Biden Budget Impacts Medicare and Medicaid

by Kristin Rowan | Dec 25, 2024

From the NAHC Newsdesk,

March 12, 2024

On Monday, March 11th, President Biden released a $7.26 trillion proposed budget for fiscal year (FY) 2025, which begins October 1st, 2024. While the White House budget is simply a request and Congress has final say on government spending, it does provide a window into the president’s priorities and where his administration wants to direct its efforts going forward. Lawmakers have not yet finalized spending for the current fiscal year — which runs through Sept. 30 — and will need to begin negotiating funding legislation for FY2025 simultaneously with ongoing debates over current fiscal year appropriations.

The FY2025 budget requests more than $130.7 billion to fund the Department of Health and Human Services (HHS). In addition to this $130.7 billion of requested appropriations, HHS also projects spending over $1.7 trillion on mandatory programs, such as Medicare and Medicaid, that are not subject to the annual appropriations process. Notably, the budget also would extend the Medicare sequester cuts by one year until 2032 (they were previously extended through 2031 by The Infrastructure Investment and Jobs Act of 2021), which would provide savings of around $7.6 billion. The budget also proposes to increase contributions to the Medicare trust fund and extend its projected solvency by increasing taxes on earned and unearned income for those individuals with annual income over $400,000 from 3.8% to 5%.

Over the coming weeks members of the Executive Branch will be testifying before key committees in the House and Senate to provide additional detail around the recommendations put forth in the budget documents. As additional relevant detail is made available, it will be covered in “NAHC Report.”

Provisions of interest in the Budget include:

Medicare

Multiple Provider Types

Home Health

- Create a Permanent Medicare Home Health Value-Based Purchasing Program:
  The Home Health Value-Based Purchasing Model, which the CMS Innovation Center launched in 2016 and expanded nationwide in 2022, successfully improved the quality of home healthcare at lower cost without evidence of adverse risks. This proposal converts the expanded model into a permanent Medicare program, similar to value-based purchasing programs already in place for other Medicare providers. [Budget Neutral]

Hospice

- The Budget proposes to implement a new “value-based purchasing” (VBP) program for hospices (and many other provider sectors that do not already have a VBP program) starting in CY2027. No further details are provided about this VBP-for-hospice program, or the other sectors’ VBP programs, other than that they would be budget-neutral, and that CMS would consider granting “hardship exemptions” to certain providers. NAHC reminds members that just last week, CMMI decided to terminate the Value-Based Insurance Design (VBID) hospice “carve-in” demonstration at the end of CY2024 (the demo had been set to run through CY2030). Over the years, various policy stakeholders have floated different Medicare hospice benefit (MHB) payment reforms, and 2010’s Affordable Care Act legislation called on CMS to pilot test a VBP program for hospices, which it has not done to-date.

Medicaid

Mirroring previous year proposals, the budget includes $150 billion over 10 years to improve and expand Medicaid home and community-based services (HCBS).

- The budget also proposes to require that states report on the national Medicaid Adult and HCBS Quality Reporting measures. Notably, this budget proposal seeks legislative authority to mandate this reporting while CMS included a mandate for states to submit HCBS Quality Reporting in their 2023 proposed Medicaid Access rule.
- The Budget proposes to require a Medical Loss Ratio (MLR) for Medicaid and CHIP managed care organizations, with required remittances if plans do not meet the minimum standard. Current law allows, but does not require, states to impose a MLR on their health plans.
- Proposes to authorize CMS to negotiate supplemental drug rebates on behalf of interested States in order to leverage savings from pooled purchasing power. (5.18 billion savings) As discussed in the State of the Union address, President Biden’s budget includes a proposal to create a Federal option that provides health care coverage to low-income individuals in States that have not expanded Medicaid. As a corollary to this proposal, the budget includes incentives for states to retain existing Medicaid expansions not default to the Federal Option. The budget contains several proposals to strengthen and streamline services for dual eligible individuals including:
  - Aligning Medicare Savings Programs and Part D Low income Subsidy Eligibility Methodologies to make it easier for states and individuals to determine eligibility and enroll in both.
  - Extending the Qualified Medicare Beneficiary (QMB) certification period. Currently states can limit QMB eligibility to periods less than one year, whereas this proposal would establish a 12-month eligibility certification. Provide CMS with the authority to unify appeals processes for Medicare and Medicaid review for individuals enrolled in integrated managed care plans by waiving amount-in-controversy minimums and allowing benefits to continue while an appeal is pending.
  - Allow retroactive coverage of Medicare Part B premiums for QMB applicants.
- A proposal to allow CMS to issue partial deferrals and disallowances that target issues of noncompliance in managed care environments and to provide CMS with additional managed care enforcement options.

Department of Labor/Healthcare Workforce

- The President’s Budget proposes to establish a national, comprehensive paid family and medical leave program administered by the Social Security Administration to ensure all workers can take up to 12 weeks of leave to care for a seriously ill loved one. Further, the President continues to call on Congress to require employers to provide at least seven paid sick days per year to all workers, and to ensure that employers cannot penalize workers for taking time off to address the health needs of a family member.
- The Budget expands workforce training along with creating career pathways to in-demand jobs through an $8 billion mandatory Career Training Fund.
- Broadens Access to Registered Apprenticeships: The Budget increases support for Registered Apprenticeships, a training tool for future workforces in a number of in-demand industries, including health care.
  - The proposal seeks to invest $70 million in the Strengthening Community college training program, which builds community colleges’ capacity to design and deliver high-quality, evidence-based training programs.
  - Invests in Caregivers Support Programs through the VA. Recognizing the critical role family caregivers play in supporting the health and wellness of veterans, the Budget provides critical funding for the Program of General Caregivers Support Services. The Budget also specifically provides $2.9 billion for the Program of Comprehensive Assistance for Family Caregivers, which includes stipend payments and support services to help empower family caregivers of eligible veterans.
  - Nursing Workforce Development — The FY 2025 budget includes $320 million for Nursing Workforce Programs, an increase of $20 million above FY 2023. The budget includes an additional $10 million to address national nursing needs, train more nurses, and strengthen workforce capacity in education, practice, and retention. HRSA will support an increase in the number of nurses trained to provide prenatal care through investments in perinatal maternal healthcare in rural and underserved community settings to increase access and improve the quality of patient care. The investment also increases the number of nurse faculty and clinical preceptors which are critical to expanding nurse training and producing more new nurses.
  - The budget also includes an increase of $10 million for Advanced Nursing Education to bolster the maternal and perinatal workforce by supporting maternal health nurses available to provide specialized care. The program will continue to increase the number of qualified nurses in the primary care workforce, including nurse practitioners, clinical nurse specialists, and Sexual Assault Nurse Examiners.
  - Health Care Workforce Innovation Program — The FY 2025 budget invests $10 million for a new program to jumpstart strategies to grow the healthcare workforce and address healthcare workforce shortages across disciplines such as physicians, nursing, and behavioral health. This new program would invest in innovative approaches to accelerate the transformation of healthcare workforce training to support a modern, robust, and diverse workforce training pipeline.
- HRSA supports the health workforce through health professions scholarships and loan repayments in return for service in underserved and rural communities. The FY 2025 budget requests $16.3 billion for HRSA, which is $2.0 billion above FY 2023. This total includes $8.3 billion in discretionary budget authority and $8.0 billion in mandatory funding and other sources.

Program Integrity and Oversight Efforts

The Budget includes a proposal to “Increase Private Equity and Real Estate Investment Trust Ownership Transparency in Long-Term Care Facilities.” This proposal continues the Administration’s aggressive oversight of Wall Street activity in health care and would require skilled nursing facilities with either of these ownership types, whether direct or indirect, to provide additional financial disclosures above and beyond other provider types.
The budget also includes a proposal that would modify the requirement that owners with a five percent or greater direct or indirect ownership must be reported on the provider/supplier’s enrollment application, to require owners with any percentage-level of interest be reported.
HHS states that “top priorities that would require additional funding for CMS include:

Increasing Medicare fee-for-service medical review, including the possible adoption of artificial intelligence (AI) and natural language processing technologies;
Addressing vulnerabilities identified by the Vulnerability Collaboration Council, report recommendations from the Government Accountability Office (GAO) and HHS-OIG, and emerging issues;
Increasing nursing home enforcement (e.g., ownership reporting validation, reviewing Part D data of beneficiaries who reside in nursing facilities, and supporting DOJ in cases brought under the False Claims Act related to quality of care) and enforcement of home and community-based services (HCBS); and
Quickly addressing fraud scams, as needed, above current levels.”

HHS states that OIG’s “key focus areas” will include managed care, nursing homes, and home and community-based services.

Health Equity

Surveys and Certifications (Medicare and Medicaid)

Generally and across provider types, CMS indicates in many places in the budget documents that they are struggling with survey backlogs, primarily amongst state survey agencies (SSAs), and mostly as a result of both lingering COVID impacts and multi-year stagnant funding from Congress for Survey & Certification activities. CMS states that “With years of flat funding, the Survey and Certification program can no longer meet statutory frequency requirements or adequately guarantee the safety and quality of care for patients receiving care in CMS certified facilities.”
They also write that “CMS forecasts an increased number of complaint surveys pending and overdue for investigation across all provider types, including some immediate jeopardy complaints. The concern with the backlog is further confounded by the aforementioned increasing number of complaints being reported as well as surveyors finding more serious quality of care issues when conducting onsite surveys. These findings result in longer surveys and possible onsite revisit surveys. They also indicate a general worsening in the quality of services being provided to patients and residents.”
Specifically for the hospice program, CMS states that “CMS did not meet the FY 2020 – FY 2022 target of 98% [of hospices surveyed within the last 36-months, as required by law] due to the COVID-19 Public Health Emergency (PHE) and reprioritization of survey activities based on guidance published throughout the PHE.”
“While Accrediting Organizations have eliminated backlogs resultant from the PHE, SAs still face challenges. As SAs reduce the backlog, we anticipate meeting the target goal of hospice facilities surveyed within the required 36 months in the upcoming years.” CMS indicates that for FY2022, the most recent year with complete data, 87.1 percent of hospices were surveyed in the last 36 months.

“This is important data for NAHC’s advocacy around CMS’ flawed Special Focus Program (SFP) design and the CMS’ plan to launch the program at the end of 2024. Given that hospice surveys are such a critical component of the SFP algorithm, it is important that CMS use accurate and up-to-date survey data; however, the budget language here seems to indicate that CMS is not caught up on the hospice survey backlog and may not be able to ensure that all hospices have indeed been surveyed in the last 36 months for at the near future.”

NAHC Position

Biden Budget Impacts Medicare “This is important data for NAHC’s advocacy around CMS’ flawed Special Focus Program (SFP) design and the CMS’ plan to launch the program at the end of 2024. Given that hospice surveys are such a critical component of the SFP algorithm, it is important that CMS use accurate and up-to-date survey data; however, the budget language here seems to indicate that CMS is not caught up on the hospice survey backlog and may not be able to ensure that all hospices have indeed been surveyed in the last 36 months for at the near future.”

The budget requests $492 million for Survey and Certification, an increase of $85 million or 21 percent above FY 2023, to fund Medicare and Medicaid provider survey and certification activities. If funded at this level, CMS claims it would have sufficient resources to ensure states:

Complete approximately 85% of the recertification surveys for statutory facilities (up from the current 65% via FY2024 levels), survey projected complaints in all facility types at an Actual Harm, Immediate Jeopardy (IJ), and Non-IJ High levels, address a portion of the current complaint backlog, and a proportional recertification survey frequency rate for non-statutory facilities with a focus on those facility types with higher beneficiary risks.
CMS also states that at this level, Hospice and ESRD facilities will have funding to perform initial surveys on new providers wanting to enter the program to gain Medicare and/or Medicaid certification

Additionally, the budget proposes, effective in FY 2026, to shift the funding mechanism for nursing home surveys from discretionary to mandatory appropriation and to increase the amounts to a level necessary to achieve a 100 percent nursing home survey frequency, adjusted annually for inflation.

Administration for Community Living

Funding for aging and disability community-based organizations

The proposal includes $2.7 billion for ACL, which is an increase of $70 million on paper above FY 2023 amounts, but it effectively represents an approximately $112 million increase due to eliminating $42 million of earmarks in the accounting tables.
ACL requests an additional $10 million to expand their Direct Care Workforce Strategies Center and fund capacity-building grants to states to support building partnerships among state Medicaid, aging, disability, and workforce agencies; coordinating and leveraging programs and funding streams; and developing and testing strategies to attract, train and retain direct care professionals.
ACL also requests $1.1 billion for nutrition services, which is the largest part of the Older Americans Act and would be an increase of $83 million above FY 2023.

Health Resources and Services Administration

HRSA — $320M line item for Nursing Workforce Development (pg. 25):

Nursing Workforce Development &mndash; The FY 2025 budget includes $320 million for Nursing Workforce Programs, an increase of $20 million above FY 2023. The budget includes an additional $10 million to address national nursing needs, train more nurses, and strengthen workforce capacity in education, practice, and retention. HRSA will support an increase in the number of nurses trained to provide prenatal care through investments in perinatal maternal healthcare in rural and underserved community settings to increase access and improve the quality of patient care. The investment also increases the number of nurse faculty and clinical preceptors which are critical to expanding nurse training and producing more new nurses.
The budget also includes an increase of $10 million for Advanced Nursing Education to bolster the maternal and perinatal workforce by supporting maternal health nurses available to provide specialized care. The program will continue to increase the number of qualified nurses in the primary care workforce, including nurse practitioners, clinical nurse specialists, and Sexual Assault Nurse Examiners. (pg. 30)

HRSA — $10m line item for a Health Care Workforce Innovation Program (pg. 25)

Health Care Workforce Innovation Program – The FY 2025 budget invests $10 million for a new program to jumpstart strategies to grow the healthcare workforce and address healthcare workforce shortages across disciplines such as physicians, nursing, and behavioral health. This new program would invest in innovative approaches to accelerate the transformation of healthcare workforce training to support a modern, robust, and diverse workforce training pipeline.(pg. 30)

HRSA — $51m line item for Medical Student Education (pg. 25)

HRSA — “HRSA supports the health workforce through health professions scholarships and loan repayments in return for service in underserved and rural communities. The FY 2025 budget requests $16.3 billion for HRSA, which is $2.0 billion above FY 2023. This total includes $8.3 billion in discretionary budget authority and $8.0 billion in mandatory funding and other sources. (pg. 27)

Medicare Advantage Stock After Election

by Kristin Rowan | Dec 22, 2024

by Kristin Rowan, Editor

Will the Change in Leadership Usher in a Change in Reimbursement Rates?

As in any election year, we have been bombarded with promises, predictions, and pandering from senate and house hopefuls as well as presidential candidates from every party. Each of them found platform issues that resonated with their followers. In turn, they have accused their opponents of all manner of sin.

Now that the election has passed and the lame duck session of congress has begun, analysts have started looking to January and how election results may impact different industries. Analysts believe Trump, along with congressional Republicans, will aggressively push Medicare Advantage. One researcher predicts that traditional Medicare will “wither on the vine.”

Privatization

Opposition to our current health care and insurance system often advocate for a single-payer system that is seen in places like England and Canada. Naysayers refer to this as the “socialization” of medicine, referring to socialist and communist governments. Privatization, on the other hand, moves healthcare out of the hands of the government and into the hands of privately held, usually for-profit, health insurance companies. Medicare Advantage has quietly moved more than 50% of all Medicare eligible patients to a privatized system. Senior policy analyst at Paragon Health Institute, Joe Alabanese believes that the Trump administration and a republican Congress would be “more friendly” to the idea of privatized health care.

Insurer Stock Prices

Whether the stock prices just before and after election day are predictive of things to come remains to be seen. For now, the information before us is this:

- Between Nov 1 and Nov 7, Humana Inc. had the largest increase in stock prices at 10.7%
- UnitedHealth Group Inc. rose 5.1% in the same time period
- Both companies had greater stock increases than the average across S&P
- Elevance Health was in keeping with the rest of the S&P with an increase of 3.6%
- Molina Healthcare, Inc. and The Cigna Group dropped 0.2% and 0.4%, respectively

Analysts say the jumps are in keeping with expectations that Republican control in Congress and in the White House will be beneficial for Medicare Advantage

Final Thoughts

It’s no secret that The Rowan Report is not a fan of Medicare Advantage. Specifically, the sales tactics used on the elderly and infirmed are predatory and the denial rate is criminal. The more eligible patients sign up for Medicare Advantage the less they will receive the care they need. Further, the more Medicaid has to supplement the cost of Medicare Advantage, the more home care agencies will suffer. Nationally, the more CMS regulates payment rates, pre-authorizations, and denial rates by privatizing Medicaid, the worse off our entire healthcare system will be.

With the state and national associations, we will continue to advocate on behalf of care at home agencies and their patients. And we hope you will too, regardless of who is in office. We have support at the federal level and we will continue to fight the good fight.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Payer or Competitor

by Tim Rowan | Dec 21, 2024

by Tim Rowan, Editor Emeritus

UnitedHealth Making Home Health Visits

Payer or Competitor…that is the question. According to a report in the Wall Street Journal, and questioned by the insurance industry’s lobbying arm, AHIP, UnitedHealth Group has increased its revenue from the Medicare Trust Fund by $50 billion by “finding” additional health issues during home visits to its MA customers.

In a July 16 investor call, CEO Andrew Witty said UnitedHealth clinicians made more than 2.5 million home health visits to UnitedHealthcare MA members in 2023. Following these visits to more than 500,000 seniors, UnitedHealth upgraded over 300,000 of them to higher payment levels by uncovering health conditions the individual seniors did not know they had.

The WSJ investigation found that between 2018 and 2021, insurers received $50 billion for diagnoses they added to members’ charts. Many of these diagnoses were “questionable,” according to that investigation.

Questionable Visits

Though a UnitedHealth spokesperson called the analysis “inaccurate and biased,” former UnitedHealth employees told the Journal home visits are often used to add diagnoses. Clinicians say they use software during visits that offer suggestions as to what illnesses a patient might have.

CEO Witty maintained in the investor call that the practice is good for seniors. “UnitedHealth clinicians discovered more than 3 million gaps in care through home visits in 2023,” he reported, “and 75% of patients receive follow-up care in a clinic within 90 days of a home visit.”

He added that the United home visit program “helps patients live healthier lives and saves taxpayers money,” concluding. “…Medicare Advantage makes programs and results like this possible.”

The Journal concluded with the finding that few of these upgraded seniors are ever seen by a physician for their newly discovered health conditions.

# # #

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

CMS 80/20 Finalized Rule

by Kristin Rowan | Dec 17, 2024

by Kristin Rowan, Editor

The Centers for Medicare and Medicaid Services (CMS) has finalized the “Ensuring Access to Medicaid Services” rule, more commonly known as the 80/20 rule. The 80/20 finalized rule requires at least 80% of Medicaid payments for home care services goes to caregiver wages. No more than 20% can be spent on administrative or other overhead costs. The White House, citing a study by The Commonwealth Fund, says that higher wages for caregivers will reduce turnover. Facing massive workforce shortages, home health, hospice, and supportive care at home agencies have been struggling to recruit and retain an adequate number of caregivers. The higher wage will also increase the quality of care, according to the study.

Prior to the 80/20 rule, there was no law or rule requiring home care agencies to report how they were spending money from federal medical payments. The rule includes requirements for states to create advisory groups to consult on rates and compensation. This changes the current Medical Care Advisory Committee regulations by increasing the percent of beneficiaries on the committee from 10% to 25% over the next two year. The Home Care Association of America (HCAOA) and the National Association for Home Care & Hospice (NAHC) argued that the rule adds administrative requirements to home care agencies while simultaneously reducing the resources available to fund them. NAHC President Bill Dombi said, “We all agree that more needs to be done to support the direct care workforce; however, this policy will make things worse, not better.” NAHC suggests the policy will force some agencies to close and others will leave the Medicaid program altogether, causing patients to have even more problems accessing care.

Exceptions to the Rule

From the text of the final rule, CMS acknowledges additional comments that the minimum direct payment to caregivers in this rule will create hardships for some agencies. Across the country, there are substantial differences among waiver programs for HCBS that are not accounted for in the rule. There is some flexibility built into the rule to account for these factors, according to CMS. Some of the flexibilities include:

Excluding some costs from the calculation
Including clinical supervisors in the calculation
Allowing states to set a different minimum for small providers
Allowing states to develop their own criteria to qualify as a small provider
Allowing states to develop criteria to exempt some providers from the rule

Exemption from the minimum payment rule for all Indian Health Service and Tribal health programs

The final rule also changes the timeline for complying with the rule from four years after the date of publication to six.

Objections to the Rule

Other comments included the need to address various reasons for the workforce shortage. In addition to low wages, commenters cited the social valuation of direct care work, lack of governmental support for some workforce pipelines, and immigration policies as deterrents to recruitment. One suggested that CMS start looking at creative strategies for developing an atypical workforce.

There were several submitted comments stating the either HHS or CMS or both does not have the authority under the Affordable Care Act to make specific requirements for minimum payments, but only to ensure that each State is assessing payment regulations and ensuring payments are economical, efficient, and ensure quality of care. A specific section of the Affordable Care Act, section 2402(a)(1) requires the Secretary of the Department of Health and Human Services (HHS) to ensure states implement service systems to allocate resources. The provision does not give HHS the authority to dictate the terms of those service systems, only to ensure the states develop those systems. Not surprisingly, CMS disagreed with those comments.

Many people questioned the 80% as being unrealistic, too high, and not based on quality data. CMS cited data from several states, who have pass-through requirements of 80-95% for all rate increases. This is not a minimum payment from all Medicaid payments, only a requirement for a minimum pass-through to direct care workers of increases in rates. Two states, Minnesota and Illinois, currently have minimum payment requirements set at 72% and 77%, respectively. CMS used these two states as justification for the 80% rule, acknowledging that it is higher than both states while also acknowledging that they did not perform a state-by-state study of the impact the 80% rule will have. CMS states the rate was set higher than those states to “encourage further steps towards improving compensation for workers.” CMS believes that requiring HCB agencies to pay their direct care workers a higher percentage of Medicaid rates than any state currently does will somehow make those agencies want to voluntarily pay even more.

The 80/20 Rule and Technology

Technological advances in telehealth, remote patient monitoring, revenue cycle management, scheduling, employee benefits, assistive technology, EVVs, EMRs, CRMs, and other software solutions can and will lower overhead costs and increase efficiency in your agency. Paperwork automation can reduce the time spent on documentation by a significant percentage. Revenue Cycle Management software can reduce claim denials and decrease reimbursement payment cycles so you can get your money faster. They can also reduce the number of unpaid claims. Employee benefit and training software can reduce responsibilities for HR teams, lessen the requirements for clinical supervisors, and cut training time in half, getting your newly recruited caregivers out in the field faster. Scheduling and onboarding software can increase your intake capabilities. The advances in generative AI allow you to create robust reports almost instantly so you can see your agency’s strengths and weaknesses and create plans for improvement.

Some of these costs will be excluded from the calculations for the 80% rule. Now is the time to invest in technology for your agency. Not only will your agency be more efficient and more effective, but you will be able to care for more patients with the same staff you have now, and the software solutions are as close to cost-neutral as they will ever be. We have a list of technology solutions that we’ve recently discovered and will be writing about in the next few weeks. If you are in immediate need of a software solution, contact us directly for a consultation.

# # #

Is Medicare Advantage Killing Seniors?

by Tim Rowan | Dec 15, 2024

by Tim Rowan, Editor Emeritus

Is Medicare Advantage Killing Us?

Dr. Steve Landers has long been eloquent in his speaking and writing about the importance of Home Health over the years. Though I was already impressed, I gained a new level of respect this week. Simultaneously with his debut as CEO of the new Alliance, Dr. Landers released an article about a recent study on the impact of Medicare Advantage on Medicare beneficiaries.

It is an article that everyone in our healthcare sector should read.

In “Home Health Cuts and Barriers are Life and Death Issues for Medicare Beneficiaries,” Dr. Landers points readers toward a study conducted by Dr. Elan Gada of UnitedHealthcare’s Optum Group. The results are disturbing. That the findings were released by a Medicare Advantage company is surprising.

Yes, Virginia, Home Healthcare Really Does Save Lives

Landers cited the study’s primary finding. “Medicare Advantage beneficiaries in their plan who did not receive needed home health care after hospitalization were 42% more likely to die in the 30 days following a hospital stay than those who received the prescribed care.” If a drug proved to be as effective as post-discharge home healthcare in saving lives, Landers wrote, “it would dominate the news, restricting access would be considered immoral, and health officials would be pushing its adoption.”

Medicare Advantage Enrollees Go Without

There are a number of reasons a hospital discharged patient might not receive home healthcare, including system issues and patient refusal. However, Dr. Gada’s study also discovered that MA customers go without post-discharge home health at a higher rate than traditional Medicare beneficiaries. Traditional Medicare beneficiaries go without in-home care about 25% of the time. Medicare Advantage beneficiaries 38% of the time. Landers notes that this data is a few years old and that the denial rate for MA customers is likely higher today.

Stop the Killing

We know the life-saving impact of post-hospital home healthcare. The question becomes: how does our little corner of the U.S. healthcare system help regulators and payers to know it as well as we do? At this week’s inaugural conference of the National Alliance for Care at Home, at least three education sessions discussed Medicare Advantage. All three offered strategies for negotiating with insurance companies and surviving under their oppressive rate structures and their frequent care denials.

UnitedHealth Group Medicare Advantage Landers

These Are Bandages, Not Cures

In previous opinion pieces, I have quoted revelations in government lawsuits against MA divisions of insurance companies. These prove the program that was originally launched to extend the lifespan of the Medicare Trust Fund actually costs CMS 118 percent of what traditional Medicare costs. At the same time, insurance company reports to shareholders proudly point out that their MA division is their most profitable.

One of last week’s most read stories was the report from UnitedHealth Group on their astounding Q3 growth.

In the Long Run

Learning to cope with MA care denials and below-cost visit payments is fine for those focused on making next month’s payroll. An entirely different tactic is needed for those focused on the care needs of their elderly parents or who are approaching age 65 themselves. The question must be asked, “Why does Medicare Advantage exist?”

Medicare Advantage Lobbyists

AHIP is the insurance company lobby. It put extreme pressure on Congress in 2009 when the Affordable Care Act was being written. That pressure resulted in then-President Obama removing a core plank from his bill. Obama struck the public option healthcare insurance plan in order to win enough votes to get the bill to his desk.

More $ Makes More $

That lobbying effort continues today precisely because MA is so profitable. How does it bring in so much cash? One after another, all of the large insurance companies have been caught padding patient assessments, the very fraud Home Health is so often accused of. Their monthly checks are determined by how much care they predict their covered lives will need, and they exaggerate it. Later, when it comes time to treat these same customers, MA plans deny care that would have been covered by traditional Medicare. They book profits at both ends, and they gladly pay the minimal fines when the practice is exposed.

The Reality of Medicare Advantage Fraud

To make each covered life more profitable, MA plans have begun calling customers to offer “free” nurse visits. These are essentially re-assessments where the MA staffer is rewarded for “finding” additional illnesses. This is not theoretical. My brother was offered a $50 gift certificate to CVS if he would allow his wife’s MA plan representative to drop in and chat with her, to “make sure she was getting all the benefits she was entitled to.”

Dr. Steven Landers: Call for Advocacy

In his article and in his speeches this week, Dr. Landers made it quite clear what must be done. EVERY person whose livelihood depends on the Medicare Trust Fund must make their voice heard. Letters and phone calls to Congress, to the Senate, to CMS, and to the Secretary of Health and Human Services, telling them you do not want to happen to your community what happened in Maine. After years of negative profit margins, in a state where MA adoption is at two-thirds, Andwell Health Partners ceased business in a wide swath of the northern regions of the state. Andwell was the only Home Health provider there.

The combined advocacy strength of NAHC and NHPCO is not enough to tip the scales. Your input is crucial.

Here's How it Works:

Your letter explaining the damage coming from shrinking CMS reimbursement and MA care denials will be opened by a Congressional staffer.
The staffer will read only enough of your letter to see its topic and which side of that topic you are on.
No need to be lengthy or eloquent
Put your topic and your position in your first paragraph
The staffer will add a checkmark in the pro or con side of their Home Health ledger.
The Congressperson, Senator, HHS Secretary will see a one-page summary of the numbers.
When the numbers are small, the summary goes into a file
When the numbers are large, the elected or appointed official will pay attention
In rare cases, you may even get a phone call

UnitedHealth Group Advocacy Medicare Advantage

Dr. Landers, in His Own Words

The article Dr. Landers wrote detailing all of these includes wording suggestions for your message in your letter and/or call. For convenience, I have included one paragraph below,* but I urge you to spend three minutes reading the entire inspiring and frightening piece. In person, he explained all this in an emotional appeal. He said he cannot emphasize enough the importance of universal participation in our new organization’s advocacy effort. Based on what we have learned about post-hospital nursing care in the home, your letters and phone calls are a matter of life and death.

Excerpt

*To save lives and avoid unnecessary suffering, Medicare officials must reverse their plans to cut Traditional Medicare home health payments for 2025 and ensure payments are stable after adjusting for the dramatically increased healthcare labor cost inflation experienced over the past 5 years. Additionally, Medicare officials and lawmakers must study and address the possibility of the disproportionate administrative and financial barriers to home health in Medicare Advantage.

We are fortunate to have leaders in Congress like Senator Debbie Stabenow, Senator Susan Collins, Representative Terri Sewell, and Representative Adrian Smith who are working to champion a comprehensive bi-partisan legislative fix. Our leaders in Washington must act swiftly, before the end of the year, to save lives and avoid further destabilizing home health services for Medicare beneficiaries.

# # #

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com