Reset Medicare home health care

The Medicare home health benefit is designed to provide in-home assistance to beneficiaries who are recovering from hospitalization or are “homebound” and need help coping with illnesses. Despite an increasingly aging population, the US has seen home health visits has declined sharply over the past two decades, as the proportion of visits increased for skilled care, especially therapeutic services (Appendix 1). a lot Medicare beneficiaries face barriers, including incomplete information or lack of understanding, that limit access to home health services.

Appendix 1: Medicare home health visits for each episode

Source: MedPAC, Annual Report to Congress, Chapter 8, 2021.

In April 2022, we convened a panel of 12 experts with national and community representation to identify opportunities to improve the way Medicare home health care works for beneficiaries who need help at home. The panel reviewed findings from structured interviews we conducted between January and March 2022 with 17 Medicare beneficiaries of various genders, races, ethnicities, and ages who needed in-home help to manage health problems, along with individuals who take care of them. Our goal was to find people who need these services and find out how well their needs are being met.

We also conducted 17 key interviews with government officials, aging and disability experts, case managers, health care providers, and advocates to gain insight into the Medicaid experience. We hoped to gain insight into strategies to improve the way Medicare home health care works within current law. Although our interviews were limited in number, the findings shed light on the need to better understand and improve access to home care that meets the situations of diverse Medicare beneficiaries and their caregivers.

Here are some lessons we learned from those conversations.

Home health services are an integral part of medical care

Home care, including ancillary services, is a necessary adjunct to medical care for the successful management of medical conditions

Our recent interviews with Medicare beneficiaries and their caregivers demonstrate how difficult it can be to manage prescription drug regimens, meet nutritional needs, maintain hygiene and cope with social isolation at home.

Dementia and other cognitive impairments add to these challenges. A recent review article found sufficient evidence that home services have been shown to increase adherence, improve patient outcomes, increase patient satisfaction and quality of life, and provide cost savings. As one leader of a local nonprofit organization serving seniors put it:

“Home care not only benefits quality of life, but is also associated with healthier lifestyles, longevity, lower costs, and better functioning of the rest of the health care system because you are in the doctor’s office for 7 minutes, then you’re home.”

Caregivers cannot handle the weight without help

Family members routinely help with personal care, perform household tasks, and provide financial assistance. They spend considerable time and effort trying to manage the time for medical examinations, prevent medical emergencies and prevent deterioration of the beneficiary’s health. Carrying out these tasks can be overwhelming and caregivers often lack the necessary resources or training to meet the care needs of beneficiaries. competition and culture can increase these challenges.

An aging expert who runs a caregiver support center that offers help to families of all cultures shared:

“There needs to be a default for home health care because families will rarely say ‘yes, I need help’ because they don’t understand the extent of what’s going to happen when that person comes home … and for how long and how they will balance that with their work.”

Lack of understanding and poor access to Medicare home health care have compromised its utility

Although Medicare is a federal program, access to the home health benefit is not guaranteed

Medicare beneficiaries and their caregivers place great importance on being able to access home health services, especially a home aide. Despite the defined scope of Medicare Home Health Benefitbeneficiaries don’t know about it, doctors don’t order it, and home health agencies do not provide home health aide services. Medicare Payment Systems, Quality Measures, and Audit Systems have led to misunderstandings among providers about what is actually covered and financial incentives that can limit the services provided.

Even a referral at hospital discharge for Medicare home health benefits is insufficient, with differences by race, ethnicity, and zip code of residence. In the words of a community legal advocate:

“Service providers won’t provide them and vendors won’t recommend them because they’re all working under the same idea. [People mistakenly believe that] it’s not covered by Medicare, and that’s where the whole conversation stops.”

Historically, indemnity has been interpreted as narrowly focused on skilled care, and many providers are unaware that the allowable scope of indemnity is broader. As a former Medicaid director described, “It’s absolutely staggering, the gap between the right under federal law and the actual practice.”

Insights from Medicaid

Leverage Medicaid’s expertise to improve the delivery of benefits at home

Over the past two decades, Medicaid has prioritized access to home and community services, including personal care services. Key strategies that support equitable access to home services include beneficiary-centered decision-making, systematic targeting and delivery of services, elimination of payment incentive conflicts, and an equitably compensated direct care workforce. Centers for Medicare and Medicaid Services (CMS) Medicare delivery and payment reforms, including efforts to integrate care for dually eligible beneficiaries, can help ensure that the Medicare home health benefit is provided in addition to the broader Medicaid package of services.

While state officials face limited bandwidth for navigating the two programs, California new office of Medicare Innovation and Integration will pay more attention to these issues. Developing a stronger home care workforce is imperative for both Medicare and Medicaid. This workforce—made up primarily of low-income women of color—faces persistent and well-documented recruitment, training and retention and regulatory challenges; the pandemic has only sharpened these problems. CMS can lead and maintain state and local efforts to increase wages, benefits, training and careers for home health aides and support for caregivers.

Medicaid prioritized increased access to home and community services, including personal care services, with federal financial support that was enhanced during the public health emergency. Access to home support through Medicaid is limited, as has long been seen waiting lists for access to home and community services. What moremany Medicare beneficiaries who need this assistance cannot qualify unless they become impoverished, a burden that falls disproportionately and unfairly on communities of color and prevents families from building wealth through home ownership. As a result, millions of Medicare beneficiaries who have worked all their lives, accumulated little savings and live on tight budgets cannot afford to pay for services not provided through Medicare, which disproportionately affects black and Hispanic beneficiaries.

How Federal Policymakers Can Reset and Redirect Medicare Home Health Benefits

Clarify Medicare policy on home health benefits

Policymakers must ensure that federal policy and regulatory practices are consistent with current law, incentivizing providers to offer the full range of services, not just skilled care. The Center for Bipartisan Policy recently recommended the CMS administrator to take a range of steps to better meet the needs of beneficiaries in the benefit structure. As CMS expands Value-based payment for home health nationally, it will be especially important to improve provider understanding and implementation of federal policy. Congress should also exercise its oversight role to examine the barriers that Medicare beneficiaries and their families face in accessing Medicare home health benefits.

Improve data, information, and research to eliminate disparities in access to home health benefits

CMS leadership has expressed a commitment to improving equity in health care. The federal government should modernize the quality and transparency of public program data by race, ethnicity, language, age, disability status, and residence; such efforts are needed to examine and eliminate disparities in access to home health services and to hold providers accountable. To better understand how racism and culture affect access to and use of home health services, federal officials should invest in research and community partnerships to engage and work with diverse communities of Medicare beneficiaries, their caregivers, and providers , anchored in these communities. Department of Health and Human Services Justice Action Plan provides an opportunity to address language, communication and stakeholder engagement. As a policy expert who addresses the needs of the Asian American and Native Hawaiian/Pacific Islander communities, emphasized,

“Having resources in the communities’ preferred language is really essential for access and even just raising awareness that the benefit exists and what paperwork needs to be filled out to find a home health care provider, all of this requires proper communication … perhaps a home health benefits ambassador who could help access the benefit, similar to an enrollment navigator.”

Real-time assistance that goes beyond a 1-800 number is also needed to help beneficiaries navigate the system, understand their rights, and appeal when services are denied.

The pandemic has heightened the urgency to realign the Medicare home health care system to better serve Medicare beneficiaries at home. The ideas and strategies offered here provide guidance for promoting greater equity and accountability in the delivery of existing Medicare home health benefits.

Authors’ note

The authors’ work described in this article was supported by the Commonwealth Fund, a national, private foundation based in New York that supports independent research on health issues and awards grants to improve health practice and policy. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund, its directors, officers or employees.