September 26, 2023 At a September 19, 2023 hearing, held by the Subcommittee on Health Care of the Senate Finance Committee and entitled “Aging in Place: The Vital Role of Home Health and Access to Care,” Subcommittee Chair Senator Benjamin L. Cardin (D – MD) confirmed what the Center for Medicare Advocacy has described for many years: Home health care can be a long-term benefit for Medicare beneficiaries who need ongoing skilled care and aide services to remain safely at home. Chairman Cardin opened the hearing by describing home care as less costly and providing more dignity and better quality of life for beneficiaries than other long-term care options. He identified the lack of a coordinated national strategy and recognized workforce and reimbursement challenges. Ranking Minority Senator Steve Daines (R – MT) similarly described home care as a critical component of the Medicare program that is cost-effective and avoids unnecessary nursing home care. Center Founder and Executive Director Judith Stein, one of five witnesses, reiterated a basic message: “enforce the law that already exists.” She described the need for payment policies, oversight measures, audits, and quality measures to be aligned with the law’s criteria for coverage in order to ensure that Medicare covers medically necessary home health care for all beneficiaries who qualify. Stein reported calls to the Center from beneficiaries and families across the country describing denials of coverage for incorrect reasons. For example, coverage and care are denied on the grounds that Medicare covers only one to five hours per week of home health aide services (when the law provides up to 28-35 hours) or that coverage is only allowed when a patient can improve (contrary to the Jimmo Settlement’s recognition that maintenance nursing and therapy services are covered). Stein described federal policies and practices that have turned Medicare home health coverage into a short-term, acute care benefit, contrary to the law. For example: Audits that look at “over-utilization,” quality measures based on improvement, increased caps on outlier payments, and incentives in the Medicare home health reimbursement system (Patient Driven Groupings Model /PDGM) that favor patients with short-term, acute care needs, Senator Catherine Cortez-Masto (D – NV) asked if any of the witnesses disagreed with these statements. No one did. Two academic witnesses reiterated many of the Center’s concerns and testified that the home health benefit should be more fully implemented. Tracy M. Mroz, Department of Rehabilitation Medicine, University of Washington, testified that the full potential of the home health care benefit has not been realized, especially in rural communities. Challenges include resource and workforce constraints. The new reimbursement system, PDGM, “may result in decreases in rehabilitation services, fewer beneficiaries accessing home health via community-entry, and shorter stays,” although “the impact is not yet known” because PDGM was implemented just as the COVID-19 pandemic began. David C. Grabowski, Department of Health Care Policy, Harvard Medical School, described high Medicare margins for home health agencies – an average 16.4% from 2001-2019 and “an all-time high in 2021 of 24.9 percent.” Enrollees in Medicare Advantage plans obtain less home health care and often receive their care from lower-rated agencies. Grabowski observed that for-profit owned and multi-state chains, using complex ownership structures, “have expanded their ownership role in the home health sector over the past decade,” raising concerns about accountability and “whether these complex entities are putting sufficient dollars back into direct patient care.” Grabowski called for improved quality measures and more support for family caregivers. Two witnesses representing the home health care agency community opposed reimbursement cuts proposed by the Administration. Carrie Edwards, Director of Home Care Services at a non-profit hospital-based home health agency in rural Nebraska, reported that the new payment model and reductions in payment have resulted in a contraction of the service area her agency covers and an inability to retain their workforce, resulting in a denial of more than 50% of the referrals for service. She supported S.2137/H.R.5159, the Preserving Access to Home Health Act of 2023. William A. Dombi, President, National Association of Home Care & Hospice, stressed the deteriorating trajectory of the home health benefit, with spending levels the same as in 1997 and agencies rejecting 50% of referrals. He criticized the rate cuts proposed by the Centers for Medicare & Medicaid Services for 2024 and argued that financial margins in traditional Medicare are used to subsidize shortfalls in payments by Medicare Advantage plans. He called on Congress to pass S.2137/H.R.5159 and to require a comprehensive analysis of the reasons for the deteriorating home health benefit. Senators at the Hearing were attentive, prepared, and asked substantive questions. Importantly, Senator Cardin ended the hearing by observing that Medicare home health coverage can be a long-term care benefit.