiary with an “early, institutional” admission to home care than for a beneficiary who avoided hospitalization, with a “late, community” admission to home care, regardless of services needed by either beneficiary. In another example, an agency may receive as much as 25% higher payment for a beneficiary admitted to home care from an institution than for a beneficiary admitted from the community, regardless of services needed by either beneficiary. Under PDGM, payment incentives are high for agencies to serve beneficiaries with short-term post-acute needs and not to serve beneficiaries with chronic long-term needs.
- The fixed dollar loss ratio that determines outlier case payments will be re-adjusted to maintain the 2.5% cap of all payments. Since 2010, outlier payments (for more significant levels of care) have been cut by more than a billion dollars. Most of the reductions have resulted in care not being provided for those who have significant needs.
- PDGM, the home health payment system for traditional Medicare beneficiaries will likely subsidize low Medicare Advantage (MA) plan payments since home health agencies often lose money when providing care to MA enrollees.
- Implementing prior authorization for home infusion therapy, or any home health service, would be a duplication of physician effort (who have already determined the care is reasonable and necessary), result in delay of care, and often lead to a prior denial for legitimate care.
- PDGM will worsen concerns regarding inequities in available care. Consideration of social determinants of health will be more meaningful when CMS develops a payment system that does not discriminate on the basis of illness or injury and when CMS does not allow agencies to cherry-pick beneficiaries based on inequitable policies.
As we have stated previously, for too long home health agencies have been able to limit access to care for certain beneficiaries and provide less care than is needed and ordered by patients’ physicians. The Center for Medicare Advocacy fears this situation will worsen under the proposed rules.
- Beneficiaries who were not recent inpatients and/or need more than 30 days of home health care will experience even greater problems accessing care than currently.
- Beneficiaries with longer-term and chronic conditions who are unlikely to improve will continue to experience a decline in the availability of Medicare home care services.
- Beneficiaries with hospital observation stays or emergency room visits will experience a decline in access to home health care, since PDGM treats them as admissions from the community and attaches lower reimbursement rates.
- Beneficiaries who need and qualify for Medicare-covered therapy will receive less therapy.
- Beneficiaries with severe functional impairments and comorbidities will have even greater problems accessing care, as agencies will not receive enough of a payment boost to provide this care.
- Access to home health aide care will continue its precipitous decline and home health aide services for beneficiaries who are not recent inpatients will all but disappear.
- Home health agencies will increase affiliations with companies that provide home health aide services on a private-pay basis.
- The number of not-for-profit home health agencies will further decline.
- Home health agencies will affiliate with inpatient health care institutions, and/or institutions will acquire home health agencies.
- Inpatient health care institutions will refer patients to affiliated home health agencies at a greater rate.
- Home health agencies will only hire sufficient staff to serve “profitable” Medicare beneficiaries – people with short-term and post-institutional care needs.
- Smaller, non-affiliated home health agencies will close or only take private-pay patients.
- Home health agencies will continue to report annualized profits of 16-20% although the budget neutral program update is much lower, while beneficiaries go without care or receive less than is ordered and needed.
While it may be impossible to prove how many people over the past decades have been denied access to the Medicare home health care for which they qualify under the law, it is not difficult to identify who those people are: Individuals with longer-term and chronic conditions who require skilled services to be able to maintain their conditions or slow decline. Most often, they also require and qualify for home health aides to help them get into and out of bed, change positions in bed, go to the bathroom, dress, eat, transfer, obtain catheter and colostomy care, and take certain medications. Such services enable many individuals to live independently in their own homes. While Medicare law covers this care, payment rules often preclude access in practice, because patients with longer-term and chronic conditions provide agencies with minimal profit margins, at best. The proposed rule will worsen this situation and lead to an even greater number of beneficiaries losing access to home care for which they qualify under the law.
Payment Models Determine What Care is Provided
Former and current Medicare home health payment systems, (Interim Perspective Payment System, IPS; 1997-1999 and Prospective Payment System, PPS; 2000-present), did not change the type of services patients need, but did change the type of services agencies were willing to provide. Responding, in part, to problems homebound patients faced in accessing therapy, IPS and PPS provided financial incentives to deliver more therapy services. While the past 20 years show agencies delivered more therapy services, the delivery of skilled nursing services and home health aide services plummeted. As reported in the 2018 MedPAC report, since 1997, the average number of visits per 60-day episode of home health care have changed as follows: Skilled nursing from 14.1 to 9.4 (down 33%); home health aides from 13.4 to 1.8 (down 87%); therapy from 3.8 to 7.5 (up 49%).
Payment policies drive what care home health agencies are willing to provide, and to which patients. Through the IPS and PPS payment policies, Medicare changed provider behavior and effectively turned the Medicare home health coverage into a short-term, acute care benefit, despite the law and Congressional intent to allow coverage so long as coverage criteria are met. The proposed PDGM rule continues this march toward making Medicare a short-term home health benefit, contrary to the law.
Significantly, in 1980 Congress repealed a 100 visit cap and prior hospital or SNF requirement for Medicare home health coverage. When Congress developed the IPS and the PPS in the 1997 Balanced Budget Act (BBA), it affirmed this Congressional intent, arranging for payment of longer term home care, thus making it clear that Medicare home health coverage is not intended to be just a short term benefit. Medicare law does not cap reasonable and necessary home care, except for a weekly limit of up to 28-35 hours a week of skilled nursing and home health aide, combined. The law has no duration of time limitation.
For decades, the Center assisted beneficiaries to remain in their homes with necessary, Medicare-covered care. These included individuals like our client Mrs. B., who had multiple sclerosis, lived alone, and needed some skilled nursing and therapy and home health aides. Today, payment policies have made it almost impossible for people like Mrs. B to obtain the care they need to stay home. In particular, the aides that helped her with key personal care is now rarely available through Medicare. Repeatedly, patients are told they can only receive an aide 1-3 times per week and usually only for bathing. Increasingly, patients are also told, however, that they can receive the personal care they need from a parallel, often affiliated, proprietary entity. This situation puts patients who stay at home nonetheless in jeopardy, and forces others into institutions. The lack of access to home health aides is driven by the current payment system that does not increase the episodic payment for providing aides. The proposed payment rule will continue and exacerbate this foolish model, which jeopardizes vulnerable patients and leads to the need for more expensive care.
The Proposed Rule Will Further Define and Limit Care
When IPS and PPS embraced the concept of a “bundled payment” for all services, the idea was that the payment “bundle” was statistically structured to balance the cost of providing care for less resource intense patients with higher resource intense patients. Thus, care would be provided for everyone who qualified. Such a balance did not occur. The last 20 years has shown that agencies largely adapted their businesses to serve the least resource-intense patients, retaining the full bundled payment, and refusing to serve higher resource-intense patients. For example, we recently spoke with a beneficiary, who was accepted by a home health agency for a weekly hour of physical therapy. The agency will be paid the Medicare bundled payment for services. In order to receive a second hour of physical therapy, however, the agency said she would have to private pay. That second hour of therapy should have been included in the Medicare episodic payment.
Home health care has become a highly profitable business. Ignoring proposals for a cap on industry profits, to return some of the average 16.4% annual margin provided over the past 20 years back to Medicare, CMS has allowed industry profits at the expense of the public, while the most vulnerable Medicare beneficiaries are denied care. While agencies have achieved an average marginal annual profit of 16.4%, program wide payment updates have been minimal – 2.1% is proposed for 2019 (FR 32370). Indeed, of all the health care sectors, home health posted the highest trading multiples for mergers and acquisitions in 2016. Purchase of agencies increased 8% in 2015, and “deal value” increased 121%. Every year a greater percentage of public funding goes to home industry profits and less to patient care. Instead of recognizing this as a major problem for Medicare, taxpayers, and patients, the proposed rule accelerates efforts that ignore Medicare coverage laws and further the process of turning Medicare home health coverage into a short-term post-acute care benefit.
The Rule Creates Incentives to Serve Post-Hospital and Short-Term Patients
The Center reiterates the comments it filed in 2017 regarding the proposed Home Health Groupings Model (HHGM). Regrettably, this proposed rule includes two additional, particularly significant payment incentives, that will drive agencies to provide care to people who have had recent inpatient stays and/or patients who only need short-term care. (See payment ratios, FR 32499-32500). While the HHGM includes much smaller payment influences based on functional need level, clinical grouping, and comorbidity group, these additional factors add disincentives to serve people who are most in need of care. If agencies are not required to serve all Medicare beneficiaries who qualify as a requirement to participate in Medicare, agencies will simply analyze the final rule to serve patients who help maximize profits. Since the vast majority of agencies are proprietary, they are compelled to do so. Services will focus on post-institutional home care for only a month. Patients who need care for more than a month and/or who avoid hospitalizations will have even less access to home care.
CMS and MedPAC analyses show a trend of increasing episodes of care that are not preceded by an inpatient stay and take this trend to be a “a significant potential for overuse.” Instead, policy-makers should recognize that planned changes in the delivery of care have resulted in less inpatient stays and more complex care being provided in outpatient status. People are being admitted as hospital inpatients less often as more and more procedures are performed on an outpatient basis. They need more home care, not less. Further, providing necessary care at home is often preferable for patients and less expensive for Medicare. In addition, CMS’s so-called “outpatient” observation policy categorizes an ever-increasing percent of hospital patients, who would have been considered inpatients in the past, as outpatients. These patients will be further harmed by the proposed payment rule, which will inevitably lead to home care providers preferring to serve people who have had prior inpatient hospital admissions. Yet these same patients need more access to home care than in the past since they cannot qualify for Medicare-covered nursing home care (which requires a prior three-day inpatient hospital stay).
Patients who are able to avoid inpatient stays, or who are categorized as outpatients, should not have their access to home care jeopardized by a lower payment ratio when their care needs are often the same or more intense than patients who have had prior inpatient admissions. The proposed rule’s explanation that, on average, more intense resources are needed post-inpatient is an erroneous rule-of-thumb that will harm many Medicare beneficiaries. The application of such non-patient-centered payment rules will overpay agencies to underserve too many beneficiaries, particularly those with longer-term and debilitating conditions
Home health agencies committed to serving people who need care for longer-term and chronic conditions are already penalized by payment disincentives, through models such as the PPS and HHVBP. They are also punished with lower quality ratings, since many of these patients are not able to improve and they face intimidating audits when they provide care for “too long”, even when patients continue to qualify for care. As a consequence, agencies are increasingly unwilling to provide care for beneficiaries with longer-term and chronic care needs. CMS should develop payment models and quality measures that encourage agencies to serve beneficiaries with the greatest health challenges, not penalize them. Regrettably, the proposed rule does the opposite, adding further disincentives to care for patients with serious illnesses and chronic conditions.
The 2018 home health proposed rule gave some consideration to a possible maintenance quality measure in the home health value based purchasing (HHVBP) model. 2019 and 2020 proposed rules do not include such a measure to judge how care is provided for people with longer-term and chronic conditions. This is particularly troubling since providers subject to HHVBP are being penalized, and soon by up to 8%, when they do not meet goals for improving patients’ conditions. This will create yet another disincentive to serve people who are not able to improve.
CMS Should Develop Rules With Equal Incentives to Provide Care for All Who Qualify Under the Law
The Center urges CMS to design payment and quality rules that effectuate Medicare coverage laws and encourage providers to serve all patients The proposed rule, is heavily weighted towards providing care for the short term is bound to further exacerbate home care access problems for individuals with longer-term and debilitating conditions. It will inevitably hamper implementation of the Jimmo Settlement, which seeks to open Medicare-coverage for skilled maintenance care, and will lead to discrimination against people with disabilities. CMS should rescind this rule and develop systems based on individual functional status and care needs so that providers are encouraged to serve all beneficiaries who qualify for coverage under the law.
Comments Regarding Specific Provisions
III.A.2. Overview and CY 2020 Implementation of the PDGM (FR 34605)
The Center disagrees that PDGM will better align payment with patient care needs. The application of PDGM will result in less patients receiving care. Providing a significant premium on timing and admission source to benefit patients with short-term, post-acute care needs will further reduce the ability of people living with long-term and chronic impairments to receive appropriate services. Further, patients who do receive care will be given less than they require and qualify for under the law. In addition, as developed by CMS, PDGM will further accelerate discriminatory service delivery practices by home health agencies.
III.F. 2. Outliers – Proposed Fixed Dollar Loss (FDL) Ratio for CY 2020 (FR 34636)
The Center understands that the FDL ratio must conform to the formula reached to achieve a 2.5% statutory cap on outliers in general, and 10% cap for each home health agency. The Center continues to believe this cap creates discriminatory access problems for high need patients with significant service requirements. Further, policies that trigger OIG audits, do not measure quality service for individuals with chronic impairments, and value based payments create major disincentives to provide adequate services to patients who need, and qualify under the law, for the greatest amount of care.
III.G. Proposed Changes to the Split-Percentage Payment Approach for HHAs in CY 2020 (FR 34636)
The Center requests that CMS take care when analyzing the impact of percentage payment splits on all agencies. Larger agencies may be able to survive waiting until all services have been provided before billing, but smaller agencies may not be able to survive the cash-flow difficulties. In geographic areas where there is already a shortage of agencies willing to serve patients, particularly those with longer-term and chronic impairments, this may prove devastating to access for beneficiaries. The number of home health agency closures, mergers and acquisitions over the past several years has resulted in access problems. Removing the split-percentage payments for agencies could exacerbate the problems.
III.H. Proposed Regulatory Change to Allow Therapist Assistants to Perform Maintenance Therapy (FR 34640)
As lead counsel in Jimmo v. Sebelius, the Center continues to seek equal coverage for beneficiaries who need safe and effective maintenance therapy to maintain their condition or slow decline. While each individual’s goals are unique, delivery of therapy services, whether to improve, maintain, or slow decline, are similar. If therapist assistants are allowed in the home health setting for someone who has goals to improve, they should be equally available for someone who has goals to maintain or slow decline of function. No difference should exist in the delivery of services.
CMS seeks feedback on whether the proposal to cover therapist assistants would require therapists to provide more frequent patient reassessment or maintenance program review when the services are being performed by a therapist assistant. The Center believes that what is true for improvement programs, regarding assessment of a therapist assistant, should also apply for maintenance programs. Again, while the goals of therapy differ for individuals who will improve and those whose conditions are not expected to improve, the therapy provided by a therapist or a therapist assistant is similar.
CMS seeks comments on whether maintenance therapy should be tracked separately or combined with improvement therapy. The Center respectfully requests that the codes be kept separate and distinct in order to track the dwindling delivery of maintenance services (or, possibly, identify an increase), CMS policies (quality measurement and value based purchasing) and OIG audits have created strong disincentives for home health agencies to serve individuals with ongoing maintenance needs. It is important to track access to services for people with maintenance needs in the future.
CMS seeks comments on possible effects on the quality of care that could result by allowing therapist assistants to perform maintenance therapy. CMS should create quality measurements that would allow the quality of such services to be determined. CMS should also recognize that home health agencies hesitate to provide maintenance services when there is no incentive, or benefit, for providing quality maintenance care. Given that the therapist and therapist assistant services are the similar for improvement and maintenance patients, and that only individual goals differ, it is expected that the oversight of therapist assistants by therapists will be equivalent, whether the patient is receiving services to improve, maintain, or slow decline.
IV. Proposed Provisions of the Home Health Value-Based Purchasing Model (FR 34641)
The Center continues to be concerned that the HHVBP Model does not provide any meaningful measurements for beneficiaries whose conditions are not improving. Without any maintenance measurements, under this model, providers are rewarded only for serving individuals whose conditions improve. This is a discriminatory model and must be revised to properly measure all individuals who qualify for services and to comply with the Jimmo settlement.
V. Proposed Updates to the Home Health Care Quality Reporting Program (HH QRP)
The concerns the Center has about the HH VBP Model also apply to the HH QRP. The Center urges CMS to adopt meaningful maintenance quality measures. Until that happens, home health agencies will not provide equal services to individuals whose conditions are not improving.
V.E.1. Proposed Transfer of Health Information to the Provider-Post-Acute Care (PAC) Measure (FR 34645)
Transfer of information across health care settings is important and makes sense for any patient, not just for those who are being discharged from a current post-acute care setting. The proposed rule discusses hospitals, SNFs and LTCHs. It is not clear from the proposed rule how, or even if, health information would be transferred to the home health agency for community admissions. Safety concerns noted in the proposed rule for individuals starting home health from institutional admissions also apply for community admissions, especially since hospital observation stays are considered “community” admissions. Reconciled medication lists should be implemented for all patients served by home health agencies, not just for those institutional admissions.
V.E.2. Proposed Transfer of Health Information to the Patient-Post-Acute Care (PAC) Measure (FR 34648)
The Center reiterates the concern that this proposed measure should also include community admissions and not only institutional admissions. Current reconciled medication lists are critical for all individuals admitted to home health care, whether from an institution or from the “community”.
Table 27 Future Measures, Measure Concepts, and Standardized Patient Assessment Data Elements (SPADES) Under Consideration for the HH QRP (FR 34651)
The Center encourages CMS to continue its stated conceptual development of functional improvement and maintenance outcomes measures. It is critical that CMS communicates to home health agencies that providing and measuring the quality of maintenance care is important.
V.G. Proposed Standardized Patient Assessment Data Reporting Beginning with the CY 2022 HH QRP (FR 34651)
Current patient assessment data does not accurately reflect the needs of patients, but rather it reflects the delivery of services by providers who chose the most profitable patients to serve over the past twenty years. CMS commonly refers to traditional Medicare as “fee-for-service” Medicare, but home health has not been fee-for-service since the prospective bundled payment system was implemented in 2000. Twenty years of choices by home health agencies to deliver the most profitable services has dramatically shifted the data to make it, if not meaningless, then certainly not an accurate representation of beneficiaries who have qualified for services under the law, but not allowed to receive services. Given the direction of PDGM, the data will reflect the incentives of PDGM: Provide less care for individuals with longer-term needs who qualify for care when they have managed to avoid a prior institutional stay.
V.J. Proposed Codification of the Home Health Quality Reporting Program Requirements (FR 34684)
The Center has concerns that the home health quality reporting requirements heavily favor improvement with no consideration of maintenance. Codification of the requirements will continue to show the inequities in the measurement of care and the lack of appropriate delivery of maintenance nursing and therapy.
VI. Medicare Coverage of Home Infusion Therapy Services (FR 34686)
The Center urges CMS to communicate more clearly with beneficiaries about which home infusion therapy services are included now, in 2020, and in 2021. There is significant confusion among beneficiaries about why some home infusion therapy is covered now and some is not. For example, we have been contacted by patients with ALS who are required to spend hours leaving the house daily for ten days in a row (then await subsequent ten day periods) to go to their doctor’s office for infusion therapy services. Having a full understanding of the impact of “temporary transitional payments”, medications that are included and why those medications were chosen, and other pertinent information about how CMS is managing this coverage, would be helpful to beneficiaries.
The Center urges CMS to place the interests of all Medicare beneficiaries at the heart of its payment and quality rules. How providers get paid and measured drives who gets access to care. Thus, these rules must carefully reflect Medicare coverage laws, and advance Congressional intent. The payment rules – past, present, future, and proposed for the future – fall short of this standard. We urge CMS to recall these payment rules while it considers the collective impact of all home health payment rules, quality measures, and conditions of participation requirements. New rules should be proposed that encourage access to home health care for all people who qualify under the law, for all services covered under the law. This includes consideration of how traditional Medicare home health payments are subsidizing Medicare Advantage payments to home health agencies.
We appreciate the opportunity to submit these comments on behalf of all those who have the legal right, and urgent need, to obtain Medicare-covered home health services.
Judith Stein, J.D.
Kathleen Holt, M.B.A, J.D.
For additional information, please contact Kathleen Holt, at Kholt@MedicareAdvocacy.org or Judith Stein at Jstein@MedicareAdvocacy.org, or at (860)456-7790.
 https://www.govinfo.gov/content/pkg/FR-2019-07-18/pdf/2019-14913.pdf, page 34602
 See PDGM, example from early admission (first 30 days) with post-institutional admission versus late admission with a community admission.
 https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2019.pdf, page 7
http://medpac.gov/docs/default-source/reports/mar19_medpac_entirereport_sec.pdf?sfvrsn=0 MedPAC, Report to the Congress: Medicare Payment Policy. March 2019. Chapter 9. 241-262. Rosarti, R. Russell, D. Peng, T. et.al. The Care Span Medicare Home Health Payment Reform May Jeopardize Access for Clinically Complex and Socially Vulnerable Patients. Health Affairs. June 2014; 952.
 MedPAC, Report to the Congress: Medicare Payment Policy. March 2018. Chapter 9. 241-262.
Rosarti, R. Russell, D. Peng, T. et.al. The Care Span Medicare Home Health Payment Reform May Jeopardize Access for Clinically Complex and Socially Vulnerable Patients. Health Affairs. June 2014; 952.
 MedPAC, Report to the Congress: Medicare Payment Policy. March 2018. Chapter 9. 241-262.
Rosarti, R. Russell, D. Peng, T. et.al. The Care Span Medicare Home Health Payment Reform May Jeopardize Access for Clinically Complex and Socially Vulnerable Patients. Health Affairs. June 2014; 952.
 Mullaney, T. Home Health Deals Commanded Impressive Valuations in 2016. Home Health Care News. January 2017.