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Insufficient Medicare reimbursements may threaten patients’ access to home health, report suggests

Homecare Insider, December 8, 2014

Most HHAs and physicians report that access to home healthcare for Medicare beneficiaries is good; however, in a new report to Congress, some providers also pointed to insufficient reimbursement as a lingering barrier to serving this vulnerable patient population.
 
The Affordable Care Act (ACA) directs the Secretary of Health and Human Services to conduct a study on HHA costs associated with providing ongoing care access to beneficiaries who have low incomes or reside in underserved areas, as well as with treating beneficiaries with severe illnesses. 
 
To satisfy this ACA provision, researchers developed the recent report to Congress, entitled “Medicare Home Health Study: An Investigation on Access to Care and Payment for Vulnerable Patient Populations.”
 
For the report, researchers surveyed 1,075 Medicare-certified HHAs and 510 physicians to examine factors associated with potential care access issues. Of those surveyed, more than 80% of HHAs and 90% of physicians reported that access to home health services for Medicare beneficiaries in their local area was “excellent” or “good.”
 
When respondents reported access issues (i.e., their inability to place or admit Medicare patients into home health), the most common obstacle was that patients did not qualify for the Medicare home health benefit. Agencies and physicians also cited family or caregiver issues as an important contributing factor in the inability to admit or place patients. 
 
In addition, one of the biggest factors contributing to both physicians’ and agencies’ inability to admit or place patients in home health related to insufficient reimbursements. About 17.2% of HHAs and 16.7% of physicians reported this barrier.
 
The ability to admit referrals varied by provider type. In terms of ownership, more than 60% of proprietary HHAs reported being unable to admit more than 10% of referrals, while only around 40% of not-for-profit HHAs reported the same trouble. Provider-based HHAs were less likely than freestanding HHAs to be unable to admit more than 20% of referrals (21.6% vs. 33.2%).
 
Smaller HHAs (i.e., ones with 50 or fewer total referrals in the prior month) were twice as likely as larger HHAs to report being able to admit all referrals (30.8% vs. 14.3%). However, smaller HHAs were also more likely to report difficulties admitting more than 20% of referrals (36.9% vs. 17.8%).
 
The survey results suggest that much of the variation in access to Medicare home health services is associated with social and personal conditions, which may limit CMS’ ability to improve access for certain vulnerable patient populations through payment policy, the report states.
 
In addition to survey results, researchers analyzed administrative data to examine the relationship between patient characteristics and estimated financial margins because margin differences—particularly those associated with patient characteristics—indicate that financial incentives may exist in the HH PPS to provide home health services for certain types of patients over others.
 
According to the report, analysis of calendar year (CY) 2010 HHA payment and cost data suggests that margins may differ substantially across the HH PPS case-mix groups. For example, margins were estimated to be lower in CY 2010 for patients who required parenteral nutrition, had traumatic wounds or ulcers, or required substantial assistance in bathing. Given that these variables are already included in the HH PPS case-mix system, the results indicate that modifications to the case-mix system may be needed, the report states.
 
Based on the results of the report, CMS plans to further explore margin differences across patient characteristics and possible payment methodology changes using more current data.
 
To read the full report, click here.