Last week, a group of Democratic senators unveiled a framework that would add non-medical home care to Medicare and make home- and community-based services a requirement under Medicaid. If actualized (with sufficient reimbursement and structural supports), this framework lays the foundation for a whole new world for non-medical home care. More than that, it signals […] The post How The New Medicare Home Care Framework Could Reshape The Industry appeared first on Home Health Care News.
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Last week, a group of Democratic senators unveiled a framework that would add non-medical home care to Medicare and make home- and community-based services a requirement under Medicaid.
If actualized (with sufficient reimbursement and structural supports), this framework lays the foundation for a whole new world for non-medical home care. More than that, it signals a potential redefinition of what counts as “health care” in the U.S. — one that more fully incorporates the kinds of daily supports that keep people safe at home.
Home health care news has previously reported that non-medical home care is moving toward a more recognized role in the overall health care system, in part through mechanisms such as the Guiding an Improved Dementia Experience (GUIDE) Model. The GUIDE model marked the first time Medicare would reimburse for activities of daily living (ADLs), and we wrote that the GUIDE Model was a critical opportunity for the home care industry because it opened the door for providers to participate in Medicare, alongside clinical care providers and vendors. We said this opportunity could be the “new renaissance for home care.”
But if a comprehensive Medicare home care benefit becomes reality, GUIDE would not be the renaissance. It would be the opening act. Direct participation in Medicare would mark a true paradigm shift for the industry.
In this week’s exclusive, members-only HHCN+ Update, I’ll dig into the proposed framework, offering analysis and key takeaways, including:
– How a Medicare home care benefit would transform the home care industry’s role in the health care ecosystem
– What the proposed framework means from an advocacy and legislative standpoint
– Why Medicare home care also introduces new risks for providers
Putting home care, HCBS on center stage
I have repeatedly heard from home care providers that the industry is not given its due and that non-medical home care services are overlooked, despite their importance in helping folks avoid falls and stay compliant with health care regimens, among many other benefits.
Making room for home care in Medicare signals a new era in which home-based care isn’t overlooked. For decades, these services have existed just outside the boundaries of what Medicare considers reimbursable care. This framework redraws that boundary.
I spoke with several advocacy leaders about what a Medicare home care benefit could look like. And it includes a slew of benefits: improved access to care, increased efficiency and a more stable payment source for providers. With rising inflation and other confounding factors making life expensive for many Americans, being able to use Medicare to pay for these services could significantly increase the number of folks who can engage a caregiver. Home care doesn’t have a demand problem, so this won’t totally transform how the industry operates. But a swath of new potential clients represents an opportunity.
At the same time, that opportunity comes with second-order effects. Expanding access through Medicare could reshape payer mix, put pressure on private-pay pricing and draw new types of competitors — including larger, more clinically integrated organizations — further into the home care space.
One key benefit that I was interested in, and asked experts about, was the potential for more streamlined care if a Medicare home care benefit is created. Damon Terzaghi, the vice president of Medicaid and home care policy at the National Alliance for Care at Home (the Alliance) verified that the framework could improve cooperation between home care and home health.
“Many of our members provide a wide range of support across home health, home care and hospice,” Terzaghi told me in an email. “This would allow those agencies to provide more comprehensive, coordinated care through the Medicare benefit. This would absolutely create more efficiency in the system and improve service delivery for individuals.”
That kind of integration could be one of the most immediate system-level impacts, particularly for providers already operating across multiple service lines. It also raises a longer-term question: whether home care begins to look more like an extension of clinical care, rather than a parallel service.
For HCBS providers, the mandatory HCBS requirement could be huge.
I saw a LinkedIn post from Alison Barkoff, an associate professor and director of the Hirsh Health Law and Policy Program at the George Washington University Milken Institute School of Public Health, who previously led HHS’ Administration for Community Living, that effectively summarized how important these changes could be.
“Medicaid, the primary payor of long-term services and supports (LTSS), has an “institutional bias,” where nursing home care is mandatory and home- and community-based services (HCBS) are optional,” Barkoff wrote. “This is about reversing that longstanding bias. … Historically, long-term care policy proposals have only had some people who need care in mind, often only older adults who need a limited amount of care. What is important here is the recognition that reform has to include all people who need LTSS — older adults, children and adults with many different types of disabilities, and people who need varying levels of care. That’s why the idea of packaging together adding a home care benefit in Medicare and strengthening Medicaid by making HCBS mandatory is really important. There are lots of issues to work through about how these programs would work together for people eligible for both programs. But the principle is that we don’t develop policies that leave people behind.”
While these upsides are clear, there are also risks for providers used to operating under a specific set of circumstances.
Medicare has shaped provider behavior through reimbursement and regulation, and home care would not be immune. What is flexible and consumer-directed today could, over time, become more rigid, more compliance-heavy, and more constrained by documentation requirements.
Home care comes into focus for policymakers
I often speak to providers and advocacy leaders about the need for education about home-based care. Not just for recipients of care, but for policymakers who may not know some of the fundamentals about in-home care. I have heard about the importance of inviting lawmakers to see firsthand how home care works, in hopes of illustrating its value and how it functions.
This new framework demonstrates that, at least to some extent, providers and advocates have made a mark on the political zeitgeist of HCBS and home care – which might be the primary hurdle to improving access to in-home care. It also suggests that long-term care, once a niche policy issue, is becoming harder for lawmakers to ignore.
I liked what Barkoff wrote about how HCBS is building “champions.”
“For too long, we’ve had one or two Senators as champions for expanding access to HCBS,” Barkoff’s post read. “Caregiving is universal, and the number of champions we have for this issue should reflect that. That 17 Senators are on this letter out of the gate (with more likely to join the effort, as I understand) is a big deal. This is just the start of a long process, but I truly feel the politically impossible is becoming the politically inevitable.”
That momentum is notable, especially given how long similar proposals have stalled. Still, the framework’s path forward is far from certain, and its ultimate fate will likely depend as much on political timing as policy design.
Overall, the letter and framework suggest there is ample reason for the home-based care industry to be hopeful. There is still work to be done – in my communication with advocacy leaders, it was clear that the framework would have to be thoughtfully implemented.
This includes ensuring that beneficiaries have access to a range of HCBS supports, including home care, personal care, care management, transportation and adult day services. It would also have to include sufficient reimbursement and avoid overly cumbersome administrative requirements.
“A benefit that is underfunded or overly burdensome would not solve the access problem families are experiencing,” Jason Lee, CEO of the Home Care Association of America (the HCAOA), said.
If the Medicare home care benefit is realized, home care would have to deal with some of the same issues as Medicare-certified home health – reimbursement rate cuts and eligibility problems, among several others. The home care industry could learn from the home health industry in terms of what works and what doesn’t to improve reimbursement status quo (or at least soften any blows).
More broadly, if GUIDE was the opening act, this proposal is the main event — but only if it’s executed correctly. The opportunity is significant. So is the risk of getting it wrong.
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