In recent years, home health care has faced relentless cuts from the Centers for Medicare & Medicaid Services (CMS), and while this has hurt the industry, providers and advocates remain hopeful that there is light at the end of the tunnel.
Organizations such as the Partnership for Quality Home Healthcare (PQHH) and Hearts for Home Care have been a driving force in making home health care a “squeaky wheel,” and they hope it will catch the attention of lawmakers.
Home Healthcare News recently interviewed PQHH CEO Joan Cunningham and Hearts for Homecare President and Executive Director David Totaro, who also serves as Chief Government Relations Officer for Bayada Home Healthcare. During their conversation, Cunningham and Totaro shared their expectations for the upcoming proposed home health care rules.
Additionally, Cunningham explained why an election year is a good time to advance home care advocacy, and Totaro described past “wins” for home care advocacy.
Below is that conversation, edited for length and clarity.
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HHCN: What are your expectations for the proposed home health care payment rules, which are typically released in late June or early July?
Cunningham: Given CMS’s stance and previous rulemaking cycles, I expect the policy of making permanent cuts to the Medicare Home Health Program will continue. We are preparing for even larger permanent cuts. We don’t know exactly what CMS has planned for the temporary cuts, i.e., clawback cuts. We can be sure that CMS will at least identify new projected amounts for the temporary cuts. Late last year, the final rule said it planned for $3.4 billion in clawbacks at some point, and we will have an update on the temporary adjustments. That $3.4 billion is expected to increase.
Totaro: I think Joan summarized it very well. Nothing I’ve seen over the last six to nine months suggests a repeat of the same. I believe we will see further cuts and reversals because CMS has not changed the pricing model at all. That’s why my team and I have been advocating in Congress since this rule was announced last year. We still have a lot of work to do.
How have the cuts of the past few years affected the home health industry? What’s been damaged? What’s gotten worse?
Totaro: I think we can all agree that when cuts of this magnitude are made and there are indications that cuts are coming, it creates a planning scenario full of uncertainty for providers. This impacts investment. Investment is important for home care: investing in technology, investing in solving workforce shortages, developing programs for recruitment and retention, and even expanding into areas where access to care has not yet been realized. These are all supposed to be CMS goals as well, but these cuts actually work in the opposite direction. Make no mistake, this is impacting our rural and hard-to-reach urban areas. Many agencies are starting to evaluate whether they can even stay in business. I just saw data that showed that more than half of the agencies providing care are actually considering whether they can stay in business or if they have to cut services altogether.
Joan, Dave mentioned that he and his team have been in Congress since the rulemaking last year. What does the yearly schedule for home health advocacy look like?
Cunningham: What we do throughout the year is policy and advocacy. And I say policy because we’re always trying to come up with a policy response that would present proposed rules, ways to improve the payment model that we follow, through the legislative process or the regulatory process. And the other part of that is advocacy. Since 2020, we’ve been working through this PDGM payment model, and I think there was excitement across the industry and the home health community as we embarked on this. The promise was that it would be a more sophisticated coding system and payment system that would better match patient condition to payment. But since 2020, the cuts have accelerated and will continue to be cuts essentially through at least 2028 and probably beyond.
We’ve had to deal with mounting cuts. So one of the things we have to do all the time is make sure that policymakers understand these impacts very vividly. Another thing that’s really worth talking about and digging into is the fact that the Medicare home health program is shrinking at a time when the public not only prefers home care, but is clamoring for the expansion of home care. [One that] We are in a very tight financial position and the future is uncertain. I don’t see how that squares with the wants and needs of the general public. Demographics suggest we are seeing more home care, not less.
Dave, can you tell us more about that and the success of your advocacy efforts at Beyada over the years?
Totaro: I just want to add one thing to what Joan said. Our schedules are always busy, and there is no stop or pause in our advocacy work. It’s consistency that’s key. One thing we’ve learned in the last six to nine months is that our role as providers is to change the conversation from about costs and cuts to why or how these cuts will affect the lives of our constituents. We’ve heard in many of our meetings that you are very interested in knowing how the actions that you have taken or the actions that you will take will affect the lives of these people. That’s why we believe that you will never stop. You continue to bring people into the meetings who can make this issue human, not just data-driven.
To answer your other question, I am very happy to lead one of the strongest advocacy teams in the industry, Hearts for Home Care, which is a separate organization from Bayada Home Health Care, but a related social service organization. We were formed with the sole focus on advocacy. We started because we believe so strongly that advocacy works. I know it’s hard for many people today to believe that it’s worth the time and effort to actually talk to lawmakers, because we’ve seen what’s happening in Washington DC, or Harrisburg, Pennsylvania, or in almost every state capitol. I’ve said to many people, “We’re not going to have a bill today that would make the second Sunday in May a day to honor all mothers, but consistency certainly does work.”
For example, just last year [my team] We participated in 17 different advocacy efforts on Medicaid in the markets we support. Through our efforts, we raised over $325 million for home- and community-based investments by state legislatures. And we just recently completed a study to demonstrate consistent advocacy efforts and compare the results to states that were inconsistent in their efforts. We found that states that have consistently advocated have seen an average 23% increase in Medicaid rates every year since 2015. States that have not been consistent, for a variety of reasons, have seen an average reduction in Medicaid rates of about 7%. I could go on and on about our successes at the state and federal level, but let’s just say that Congress really saw home health as a solution during the COVID crisis, not a cost. And I think it’s because we all came together as one industry, powerfully and loudly.
Joan, when you talk about grassroots advocacy, what does that actually mean, and what do providers need to do to get involved in these efforts?
Cunningham: It’s very easy: just go to our website or the NAHC website and click a button to join.
What we’re trying to say is that there are thousands, tens of thousands of home health advocates across the country, many of whom work in home health organizations and home care organizations. If you’ve ever visited an agency like Bayada, you’ll see so many people who, despite having so many options as to where they can work in the healthcare field, choose to work in organizations that provide home care. One of the reasons for that is because they’ve experienced it first-hand and seen the benefits and how valuable it is to the people who receive home care. They’ve never looked back and they’ve never left the field. So we have a passionate workforce.
We also have what I call the grassroots, senior leaders of home care organizations who have very strong relationships with local policymakers, including people like Dave Totaro and senior leaders of Veyada and all the home care organizations across the country, and we’re really relying on them to make a personal commitment to get our message out to senior policymakers on Capitol Hill and in state capitals across the country.
What is the most important thing providers can do?
Cunningham: Whatever you have already done, call, email, visit, do it again. Because repetition is key in advocacy. One person making one call or one email is not enough. It has to be done over and over and over again to have the needed impact. Home health is not competing with all the other medical disciplines that want policy and law changes. We are competing with transportation, environment, taxes, housing, every other stakeholder. We need to keep our message at the forefront with lawmakers and policymakers, not just once. We need to be repetitive, sustained, and consistent over a period of time. Otherwise, our voices will be drowned out by other voices. Volume matters, and the number of voices matters. That is why we need to do 50% more of what we have done so far. If every advocate does that, we will see a pretty significant change and increase in our advocacy efforts.
What is your ultimate goal for your advocacy efforts this year? What can you realistically accomplish with your advocacy efforts this year to put home health care providers in a better position by the end of the year?
Totaro: Our ultimate goal this year is to stop these cuts, regardless of current or future clawbacks. We have introduced legislation in Congress sponsored by Senators Stabenow and Collins, and Representatives Sewell and Smith, who are long-time and respected advocates for home health care, and it is our goal to pass this bill this year.
Joan, we spoke last month and you said that this is a good thing because it’s an election year and it allows lawmakers to be in closer contact with their constituents.
Cunningham: “Any time it’s an election year, I think Congress is keenly aware of the fact that they’re up for reelection. We’re going to use that to our advantage. This year we’re going to make sure that the squeaky wheels of home health are greased, that we put policies in place that are supported, and that we remove any obstacles that are in our way. We see election years as opportunities.
