Implications of 2020 Skilled Home Healthcare Payment Reform for Persons with Dementia

Abstract

BACKGROUND/OBJECTIVES: The Medicare home health benefit provides episodic skilled home-based clinical care to the growing population of community-dwelling persons with dementia. As of January 1, 2020, home health payment changed: episodes shortened from 60 to 30 days, and episodes initiated in the community are now reimbursed at lower rates than episodes following institutional stays. We aim to assess the potential impact of these policy changes on this population. DESIGN/SETTING: Cross-sectional study using the Medicare claims-linked National Health and Aging Trends Study (NHATS). PARTICIPANTS: A total of 1,867 NHATS respondents who received home health between 2011 and 2017. MEASUREMENTS: Dementia was defined through both selfreport and a validated cognitive assessment through NHATS. We described the demographic, socioeconomic, and health characteristics of older adults with dementia receiving home health compared with those without dementia. We then assessed the association of dementia with both receiving community-initiated home health (vs postinstitutional) and visit timing during the home health episode. RESULTS: Over a follow-up period of just over 4 years, 50.2% of persons with dementia used home health compared with 15.3% of persons without dementia. Most home health provided to persons with dementia was initiated in the community (61%), compared with 37% of episodes provided to persons without dementia. Persons with dementia were more likely to receive care in days 31 to 60 of the episode compared with those without dementia. CONCLUSIONS: Shortening episodes and reimbursing community-initiated episodes at lower rates may disproportionately impact the highly vulnerable population of older adults with dementia, who receive more communityinitiated care over longer time periods. Our work highlights the need to better understand the unique role of home health in meeting gaps in both acute-and long-term care systems for older adults with dementia.

Patient cognitive impairment associated with higher home health care delivery costs

“…These actions have previously led to reduced access for older adults with greater disability and social vulnerability 18,21,46,47 . Against this backdrop, the January 2020 implementation of the revised home health payment system (PDGM) has prompted concerns that the provisions contained therein, including failure to adjust for cognitive impairment, may threaten home health access for older adults with cognitive impairment 16,17 . Results of the present study amplify these concerns by suggesting that home health agencies incur greater care delivery costs for those with cognitive impairment.…”

“…This echoes research demonstrating an association between cognitive impairment and greater care needs in other care settings. [3][4][5][6]8 While there is limited information specific to home health, prior work indicates that patients with cognitive impairment receive a greater number of visits 17 over a longer period of time, 16 and that receiving more visits lowers the risk of unplanned readmission and institutionalization for these patients. 45 Given this link between care intensity and outcomes, it is concerning that CMS reported a decline in the average number of home health visits provided following the recent payment system revision.…”

“…14 Yet, with the exception of a comorbidity category for patients who have both a dementia diagnosis and a pressure ulcer, PDGM does not adjust for the presence of cognitive impairment. 14 Simultaneously, PDGM reduces reimbursement for patterns of home health utilization, which are more common among those with cognitive impairment, including entering home health without an immediately preceding hospitalization, 15 receiving services during the latter half of a home health episode, 16 and incurring multiple successive home health episodes. 16,17 In the past, home health agencies have been highly responsive to Medicare payment system revisions, leading to reduced home health access for beneficiaries with greater disability, clinical severity, and social vulnerability.…”

Cognitive impairment associated with greater care intensity during home health care

“…Additionally, our findings confirm the recognized need for supportive home-based services for community-dwelling older adults with cognitive impairment. 10,34 Compared to those without cognitive impairment, cognitively impaired Medicare beneficiaries access HHC at higher rates 35 and using different referral pathways. 22 During HHC they require greater family caregiver support 36 and a greater number of visits (particularly skilled nursing visits).…”

Home Health Agencies With More Socially Vulnerable Patients Have Poorer Experience of Care Ratings

“…Evidence has shown that albeit having a modest impact on improving outcome measures, HHVBP has not led to any improvement in experience of care in HHC (Teshale et al, 2020). Rather, the value-based payment reform may penalize more CHHAs with fewer clinical and administrative resources, thus worsening the socioeconomic and racial/ethnic disparities in HHC (Ankuda et al, 2020). Multiple quality initiatives have been implemented in HHC since 2012, such as the HHVBP and the more recent PDGM that may have affected the experience of home health care among Medicare beneficiaries and socioeconomic and racial/ethnic disparities (Alliance for Home Health Quality and Innovation, 2021).…”