Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

Overview: The Crisis in Medicare Home Health Coverage and Access to Care

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Today the Center for Medicare Advocacy launches a Ten-Part Series to examine and continue work to resolve the growing crisis in access to Medicare home health coverage and necessary care. We invite you to follow this Series and provide Medicare home health stories at https://www.medicareadvocacy.org/submit-your-home-health-access-story/

Medicare Home Health Crisis Series

  1. Overview – The Crisis in Medicare Home Health Coverage and Access to Care
  2. Medicare Home Health Coverage, Legally Defined
  3. Medicare Coverage Is Based On a Need For Skilled Care – Improvement Is Not Required
  4. Misleading and Inaccurate CMS Home Care Publications
  5. The Home Care Crisis: An Elder Justice Issue
  6. Beneficiary Protections Are Lacking In Home Health Provider Conditions Of Participation
  7. Barriers to Home Care Created by CMS Payment, Quality Measurement, and Fraud Investigation Systems
  8. Proposed CMS Systems Will Worsen the Home Care Crisis
  9. A Further Examination of the Home Care Crisis: Published Articles and Statistical Trends
  10. Strategic Plans to Address and Resolve the Medicare Home Care Crisis

Overview: The Crisis in Medicare Home Health Coverage and Access to Care (Part 1 in a Series)

Medicare beneficiaries with long-term and debilitating conditions are often unable to access Medicare-covered home health services for which they are eligible under the law. For too many people this means not being able to remain at home, doing so at the risk of their health and well-being, or being forced to move to an institution.

How Do Home Health Agencies Factor into the Crisis?

Home health agencies are discouraged by the Medicare payment system, quality reporting measures, and overzealous fraud investigations from providing care to people who need more services for longer periods of time and whose underlying conditions will not improve.  As a result, most Medicare-certified home health agencies will not provide care, or will provide only minimal care, to these particularly vulnerable individuals. For example:

A Medicare beneficiary with Multiple Sclerosis has an order from her doctor for Medicare-covered home health care. She contacts all Medicare certified home health agencies that serve her home region. She is told by each agency that they do not have the resources to serve her. Some agencies say they have the ability to offer her a drastically reduced amount of services, before they even assess her needs. She is left to accept what little services are offered to her by a limited number of agencies.

What is Causing the Crisis?

Home health agencies are extremely reluctant to serve people who have long term and debilitating conditions due to various disincentives, including Medicare payment and quality measures and fear of triggering fraud investigations. In fact, recent Medicare payment and quality regulations and policies discourage home health agencies from serving individuals with long-term and debilitating conditions – contrary to Medicare coverage law. For example:

  1. CMS refers to the Medicare home health benefit as an acute, short-term benefit. Although there is no legal duration of time limit for those who meet coverage criteria.
  2. Medicare’s Conditions of Participation do not require, or even encourage, home health agencies to actually care for Medicare beneficiaries.
  3. Medicare’s Conditions of Participation do not protect Medicare beneficiaries from arbitrary discharge by a home health agency.
  4. The Prospective Payment System (PPS), which pays home health agencies to provide services to Medicare patients, was intended to pay for all types of beneficiaries’ home health care needs. But, agencies find it more lucrative to only serve those with short-term, acute care needs.
  5. Relatively recent Home Health Value Based Purchasing (HHVBP) regulations provide payment incentives based on quality measures that require beneficiaries’ conditions to improve. Improvement means greater pay. Lack of improvement means a reduction in payment.
  6. The CMS Star rating system, developed to promote “quality” home health agencies, is predicated upon improvement in a beneficiary’s condition. If a beneficiary does not improve, and many patients with long-term and debilitating conditions will not, the quality rating of the agency will decline.

What Should Be Done to Alleviate the Crisis?

  1. All CMS and Social Security Administration home health materials should be reviewed and updated to accurately reflect Medicare coverage law. (See attached re concerns about the March 2017 Medicare Home Health Booklet.)
  2. Medicare’s home health Conditions of Participation must be changed to protect access to home health coverage for all Medicare’s beneficiaries.
  3. The Conditions of Participation must require Medicare-certified agencies to serve all Medicare patients and to discharge Medicare patients only for specified reasons.
  4. Medicare-certified agencies must be required to have adequate staffing to provide all Medicare covered services
  5. Medicare’s payment systems and quality incentive programs must not discriminate against patients who will not improve, but who require Medicare-covered home care to maintain their conditions or slow decline.
  6. Medicare’s fraud investigations must not be based on the duration of home health coverage when services are reasonable and necessary.  Further, CMS ought to investigate home health agencies that under serve Medicare patients.

Change is Needed

People who advocate and care for Medicare beneficiaries can join with the Center for Medicare Advocacy to help correct this crisis. Go to MedicareAdvocacy.org for more information. Tell your story at https://www.medicareadvocacy.org/submit-your-home-health-access-story/.