October 30, 2020 – While the coronavirus pandemic has forced positive change elsewhere in the healthcare industry, Medicare home healthcare policies still have room to improve, a Commonwealth Fund study discovered.
As the healthcare industry has had to adapt to the coronavirus, certain modes of care have seen greater use than they did prior to the pandemic. The Medicare program has particularly relied upon and worked to enhance home healthcare for care delivery.
Medicare beneficiaries are eligible for home healthcare if they require at-home post-acute, skilled care following a hospital discharge or if they have long-term needs that keep them fairly restricted to the home.
Home healthcare includes skilled nursing care such as speech therapy or medical social services. Geographic location, perceived quality, and caregiver availability are all factors that patients consider when selecting home healthcare services.
However, Medicare home healthcare does not offer unlimited coverage. There are limits on the number of hours per day and per week that the program covers, which do not total a typical full-time job’s work week hours.
This may drive beneficiaries to coordinate with two providers, one through Medicare and the other through Medicaid, in order to cover the full scope of the patient’s needs. This can lead to poor quality of care for Medicare beneficiaries.
Home healthcare patients and skilled nursing facility patients have similar characteristics. In each case, they are more likely to be 65 years of age and older, female, and non-Hispanic White.
Racial disparities were clear in home health patient outcomes between minority patient populations and White patient populations. However, access to home health was not the reason for those disparities, as might be assumed. Rather, non-White beneficiaries actually were more likely to receive services.
Overall, home healthcare made up $40 billion of Medicare’s expenditures in fiscal year 2018, or 5.3 percent of all Medicare spending and almost one-third of all Medicare spending on post-acute care.
Of all Medicare dollars spent on care for those who fall in the first category of eligible beneficiaries in need of post-acute care, almost 50 percent goes toward skilled nursing facility care. About a third goes to home health and the remaining 20 percent is spent on long-term care hospitals and inpatient rehabilitation facilities.
“The large amount of federal funding directed to this benefit underscores the importance of efforts to ensure Medicare home health is both sustainable and cost-effective for the long term,” the researchers argued.
CMS and states have implemented a couple of different strategies in trying to reimburse for home healthcare services including a bundled payment model called the Patient-Driven Groupings Model, which is expected to raise rural provider payments by 3.4 percent.
States have also used value-based purchasing to reduce home healthcare spending and improve patient outcomes.
The coronavirus pandemic brought major changes to the healthcare industry.
In home health, the Coronavirus Aid, Relief, and Economic Security (CARES) Act made changes to home health services certification to make it more flexible, though the researchers noted that the changes could also lead to over-utilization and fraud.
Telehealth policies helped fuel the breakthrough in telehealth utilization in Medicare and throughout the healthcare industry.
However, the waivers did not have the same effect for home health.
“The ability for home health agencies to bill Medicare for telehealth remains limited, as only in-person visits can be reported on the claim,” the researchers found.
“Limiting the ability to bill for telehealth may reduce the potential for fraud and overbilling of Medicare. However, strengthening telehealth access could enable critical monitoring of patient status at a time when beneficiaries are not eager to have providers visit their homes. Overall, expanded telehealth billing authority could reduce unmet needs for home health users.”
Medicare Advantage has acquired a reputation for having lower home healthcare quality than its fee-for-service counterpart program. But greater flexibilities from CMS due to the coronavirus pandemic may help improve that reality.
In fact, it may already be having an effect: three major Medicare Advantage payers are focusing on home health and out-of-pocket healthcare costs in 2021.
The researchers saw opportunities to improve home health overall through several policy recommendations.
Policymakers should focus on expanding opportunities for home healthcare to occur. This could be made possible by integrating home healthcare, healthcare, and social care as well as building out the post-acute care benefit. Paying caregivers as they care for beneficiaries with coronavirus could also help improve and expand home healthcare.
The home healthcare workforce is lacking but a couple of policy changes could remedy this. By increasing pay to make the role more desirable and to acknowledge the risks of providing at home care during the pandemic.
Also, if a broader range of licenses could serve patients in the home that could naturally expand the scope of the home health workforce. For example, nurse practitioners can and physicians assistants can now certify patients for home healthcare, but they can do little in home health other than that.
Finally, data and regulatory oversight could be crucial to improving the quality of home healthcare in Medicare.
“The impact of COVID-19 on Medicare home health services is not fully understood. More research is needed on how COVID-19 affects home health use, particularly for populations experiencing disparities in accessing care,” the researchers concluded.