‘They Shot from the Hip’: Home Health Providers Sound Off on CMS

The COVID-19 virus has thrown a wrench into any home health care plans the U.S. Centers for Medicare & Medicaid Services (CMS) initially had for 2020.

Instead of mainly focusing on the launch of the Patient-Driven Groupings Model (PDGM) and other initiatives, the agency has had to make a slew of critical decisions in support of home health providers and their Medicare peers dealing with unprecedented circumstances.

For the most part, home health providers are generally pleased with how CMS has managed the public health crisis. But some still see major holes in the agency’s response. 

“I think CMS has done well. They’ve done a pretty good job on [coronavirus support] so far,” one executive from an Illinois-based home health agency told Home Health Care News. “They provided funding through the CARES Act. They loosened some of the [reporting] requirements. They opened up telehealth, which created a lot of access. If you look at it from the perspective of how quickly they had to do everything, I think they did a pretty good job.”

To gauge the industry’s evolving perception of CMS and its COVID-19 track record, HHCN recently surveyed more than 100 individuals who work in home health care, gathering feedback across four weeks in May. In addition to the survey, HHCN interviewed multiple industry executives from a variety of home health agencies, granting them anonymity for candid insights into their operations.

Overall, nearly 70% of the provider representatives who took part in the HHCN survey said CMS has been “somewhat supportive” during the COVID-19 crisis.

Over 17% of survey participants said CMS has been “very supportive,” while just 15% found the agency to be “not supportive at all” during the public health emergency. 

“They have responded like they do to environmental disasters,” another executive from a Maine-based home health agency told HHCN. “[But CMS hasn’t] fully understood the scope of home health services and the importance that technology and telehealth plays.”

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CMS action

Since March, CMS has taken several steps to aid home health agencies during the COVID-19 outbreak, some permanent and others temporary.

Those actions include broadening the definition of “homebound” to expand access to home health care and allowing certain non-physicians to certify the need for services. CMS has additionally provided flexibility around the Review Choice Demonstration (RCD), and reduced certain training and supervisory-visit requirements.

On top of all that, CMS has helped keep providers afloat by mitigating the coroanvirus’s impact on cash flow. Specifically, the agency distributed roughly $1.7 billion through its advanced and accelerated payment programs, while sending billions more to providers under the CARES Act Provider Relief Fund.

“The funding of providers through the CARES Act and other payments was crucial,” the Illinois executive said. “I think that was just fantastic and necessary for a lot of providers.” 

About one-third of the industry representatives who took part in HHCN’s survey said CMS’s cash-flow relief was most helpful to surviving COVID-19 disruption. 

Meanwhile, 27% of participants said granting non-physician certification was the agency’s single-most helpful action, with roughly 25% viewing the broadening of “homebound” as the biggest lifeline. 

During follow-up interviews, some industry insiders said they were grateful for the increased flexibility, but that the fast-paced nature in which CMS had to respond to the crisis left more room for errors or unintended consequences. 

“I think that CMS tried to respond quickly with the 1135 Waiver and all of its allowances, and I believe that CMS had great intentions with the accelerated payment option, which they later amended,” another executive from a Texas-based home health company told HHCN. “[But] I think they shot from the hip on the accelerated payments without thinking it fully through, which can cause mass chaos on the back end.”

After announcing an expansion to its accelerated and advanced payment programs on March 28, the agency changed course on April 26.

Doing more

CMS’s focus was pulled in different directions early on, as hospitals braced for an influx of sick patients and nursing homes dealt with an outsized portion of the U.S. COVID-19 death toll. Nursing homes remain in crisis mode across most of the country.

At the same time, a majority of home health agencies have lost revenue since mid-March, putting their near-term financial health in jeopardy. 

Some providers feel as if the home health industry’s woes have been backburned by CMS.

“I think that they have been very responsive to the needs in the hospital setting,” the Maine executive told HHCN. “I do not feel that they fully understand the complexity of the patients seen by home health and hospice providers.”

One issue, in particular, that providers have objected to is the granted flexibility that now allows hospitals and other eligible practitioners to conduct billable telehealth visits with patients in their homes. Despite that development, home health agencies themselves are still unable to collect reimbursement for telehealth visits. 

“I do believe there was so much more that CMS could have done to allow the home care industry to operate more efficiently and effectively,” the Texas executive said. “For example, allowing telehealth visits to be billable.”

Generally, executives interviewed by HHCN said they thought ongoing limitations around telehealth reimbursement reflected a disconnect between CMS and the home health world. 

“Allowing telehealth visits to be billable would be the first thing they should have done,” the executive from Texas continued. “It is great that they allowed telehealth visits to be made [in general], but it goes to show the tremendous misunderstanding that CMS has for agency relations. They basically were saying, ‘Take care of the patient, but we aren’t going to take care of you.’ They expected agencies to ensure that care was provided through telehealth, but they didn’t make those telehealth visits billable.”

That is one reason why home health agencies have struggled with financial losses during the last few months, the executive said. 

“It resulted in significant financial losses for agencies in the form of Low-Utilization Payment Adjustments (LUPAs),” the individual noted. “That is typical CMS. Expect more with less.”

A LUPA is an adjustment to a provider’s reimbursement that’s triggered if a certain total of in-person visits isn’t hit. More than 67% of home health agencies have seen their LUPA rates at least double amid the coronavirus, according to statistics from the National Association for Home Care & Hospice (NAHC). 

Moving forward

Home health providers are hopeful that CMS will continue making amendments to the status quo.

The top priority continues to be on the telehealth front. 

Nearly half of all HHCN survey respondents said telehealth reimbursement was the No. 1 thing they wanted out from CMS. About one-third of respondents said increasing home health reimbursement would be most beneficial to their agency. 

Some home health insiders feel that CMS has done the best it could given the circumstances.

“I think at this point, I feel CMS has done everything that they possibly can and then some,” the executive in Illinois said. “The only problem I had was what they were doing up until now. But since COVID, it’s all been positive.” 

On the other hand, some believe that the home health moves made by CMS during the coronavirus are still not enough. 

“It is my hope that CMS realizes the vital part that home care and hospice providers play in the health care continuum,” the Texas executive said. “I hope that through this public health emergency, our industry will no longer be looked at as an ‘afterthought’ of acute care, but as a partner in the continuum of care.”