Medicare Home Health Is Not a Short-Term Benefit – Despite Payment Policies to The Contrary

Results from the first year of Medicare’s home health payment system, PDGM (Patient Driven Groupings Model) reveal that Medicare home health payments for the first 30 days of care are, on average, more than 34% higher than for subsequent 30-day periods of care - regardless of the amount of home health services a patient needs, or for how long.[1]

Although Medicare coverage for home health care is not time-limited under the law[2] (as long as a beneficiary is homebound and needs intermittent or part-time skilled services), Medicare beneficiaries are being discharged from home health services faster than ever before. The Center for Medicare Advocacy hears regularly from beneficiaries who are told by home health agencies that their agency “only provides short-term care.”

Beneficiaries with longer-term and chronic conditions – such as diabetes, stroke, paralysis, multiple sclerosis, Parkinson’s, ALS, heart disease, pulmonary disorders and more – are too often denied ongoing care for which they legally qualify. Beneficiaries who need continuing home health services to stay safely at home are left to fend for themselves, although most are not able to do so.

Repeatedly, the Centers for Medicare & Medicaid Services (CMS) has implemented practices that have a discriminatory impact (through policies, procedures, payment and quality models) to encourage that only short-term, post-acute care services are provided. Payments, quality reporting measures, the value-based purchasing model (HHVBP), CMS audits of home health agencies by the Office of Inspector General (OIG) and Medicare Administrative Contractor (MAC) and state enforcement training programs cumulatively limit Medicare home health care to only a short-term, post-acute care benefit.[3] Beneficiaries who legally qualify for longer-term coverage are unable to find agencies to provide services.  

PDGM, the Medicare home health payment model implemented in 2020, is one such discriminatory policy. Case-mix weights[4] in PDGM are applied to a national standard base rate, calculated with a labor component for the geographic region serving the patient. The first full year of PDGM illustrates the sharp payment decline to agencies after 30 days of home health care. The table below, shows the decrease in case-mix (equating to a similar decrease in payment), from the first 30 days to the second 30 days of care for the complete list of  clinical groups in PDGM (every patient fits into one of these clinical groups). After the first 60 days of home health care, payments decline even further.

PDGM Case Mix for 2020 Data[5]

Clinical Group	Period 1 (Day 1-30) Case Mix	Period 2 (Day 31-60) Case Mix	% Decrease from Period 1 to Period 2
Neuro/Stroke rehab	1.449	0.998	31%
Wounds	1.502	1.089	27%
Complex nursing	1.224	0.786	36%
Musculoskeletal rehab	1.375	0.896	35%
Behavioral health	1.136	0.726	36%
MMTA* – Surgical aftercare	1.281	0.767	40%
MMTA – Cardiac/circulatory	1.277	0.816	36%
MMTA – Endocrine	1.384	0.954	31%
MMTA – GI/GU	1.265	0.790	38%
MMTA – Infectious disease	1.283	0.818	35%
MMTA – Respiratory	1.288	0.800	38%
MMTA – Other	1.261	0.817	35%
Overall	1.346	0.887	34%

*MMTA = Medication, Management, Teaching and Assessment

Conclusion

PDGM is a significant factor in reducing, and often eliminating, access to ongoing home health care for beneficiaries with longer-term and chronic conditions. CMS should develop payments, policies and practices that support home health care for all individuals who qualify for coverage under the law.

If you, or someone you know, is prematurely discharged from home health care, or unable to obtain home health services, please contact the Center for Medicare Advocacy.

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[1] Strategic Healthcare Programs National Client Database, as reported by DecisionHealth on February 25, 2021.
[2] 42 C.F.R. 42 CFR § 409.48; Medicare Benefit Policy Manual, Chapter 7, § 70.1.
[3] See these topics discussed in greater detail in Articles and Updates Section of the CMA website: https://medicareadvocacy.org/medicare-info/home-health-care/.
[4] PDGM case-mix weights include: Admission Source (institution or community), Functional Impairment Level (low-medium-high), Co-Morbidity Adjustment (none-low-high). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Overview-of-the-Patient-Driven-Groupings-Model.pdf.
[5] Strategic Healthcare Programs National Client Database, as reported by DecisionHealth on February 25, 2021.