A report released from the Bipartisan Policy Center (BPC) identified barriers for Medicare beneficiaries trying to access home health services and makes recommendations on changes to the fee-for-service Medicare home health benefit. Researchers conducted a literature review, interviews with policy experts including LeadingAge staff, and a roundtable discussion with experts and stakeholders.

Specifically, LeadingAge shared concerns regarding the benefit’s current structure which incentivizes rehabilitative care geared toward functional improvement. For example, quality measures focus on functional improvements and payment decreases with the number of episodes, ultimately limiting access for individuals who may never improve or those needing more time and support to improve. We also shared that the backbone of many home and community based services, including home health, is unpaid family supports and the current home health benefit does not do enough to support individuals who have no natural supports. LeadingAge also cautioned against BPC’s recommendations to increase home health aide visits without also a corresponding increase in Medicare payments or a shift in payment methodology to make home health aide positions competitive. There is an undeniable direct care workforce crisis. LeadingAge has been at the forefront of promoting and professionalizing this workforce through the work of the LeadingAge LTSS Center. Continuing to shift the burden of care to the direct care workforce without thoughtful investments is not a long-term solution. One familiar recommendation of the report is updating conditions of participation to include standards for aide staffing, like ratios. During the webinar releasing this report, LeadingAge’s Senior Vice President of Public Policy & Advocacy, Ruth Katz, emphasized the realities of the current workforce crisis and the need for payment changes to adequately account for aide staffing.

The report did not examine whether Medicare Advantage enrollees face similar barriers and the report’s recommendations only address the coverage, quality, and availability of traditional Medicare home health. Far too often, LeadingAge hears from members that the reimbursement and coordination in Medicare Advantage fall short of fee-for-service and creates negative outcomes for beneficiaries.

BPC found four critical barriers:

• Inconsistent Medicare coverage determinations influence which beneficiaries home health agencies serve;
• Payment methodology and quality measures disincentives services for those with higher levels of need or without an expectation of functional improvement;
• Home health agencies overlook the importance of home health aides on recovery and health outcomes; and
• Beneficiaries and family caregivers are not appropriately educated about home health services and do not receive adequate support.

Despite the evidence-based benefits of home health care, BPC research underscored that fraud and abuse guardrails and the home health payment system have tempered the availability of appropriate home health services. Researchers also found beneficiaries from racial and ethnic minorities experience more adverse events, a greater decline in functional status, and worse experiences when receiving home health care.

The report makes recommendations in four areas:

Streamline Coverage and Eligibility Determination

• Establishing uniform reviews, training requirements for Medicare Administrative Contractors (MACs), monitoring outliers, and instituting penalties on MACs for unwarranted denials;
• Requiring MACs report on denials to identify access disparities; and
• Establishing baseline functional and cognitive impairments that indicate medical necessity like Medicaid HCBS criteria.

Adjust Quality and Payment Incentives

• Updating the prospective payment system to capture costs for chronic illness and cognitive deficits;
• Developing measures reflecting stabilization and rewarding outcomes when improvement is unlikely; and
• Developing measures to reduce racial and ethnic disparities.

Optimize Service Availability

• Creating toolkits for agencies to determine appropriate mix of services;
• Using existing claims data to track social determinates of health; and
• Updating conditions of participation to include standards for aide staffing, like ratios, and penalties for withholding services.

Improve Beneficiary Experience

• Education and outreach to certifying providers, beneficiaries and family caregivers;
• Establishing robust monitoring programs for beneficiary satisfaction; and
• Enforcing conditions of participation for family caregiver education.