By Judith Graham
FEBRUARY 3, 2020
The
decision came out of the blue. “Your husband isn’t going to get any better, so
we can’t continue services,” an occupational therapist told Deloise “Del”
Holloway in early November. “Medicare isn’t going to pay for it.”
The
therapist handed Del a notice explaining why the home health agency she
represented was terminating care within 48 hours. “All teaching complete,” it
concluded. “No further hands on skilled care. Wife states she knows how to
perform exercises.”
That
came as a shock. In May 2017, at age 57, Anthony Holloway was diagnosed with
ALS (amyotrophic lateral sclerosis): The Frederick, Maryland, man can’t walk,
get out of bed or breathe on his own (he’s on a ventilator). He can’t use the
toilet, bathe or dress himself. Therapists had been helping Anthony maintain
his strength, to the extent possible, for two years.
“It’s
totally inhumane to do something like this,” Del said. “I can’t verbalize how
angry it makes you.”
Why the
abrupt termination? SpiriTrust Lutheran,
which provides senior services in Pennsylvania and Maryland, said it could not
comment on the situation because of privacy laws. “In every client situation
SpiriTrust Lutheran is committed to insuring the safety and well-being of the
individual,” wrote Crystal Hull, vice president of communications, in an email.
But its
decision comes as home health agencies across the country are grappling with a
significant change as of Jan. 1 in how Medicare pays for services.
(Managed-care-style Medicare Advantage plans have their own rules and are not
affected.)
Agencies
are responding aggressively, according to multiple interviews. They are cutting
physical, occupational and speech therapy for patients. They are firing
therapists. And they are suggesting that Medicare no longer covers certain
services and terminating services altogether for some longtime, severely ill
patients.
Altogether,
about 12,000 home care agencies (most of them for-profit) provided care to 3.4
million Medicare beneficiaries in 2017, the most recent year for which data is
available.
To qualify for services, a person must be
homebound and in need of intermittent skilled care (less than eight hours a
day) from nurses or therapists.
Previously,
Medicare’s home health rates reflected the amount of therapy delivered: More
visits meant higher payments. Now, therapy isn’t explicitly factored into
Medicare’s reimbursement system, known as the Patient-Driven Groupings Model (PDGM).
Instead,
payments are based on a patient’s underlying diagnosis, the presence of other
complicating medical conditions, the extent to which the patient is impaired,
whether he or she is referred for services after a hospitalization or a stay in
a rehabilitation center (payments are higher for people discharged from
institutions) and the timing of services (payments are higher for the first 30
days and lower thereafter).
Agencies
now have a stronger financial incentive to serve patients who need short-term
therapy after a stay in the hospital or a rehabilitation facility, said
Kathleen Holt, associate director of the Center for Medicare Advocacy. Also
attractive will be patients who need nursing care for complex conditions such
as post-surgical wounds.
At the
same time, there are fewer incentives to serve patients who need extensive
physical, occupational and speech therapy.
The new
system encourages a “holistic” assessment of patients’ needs, and there’s
convincing evidence that home health agencies sometimes provided too much
therapy under Medicare’s previous system, said Jason Falvey, a postdoctoral
research fellow in the geriatrics division at Yale School of Medicine. Between
2000 and 2016, Medicare home health therapy services soared 112%, according to
the most recent data published
by the Medicare Payment Advisory Commission.
But the
risk now is that too little therapy will be offered, Falvey said.
“We are
very concerned about that potential,” said Kara Gainer, director of regulatory
affairs for the American Physical Therapy Association.
Early
reports from the field substantiate reason for concern.
Last
fall, the National Association for Home Care and Hospice asked 1,500 agencies
how practices would change under PDGM. One-third said “categorically, across
the board, we’re going to reduce our therapy services,” said William Dombi, the
association’s president.
Dombi
said his group has advised agencies that these cuts “may not be a good move”
medically (patients might deteriorate without therapy and end up in the
emergency room or the hospital) or “from a business perspective.” (If more
patients end up worse off and going to emergency rooms or are hospitalized,
that will reflect poorly on agencies and may affect referrals.)
The
American Occupational Therapy Association is also surveying members. Based on
526 responses to date, occupational therapists and assistants are being laid
off, asked to decrease the number of visits to clients and directed to provide
services for less than 30 days, said Sharmila Sandhu, vice president of
regulatory affairs.
In an
email, a spokesman for the Centers for Medicare & Medicaid Services said
the federal agency is “monitoring the implementation of the PDGM, including
therapy service provision, at the national, regional, state, and agency level.”
(A similar system for skilled nursing facilities that provide rehabilitation
was implemented in October.)
“We do
not expect home health agencies to under-supply care or services; reduce the
number of visits in response to payment; or inappropriately discharge a patient
receiving Medicare home health services as these would be violations of
[Medicare] conditions of participation,” the spokesman wrote.
Yet
that appears to be happening.
Carrie
Madigan, an occupational therapist who worked for Kindred at Home in Omaha,
Nebraska, said she was laid off in November as the company — the largest U.S.
home health provider — cut therapy positions nationwide. Her agency lost four occupational
therapists and three physical therapists last year as it implemented layoffs
and cut back on therapy visits in anticipation of PDGM, she said.
A
company spokesperson wrote in an email that Kindred at Home doesn’t discuss
staffing decisions. The person maintained that its “focus always has been, and
will remain, on providing the right care at the right time for our patients.”
Several
large agencies said they had prepared extensively for PDGM. The Visiting Nurse
Service of New York has trained coaches to work with Medicare home health
patients and is bringing remote monitoring equipment into people’s homes to
track their progress, said Susan Northover, senior vice president of patient
care services. The agency provided home health services to more than 30,000
Medicare beneficiaries in and around New York City last year.
Under
PDGM, there are 432 ways of classifying patients. For each, the group is
recommending “the amount of time we think a patient should be receiving care,”
based on extensive analysis of historical data, Northover said. “I absolutely
see no change in how we will provide therapy going forward.”
Encompass
Health of Dallas serves about 45,000 home health patients in 33 states, most of
them covered by Medicare. It’s using an artificial intelligence tool to predict
what kind of services, and how many, patients will need. “We’ve been able to
eliminate some wasted visits” and become more efficient, said Bud Langham,
chief strategy and innovation officer.
Langham
said he was disturbed by reports he was hearing that “agencies are taking a
very draconian approach to PDGM.”
“That’s
dangerous, and it’s going to lead to worse outcomes,” he said.
In
Frederick, Maryland, the Holloways have struggled since SpiriTrust terminated
Anthony’s services Nov. 11. Four other agencies rejected Anthony as a patient.
Without help stretching his limbs and strengthening his core muscles, he’s in
more pain and has four new bedsores on his backside.
“He’s
developing scoliosis, and he’s slumping in his wheelchair,” Del said. “And he
can’t get comfortable at night. We spend hours trying to reposition him so he’s
able to sleep.”
Before
his services were cut off, Anthony had been getting three hours of physical
therapy, two hours of occupational therapy, one hour of speech therapy per
week, plus a visit every other week from a registered nurse.
In an email,
Hull of SpiriTrust wrote that “individualized plans of care are developed
specific to the needs of each client” and that “PDGM did not influence any
decision made specific to this particular client’s plan of care.”
Before
retiring in 2016 because of ill health, Anthony was chief of police for the
U.S. Bureau of Engraving and Printing. “It seems to me nobody cares about
what’s happening to me,” he told me. “It makes me feel terrible — awful, less
than human.”
Several
times, health care providers have suggested that Anthony move to a nursing
home, Del said.
“He’d
have to go to a ventilator facility, and there’s only one in my area, and
everyone in it was really old and drugged when I visited,” she said. “How can
he live in a place like that when he can’t use his arms or hands or operate a
call button?”
There
is a glimmer of hope. A few days before I spoke with the couple, a fifth home
care agency said it would initiate services: two hours each of physical and
occupational therapy, one hour of speech therapy and one hour for a home health
aide every week.
“I’m
relieved, but I also feel I’m walking on eggshells,” Del said, “since they can
terminate you at any time.”
Judith Graham: khn.navigatingaging@gmail.com, @judith_graham
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